Session Preparation, Behavioral Rehearsal and Homework Assignment: Do these Therapeutic Delivery Strategies Improve Trauma Treatment Outcomes for Youth in Community Outpatient Settings?

Abstract

Several studies have demonstrated that trauma-focused cognitive-behavioral therapy (TF-CBT) is effective but many children do not complete treatment and some improve less than others, suggesting it is important to look at potential treatment moderators. Although the components of TF-CBT outline what content to cover in sessions, therapeutic delivery strategies (i.e., adjunct techniques therapists use to provide treatment content beyond the prescribed clinical components) may also contribute to outcomes. This study used administrative data from a statewide dissemination of TF-CBT to examine whether three therapeutic delivery strategies (session preparation, behavioral rehearsal and homework assignment) predicted posttraumatic stress symptom improvement and successful treatment completion. The sample included 2,499 children ages 3–17 who received TF-CBT from 448 therapists. Therapists collected data from families on demographics and posttraumatic stress symptoms, and therapists reported on treatment dosage and therapeutic delivery strategies provided to each family. Approximately 44% of children successfully completed treatment. When children or caregivers engaged in behavioral rehearsal of TF-CBT skills in more sessions, caregivers reported greater child symptom improvement and the child was more likely to successfully complete treatment. The extent that therapists prepared for sessions and discussed homework during sessions did not significantly predict outcomes. Analyses controlled for child characteristics at intake and treatment dosage. These findings suggest that therapists should plan ample opportunities for families to engage in behavioral rehearsal when implementing TF-CBT.

Trauma-focused cognitive-behavioral therapy (TF-CBT; Cohen et al., 2017) is a well-established evidence-based treatment (EBT) for children with posttraumatic stress symptoms (see Dorsey et al., 2017). TF-CBT was designed to provide children with coping skills and gradual exposure to reduce symptoms of posttraumatic stress through the provision of nine treatment components: Psychoeducation and Parenting skills, Relaxation strategies, Affective modulation, Cognitive coping skills, Trauma narration and processing, In-vivo exposure, Conjoint parent-child sessions, and Enhancing safety (PPRACTICE components; see Cohen et al., 2017, for more details). Several randomized trials have demonstrated that children with a variety of traumatic experiences who received TF-CBT improved more than children who received other types of treatments (e.g., Cohen et al., 2004; Jensen et al., 2014). However, many children do not receive the full course of treatment. Rates of trauma treatment completion vary depending on several factors, including the type of study, with lower completion rates in studies that were not randomized controlled trials (Wamser-Nanney & Walker, 2023). For example, Lang et al. (2017) found that only 34% of children who received TF-CBT in a statewide system of care successfully completed the entire treatment model. Children who completed TF-CBT displayed more symptom improvement than those who did not (Lang et al., 2017), indicating the importance of providing all the essential components of the treatment model and client retention in services.

Although children who receive TF-CBT experience a reduction in symptoms, on average, there is variability in the extent of improvement (e.g., Knutsen et al., 2020), so researchers have examined predictors of symptom severity. Most of these studies have focused on child and family characteristics and therapist demographics, theoretical orientation, or clinical experience (e.g., Kane et al., 2016; Knutsen et al., 2020; Last et al., 2019; Lenz & Holllenbaugh, 2015; Pfeiffer et al., 2020). Research on predictors of TF-CBT outcomes have typically examined symptom improvement and there is limited research on predictors of treatment completion; when treatment completion has been examined, primarily only child and family characteristics have been considered (Wamser-Nanny & Walker, 2023).

While it is important to be aware of pre-treatment characteristics of the child, family, and therapist that may predict outcomes, most of these characteristics cannot be changed. A few studies have examined whether treatment dosage moderates outcomes but findings are inconsistent. Although longer treatment length or greater number of sessions was associated with greater improvement in a few studies (e.g., Deblinger et al., 2011; Trask et al., 2011), it was not a significant predictor of outcomes in other studies (e.g., Morina et al., 2016; Yohannan et al., 2022). Besides session attendance, treatment dosage also refers to the amount of a specific treatment model that the client received. The involvement of a caregiver is central to the TF-CBT model, but prior research is mixed as to whether caregiver involvement optimizes outcomes (Dorsey et al., 2017; Morina et al., 2016; Trask et al., 2011; Yohannan et al., 2022). It is possible that adherence to the clinical components of the treatment model may impact outcomes. Studies of TF-CBT have often measured treatment fidelity using ratings of which PPRACTICE components were provided in session, such as the TF-CBT Brief Practice Checklist provided with the treatment manual (Deblinger et al., 2014). In one study of a statewide dissemination of TF-CBT, Amaya-Jackson et al. (2018) found that greater treatment fidelity predicted greater reduction in child-rated posttraumatic stress symptoms but treatment fidelity did not significantly predict other outcomes in the study such as child depression, externalizing behaviors, and parent-rated change in child posttraumatic stress.

