Program Profile: Child and Family Traumatic Stress Intervention (CFTSI)

This is a brief early intervention and secondary prevention model, designed to prevent the development of chronic posttraumatic stress disorder (PTSD), for children aged 7–18 years who have recently experienced a potentially traumatic event. The program is rated Promising. Compared with the comparison group, the intervention group was statistically significantly less likely to have a PTSD diagnosis or receive a partial/full PTSD diagnosis; they also showed a lower severity of PTSD symptoms.

A Promising rating implies that implementing the program may result in the intended outcome(s).

This program's rating is based on evidence that includes at least one high-quality randomized controlled trial.

Program Goals

Child and Family Traumatic Stress Intervention (CFTSI) is an early intervention and secondary prevention model that aims to reduce traumatic stress reactions and posttraumatic stress disorder (PTSD). It is delivered to children aged 7–18 years, together with their parent or caregiver, after the child has experienced a potentially traumatic event (PTE). Examples of PTEs are events such as sexual and physical abuse, domestic violence, community violence, rape, assault, and motor vehicle accidents. Children are referred by law enforcement, child protective services, pediatric emergency rooms, mental health providers, forensic settings, and schools.

Given in four brief, manualized sessions, the goals of CFTSI are to:

• Improve screening and identification of children impacted by traumatic stress
• Reduce traumatic stress symptoms
• Increase communication between the caregiver and the child about the child’s traumatic stress reactions
• Provide skills to help master trauma reactions
• Assess the child’s need for longer-term treatment
• Reduce concrete external stressors (e.g. housing issues, systems negotiation, safety planning, etc.)

Program Activities

In the first session, treatment providers meet with the parent or caregiver alone. The process is explained step-by-step and its intervention, rationalized. Providers use a psycho–educational approach when explaining typical reactions to PTEs and the importance of familial support. A series of questionnaires are completed in order to assess the parent or caregiver’s psychological status throughout the intervention. During this session, providers discuss external stressors related to the PTE, and a case management plan is set up.

The second session occurs as close to the first session as possible and includes the provider, child, and parent or caregiver. The first half of this session starts with just the provider working with the child. This is followed by the provider, child, and parent or caregiver together. The second half of this session lays the groundwork for future aspects of the intervention. A series of questionnaires, similar to those given to the parent or caregiver during session 1, are also completed by the child. Then answers from both participants are compared. Areas of agreement are praised and areas of disagreement are seen as opportunities to improve communication by helping the child learn how to better inform the parent or caregiver about their symptoms and helping the parent or caregiver be more aware, receptive, and supportive of the child. Providers end the session by providing the child and parent or caregiver with behavioral skill modules to work on as homework before the next session. These areas include sleep disturbance, depressive withdrawal, tantrums, intrusive thoughts, anxiety, and techniques to manage traumatic stress symptoms.

The third session includes all three participants, where the child completes questionnaires, with the parent or caregiver providing perspective on the items mentioned. The main emphasis is adjustment of communication efforts to improve the effectiveness of behavioral skill modules as well as other supportive measures.

The final session is delivered almost identically as the third, with the end of this session focused on future check-ins and possible plans for more extensive treatments.

Program Note

Child and Family Traumatic Stress Intervention (CFTSI) is currently in use in child advocacy centers and children’s mental health clinics in New Haven, and in New York City in collaboration with Safe Horizon. It is also being implemented in Philadelphia in collaboration with the Children’s Hospital of Philadelphia and St. Christopher’s Hospital for Children emergency departments.

Study

Berkowitz, Stover, and Marans (2010) conducted a randomized controlled trial at the Trauma Section of the Yale Child Study Center with youth aged 7–17 years who were exposed to a potentially traumatic event (PTE) and exhibited at least one symptom of posttraumatic stress disorder (PTSD). Children were referred for service by police or a forensic sexual abuse program. Children were recruited from a pediatric emergency department following a record review, by follow-up phone call. The study recruitment occurred from November 2006 to May 2009, with follow-up interviews completed by September 2009. All screened youth and families were offered services regardless of agreement to participate in the study.

Of the 735 families contacted by phone and screened, youth who had one new symptom since the PTE as reported by either the youth or caregiver were further screened for eligibility. Youth were excluded if they were receiving counseling or metal health services, had a developmental delay or diagnosed psychotic or bipolar disorder, were non–English speaking, or refused participation in the study. After screening all youth for inclusion criteria, researchers obtained consent for a total sample of 112. After randomization to either Child and Family Traumatic Stress Intervention (CFTSI) or the comparison intervention, a final sample of 106 participants was obtained. The treatment youth (n= 53) received the CFTSI model. Comparison youth (n= 53) received a protocolized psycho–educational (including relaxation training) and supportive four-session intervention that included an initial meeting with the adult caregiver, two individual youth sessions, and a fourth feedback session with both the caregiver and the youth. There were no significant differences between groups on age, ethnicity, or PTE type. The average age of youth was 12, with 48 percent male, 32 percent Caucasian, 37 percent African American, 22 percent Hispanic, 7 percent multiethnic, and 2 percent other ethnicities. The nature of the PTEs that brought youth to the study included motor vehicle accidents (24 percent), sexual abuse (18 percent), witnessing violence (19 percent), physical assaults (21 percent), injuries (8 percent), animal bite (5 percent), and threats of violence (5 percent).

Baseline interviews and the first treatment session occurred at the initial visit, within 30 days of the youth’s exposure to a PTE. All participants were interviewed by a research assistant at baseline, immediately following their fourth treatment session (4 weeks from baseline), and at 3 months posttreatment. The UCLA Posttraumatic Stress Disorder Index (Pynoos et al. 1998) was used to assess posttraumatic symptomatology related to subjective distress and PTSD diagnostic criteria B (re-experiencing), C (arousal), and D (avoidance) symptoms and can be used to diagnose full or partial PTSD based on DSM-IV criteria (Steinberg, Brymer, Decker, and Pynoos 2004). The Trauma Symptom Checklist for Children was administered at all time points to evaluate posttraumatic symptomatology (Briere 1996).

Group differences in symptom severity were assessed using repeated measures with mixed-effects models of intervention group, time, and the interaction of intervention and time. Logistic regression analyses were performed to assess treatment condition and any subsequent traumas experienced as predictors for full and partial PTSD diagnosis at 3-month follow-up. An exploratory chi-square analysis was performed to examine the differences in PTSD symptom criteria at follow-up.

The intervention is facilitated by a provider manual containing de­tailed case vignettes, a decision tree for identify­ing Child and Family Traumatic Stress Intervention (CFTSI) cases, and easy-to-read handouts for children and caregivers. Spanish-language versions of the clinical assessment tools are available.

These sources were used in the development of the program profile:

These sources were used in the development of the program profile: