Salloum, 2014

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Cogn Behav Pract. Author manuscript; available in PMC 2015 February 01.
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Cogn Behav Pract. 2014 February 1; 21(1): 97108. doi:10.1016/j.cbpra.2013.07.004.
Development of Stepped Care Trauma-Focused Cognitive-

Behavioral Therapy for Young Children
Alison Salloum,
University of South Florida, Tampa
Michael S. Scheeringa,
Tulane University
Judith A. Cohen, and

Center for Traumatic Stress in Children and Adolescents, Allegheny General Hospital
Eric A. Storch
University of South Florida, Tampa
Abstract
Young children who are exposed to traumatic events are at risk for developing posttraumatic stress
disorder (PTSD). While effective psychosocial treatments for childhood PTSD exist, novel
interventions that are more accessible, efficient, and cost-effective are needed to improve access to
evidence-based treatment. Stepped care models currently being developed for mental health
conditions are based on a service delivery model designed to address barriers to treatment. This
treatment development article describes how trauma-focused cognitive-behavioral therapy (TF-
CBT), a well-established evidence-based practice, was developed into a stepped care model for
young children exposed to trauma. Considerations for developing the stepped care model for
young children exposed to trauma, such as the type and number of steps, training of providers,
entry point, inclusion of parents, treatment components, noncompliance, and a self-correcting
monitoring system, are discussed. This model of stepped care for young children exposed to
trauma, called Stepped Care TF-CBT, may serve as a model for developing and testing stepped
care approaches to treating other types of childhood psychiatric disorders. Future research needed
on Stepped Care TF-CBT is discussed.
Keywords
stepped care; posttraumatic stress disorder; trauma-focused cognitive-behavioral therapy; young
children
2013 Association for Behavioral and Cognitive Therapies. Published by Elsevier Ltd.
Address correspondence to Alison Salloum, Ph.D., University of South Florida, School of Social Work, 13301 Bruce B. Downs Blvd.,
MHC 1400, Tampa, FL 33612-3870, asalloum@usf.edu.
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Salloum et al. Page 2
Young children are exposed to a wide range and frequency of traumatic events (Finkelhor,
Ormrod, & Turner, 2009), conferring substantial risk for the development of posttraumatic
stress disorder (PTSD; Finklehor et al., 2009; Scheeringa & Zeanah, 2008). Evidence-based
practices (EBP) for young children exposed to trauma have been established (e.g., Cohen,
Deblinger, Mannarino, & Steer, 2004; Scheeringa, Weems, Cohen, Amaya-Jackson, &
Guthrie, 2011), but many children in need of EBP do not receive it (Essau, Conradt, &
Petermann, 2002). Reasons why include limited availability of trained therapists, costs,
stigma, and logistical barriers such as time, work demands, child care, and transportation
(Bringewatt & Gershoff, 2010).
Service delivery approaches that address treatment barriers are critically needed. Stepped
care is one such approach that may provide treatment in a more efficient, accessible, and
cost- effective way than standard treatment delivery systems. For example, stepped care
models provide treatment in steps where the patient is carefully monitored for improvement,
and the patient ends treatment once improvements have been obtained. Stepped care
delivery models usually begin with less therapist time and more convenient interventions for
patients, and, if indicated based on a predetermined criteria, progress to more intensive care
(e.g., weekly therapist-directed therapy). Alternatively, standard treatment delivery systems
often have one mode of treatment that demands intensive therapist time and requires the
patient to attend weekly sessions until the entire treatment model is completed.
Stepped care approaches are being developed to address mental health conditions (National
Collaborating Centre for Mental Health, 2011) such as adult depression (Franx, Oud, Lange,
Wensing, & Gro, 2012), obsessive-compulsive disorder (OCD; Tolin, Diefenbach, &
Gilliam, 2011), and childhood anxiety (van der Leeden et al., 2011). Franx et al. (2012)
suggest that there are challenges as well as advantages to implementing stepped care in
different settings. A challenge may be that clinicians will need to routinely utilize structured
measurement tools to determine if additional steps are indicated. An advantage may be that
clinicians may not spend as much time with patients who are receiving the less intensive
steps and will be able to provide different treatment options to patients instead of one
standard treatment.
The evidence on stepped care models is preliminary but promising. In one of the first
randomized clinical trials comparing a two-step treatment for adult OCD versus standard
therapist-directed treatment, results suggest that there were equally significant decreases in
OCD symptoms and similar satisfaction scores among the two conditions. Importantly,
stepped care treatment had significantly lower costs to patients and third-party payers than
standard care (Tolin et al., 2011). In one of the first open trials of a stepped care model for
childhood anxiety (e.g., separation anxiety, social phobia, specific phobia, and generalized
anxiety disorder), 133 children (ages 8 to 12 years) participated in a three-step CBT protocol
that added more sessions with intensifying parent involvement with each step. Step One
consisted of 10 child and 4 parent CBT sessions, with Steps Two and Three each adding 5
parent-child CBT sessions. Intent-to-treat analysis indicated that 45% of the children
responded to Step One, 17% responded to Step Two, and 11% responded to Step Three, for
a total of 74% of the children no longer meeting criteria for an anxiety disorder (van der
Leeden et al., 2011).
A stepped care model with two steps has been developed for young children exposed to
trauma. This stepped care model for children exposed to trauma is called Stepped Care TF-
CBT. Step One is based on Preschool PTSD Treatment (Scheeringa et al., 2011), Trauma-
Focused Cognitive Behavioral Therapy (TF-CBT; Cohen et al., 2004), research on the use of
minimal therapist assistance (Hirai & Clum, 2006; Salloum, 2010), telehealth, bibliotherapy
(e.g., Lyneham & Rapee, 2006), and computer-assisted treatments (e.g., Khanna & Kendall,
2008). Step One involves parent-led therapist-assisted treatment which includes three face-
to-face meetings with a therapist, bibliotherapy where the parent and child have 11 parent-
child meetings at home working in an empirically based CBT workbook, weekly telephone
support, and web-based psychoeducation. Step Two is standard TF-CBT, therapist-directed
treatment.
The purpose of this article is to discuss specific considerations for the development of
Stepped Care TF-CBT, and to describe this stepped care model for young children exposed
to trauma. Specific considerations for the development of Stepped Care TF-CBT that are
addressed include therapeutic approach, types of steps, number of steps, training of
providers, entry point, and inclusion of parents. The components of Stepped Care TF-CBT
include Step One, Maintenance Phase, and Step Two. Each component is described and
issues such as noncompliance, determining responder status and monitoring treatment,