It is important to distinguish therapy content (i.e., what clinical components are provided in treatment) from therapeutic delivery strategies (i.e., how the content is provided to the client; Cox et al., 2020; Garland et al., 2010; Kaminski et al., 2008). For TF-CBT, the content of therapy consists of the PPRACTICE components, whereas therapeutic delivery strategies are the techniques that therapists use in providing the treatment components, such as modeling new skills to the client and providing opportunities for the client to practice skills in session. These therapeutic delivery strategies can be applied to the provision of cognitive-behavioral therapy (CBT) in general, for various clinical concerns. So far, research has examined therapeutic delivery strategies in community settings for children receiving CBT for anxiety (Cox et al., 2020) and usual care for disruptive behavior problems (Garland et al., 2010). In a meta-analytic review of practices included in various parent training programs for behavior problems in young children, Kaminski and colleagues (2008) found that in addition to program content such as fostering positive parent-child interactions and teaching parents to use time-out, treatment programs that required parents to practice skills with their child in session demonstrated larger improvements in parenting behaviors and child externalizing symptoms. However, research has not explored the strategies therapists use to deliver TF-CBT and whether these therapeutic delivery strategies are associated with outcomes. The TF-CBT model emphasizes the acquisition of skills for children to cope with symptoms of posttraumatic stress and the application of their learned skills in gradual exposure throughout treatment (Cohen et al., 2017). Therefore, the TF-CBT developers advise therapists to utilize a few key strategies in delivering TF-CBT (Cohen et al., 2017): preparing for each session in advance, encouraging the client to practice skills in session (behavioral rehearsal), and assigning and reviewing homework with the client.

Session preparation may include reviewing the treatment plan and prior session notes, referencing the treatment manual, examining results of emotional and behavioral measures, preparing materials, and planning the agenda and content of the session. TF-CBT is a manualized treatment with several components that can be implemented flexibly depending on the family’s needs and gradual exposure is at the core of the TF-CBT model (Cohen et al., 2017). Therefore, therapists should plan each session to cover the PPRACTICE components and increase exposure to trauma reminders as treatment progresses (Cohen et al., 2012). The treatment manual indicates that therapists should set an agenda for each session, which can have major benefits for children who have experienced trauma and their families (Cohen et al., 2017). Traumatic experiences can be disruptive and unpredictable for children and their families and structured therapy sessions can be helpful in providing a sense of security and predictability so that children become familiar with the typical layout of sessions (for example, starting each session with a symptom check-in, followed by homework review, then working on the planned PPRACTICE component). Session preparation can also help keep treatment on track when crises of the week (COWs) arise; a specified session plan allows therapists to incorporate the COW into the planned content, review previously learned skills to cope with the COW, or redirect the client back to the planned agenda (Cohen et al., 2017).

Skill practice, also referred to as behavioral rehearsal, is a key cognitive-behavioral therapeutic technique that is best applied with the support of the therapist in session at first and then outside of sessions. Learning and generalizing behavioral skills is especially important for children suffering traumatic stress, who may experience reminders or distress in various settings. In contrast to simply telling clients what they should do, showing them what they should do, or asking them to practice skills outside the session, behavioral rehearsal is a form of active delivery in which the therapist encourages the client to try out new skills in the session (Cox et al., 2020). Similar to the importance of practice in sports, the therapist as a coach facilitates practice in sessions to support the development of the client’s coping skills and ability to challenge maladaptive cognitions, emotions, and behaviors (Kendall, 2012). Since TF-CBT is a skills-based treatment, it is imperative that children and parents rehearse new skills in session so that they can use them in their daily lives. In fact, the TF-CBT developers indicate that the PPRACTICE acronym for components of the treatment model also conveys that skills should be practiced throughout treatment, during sessions, and between sessions (Cohen et al., 2017). For example, one way to practice skills is through role play and Cohen et al. (2017) provide examples of caregiver sessions in the TF-CBT treatment manual with the therapist acting in the role of the child while the caregiver practices parent management skills such as praise or selective attention. Skill practice is essential to developing self-efficacy, which is a core value of TF-CBT (Cohen et al., 2017), so that children and families can use their skills outside the therapy sessions in the range of settings where children may experience trauma reminders and traumatic stress symptoms.

In addition to practicing skills in session, the TF-CBT model emphasizes homework assignments to practice skills outside of session. Homework is commonly implemented in many EBTs for children (e.g., Garland et al., 2008; Nangle et al., 2016) and can provide opportunities for the client to generalize therapy skills to real life situations (Garland et al., 2010a; Hudson & Kendall, 2002). Homework may be especially important in exposure-based treatments such as TF-CBT, creating opportunities for the child to practice new coping skills in situations where the child may experience symptoms of posttraumatic stress. For children who have experienced trauma, there may be day-to-day reminders that evoke emotional and behavioral reactions and homework assignments should be scaffolded so that children can apply skills from structured in-session behavioral rehearsal to the actual circumstances they experience distress or impairments in functioning. Particularly in the early phases of TF-CBT, sessions with the caregiver usually do not include the child, so homework should be assigned for the caregiver to practice parenting skills that they learn in sessions with their child outside of sessions to support their child’s coping skill development. Past research has primarily focused on client completion or compliance with homework, without regard to the therapist’s influence in how they assign and review homework in session with the client, which contributes to homework completion (Kazantzis & L’Abate, 2007). To increase the likelihood families will complete homework, therapists should work collaboratively with the child or caregiver to design the homework assignment during the session (for example, eliciting the child’s input to determine what settings they will practice a skill or how they will record emotion ratings; see Friedberg & McClure, 2015). When therapists assign and review homework in sessions, it reinforces the importance of practice outside of sessions and contributes to continuity in skill development between sessions (Friedberg & McClure, 2015; Garland et al., 2010a; Hudson & Kendall, 2002). When reviewing homework, the therapist can also check the child or caregiver’s developing competence in using skills without the support of the therapist outside of sessions and determine whether additional practice or remediation is needed (Hudson & Kendall, 2002).

