Building the framework for ongoing discovery: coding practice elements in child traumatic stress intervention studies

ABSTRACT

Background: Data re-use and secondary analysis present significant opportunities to advance knowledge in the traumatic stress and psychotherapy research fields and fully realize the contributions of prior research participants. However, to enable meaningful cross-study analyses of intervention studies, systematic approaches to characterizing intervention components are needed.

Objective: This paper describes the development of a comprehensive framework for categorizing practice elements in child traumatic stress interventions, designed as part of the Child Trauma Prevention and Treatment (CTPT) Data Archive project.

Method: Through review of existing literature, expert consultation, and systematic refinement, we developed a framework for categorizing practice elements in child traumatic stress interventions.

Results: We identified 54 practice elements across five categories targeting the child, parent/family, elements addressing any intervention participant, the broader context, and process elements. This framework enables researchers to describe child traumatic stress interventions at a granular level, facilitating novel analyses examining specific intervention components across nominally distinct intervention models. Application of this framework to active arms within multiple intervention studies demonstrates its utility for characterizing diverse prevention and treatment approaches.

Conclusions: This work represents an essential step toward enhancing the value of integrated data resources and advancing evidence-based traumatic stress interventions for children and families.

HIGHLIGHTS

• A novel framework specifies 54 discrete therapeutic techniques applied in child trauma interventions, enabling researchers to describe interventions at a granular level and facilitating analyses of specific intervention components across different treatment models.

• Using a rigorous four-step process to develop this framework: starting with a comprehensive review of existing research, consulting 10 international trauma experts to rate the importance of each therapeutic technique, refining the list based on expert feedback, and testing the framework's feasibility by coding practice elements in several intervention studies.

• This framework enhances the value of integrated data resources by enabling meaningful cross-study analyses, allowing researchers to combine data from different studies to examine which specific therapeutic components are most effective, ultimately advancing evidence-based trauma interventions for children and families.

1. Introduction

Traumatic experiences affect millions of children worldwide, with significant implications for their psychological, social, and physiological development (Bürgin et al., 2022; Kessler et al., 2017; Mclaughlin et al., 2019). These experiences can lead to the development of various mental health problems, including post-traumatic stress disorder (PTSD), depression, anxiety, and behavioral disorders (Angelakis et al., 2020; Bryce & Collier, 2022; Lai et al., 2013; Marthoenis et al., 2019; Spinazzola et al., 2021; Tan & Mao, 2023). Furthermore, childhood exposure to traumatic stressors can have long-lasting effects on cognitive development, social relationships, and physical health, underscoring the importance of effective intervention strategies (De Bellis & Zisk, 2014; Hughes et al., 2021; Johnson et al., 2021; Matte-Landry et al., 2023; Mavranezouli et al., 2020).

While numerous interventions have demonstrated efficacy in preventing or treating trauma-related symptoms, significant questions remain regarding the specific mechanisms of change, differential effectiveness across populations, and essential components of successful interventions (Dorsey et al., 2017). Further research is needed to understand how intervention components may interact with factors such as the timing of intervention, the severity of trauma exposure, and individual characteristics, to influence treatment outcomes (Gutermann et al., 2016).

Integrative, cross-study analyses that leverage data from numerous studies can help to address these questions, providing greater statistical power and greater ability to examine findings across diverse child populations (Kassam-Adams & Olff, 2020). Although meta-analytic approaches can provide some insight (Roberts et al., 2019), combining datasets containing individual participant-level data (IPD) can help identify patterns of risk and resilience, investigate the effectiveness of different intervention components, include greater representation of marginalized populations, and inform the development of more targeted and efficient interventions (Sadeh et al., 2023). FAIR (Findable, Accessible, Interoperable, and Reusable) data practices that facilitate data sharing, data harmonization, and comprehensive metadata documentation are essential for data re-use in meaningful cross-study analyses (Kassam-Adams & Olff, 2020). The concept of FAIR also applies to metadata, taxonomies, and harmonization frameworks, i.e. these should themselves be as findable, accessible, interoperable, and re-usable as possible (Jacobsen et al., 2020).

