Examining the Feasibility of Telehealth Trauma-Focused Cognitive Behavioural Therapy (TF-CBT) with Young People in Foster Care

Abstract

Purpose: Despite the high rate of trauma exposure among young people with child welfare involvement, various systematic and patient barriers exist that inhibit utilization of evidence-based trauma treatments. One strategy for alleviating barriers to such treatments is using telehealth. A few studies have found that the clinical outcomes of telehealth TF-CBT are comparable to those found from clinic-based, in-person treatment administration. Studies have yet to examine the feasibility of telehealth TF-CBT with young people in care. The current study sought to address this gap by examining outcomes for patients who received telehealth TF-CBT, along with factors that may have impacted successful completion, at an integrated primary care clinic exclusively serving young people in care. Methods: Patient data were collected retrospectively from the electronic health records of 46 patients who received telehealth TF-CBT between March 2020 and April 2021, and feedback was sought via focus group from 7 of the clinic’s mental health providers. A paired-sample t-test was conducted to evaluate the impact of the intervention for the 14 patients who completed treatment. Results: Responses from the Child and Adolescent Trauma Screen showed a significant decrease in posttraumatic stress symptoms when comparing pre-treatment scores (M = 25.64, SD = 7.85) to post-treatment scores (13.57, SD = 5.30), t(13) = 7.50, p < .001. The mean decrease in scores was 12.07 with a 95% confidence interval ranging from 8.60 to 15.55. Themes emerging from the focus group centered on home environment, caregiver participation, and systemic topics. Conclusions: Findings suggest that telehealth TF-CBT with young people in care is feasible but relatively low completion rates suggest that barriers to treatment completion remain.

Introduction

Almost 425,000 young people in the United States (US) experienced foster care in 2019 (U.S. Department of Health and Human Services [HHS], 2020). Most of these young people were removed from their homes because of adverse experiences, such as neglect (63%), parental substance use (34%), and physical abuse 13% (HHS, 2020). Research suggests that such adverse experiences can be traumatic, meaning they can be “experienced by an individual as physically or emotionally harmful or life threatening and … [have] lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being” (Substance Abuse and Mental Health Services Administration [SAMHSA], Trauma and Justice Strategic Initiative, 2012, p. 2). Although removal is sometimes the only option for ensuring a young person’s safety, the act itself can be traumatic (Mitchell & Kuczynski, 2010).

Another source of potential trauma for young people in the U.S. foster care system is placement disruption. Indeed, placement changes are all too common, with 35% of young people experiencing more than two placements (Casey Family Programs, 2018). Instability in placement can result from individual child characteristics (e.g., age, problematic behaviors), placement elements (e.g., number of children in the home), foster parents characteristics (e.g., empathy and tolerance for child in their care), and organizational factors (e.g., parents losing the support they need to maintain a placement) (Carnochan et al., 2013; Casey Family Program, 2018).

Stein and colleagues (2001) found that 90% of children ages 6 to 12 in care had been exposed to trauma, with nearly half reporting exposure to four or more types of traumatic events. Many young people in care fit the definition of having what is known as complex trauma, which Ford and Courtois (2009) described as involving repeated or prolonged exposure to trauma; direct harm, abandonment, or neglect from caregivers; and the potential for significant impact on a child’s development.

The high level of trauma exposure among young people in care places them at greater risk of developing mental health concerns and problematic externalizing behaviors (Kessler, 2000; Marshall et al., 2020; McLaughlin et al., 2013; Mongillo et al., 2009). The most common diagnoses in this population include emotional disorders such as depression, posttraumatic stress disorder (PTSD) and other trauma-stressor related disorders (Pecora et al., 2009; Salazar et al., 2013). Prior research with young people who have aged out of care has found prevalence rates of PTSD ranging from 14 to 30% (Bartlett & Rushovich, 2018; Keller et al., 2010; Pecora et al., 2005). A comprehensive review of children entering foster care revealed that 25% exhibited trauma symptoms so severe that they required treatment (American Academy of Pediatrics, 2013).

