Intervention and Evaluation Paper David Lee Azusa Pacific University Introduction?The use of Evidence-Based Practices (EBPs) has made significant strides in treatment planning in the field of Social Work. EBPs provide clinicians with a scientifically proven methodology that integrates clinical expertise and current research evidence to provide effective care for consumers. One EBP that has been shown to be effective in treating children and adolescents with post-traumatic stress disorder (PTSD) is the use of trauma-focused cognitive-behavioral therapy (TF-CBT). According to Cohen (as cited in Cardeña & Croyle, 2005), “Of all the current psychotherapeutic models used to treat traumatized children, only TF-CBT and community care have received an adequate empirical evaluation to evaluate efficacy” (p. 113). TF-CBT has undergone numerous randomized control trials, systematic reviews, and meta-analyses that have determined its usefulness in clinical work.?According to Syros (2017), “TF-CBT is designed for children with PTSD with or without comorbid depression, anxiety, and other emotional problems associated with trauma such as shame and self-immolation” (p. 1). TF-CBT requires that trained clinicians engage both child/adolescent consumers along with their parents to help process thoughts and feelings related to the traumatic event. It is also used to improve communication between family members so that distressing thoughts and negative behaviors can be better managed. Through the specific use of interventions such as trauma narrative, motivational interviewing, cognitive coping, and relaxation techniques, symptoms related to PTSD can be reduced within 12-16 sessions. Numerous mental health and community service agencies have adopted TF-CBT due to its success and the research that has been done to prove its success. The following studies were conducted by researchers that have deemed the TF-CBT’s effectiveness and applicability in the treatment process.Randomized Controlled Trial?Scheeringa, Weems, Cohen, Amaya-Jackson, & Guthrie (2011) conducted a randomized controlled trial to determine the overall efficacy of TF-CBT in treating PTSD in children aged between 3 and 6 years old who were exposed to trauma. Limited studies have shown TF-CBT to be effective in treating school-age children and adolescents exposed to sexual abuse; however, there has been a lack of data addressing its effectiveness towards young children. Regarding previous studies, Scheeringa et al. (2011) report that “these conclusions were based on randomized trials that involved primary school-age children and adolescent youth. However, only two randomized studies have focused exclusively on young children and both were limited to sexual abuse” (p. 853). ?To address key goals in their study, Scheeringa et al. (2011) developed three main hypotheses; the first which was that PTSD symptoms would be reduced using 12 sessions incorporating TF-CBT interventions in comparison to those on the waiting list for treatment. The second was that the effect size of the treatment would be large. The third was that consumers would understand and complete the treatment material. Participants were chosen from the nearby New Orleans area such as those from Level 1 Trauma Centers, battered women’s programs, and victims of Hurricane Katrina. They also had to meet the criteria of having experienced a life-threatening trauma, between the ages of 24-36 months, and display four or more symptoms related to PTSD. ?According to Scheeringa et al. (2011), participants were randomly grouped to be enrolled in either Immediate Treatment (IT) or Waiting List (WL). TF-CBT interventions that were utilized during treatment included techniques such as psychoeducation related to PTSD, recognition of feelings, learning coping skills, and exposure to gradual reminders related to the trauma. The results found that three to six-year-oldchildren within the IT group receiving TF-CBT was more effective in reducing PTSD symptoms in comparison to those in the WL. Children placed in the WL group showed no decrease in symptoms. Scheeringa et al. (2011) also report that children within the IT group were unable to complete some of the interventions that required them to express verbal narratives; however, most of TF-CBT interventions were able to be successfully completed. ?Scheeringa et al. (2011) conclude that “this study provided support for both the effectiveness and feasibility of a structured treatment protocol for very young children who have posttraumatic stress symptoms from a variety of traumatic experiences” (p. 860). Some limitations in this study pertained to participants who were unable to complete their treatment due to Hurricane Katrina. Similarly, this study was conducted using young children who were mostly minority and came from single-parent households with few research studies to compare to. Future studies should be aimed at exploring larger diverse sample sizes that provide a better generalization of TF-CBT and effectiveness towards treating PTSD.?In a separate study, Diehl, Opmeer, Boer, Mannarino, & Lindauer (2015) conducted a randomized controlled trial to compare the overall effectiveness of TF-CBT and eye movement desensitization and processing (EMDR) in children with PTSD. Although TF-CBT has been shown to reduce PTSD symptoms, if untrained TF-CBT therapists are unavailable to provide it,then alternative treatments such EMDR may be considered. According to Diehl et al. (2015), “international guidelines for the treatment of PTSD advise TF-CBT for the treatment of children with PTSD” (p. 228). However, EMDR has also seen positive benefits in treating children with PTSD but lacks concrete research data. The purpose of their study was to provide demonstrate the effects of TF-CBT and EMDR in outpatient facilities and to show which treatment was most efficient. ?Diehl et al. (2015) reports that children were chosen from the trauma center in Amsterdam and had to meet the following criteria to be considered: between the ages of 8 to 18 years old, ability to comprehend the Dutch language, exposure to at least one traumatic event, having experienced one traumatic event within the last 4 weeks, and reported either partial or full PTSD by child or caretaker. Afterwards, participants were randomly put into either a TF-CBT or EMDR group to receive