PRACTICE BRIDGE

Implementing Trauma Focused-Cognitive

Behavioral Therapy for Youth under
Probation: Lessons Learned
Maria Eva Pangilinan1*
1
County of Santa Clara Health System, California, USA

*Corresponding author: Maria Eva Pangilinan: eva_pangilinan@yahoo.com

Abstract:
Citation: Pangilinan M.E. (2019)
Implementing Trauma Focused- OBJECTIVE: The implementation of Trauma Focused
Cognitive Behavioral Therapy for
Youth under Probation: Lessons Cognitive Behavioral Therapy (TF-CBT) for youth under
Learned. Open Science Journal 4(1) probation is underresearched. Since the TF-CBT project
implementation goal was not met, the author aimed to address
th
Received: 13 February 2019 the following questions: What were the unaddressed barriers to
th
Accepted: 29 June 2019 TF-CBT participation and completion? What factors could have
th significantly impacted TF-CBT completion? Were the positive
Published: 30 September 2019
outcomes of TF-CBT on the project's proposed measures
Copyright: © 2019 This is an
open access article under the terms
confirmed? The author also aimed to capture the lessons from
of the Creative Commons the TF-CBT project implementation.
Attribution License, which permits
unrestricted use, distribution, and
METHOD: Administrative documents were reviewed focusing on
reproduction in any medium, the project set-up, flow of participation and TF-CBT completion
provided the original author and
source are credited. to identify the barriers. Chart reviews included data for 54 out
of 60 TF-CBT participants. Three TF-CBT youth groups were
Funding: The author(s) received
no specific funding for this work identified. TF-CBT with no in vivo (C7, n = 12), four to six
TF-CBT components, including trauma narration (C4-6, n =
Competing Interests: The
author has declared that no 13), and one to four components in phase I of TF-CBT (C1-4, n
competing interest exists. = 29). Groups were compared on demographics, pre-TF-CBT
DOI:https://doi.org/10.23954/osj. trauma and functioning, quality and fidelity of TF-CBT, justice
v4i1.2012 involvement, and services satisfaction. Outcome measures were
change scores on the UCLA Post Traumatic Stress Disorder
Reaction Index, Youth Outcome Questionnaire and youth
arrests. All statistical tests were set at p < .05.
RESULTS: Of 154 youth referrals, 60 youth received at least
one treatment session.

Open Science Journal – September 2019 1

Open Science Journal
Practice Bridge

Significant between-groups difference in parental involvement

(χ2 = 6.08, p < .05) and number of trauma events experienced
(F = 3.58, p < .05); and significant decrease in overall trauma
symptom scores before and after TF-CBT participation with a
very large effect size in group C7 (t = 3.73, p < .001, d = 1.08)
were found.
LESSONS LEARNED: The barriers arising from the youth’s
distrust and therapist’s skills were unaddressed. The therapists
were possibly viewed by the youth as part of the police system
(which justice involved youth likely do not trust). Future
implementations must consider: the need for sufficient training
of therapists; the value of clinical quality review, routine
collection of information on families of justice involved youth,
justifiable waiving of eligibility requirements; tracking on
behaviors that are incompatible with those that warrant arrests;
and, a coherent communications protocol.

Keywords: Juvenile justice, Youth under probation, Trauma, TF-CBT,

Fidelity, PTSD

Introduction

Research and studies on crime and delinquency among youth documented as

far back as the 1960s have shown that childhood trauma is a significant risk
factor in juvenile delinquency and criminal behavior [1, 2, 3, 4, 5, 6, 7, 8, 9].
Symptoms of trauma have also been associated with delinquent or criminogenic
behavior [10, 11, 12, 8]. Persons with traumatic experiences relive disturbing
memories, are chronically anxious, feel guilty, emotionally numb, and self-
medicate with drugs and alcohol [13, 14]. Untreated trauma negatively affects
help-seeking and treatment engagement resulting in premature withdrawal from
therapy and increasing the likelihood of committing another offense [15, 16, 17,
18, 19, 20, 21].
To date, Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) has been
shown by various studies to be more effective in helping children and families
recover from trauma compared to other treatments typically used with
traumatized children [22]. These studies include eight randomized controlled trials
(RCTs) — including three with posttreatment follow-ups. In four other RCTs,
TF-CBT was shown to be superior to waitlist conditions. In another RCT, TF-
CBT was found to be just as equally effective and efficient as eye movement
desensitization and reprocessing (EMDR) therapy in improving PTSD symptoms.
TF-CBT was superior for improving children’s depressive and hyperactive
symptoms than EMDR. In a fairly recent review and meta-analysis of studies on
TF-CBT, the researchers had concluded that TF-CBT “is an effective

Open Science Journal – September 2019 2

Open Science Journal
Practice Bridge

intervention for the treatment of post-traumatic stress disorder (PTSD) in youth”

[23].
TF-CBT consists of nine sequential components which may be completed in 8
to 12 weekly sessions: 1. Psychoeducation, 2. Relaxation skills, 3. Affective
expression and modulation skills, 4. Cognitive coping and processing skills, 5.
Trauma narration and cognitive processing, 6. In vivo mastery of trauma
reminders, 7. Conjoint child-parent sessions, and 8. Enhancing future safety and
development. Parenting skills is a TF-CBT component that is provided along
with each of these eight components. The acronym for these components is
PRACTICE. TF-CBT requires gradual exposure to trauma reminders over three
phases: I. stabilization and skills-building in the first four components, II. trauma
narration and processing, and III. integration and consolidation in the last three
components. All the components should be provided to all children receiving TF-
CBT treatment and therapists must have clear clinical justifications for changing
the order of the PRACTICE components and/or exclusion of in vivo mastery.
Provision of each component could take a full 90 min that is equally divided
between the youth and the caregiver [24, 22].
In two independent RCTs, TF-CBT was demonstrated to be overall effective
in trauma symptom reduction for youth in foster care (child welfare system) [25]
and residential treatment facility (RTF) (juvenile justice systems) [26]. However,
experts in mental health and juvenile justice have reported a lack of systematic
research on TF-CBT for youth on probation [27, 28, 29]. Some of the reasons for
this gap in research could be due to what Cohen et al. had pointed out [26]: in an
RTF, the youth are more available to complete therapy and do not have to
contend with the multitude of factors (that serve as barriers to completion) that
could impede the therapy in outpatient settings; and the youth may also feel safer
than in their own home or community environment.
A Bureau of Justice Assistance (BJA) Justice and Mental Health
Collaborative Project (JMHCP) Grant proposed TF-CBT as an option for youth
on probation in Santa Clara County (SC County) in California, with primary
focus on nonviolent females. The data for the year prior to TF-CBT
implementation showed that 46% of 3,555 youth (18% of which were females),
under SC County court's jurisdiction were classified as nonviolent offenders. The
TF-CBT Grant’s goal was to have at least 60 youth complete TF-CBT each year
during the duration of the Grant (i.e., at least a total of 120 youth in two years)
[30]. However, in over three years of TF-CBT implementation, only 60 youth
participated in the BJA funded TF-CBT and received at least one TF-CBT
session [31]. Since the County's project implementation goal was not met and
implementation of TF-CBT for youth under probation is underresearched, it is
worthwhile to conduct this study to systematically explore answers to the
following questions: What were the unaddressed barriers to TF-CBT participation
and completion? What factors could have significantly impacted TF-CBT
completion? Were the positive outcomes of TF-CBT on the project’s proposed
measures (i.e., trauma symptom reduction, improvement in the youth’s mental
and behavioral functioning and reduction in youth arrests) confirmed? What are
the lessons learned from the TF-CBT project implementation?

Open Science Journal – September 2019 3

Open Science Journal
Practice Bridge

Method

A review of administrative documents was conducted to potentially identify

the unaddressed barriers to participation. Client charts were reviewed to possibly
identify the factors that significantly impacted TF-CBT participation and to
reconfirm the positive outcomes of TF-CBT.

I. Review of Administrative Documents

The review of administrative documents was focused on the project set-up,

flow of youth participation and completion of TF-CBT. Data reports on referrals
and TF-CBT participation (i.e., data on the results of screening, admission, and
completion); the 2011 project proposal; quarterly reports to BJA from the 4th
quarter of 2011 through the second quarter of 2015; monthly management
meeting minutes from 2012 to 2015, and; other reports from the TF-CBT lead
clinic’s lead therapist and the manager [30, 31] were reviewed.

II. Charts Review: Factors that impact TF-CBT and

reconfirm outcomes of TF-CBT

Youth demographics, pre-TF-CBT trauma and functioning scores, justice

system involvement, and services satisfaction, and; assessment and treatment
services provided were analyzed for their impact on completion of TF-CBT.
Consent to participate in the study was obtained and the sample of charts was
limited to those who agreed to participate in the study. The University of
California at Los Angeles (UCLA) Post Traumatic Stress Disorder for Children
and Adolescents Reaction Index DSM-IV (Revision) scale (PTSD RI) [32], Youth
Outcome Questionnaire (YOQ) [33], and youth arrests were used to assess TF-
CBT outcomes. The eight-item Consumer Satisfaction Questionnaire (CSQ-8)
[34], was used to assess services satisfaction. Statistical analytic procedures were
applied to compare three TF-CBT youth groups based on their demographic,
clinical and justice-involvement characteristics.
Study participant's consent. TF-CBT therapists handed out and explained the
Institutional Review Board (IRB) approved Study Participant’s Consent Form to
youth and parent as soon as appropriate during TF-CBT participation and
informed youth and parent that study participation was voluntary. The consent
form was available in two versions (youth only and parent/guardian only), and in
three languages (English, Spanish, and Vietnamese) — this was considering that
justice system involved youth in SC County who were 65% Latinos/Hispanics,
15% Whites, 20% Other Non-Whites were predominantly economically poor or
very poor [30]; that the languages of the recipients of social services assistance (n
= 236,070) included English (43%), Spanish (37%), Vietnamese (12%), Chinese
(4%), Tagalog (2%) or some other languages (2%) in 2010 [35]; and advise by
Mental Health Department (MHD) clinic staff for children and youth located at
the Juvenile Probation Department (JPD).
Study sample. Data from March 2012 to March 2015 were reviewed for 54 of
60 youth who participated in TF-CBT. Excluded were four participants who did
not sign the IRB approved consent forms and two who were still undergoing TF-