There is limited research on therapeutic delivery strategies for child trauma treatment. Although studies have not examined the importance of practicing skills in TF-CBT therapy sessions, a few studies have examined overlapping constructs of child or caregiver involvement, adherence, or participation in other types of cognitive and behavioral therapies. There are slight variations in the definitions of these constructs, but they are typically conceptualized as the client actively engaging in therapy activities, which includes practicing skills in session and completing homework amongst other characteristics such as openness to therapy, asking questions, or self-disclosure (Chu & Kendall, 2004; Nix et al., 2009; Nock & Ferriter, 2005). In these studies, greater child or caregiver involvement or participation were associated with greater symptom improvement posttreatment (Chu & Kendall, 2004; Garvey et al., 2006). Homework is commonly included in many EBT manuals and is associated with positive treatment outcomes in a meta-analysis of studies with primarily adult populations (Kazantzis et al., 2016) but results are less clear for child populations (e.g., Hughes & Kendall, 2007; Lee et al., 2019; Simons et al., 2012). Studies on client participation in session and homework completion have been examined in the treatment of child anxiety, depression, or disruptive behaviors, but prior research has not looked at how practicing skills may be related to outcomes for children who received TF-CBT. Although it seems important for therapists to prepare for therapy sessions with a session agenda and plan of which component and level of exposure to focus on, there is little research on whether session preparation is associated with outcomes. When therapists display greater treatment fidelity, children may be more likely to improve from TF-CBT (Amaya-Jackson et al., 2018), so children should benefit more when therapists prepare sessions to align with the treatment model; however, additional research is needed.

Overall, few studies have examined therapeutic delivery strategies and the impact on treatment outcomes. The TF-CBT manual and guidelines for implementing CBT recommend that therapists prepare for sessions, encourage client skill practice during sessions, and assign and review homework, but there is no prior research on therapeutic delivery strategies as predictors of TF-CBT outcomes. In the current study, the first research question examined whether these therapeutic delivery strategies predicted change in posttraumatic stress symptoms and the second research question looked at whether these therapeutic delivery strategies predicted successful treatment completion for children who received TF-CBT in community outpatient settings. We hypothesized that greater use of all three therapeutic delivery strategies would be associated with greater reduction in posttraumatic stress symptoms and successful treatment completion.

Method

Statewide Dissemination of TF-CBT

This study was conducted retrospectively using archived data collected from therapists who provided TF-CBT as part of a statewide dissemination of EBTs. Across Connecticut, several therapists have been trained in TF-CBT since 2007 (Lang et al., 2015) and this EBT has been sustained through a statewide Dissemination and Support Center (DSC) model (citation omitted), which includes considerable implementation supports such as data collection/reporting, agency-based implementation consultation, therapist credentialing, and performance-based sustainability funding incentives for agencies. Therapists received training and clinical consultation from national TF-CBT trainers, and some have become certified TF-CBT therapists. Each therapist collected demographics, clinical characteristics, and measures from children and families as part of the intake evaluation and periodically during treatment, and entered the data into a secure online database for quality improvement purposes. This study was conducted retrospectively from data obtained for administrative purposes. We consulted with the IRB of Eastern Connecticut State University who determined that our study did not qualify as human subjects research because it used de-identified archived administrative data.

Participants

Participants were 2,499 children ages 3–17 who received TF-CBT from 448 therapists at 44 clinics/practice settings trained as part of the statewide dissemination of TF-CBT and were discharged between 2015 and 2019 with at least two completed assessments of symptom ratings. Children were, on average, 11.52 years old (SD = 3.57) at the time of intake. There were slightly more females (59.1%) and the sample was racially and ethnically diverse (37.7% Hispanic, 42.9% non-Hispanic White, 14.8% non-Hispanic Black, 4.6% other/multiracial). The most commonly reported trauma exposure included death of someone they knew (76.6%), witnessing violence (71.1%), and unexpected separation from a caretaker for several days (65.0%), and many children experienced multiple types of trauma (M(SD) = 7.21(3.32)).

Measures

Child Demographics and Session Information

Child age, sex, and race/ethnicity were collected as part of the clinical intake evaluation. Therapists filled out a monthly session form for each month of a child’s treatment episode, which included questions about the number of visits the child and/or caregiver attended that month, the percentage of sessions spent with the caregiver, and which PPRACTICE components were provided (yes/no) that month. For each child, the number of visits were summed across the months the child was in treatment to obtain a total number of visits attended by the child and/or caregiver during the treatment episode. The proportion of sessions the caregiver attended during the treatment episode was aggregated across months and the number of TF-CBT components provided was determined by the therapist indicating use of each of the nine PPRACTICE components at least once during the treatment episode.

Therapeutic Delivery Strategies

Therapists responded to three questions on the monthly session form about their use of three therapeutic delivery strategies for each child to whom they provided TF-CBT. Using a 5-point Likert scale ranging from 0 to 4 (“None (0%)” [0], “A few (1–33%)” [1], “Some (34–66%)” [2], “Most (67–99%)” [3], “All (100%)” [4]), therapists rated how many sessions in that month they prepared materials or a session plan before the session, assigned or reviewed homework during the session, and whether the child and/or caregiver practiced/demonstrated skill(s) in session (behavioral rehearsal). For each child, the ratings for each type of therapeutic delivery strategy were averaged over all completed monthly session forms to create a mean session preparation score, mean homework assignment/review score, and mean behavioral rehearsal score to capture the average frequency with which they used each strategy over the course of the treatment episode.