Trauma-Focused Cognitive Behavioral Therapy (TF-CBT)

TF-CBT is an evidence-based treatment (EBT), meaning a treatment that is back by scientific evidence, for treating individuals who have experienced trauma. When used with young people, this conjoint child and caregiver treatment has demonstrated effectiveness in a variety of environments and with children and families from diverse racial and cultural backgrounds, including with young people with child welfare involvement (Cohen & Mannarino, 2015; Weiner et al., 2009). The California Evidence-Based Clearinghouse for Child Welfare (2019) gave TF-CBT the highest scientific rating, citing empirically robust support for the intervention with this population. Given the importance of effective mental health treatment for young people in care, identifying strategies to increase access is critical. One such option is telehealth (e.g., Stewart et al., 2017).

Telehealth Reduces Barriers to Access

Several barriers exist that make providing EBTs to young people difficult. For example, caregivers can experience logistical challenges related to employment (e.g., leave restrictions, scheduled work hours), transportation and having multiple children in their care as well as personal difficulties such as substance use and mental health problems (Kemp et al., 2009; Reardon et al., 2017). These barriers can limit the ability for children in their care to receive EBTs and/or to complete treatment (Mersky et al., 2015).

Telehealth has the potential to address some of these barriers. Saliency of telehealth service delivery drastically increased in the context of COVID-19, as behavioral health providers transitioned to this modality in the interest of public safety (Smith et al., 2020). In addition to ameliorating public safety concerns, utilizing interactive technologies (e.g., videoconferencing through computer and/or tablet) to provide healthcare services has been shown to minimize barriers to accessing care while simultaneously addressing healthcare disparities (e.g., Comer & Myers, 2016; Kazdin, 2008). For example, utilizing telehealth can circumvent the need for caregivers to take time off work to transport children to weekly in-person appointments, which can reduce financial burden for families (Spaulding et al., 2010). Indeed, patients and families that utilize telehealth treatment have reported lower transportation expenses and less stigmatization in receiving mental health treatment from home (Oesterle et al., 2020; Tarp et al., 2017).

Studies have found that implementing EBTs via telehealth is feasible and can be as effective as in-person delivery. For example, Elbin et al.’s (2021) study found that scores for therapeutic alliance and session satisfaction were not significantly different between patients receiving in-person and telehealth treatment. Additional research has shown effectiveness across a number of disorders in youth, such as attention-deficit/hyperactivity disorder (Myers et al., 2015), depression (Nelson et al., 2003), and obsessive-compulsive disorder (Orsolini et al., 2021). Overall, reviews of the telehealth treatment modality on youth shows positive clinical outcomes in both urban and rural settings with high levels of diagnostic accuracy (Hilty et al., 2013).

Telehealth Delivery of TF-CBT

Research on telehealth TF-CBT with young people is scant. Only two studies (Stewart, Orengo-Aguayo, Cohen et al., 2017; Stewart, Orengo-Aguayo, Young et al., 2020) were identified, both of which included young people receiving telehealth TF-CBT in home and school environments. Both studies found clinically significant symptom improvement and lower attrition rates than typically seen in TF-CBT studies (0% and 11.4%, compared to 33–77% found in studies of in-person TF-CBT with children) (Cohen et al., 2011; Scheeringa et al., 2011; Wamser-Nanney & Steinzor, 2017). Thus, it is possible that offering telehealth TF-CBT may help overcome barriers to completion. However, no studies were identified that specifically focused on young people in care.

Present Study

The effectiveness for TF-CBT with young people in care is well established, but less is known about the use of the telehealth modality to deliver the intervention. To understand its effectiveness with this population, more information is needed about factors that contribute to or inhibit successful implementation. To begin to address this gap in the literature, the current investigation sought to examine outcomes for patients who received TF-CBT via telehealth, along with factors that may have impacted successful completion, at an integrated primary care clinic exclusively serving young people in care.

Methods

Setting and Participants

This study took place in an integrated primary care clinic exclusively serving young people in foster care. The clinic provides medical and behavioral health services to approximately 2,000 young people per year at the suburban and urban campuses of a tertiary children’s hospital in the southwestern United States. Services offered include primary care, therapy (TF-CBT, CBT, play therapy, and parent-child interaction therapy) and psychological testing, developmental assessment and education, psychiatry visits, and integrated visits involving both medical and behavioral health providers. At the outset of the pandemic, behavioral health services moved from in-person to virtual.