Open Science Journal – September 2019 4

Open Science Journal
Practice Bridge

CBT. Forms were signed in both versions for 44 youth, in youth only for six
participants, in parent/guardian only for four participants.
Tools and measures. The BJA Grant proposed use of the following tools and
measures: PTSD RI [32], YOQ [33], and youth arrests. The CSQ-8 [34] was
selected to assess satisfaction with health services. The PTSD RI and YOQ were
available in English and Spanish languages. These tools were translated with
permission into Vietnamese using translating agencies assisted by MHD staff for
back translations since Vietnamese was the third most prevalent language among
CA State health insurance (MediCAL) beneficiaries in SC County [31], and it was
also specifically requested by managers of mental health services to justice system
involved youth. The CSQ was available in English, Spanish and Vietnamese
languages.
(a) PTSD RI. The PTSD RI is not meant to be used as a diagnostic tool. The
PTSD RI was used to screen for any trauma event, assess severity of reactions to
the traumatic events (trauma symptoms), determine TF-CBT project eligibility
based on 17 of the 22 PTSD RI items (PTSD RI-17), and assess the change in
severity of reactions to trauma event(s) that were indicated before TF-CBT. Each
item is rated on a scale from 0 to 4 (never to almost every day). The internal
consistency or Cronbach’s Alpha reliability (α) scores across versions of the PTSD
RI were in the .90s range and the test-retest reliability has ranged from good to
excellent [36, 37]. While some filled out the forms independently, many youth or
youth and parent were assisted by the TF-CBT therapists, taking 5 to 15 min to
complete the forms. The therapists decided to administer the PTSD RI to the
youth after completing TF-CBT.
In the current study, all 22 items of the PTSD RI [32] were remapped onto
the new DSM-5 criteria for PTSD [38] which resulted in a 19-item scale (PTSD
RI-19) but lacked an item for reckless or destructive behavior. The highest
possible scores for PTSD RI-17 and PTSD RI-19 were 68 and 76, respectively.
(b) YOQ. The 30-item YOQ Version 30.2 [33] for either the adolescent or the
parent was used to assess change in mental and behavioral functioning (Somatic,
Social Isolation, Aggression, Conduct Problems, Hyperactivity/Distractibility, and
Depression/Anxiety), with each of the items rated on a scale from 0 to 4 (never
to almost always). The α score was .92 across versions and community sample
and outpatient data. Only the total score was recommended in tracking treatment
efficacy because the subscales needed further psychometric validation [39]. The
YOQ was to be administered to eligible participants before and after they have
completed TF-CBT.
In this study, to retain as many youth YOQ data as possible, a missing
response to an item was replaced with the item sample mean for one youth. In
another case, the YOQ subscales' scores with all items answered were included in
the analysis but the total score was excluded. This was in accordance with the
YOQ scoring procedure that invalidated a case if more than 10% of the 30 items
were not answered [39].
(c) Youth Arrests. The youth arrests, types of arrests, and number of days in
a locked Juvenile Probation Department facility (L-JPDf) were BJA’s primary
outcome measures. BJA required calendar year quarter (CY Qtr) reporting on the
number of participants who were arrested, number of days in a L-JPDf, number
of youth who completed or dropped out of the program. The SC County Juvenile
Probation Department (JPD) uses the Juvenile Record System (JRS) and the

Open Science Journal – September 2019 5

Open Science Journal
Practice Bridge

Juvenile Arrest System (JAS) which are part of the Criminal Justice Information
Center (CJIC) electronic data system. While JPD provided CY Qtr data extracts
with dates unspecified, the JPD did not provide the arrests data prior to any of
the youth's CY Qtr of TF-CBT participation. Because arrests were outcomes
measures, the author confirmed that none of the youth was provided the final
TF-CBT treatment (txFin) in a L-JPDf; none of the youth were in a L-JPDf for
all 90 days of the last TF-CBT treatment CY Qtr; one was in a L-JPDf during
the entire three CY Qtrs after the last TF-CBT treatment CY Qtr (i.e., post
Qtr1, Qtr2, Qtr3), one during the entire post-TF-CBT CY Qtr1, and another
during the full post-TF-CBT CY Qtr2.
(d) CSQ-8. The 8-item CSQ-8 was to be administered after the youth had
completed TF-CBT. The response to the questions is a rating on a scale from 1 to
4 (poor to excellent). The overall score is the sum of all eight items. It has
excellent psychometric properties [40, 34].
Study design. The lead TF-CBT clinic's lead therapist identified the
components covered per session for all study participants. This lead therapist
(who was in direct communication with and received updates from TF-CBT
therapists) reported on case status/issues at weekly clinical team meetings, and
that the clinical team/therapists decided to not provide in vivo — the reasons
cited were concerns with client safety associated with extended exposure to
abusive home environments, dangerous (gangs) neighborhoods or difficulty in
recreating the event.
Therapists reported a total of 23 participants as completed TF-CBT while 31
as not completed TF-CBT. However, chart reviews showed that four of those
participants reported as completed TF-CBT actually completed only five
components (ending TF-CBT with trauma narration and cognitive processing,
component 5). Two of those reported as not completed TF-CBT, did complete
five components. One reported as completed finished six components only — the
reason was that the youth's parent could be incarcerated, hard to engage or
dysfunctional families. Based on review of the number of TF-CBT components
that were completed, missed, and sequence of completion, three distinct youth
groups were identified. These groups are as follows:
One youth group was sequentially provided seven components or TF-CBT
without in vivo mastery (C7, n = 12). Therapists provided the conjoint child-
parent session (component 7) and enhancing future safety & development
(component 8) in one session for all youth in TF-CBT C7, and; one case had
component 7 after component 8.
A second youth group was nonsequentially provided four to six components,
including the trauma narration and cognitive processing component (C4-6, n =
13). This group consisted of 11 youth who were reported by therapists as
completed and two of the youth who were reported as not completed and had up
to the trauma narrative and processing (component 5). In addition to missing in
vivo, other components that were not provided to group C4-6 were: components 7
& 8 (n = 6) for those ending with component 5; components 8 (n = 3) or 3 (n =
1) for those ending with component 7; and components 1 (n =1 ) or 7 (n =2) for
those ending with component 8. In this group, the order of provision of the first
four components were made to address the immediate needs of the youth
(relaxation technique to address sleep problems prior to psychoeducation and
parenting); prior components were reviewed before proceeding to the next to

Open Science Journal – September 2019 6

Open Science Journal
Practice Bridge

ensure that skills in the components were learned; two or more new components
were introduced in one session in some cases, and then repeating components.
Therapists started with components 2, 3, 4 or a combination for four youth; and
component 4 before 3 for five youth. In a session, therapists provided a
combination of the first four components for seven youth.
And a third group consisted of the youth who were provided one to four or
any of the first four components of TF-CBT (C1-4, n = 29). In a session,
therapists provided a combination of the first four modules for two youth in TF-
CBT C1-4 and then reviewing the first four modules. Therapists started with
components 2 or 3 for four youth; and component 4 before 3 for eight youth.
Statistical analysis. Descriptive data analysis and statistical tests were
performed using SPSS v.22.0. All tests were set at p <.05. Cohen's d was
calculated for an estimate of effect size. Normality was set at 2.0 for skewness and
kurtosis. The reliability of measurement tools were assessed. Nominal variables
were coded and quantitative variables that violated the assumption of normality
were recoded prior to statistical significance tests.
(a) Reliability of outcome and satisfaction tools. Cronbach's Alpha (α) tests
were performed on the PTSD RI, YOQ and CSQ-8 to assess internal consistency
of the scales. The PTSD RI-19 α scores before TF-CBT ranged from .80 to .89 for
All participants, groups C7 and C1-4, and for groups C7 and C4-6 after TF-CBT.
The PTSD RI-19 α scores for C4-6 were at .56 before TF-CBT and at .86 after
TF-CBT. YOQ α scores were between .75 and .96 before and after TF-CBT for
All participants and the three youth groups. Only the PTSD RI-19 and YOQ
total scores were used for outcome analysis because of the overall low subscales
reliability scores (see Appendix A for subscales α scores).

Table 1: Reliability of Pre and Post TF-CBT PTSD RI and YOQ Scales
All C7 C4-6 C1-4
Scales M(SD) α M(SD)range a M(SD)range a M(SD)range a
Pre-TF-CBT
Total PTSD RI-19 n = 51 to 54 .80 n = 12 .82 n = 11 to 13 .56 n = 28 to 29 .84
37.47 (12.04) 41.42 (12.63)25-68 39.27 (8.75)22-54 35.07 (12.89)13-60
Overall YOQ n = 52 to 53 .86 n = 12 .75 n = 13 .91 n = 27 to 29 .87
46.70 (16.93) 46.92 (13.75)20-71 44.69 (19.44)21-88 47.59 (17.47)16-83
Post-TF-CBT
Total PTSD RI-19 n = 12 n = 10
23.75 (12.50)11-55 .89 21.20 (12.15)0-37 .86
Overall YOQ n=8 n = 10
34.50 (15.11)12-55 .86 26.90 (22.89)0-77 .96
CSQ n = 21 .92 n = 10 .95 n = 11 .82
27.62 (4.47) 26.40 (5.78)15-32 28.73 (2.65)25-32
Note. TF-CBT = Trauma-Focused Cognitive Behavioral Therapy; C7 = sequentially completed TF-
CBT without in vivo; C4-6 = nonsequentially completed 4 to 6 components including trauma narration
& processing; C1-4 = completed 1 to 4 of any one or a combination of the first four TF-CBT
components; PTSD RI = Post Traumatic Stress Disorder Reaction Index; YOQ = Youth Outcomes
Questionnaire; CSQ-8 = Client Satisfaction Questionnaire.