The Child Trauma Data Archives (CTDA) project is part of the FAIR data theme of the Global Collaboration on Traumatic Stress (GCTS, https://www.global-psychotrauma.net/fair) dedicated to gathering, preserving, and sharing datasets in a standard form to serve as an ongoing resource for traumatic stress researchers (Kassam-Adams et al., 2020). CTDA encompasses the Prospective studies of Acute Child Trauma & Recovery (PACT/R) Data Archive, which focuses on natural recovery trajectories, and the Child Trauma Prevention & Treatment (CTPT) Data Archive, which focuses on interventions aimed at prevention or treatment of the impact of trauma. A significant challenge in creating an archive of child trauma intervention study datasets is how to categorize and describe intervention components in ways that support meaningful cross-study analysis (Hien et al., 2022; Thomas et al., 2019). Interventions with people exposed to trauma are typically characterized at the level of named or ‘branded’ protocols (e.g. Trauma-Focused Cognitive Behavioral Therapy) or broad intervention models (e.g. cognitive–behavioral, supportive, psychodynamic) (Hien et al., 2022). However, these categorizations may obscure both important variations and commonalities in the specific practice elements across studies. Interventions sharing a common theoretical orientation or name can involve varying sets of therapeutic strategies, while interventions with different names may share many common elements (Chorpita & Daleiden, 2009).

To address this challenge, we sought to develop, as a FAIR metadata resource, a practical and comprehensive framework for characterizing specific elements within child trauma interventions. These ‘practice elements’ are specific clinical techniques or strategies used as part of a larger intervention plan (Chorpita & Daleiden, 2009). For child mental health interventions more broadly, the seminal work of Chorpita et al. (2005, 2009) has mapped common practice elements across different intervention approaches to enable better documentation and evaluation of treatment delivery, efficiency, and effectiveness (Chorpita & Daleiden, 2009). The Distillation and Matching Model described by Chorpita et al. (2005, 2009) has helped to identify practice elements that are common across child mental health treatments, e.g. psychoeducation for child or parent, and other elements that vary depending on the condition that is the focus of treatment, e.g. attention to differential reinforcement and monitoring is more common in treatment of externalizing disorders than internalizing disorders (Chorpita & Daleiden, 2009). Several systematic or conceptual reviews have built on this work to examine practice elements in treatment for children who experienced various types of traumatic exposures, including armed conflict (Brown et al., 2017), disaster (Pfefferbaum et al., 2017), maltreatment (Bentovim & Elliott, 2014), in school-based trauma interventions (Du Mello Kenyon & Schirmer, 2020), in usual care for trauma-exposed youth (Borntrager et al., 2013), in social work practice with child trauma (Strand et al., 2013), and in parent/caregiver-focused models (Kiser et al., 2020). To our knowledge, no prior work has systematically examined practice elements specifically within secondary prevention interventions for trauma-exposed children.

With relevance to child trauma interventions, it seems reasonable to expect that some elements may be more common in certain intervention models, e.g. building parent–child attunement in parent–child interventions (Chu et al., 2021), challenging maladaptive thoughts in cognitive–behavioral interventions (Dalgleish et al., 2015). Others may be unique to specific protocols, e.g. bilateral stimulation in Eye Movement Desensitization and Reprocessing (EMDR) approaches (Adler-Tapia & Settle, 2023). By identifying patterns of shared and distinct components, we can move beyond broad comparisons of intervention protocols to develop a more nuanced understanding of which specific components contribute to effectiveness.

A number of empirical studies provide compelling evidence for the clinical usefulness of identifying granular practice elements. Prior investigations have implemented modular practice elements frameworks in treatment intervention trials or in real-world clinical practice, demonstrating the potential of this approach to improve treatment outcomes for a variety of child mental health concerns (Weisz et al., 2012; Chorpita et al., 2017; Nakamura et al., 2011). For example, the Modular Approach to Therapy for Children (MATCH) protocol (Chorpita et al., 2017), which utilizes a single modular design allowing for flexible selection and sequencing of procedures, has demonstrated significant benefits for both efficacy and efficiency. In a cluster randomized effectiveness trial, youth treated with MATCH, which included procedures relevant to traumatic stress, showed significantly faster rates of improvement over time on clinical and functional outcomes compared to community-implemented treatment (CIT). The modular approach also proved more efficient, requiring significantly fewer sessions delivered over significantly fewer days compared with the CIT condition (Chorpita et al., 2017). Furthermore, evidence suggests advantages for dissemination and sustainability, as therapists showed significantly greater overall satisfaction with the modular treatment protocol relative to standard evidence-based treatments and usual care (Borntrager et al., 2009; Chorpita et al., 2017). Similarly, within school-based trauma interventions, systematic reviews support moving beyond branded protocols, noting that effective interventions contain common practice elements such as social skills training, coping skills training, and relaxation techniques (Du Mello Kenyon & Schirmer, 2020). Other work has also demonstrated the utility of incorporating practice elements when teaching trauma-focused treatment approaches to therapists in training (Layne et al., 2014).