flexibility, and implementation are discussed. A case example to illustrate Stepped Care TF-
CBT is provided.
Stepped Care
Generally, there are two guiding principles underlying stepped care models. First, the initial
step needs to be intensive enough to lead to likely improvements and least restrictive in
terms of the therapist time. Other factors that minimize clients time and inconveniences
may also be considered as least restrictive when developing the steps. Provider cost (i.e.,
therapist time) is a major factor when developing stepped care with health care costs a major
concern. Second, stepped care models need to be self-correcting with systematic
monitoring systems that indicate when the client needs to be stepped up (Bower & Gilbody,
2005, p. 11). Self-correcting monitoring systems have preestablished criteria with selected
measures that are used to indicate if treatment should end or if more treatment is needed.
Self-correcting monitoring systems recognize that not all individuals need the full package
of evidence-based treatments. The underlying assumptions of stepped care models are that
the lower-intensity steps are equivalent in outcomes to standard care at least for a proportion
of clients, are more efficient and reduce provider costs, and are acceptable to providers and
consumers (Bower & Gilbody).
Considerations for the Development of Stepped Care TF-CBT

Therapeutic Approach
The therapeutic approach should be one of the first considerations in developing a stepped
care model for children exposed to trauma. Treatment modalities may differ within a
stepped care model but there must be supporting evidence for the therapeutic methods being
delivered. TF-CBT is the most well-established treatment for childhood PTSD (Silverman et
al., 2008). CBT for childhood trauma has demonstrated efficacy with children of all ages,
from diverse backgrounds, in individual or group settings, and with children who have
experienced multiple and different types of traumatic events. In addition, CBT has shown to
be effective with diverse presenting trauma symptoms (e.g., with or without full PTSD
diagnosis, with or without other comorbid disorders such as depression, anxiety, behavioral
problems or complex trauma presentations; e.g., Cohen et al., 2004; Scheeringa et al., 2011).
Developing a stepped care model for childhood PTSD that can treat all types of traumas is
important for several reasons, including generalizability, training of clinicians, and ease of
implementation. Some models may use different theoretical approaches for different steps
(Bower & Gilbody, 2005). Eye movement desensitization and reprocessing (EMDR), which
has gained some empirical support for the treatment of childhood trauma (Fleming, 2012),
could have been provided as Step One, with TFCBT as Step Two, but this approach requires
clinicians to be trained and certified in two different approaches, which limits treatment
availability. CBT is used to treat many disorders and the specific therapeutic methods make
CBT amenable to clearly defined steps (Bower & Gilbody). Therefore, CBT, the most well-
studied individual therapy model, was the therapeutic approach utilized for Stepped Care
TF-CBT.
Types of Steps
It is important to consider what treatment should be provided for each step when developing
a stepped care model. For example, though medication may be considered in a stepped care
model (Bower & Gilbody, 2005), it was not included in Stepped Care TF-CBT because (a)
psychotherapy is considered the first-line treatment before medication for childhood PTSD
(Cohen et al., 2010) and (b) concerns about the acceptability of medication use in young
children (Stevens et al., 2009). Self-help approaches may also be part of stepped care
approaches, but were not included in the present model given limited data on the
effectiveness of self-help methods for PTSD (Hirai & Clum, 2006).
Offering group treatment as a first step is a viable option within a stepped care model. For
example, for war-exposed adolescents, Layne et al. (2009) developed a three-step model
consisting of a classroom-based intervention to provide psychoeducation and skill building,
a targeted trauma and grief-focused therapy group, and referral to community mental health
for those needing additional treatment. Similarly, for children after a natural disaster, Jaycox
et al. (2010) conducted a field trial with school-based group CBT as the first tier (or step)
and clinic-based TF-CBT as the second tier (step two). Schools are ideal for stepped care
models that begin with group intervention: they contain large numbers of children who are
in need of treatment at one time, and classrooms provide ideal settings for conducting group
treatment. However, school-based models may not be transportable to community mental
health settings. Additionally, the last step in school-based models is often a referral to
community mental health treatment, but for those children being referred, barriers such as
time and transportation still remain (Jaycox et al.). Therefore, we sought to develop a TF-
CBT stepped care model that could be used in outpatient and home settings.
Number of Steps
Key considerations for determining the number of steps should be length of treatment,
number of assessments needed for determination of stepping up or not, and providing steps
that result in significant improvements for a proportion of children. To ensure that the entire
Stepped Care TFCBT protocol was not longer than the typical most well-established