Open Science Journal – September 2019 7

Open Science Journal
Practice Bridge

The PTSD RI-17 α scores ranged from .75 to .88 for All participants, for C7
and C1-4 before TF-CBT, and for C7 and C4-6 after TF-CBT. The PTSD RI-17
α scores for C4-6 before and after TF-CBT were .32 and .85, respectively. The
pre-TF-CBT α scores for the full scale, and the subscales reexperiencing (5
items), avoidance (7 items), and increased arousal (5 items) subscales were .75,
.73, .53 and .47, respectively. The post-TF-CBT a scores were .88 (n = 12) for C7
and .85 (n = 10) for C4-6. The post-TF-CBT CSQ α scores were in the .90s range
for All participants and C7, and .82 for C4-6.
(b) Statistical tests. Chi-squared (χ2) and F-tests were performed to assess for
the impact of youth demographic and clinical characteristics, youth justice
system involvement, and measures of quality and fidelity of TF-CBT on
completion of TF-CBT. Chi-squared tests were performed to assess for significant
difference between TF-CBT services groups (BGs) on the following categorical or
binomial coded variables: sex, ethnicity, preferred language, number of symptom
domains met on the PTSD RI-17, arrests during TF-CBT, types of arrests,
number of days in a L-JPDf, number of days between the last ATCP and tx1,
number of in-person ATCP sessions, parental involvement, number of
components completed, and duration of engagement in CY Qtrs. F-tests were
conducted to assess for significant difference BGs on the following continuous
variables: age, pre-TF-CBT number of trauma events experienced, pre trauma
score on PTSD RI-19, pre YOQ score, end and start time lags, number of
treatment sessions (txS), total amount of time for services received in min,
number of days engaged from the youth's TF-CBT tx1 to txFin, and average
number of days between txS. Significant BGs difference tests were not performed
on the amount of time spent per session because of the high kurtosis found for
this variable. F-test was performed to assess for significant difference in services
satisfaction between C7 and C4-6.
To reconfirm the positive outcome of TF-CBT, the youth’s pre and post TF-
CBT PTSD RI and YOQ data were analyzed. Paired samples t-tests were
performed to assess change before and after TF-CBT participation in symptom
reduction on the PTSD RI, and improvement in mental and behavioral
functioning on the YOQ. The trauma symptom reduction outcome of TF-CBT
could only be performed for C7. Assessing trauma symptom reduction for C4-6
was not performed due to the low internal consistency of the PTSD RI-19 scores
before TF-CBT (α = .56) (see Table 1). Since the PTSD RI and YOQ were
intended to be administered after completing TF-CBT, data were not found for
the C1-4 youth who were reported by therapists as not completed TF-CBT.
Paired samples t-tests were performed (a) for C7 and C4-6 to assess improvement
in mental and behavioral functioning on the YOQ before and after TF-CBT
participation. The youth’s post-TF-CBT justice involvement data were examined.
Chi-squared tests were performed at each of the post TF-CBT CY Qtr of
participation to assess significant difference BGs in justice system involvement
(arrests during TF-CBT, time spent in a L-JPDf, and the type of arrests).
(c) Coding of factors. The five parental (parent/s, family member/s or
guardian) involvement categories were (i) therapist played the parent role, (ii)
parent was involved during assessment only, (iii) parent was inconsistently
involved, (iv) family member was involved, and (v) parent was involved. These
five categories were regrouped into three and two categories (respectively,
categories i plus ii, iv plus v, and iii; AND categories i plus ii plus iii, and iv plus

Open Science Journal – September 2019 8

Open Science Journal
Practice Bridge

v). The categories for the types of arrests were (i) none, (ii) administrative
violation for the same offense, (iii) a new offense, and (iv) administrative
violation for the same offense plus new offense. Arrests during TF-CBT was the
sum of all arrests coded as 1 (arrests) or 0 (no arrest) in each CY Qtr of TF-CBT
participation, since arrests could occur: before or after ATCP, before tx1 in the
first CY Qtr of TF-CBT participation, or after the last TF-CBT treatment in the
last CY Qtr of TF-CBT participation. Time spent in a L-JPDf during TF-CBT
was the sum of the actual number of days in L-JPDf for all the CY Qtrs during
TF-CBT coded as 1 (not a day) or 0 (a day or more) because the dates were
unspecified. Number of days for ATCP was coded 1 (no more than two sessions)
or 0 (more than two sessions) since per therapists, it had generally taken them
one to two sessions for ATCP even with youth groups referred by social services
agencies. Number of days between the last ATCP and tx1 was coded as 1 (no
more than seven days) or 0 (more than seven days) to be in alignment with the
TF-CBT recommended weekly face-to-face sessions and limits the duration of
exposure by the youth to other events that might significantly bear on the pre-
TF-CBT scores on the PTSD RI and YOQ.
Additionally, the start time lag and the end time lag were assessed for any
significant BGs difference, given that those who start TF-CBT later in the first
treatment CY Qtr or end earlier in the last treatment CY Qtr may have arrests
and the time/days spent in a L-JPDf prior to starting or after ending TF-CBT.
Within the treatment CY Qtr, the start time lag was the difference between the
date of tx1 and the first day of the treatment CY Qtr. The end time lag was
difference between the date of the last TF-CBT treatment and the last day of the
treatment CY Qtr.

Results

The SC County Superior Court formed a TF-CBT project collaborative

planning and implementation (P&I) committee for the SC County Superior
Court, JPD, and MHD to prepare for project implementation. The P&I
committee provided oversight to development of the BJA approved project
implementation plan (including staffing and funding) and during implementation.
The data revealed that: 31.82 % of the youth referred by JPD to MHD did not
respond, 12.7% of eligible youth declined participation, 47.89% of the trauma
assessed youth were returned by MHD to JPD due to ineligibility, and 57.41% of
study participants were reported as not completing TF-CBT. No significant
findings were found based on youth demographic characteristics, justice
involvement and services satisfaction. Significant findings suggested that
completion of TF-CBT was associated with parental involvement during TF-CBT
sessions, the number of trauma events experienced by the youth before TF-CBT,
and some of the measures of the quality and fidelity of TF-CBT for the youth.
Trauma symptom reduction outcome of TF-CBT (on the PTSDI RI-19) was
confirmed only in C7, which was the least traumatized and most engaged of the
three TF-CBT services youth groups.

Open Science Journal – September 2019 9

Open Science Journal
Practice Bridge

I. Project Set-Up: Prior to implementing TF-CBT

The P&I committee had ensured readiness for implementation with a trained
clinical team, a referral and recruitment system between JPD and MHD, an
admission criteria, data collection system, and client consent forms [31]. Approval
by the SC County's Institutional Review Board (IRB) for outpatient services of a
proposed study on the effectiveness of TF-CBT for youth under probation was
secured.
Clinical team. The project started with one clinic and two therapists already
trained in TF-CBT. TF-CBT therapists licensed as clinical social workers
(LCSW) or marriage and family therapists (LMFT) received eight hours of online
trainings that covered each of the TF-CBT components and a two-day intensive
training (14 hours) on each of the components. These therapists with at least 10
years of clinical work experience had been trained in cultural-competence by
MHD and prior to working with MHD. Weekly consultations with the MHD
manager with extensive TF-CBT work experience was available.
Recruitment and referral. All youth under a general court order to seek and
undergo counseling and referred by the JPD to the MHD for assessment between
February 2012 and February 2015 were contacted by telephone by a TF-CBT
therapist. Probation Officers (POs) were trained to introduce TF-CBT as one of
the options that potential TF-CBT project participants could select. To recruit
youth on probation, POs and the TF-CBT clinical team jointly presented to
youth at JPD their available counseling options, including TF-CBT. POs alerted
MHD staff of any referrals and the date of youth's appearance before the Judge
in the Juvenile Court. MHD clinicians returned completed Status Report Forms
to JPD/POs [31].
Admission criteria. TF-CBT was offered to youth under the jurisdiction of SC
Juvenile Court who met the following criteria: (i) the youth was legally
nonviolent (ii) the youth’s trauma experience was confirmed by a TF-CBT
therapist by the PTSD RI [32] (iii) the State of CA and MHD medical necessity
requirements were met (iv) the eligibility cutoff score on the PTSD RI was met,
and (v) the assigned therapist determined that TF-CBT was the appropriate
first-line treatment.
Data collection. The BJA Grant required aggregate CY quarterly reports on
data relevant to the objectives of the project. These were the number of
participants who completed and did not complete TF-CBT, number of
participants arrested, number of participants arrested for administrative violation
for the same offense or a new offense, total number of days spent in a L-JPDf by
participants, and number of participants hospitalized for mental health-related
illness during CY Qtr reporting timeframes. The latter was not collected since the
project was not set up for that. MHD set up its EHR for fiscal management and
evaluation data collection, including demographics and services data, and had
provided oversight for clinical consultations. MHD wad poised to submit required
CY Qtr arrests data reports out of CJIC to BJA on the participants who were
arrested, the types of arrests and the number of days in a L-JPDf, and program
completion reports based on therapists manual tracking of program completion
(i.e., TF-CBT completion for this project). Monthly reports were provided by
MHD to the P&I committee on the number of youth who were referred by JPD,
screened and admitted by MHD, and dropped out of TF-CBT. Additionally, as

Open Science Journal – September 2019 10

Open Science Journal
Practice Bridge

proposed in the BJA Grant, a focus group discussion (FGD) was conducted
midyear into TF-CBT implementation. It explored what worked and what did
not work with active TF-CBT youth and parent participants.