Focusing on these elements, rather than rigid protocols, promotes practical implementation in real-world settings (Du Mello Kenyon & Schirmer, 2020).

The development and application of a granular practice element framework allows researchers to address specific, high-priority research gaps that traditional protocol comparisons cannot resolve. By standardizing and codifying the intervention components (Hien et al., 2022), the framework enables novel integrated cross-study analyses to address critical questions about therapeutic mechanisms, differential effectiveness, and efficiency (Chorpita & Daleiden, 2009). These questions include moving beyond broad comparisons to identify which specific practice elements are the ‘active ingredients’ contributing to intervention effectiveness (Chorpita et al., 2005); examining efficacy across diverse participant factors such as age and developmental level; and addressing issues of equity by determining elements that are effective for children who are members of marginalized groups (Sadeh et al., 2023). This shift requires a taxonomy to help organize existing interventions according to their constituent parts, ultimately supporting the development of more modular, flexible, and efficient treatment approaches tailored to specific needs across diverse settings.

1.2. Aims of the current study

In this paper, we describe our development of a FAIR framework for coding practice elements in intervention studies focused on secondary prevention or treatment of the impact of trauma (i.e. exposure to potentially traumatic events and experiences) in children. We describe the process of distilling practice elements through literature review, consultation with experts, and systematic refinement, and then demonstrate application of this framework to several intervention studies to illustrate its utility for characterizing diverse trauma prevention and treatment interventions.

We focus specifically on practice elements relevant to child trauma interventions, and build on the foundations established by Chorpita et al. (2005, 2009). Our goal is to establish a FAIR metadata resource – a set of child trauma practice elements that will be a practical tool for characterizing each intervention arm in child trauma intervention study datasets, as a means to support meaningful integrative cross-study analyses. As a ‘living document’, this resource can be extended as research and practice evolve. We hope to set the stage for more nuanced examination of child trauma interventions beyond comparisons of branded protocols to the identification of active ingredients within diverse approaches.

2. Methods

We undertook a systematic process to build a comprehensive framework for coding practice elements in child trauma intervention studies and datasets, using the following steps:

2.1. Step 1. Create initial list of practice elements for child trauma interventions

The core CTDA team (YS, NKA, LG, HK) began by creating an initial comprehensive list of practice elements based on a review of meta-analyses (Du Mello Kenyon & Schirmer, 2020), systematic reviews (Bentovim & Elliott, 2014; Borntrager et al., 2013; Brown et al., 2017; Pfefferbaum et al., 2017), and conceptual reviews (Kiser et al., 2020; Strand et al., 2013) that have addressed practice elements in child trauma interventions. The initial list was derived from existing secondary literature (meta-analyses, systematic reviews, and conceptual reviews), rather than individual treatment manuals, to ensure the practice elements identified were already recognized as common or evidence-informed across multiple studies, consistent with the Distillation and Mapping Model (Chorpita & Daleiden, 2009). We refined the list to remove duplicates, clarify definitions, and sort elements into sensible categories and domains based on the primary target of the intervention technique; i.e. the person, system, or process being addressed.

