The effectiveness of trauma-focused cognitive-behavioral therapy (TF-CBT) on internalized problems in bereaved children

Document Type : Original Article


1 Master's student, Department of Psychology, Sari Branch, Islamic Azad University, Sari, Iran

2 Assistant Professor, Department of Psychology, Sari Branch, Islamic Azad University, Sari, Iran


Aim: The purpose of this study was to investigate the effectiveness of trauma-focused cognitive behavioral therapy on internalized problems in bereaved children. Method: The research method was semi-experimental with a pre-test and post-test design with a control group. The statistical population was all children aged 9 to 11 years old in Sari city who lost one of their parents due to covid-19 disease. In order to select a statistical sample, 30 people who met the criteria of the study and were willing to receive treatment were selected and assigned to an experimental group and a control group (each group contains 15 people) by a simple random method. The experimental group received Cohen, Mannarino and Knudsen's (2004) trauma-focused cognitive-behavioral therapy in a group method during 16 90-minute sessions, and the control group did not receive any intervention until the follow-up test. The instruments used in this study included the Achenbach Child Behavior Inventory (CBCL, Achenbach & Rescurella, 2001). The data obtained in the three stages of pre-test, post-test and follow-up were analyzed using SPSS-22 software by variance analysis with repeated measurements. Results: The results showed that the trauma-focused cognitive behavioral therapy led to the reduction of the internalized problems in bereaved children (P<0.01). The results also showed that the effect of the treatment was permanent during follow-up. Conclusion: The research results provide evidence that trauma-focused cognitive-behavioral therapy is a suitable method for reducing internalized problems in children and can lead to improving the mental health of bereaved children.


Main Subjects

سالمی، صفورا.، نعامی، عبدالزهرا.، زرگر، یداله.، و داودی، ایران. (1395). اثربخشی درمان شناختی رفتاری متمرکز بر تروما بر شایستگی اجتماعی و تنظیم هیجانی کودکان آزاردید. پژوهش های روانشناسی اجتماعی،  6 (23)، 76-65.
ویسی، سعید.، ایمانی، صدف.، بهروز، بهزاد.، و ایمانی، سارینا. (1399). ارزیابی ویژگیهای روانسنجی مقیاس کوتاه ترس از ابتلا به بیماری کرونا ویروس (کووید-19). مجله پیشرفت­های نوین در علوم رفتاری، 5 (42)، 10-1.
Alvis, Lauren M.; Dodd, Cody G.; Oosterhoff, Benjamin; Hill, Ryan M.; Rolon-Arroyo, Benjamin; Logsdon, Tami; Layne, Christopher M.; Kaplow, Julie B. (2020). Caregiver behaviors and childhood maladaptive grief: Initial validation of the Grief Facilitation Inventory. Death Studies. Pp 1-8. DOI: 10.1080/07481187.2020.1841849
 Benuto, L. (2014). Trauma-focused cognitive behavioral therapy for juvenile victims of sexual Abuse. Juvenile Sex Offenders, 291-312.
Black D, Urbanowicz MA. Family interventions with bereaved children. J Child Psychol Psychiatry. 1987; 28:467–476. doi: 10.1111/j.1469-7610. 1987.tb01767.x.
Bor, W., Dean, A. J., Najman, J., Hayatbakhsh, R. (2014). Are child and adolescent mental health problems increasing in the 21st century? A systematic review. Aust N Z J Psychiatry, 48, 606–616.
Boelen PA, van den Bout J. (2010). Anxious and depressive avoidance and symptoms of prolonged grief, depression, and post-traumatic stress disorder. Psychol Belg. 2010; 50:49–67.
Boelen, P.A., de Keijser, J., van den Hout, M.A., & van den Bout, J. (2007). Treatment of complicated grief: A comparison between cognitive behavioral therapy and supportive counseling. Journal of Consulting and Clinical Psychology, 75, 277–284.
Boelen, Paul A., Keijser, Jos de., Hout, Marce, A. van den, and Bout, Jan van den. (2011). Factors Associated with Outcome of Cognitive– Behavioural Therapy for Complicated Grief: A Preliminary Study. Clinical Psychology and Psychotherapy. 18, 284–291.
Böttche M, Kuwert Ph, Pietrzak R, Knaevelsrud Ch (2016). Predictors of outcome of an Internet-based cognitive-behavioural therapy for post-traumatic stress disorder in older adults. Psychology and Psychotherapy: Theory, Research and Practice. 89, 1, 82–96.
 Chen, X., Lewis, G., Liu, J. (2011). Childhood internalizing behavior: analysis and implications. Journal of Psychiatric and Mental Health Nursing, 18(10): 884-894.