II. Project Set-Up: During implementation of TF-CBT

The P&I committee met every month at the Juvenile Court Judge's Chamber,
accessed technical assistance and submitted quarterly reports to BJA. This
monthly meetings facilitated discussions to making adjustments to referrals and
admission criteria (as soon as MHD reported low referrals from JPD and
nonresponse by the youth), and redefining the nonviolent criteria. The P&I
committee was updated on MHD discussions on having more clinics and
therapists available for TF-CBT to improve access to TF-CBT, and adding
motivational interviewing during assessment — therapists have reported about
needing more time during assessment and treatment planning, about difficulty in
connecting with the youth or establishing alliance, and that assessment and
treatment care planning had taken longer because of youth's low trust. Managers
supported letting therapists decide on when therapy was considered completed
and reporting completion.
Adjustments to admission criteria. TF-CBT was offered to youth under the
jurisdiction of SC Juvenile Court. The cutoff score on the PTSD RI was lowered
from: 30 to 25 within three months of project implementation; 25 to 20 around
the third quarter of implementation; and after a year into the project, further
relaxed to meeting at least one of three symptom-domain criterion:
reexperiencing, avoidance and increased arousal on the PTSD RI [31].
Furthermore, of the 54 youth participants in this study, 15 met one trauma
symptom-domain, 23 met two symptom-domains, and 14 met 3 symptom-
domains (respective range of scores: 13-37, 21-41, and 34-62). One youth
participant had a pre-post TF-CBT YOQ, and a post-TF-CBT but not pre-TF-
CBT PTSD RI data; and another youth participant, who was exposed to
traumatic events did not meet any symptom domain criteria scored 13.
Redefining the legal definition of nonviolent youth. Originally, the TF-CBT
Grant was intended for nonviolent youth (prioritizing females) with no history of
violence. However, due to insufficient count and low response from the youth
referred by JPD, the nonviolent criterion was redefined (within the first Qtr of
implementation) to mean the youth’s current arrest was not for violence and still
met the funding’s requirement of legally nonviolent youth (defined by the State
of CA Code).
A year and a half into the TF-CBT project — considering the insufficient
number of female youth with no history of violence, JPD also referred to MHD
those whose arrests at the time of referral were for nonviolence; females on
judicial deferment pending probation period; and, 11 to 14-year-old males [31].
Improvements to access clinical services. Midyear into the first year of project
implementation, adjustments were made following the findings and suggestions
from the FGD. The implementation was expanded to four county clinics with 13
therapists trained in TF-CBT to address and avoid service access issues (e.g.,
wait time, clinic location, and staffing). All therapists had cultural competence
trainings. Three bilingual (English-Spanish) and bicultural (Latinos/Hispanics)
therapists were available. Participants were matched as closely as possible, with

Open Science Journal – September 2019 11

Open Science Journal
Practice Bridge

linguistically or culturally appropriate clinicians. For the convenience of youth

and their families, and with due consideration for safety of therapists, TF-CBT
sessions were held in schools, homes, L-JPDf, or SC County outpatient clinics
[31].
Incorporating motivational interviewing. Motivational interviewing was added
to the clinical assessment before the end of the first year of implementation to
improve youth engagement (anticipate barriers to engagement and to avoid
premature disengagement/terminations). By the second year of TF-CBT
implementation, therapists who had the option to seek guidance, consulted with
Dr. Anthony Mannarino (one of the TF-CBT developers).
Reporting of completion. Clinic managers also approved/supported reporting
completion per therapist’s judgment by the end of the first year of
implementation. In over three years, only 23 of 54 participants were reported by
therapists as completed TF-CBT and 31 were reported as dropped out or did not
complete TF-CBT.

III. Flow of Youth Participation and TF-CBT Completion

Of 154 youth referred by JPD to MHD (whose arrests at the time of referral
were confirmed as not for violent behaviors), 105 were screened and assessed,
while 49 did not respond or declined assessment. Of these 105 who were screened
and assessed between March 2012 and March 2015 by MHD: 71 were eligible and
offered TF-CBT, and 34 were not offered TF-CBT (30 did not meet any of the
prior eligibility criteria or any one of three symptom-domain criterion on the
PTSD RI to be eligible; and, four referred in the beginning of the program were
disqualified based on two prior eligibility cutoff scores on the program eligibility
tool). The 34 who were disqualified were referred back by MHD to JPD. Of those
71 eligible youth (a) 60 received at least one individual TF-CBT treatment
session including one who was transferred to a community-based provider because
a TF-CBT was established locally (b) two started TF-CBT in April 2015 and
were no longer tracked for this study, and (c) of the nine remaining eligible
youth, two declined participation while seven did not show up for any session due
to among others relocation or pregnancy — the reasons for declining were:
therapy was not needed, and nonacceptance of screening results. Of the 54 youth
participants, four withdrew after the first session, seven after the third and three
after the fourth. One participant completed TF-CBT in seven sessions, and the
rest (n = 39) finished at least eight sessions (including 15 who had one or more of
the first four TF-CBT components).
Per the anecdotal reports of therapists of youth nonresponse, nonresponse
could be due to changes of POs (who are routinely reassigned elsewhere) that
may have affected continuity of communications with the youth. Reassignment of
POs may have disrupted establishing connection and in turn lead to nonresponse
or low response. JPD/POs and MHD/therapists have stated that poor response
could be due to dysfunctional families and their unaddressed needs (associated
with a parent’s incarceration, health or economic issues). Regarding the
premature therapy withdrawal, therapists offered these reasons (a) the
unaddressed youth's dysfunctional families’ needs and that youth whose parents
were not involved tended to drop out (b) youth’s loss of interest after getting off
probation, getting rearrested or absconding, scheduling conflicts with other court-

Open Science Journal – September 2019 12

Open Science Journal
Practice Bridge

required programs, and (c) TF-CBT did not adequately address the needs
associated with symptoms of comorbidities manifested during TF-CBT.

IV. Impact of Characteristics of TF-CBT Youth Groups

and TF-CBT Completion

Demographics and justice involvement did not significantly impact TF-CBT

completion. Majority of All youth participants were Latinos/Hispanics (68.5%),
were males (57.4%), and indicated English as their preferred language (92.6%).
On average, the youth were 16 years old; and, had an average start lag of 41 days
(range, 6 to 85) and end lag of 51 days (range, 9 to 90). The sum of arrests
during TF-CBT averaged one (range, 0 to 3). The average number of days in a
L-JPDf was 23 (range, 0 to 161). The current study found no significant
difference BGs in demographic composition and in juvenile justice system
involvement during TF-CBT (see Table 2).

Table 2: Youth Demographic Characteristics and Justice System Involvement

All C7 C4-6 C1-4
n = 54 n = 12 n = 13 n = 29
Youth Demographic Characteristics
Sex: Male (57.4%) 7 (58.3%) 8 (61.5%) 16 (55.2%)
Female (42.6%) 5 (41.7%) 5 (38.5%) 13 (44.8%)
Ethnicity: Latino/Hispanic (68.5%) 8 (66.7%) 8 (61.5%) 21 (72.4%)
White (13.0%) 2 (16.7%) 1 (7.7%) 4 (13.8%)
Black (5.6%) 1 (8.3%) 0 (0.0%) 2 (6.9%)
Asian, PI, & Native Americana (7.6%) 0 (0.0%) 3 (23.1%) 1 (3.4%)
Other/Unknown (5.6%) 1 (8.3%) 1 (7.7%) 1 (3.4%)
Preferred Language: English (92.6%) 11 (91.7%) 11 (84.6%) 28 (96.6%)
Spanish (5.6%) 1 (9.1%) 1 (7.7%) 1 (3.4%)
Vietnamese (1.9%) 0 (0.0%) 1 (7.7%) 0 (0.0%)

M(SD) range
Age at assessment (in years) 16.2(1.1) 15.9(1.1) 14-17 16.2(0.9) 14-17 16.3(1.2) 14-18
Justice System Involvement during TF-CBT
TF-CBT start lag (in days) 41.3(22.5) 42.6(19.8) 9-77 43.1(24.3) 7-78 40.0(23.3) 6-85
TF-CBT end lag (in days) 50.6(25.1) 43.5(24.8) 10-91 53.0(27.0) 9-87 52.5(24.6) 9-90
Sum of Qtr arrests (coded 1 or 0 per Qtr) 0.8(1.0) 1.0(1.2) 0-3 0.5(0.9) 0-3 0.8(1.0) 0-3
Days in locked juvenile facility ((1.21)
22.7(40.0) 28.7(44.7) 0-114 18.5(44.1) 0-154 22.1(37.3) 0-161
Note. TF-CBT = Trauma-Focused Cognitive Behavioral Therapy; C7 = sequentially completed TF-CBT without in
vivo; C4-6 = nonsequentially completed TF-CBT, including trauma narration & processing; C1-4 = completed 1 to 4
of any one or a combination of the first four TF-CBT components; PI = Pacific Islander; Qtr = quarter. a Combined
to avoid identification.

Clinical characteristics of youth groups had impact on TF-CBT

completion. More than half of the youth participants (64.8%, n = 54) had a
parent or family member involved consistently during treatment sessions. The
number of sessions for the therapists to complete in-person ATCP prior to TF-
CBT tx1 ranged from 1 to 8, and 61.1% of the participants took three or more
in-person sessions. The number of trauma events experienced by the youth
before TF-CBT ranged from 1 to 13 and averaged five. The number of TF-CBT

Open Science Journal – September 2019 13

Open Science Journal
Practice Bridge

txS ranged from 1 to 24 and the average was nine. Instead of strict weekly
sessions, the average number of days between TF-CBT txS became 16 days
because the youth cancelled or did not show up as scheduled (see Table 3).