2.2. Step 2. Obtain expert consultation

To ensure our framework adequately and sufficiently captures practice issues pertaining to child trauma intervention, we obtained feedback from an international set of 10 experts in child trauma and trauma intervention research (AdH, DH, TJ, MAL, RMS, RDVN, NRN, MO, SO, GS). The 10 international experts were purposefully selected to ensure heterogeneity in expertise across various trauma-informed theoretical orientations (e.g. cognitive–behavioral, attachment-focused, implementation science) and diverse fields of practice, including secondary prevention, treatment research, and community implementation. Experts were recruited based on their established publication records and international recognition in the field of trauma intervention, particularly with children and adolescents, to support the framework's broad generalizability. In a survey administered via REDCap (Research Electronic Data Capture; Harris et al., 2009), experts rated the relevance (Likert scale 1–5 where higher scores are more relevant) of each potential practice element for research in child trauma interventions (i.e. ‘Is this element relevant to include as a feature of child trauma interventions? Is it something that you or other researchers may want to characterize or analyze in future analyses using these data?’). Notably, given our focus on enabling a broad range of future uses of these data, we asked experts to rate relevance for research analyses regardless of the likely effectiveness of a practice element in reducing or preventing trauma symptoms. We defined ‘relevant’ elements as those with a mean relevance rating of 3 or above on a Likert scale (1–5).

Experts were invited to add qualitative remarks regarding definition of elements and to suggest additional practice elements for consideration. All ratings were provided separately for secondary prevention interventions and for treatment interventions (see supplemental material A: copy of the expert survey).

2.3. Step 3. Refine list of elements and coding scheme

Based on expert commentary and anticipated uses of the framework by future researchers analysing data from the CTPT archive, we made final refinements to create a list of practice elements classified into five major categories based on the target (e.g. person, context, or process) of the technique and conceptual domains within each category.

2.4. Step 4. Test feasibility by coding practice elements in several intervention studies

We used the framework to examine each intervention or active comparison arm in four studies, coding practice elements in each arm, in consultation with the original investigators for each study (JF, TJ, MAL, SO, NKA). This set of four RCTs was purposefully selected based on three inclusion criteria to ensure the framework’s versatility: (1) representation of both secondary prevention and treatment models; (2) diversity in delivery modalities (e.g. online/self-directed vs. clinician-led); and (3) representation from diverse geographic settings (i.e. USA, Switzerland, and Norway).

Feasibility was defined as the ability of the framework to accurately and comprehensively characterize the distinct practice elements delivered across these diverse intervention arms. To assess this, the original investigators completed a structured checklist using the 54 practice elements and their definitions (supplemental material B: practice elements framework – categories and defintions) to indicate the presence or absence of each element within their protocol. Consultation with these investigators ensured maximal descriptive accuracy, as they possess the most granular knowledge of their protocols’ implementation. This step was designed to establish the framework’s internal validity; testing inter-rater reliability (IRR) was not the primary objective of this initial feasibility phase.

3. Results

Each step of the development process supported the creation and refinement of a framework for coding practice elements in child trauma intervention studies and datasets.

3.1. Step 1. Create initial list of practice elements for child trauma interventions

We listed all practice elements (N = 81) identified in any of the meta-analyses or systematic or conceptual review papers in our literature review. After removing duplicates, we drafted brief definitions for each element. To help make the framework more comprehensible and usable for future researchers, we categorized practice elements by the primary target of the intervention technique (child, parent/family, broader context, or process) and within each of these categories by conceptual domain (e.g. psychoeducation, affect/emotional processing, attention to social context, relapse prevention). The sorting process focused on ensuring non-redundancy and clarity of definitions to support systematic coding. The resulting list of 68 practice elements and draft definitions can be seen in the expert survey (see supplemental material B: practice elements framework – categories and definitions).

3.2. Step 2. Obtain expert consultation

3.2.1. Relevance assessment

For prevention interventions, 47 of the 68 elements (69%) were rated as relevant, based on the mean score across all 10 experts, while for the treatment interventions, 61 (90%) of elements were rated as relevant (see supplemental material C: Mean expert ratings of relevance of candidate practice elements).

3.2.2. Differences between prevention and treatment elements

Expert ratings showed only minimal differences in relevance of practice elements for secondary prevention versus treatment interventions. Elements with somewhat lower relevance for secondary prevention included several targeting the child (imaginal exposure, in-vivo exposure, and developing a trauma narrative with child) and several related to process (monitoring in session, initial assessment of child symptoms/context, termination rituals/interventions, reevaluation post-termination, ‘booster’ sessions).