Cohen, J. A., & Mannarino, A. P. (2015). Trauma-focused Cognitive Behavior Therapy for Traumatized Children and Families. Child and adolescent psychiatric clinics of North America, 24(3), 557–570.
Cohen, M., & Mannarino, A. (2015). Trauma-focused Cognitive Behavior Therapy for Traumatized Children and Families. Family-Based Treatment in Child & Adolescent Psychiatry, 24(3), 557–570.
Cohen JA, Mannarino AP, Knudsen K. Treating childhood traumatic grief: a pilot study. J Am Acad Child Adolesc Psychiatry. 2004; 43:1225–1233.
Cohen, J.A., Mannarino, A., & Berliner, M. (2010). Trauma focused CBT for children with co-occurring trauma and behavior Problems. Child Abuse & Neglect, 34, 215–224.
Cohen JA, Mannarino A, Deblinger E, Deblinger E. Trauma-Focused Cognitive Behavioral Therapy for Children and Adolescents. Journal of interpersonal violence, 2000;15 (11), 1202-12.
 Cohen, J. A., Mannarino, A. P, & Knudsen, K. (2004). Treating sexually abused children: One year follow-up of a randomized controlled trial. Child Abuse & Neglect. Child Maltreatment, 43, 1225-1233.
 Cohen, J.A., Mannarino, A., & Knudsen, K. (2007). Treating sexually abused children: One year follow-up of a randomized controlled trial. Child Abuse & Neglect. Child Maltreatment, 43, 1225-1233.
Cohen JA, Mannarino AP, Staron V. A pilot study of modified cognitive-behavioral therapy for childhood traumatic grief (CBT-CTG) J Am Acad Child Adolesc Psychiatry. 2006; 45:1465–1473. doi: 10.1097/01.chi.0000237705.43260.2c.
Cohen JA, Mannarino AP. A treatment outcome study for sexually abused preschool children: initial findings. J Am Acad Child Adolesc Psychiatry. 1996; 35:42–50. doi: 10.1097/00004583-199601000-00011. A published erratum appears in J Am Acad Child Adolesc Psychiatry 1996, 35:835.
 Cohen, J.A., Mannarino, A.P., & Knudsen, K. (2004b). Treating childhood traumatic grief: A pilot study. Journal of the American Academy of Child and Adolescent Psychiatry, 43, 1225–1233.
Cohen, J. A., Mannarino, A. P. (2008). Trauma-focused Cognitive Behavior Therapy for Traumatized Children and Families. Child and adolescent mental health, 13, No. 4, 2008, pp. 158–162.
Cohen, J. A., Berliner, L., & Mannarino, A. (2010). Trauma focused CBT for children with co-occurring trauma and behavior problems. Child Abuse & Neglect, 34(4), 215–224.
Currier JM, Holland JM, Neimeyer RA. The effectiveness of bereavement interventions with children: a meta-analytic review of controlled outcome research. J Clin Child Adolesc Psychol. 2007;36:253–259. doi: 10.1080/15374410701279669.
 Darawshy, N.A., Haj-Yahia, M.M. (2018). Palestinian adolescents' exposure to community violence and internalizing and externalizing symptoms: Parental factors as mediators, Children and Youth Services Review, 95, 397-406.
Domaradzka, Ewa., and Fajkowska, Małgorzata. (2018). Cognitive Emotion Regulation Strategies in Anxiety and Depression Understood as Types of Personality. Frontiers Psychology. Jun 12.
Duan, L., & Zhu, G. (2020). Psychological interventions for people affected by the COVID-19 epidemic. The Lancet Psychiatry, 7(4), 300-302.
Garnefski, N., Teerds, J., Kraaij, V., Legerstee, J., & van den Kommer, T. (2004). Cognitive emotion regulation strategies and depressive symptoms: Differences between males and females. Personality and Individual Differences, 36, 267-276.
Garnefski, N., Kraaij, V., &Spinhoven, P (2001). Negative life events, cognitive emotion regulation and depression. Personality and Individual Differences, 30, 1311-1327.
Gross, J. J. and O. P. John. (2003). Individual differences in to emotion regulation processes: implications for affect, relationships, and well-being. Journal of personality and social psychology.85(2): 348.
Gross, James J., Jazaieri, Hooria. (2014). Emotion, Emotion Regulation, and Psychopathology: An Affective Science Perspective. Clinical Psychological Science, Vol 2(4), 387–401.
Harrison, L., & Harrington, R. (2001). Adolescents’ bereavement experiences. Prevalence, association with depressive symptoms, and use of services. Journal of Adolescence, 24(2), 159–169.