treatment. According to Diehl et al. (2015), TF-CBT interventions that were utilized in this trial were: psychoeducation, relaxation,effective expression and regulation, cognitive coping, gradual exposure by creating the child’s trauma narrative, parent management skills, and enhancing future safety. EMR interventions that were used in the separate group included: preparation of target memory, desensitization of memory, identifying and processing of body sensations, and re-evaluation of the target. Both treatment interventions were to be completed by participants within 8 sessions to determine overall effectiveness.?The results of this randomized controlled trial revealed that both TF-CBT and EMDR were successful in reducing PTSD related symptoms and that there was no significant difference treating children exposed to trauma using both interventions. According to Diehl et al. (2015), “overall, our results on comorbid problems suggest that parents of children in the TF-CBT condition reported more positive treatment effects than parents in the EMDR condition” (p. 234). The primary reason for this was that parents were more actively involved in their child’s treatment process and learned methods to better cope with their children’s behaviors and emotions. In the treatment group utilizing EMDR, it was found that comorbid problems were not significantly decreased in comparison to TF-CBT. ?Although this study was able to demonstrate the effectiveness of both TF-CBT and EMDR in treating children with PTSD, some limitations were addressed. The therapists in this study were trained in both TF-CBT and EMDR, however lack of experience in either intervention could have influenced the results. According to Diehl et al. (2015), the ideal number of participants was 150, but only 48 were included in this trial. Due to the small sample size, the results have limited power in detecting specific differences using the two different intervention approaches. Similarly, Diehl et al. (2015) suggestthat future studies specifically target predictive factors of treatment effects to determine who would benefit from the interventions. ?????Systematic Review?A systematic review was conducted by Gary and McMillen(2012) to evaluate the evidence pertaining to TF-CBT and its ability to reduce symptoms of PTSD in children who have experienced or witnessed trauma. According to Gary (2012), “systematic reviews can assess the effectiveness of an intervention on a variety of measured outcomes, at a variety of times post completion, and against a variety of neutral or active conditions” (p. 749). Since TF-CBT is highly used by clinicians and endorsed by numerous organizations in treating consumers with PTSD, a systematic review will also be able to reveal any inconsistencies across previous studies and any possible implications. Through theirextensive search, Gary (2012) were able to locate 10 studies that were included in their systematic review. Two studies compared TF-CBT in relation to a wait list control or alternative treatment, while the other eight studies compared the active TF-CBT condition with one attention control condition. ?Gary (2012) reports that “study quality was consistently high amongst all ten studies. All used controlled, randomized designs, widely used measurement scales and appropriate analytic methods” (p. 752). From these studies, it was found that TF-CBT was highly effective in treating children with PTSD when compared to factors such as waitlist conditions and community care. Similarly, Gary (2012) reports that TF-CBT interventions may also help children who are suffering from depression and behaviors associated with it. The success of TF-CBT verifies that clinicians can utilize this therapy approach to treat children with exposure to trauma and reduce PTSD related symptoms. Gary (2012) found that “This systematic review was able to identify that TF-CBT is effective for the treatment of PTSD in children and may hasten recovery for post-trauma depression and behavioral problems” (p. 756). They also suggest that future studies to compare TF-CBT to EMDR or manualized play therapy as both have also been successful in treating children exposed to trauma. Although TF-CBT has been validated in its work with children and PTSD, additional research should be emphasized in non-TF-CBT interventions to see how it compares in efficacy and efficiency. Gary (2012) concludes that future systematic reviews should be conducted on other therapies and interventions in treating PTSD so that clinicians and parents may select the appropriate approach towards determining which treatment approach is best for them. ConclusionDue the negative impact of trauma amongst children and adolescents such as exposure to natural disasters, sexual and physical abuse, neglect, domestic violence, and crime, clinicians need a proven approach to address consumer’s emotional and behavioral problems related to PTSD. Although alternative treatment approaches such as play therapy and EMDR have also seen success in addressing these issues; there is a lack of concrete evidence in comparison to studies conducted on TF-CBT. TF-CBT has also become a manualized approach and widely distributed worldwide so that clinicians can easily apply its approach during treatment. Various meta-analysis, systematic reviews, and randomized controlled trials have been conducted to show TF-CBT’s effectiveness in treating PTSD related symptoms and behaviors within consumers.?Through extensive research and analysis, numerous studies have verified the effectiveness of incorporating TF-CBT in treatment and its ability to reduce PTSD related symptoms in children exposed to trauma. Randomized controlled trials conducted by Scheeringa et al. (2011) and Diehl et al. (2015)demonstrated the use of TF-CBT when compared to factors such as a WL group and alternative treatments such EMDR; thisshowed that TF-CBT was efficient in improving symptoms. Similarly, the systematic review conducted by Gary (2012) was able to thoroughly check ten previous conducted studies that contained comparative components and attention controls that also revealed the prominent use of TF-CBT amongst clinicians in treating PTSD was positive. Due to the success of TF-CBT in treatment, numerous agencies and organizations have adopted its manualized approach towards helping consumers.