3.2.3. Summary of open-ended comments

Experts suggested several refinements through their comments. The core team reviewed these remarks based on predefined criteria of clarity, non-redundancy, and maximizing conceptual fit within the taxonomy. Based on experts’ recommendations, two new practice elements (‘rumination-focused cognitive work’, ‘reducing avoidance behaviors’) were added. Expert comments also suggested merging several elements for clarity and parsimony. Methodological considerations raised by experts included age-dependence of certain aspects, difficulties in establishing universal vs. targeted application, and challenges in differentiating between skills and therapeutic approaches. Augmenting formal expert ratings, comments enabled clarification, consolidation, or expansion of elements and their definitions to better capture the nuances of practice elements in child trauma interventions.

3.3. Step 3. Refine list of elements and coding scheme

Decisions to modify the initial list were based on a systematic review of expert ratings and qualitative feedback. The core CTDA team examined all practice elements with a mean relevance rating lower than 3 to identify candidates for merging or omission. Based on this quantitative criterion and expert feedback on non-redundancy and conceptual fit, three elements were omitted (self-reward skills, assign thought record or daily diary, modelling), and ten elements were merged. For example, play, art, and dance therapy were consolidated into ‘expressive therapies’ to streamline the taxonomy. Similarly, ‘personal safety skills (interpersonal /emotional safety)’ were merged with ‘emotional regulation’ and the definition modified accordingly. Conversely, several lower-rated elements – such as bilateral stimulation and massage therapy – were strategically retained due to anticipated research uses by future CTPT archive analysts. This retention was necessary to ensure the framework can accurately characterise specialized or emerging modalities (e.g. EMDR) and specifically capture practice elements known to be present in studies already planned for inclusion in the CTPT Data Archive. As noted above, two new elements (‘rumination-focused cognitive work’ and ‘reducing avoidance behaviours’) were added following direct expert recommendations to address gaps in the initial list. Given the overall similarity of ratings for secondary prevention and treatment interventions, we chose to proceed with a single comprehensive list that includes items relevant to either context. Our aim is to provide a comprehensive resource that researchers can refer to based on their specific needs.

The resulting framework includes 54 practice elements classified into five major categories based on the target (e.g. person, context, or process) of the intervention technique (Table 1). The complete operational definitions for all 54 practice elements are provided in see supplemental material B: practice elements framework – categories and definitions.

Table 1.

Example: coding practice elements from five active arms of four intervention studies.

	Secondary prevention/early intervention studies		Treatment intervention studies
	Coping Coach (CC) RCT a	EPICAP RCT b	TF-CBT vs Usual care RCT c	TARGET vs Enhanced Treatment As Usual (ETAU) RCT d
Practice element	CC arm	EPICAP arm	TF-CBT arm	TARGET arm	ETAU arm
ELEMENTS ADDRESSING ANY INTERVENTION PARTICIPANT
Engagement/working alliance
1.1 Build working alliance/rapport		X	X	X	X
1.2 Goal setting (overall)		X	X	X	X
1.3 Agenda setting (in session)			X
1.4 Supportive listening			X		X
1.5 Motivational enhancement			X
CHILD
Psychoeducation
2.1 Psychoeducation (child) about trauma	X	X	X	X
2.2 Psychoeducation (child) not trauma-specific
Affect/Emotional processing
2.3 Feelings identification	X	X	X	X
2.4 Emotional expression/communication			X
2.5 Emotional regulation skills		X	X	X
2.6 Grief/loss processing			If needed
Cognitive processing
2.7 Psychoeducation – thoughts/feelings/behaviors model	X		X	X
2.8 Developing trauma narrative (with child)		X	X
2.9 Identify & challenge maladaptive/negative thoughts	X		X	X
2.10 Generate & practice alternative thoughts	X		X	X
2.11 Rumination focused cognitive work
Exposure
2.12 Reducing avoidance behaviors	X		X
2.13 Imaginal exposure		X	X
2.14 In-vivo exposure		X	X
Bilateral stimulation
2.15 Bilateral stimulation
Coping skills
2.16 Positive activity scheduling
2.17 Mind-body techniques (relaxation, breathing)		X	X
2.18 Problem solving		X	X		X
2.19 Resilience building and skills			X		X
2.20 Social support skills training and enhancement		X			X
Non-verbal or expressive therapies
2.21 Expressive therapies				X
2.22 Mindfulness/Meditation
2.23 Massage therapy
Safety skills
2.24 Personal safety skills (physical safety)			X
Other practices
2.25 Assessment (conducted with child) as an intervention element
2.26 Insight building and meaning-making activities
2.27 Group cohesion
PARENT/FAMILY
Psychoeducation
3.1 Psychoeducation (parent) about trauma		X	X
3.2 Psychoeducation (parent) not trauma-specific			X
3.3 Psychoeducation (parent) – developmental guidance			X
Parenting practices
3.4 Parent coping/self-regulation skills			X
3.5 Training parents in child behavior management		X	X
Attachment/strengthening relationships
3.6 Cocreation of a trauma narrative between parent and child			X
3.7 Promoting parent/caregiver-child attunement and communication			X
3.8 Interventions to strengthen family structure, flexibility, communication
Other practices
3.9 Assessment (conducted with parent) as an intervention element
3.10 Individual therapy for parent/caregiver
BROADER CONTEXT
Attention to social context
4.1 Psychoeducation (with teacher or school staff) about trauma
4.2 Advocacy
4.3 Case management or collaborative intervention service planning
4.4 Specific cultural/religious practices
PROCESS
Access/availability
5.1 Access promotion (location, transport)		X
5.2 Addressing practical barriers to treatment
Assessment/monitoring
5.3 Initial assessment of child symptoms/context			X
5.4 Monitoring prior to session
5.5 Monitoring in session			X
5.6 Reevaluation (post-termination)			X
Activities outside session
5.7 Assign homework			X
Relapse prevention
5.8 Termination rituals/Interventions			X