Hicks, B.M., South, S.C., Dirago, A.C., Iacono, W.G., & Mcgue, M. (2009). Environmental adversity and increasing genetic risk for externalizing disorders, Archives of General Psychiatry, 66 (6), 640-648.
Horsley, H., & Patterson, T. (2006). The effects of a parent guidance intervention on communication among adolescents who have experienced the sudden death of a sibling. The American Journal of Family Therapy, 34(2), 119–137.
Hudson, J., Deveny, C., Taylor, L. (2005) Nature, assessment and treatment of general. anxiety disorder in children. Pediatric annals, 34(2): 97-106.
Huang, Y., & Zhao, N. (2020). Generalized anxiety disorder, depressive symptoms and sleep quality during COVID-19 epidemic in China: a web-based cross-sectional survey. Med Rxiv.
Kaplow, J. B., Layne, C. M., Oosterhoff, B., Goldenthal, H., Howell, K. H., Wamser-Nanney, R., Burnside, A., Calhoun, K., Marbury, D., Johnson-Hughes, L., Kriesel, M., Staine, M. B., Mankin, M., Porter-Howard, L., & Pynoos, R. (2018). Validation of the persistent complex bereavement disorder (PCBD) checklist: ADevelopmentally Informed Assessment Tool for Bereaved Youth. Journal of Traumatic Stress, 31(2), 244–254.
Kaplow JB, Layne CM, Pynoos RS, Cohen JA, Lieberman A. DSM-V diagnostic criteria for bereavement-related disorders in children and adolescents: developmental considerations. Psychiatry. 2012;75:243–266.
Kaplow, J. B., Layne, C. M., Saltzman, W. R., Cozza, S. J., & Pynoos, R. S. (2013). Using Multidimensional grief theory to explorethe effects of deployment, reintegration, and death on military youth and families. Clinical Child and Family Psychology Review, 16(3), 322–340. 10.1007/s10567-013-0143-1
Kendall, P. C., Compton, S. N., Walkup, J. T., Birmaher, B., Albano, A. M., Sherrill, J., Piacentini, J. (2010). Clinical characteristics of anxiety disordered youth. Journal of Anxiety Disorders, 24,360– 365.10.1016/j.janxdis.2010.01.009 [PubMed: 20206470]
Landers, A.L., Bellamy, J.L., Danes, S.M., Hawk, S.W.(2017). Internalizing and externalizing behavioral problems of American Indian children in the child welfare system. Children and Youth Services Review, 81: 413-421.
Layne, C. M., & Kaplow, J. B. (2020). Assessing bereavement and grief disorders. In E. A. Youngstrom, M. J. Prinstein, E. J. Mash, & R. A. Barkley (Eds.), Assessment of disorders in childhood and adolescence (5th ed., pp. 471–508). Guilford.
Listug-lunde, L., Bredmeier, K., Tyan, W.D. (2005). Concurrent parent and child group outcomes for child externalizing disorders. International Journal of Behavioral Consultation and Therapy, 1(2), 124- 130.
Macdonald, G., Higgins, J. P. T., Ramchandani, P., Valentine, J. C., Bronger, L. P, Marissiaux, A., & Grosbois, N. (2008). Theory of mind “beliefs”, developmental characteristics and social understanding in children and adolescents with intellectual disabilities. Sesearch in Developmental Disabilities, 29(6), 547-566.
Melhem, N.M., Moritz, M.P.H., Walker, M.S.W., Shear, M.K., &Brent, D. (2007). Phenomenology and correlates of complicated grief in children and adolescents. Journal of American Academy of Child and Adolescent Psychology, 46, 493–499. DOI: 10.1097/chi.0b013e31803062a9
Melhem NM, Porta G, Shamseddeen W, Walker Payne M, Brent DA. Grief in children and adolescents bereaved by sudden parental death. Arch Gen Psychiatry. 2011; 68:911–919. doi: 10.1001/archgenpsychiatry.2011.101.
Moor, E.L., Denollet, J., Laceulle, O.M. (2018). Social inhibition, sense of belonging and vulnerability to internalizing problems. Journal of Affective Disorders, 225, 207-213.
 Ochsner K.N., Gross J.J. (2005). The cognitive control of emotion. Trends in Cognitive Sciences. 9(5):242-9.
Perle, J.G., Levine, A.B., Odland, A.P., Ketterer, J.L., Cannon, M.A., Marker, C.D. (2013). The Association between Internalizing Symptomology and Risky Behaviors. Journal of Child & Adolescent Substance Abuse, 22(1), 1-24.