Posttraumatic Stress Symptoms

Children and caretakers independently completed the Child PTSD Symptom Scale (CPSS; Foa et al., 2001) at intake and approximately every three months during treatment. The CPSS included 17 items covering symptoms of posttraumatic stress from the DSM-IV criteria for PTSD (e.g., “trying not to think about, talk about, or have feelings about the event,” “having bad dreams or nightmares,” “being jumpy or easily startled”). Each item was rated on a 4-point Likert scale ranging from 0 = Not at all to 3 = 5 or more times a week/almost always. The total score was calculated as the sum of the 17 items (α = 0.86 – 0.87 in this sample at intake), with a possible range of 0–51. Higher scores signify greater posttraumatic stress symptoms. The CPSS total score has demonstrated good test-retest reliability and convergent validity (Foa et al., 2001). The change score was calculated as the difference between the last available score and first available score. Negative change scores indicate reduction in posttraumatic stress symptoms during treatment, with more negative numbers indicating greater reduction (i.e., more improvement).

Treatment Completion

Successful completion of treatment was defined by use of required TF-CBT components for each child and therapist reports of reason for discharge. TF-CBT consists of nine treatment components (PPRACTICE components; see Cohen et al., 2017, for more details). Although gradual exposure is central to the TF-CBT model and infused throughout treatment, the treatment component of in-vivo exposure is not necessary in every case and is recommended as needed (Cohen et al., 2017). The involvement of a caregiver is emphasized in TF-CBT and most children in this sample (93.5%) had a caregiver (biological parent, grandparent, foster or adoptive parent, etc.) in attendance for at least 10% of sessions. Although parenting skills with caregivers in sessions and conjoint parent-child sessions are typically indicated in the treatment model, TF-CBT was still provided even if a caregiver was not able to attend sessions to complete these treatment components.

At discharge, therapists reported the reason each case was closed from a list of 11 possible options (e.g., “Successfully completed selected evidence-based practice model requirements”, “Family discontinued treatment”, “Referred to a higher level of care”, etc.) We categorized children as successfully completed treatment if (1) they completed all eight essential components of TF-CBT (PPRACTCE; in-vivo exposure optional) if a caregiver attended at least 10% of sessions or six components of TF-CBT (PRACTE; parenting skills and conjoint sessions not required) if a caregiver was in attendance less than 10% of sessions; and (2) the therapist reported the child successfully completed treatment at discharge.

Data Analysis Plan

We conducted multilevel modeling with children nested within therapists nested within clinics/practice settings (three-level models) using SAS 9.4. We started with unconditional models to calculate the intraclass correlation (ICC) in order to estimate the proportion of variance of each outcome accounted for by different levels in the model. Then, predictor variables were added to the model in a stepwise manner, starting with intake child characteristics (age, sex, race/ethnicity, posttraumatic stress symptom severity at intake), followed by treatment dosage (number of sessions, proportion of caregiver attendance in sessions), and then therapeutic delivery strategies (session preparation, behavioral rehearsal, homework assignment or review). We added control variables and therapeutic delivery strategies as level one fixed effects because these predictors vary by child, which was level one in the model. Continuous predictor variables were grand mean centered. For the first research question examining therapeutic delivery strategies and change in posttraumatic stress symptoms, we conducted multilevel modeling using PROC MIXED (Singer, 1998). Analyses were conducted separately for caregiver-rated and child-rated symptom severity, and controlled for the number of treatment (PPRACTICE) components provided during the episode in addition to the covariates mentioned previously. For the second research question examining therapeutic delivery strategies and successful treatment completion, we conducted multilevel modeling using PROC GLIMMIX since the outcome variable was binary (Ene et al., 2015). The number of treatments components was not included as a covariate in this model because these components were part of the definition of the outcome variable (successful treatment completion).

Results

Descriptive Statistics

Means, standard deviations, and correlations of child clinical characteristics, treatment dosage, and therapeutic delivery strategies are provided in Table 1. On average, the sample had clinically elevated posttraumatic stress symptoms at intake and symptoms improved over the course of treatment. Therapists provided an average of 6.76 (SD = 2.06) PPRACTICE components. Just under half the sample (43.7%) successfully completed treatment. On average, therapists reported they prepared for most (67–99%) sessions, and therapists assigned/reviewed homework and had the child practice skills during some (34–66%) sessions. Use of the three types of therapeutic delivery strategies were highly correlated with each other (r = .50 – 0.74).

Table 1.

Descriptives and correlations of child clinical characteristics, treatment dosage, and therapist delivery strategies

	Descriptives	Bivariate correlations
Variable	M(SD)	1.	2.	3.	4.	5.	6.	7.
1. Caregiver-rated CPSS at intake	18.20(10.47)	--
2. Child-rated CPSS at intake	20.57(10.72)	0.33***	--
3. Number of visits	23.62(12.19)	0.08***	0.06**	--
4. Proportion of caregiver attendance	0.42(0.20)	0.01	− 0.16***	− 0.04	--
5. Number of TF-CBT components provided	6.76(2.06)	0.00	0.01	0.43***	0.06**	--
6. Session preparation	3.28(0.92)	0.03	0.03	0.01	0.06**	0.12***	--
7. Behavioral rehearsal	2.24(1.11)	0.02	0.06**	0.10***	0.11***	0.33***	0.50***	--
8. Homework assigned/reviewed	2.24(1.19)	0.04*	0.08***	0.03	0.07***	0.25***	0.52***	0.74***