Table 3: Clinical Characteristics by TF-CBT Services Group

All C7 C4-6 C1-4
Therapist's Connection with Youth & Parent n = 53-54 n = 12 n = 12-13 n = 29
Parent/Family Involvement during TF-CBT
During assessment only 5 (9.3%) 0 (0.0%) 1 (7.7%) 4 (13.8%)
Therapist played role 11 (20.4%) 0 (0.0%) 3 (23.1%) 8 (27.6%)
Parent inconsistent 3 (5.5%) 1 (8.3%) 0 (0.0%) 2 (6.9%)
Parent or family member 35 (64.8%) 11 (91.7%) 9 (69.2%) 15 (51.7%)
a
Days between last ATCP & tx1: M(SD)range 20.3(26.0) 13.1(11.1)0-35 6.0(4.7)0-14 29.2(31.7)0-126
Days Between Last ATCP to tx1: up to 7 25 (46.3%) 5 (41.7%) 9 (69.2%) 11 (37.9%)
more than 7 28 (51.9%) 7 (58.3%) 3 (23.1%) 18 (62.1%)
a
M(SD)range .5(.5) .4(.5)0-1 .7(.4)0-1 .4(.5)0-1
Number of in-person ATCP sessions: up to 2 21 (38.9%) 2 (16.7%) 8 (61.5%) 11 (37.9%)
more than 2 33 (61.1%) 10 (83.3%) 5 (38.5%) 18 (62.1%)
range 1-8 1-4 1-4 1-8
a
M(SD)range 0.4(.5) .2(.4)0-1 .6(.5)0-1 .4(.5)0-1

All C7 C4-6 C1-4

Youth Trauma Characteristics n = 54 n = 12 n = 13 n = 29
b
Disaster (1,0,1,0) 10 (18.5%) 2 (16.7%) 3 (23.1%) 5 (17.2%)
Bad accident (1,0,1,0) 24 (44.4%) 4 (33.3%) 5 (38.5%) 15 (51.7%)
A place with ongoing war (9,1,4,4) 4 (7.4%) 1 (8.3%) 1 (7.7%) 2 (6.9%)
Hit, punched, kicked at home (4,0,1,3) 19 (35.2%) 2 (16.7%) 5 (38.5%) 12 (41.4%)
Seeing family member hit, punched, kicked at home (2,0,1,1) 31 (57.4%) 6 (50.0%) 6 (46.2%) 19 (65.5%)
Beat up, shot at/threatened in school/neighborhood (2,1,0,1) 30 (55.6%) 6 (50.0%) 8 (61.5%) 16 (55.2%)
Seeing someone else in above, including killed (0,0,0,0) 39 (72.2%) 4 (33.3%) 8 (61.5%) 27 (93.1%)
Seeing dead body in neighborhood (3,0,0,3) 25 (46.3%) 2 (16.7%) 6 (46.2%) 17 (58.6%)
Sexually touched by someone much older against will (7,2,0,5) 17 (31.5%) 1 (8.3%) 5 (38.5%) 11 (37.9%)
Violent death/injury of loved one (0,0,0,0) 34 (63.0%) 7 (58.3%) 10 (76.9%) 17 (58.6%)
Scary medical treatment (3,1,0,2) 19 (35.2%) 4 (33.3%) 4 (30.8%) 11 (37.9%)
Forced sex (6,2,1,3) 9 (16.7%) 1 (8.3%) 2 (15.8%) 6 (20.7%)
Others not on list (scary, dangerous or violent) (10,2,1,7) 21 (38.9%) 5 (41.7%) 8 (61.5%) 8 (27.6%)
c
Sum of trauma events experienced (38,7,9,22) 282(40.2%) 45(28.9%) 71 (42.0%) 166 (44.0%)

M(SD)range
Number of PTSD symptom domains 1.9(1.0) 2.2(0.6)1-3 1.8(0.8)1-3 1.9(0.8)0-3
Number of trauma events experienced 5.3(2.4) 3.8(1.5)1-6 5.7(2.3)2-11 5.7(2.5)2-13
Quality and Fidelity of TF-CBT M(SD)range
Engagement duration (in CY Qtr) 2.5(1.0) 3.2(.6)2-4 2.8(.8)1-4 2.0(.9)1-4
Number of days engaged in program 132(80) 201(38.7)133-259 156(63)74-302 93(76)0-252
Number of components completed 4.2(2.1) 7.0(0)7-7 5.5(0.8)4-6 2.5(1.0)1-4
Number of TF-CBT txS 9.0(5.5) 13.6(5.0)7-22 12.3(4.5)8-24 5.6(3.6)1-15
d
Average of number of days between txS 95.(5.(
16.1(8.7) 17.0(8.0)7.8-37.0 13.5(6.6)8.2-33.6 17.1(10.0)4.8-41.7
Average of time spent per txS (in min) 76.8(17.9) 71.2(8.8)53-83 76.2(12.0)63-111 79.5(17.9)30-143
Services received (in min) 675(425) 963(346)459-1605 940(361)503-1695 437(336)45-1734
Note. TF-CBT = Trauma-Focused Cognitive Behavioral Therapy; C7 = sequentially completed TF-CBT without in vivo; C4-6 =
nonsequentially completed TF-CBT 4 to 6 components, including trauma narration & processing; C1-4 = completed 1 to 4 of any
one or a combination of the first four TF-CBT components; ATCP = assessment and treatment care planning; tx1 = first TF-CBT

Open Science Journal – September 2019 14

Open Science Journal
Practice Bridge

treatment session; PTSD = post-traumatic stress disorder; txS = TF-CBT treatment session(s). CY Qtr = calendar year
a b c
quarter(s). values indicated are M(SD)range. Number of missing responses on 12 events for columns left to right. Denominator =
d
sample size n x 13 events. n = 50 for All and n = 25 for C1-4.

(a) Parental involvement impacted completion. Significant difference BGs

was found in parental involvement during TF-CBT sessions (two categories: χ2
= 6.08, df = 2, p = .048; three categories: LR = 12.04, df = 4, p = .017). Almost
all of the youth in C7 had parents consistently involved during TF-CBT (91.7%)
compared to C4-6 (69.2%) and C1-4 (51.7%) (refer to Table 3). No significant
difference BGs was found in the time interval between the last ATCP and tx1
and number of in-person ATCP sessions.
(b)Youth trauma events experienced impacted completion. For All youth
participants (n = 54) the average number of trauma symptom-domains indicated
before TF-CBT by the youth was two (see Table 3), symptom scores on the
PTSD RI-19 was 37.47 (range, 22 to 60); and the mental and behavioral
functioning scores on the YOQ was 46.70 (range, 16 to 88) (see Table 1). C7 was
the least traumatized (28.9% of the group had exposure to 1 to 6 traumatic
events) compared to C4-6 (42% had experienced 2 to 11 traumatic events) and
the youth in C1-4 (44% had 2 to 13 traumatic events experienced). C1-4 was
relatively more traumatized than C4-6 and C7 (more than 50% of the youth in
C1-4 indicated having experienced 6 of 12, average = 6 events) compared to 3 of
12 events (average = 6) in C4-6, and 1 of 12 events (average = 4) in C7 (see
Table 3). Significant BGs difference was found in number of trauma events
experienced (F = 3.58, df = 2, p =.035). No significant difference BGs was found
in number of symptom domains and total scores on trauma symptoms and
functioning.
(c) Quality and fidelity of TF-CBT. For All participants, the total amount of
time for services received ranged from 45 to 1734 min (average, 675 min), the
average number components completed was five and amount of time spent per
session was 76.8 minutes (range, 53 to 143 min) (see Table 3). The groups
significantly differed (a) in total number of days engaged in the program (F =
12.44, df = 2, p = .000) and duration of engagement in CY Qtr (χ2 = 16.70, df =
6, p = .010), and (b) in quality based on number of txS (F = 21.44, df = 2, p =
.000), total amount of time for services received (F = 15.00, df = 2, p = .000),
and the number of components provided (χ2 = 94.86, df = 12, p = .000). No BGs
difference was found in the average number of days between TF-CBT txS and in
all the other measures of quality and fidelity of TF-CBT that were examined. Of
the three groups, C7 had the most number of sessions, amount of time received,
and longest duration of engagement (in addition to C7 having the most number
of components completed) while C1-4 had the least in fidelity of TF-CBT.
Also noted: Trauma narration and processing was provided more than four
times to youth in C7 (n =5, with one who had an 8- and then 38-min sessions on
the same day) and C4-6 (n = 7, with one who had a 23- and then 70-min sessions
on the same day). TF-CBT components provided in at least three different
sessions were: (a) trauma narration and processing to youth in C7 (n = 8), and
C4-6 (n = 11); (b) cognitive coping and processing to youth in C7 (n = 2), C4-6
(n = 1) and C1-4 (n = 2); (c) affect expression and modulation to youth in C7 (n
= 1), C4-6 (n = 1), and C1-4 (n = 2); (d) relaxation to youth in C1-4 (n = 4);

Open Science Journal – September 2019 15

Open Science Journal
Practice Bridge

and (e) psychoeducation and parenting to youth in C4-6 (n = 1) and C1-4 (n =

1). 24.1% completed all four components in phase I in 8 to 15 sessions.
V. Satisfaction with Services Had No Impact on TF-CBT
Completion

There were a few indicated that the program did not meet or met only very
little of their needs (n =3), the amount of help was not satisfactory (n = 2), or
they would not come back (n = 3). The program satisfaction average score was
high at 3.3 (TF-CBT C7, n = 10) and 3.6 (TF-CBT C4-6, n = 11) on a scale of 1
to 4. Groups C7 and C4-6 were not significantly different in services satisfaction
on CSQ-8 total sum of scores.

VI. Significant Trauma Symptom Reduction Was Found

in C7 (TF-CBT without in vivo)

This study found significant decrease in overall trauma symptom scores on the
PTSD RI-19 before and after TF-CBT participation with a very large effect size
in group C7 (t = 3.73, p < .001, n = 12, d = 1.08). No significant improvement
in mental and behavioral functioning scores on the YOQ after TF-CBT
participation was found in either C7 or C4-6 (see Table 4). The χ2 tests results
yielded no significant different outcome on measures of justice system
involvement between TF-CBT services groups at each of the four post-TF-CBT
CY Qtrs.

Table 4: Change in Trauma Symptoms and Mental and Behavioral Functioning within TF-CBT Services Groups
Measures Paired t-test Pre-TF-CBT Post-TF-CBT
M(SD) 95 % CI t df p Cohen’s M(SD) M(SD)
d n n
Trauma Symptoms C7 17.67(16.39)7.25,28.08 3.73** 11 .003 1.08 41.42(12.63) 23.75(12.50)
PTSD RI-19 12 12
Overall Functioning C7 15.25(22.79)-3.80,34.30 1.89 7 .100 0.67 46.92(13.75) 34.50(15.11)
YOQ 12 8
C4-6 19.30(32.15)-3.70,42.30 1.90 9 .093 0.60 44.69(19.43) 26.90(22.89)
13 10
Note. TF-CBT = Trauma-Focused Cognitive Behavioral Therapy; PTSD RI = Post Traumatic Stress Disorder
Reaction Index; YOQ = Youth Outcomes Questionnaire; C7 = sequentially completed TF-CBT without in vivo; C4-6
= nonsequentially completed 4 to 6 components including trauma narration & processing. ** p < .01.