treatment (standard TF-CBT typically takes 12 to 16 weeks), all steps needed to be
completed within 12 to 16 weeks. Patients who responded to the first step needed to have
similar outcomes as those who responded after all of the steps. Therefore, the first step
needed to be long enough or with enough intensity to result in a substantial number of
children improving after Step One. Also, the number of steps established the number of
assessments required to determine if stepping up was indicated or not. For these reasons,
Stepped Care TF-CBT has two steps.
Training of Providers
Another consideration for developing stepped care for children exposed to trauma should be
training of providers. Dissemination and implementation of evidence-based treatments has
been a major challenge in the childhood trauma field (Self-Brown, Whitaker, Berliner, &
Kolko, 2012). However, with the TF-CBT web-based course and training methods such as
learning collaboratives, ongoing supervision, and train-the-trainer (Cohen & Mannarino,
2008), TF-CBT has become a widely used EBP. In fact, in a recent study of 262 clinicians
providing treatment to maltreated children, TF-CBT was the most widely used evidence-
based treatment (Allen, Gharagozloo, & Johnson, 2012). By using a method such as TF-
CBT that is well into the dissemination phase of treatment development (e.g., CATS
Consortium, 2007) in a stepped care model, training therapists on the implementation of
Stepped Care TF-CBT may not take as long as it would if a completely new treatment
method were being provided. However, training for Step One on how to implement the
parent-led therapist-assisted treatment needed to occur even for those therapists already
trained in Preschool PTSD Treatment (Scheeringa et al., 2011) and TF-CBT. Training needs
depended on the level of training already obtained for Preschool PTSD Treatment
(Scheeringa et al.) and TF-CBT (Cohen, Mannarino, & Deblinger, 2006). Methods for
training on Stepped Care TF-CBT consisted of similar training requirements for TF-CBT
(Cohen & Mannarino, 2008) such as the TF-CBT web-based course (http://tfcbt.musc.edu/),
live training plus ongoing consultation and supervision, learning collaborative or mixed
learning methods.
Entry Point
In terms of the organization of the steps, one question to consider should be the entry point
for different patients. There has been little research to identify beforehand those children
who will respond to the lower level of care, and those children who will respond only to the
full treatment package of the more intensive treatment. Research is needed to examine
predictors that may indicate the best initial level of care such as severity of PTSD, comorbid
syndromes, cognitive factors, and neurobiological factors. With a goal of providing the least
restrictive treatment as the first step, and in the absence of data on predictors to suggest
which children would respond better to Step One versus starting with Step Two, Stepped
Care TF-CBT currently begins all children with Step One.
Parent Role
For stepped care models with children, one consideration should be whether the first step
will include the parent only, the parent and child, or the child only. Involving parents and
children is critical in the treatment of young children with PTSD. Findings from three
randomized clinical trials suggest that while parent-only treatment for child sexual abuse is
helpful in terms of increasing parenting skills and addressing child externalizing behavior,
child participation in therapy, including young children, results in greater improvements in
child PTSD than parent-only treatment (Deblinger, Lippmann, & Steer, 1996; King et al.,
2000). Therefore, we include parents in both steps, with the parent actually leading the
treatmentwith therapist assistance in the first step. A major barrier for parents seeking
and completing treatment is the desire to solve the problem on their own, resulting in
reduced help-seeking behaviors (Kessler et al., 2001; Pavuluri, Luk, & McGee, 1996;
Thurston & Phares, 2008). Parent-delivered treatment in which parents take responsibility
for their children's improvement may address this barrier and improve parents self-efficacy
(Leong, Cobham, de Groot, & McDermott, 2009). Having parents lead the first step also
allows parents to individualize the treatment and include culturally relevant strategies since
they know their child better than the therapist. These studies support the rationale for
including parents and children in Stepped Care TF-CBT.
An important research question that requires further exploration is the influence of the
parent's trauma exposure, distress level, anxiety or PTSD on completing the parent-led
treatment and on treatment outcomes. Preliminary evidence from two case reports suggests
that as long as parents can manage their posttraumatic stress symptoms sufficiently to
complete the trauma-related activities with the child, children can improve in PTSD
symptoms despite the parent's posttraumatic stress severity (Scheeringa et al., 2007). In an
open pilot trial of a parent-only group CBT with 24 parents whose children had various
types of anxiety disorders (two with PTSD) in which children completed CBT homework
with their parents at home, parents with anxiety disorders reported more improvement in
their children's anxiety than parents without anxiety disorders (Thienemann, Moore, &
Tompkins, 2006).
Stepped Care TF-CBT Components