Note. CPSS = Child PTSD Symptom Scale. TF-CBT = trauma-focused cognitive-behavioral therapy

* p < .05. **p < .01. ***p < .001

Therapeutic Delivery Strategies and Change in Posttraumatic Stress Symptoms

The ICC_therapist was 0.11 for caregiver-rated change in posttraumatic stress symptoms and 0.09 for child-rated change in posttraumatic stress symptoms, indicating that 9–11% of the variation in child posttraumatic stress symptom change was accounted for by the therapist. It is important to note that therapeutic delivery strategies varied for the multiple children that therapists served, which was not captured by the ICC_therapist. The ICC_clinic was 0.02 for caregiver-rated change in posttraumatic stress symptoms and 0.01 for child-rated change in posttraumatic stress symptoms, indicating that 1–2% of the variation in child posttraumatic stress symptom change was accounted for by clinic. Thus, most of the variation in posttraumatic stress symptom change was between children (87–90%).

On average, children’s posttraumatic stress symptoms improved during treatment (M_{caregiver−rated} = -7.76, M_{child−rated} = -9.02), based on the unconditional model without any predictors. Child characteristics, treatment dosage, and therapeutic delivery strategies were included in the model to examine predictors of child posttraumatic stress symptom change (see Table 2). Greater severity of posttraumatic stress symptoms at intake significantly predicted greater reductions in posttraumatic stress symptoms; for each one-point increase in the child’s CPSS intake score, there was a greater improvement in the caregiver-rated CPSS change score by 0.64 points and child-rated CPSS change score by 0.60 points, controlling for the other variables in the model. When clinicians provided more PPRACTICE components, both caregivers and children reported a greater reduction in the child’s posttraumatic stress symptom severity; for each additional PPRACTICE component the clinician provided, there was greater improvement in CPSS by 1.07 points based on caregiver ratings and 1.42 points based on child ratings. Greater number of sessions attended significantly predicted less improvement in caregiver ratings of child symptom severity but not child ratings of symptom severity; for each additional session attended, there was less improvement in CPSS by 0.04 points. The proportion of caregiver attendance was not a significant predictor. In terms of therapeutic delivery strategies, only behavioral rehearsal was significant in predicting greater improvement in caregiver-rated posttraumatic stress symptoms; for each one-point increase on the Likert rating scale that the clinician reported the child and/or caregiver practiced skills during more sessions, there was a greater improvement in caregiver-rated CPSS change score by 0.57 points.

Table 2.

Multilevel models predicting change in trauma symptom severity

	Caregiver-rated CPSS Change		Child-rated CPSS Change
	B	SE	B	SE
Intercept	-7.36***	0.41	-8.03***	0.37
Age	- 0.01	0.05	0.13*	0.06
Sex (male)	- 0.08	0.36	-1.25**	0.37
Hispanic	- 0.54	0.41	-1.12*	0.41
Non-Hispanic Black	- 0.89	0.57	-1.29*	0.55
Other Race	-1.00	0.86	1.50	0.85
CPSS overall severity intake	- 0.64***	0.02	- 0.60***	0.02
Number of visits	0.04*	0.02	0.01	0.02
Proportion of caregiver attendance	0.67	1.09	-1.07	1.00
Number of TF-CBT components provided	-1.07***	0.11	-1.42***	0.11
Session preparation	0.15	0.28	- 0.07	0.27
Behavioral rehearsal	- 0.57*	0.29	- 0.21	0.28
Homework assigned/reviewed	0.04	0.27	0.27	0.26

Note. CPSS = Child PTSD Symptom Scale. TF-CBT = trauma-focused cognitive-behavioral therapy

* p < .05. **p < .01. ***p < .001

Interestingly, child demographics significantly predicted child-rated change in posttraumatic stress symptoms but not caregiver-rated child symptoms. Younger children reported more improvement than older children and male children reported more improvement in posttraumatic stress symptoms than females, controlling for the other variables in the model. Hispanic children and non-Hispanic Black children had significantly greater improvement in posttraumatic stress symptoms compared to non-Hispanic White children, controlling for the other variables in the model. None of the therapeutic delivery strategies predicted child-rated posttraumatic stress symptom change when accounting for child demographics and treatment dosage.

Therapeutic Delivery Strategies and Successful Treatment Completion

The ICC_therapist was 0.15 and the ICC_clinic was 0.02, indicating that 15% of the variation in the likelihood of successful treatment completion was accounted for by the therapist and 2% by the clinic. Similar to posttraumatic stress symptom change, most of the variation in successful treatment completion was between children (83%). Child characteristics, treatment dosage, and therapeutic delivery strategies were included in the model to examine predictors of successful treatment completion (see Table 3). Child demographics did not significantly predict treatment completion but greater posttraumatic stress symptoms at intake predicted lower likelihood of completing treatment successfully (OR = 0.97). A greater number of sessions attended significantly predicted greater likelihood of completing treatment successfully (OR = 0.09) and the proportion of caregiver attendance did not. As with caregiver ratings of child posttraumatic stress symptom change, behavioral rehearsal was the only significant therapeutic delivery strategy; when the child and/or caregiver practiced skills during more sessions, there was a greater likelihood of successfully completing treatment (OR = 1.84).

Table 3.

