between the child’s trauma exposure and current clinical
presentation. We also educate the child and caretakers about the
impact of the specific trauma that the child has experienced.
So for example, for a child who was sexually abused, the
early part of the treatment might involve talking about what
sexual abuse is and how often it happens — giving them
information so they understand that they’re not the only ones
who’ve experienced this. We try to normalize this experience
and tell them that lots of kids who’ve experienced it feel
ashamed, or scared, or other things they’re feeling.
Then we help the youngster with skills development, such
as relaxation skills and other affective-regulation skills. For
example, if they’re having bad dreams or intrusive thoughts,
they can use deep breathing or relaxation strategies. They also
learn how to use feeling words to describe what’s going on —
like “I’m feeling really angry” or sad. Because we know that
when children can describe their feelings, they’re less likely to
act out those feelings in destructive ways.
We also work with children to understand the basics
of cognitive processing, so they begin to understand the
relationships between thoughts, feelings and behaviors.
All of this is done early, to really help children stabilize
their emotions and their behavior. During this early part, most
children start to improve some.
Then, we launch into them sharing the details of what
happened to them. That’s the trauma narration and processing.
As the child recounts the narration, the therapist might note
distortions in the thoughts, such as, “It was my fault,” and then
help the child resolve those distortions.
Usually, TF-CBT takes 12 to 18 sessions. For children with
really complex trauma backgrounds, it can be as long as 25
How does this differ from cognitive behavioral
therapy with adults?
In many ways it’s kind of a hybrid. We’re using cognitive
behavioral interventions in the early part of treatment to help
a child stabilize, but then we move on to trauma narration and
That involves helping children slowly, incrementally, one
step at a time, be able to tell their stories about the trauma
they’ve experienced, their feelings about those experiences, and
their thoughts about those experiences, and then helping to
identify any distortions or unhelpful thoughts that they have
about their trauma.
For example, when children have thoughts like, “It was my
fault that this happened,” the goal is to help them look at their
trauma in a different way so that they have more accurate and
more helpful thoughts about their trauma exposure.
Are there big differences in how this works for older
children, teens and younger preschool-age children?
No. The outcomes with the younger children are as good
as with the older children. But of course how you would
implement the model with a young child — a 3-, 4-, or 5-year-
old — is going to be very different than with a teenager.
With 3-, 4- and 5-year-olds, we use a lot of play materials
in a structured way, to help the children learn how to identify
feelings and more easily express feelings and progress through
TF-CBT. With an older youth or adolescent, TF-CBT will
include more typical verbal psychotherapy, although we try to
incorporate interests and activities that the youth enjoys. So if
a teen enjoys music, they might listen to music and talk about
the emotions it evokes. And that gives them the opportunity to
talk about emotions more generally, which they can transfer to
talking about trauma.
“As therapists, we have to be brave enough to talk to children
about it so that they can begin to externalize their feelings and
their thoughts instead of those memories just living inside of
them,” says Dr. Anthony Mannarino.