Participants included patients and behavioral health providers. Patients needed to have exposure to and active symptoms of trauma to be included in the study. They also had to have received TF-CBT from one of the clinic’s trained therapists via telehealth between March 2020 and August 2021. During the majority of the timeframe for this study, behavioral health services were exclusively offered via telehealth because of the pandemic. Forty-six patients met inclusion criteria for the study. Of those, 14 completed the treatment via telehealth.

Mental health providers included in the study needed to be trained in TF-CBT and to have provided TF-CBT via telehealth during the study period. A total of seven providers were included in the focus group portion of this study. Participants included a psychologist, a postdoctoral fellow, four licensed clinical therapists, and a predoctoral intern. Of the seven participants, all were trained in TF-CBT, and five were certified.

Measures and Procedure

Both qualitative and quantitative data were used to capture the experience of and outcomes from delivering TF-CBT via telehealth. The study was approved by the institutional review board of the lead author.

Retrospective Chart Review

Patient data were collected retrospectively from the electronic health records of 46 patients who received TF-CBT via telehealth between March 2020 and April 2021. Data gathered for each patient included scores on the Child and Adolescent Trauma Screen (Sachser et al., 2017) from pre- and post-intervention delivery. The CATS assesses trauma exposure and posttraumatic stress symptoms (PTSS) of children and adolescents aged 3–17 using a checklist that includes 15 potentially traumatic events or sequences of events, 20 listed PTSS, and 5 impairment items, all based on DSM-5 PTSD diagnostic criteria. A sum of items endorsed determines the severity of PTSS a child is experiencing at a given time. A total score of 15 or higher is deemed clinically significant. This assessment can be administered as a self-report or as an interview, and caregiver- and youth-reported versions of the screen are available. The self-report measure is available for children aged 7–17, and there are two caregiver versions – one for youth aged 3–6 and one for 7- to 17-year-old patients. This assessment has demonstrated strong internal reliability through multiple international validation studies, with Cronbach alphas ranging from 0.88 to 0.94 (Sachser et al., 2017). For this study, CATS scores obtained from children (for ages 7–17) and caregivers (for children ages 3–6) were pulled from the health record. Other data obtained from health records included: demographics (age, gender, race/ethnicity), placement type (foster, kinship), and known trauma exposures (physical abuse, sexual abuse, neglect, abandonment, domestic violence, parental substance abuse).

Focus Group

A one-hour focus group was held on a virtual platform with seven of the clinic’s mental health providers. Participants gave verbal consent to participate and did not receive any monetary incentive for their involvement. The focus group protocol consisted of six questions designed to elicit feedback on the experience of delivering TF-CBT via telehealth and to help nuance findings from the retrospective chart review. Questions focused on the strengths, weaknesses, and effectiveness of conducting TF-CBT via telehealth; virtual administration of the CATS assessment; the high incompletion rate; and any additional information participants thought important to share.

Data Analysis

The Shapiro–Wilk test was used for normality testing. A paired-sample t-test was employed to determine if changes in CATS scores pre- and post-treatment were significant. All analyses were done using the Statistical Package for Social Sciences version 25 (IBM Corp., 2017). P-values less than 0.05 were considered significant. Qualitative data from the focus group were reviewed by the authors to identify themes related to TF-CBT delivery and feasibility. Data are available upon request.

Results

Table 1 provides demographic and placement characteristics of the patient sample. The mean age of the patient sample was 9.48 (SD = 3.58; Range = 4–17 years). The sample included 21 males and 25 females. Of the 46 young people participating in the study, 26.0% identified as Hispanic, 37.0% as African American, and 37.0% as Caucasian. The majority of participants were placed in foster homes (67.4%). The most common trauma exposure was neglect (89.1%).

Table 1.

