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Childhood physical and/or sexual abuse—something more than 100,000 youth in the United States have experienced—has been observed to detrimentally impact youth across biological, psychological, and social domains, and may lead to posttraumatic stress and trauma-related behavioral problems (Putnam, 2003; U.S. Department of Health & Human Services, 2016). Such abuse can also seriously impact youths’ family systems, negatively affecting family members and their relationships with each other and with the child. For example, non-offending caregivers may struggle to manage their own abuse-related distress and cognitive distortions as well as their child’s trauma-related symptoms and behavior (Runyon, Spandorfer, & Schroeder, 2014; van Toledo & Seymour, 2016). As a result, therapy for children with a history of alleged abuse often includes both the child and a non-offending caregiver (Celano, Hazzard, Webb, & McCall, 1996; Cohen & Mannarino, 1996). Several evidence-based forms of such therapy have been developed to address abuse-related traumatic stress; however, a significant portion of families that begin trauma-focused therapy do not complete it (Murphy, Sink, Ake, Carmody, Amaya-Jackson, & Briggs, 2014; Wamser-Nanney & Steinzor, 2016).

Identification of factors associated with treatment completion may assist service providers in recognizing families who are particularly vulnerable to drop out and inform efforts to provide additional supports to families during treatment.  Our study attempts to inform such efforts related to one specific form of trauma-focused therapy: Trauma-Focused Cognitive Behavioral Therapy (TF-CBT; Cohen, Mannarino, & Deblinger, 2006). TF-CBT is an evidence-based form of treatment for childhood traumatic stress that utilizes sequenced components incorporating exposure techniques and cognitive processing of the traumatic event. Families participating in TF-CBT typically include the child with traumatic stress and at least one caregiver.

To date, only one published study has investigated factors associated with TF-CBT attrition (Wamser-Nanney & Steinzor, 2017), and no study has examined the impact of multiple caregivers participating in TF-CBT. Similarly, no empirical studies have examined how the number of pre-treatment assessment sessions may impact therapy completion. According to a systemic perspective, the presence of another caregiver may convey a “united front” in support of treatment to the child and support the primary caregiver in managing abuse-related distress. Similarly, no empirical studies have examined how the number of pre-treatment assessment sessions may impact therapy completion. A greater number of assessment sessions may threaten TF-CBT completion by increasing contributing to treatment burden and/or while delaying the benefits of therapy (e.g., psychoeducation, coping skill development).

Using archival data from a sample of children participating in TF-CBT with a primary caregiver at a hospital-based child advocacy center, we examined the impact of a second (non-primary) caregiver’s treatment attendance, the number of pre-treatment assessment sessions, and baseline child traumatic stress symptoms on treatment completion, while controlling for demographic variables and the other predictor variables.

Results revealed that families whose sessions more frequently included an additional, non-primary caregiver (e.g., a grandparent accompanying a parent) were more likely to complete treatment, even when we controlling for other predictive variables. Taking a systemic perspective, having another caregiver involved may have conveyed a “united front” in support of treatment to the child while also providing emotional support to the primary caregiver, who may have been managing abuse-related distress of their own. Other factors may also account for the relationship between additional caregiver involvement and treatment completion. For example, families with additional caregivers involved in treatment may experience fewer structural barriers to attendance (e.g., time, money, transportation, sibling child care) or less divisiveness related to the alleged perpetrator (e.g., perpetrator is/was not another caregiver or family member).

Additionally, our results demonstrated that families with more pre-treatment diagnostic evaluation sessions were less likely to have completed treatment. A number of factors may have contributed to the length of the initial evaluation period, including logistical factors (timeliness in attendance, transportation difficulties) and child or family characteristics (complexity of trauma history, degree of avoidance of trauma-related material). If these factors persisted during treatment, they may have affected attendance at subsequent sessions and increased the likelihood of treatment drop out. It is also possible that a greater number of evaluation sessions delayed the initiation of treatment, which may have contributed to frustration for families and interfered with the formation of a therapeutic alliance.