Figure 1 provides a graphic representation of the assessment and treatment flow of Stepped
Care TF-CBT. The following section describes the components of Stepped Care TF-CBT.
Step One
Step One of Stepped Care TF-CBT includes four main components: three in-office therapist-
led sessions, a parent-child workbook (Stepping Together), scheduled weekly phone
meetings, and information from the National Center for Childhood Traumatic Stress
Network (NCTSN) website. Information from the NCTSN website (http://www.nctsn.org/)
is printed and provided for parents who do not have access to the internet. However, in the
United States about 68% of households have internet access (U.S. Department of
Commerce, 2011). Research suggests that some face-to-face contact may increase treatment
compliance and satisfaction by children and parents (Spence, Holmes, March, & Lipp,
2006). Therefore, three face-to-face therapy sessions are included in Step One. The first
meeting is designed to provide a general orientation to Step One (materials, structure,
rationale, schedule and time commitment, and guidelines). The second meeting is
strategically timed at 2 weeks after the first in order to provide technical assistance for
relaxation strategies and to help establish the trauma exposures meetings (which are called
Draw It, Imagine It, and Next Step). The purpose of the final meeting is to provide support
and motivation to complete Step One.
The parent-child workbook, called Stepping Together, is based on the CBT Preschool PTSD
Treatment manual (Scheeringa, Amaya-Jackson, & Cohen, 2002) that has been used in a
National Institute of Mental Health funded treatment study with young children
experiencing PTSD due to a range of traumatic events (Scheeringa et al., 2011). Stepping
Together is written at a sixth grade level and in a user-friendly format (e.g., icons, white
space, call-out boxes, checklists). The techniques used in Stepping Together are consistent
with the core components of effective treatment for trauma-exposed children, including
stress management techniques, behavior management and skill building activities (e.g.,
gaining knowledge about trauma reactions and identifying feelings), having the child tell
their story about the trauma in an organized fashion, and participation in structured gradual
exposure to trauma reminders (Amaya-Jackson & DeRosa, 2007; NCTSN, 2012).
Stepping Together provides activities for the parent to work with the child to complete the
child's book called My Steps. There are a total of 11 parent-child meetings that occur at
home: after both in-office Sessions 1 and 2, there are 4 parent-child meetings at home; after
in-office Session 3, there are 3 parent-child meetings at home. The first 4 parent-child
meetings focus on coping skillsbehavior management, relaxation, affect identification and
regulation and telling the story about what happened to identify and rate the scariness of
the trauma reminders, developing a scary ladder (i.e., stress hierarchy) of trauma
reminders. During the first 4 parent-child meetings, children learn about the feelings score
and are taught to rate their feeling, such as none scared, medium scared, a little
scared, and a lot scared. The feelings score helps the child identify how much s/he is
experiencing the feeling and to communicate with the parent about the intensity of the
feeling. Parent-child meetings 5 through 8 include trauma exposure activities where the
child begins with the least scary trauma reminder, drawing a picture of the reminder,
imagining it for 30 seconds and then with the parent completing a Next Step, which is an in
vivo activity (i.e., exposure). The child moves up the scary ladder to reminders that are
scarier, repeating the same steps: drawing a picture of the trauma reminder, imagining it for
30 seconds, and completing a Next Step. During the final three parent-child meetings, the
child and parent complete the trauma exposure activities, discuss a relapse plan, and review
the child's My Steps book, which has all of the activities and worksheets that they have
worked on together. For more information about Step One, see Salloum and Storch (2011).
In families with two caregivers, it is recommended that only one parent lead the parent-child
meetings, while the other parent provides support and encouragement. For example, if there
are several children in the family, the non-lead parent may arrange to spend time with the
other children allowing the lead parent and child to have their meetings uninterrupted. It
may be easier for the child to talk about the traumatic event with the lead parent versus
talking with both parents.
Phone support is included to encourage compliance and completion of Step One. In fact,
preliminary evidence on computer-based therapy with children with anxiety disorders
suggests that adding weekly phone contact may help decrease attrition and improve
completion of assignments (Carlbring et al., 2006, 2007). The purpose of the phone
meetings in Step One is to provide motivation, support, and technical assistance. For
example, for the first two phone calls the therapist (a) asks how the parent is doing with the
parent-child workbook; (b) asks how the behavior plan is progressing and problem-solves if
needed; (c) provides positive, motivational comments to encourage the parent and problem-
solve if the parent has not completed the meetings; (d) asks the parent about their own social
support and incorporation of relaxation management; and (e) problem-solves with the parent
about potential barriers to completing treatment. The third and fourth phone calls focus on
helping the parent to problem-solve ways to complete the meetings if they are behind and to
address any questions or concerns they might have about the Next Steps (trauma exposures).
The purpose of the fifth and sixth calls is to explain the importance of completing the final
three parent-child meetings, which focus on the integration of the trauma narrative and
relapse prevention, offer encouragement and support, and encourage completion of the
workbook.
A web-based component used in Stepped Care TF-CBT provides psychoeducation to the

parent, and through two video demonstrations helps parents teach their children the
relaxation exercises and demonstrates how to perform the exposure activities. The parent-
child workbook includes the address of the NCTSN website to help the parent learn more
about childhood trauma. The link to this website is available on a password-accessible
Stepping Together website that also contains two video demonstrations so that parents may
review this information at their convenience. For parents who do not have internet access,
the therapist prints the most salient handouts from the NCTSN, such as What is Child
Traumatic Stress, and shows the parent the video demonstrations during Sessions 1 and 2.
Noncompliance With Step One