Discussion

This study reconfirms that TF-CBT (even without in vivo) results in trauma
symptom reduction. However, in order to maximize the benefits of TF-CBT for
youth under probation, it is important to tackle the apparent distrust by the
youth (of parent/caregiver, therapist, POs and the situation); and, recognize the
need to fully prepare therapists in working with justice involved youth within the
context of the justice system — both of which are crucial to improving the
quality and fidelity of TF-CBT and program effectiveness for the youth under

Open Science Journal – September 2019 16

Open Science Journal
Practice Bridge

probation. The author draws important lessons from SC County's TF-CBT

project implementation.
The current study's findings of significant reduction in trauma symptoms on
the PTSD RI-19 in C7 (TF-CBT without in vivo, n = 12) is consistent with
earlier meta-analytic or empirical studies on effectiveness of TF-CBT that have
reported generally large effect sizes for TF-CBT on trauma symptom reduction
[27, 41, 42, 43, 44]. However, the findings of no improvement in mental and
behavioral functioning on the YOQ before and after TF-CBT participation was
manifest on the last day of TF-CBT treatment session; and, no impact of TF-
CBT on arrests at first, second, third and fourth CY Qtr after TF-CBT
participation, are not consistent with past studies on TF-CBT effectiveness. Prior
studies have reported no greater than a medium effect size on behavioral
functioning [27], and an earlier TF-CBT effectiveness study in a community
setting, where the effect of TF-CBT over time (i.e., up to a year from the
beginning of TF-CBT treatment implementation; and 10 sessions on average) was
found to be the least stable on externalizing behavioral problems [45]. Perhaps,
the 17-day average interval between txS (in C7) which is way beyond the
recommended weekly sessions may have affected skills-building and continuity of
youth and family/caregiver’s supervised learning. This time interval does not
allow for continuity of skills to “take hold” and likely contributed to poorer
outcomes and potentially to poorer retention. It is also possible that the exclusion
of in vivo mastery had affected the outcome — although in vivo is an optional
component when clinically indicated [24, 22], not all the anecdotal reasons cited
by therapists for in vivo exclusion in the current study were convincing. In a
RCT study to compare TF-CBT and client-centered therapy (CCT), families
experiencing ongoing exposure to intimate partner violence (IPV), which is
similar to the current study's population were provided in vivo component that
focused not on mastery of reminders of past IPV, but on helping the youth
develop the ability to distinguish between real danger and generalized fears [46,
47].
Overall, despite the TF-CBT project’s readiness and responsiveness that
enabled implementation, the unaddressed barriers could very well be due to
youth low disclosure and development of trust and therapist’s skills. These
barriers are reflected in the youth's nonresponse, eligible youth declining
participation, MHD returning youth to JPD due to ineligibility, and youth
reported as not completing TF-CBT. This study finds the significant BGs
difference (especially between C7 compared to C4-6 and/or C1-4) in the youth's
trauma events experienced, in parental involvement, and engagement suggesting
that multiply traumatized youth and their families would have and present more
difficulties in completing TF-CBT.
The author calls attention to important lessons from studying SC County's
TF-CBT project implementation. First of all, given that creating an environment
where a relationship of trust between therapist and client is established is
paramount, it is possible that the MHD was viewed by the youth as part of the
police system which they instinctively do not trust — the importance of trust in
the police (law enforcement) by juveniles/adolescents has been repeatedly
emphasized [48] and research has even shown that compared to adults, juveniles
tend to profess more hostile attitude against the police, and even more so if they
reside in metropolitan areas [49]. Apparently, the trainings have not sufficiently

Open Science Journal – September 2019 17

Open Science Journal
Practice Bridge

prepared the therapists in building trust and caring connection (empathy) with
the youth and their caregiver(s), handling ethical conflicts within the context of
the justice system, and skillfully assessing trauma and developing treatment plans
— it is the ethical responsibility of therapists to inform clients of the limits of
confidentiality in therapy [50] and seek confidential consultation from experts and
experienced colleagues on ethical conflicts experienced by therapists in a
correctional environment [51, 52, 53]. It is a serious oversight to not have
recognized the need to fully prepare and support therapists through trust-
building trainings and consultations to effectively work with justice system
involved youth with a background of significant trauma events and coming from
a dysfunctional environment (home or neighborhood).
Therapists should be prepared in trauma assessment anticipating the fear or
distrust and the need to protect oneself from the unfamiliar situation (prior to
contact, during assessment and treatment sessions) by multiply traumatized
justice involved youth. The preparations could include trainings (a) in trust-
building and empathy (b) in providing assistance to low disclosing youth and
their caregiver early on during ATCP and in completing self-administered tools
(such as the PTSD RI and YOQ), and (c) on when and how a therapist would be
suitable to play the parent role to provide TF-CBT and in engaging parents or
caregivers — in a study involving a similar population, it has been shown that
therapists who had training in how to assess readiness and engage foster parents
prior to TF-CBT had more of the youth completing TF-CBT [25]. Therapists
could avail of expert consultations on creative ways to provide in vivo if
appropriate and systematically addressing challenges to fidelity of TF-CBT.
These trainings could potentially reduce the reluctance to disclose severity of
need as well as the therapist-youth/family connection that impact the outcome of
therapy.
Second, a clinical quality peer review (CQR) staff/team could be designated
to support therapists starting from the ATCP sessions, in improving the quality
and fidelity of TF-CBT for multiply traumatized youth. An outcome reporting
protocol that includes a clear definition of levels of participation, services or
completion would be useful for CQR — as such gives an indication of the fidelity
of TF-CBT and guidance for follow-up case planning and management. In
addition, therapists could assess by the third session the youth’s and the
caregiver’s satisfaction with services (considering that 48.3% in C1-4 have
dropped out by the fourth session) and addressing issues, such as caregiver
limitations that impact youth participation that could reduce withdrawal from
therapy. In other words, including a standard clinical quality review and
management team would have benefitted this project's implementation.
Third, on the author’s side, because the IRB study consent was limited to
youth-related data only, a very systematic data collection of information on
parents and family could not be done. Information on parents and family could
be routinely collected since this data collection may be pertinent to explaining
the noninvolvement of parent(s) and family or guardian and understanding
barriers to maximizing the conjoint parent-child session.
Fourth, with clear guidance, skillful and experienced therapists should be able
to offer TF-CBT and make it easy for youth under probation to avail of the
therapy — given that the youth's overall low disclosure as a response to the
stigma attached to mental illness and involvement with the legal justice system is

Open Science Journal – September 2019 18

Open Science Journal
Practice Bridge

well known [54] and the extensive literature and research studies that have
associated delinquent behaviors and justice involvement with significant youth
trauma events which could manifest as violent or aggressive behavior [55, 56, 10,
57]. Recognizing that it is critical for youth under probation to be assessed for
trauma, and their suitable caregiver be engaged by therapists, eligibility
requirements could be waived (with clear justifications and supporting
documentation) so the youth do not miss the opportunity for TF-CBT.
Fifth, future implementations should consider tracking and systematically
collecting data on behaviors that are incompatible with those that would warrant
arrests (e.g., youth’s attendance in supervised social-educational programs that
may be school, community or faith-based) to show the impact of TF-CBT on
behavioral functioning — as arrests and incarceration data have been viewed as
more indicative of the official response to criminal behavior [58], and considering
that in the current study, arrests might not have been precisely captured due to
the fact that behaviors that warrant arrests must be reported by someone and/or
seen, caught and recorded by proper authorities.
And Lastly, a coherent communications protocol between and among POs,
therapists, youth, and caregivers for introduction of TF-CBT, role clarifications,
expectations and other opportunities for the youth could result in greater
interest, reduce nonresponse, build trust, and avoid conflicts of schedules with
other programs. The need for a coherent communications protocol should not
have been overlooked.

Conclusion

Many have strongly argued for better and cost-effective alternatives to youth
incarcerations in the USA. The literature reviews include a vast number of
studies (a) that have captured the evidence for the negative impact of
incarceration on juvenile offenders' health and development [59, 60, 61, 62, 63]
and savings from and cost-effectiveness of community-based programs compared
to imprisonment [61, 63] and (b) that provide support for Evidence-Based
Therapies (EBTs) — when properly implemented with fidelity, as a better choice
than incarceration [60, 63]. The reduction in trauma symptoms in multiply
traumatized youth under probation would certainly help prepare these youth for
follow-up programs that may then focus on behavioral functioning. To improve
techniques and processes, it is critical that the outcomes and lessons from
implementations of EBTs (such as TF-CBT) in community or outpatient setting
for youth under probation and similar populations are disseminated.

Acknowledgment

The TF-CBT collaborative project was funded by the U.S. Bureau of Justice
Assistance Justice and Mental Health Collaborative Project (JMHCP) 2011
Grant to the Santa Clara County Superior Court. The members of the JMHCP
TF-CBT Committee were: Judge Patrick Tondreau, TBowles, KDelima, &
CMoran with Superior Court; KAvila, LGarnette, JHowe, JSanchez, & LSmith

Open Science Journal – September 2019 19

Open Science Journal
Practice Bridge

with the JPD; YAscue, BCopley, AKong, SMonte, BSalada, STerao, & DWiley
with the MHD; MEPangilinan with Research and Evaluation; the unidentified
youth and their families who participated in the program; YAscue, BSalada,
KAvila, HNguyen, APham, AKong, & PEspejo for help with data collection and
retrieval; EBautista for data entry; F&C TF-CBT Clinical Team; Dr. Anthony
Mannarino for TF-CBT training and consultancies; Ms. CKimmelman-DeVries &
Dr. Marrow for program technical assistance; and the UCSF Research Group:
Drs. Martha Shumway, SDarrow, LFields, JParmenter, DYoung, HZhang,
CValdez, CChia-Ying & AMeltzer for helpful comments on the manuscript.
Special acknowledgements to Yuki Ascue for invaluable assistance and
suggestions.

Disclaimer

The research reported here does not reflect the views of the Santa Clara
County Behavioral Health Services Department, Juvenile Probation Department
and Superior Court of Santa Clara County.