The five major categories that structure the framework are:

• Elements Addressing Any Intervention Participant (n = 5): These elements include fundamental engagement and working alliance practices, such as supportive listening, building rapport, motivation enhancement, and overall goal setting.

• Child-Focused Elements (n = 27): These elements are directed toward the child and span several conceptual domains. These domains include psychoeducation, affect/emotional processing, cognitive processing, exposure, coping skills, and non-verbal or expressive practices.

• Parent/Family Elements (n = 10): These elements target parents, caregivers, or the family system. They include psychoeducation with a parent about trauma, training parents in child behavior management, and efforts to promote parent/caregiver-child attunement.

• Broader Context Elements (n = 4): These elements address the larger systems surrounding the child, such as providing psychoeducation with school staff about trauma, or case management and collaborative intervention service planning.

• Process Elements (n = 8): These elements relate to the delivery and logistics of the intervention, including promoting access (location, transport), initial assessment of symptoms, and assigning homework.

This framework is published on the Child Trauma Data Archives website (www.childtraumadata.org/) as a freely available FAIR metadata resource.

3.4. Step 4. Test feasibility by coding practice elements in several intervention studies

To test the feasibility of the framework, we applied it to the four RCTs identified through our purposeful selection process (see Methods: Step 4). These studies, conducted in three countries, allowed for the coding of practice elements across five active study arms. By selecting these specific trials, we were able to test the framework against interventions that varied in approach, target population, and delivery modality, including two studies focused on secondary prevention and two on treatment.

3.4.1. Secondary prevention studies

Coping Coach is a universal secondary prevention intervention delivered online in a game-like format for school-age children following acute potentially traumatic events. Kassam-Adams et al. (2016) report on a randomized controlled trial (RCT) in the United States comparing Coping Coach (intervention arm) to a wait list control arm, for children admitted to hospital following an acute medical event. The wait list condition did not include a formal alternative intervention and was not coded. Using our framework, we identified multiple practice elements in the Coping Coach intervention arm, all targeting the child (see Table 1). This coding of elements highlights the Coping Coach intervention's focus on providing children with psychoeducation, emotional processing skills, and cognitive processing skills without direct intervention with parents or broader systems.

Early Psychological Intervention for Children and Parents (EPICAP) is a targeted secondary preventive intervention delivered as a two-session cognitive–behavioral intervention within acute medical care settings or the family’s home. Kramer and Landolt (2014) report on an RCT in Switzerland comparing EPICAP to a usual care condition for children aged 2–16 following road traffic accident or burn injury. The usual care condition did not include a formal alternative intervention and was not coded. Our coding of the intervention arm of this RCT identified practice elements targeting children and parents as well as a process element (see Table 1). This coding reflects EPICAP’s focus on engaging both children and parents for psychoeducation, and addressing emotional and cognitive processing skills, and using elements of exposure, while addressing parents’ abilities to support child recovery.