Demographics

	Total Sample (N = 46)		Completed via Telehealth (N = 14)	Not Completed via Telehealth* (N = 32)
Age n (%)
4–6		13(28.3%)	2 (14.3%)	11 (34.4%)
7–11		19(41.3%)	7 (50.0%)	12 (37.5%)
12–17		14(30.4%)	5 (35.7%)	9 (28.1%)
Gender n (%)
Male		21(45.7%)	9 (64.3%)	12 (37.5%)
Female		25(54.3%)	5(35.7%)	20 (62.5%)
Race/Ethnicity n (%)
White		17(37.0%)	5 (35.7%)	12 (37.5%)
White/Hispanic		12(26.0%)	5 (35.7%)	7 (21.9%)
Black/African-American		17(37.0%)	4 (28.6%)	13 (40.6%)
Placement Type. n (%)
Foster Home		31(67.4%)	10 (71.4%)	21 (65.6%)
Kinship		13(28.3%)	4(28.6%)	9 (28.1%)
Emergency Shelter		2(4.3%)	0 (0.00%)	2(6.3%)
Trauma Exposure (Not exclusive) n (%)
Neglect	41(89.1%)		11 (78.6%)	30(93.8%)
Abuse	17(37.0%)		7 (50.0%)	10 (31.3%)
Domestic Violence	14(30.4%)		2 (14.3%)	12 (37.5%)
Parental Substance A Abuse	26(56.5%)		7 (50.0%)	19 (59.4%)

*Includes three patients that participated in treatment via hybrid model

Clinical Outcomes

The mean number of treatment sessions for the entire sample was 13.26 (SD = 8.45, range 1–38). Telehealth TF-CBT was completed by 14 (30.4%) patients in the sample over an average of 21.8 sessions (SD = 8.02, range 9–38).

A paired-sample t-test was conducted to evaluate the impact of the intervention. The results showed a significant decrease in CATS scores before (M = 25.64, SD = 7.85) to after (13.57, SD = 5.30) treatment, t(13) = 7.50, p < .001. The mean decrease in the test score was 12.07 with a 95% confidence interval ranging from 8.60 to 15.55. Caregiver scores were used to determine change in PTSS for three of the 14 patients, either because the child was younger than age 7 or clinician’s judgement regarding the patient’s ability to complete the screener.

For patients who did not complete the treatment via telehealth (n = 32) chart review revealed that the most common reason for therapy ending was placement change (n = 16; 50.0%). Specifically, 12 patients (75.0%) moved to a new foster home, and 4 patients (25.0%) were admitted into residential treatment facilities. For six patients, the mental health provider determined that a different therapy modality would better meet the child’s needs. Four patients changed to parent-child interaction therapy and two to play therapy. Seven patients dropped out of treatment, with or without communication from caregiver. Three individuals completed the treatment via a hybrid model (both telehealth and in-person) based on clinical judgment.

Focus Group Outcomes

Three themes emerged from the focus group held with mental health providers: the home environment, caregiver participation, and systemic topics.

The Home Environment

The influence of home environment on treatment quality was a significant topic of conversation during the focus group. Clinicians discussed how telehealth allowed for a better perspective on the patient-caregiver dynamic because treatment took place in a more natural setting (i.e., the child’s home). A clinician in the focus group explained, “[TF-CBT] helps with parenting too, because I can see the behaviors they are trying to manage. I get to see what they’re dealing with at home.”

Focus group participants also described challenges to delivering treatment to patients who were in their home environments. They noted that patients sometimes had screen fatigue, shorter attention span, and more distractions. A clinician expressed concern about the challenge with attention span and distractions as follows: “A biggest weakness for me is trying to figure out how to make it engaging on the screen.” Another clinician stated, “A couple of the younger kiddos, I’m seeing them for shorter sessions because I can’t keep them engaged for one hour. I can get more done in 30 minutes, so it takes more sessions.” Participants stated that this can be particularly problematic for young people in care, who often have experienced complex traumas that require longer treatment lengths and session times.

Internet connection was also discussed as a source of angst throughout treatment for patients, caregivers, and clinicians. It was described as sometimes playing a detrimental role in treatment progress. A clinician stated: “The trauma narrative part is tricky because if the connection is dicey, it becomes anxiety promoting. If the connection is okay, it can be effective.”

Privacy in the home environment was another obstacle mentioned by providers. Clinicians discussed how many patients live in homes where multiple children share bedrooms and other living spaces, and room for confidential treatment was not always readily available. They reported that it was crucial to make accommodations for ensuring a higher level of privacy, especially during more sensitive parts of treatment. A clinician explained, “[Patients] worry or wonder… what if someone walks by, you know, perception of privacy plays a part in that.”