Noncompliance with Step One is addressed in four main ways. First, if parents are not
completing the parent-child meetings or activities, the therapist problem-solves with the
parent about ways to complete the activities as scheduled. Second, if the parent has not
completed the parent-child meetings as scheduled, the parent is encouraged to make up the
meetings and activities in the following week. Third, as a general rule, if the parent has not
completed three of the four meetings before the first in-office therapy session, stepping up to
therapist-directed care (Step Two, standard TF-CBT) may be indicated and should be
discussed with the parent. Fourth, in cases where it is judged by the parent and therapist that
the child requires more intensive clinical monitoring (i.e., the parent is not making
significant progress in implementing Step One or the child's behavior has significantly
worsened), Step One should be terminated and Step Two started.
Some children who are participating in trauma-focused therapy may have temporary periods
of minor regression or worsening of symptoms before they improve. It may be that parents
perceive their child is getting worse if the child starts talking more about what happened,
when in fact not avoiding traumatic reminders may be a sign of the child improving.
Therefore, it is important to have a monitoring system that helps define and determine
significant worsening so that the child with minor worsening does not terminate Step One
unnecessarily, but that the child with significant clinical worsening steps up to therapist-
directed care. Also, to minimize burden on the parent, child and therapist, we recommend
the use of brief rating tools such as the Clinical Global ImpressionImprovement Scale
(Guy, 1976; Research Unit on Pediatric Psychopharmacology Anxiety Study Group
[RUPP], 2001) to be completed once a week (either in-session or via phone) by the parent
and therapist, and the child, if aged 7 or above. The CGI-Improvement (Guy, 1976)
modified version that has been used in child treatment trials (e.g., RUPP, 2001) is based on
an 8-point rating scale of overall improvements since the first assessment (8 = very much
worse; 7 = much worse; 6 = minimally worse; 5 = no change; 4 = minimally improved; 3 =
improved; 2 = much improved; 1 = free of symptoms). A rating of 1, 2, or 3 is used to
indicate treatment response. Clinical worsening is defined as three consecutive ratings by the
therapist or parent of 6 or a rating of 7 or 8. If one party indicates clinical worsening and the
other does not, the parent and therapist (and child, if age appropriate) should discuss and
make a determination about continuing Step One while monitoring improvement status or
stepping up. In some instances, the therapist may want to consult with another mental health
professional about the severity of the clinical worsening rating to obtain another opinion and
then discuss this with the parent before deciding to end Step One. In some cases, it may be
decided that an additional session be conducted in Step One to address the noted concern.
The use of additional sessions is discussed further in the Flexibility section below. An
assessment may be conducted to provide more insight into whether Step Two is needed.
Maintenance Phase
If the child responds to Step One (see Responder Status section below), the parent and child
begin the maintenance phase. The maintenance phase is designed to promote open
communication between the parent and child and to encourage the parent and child to
continue to use the tools they learned in Step One. During this time, parents have one 30-
minute parent-child meeting per week. The purpose of these meetings is for parent and child
to spend time together having fun. The parent is informed that she or he does not need to
talk about the trauma anymore unless the child wants to talk about it. An aim of these
meetings is to strengthen the relationship between the parent and child and it is
recommended that the meetings start or end with a relaxation exercise. In fact, the parent is
asked to practice the relaxation exercises three times a week with the child. Parents are also
encouraged to continue praising the child for positive behavior and using the behavior plan
if it was established in Step One. Lastly, parents are encouraged to continue to have the
child use the feeling scores.
Step Two
If the child does not respond to Step One, s/he steps up to Step Two to receive nine (90
minute) in-office, therapist-directed TF-CBT therapy sessions. The treatment components
(see Figure 1) that are common to standard TF-CBT are delivered within these sessions (see
Cohen et al., 2006, for more information about standard TF-CBT). Since the child has
typically already received three therapist-directed sessions in Step One, some of the
components may be combined and reviewed in one session. Parents may choose to complete
Step Two over 9 weeks with weekly sessions, or have some weeks with double sessions to
complete treatment faster.
Flexibility
Stepped Care TF-CBT allows for two additional sessions to be provided in Step One or Two
as needed. Therapists are encouraged to use these additional sessions judiciously. Examples
of when additional sessions may be needed in Step One include the need to address
boundary issues with a child who may be acting out sexually or inappropriately, or when
safety issues need to be addressed if there is ongoing domestic violence or another traumatic
event. Additional sessions may be provided in Step Two when any particular component of
TF-CBT needs to be addressed further, such as when a child is having difficulty with affect
modulation.
Step One Responder Status and Step Two Monitoring