References
1. Zelechoski, A. (2016). Trauma, adverse experience, and offending. In K. Heilbrun (Ed.), APA
handbook of psychology and juvenile justice (pp. 325-342). http://dx.doi.org/10.1037/14643-015
2. Abram, K., Teplin, L., Charles, D., Longworth, S., McClelland, G., & Dulcan, M. (2004).
Posttraumatic stress disorder and trauma in youth in juvenile detention. Archives of General
Psychiatry, 61, 403-410. http://dx.doi.org/10.1001/archpsyc.61.4.403
3. Abram, K., Washburn, J., Teplin, L., Emanuel, K., Romero, E., & McClelland, G. (2007).
Posttraumatic stress disorder and psychiatric comorbidity among detained youths. Psychiatric
Services, 58(10), 1311-1316. doi:10.1176/appi.ps.58.10.1311
4. Maschi, T., Bradley, C., & Morgen, K. (2008). Unraveling the link between trauma and
delinquency. Youth Violence and Juvenile Justice, 6, 136-157.
http://dx.doi.org/10.1177/1541204007305527
5. Bender, K. (2010). Why do some maltreated youth become juvenile offenders? A call for further
investigation and adaptation of youth services. Children and Youth Services Review, 32, 466-473.
http://dx.doi.org/10.1016/j.childyouth.2009.10.022
6. Wilson, H., Stover, C., & Berkowitz, S. (2009). Research review: The relationship between
childhood violence exposure and juvenile antisocial behavior: a meta-analytic review. The Journal
of Child Psychology and Psychiatry, 50(7), 769-779. doi:10.1111/j.1469-7610.2008.01974.x
7. Ford, J., Elhai, J., Connor, D., & Frueh, B. (2010). Poly-victimization and risk of posttraumatic,
depressive, and substance use disorders and involvement in delinquency in a national sample of
adolescents. Journal of Adolescent Health, 46(6), 545-552.
8. Ford, J. (2012). Posttraumatic stress disorder among youth involved in juvenile justice. In E.L.
Grigorenko (Ed.), Handbook of juvenile forensic psychology and psychiatry (pp. 485-501).
doi:10.1007/978-1-4614-0905-2_31
9. Heilbrun, K., & Locklair, B. (2016). Forensic assessment of juveniles. In K. Heilbrun (Ed.), APA
handbook of psychology and juvenile justice (pp. 345-363). http://dx.doi.org/10.1037/14643-016
10. Feierman, J. & Ford, J. (2016). Trauma informed juvenile justice systems and approaches. In K.
Heilbrun (Ed.), APA handbook of psychology and juvenile justice (pp. 545-573).
http://dx.doi.org/10.1037/14643-025
11. Ford, J., Chapman, J., Mack, M., & Pearson, G. (2006). Pathway from traumatic child
victimization to delinquency: Implications for juvenile and permanency court proceedings and
decisions. Juvenile and Family Court Journal, 57, 13-26. http://dx.doi.org/10.1111.j.1755-
6988.206.tb00111.x

Open Science Journal – September 2019 20

Open Science Journal
Practice Bridge

12. Norman, S., Elbogen, E., & Schnurr, P. (Updated Feb 2016). Research findings on PTSD and
violence. Retrieved from http://www.ptsd.va.gov/professional/co-
occurring/research_on_ptsd_and_violence.asp
13. Allwood, M., Bell, D., & Horan, J. (2011). Posttrauma numbing of fear, detachment, and arousal
predict delinquent behaviors in early adolescence. Journal of Clinical Child & Adolescent
Psychology, 40, 659-667. doi:10.1080/15374416.2011.597081
14. Chassin, L., Mansion, A., Nichter, B. & Pandika, D. (2016). Substance use and substance use
disorders as risk factors for juvenile offending. In K. Heilbrun (Ed.), APA handbook of psychology
and juvenile justice (pp. 277-305). http://dx.doi.org/10.1037/14643-013
15. Dierkhising, C., Ko, S., Woods-Jaeger, B., Briggs, E., Lee, R., & Pynoos, R. (2013). Trauma
histories among justice-involved youth: findings from the national child traumatic stress network.
European Journal of Psychotruamatology, 4: 20274 - http://dx.doi.org/10.3402/ejpt.v4i0.20274
16. Ford, J., Chapman, J., Hawke, J., & Albert, D. (2007). Trauma among youth in the juvenile
justice system: Critical issues and new directions (Research and Program Brief). Delmar, NY:
National Center for Mental Health and Juvenile Justice. www.ncmhjj.com
17. Kerig, P., Ward, R., Vanderzee, K., & Arnzen Moedell, M. (2009). Posttraumatic stress as a
mediator of the relationship between trauma and mental health problems among juvenile
delinquents. Journal of Youth and Adolescence, 38, 1214-1225. http://dx.doi.org/10.1007/s10964-
008-9332-5
18. Kerig, P., Bennett, D., Thompson, M., & Becker, S. (2012). “Nothing really matters”: Emotional
numbing as a link between trauma exposure and callousness in delinquent youth. Journal of
Traumatic Stress, 25, 272-279. http://dx.doi.org/10.1002/jts.21700
19. King, D., Abram, K., Romero, E., Washburn, J., Welty, L., & Teplin, L. (2011). Childhood
maltreatment and psychiatric disorders among detained youths. Psychiatric Services, 62, 1430-
1438. http://dx.doi.org/10.1176/appi.ps.004412010
20. Mallett, C., Stoddard Dare, P., & Seck, M. (2009). Predicting juvenile delinquency: The nexus of
childhood maltreatment, depression and bipolar disorder. Criminal Behavior and Mental Health,
19, 235-246. http://dx.doi.org/10.1002/cbm.737
21. Rosenberg, H., Vance, J., & Rosenberg, S., Wolford, G., Ashley, S., & Howard, M. (2014).
Trauma exposure, psychiatric disorders, and resiliency in juvenile-justice-involved youth.
Psychological Trauma: Theory, Research, Practice, and Policy, 6, 430-437.
http://dx.doi.org/10.1037/a0033199
22. Cohen, J. Mannarino, A., & Deblinger, E. (2017). Treating trauma and traumatic grief in
children and adolescents. New York, NY: The Guilford Press.
23. Cary, C & McMillen, C. (2012). The data behind dissemination: A systematic review of trauma-
focused cognitive behavioral therapy for use with children and youth, Children and Youth
Services Review, 34, 748-757. doi:10.1016/j.childyouth.2012.01.003
24. Cohen, J. Mannarino, A., & Deblinger, E. (2006). Treating trauma and traumatic grief in
children and adolescents. New York, NY: The Guilford Press.
25. Dorsey, S., Pullmann, M., Berliner, L., Koschmann, E., McKay, M. & Deblinger, E. (2014).
Engaging foster parents in treatment: A randomized trial of supplementing Trauma-focused
Cognitive Behavioral Therapy with evidence-based engagement strategies. Child Abuse &
Neglect, 38, 1508-1520. http://dx.doi.org/10.1016/j.chiabu.2014.03.020
26. Cohen, J.A., Mannarino, A. P., Janlowski, K., Rosenberg, S., & Wolford, G.L. (2016). A
randomized implementation study of TF-CBT for adjudicated teens in residential treatment
facilities. Child Maltreatment, 21, 156-167. doi:10.1177/1077559515624775
27. Arellano de, M., Lyman, D., Jobe-Shields, L., George, P., Dougherty, R., Daniels, A., Ghose, S.,
Huang, L., & Delphin-Rittmon, M (2014). Trauma-focused cognitive behavioral therapy:
Assessing the evidence. Psychiatric Services, 65, 591-602. doi:101176/appi.ps.201300255
28. Osher, F. (2012a, March). Implementing evidence-based practices. Orientation and Technical
Assistance Events for FY 2011 JMHCP. Plenary session conducted at the Council of State
Governments Justice Center, Washington D.C.
29. Osher, F. (2012b, March). Targeting the right people for the right intervention. Orientation and
Technical Assistance Events for FY 2011 JMHCP. Plenary session conducted at the Council of
State Governments Justice Center, Washington D.C.
30. Santa Clara County Superior Court (2011). Justice and Mental Health Collaborative Project
Proposal Submitted to the Bureau of Justice Assistance. Unpublished.
31. Santa Clara County Superior Court (2012-2015). Santa Clara County Superior Court Reports to
Bureau of Justice Assistance: 2012-2015. Retrieved from https://www.bjaperformancetools.org/
32. Pynoos, R. & Steinberg, A. (2012). University of California Post Traumatic Stress Disorder
Reaction Index (UCLA PTSD-RI) Version 2012. Unpublished.