Multilevel models predicting change in treatment completion

	Completed Treatment Successfully
	B	SE
Intercept	- 0.48**	0.15
Age	- 0.02	0.02
Sex (male)	0.21	0.11
Hispanic	- 0.01	0.13
Non-Hispanic Black	- 0.22	0.18
Other Race	- 0.23	0.26
CPSS overall severity intake	- 0.03***	0.01
Number of visits	0.09***	0.01
Proportion of caregiver attendance	0.42	0.32
Session preparation	0.12	0.09
Behavioral rehearsal	0.61***	0.09
Homework assigned/reviewed	- 0.15	0.09

Note. CPSS = Child PTSD Symptom Scale

* p < .05. **p < .01. ***p < .001

Discussion

Several studies have documented the effectiveness of TF-CBT for reducing child posttraumatic stress symptoms (see Dorsey et al., 2017), but many children do not receive the full course of treatment (Wamser-Nanney & Walker, 2023) and there is variability in the extent of improvement from treatment (Knutsen et al., 2020). Therefore, it is necessary to understand what factors contribute to treatment completion and symptom improvement. In providing TF-CBT, in addition to the core PPRACTICE model components, clinicians are encouraged to prepare for each session, facilitate opportunities for the child and caregiver to practice skills in session, and assign and review homework with the family. This study examined whether these three therapeutic delivery strategies predicted treatment outcomes for children who received TF-CBT in a statewide outpatient system of care. Child or caregiver behavioral rehearsal in session significantly predicted caregiver-rated symptom improvement and treatment completion, whereas therapist session preparation and discussion of homework in session did not, controlling for child demographics, pre-treatment symptom severity, and treatment dosage.

Since TF-CBT is a skills-based treatment, practice is essential for the child and caregiver to learn how to cope with symptoms of posttraumatic stress (Cohen et al., 2017). In CBT generally, it is recommended that therapists act as coaches who facilitate practice in session so that clients can develop their coping skills with the support of the therapist before using skills in their daily lives (Kendall, 2012). Prior research has found an association between symptom improvement and the broader construct of client involvement or participation in treatment for anxiety and disruptive behaviors (Chu & Kendall, 2004; Garvey et al., 2006). The current study is the first to focus on child or caregiver behavioral rehearsal during TF-CBT, which was positively associated with symptom improvement and treatment completion. When children and caregivers practice adaptive cognitive-behavioral skills in session, they develop the ability to challenge maladaptive thoughts, feelings, and behaviors, which can result in reduced symptoms of posttraumatic stress.

In this study, behavioral rehearsal significantly predicted caregiver ratings but not child ratings of posttraumatic stress symptom change. Interestingly, several child demographic characteristics significantly predicted child-rated symptom change but not caregiver-rated symptom change, and it may be that demographics have stronger associations with child perceptions of their symptoms. Prior studies have reported mixed findings on demographic predictors of posttraumatic stress symptoms, which may be due in part to who is rating symptoms and further research should explore these differential results. There may be other characteristics of the child that could impact their abilities to engage in treatment and ratings of symptoms. For example, the child’s ability to remember and use cognitive-behavioral skills taught in session could be dependent on the child’s level of executive functioning, which was not measured in the current study. Furthermore, exposure to traumatic events could impact a child’s executive functioning abilities (e.g., Malarbi et al., 2017) and there is recent research on the potential for TF-CBT to improve executive functioning, which may be associated with decreased posttraumatic stress symptoms (Lee & Brown, 2022). Additional research is necessary on the interplay between trauma experience, child cognitive impairments, and clinician use of therapeutic delivery strategies in trauma treatment. Evaluation of executive functioning was not part of the typical assessment practice in the community outpatient clinics in the current study but is an important child capacity that should be measured in clinical care to determine what adaptations are needed in implementing behavioral rehearsal in session and assigning homework.

Greater child or caregiver behavioral rehearsal also predicted greater likelihood of completing treatment. Many children who have experienced trauma display avoidance symptoms, and caregivers may as well (Yasinski et al., 2018). Gradual exposure is infused throughout TF-CBT and families may drop out to avoid exposure in therapy, which can be anxiety-inducing, and two studies have found that child and caregiver avoidance behaviors during trauma treatment increase the risk of dropout (Chasson et al., 2008; Yasinski et al., 2018). When children and caregivers engage in behavioral rehearsal, it may allow them to develop skills and self-efficacy to cope with gradual exposure during treatment and may therefore reduce the likelihood of dropping out of treatment to avoid exposure. The decision to remain in treatment is usually made by the caregiver, rather than the child, so it may be especially important that caregivers perceive that therapy is worthwhile and children’s ratings of whether their caregivers approve of treatment is associated with dropout from TF-CBT (Ormhaug & Jensen, 2018). Compared to other session activities, skill-building may be more salient to caregivers that they are learning something in therapy and may motivate continuation with treatment.