Qiu, J., Shen, B., Zhao, M., Wang, Z., Xie, B., & Xu, Y. (2020). A nationwide survey of psychological distress among Chinese people in the COVID-19 epidemic: implications and policy recommendations. General psychiatry, 33(2).
Richman, Smart L, Kubzansky, L, Maselko, J. (2005).  Positive Emotion and Health: Going Beyond the Negative. Journal of Health Psychology.  24: 422-9.
Segal, ZV., Williams, JMG., & Teasdale, JD. (2002). Mindfulness based cognitive therapy for depression: A new approach to preventing relapse. New York: Guilford Press.
Shanafelt, T., Ripp, J., & Trockel, M. (2020). Understanding and addressing sources of anxiety among health care professionals during the COVID-19 pandemic. JAMA. 2020;323(21):2133-2134. doi:10.1001/jama.5893.
Shapiro, D., Howell, K., & Kaplow, J. (2014). Associations among mother-child communication quality, childhood maladaptive grief, and depressive symptoms. Death Studies, 38(1–5), 172–178. 07481187.2012.738771
Shear, K., Frank, E., Houck, P.R., & Reynolds III, C.F. (2005). Treatment of complicated grief. A randomised controlled trial. JAMA, 293, 2601–2608.
Silva, C.T.B., Costa, M.A., Kapczinski, F., Aguiar, B.W., Salum, G.A., Manfro, G.G. (2017). Inflammation and internalizing disorders in adolescents. Progress in Neuro-Psychopharmacology and Biological Psychiatry, 77, 133-137.
Spuij M, Reitz E, Prinzie P, Stikkelbroek Y, de Roos C, Boelen PA. (2012). Distinctiveness of symptoms of prolonged grief, depression, and posttraumatic stress in bereaved children and adolescents. Eur Child Adolesc Psychiatry. 21:673–679.
Spuij M, van Londen-Huiberts A, Boelen PA. Cognitive-behavioral therapy for prolonged grief in children: feasibility and multiple baseline study. Cogn Behav Pract. 2013; 20:349–361. doi: 10.1016/j.cbpra.2012.08.002.
Spuij M, Dekovic M, Boelen PA. An open trial of “grief-help”: a cognitive-behavioural treatment for prolonged grief in children and adolescents. Clin Psychol Psychother. in press.
Spuij, M., Prinzie, P., Zijderlaan, J., Stikkelbroek, Y., Dillen, L., Roos, C. D., & Boelen, P. A., (2011). Psychometric Properties of the Dutch Inventories of Prolonged Grief for Children and Adolescents, Clinical Psychology and Psychotherapy Co. DOI:10.1002/cpp.765
 Spuij, Mariken.,  Prinzie, Peter., Dekovic, Maja.,  Bout, Jan van den,.  Boelen, Paul A. (2013). The effectiveness of Grief-Help, a cognitive behavioural treatment for prolonged grief in children: study protocol for a randomised controlled trial. Nov 20. doi: 10.1186/1745-6215-14-395.
Stroebe, Margaret S., Stroebe, Wolfgang., Hansson, Robert O. (1993). Handbook of bereavement Theory, research, and intervention. Cambridge University Press.
Thapar, A., Collishaw, S., Pine, D. S., Thapar, A. K. (2012). Depression in adolescence. Lancet, 379(9820),1056-1067.
Twenge, J. (2000). The age of anxiety? The birth cohort change in anxiety and neuroticism, 1952-1993. J of Personality and Social Psychology, 79, 1007-1021.
Wolgast, A., Donat, M. (2019). Cultural mindset and bullying experiences: An eight-year trend study of adolescents' risk behaviors, internalizing problems, talking to friends, and social support. Children and Youth Services Review, 99, 257-269.
Wu, X.Y., Bastian, K., Ohinmaa, A., Veugelers, P. (2018). Influence of physical activity, sedentary behavior, and diet quality in childhood on the incidence of internalizing and externalizing disorders during adolescence: a population-based cohort study. Annals of Epidemiology, 28(2), 86-94.
Wagner, B., Knaevelsrud, C., & Maercker, A. (2006). Internetbased cognitive–behavioral therapy for complicated grief: A randomized controlled trial. Death Studies, 30, 429– 453.
Wu, J. (2018, August 20). Trauma-Focused Cognitive Behavioral Therapy. The National Child Traumatic Stress Network.
Yap, M., Jorm, A. (2015). Parental factors associated with childhood anxiety, depression, and internalizing to teachers and parents' report: Systematic review and meta-analysis study. Fundamentals of Mental Health, 213- 221.