Our findings suggest that both family-and treatment-related variables are associated with treatment completion for families participating in TF-CBT and may have important implications for the delivery of trauma-focused interventions. Consistent with a systemic approach, clinicians may be able to facilitate treatment completion by prioritizing the attendance and participation of a supportive second caregiver from the initiation of services. Including an additional, supportive caregiver in treatment may help clinicians elicit buy-in from families and may lead to regular attendance, greater likelihood of completion, and a broader systemic impact. Additional steps that may facilitate treatment completion include addressing potential barriers (e.g., transportation, scheduling, childcare) early on and limiting the number of sessions devoted to assessment to prevent further delay in initiation of TF-CBT.


Celano, M., Hazzard, A., Webb, C., & McCall, C. (1996). Treatment of traumagenic beliefs among sexually abused girls and their mothers: An evaluation study. Journal of Abnormal Child Psychology, 24(1), 1-17. doi:10.1007/bf01448370

Cohen, J. A., & Mannarino, A. P. (1996). A treatment outcome study for sexually abused preschool children: Initial findings. Journal of the American Academy of Child & Adolescent Psychiatry, 35(1), 42-50. doi:10.1097/00004583-199601000-00011

Cohen, J. A., Mannarino, A. P., & Deblinger, E. (2006). Treating trauma and traumatic grief in children and adolescents: New York : Guilford Press, 2006.

Murphy, R. A., Sink, H. E., Ake, G. S., Carmody, K. A., Amaya-Jackson, L. M., & Briggs, E. C. (2014). Predictors of treatment completion in a sample of youth who have experienced physical or sexual trauma. Journal of Interpersonal Violence, 29(1), 3-19. doi:10.1177/0886260513504495

Putnam, F. W. (2003). Ten-year research update review: Child sexual abuse. Journal of the American Academy of Child & Adolescent Psychiatry, 42(3), 269-278. doi:10.1097/00004583-200303000-00006

Runyon, M. K., Spandorfer, E. D., & Schroeder, C. M. (2014). Cognitions and distress in caregivers after their child's sexual abuse disclosure. Journal of Child Sexual Abuse, 23(2), 146-159. doi:10.1080/10538712.2014.869291

U.S. Department of Health & Human Services, A. f. C. a. F., Administration on Children, Youth and Families, Children’s Bureau. (2016). Child maltreatment 2014.  Retrieved from http://www.acf.hhs.gov/programs/cb/research-data-technology/statistics-research/child-maltreatment.

van Toledo, A., & Seymour, F. (2016). Caregiver needs following disclosure of child sexual abuse. Journal of Child Sexual Abuse, 25(4), 403-414. doi:10.1080/10538712.2016.1156206

Wamser-Nanney, R., & Steinzor, C. E. (2016). Characteristics of attrition among children receiving trauma-focused treatment. Psychological Trauma: Theory, Research, Practice, and Policy, 8(6), 745-754. doi:10.1037/tra0000143

Wamser-Nanney, R., & Steinzor, C. E. (2017). Factors related to attrition from trauma-focused cognitive behavioral therapy. Child Abuse & Neglect, 66, 73-83. doi:10.1016/j.chiabu.2016.11.031

Discussion Questions:

  1. What potential unexamined mediating variables may explain the relationship between additional caregiver involvement and treatment completion?
  2. What are the pros and cons of extended pre-treatment assessment? What strategies might clinicians use to balance these advantages and disadvantages?

Reference Article

Celano, M. , NeMoyer, A. , Stagg, A. and Scott, N. (2018), Predictors of Treatment Completion for Families Referred to Trauma Focused‐Cognitive Behavioral Therapy after Child Abuse. JOURNAL OF TRAUMATIC STRESS. doi:10.1002/jts.22287

About the Authors:

Anna Stagg, MEd, PhD, is a psychologist at the Stephanie V. Blank Center for Safe and Healthy Children, a Department of Children's Healthcare of Atlanta, and an adjunct faculty member at Emory University School of Medicine, Department of Psychiatry and Behavioral Sciences. Her clinical and research interests include parent/caregiver-child attachment relationships, child abuse, and the implementation of evidence-based interventions to address childhood trauma and its systemic impact.

Amanda NeMoyer, J.D., Ph.D. is a Postdoctoral Research Fellow at the Disparities Research Unit, Massachusetts General Hospital and Department of Health Care Policy, Harvard Medical School.  Her research interests focus on evaluating and improving existing juvenile and criminal justice policies and identifying and addressing racial/ethnic disparities in mental health.