Although practicing skills in session significantly predicted treatment completion and caregiver ratings of posttraumatic stress symptom change, there were nonsignificant findings for therapists assigning and reviewing homework to practice skills outside of sessions. Most previous studies examined whether clients completed homework for other types of EBTs and findings are inconclusive on whether homework completion is associated with child outcomes (e.g., Hughes & Kendall, 2007; Lee et al., 2019; Simons et al., 2012). In this study, we looked at the therapeutic delivery strategy of assigning and reviewing homework in session, which has rarely been examined in prior research (Kazantzis & L’Abate, 2007). Although discussing homework in session should increase the likelihood that clients would complete the assignment (Friedberg & McClure, 2015; Hudson & Kendall, 2002), research is needed to determine whether assigning and reviewing homework in session is associated with homework completion. Also, therapists reported whether they assigned or reviewed homework as one variable in this dataset, but it is possible that there is a distinction between assigning homework and reviewing whether the client completed the assigned homework in the following session. It may be that some therapists assign homework for the client to practice outside of session but do not follow-up in the next session to discuss whether the client completed the homework, problem-solve barriers, and reinforce skill practice outside of session, and future research should explore the impact of assigning and reviewing homework as separate variables. Moreover, how the therapist assigns or reviews homework may matter for treatment outcomes and future research should explore whether therapists are merely handing children a worksheet to complete out of session or if therapists spend time in session connecting the homework to treatment goals, demonstrating the homework task, checking for comprehension of the assignment, or following up to check in about homework completion in the next session and processing the out of session activity. It is worth noting that assigning homework did not predict dropout in this study, which counters one common concern about the use of homework in therapy. Many therapists reported hesitation in assigning homework because of concerns that families may be too overwhelmed with the additional stress of completing homework and that directive therapeutic strategies such as assigning homework would negatively impact the therapeutic relationship (Garland et al., 2010). Some children may be resistant to homework in therapy given common negative attitudes about academic homework (Hudson & Kendall, 2002). Although assigning and reviewing homework did not predict better treatment outcomes in this study, it also did not predict worse outcomes.

Preparing for sessions would appear important to ensure a review of the child’s previous sessions and symptoms as well as preparing for the next session, but it did not significantly predict outcomes in this study. There is no prior research on the impact of session preparation and this construct could include a range of possible activities, such as reviewing session notes, referencing the treatment manual, examining results of emotional and behavioral measures, preparing materials, planning the agenda and content of the session. It is unclear from the current study if certain preparation activities may be beneficial in comparison to other activities. There is emerging research (Last et al., 2024) on the ways in which therapists typically prepare for sessions, if at all, and additional research is needed on whether different preparation activities predict treatment outcomes. Although the amount of session preparation was not significantly related to outcomes in this study, there is prior research on the importance of clinician fidelity to TF-CBT and reduced posttraumatic stress symptoms (Amaya-Jackson et al., 2018). Session preparation may be needed particularly for clinicians who are new to TF-CBT so that they appropriately review the treatment manual and prepare to implement the treatment with fidelity. In the current study, therapists reported that they prepared for most sessions (on average, over two-thirds of sessions), which may have limited variability to detect effects.

On the other hand, therapists in this sample reported that they assigned or reviewed homework in about half of sessions, and children or caregivers practiced skills in about half of sessions. Lower rates of homework assignment and client skill practice have been reported in usual care. For example, in a study examining treatment practices for children with disruptive behaviors, Garland, Brookman-Frazee, Hurlburt, and colleagues (2010) found that assigning or reviewing homework was observed in 16% of child sessions and 13% of caregiver sessions. In terms of role play or practice, children engaged in 35% of sessions whereas caregivers rarely did (8% of sessions; Garland et al., 2010). Since the TF-CBT model emphasizes practice throughout treatment and exposure to trauma reminders are gradually incorporated into sessions, it is recommended that therapists include more opportunities for behavioral rehearsal as children and caregivers are learning new skills and applying the skills to coping with exposure to trauma reminders.

In this study, we examined the role of therapeutic delivery strategies after controlling for child characteristics at intake and treatment dosage. Several prior studies have examined child demographic characteristics with divergent findings (e.g., Kane et al., 2016; Knutsen et al., 2020; Last et al., 2019; Lenz & Holllenbaugh, 2015) and our study results varied depending on the outcome. Child age, gender, and race/ethnicity were not associated with caregiver ratings of posttraumatic stress symptom change nor treatment completion. However, younger children and male children reported greater improvement in posttraumatic stress symptoms. Additionally, Hispanic and non-Hispanic Black children reported significantly greater improvement in symptoms than non-Hispanic White children. Given that research on EBTs often include less diverse youth than the clientele in community mental health clinics, some clinicians have raised concerns about the applicability of EBTs with diverse youth (Southam-Gerow et al., 2012). It appears that EBTs such as TF-CBT may be particularly helpful from the perspective of racial/ethnic minority children. For both caregiver- and child-rated symptoms, greater posttraumatic stress severity at intake significantly predicted greater symptom improvement, which may be explained in part by regression to the mean with higher intake symptom severity allowing for more room for symptom change. However, greater intake severity was associated with a lower likelihood of completing treatment, which may be due to co-occurring stressors (e.g., greater additional crises, parental distress) that may hinder successful treatment implementation (Chorpita et al., 2014; Morris et al., 2012). When children received more of the PPRACTICE components that make up the TF-CBT model, they improved more, which supports the importance of engaging clients in completing treatment.