The threshold to end treatment after Step One is stringent since treatment will be terminated
and gains need to be maintained. The decision to end treatment after Step One is based on
meeting responder status. Responder status uses multiple methods, including a
semistructured diagnosis measure, below the cutoff score on a trauma symptom self-report
measure and an independent evaluation of overall improvement. Responder status is defined
as children who have three or fewer PTSD symptoms as measured by a semistructured
diagnostic interview with parents, the Diagnostic Infant and Preschool Assessment (DIPA;
Scheeringa, 2008), or a total score of 40 or less on the Trauma Symptom Checklist for
Young Children Posttraumatic Stress total score (TSCYC-PTS; Briere, 2005) and a score of
3 (improved), 2 (much improved), or 1 (free of symptoms) on the Clinical Global
ImpressionImprovement scale (RUPP, 2001). The criterion of three or fewer PTSD
symptoms is slightly below the average number of PTSD symptoms preschool children had
after participating in 12 weekly therapist-directed CBT sessions for preschool PTSD
(Scheeringa et al., 2011).
Step Two includes a monitoring system to individualize the optimal amount of treatment for
each child. Allowing early termination of Step Two prevents children who respond before
the completion of Step Two, perhaps due to the cumulative effects of Step One and Step
Two treatment, from unnecessarily receiving the full treatment package.
To monitor if responder status is met prior to the completion of Step Two, the parent and
therapist complete the CGI-I independently at the beginning of each Step Two session. If
both parent and therapist note two consecutive weeks of a CGI-I score of 3 (improved), 2
(much improved), or 1 (free of symptoms), and the the child is not in the middle of the
trauma narration or conjoint component, then the TSCYC-PTS is administered. If there is a
total score of 40 or less on the TSCYC-PTS, the therapist discusses with the parent the
option of termination or continuing treatment (i.e., parent preference). If Step Two is
terminated, a final treatment session occurs to end treatment with the child, which includes
discussion of progress and relapse prevention. After the final session, a postassessment is
scheduled for the following week.
Implementation Considerations
Exploring how Stepped Care TF-CBT generalizes to various settings is important to the
implementation of Stepped Care TF-CBT. For example, children in community-based
settings often have comorbidity, including externalizing symptoms, and are from low-
income families with single caregivers (Southam-Gerow, Weisz, & Kendall, 2003). It may
be that these children need additional therapist-led sessions to address behavioral problems.
In addition, the therapist may need to problem-solve with single caretakers about when they
can find time at home to have the parent-child meetings. Further, parents who are not
engaged in Step One by the second parent-child meeting need to be stepped up. Another
implementation consideration is whether phone meetings and assessments for responder
status are reimbursable to the provider, as well as the feasibility of implementation of
Stepped Care TF-CBT over time.
There are some children for whom stepped care is contraindicated. Exclusions to
participating in Stepped Care TF-CBT include the following: (a) there is no nonoffending
parent to participate in treatment or a perpetrator still lives in the home (e.g. mother's
boyfriend, sibling); (b) any condition that would limit the caregiver's ability to understand
CBT and the child's ability to follow instructions; (c) parent reading level below the seventh
grade (currently Stepping Together is only in English so fluency in English is also required);
(d) parent has had substance use disorder within the past 3 months; and (e) the child or
parent is suicidal.
Case Example
The following case illustrates the components of Stepped Care TF-CBT: three in-office
therapist sessions, 11 parent-child meetings at home using the Stepping Together parent-
child workbook, brief phone support, a web-based component, and assessments.
Presenting Problem
A 5-year-old Caucasian boy and his mother participated in Stepped Care TF-CBT. The child
was experiencing posttraumatic stress symptoms due to an accident, subsequent medical

procedure, and hospitalization. Three months before starting Stepped Care TF-CBT, the
child was pushed off a ledge by another young boy and broke his arm. The boy was
hospitalized for 3 days after the accident, had surgery on his arm, and underwent physical
therapy. At baseline assessment, the mother reported the following about her child: overly
worried about the use of his arm, breathing increased if he was reminded about what
happened, avoided doctors and hospitals, did not want to play basketball although physically
able, had difficulty falling asleep, was less happy and very clingy, and had become worried
about dying. The mother reported that the teacher reported that the child was having trouble
with things he did not have difficulty with before (i.e., decreased concentration). Due to the
severity of the child's symptoms, the mother indicated that she expected about 50%
improvement (on a scale from 1 to 100%) at the end of treatment. The child had 15
symptoms and 5 areas of impairment on the DIPA, a CGI-Severity rating of 5 severe
symptoms, and a 39 on the TSCYC-PTS. The therapist was a registered mental health
clinical intern who practiced at a nonprofit community trauma center and was trained in
Stepped Care TF-CBT by the first three authors. The person who completed the assessments
was a registered marriage and family therapist intern who practiced at the same community
trauma center and was trained by the first, second, and last author on the assessments.
Session 1, Parent-Child Meetings 1 to 4

The therapist met with the mother and child and explained that they would have four parent-
child meetings at home and they would begin to learn tools to help make the child feel
better. The parent reported that she thought that since the baseline assessment, her child had
minimally improved. The therapist met with the child and the mother in the office and had
the child decorate his My Steps book. The therapist worked with the child on the first page
of the book and asked the child to state what had happened that was scary. The child
reported that his friend pushed him off the ledge and he broke his arm. The therapist wrote
this down, but did not ask any other questions. The therapist then taught the mother and
child belly breathing and muscle relaxation. The therapist then met with the mother to
encourage her to go to the NCTSN website to learn more about childhood PTSD, plan the
scheduled phone calls, and briefly review the first four parent-child meetings at home.
The parent and therapist spoke on the phone after the first two parent-child meetings. The
parent reported that the child liked the meetings and that they both found them helpful.
However, during the second week, the mother reported via the phone that her child had
become much worse after having an experience where he swallowed water while
swimming in the ocean. The parent was concerned about continuing the parent-child
meetings as she reported that her child seemed to have a panic attack after the water
incident. The therapist encouraged the mother to continue to use the tools that they had
learned in the first three meetings, and then come in for Session 2.