3.4.2. Treatment studies

Trauma-focused cognitive behavioral therapy (TF-CBT) is a treatment approach often delivered within community mental health settings. Jensen et al. report on an RCT comparing TF-CBT treatment in community settings in Norway to usual care in those settings, for youth ages 10–18 who had experienced diverse traumatic events and met a cut-off for PTSS symptoms (Jensen et al., 2014). The usual care condition did not include a formal alternative intervention and was not coded. Our coding of the intervention arm of this RCT identified a rich set of practice elements targeting children and parents, with a strong focus on building engagement and working alliance as well as gradual exposure to trauma reminders (see Table 1). This coding reflects TF-CBT’s focus on psychoeducation, emotional and cognitive processing skills, coping skills, and use of exposure tasks. The coding captures TF-CBT’s explicit attention to building parent–child attunement and a shared narrative regarding trauma.

Trauma Affect Regulation: Guide for Education and Therapy (TARGET) intervention is a 12-session treatment approach for PTSD focusing on emotional regulation. Ford et al. (2012) report on an RCT in the United States comparing TARGET treatment to a well-described ‘enhanced treatment as usual’ (ETAU) condition involving relational supportive therapy, for girls ages 13–17 involved in delinquency who had a full/partial diagnosis of PTSD. We coded both arms of this RCT to identify practice elements (see Table 1). This coding reflects that interventions in both arms included elements aimed at building engagement and working alliance with youth and did not directly engage parents or family members. This coding captures the TARGET intervention’s focus on psychoeducation, emotional and cognitive processing, and in contrast, the ETAU arm’s focus on problem solving, resilience building and social support skills with youth.

4. Discussion

The development of a clear, comprehensive and FAIR framework for characterizing practice elements in child trauma interventions is a crucial advance toward enabling more nuanced cross-study analyses. By systematically coding interventions at the level of practice elements, rather than relying solely on branded protocols or broad theoretical categories, researchers can address longstanding questions about which specific components are most effective, for whom, and under what circumstances (Chorpita & Daleiden, 2009). Our use of this framework to code intervention arms across multiple studies and study arms was able to delineate variations in practice elements across interventions that share a broadly similar target and overlapping conceptual approaches, and to identify similar practice elements across theoretically divergent interventions. This may be crucial for future analyses to tease apart active ingredients in effective interventions.

The integration of decades of research results, through the Child Trauma Data Archives or other efforts that bring together individual participant-level data, will allow for novel analyses addressing critical questions such as: Does parent–child co-creation of the trauma narrative enhance parent–child agreement on symptom report? Are there practice elements that work particularly well with children who are members of marginalized groups? Does the efficacy of selected practice elements vary by age or developmental level in the child? Our expert consensus process was not aimed at identifying elements that are likely to be effective, but rather at a perhaps more important goal – creating the basis for future investigations, including meta-analyses and integrated cross-study IPD analyses, to answer these crucial questions about specific elements within interventions that aim to prevent or treat the impact of trauma for children.

This granular approach allows us to move beyond broad comparisons of intervention protocols and toward a more sophisticated understanding of the mechanisms and active ingredients that drive therapeutic change. Many evidence-based trauma interventions for children and adolescents share substantial overlap in their core techniques and hypothesized mechanisms, such as psychoeducation, emotional processing, cognitive processing, exposure, and parental involvement (Strand et al., 2013). This shift toward identifying core, granular therapeutic elements aligns with the broader movement toward transdiagnostic treatment approaches, which target shared underlying mechanisms rather than disorder-specific symptoms (Blom et al., 2014; Conway et al., 2019; Watson et al., 2022; Zalta & Shankman, 2016). For example, the Transdiagnostic Unified Protocol demonstrates how interventions can effectively address common negative affective processes across multiple diagnostic categories, achieving significant improvements in both anxiety and depression through shared therapeutic mechanisms(Carlucci et al., 2021). By mapping these shared components, such frameworks create a taxonomy to help organize existing interventions according to their constituent parts, supporting the development of more modular, flexible treatment approaches that can be tailored to individual child and family needs across diverse settings.