Although the involvement of a caregiver is central to the TF-CBT model, the proportion of sessions the caregiver attended was not associated with outcomes in this study. Prior research is mixed regarding the impact of caregiver involvement in TF-CBT (e.g., Morina et al., 2016; Trask et al., 2011; Yohannan et al., 2022); studies have found that children improved even when they received TF-CBT without caregiver involvement (Cohen et al., 2016; Deblinger et al., 1996) and CBT without caregiver involvement is considered a well-established treatment for child posttraumatic stress (Dorsey et al., 2017). In the current study, we measured caregiver attendance and it may be that treatment outcomes are enhanced based on the extent of the caregiver’s active participation in therapy (and not just attendance), which should be explored in future studies. The amount and impact of caregiver involvement may also depend on child characteristics, such as age and type of symptoms. For instance, greater caregiver involvement may be important for younger children who need support managing safety or using their newly learned skills outside of sessions. There is extensive evidence for the use of parent management strategies to address children’s disruptive behavior problems (e.g., Kaminski & Claussen, 2017), so greater caregiver attendance in sessions focused on effective parenting practices would be necessary for children who display these difficulties related to trauma exposure. Research is needed on how much caregivers should be involved in TF-CBT for best outcomes, for whom, and under what circumstances.

Some limitations of this study were noted previously and there are additional limitations. This naturalistic study used an administrative dataset, which limited the types of variables included. Although analyses controlled for some pre-treatment characteristics of the child, data were not available on other possible variables that may contribute to treatment outcomes such as the quality of the therapeutic relationship, client avoidance behaviors, or timing of the traumatic event. For example, a few studies have found that the therapeutic relationship, child avoidance, and caregiver avoidance predicted post-treatment symptom severity and dropout from TF-CBT (e.g., Ormhaug et al., 2014; Yasinski et al., 2018), and these variables could impact the use of therapeutic delivery strategies. When there is a stronger therapeutic alliance and less avoidance from the child or caregiver, therapists may be more likely to use behavioral rehearsal or discuss homework in session, and future research should explore the relations amongst these variables in predicting treatment outcomes. There are also other therapeutic delivery strategies that were not assessed in the current study, such as the therapist using collaborative teaching techniques, modeling behaviors in session, or using positive reinforcement, which should be explored in future studies. Another limitation was that clinicians reported the extent that the therapeutic delivery strategies were implemented on a monthly basis and there was no independent verification of the extent of therapeutic delivery strategy used in sessions. Also, the rating of therapeutic delivery strategies was averaged across all months the child was in treatment, which did not account for fluctuation in the use of therapeutic delivery strategies throughout the duration of treatment. However, Cox et al. (2020) suggested measuring therapeutic delivery strategies across the treatment episode for a child, rather than each session, because therapeutic delivery strategies can be used for many treatment components throughout the episode of care. The three therapeutic delivery strategies in this study were highly correlated (r = .50 – 0.74), which may explain why session preparation and homework assignment were not significant predictors in addition to behavioral rehearsal in the same analytic model; although collinearity statistics (tolerance > 0.4 and variance inflation factor < 3) indicated minimal concern of multicollinearity. The current study did not include data on how clinicians determined whether to use each therapeutic delivery strategy, and future research should collect qualitative data from therapists on their reasons for using therapeutic delivery strategies as well as barriers. Qualitative studies on client perspectives of therapeutic strategies and involvement in therapy would also inform practices that take into account client preferences in treatment. Our study included families who did not complete treatment but the study sample was limited to children with at least two assessments of symptom ratings, so findings may not apply to children with incomplete assessment data such as those who drop out of treatment after only a few sessions. Although we examined predictors of treatment completion, results of this study may not generalize to early dropouts since they were not included. It is possible that therapeutic delivery strategies are especially important for these families; if therapists are more prepared and incorporate behavioral rehearsal into early sessions, children and caregivers may be able to start building skills that promote self-efficacy in coping with traumatic stress and may perceive therapy as beneficial with structured skill-building sessions to continue attending. Conversely, some families may find that homework assignment in the first couple sessions to be overwhelming and may disengage with treatment perceived as too demanding. More research is needed on families who terminate treatment after a few sessions and predictors of early dropout. Another limitation is that assessments were scheduled approximately every three months so the second assessment may not have been completed at the same time families discontinued treatment and therefore may not capture symptom change over the entire treatment period. Although a strength of this study was the use of data from a statewide dissemination of TF-CBT in outpatient settings that included diverse youth, the findings may not generalize to other settings or levels of care.

Although research has established what types of treatments are effective for children with posttraumatic stress symptoms, few studies have examined how therapists deliver EBTs may impact child outcomes. Practice is essential to the TF-CBT model and therapists should plan sessions to provide regular opportunities for children and caregivers to rehearse cognitive-behavioral skills to reduce maladaptive symptoms. Therapists may teach a new skill and model it, but clients should be actively involved in using the skill themselves, first in session with the support of the therapist and then through gradual exposure activities during and between sessions. For example, when introducing relaxation skills, therapists should encourage children to practice deep breathing in the session and provide feedback and support as needed. Then, therapists should plan exercises for the child to use deep breathing as trauma reminders are gradually incorporated into subsequent sessions. When children and caregivers practice during treatment, they perfect their abilities to cope with posttraumatic stress.

Author Contributions

Phyllis Lee: Conceptualization, Methodology, Formal analysis, Writing – original draft. Jason M. Lang: Conceptualization, Project administration, Supervision, Writing – review & editing. Kellie Randall: Conceptualization, Data curation, Project Administration, Writing – review & editing.

Funding

This was an unfunded study.

Data Availability

Data is not available because written consent was not obtained for the data to be shared publicly.

Declarations

Ethical Approval

This study used de-identified archived administrative data that was determined not to qualify as human subjects research by the Eastern Connecticut State University IRB.

Competing Interests

The authors declare that they have no conflicts of interest to disclose.