Since the parent had not completed parent-child meeting four, the therapist completed the
fourth meeting in the office with both the child and parent together. They completed the My
Steps worksheet where the child is asked what happened, along with several follow-up
questions such as, What did you see? What did you hear? What did you smell? and so
on. The therapist had the mother write in the child's book as he answered the questions. She
wrote, I was playing on a wall at the party and my friend pushed me off and I landed on my
arm. Mommy and my grandmother were there. They took me to the hospital. I was afraid
my bone was going to come out of my arm. My arm hurt really bad, and they put these long
pins in my arm. The therapist worked with the child to complete the scary ladder. The not-
too-scary thing was watching TV at the hospital. The two medium scary things were
when I thought my bone was going to come out of my arm and hearing all of the
machines (referring to the machines in the hospital), and the most scary was getting the
pins in my arm. The parent was given Part II of the Stepping Together workbook.
During the next four parent-child meetings at home, the parent and child discussed safety
such as not pushing other children or climbing on things when his mother was not around or
didn't know. He continued to practice ways that he could calm himself down such as
thinking about his happy place, using relaxation and practicing muscle exercises (which
consisted of tightening his muscles and relaxing them), and using his feelings score to
identify his feelings and let his mother know how he was feeling.
During the fifth parent-child meeting, the child worked on the not-too-scary reminder
(watching TV at the hospital) by drawing about it, thinking about it, and then doing a Next
Step. For this Next Step his mother wrote in the child's My Steps book, Watched a Mario
movie in bed with pillows propping up his left arm. We drank apple juice just like we did at
the hospital. We remembered how it felt to do all this and how his arm felt. He said his scary
score was 3 (a lot scared) in the beginning and then 0 (none scared) at the end when we
practiced his relaxation exercise.
During parent-child meeting six, the parent had the child draw a picture of the medium scary
reminder (My bone was going to come out of my arm), imagine it for 30 seconds, complete
a Next Step, and then practice the relaxation exercises. The parent wrote in the My Steps
book for this Next Step, We went to the wall where the accident happened. At first he was
a little scared. We looked at the wall. He jumped off it with my assistance. He played with a
ball he found. During parent-child meeting seven, the child drew and imagined for 30
seconds the reminder about the machines at the hospital. For the Next Step the parent and
child talked about when the child was in the hospital. The parent wrote in the My Steps book
for this Next Step, We talked about the ER and hospital stay. We remembered the sounds,
visitors, and what we ate and drank. During the eighth parent-child meeting the child drew
and imagined the pins in his arm. For the Next Step the child looked at the X-ray picture of
the pins in his arm. The parent wrote in the My Steps book for this Next Step, We looked at
the X-rays that shows the pins in his arm.

At the third session, the child reported to the therapist that he had started playing basketball.
The child and mother reviewed with the therapist his drawings in the My Steps book. When
discussing the final Next Step, the therapist and mother talked with the child about the
scary pins that were in his arm actually being helper pins because they made his arm
feel good and he could play again. The child liked the idea of calling them helper pins. The
therapist then gave Part III of Stepping Together to the parent, and they scheduled the
remaining phone calls and midassessment. The therapist encouraged the child to continue to
use his relaxation exercises, especially when he became scared or worried.
The parent and child completed the workbook by repeating the final Next Step, which
consisted of looking again at the X-rays that showed the pins in his arms. They discussed
relapse prevention such as what he can do when he gets reminded of what happened now
and in the future. During these meetings they reviewed the entire My Steps book, which
included reviewing all of the tools he learned as well as his story about what happened and
what he did for each item on the scary ladder.
Midassessment
The child had five symptoms of PTSD and three areas of impairment on the DIPA, which
was a 67% decrease in number of symptoms and 40% decrease in areas of impairment from
baseline to midassessment. The TSCYC-PTS score was 37. The independent evaluators
rated impairment as a 3, indicating moderate impairment on the CGI-Severity and the
CGI-Improvement as much improved. The parent was asked if she thought her child
needed more trauma-focused treatment or if she felt that she could comfortably stop at this
time. The parent reported that with his improvements and tools that he learned, she felt
comfortable stopping treatment. The parent and child then entered the maintenance phase
where they continued to have parent-child meetings, and the child used his feelings score
and relaxation. The parent reported spending about 30 minutes on the NCTSN website and
about 10 minutes watching the stepped care demonstration videos.
Post and 3-Month Follow-up Assessment

The number of DIPA symptoms decreased from three at the postassessment to 0 at the 3-
month follow-up assessment. Similarly, there were three areas of impairment endorsed at the
postassessment whereas at the follow-up assessment there were no areas of impairment. The
TSCYCPTS score decreased from 39 at baseline to 32 at postassessment and 27 at follow-