The harmonization of intervention descriptions and the use of common data elements, as advocated in recent methodological literature, are essential for maximizing the value of integrated data resources (Kassam-Adams & Olff, 2020). Using a FAIR metadata resource to enable standardized reporting and data sharing practices will enhance the comparability of studies and facilitate large-scale meta-analyses of aggregated or individual participant-level data, increasing statistical power and the generalizability of findings (Riley et al., 2015).

Finally, this framework is aligned with the FAIR data principles. By facilitating standardized approaches to describe intervention components, our approach enhances the findability of more granular intervention data and improves interoperability through common taxonomies that can be shared across studies and theoretical orientations. Most importantly, clear reporting of intervention elements improves the reusability of data, allowing researchers to conduct secondary analyses and build upon existing knowledge (Jacobsen et al., 2020). This provides a clear example of how FAIR principles can both maximize the individual scientific value of each study, honour the contributions of research participants, and facilitate a more cumulative and collaborative approach to advancing evidence-based trauma treatments for children and families (Kassam-Adams & Olff, 2020). FAIR data and metadata practices that facilitate use of data across studies also enable better inclusion and analysis of underrepresented and vulnerable populations, addressing disparities in access to effective care and supporting more equitable outcomes (Sadeh et al., 2023).

5. Future directions and recommendations

As interventions and research methods advance, ongoing refinement of the practice elements framework will be required. While the framework is comprehensive, it is not exhaustive of all potential current or future practice elements relevant to child trauma interventions. This framework is a ‘living document’, it is designed with the intention that it be expanded or extended as practice and research evolve. As researchers continue to add studies to the CTPT Data Archive and other repositories, we expect that the coding process may reveal elements missing in this initial framework. This framework might be combined with others, such as the Behavior Change Intervention Ontology (BCIO; M Marques et al., 2024; Michie et al., 2021), to code the dose and scheduling of intervention elements (e.g. duration, frequency, or total number of sessions dedicated to a specific element). Used together, these frameworks can facilitate investigations into mechanisms of action and treatment efficiency.

We demonstrated the feasibility of coding practice elements within intervention arms; however, future work should assess inter-rater reliability (IRR) for such coding using independent raters to ensure objectivity. It should be acknowledged that using the original investigators for coding in this initial feasibility test may have introduced investigator bias, as they possess detailed knowledge of their own protocol's application. The absence of independent coding means the feasibility test primarily confirmed the framework's utility as a descriptive tool, not its objective usability. Therefore, subsequent validation efforts should involve independent coders and formal IRR testing to determine the framework’s generalizability and feasibility for broader application. Furthermore, the initial identification of practice elements relied primarily on English-language secondary literature and expert consultation, which may have introduced language or cultural bias that affects the framework’s generalizability to non-Western contexts. To advance the framework as a truly FAIR metadata resource, future maintenance must incorporate data derived from diverse cultural and linguistic groups, ensuring the taxonomy remains equitable and accurate. We were not able to code practice elements for comparison arms of three of the four studies examined here. This limitation is not unique to this coding framework in that it is often hard for researchers to characterize the interventions (if any) that are delivered to participants assigned to comparison arms involving ‘treatment as usual’. For these purposes, a strength of studies with active comparison arms (like that by Ford et al. (2012)) is an ability to better delineate the practice elements delivered to participants assigned to control conditions.

6. Conclusion

FAIR data principles suggest attention to metadata across the research lifecycle. If researchers begin to document practice elements in each arm of a child trauma intervention study as they design their study protocol, this could improve study design, help clarify what exactly is being evaluated, and contribute to intervention science by ‘baking in’ metadata that will allow more granular examination of intervention components. It is our hope that adoption of consistent coding and documentation of practice elements in intervention studies will allow future researchers to examine in detail the mechanisms through which specific practice components exert their effects, and to assess the effectiveness of modular or transdiagnostic interventions that make use of these components.

Funding Statement

This work was funded by the US Eunice Kennedy Shriver National Institutes of Child Health and Human Development (NICHD) award number R03HD105319, the Bar-Ilan University, Israel, Postdoctoral Fellowship for Women, and the Trauma Data Institute.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

The datasets used for this study are available to qualified researchers by request through the Child Trauma Data Archives project: www.childtraumadata.org, without individually identifiable information.

Supplemental Material

Supplemental data for this article can be accessed online at https://doi.org/10.1080/20008066.2026.2650097.