Caregiver Participation

Clinicians also talked about the importance of caregiver involvement in making this treatment modality effective and confirmed that there is a strong connection between an “engaged and motivated caregiver” and maximum treatment effectiveness. Clinicians discussed that because treatment was delivered to patients in the home, it was easier for caregivers to give a mild commitment and minimally participate in treatment. Focus group participants described how caregivers would sometimes log on to sessions while in bed or while completing household tasks. Sometimes caregivers logged in from public environments (e.g., drive-thru line, grocery store), in which case visits had to be rescheduled.

Focus group results further revealed that administering CATS assessments was more difficult than in-clinic administration. Youth CATS assessments were often filled out orally during the virtual session; however, clinicians depended on caregivers to fill out assessments on their own and then send back the completed assessments. Clinicians confirmed that sometimes it took weeks to receive the assessment, or it was submitted incomplete.

Systemic Topics

Overall focus group findings aligned with current literature supporting the general effectiveness of administering TF-CBT via telehealth. Participants revealed that telehealth TF-CBT allowed for more flexibility with caregiver and patient scheduling. They also noted improvement in patient attendance at scheduled appointment times as a positive outcome of telehealth delivery. However, preliminary results revealed that the treatment retention for this sample was low. A clinician explained:

I don’t know if telehealth alone can overcome that [low retention rate]. When a kid changes placements, oftentimes we don’t have access to continue to see them. They might go to an RTC [residential treatment center] or residential living situation where they have their own provider or the foster home has a therapist they usually use.

Short notice of a patient placement change and poor communication across social services were discussed by providers as major factors in high rates of treatment incompletion. A clinician shared her experience as follows:

I feel like our timeline is really short. I get notified maybe two weeks that they are moving. There’s a lot to do with treatment summary and transition summary. I recommend they continue, but kids are also moving case workers, and [I am] not sure if my verbal instructions are getting carried over.

Focus group discussion also touched on the infeasibility for children who are admitted to RTCs or emergency shelters to virtually continue TF-CBT. A clinician explained, “I logged on and shelter workers said they were moved today. No one communicated that to me…. There are system barriers that impact our ability to continue to provide that treatment.”

Discussion

Telehealth has been found to help reduce barriers to evidence-based mental health treatments, including TF-CBT (Elbin et al., 2021; Hilty, 2013; Myers et al., 2015; Nelson et al., 2003; Orsolini et al., 2021). Less is known, however, about the feasibility and effectiveness of TF-CBT delivered via telehealth with young people involved in foster care. This retrospective review study addressed this gap by examining the delivery of telehealth TF-CBT at a clinic exclusively serving young people in care. In this study, 17 patients completed treatment, with 14 (30.4%) completing via telehealth, and three completing via a hybrid model based on clinician judgment that changing to in-person sessions from telehealth would be more appropriate to meet the patients’ clinical needs.

When focusing on effectiveness and clinical treatment outcomes, all patients who completed treatment displayed a decrease in reported PTSS, as seen by lower CATS scores from baseline to posttreatment, with 53.0% of patients no longer having clinically significant trauma symptoms upon treatment completion. This study did not include an TF-CBT comparison group, but clinical outcomes of patients in this study who completed treatment virtually were comparable to treatment outcomes found in studies of in-person TF-CBT treatment in other studies (e.g., Cohen et al., 2011; Jensen et al., 2017; Peters et al., 2021).

Present findings revealed high attrition rates despite the use of telehealth. While this modality may have increased access (based on the focus group results with providers), it was not enough to ensure successful completion of TF-CBT for most of the study’s participants. This finding contradicts the studies conducted by Stewart et al. (2017, 2020), in which low attrition rates were found (73.3% of participants in Stewart, Orengo-Aguayo, Cohen et al. [2017] and 64.7% in Stewart, Orengo-Aguayo, Young et al. [2020] completed telehealth treatment). A possible explanation for this difference may be patient setting: whereas patients in this study were participating in therapy from their homes, patients in the Stewart et al. studies received treatment while at school. The structure and routine of the school environment may have been more conducive to successfully attending and completing sessions compared to the home environment, in which caregivers may forget about appointments, have unstable Internet access, or have other priorities to which they must attend. Also, in Stewart, Orengo-Aguayo, Cohen et al. (2017), the average number of sessions was 14.13; in this study, the average was 21.8 sessions. (Stewart et al., 2020] did not include the average number of sessions completed.) The shorter timeframe may have allowed for fewer possible disruptions to treatment. Finally, it was unclear whether either of those studies included any young people in care.