up assessment, resulting in a 31% decrease from baseline to follow-up assessment. The CGI-
Severity rating was 2 (mild impairment) at postassessment and 0 (no impairment) at follow-
up, and the CGI-Improvement remained at 2 (much improved) at the postassessment and
decreased to 1 (very much improved) at the 3-month assessment.
Conclusion
This treatment development article describes the considerations that were taken into account
when developing a stepped care model for young children exposed to trauma. These
considerations included therapeutic approach, types of steps, number of steps, training of
providers, entry point, and inclusion of parents. A specific stepped care model called
Stepped Care TF-CBT, which includes Step One, Maintenance Phase, and Step Two, was
described. In addition, issues such as noncompliance, determining responder status and
monitoring treatment, flexibility, and implementation were discussed. A case example was
described to illustrate Stepped Care TF-CBT.
Our preliminary case study (Salloum & Storch, 2011) and research from a small pilot study
(Salloum et al., 2013) suggest that Stepped Care TF-CBT may be an acceptable service
delivery approach to parents. For example, in a case study (e.g., Salloum & Storch) with a 5-
year, 9-month-old Hispanic boy who had been physically abused and witnessed domestic
violence, the child responded to treatment after Step One. After Step One his grandmother,
who led the treatment, reported 32 (very satisfied) on the Client Satisfaction Questionnaire
(CSQ; Nguyen, Attkisson, & Stegner, 1983), which is the highest score (range for this
measure is 8 to 32). Similarly, in a small open trial with nine young children (ages 3 to 6)
who participated in Stepped Care TF-CBT, five of the six children (83%) who completed
Step One responded to treatment and one child responded after Step Two (two dropped out
and one was withdrawn due to the parent being hospitalized). Satisfaction scores on the CSQ
were 28 (SD = 7.45) at midassessment and 31.50 (SD = 1.0) at postassessment.
Currently, a randomized clinical trial comparing Stepped Care TF-CBT versus standard care
TF-CBT is underway to determine to what extent there are comparable improvements in
PTSD symptoms (primary outcome), internalizing and externalizing behaviors, impairment,
and satisfaction levels, and to examine the percentage of children who respond to Step One.
It will be important to examine if there are differential characteristics between those children
who respond to Step One and those children who need to step up. Until more research on
effective, less intensive first steps is conducted to differentiate predictors of responders and
nonresponders, we cannot accurately match the individual to the best level of care needed
(Haaga, 2000). Future studies can examine matched-care within a stepped care model. In
addition, a preliminary comparison of costs associated with delivering Stepped Care TF-
CBT and standard care TF-CBT needs to be conducted. As this research on stepped care for
young children is underway, we are also modifying the model to be applicable to older
children.
Stepped Care TF-CBT has the potential to be an evidence-based treatment that is more
efficient, accessible, and cost-effective than standard TF-CBT. Studies have shown high
rates of victimization among children and young children. Young children have the same
rate or higher than other age groups for interpersonal violence such as witnessing domestic
violence and neglect (Finkelhor, Ormrod, Turner, & Hamby, 2005). Trauma exposure can
cause neurobiological, emotional, social, and cognitive impairment in young children that
can derail development (Chu & Lieberman, 2010). Despite the high trauma exposure
(Finkelhor et al., 2005; Finkelhor et al., 2009), accessible treatment by trained therapists to
deliver EBP to children exposed to trauma remains limited (Allnock et al., 2012). Stepped
Care TF-CBT may serve as a model for developing and testing stepped care approaches to
treating other types of childhood psychiatric disorders. Without delivery methods that
provide effective, accessible, and affordable treatment to children at an early age, young
children with PTSD are at risk for a developmental trajectory of impairment and chronic
distress that not only places an undue burden on the child, but imposes significant costs on
society.
Acknowledgments
The authors would like to thank David Tolin, Ph.D., Anxiety Disorders Center, The Institute of Living and Yale
University School of Medicine, for his consultation on the development of the stepped care model for young
children after trauma; and Crisis Center of Tampa Bay and Mary Lee's House in Tampa, Florida, where Stepped
Care TF-CBT is being developed and tested. The project was supported by National Institute of Mental Health
award R34MH092373 to Dr. Salloum. The content is solely the responsibility of the authors and does not
necessarily represent the official views of the National Institute of Mental Health or the National Institutes of
Health.
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Highlights
Stepped Care TF-CBT is designed to address treatment barriers.
Considerations for the development of Stepped Care TF-CBT are discussed.
Parent-led therapist-assisted treatment is used as a first-line treatment.

Figure 1.
Treatment model for Stepped Care TF-CBT for young children

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Cogn Behav Pract. 2014 February 1; 21(1): 97108. doi:10.1016/j.cbpra.2013.07.004.

Development of Stepped Care Trauma-Focused Cognitive-

Judith A. Cohen, and

issues such as noncompliance, determining responder status and monitoring treatment,

Considerations for the Development of Stepped Care TF-CBT

Stepped Care TF-CBT Components

talking with both parents.

A web-based component used in Stepped Care TF-CBT provides psychoeducation to the

Noncompliance With Step One

Step One Responder Status and Step Two Monitoring

was experiencing posttraumatic stress symptoms due to an accident, subsequent medical

Session 1, Parent-Child Meetings 1 to 4

Session 2, Parent-Child Meetings 5 to 8

Session 3, Parent-Child Meetings 9 to 12

Post and 3-Month Follow-up Assessment

TSCYCPTS score decreased from 39 at baseline to 32 at postassessment and 27 at follow-

Allnock D, Radford L, Bunting L, Price A, Morgan-Klein N, Ellis J, Stafford A. In demand:

Amaya-Jackson L, DeRosa RR. Treatment considerations for therapists in applying evidence-based

approach. Behavioral and Cognitive Psychotherapy. 2011; 39:5575. doi:10.1017/

Considerations for the development of Stepped Care TF-CBT are discussed.

Parent-led therapist-assisted treatment is used as a first-line treatment.

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