Open Science Journal – September 2019 21

Open Science Journal
Practice Bridge

33. Burlingame, G., Wells, M., Lambert, M., & Reisinger, C. (1998 & 2002). Youth Outcome
®
Questionnaire (Y-OQ -30.2). American Professional Credentialing Services.
34. Attkisson, C. & Larsen, D. (2009). Client Satisfaction Questionnaire. www.CSQscales.com
35. Santa Clara County Social Services Agency (January 1, 2011). Quarterly Statistical Data of
Public Assistance Families in the County of Santa Clara. Retrieved from
https://www.sccgov.org/sites/ssa/debs/stats/Documents/Quarterly-Stat-2011_01.pdf
36. Steinberg, A., Brymer, M., Decker, K., & Pynoos, R. (2004). The University of California, Los
Angeles Post Traumatic Stress Disorder Reaction Index. Current Psychiatry Reports, 6(2), 96-
100.
37. Steinberg, A., Brymer, M., Kim, S., Briggs, E., Ippen, C., Ostrowski, S., Gully, K., & Pynoos, R.
(2013). Psychometric properties of the UCLA PTSD Reaction Index: Part I. Journal of
Traumatic Stress, 26:1- 9.
38. American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders
th
(5 ed.). Arlington, VA: American Psychiatric Publishing.
39. Burlingame, G., Dunn, T., Hill, M., Cox, J., Wells, M.G., Lambert, M., & Brown, G. (2004).
TM
Administration and Scoring Manual for the Y-OQ -30.2. www.OQMeasures.com
40. Attkisson, C. & Greenfield, T. (2004). The UCSF Client Satisfaction Scales: I. The Client
Satisfaction Questionnaire-8. In M.E. Maruish (Ed.), The use of psychological testing for
rd
treatment planning and outcomes assessment (3 Ed) (pp. 799-811). Vol 3. Mahwah, NJ:
Lawrence Erlbaum Associates.
41. Murry, L., Skavenski, S., Kane, J., Mayeya, J., Dorsy, S., Cohen, J., Michalopoulos, L., Imasiku,
M. & Bolton, P (2015). Effectiveness of trauma-focused behavioral therapy among trauma-
affected children in Lusaka, Zambia: A randomized clinical trial. Journal of American Medical
Association Pediatrics, 169, 761-769. doi:10.1001/jamapediatrics.2015.0580
42. O'Donnell, K., Dorsey, S., Gong, W., Ostermann, J., Whetten, R., Cohen, J., Itemba, D.,
Manongi, R. & Whetten, K (2014). Treating maladaptive grief and post-traumatic stress
symptoms in orphaned children in Tanzania: group-based trauma-focused cognitive-behavioral
therapy. Journal of Traumatic Stress, 27, 664-671. Abstract retrieved from
http://psychnet.apa.org
43. Sachser, C., Keller, F. & Goldbeck, L. (2016). Complex ptsd as proposed for ICD-11: Validation
of a new disorder in children and adolescents and their response to trauma-focused cognitive
behavioral therapy. Journal of Psychology and Psychiatry, No pagination Specified. Abstract
retrieved from http://psychnet.apa.org
44. Sanders, B. & Hanson, R. (2013, September). Can RCT treatment effects be achieved in
community practice of trauma treatment? Paper presented at the Thirteenth ISPCAN European
Regional Conference on Child Abuse and Neglect, International Society of Child Abuse and
Neglect, Dublin, Ireland. Abstract retrieved from http://psychnet.apa.org
45. Webb, C., Hayes, A., Grasso, D., Laurenceau, JP., & Deblinger, E. (2014). Trauma-focused
cognitive behavioral therapy for youth: Effectiveness in a community setting. Psychological
Trauma: Theory, Research, Practice, and Policy, 6, 555-562. http://dx.doi.org/10.1037/a0037364
46. Cohen, J., Mannarino, A., & Iyengar, S. (2011). Community treatment of posttraumatic stress
disorder for children exposed to intimate partner violence. Archives of Pediatrics & Adolescent
Medicine, 165(1), 16-21.
47. Cohen, J., Mannarino, A., & Murray, L. (2011). Trauma-focused CBT for youth who experience
ongoing traumas. Child Abuse and Neglect, 35, 637-646. DOI:10.1016/j.chiabu.2011.05.002
48. Tyler, T. (2015). Why trust matters with juveniles. American Journal of Orthopsychiatry, 85(6),
93-99.
49. Hurst, Y. (2007). Juvenile attitudes toward the police. Criminal Justice Review, 32(2), 121-141.
50. Appelbaum, P. (2002). Privacy in psychiatric treatment: Threats and responses. American
Journal of Psychiatry, 159, 1809-1818.
51. Bonner, R., & Vandecreek, L. (2006). Ethical decision making for correctional mental health
providers. Criminal Justice and Behavior, 33, 542-564.
52. Bruggen, Eytan, Gravier, & Elger (2013). Medical and legal professionals' attitudes towards
confidentiality and disclosure of clinical information in forensic settings: A survey using case
vignettes. Medicine, Science, and the Law, 53, 132-148. doi:10.1258/msl.2012.012045
53. Wangmo, T., Handtke, V., & Elger, B. (2014). Disclosure of past crimes: An analysis of mental
health professionals' attitudes towards breaching confidentiality. Journal of Bioethical Inquiry,
11, 347-358.
54. Louden, J., Manchak, S., Ricks, E., & Kennealy, P. (2018). The role of stigma toward mental
illness in probation officers' perceptions of risk and case management decisions. Criminal Justice
and Behavior, 45, 573-588. doi:10.1177/00093854818756148

Open Science Journal – September 2019 22

Open Science Journal
Practice Bridge

55. Baer, J. & Maschi, T. (2003). Random acts of delinquency: Trauma and self-destructiveness in
juvenile offenders. Child and Adolescent Social Work Journal, 20, 85-98.
56. DeLisi, M., Drury, A., Kosloski, A., Caudill, J., Conis, P., Anderson, C., Vaugn, M. & Beaver, K.
(2010). The cycle of violence behind bars: Traumatization and institutional misconduct among
juvenile delinquents in confinement. Youth Violence and Juvenile Justice, 8, 107-121.
doi:10.1177/1541204009349399
57. Krischer, M. & Sevecke, K. (2008). Early traumatization and psychopathy in female and male
juvenile offenders. International Journal of Law and Psychiatry, 31, 253-262.
doi:10.1016/j.ijlp.2008.04.008
58. Elliott, D. (1995). Lies, damn lies and arrest statistics. The American Society of Criminology
Meetings. The Sutherland Award Presentation. Boston, Massachusetts. Retrieved from
https://www.colorado.edu/UCB/Research/cspv/publications/papers/CSPV-015.pdf
59. Henggeler, S. (2016). Community-based interventions for juvenile offenders In K. Heilbrun (Ed.),
APA handbook of psychology and juvenile justice (pp. 575-595). http://dx.doi.org/10.1037/14643-
026
60. Mendel, R. (2011). No place for kids: The case for reducing juvenile incarceration. Baltimore,
MD: Annie E. Casey Foundation. Retrieved from https://files.eric.ed.gov/fulltext/ED527944.pdf
61. Bryer, S. & Levin, M. (2013). The comeback states: Reducing youth incarceration in the United
States. Washington, DC: National Juvenile Justice Network and the Center for Effective Justice,
Texas Public Policy Foundation.
62. Lambie, I., & Randell, I. (2013). The impact of incarceration on juvenile offenders. Clinical
Psychology Review, 33, 448-459. http://dx.doi.org/10.1016/j.cpr.2013.01.007
63. Petteruti, A., Walsh, N., & Velazquez, T. (2009). The costs of confinement: Why good juvenile
justice policies make good fiscal sense. Washington, DC: Justice Policy Institute.
http://www.justicepolicy.org

Open Science Journal – September 2019 23

Open Science Journal
Practice Bridge

Appendix A: PTSD RI-19 and YOQ Subscales Reliability for All Participants and by TF-CBT Youth Group
Pre-TF-CBT Post-TF-CBT
All C7 C4-6 C1-4 F-score C7 C4-6
Clinical M a M a M a M a M a M a
Characteristics (SD) (SD) (SD) (SD) (SD) (SD)
range range range range range
Trauma Symptoms n = 51-54 n = 12 n = 11-13 n = 28-29 n = 51-54 n = 12 n = 10
on the PTSD RI-19
Intrusion 9.39 .73 10.83 .82 10.00 .76 8.52 .66 1.07 4.92 .63 4.90 .85
(4.93) (5.62) (5.24) (4.46) (3.15) (4.04)
3-20 0-17 0-17 2-12 0-13
Avoidance 4.04 .48 3.17 .41 4.31 .06 4.28 .59 1.17 2.75 .00 2.70 .64
(2.24) (2.29) (1.93) (2.33) (1.55) (2.63)
0-8 0-8 0-8 1-6 0-8
Negative Cognitions 11.44 .65 13.25 .63 12.73 .36 10.21 .69 1.98 7.42 .84 5.60 .81
(5.16) (5.40) (4.13) (5.23) (5.62) (5.08)
4-24 5-18 0-22 2-22 0-15
Arousal / Reactivity 12.68 .47 14.17 .38 12.69 .47 12.04 .49 1.36 8.67 .73 8.00 .65
(3.77) (3.27) (3.50) (4.01) (4.34) (4.35)
8-19 8-20 1-18 2-16 0-15

Functioning on the n = 52-53 n = 12 n = 13 n = 27-29 n=8 n = 10

YOQ
Somatic 5.11 .63 5.83 .47 5.54 .62 4.61 .68 0.79 4.50 -.17 3.00 .85
(16.93) (2.98) (6.94) (11.80) (1.93) (3.62)
3-11 0-9 0-12 2-8 0-11
Social Isolation 1.23 .11 1.42 -.70 0.92 .06 1.30 .37 0.37 1.25 .11 1.50 .94
(1.53) (1.44) (1.74) (2.83) (1.39) (2.72)
0-4 0-4 0-5 0-4 0-7
Aggression 3.28 .64 3.08 .79 3.23 .78 3.39 .55 0.05 1.75 .80 1.50 .53
(2.82) (2.78) (8.86) (8.25) (2.44) (1.90)
0-9 0-10 0-10 0-7 0-5
Conduct Problems 8.27 .73 8.08 .60 8.15 .80 8.41 .76 0.02 5.50 .71 4.30 .77
(5.01) (4.48) (5.24) (5.29) (4.44) (3.50)
0-14 0-16 1-17 0-12 0-11
Hyperactivity 6.15 .40 5.67 .34 5.08 .57 6.89 .26 2.27 3.88 .75 2.90 .80
/Distractibility
(2.74) (2.71) (2.87) (2.56) (2.80) (2.51)
3-12 0-12 0-11 0-9 0-7
Depression / Anxiety 9.50 .52 10.25 .14 9.92 .72 8.96 .50 0.52 6.75 .52 5.90 .94
(3.40) (3.22) (4.94) (3.88) (3.69) (6.19)
6-16 3-20 2-18 2-12 0-21
Note. PTSD = Post Traumatic Stress Disorder; YOQ = 30-item Youth Outcomes Questionnaire Version 30.2.
TF-CBT = Trauma-Focused Cognitive Behavioral Therapy; C7 = sequentially completed TF-CBT without in vivo;
C4-6 = nonsequentially completed 4 to 6 components including trauma narration & processing; C1-4 = completed 1 to
4 of any one or a combination of the first four TF-CBT components.

Open Science Journal – September 2019 24