Overall trauma treatment tends to have higher attrition rates, with up to three-fourths of children dropping of trauma- focused treatment, including TF-CBT (Wamser-Nanney, 2021; Gillies et al., 2013; Scheeringa et al., 2011). There are various reasons why premature termination of treatment may occur such as lack of treatment progress, patient logistical barriers, or negative perspectives of mental health treatment or clinician from caregivers (Wamser-Nanney & Steinzor, 2016). More behavioral and mental health difficulties, such as comorbid diagnoses of oppositional defiant disorder (ODD), and generalized anxiety disorder (GAD), alongside trauma symptoms are also related to higher levels of attrition (Fraynt et al., 2014; Sprang et al., 2013). Similarly, caregivers’ perceptions of their children’s trauma symptoms strongly influence treatment attendance. Caregivers often enroll their child in trauma therapy after an initial recommendation from a professional (e.g., primary care physician, psychologist), however they might not perceive this treatment as a necessity or sufficient especially if immediate behavioral change is not noticed (Wamser-Nanney & Steinzor, 2017).

When comparing treatment completion rates to non-foster care youth receiving the same treatment modality, dropout rates of young people in foster care are exponentially higher. Placement change has been associated with a disruption in healthcare continuity and utilization, especially with mental health services (Fawley-King & Snowden, 2012; Rubin et al., 2004). The primary consideration for social services in placing a child is necessary safety, and sometimes moving a child for safety reasons results in loss of such continuity. In this sample, placement changes included patients moving to a new foster home or being admitted into an RTC. Focus group participants explained that when a placement change occurs, the new caregivers may have a preferred provider and not want to continue with a current provider doing TF-CBT treatment. Similarly, RTCs often have in-house mental health providers. Thus, even though they could continue with their existing TF-CBT provider via telehealth, there are many obstacles within policy and communication that inhibit continuity of care.

Treatment length, combined with high frequency of placement change, was also a contributing factor to low retention rates in this population. Extended treatment length leads to higher probability of placement change during treatment, which increases likelihood of TF-CBT incompletion. Findings from this study suggest that the length and structure of TF-CBT may inhibit the effectiveness of TF-CBT for children in care because the majority of young people in this sample did not complete it. More research is needed in this regard. It is possible that this population could benefit from a more intensive, abbreviated TF-CBT treatment model. For younger children, it may also be necessary to adapt the treatment to have shorter telehealth sessions to accommodate patients’ attention spans. Efforts to implement and evaluate such adaptations are warranted.

Limitations

This study had several limitations. It was a retrospective study and therefore subject to missing data and possible data entry errors. The sample size was small and included patients seen at one clinic, which limits generalizability. More studies, using larger and more geographically diverse samples, are needed to gauge the effectiveness of this modality. Further, this study took place during the pandemic. It is possible that participants were experiencing higher levels of stress and anxiety (Hawes et al., 2021; Racine et al., 2021; Samji et al., 2021) during this time, which could have impacted treatment and could further limit generalizability. Finally, a comparison group was not available to include in this study. Future research should directly compare attrition rates for telehealth versus in-person treatment modalities.

Conclusion

Findings from this study suggest that telehealth TF-CBT with young people in care is feasible but barriers to treatment completion still exist. Significant declines in trauma symptoms were seen for individuals who completed treatment. The large number of young people who did not complete treatment due to placement changes, however, points to a potential need for greater emphasis on coordination and continuity of mental health treatment for young people involved in the child welfare system. Indeed, telehealth should, in theory, increase ability for providers to continue to offer services, even when a child moves. More research is needed to better understand the benefits and limitations of telehealth delivery of TF-CBT for young people in care.

Declarations

Conflict of interest

On behalf of all authors, the corresponding author states that there is no conflict of interest.