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Research Question: For children in foster care experiencing trauma, does trauma-focused therapy, compared to standard counseling, result in reduced trauma symptoms and improved mental health?

Introduction to Trauma-Focused Interventions for Children in Foster Care Foster care children are one of the most vulnerable groups within the child welfare

system, and the trauma exposure and mental health issues among this group are much higher than those in the general population. Studies have shown that such children have frequently undergone various negative childhood events such as maltreatment, neglect, separation from their biological families, and instability in their placements. These traumatic events are the causes of a broad spectrum of psychological challenges, such as post-traumatic stress disorder, anxiety, depression, behavioral issues, and attachment disorders (Gontijo et al., 2022). It is estimated that the rate of mental health disorders in foster children is significantly greater than in non-foster groups, and research shows that 80% of foster children might need mental health care (National Conference of State Legislatures, 2020). The knowledge of effective interventions to help manage trauma and enhance healing is essential in enhancing outcomes and helping the long-term wellbeing of this population.

Trauma-focused therapy and, in particular, evidence-based interventions like Trauma- Focused Cognitive Behavioral Therapy (TF-CBT) have become a promising intervention specifically targeting the symptoms of trauma in children (Syros et al., 2022). These treatment approaches include psychoeducation, development of coping skills, narrative processing of trauma, and involvement of the caregiver to enable children to process traumatic experiences and acquire healthier coping strategies. Conversely, conventional counseling methods might ignore or not directly treat trauma symptoms or employ evidence-based elements of trauma treatment.

The literature review will focus on the effectiveness of trauma-focused therapy over the usual counseling interventions in mitigating the symptoms of trauma and enhancing mental health outcomes among children in foster care. This review will inform social work practice and policy decisions about mental health service delivery to foster children by synthesizing existing research evidence to eventually lead to more effective trauma-informed care-based approaches to child welfare.

References Gontijo, M. L., Moreira, J. M., Silva, T. R., & Alves, C. R. L. (2022). Impact of adverse

childhood experiences (ACE) on the development of 18-months-old children. Journal of Affective Disorders Reports, 10, 100401. https://doi.org/10.1016/j.jadr.2022.100401

National Conference of State Legislatures. (2020, November 1). Mental Health and Foster Care. Www.ncsl.org. https://www.ncsl.org/human-services/mental-health-and-foster-care

Syros, I., Anastassiou, X. H., & Karantzali, A. (2022). Trauma-Focused Cognitive Behavioral Therapy (TF-CBT), Cognitive Behavioral Intervention on Trauma in Schools (CBITS), and Other Promising Practices in the Treatment of Post-Traumatic Stress Disorder in Children and Adolescents: Evidence Evaluation. OBM Neurobiology, 06(04), 1–34. https://doi.org/10.21926/obm.neurobiol.2204146

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Body. Foster children are one of the most exposed populations in the child welfare system as

they experience extremely high rates of abuse, neglect, and other mental health issues. The most common and recommended evidence-based treatment of this population is Trauma-Focused Cognitive Behavioral Therapy (TF-CBT). The following discuss recent studies on whether TF- CBT results in improved outcomes relative to standard or usual care methods.

Reference Esterer, M., Carlson, J. S., Roschmann, S., Kim, H., Cowper, A., Cranmer-Fosdick, H., Ludtke,

M., & DeCicco, B. (2023). Exploring early termination patterns and effectiveness of trauma-focused cognitive behavioral therapy for children in foster care. Children and Youth Services Review, 147, 106841. https://doi.org/10.1016/j.childyouth.2023.106841

This paper analyzed the effectiveness of TF-CBT in children who are already in foster care, as well as the factors that were predictive of premature treatment discontinuation. The authors examined a sample of foster care youth who were being treated with TF-CBT in various service settings and assessed post-traumatic stress symptoms and functional impairment at the beginning and end of treatment. Findings indicated that children who attended the entire course of TF-CBT had statistically and clinically significant improvements in their post-traumatic stress symptoms and general functioning in their daily living. However, the researchers also found out that older children and those who received TF-CBT at home were far more likely to drop out before the treatment was completed. Older children had a 7.8% greater likelihood of premature termination and youth in home-based care had a 57.1% greater likelihood of premature termination. Notably, race, ethnicity, gender, and pre-treatment symptom levels were not predictors of early termination. This paper is a strong advocate of TF-CBT in foster care children by proving its efficacy in cases of treatment adherence. It is directly connected to the research question because it specifically focuses on foster care youth, assesses the consequences of trauma symptoms, and determines the practical constraints that could limit the efficacy of TF- CBT in this specific population.

Reference Hultmann, O., Broberg, A. G., & Axberg, U. (2023). A randomized controlled study of trauma

focused cognitive behavioural therapy compared to enhanced treatment as usual with patients in child mental health care traumatized from family violence. Children and Youth Services Review, 144, 106716. https://doi.org/10.1016/j.childyouth.2022.106716

This is a randomized controlled trial, which is among the most directly related studies to the research question, as it directly compares TF-CBT to a control condition of enhanced treatment as usual (eTAU). The study population consisted of 89 children aged between 5 and 17 years old and all were previously exposed to family violence, including child maltreatment and intimate partner violence. The participants were randomly selected to receive either TF-CBT or eTAU and assessed at 6 and 12 months. The results showed that both groups significantly reduced their trauma and mental health symptoms with small to medium effect sizes at both

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points in time. No statistically significant differences were however found between the two treatment groups, that is, TF-CBT did not perform better than the enhanced control condition. This is a significant point of difference to the research question since it indicates that in case standard counseling is highly structured and supervised, it can also produce similar outcomes. This research partly contradicts the question by demonstrating that TF-CBT is not necessarily more effective than standard care, especially in the case of multi-traumatized children and when the comparison treatment is also improved.

Reference Martin, A. N., McLeigh, J. D., & Lamminen, L. M. (2023). Examining the feasibility of

telehealth trauma-focused cognitive behavioural therapy (TF-CBT) with young people in foster care. Journal of Child & Adolescent Trauma, 16. https://doi.org/10.1007/ s40653-023-00538-w

The research was conducted in a primary care clinic that is integrated and serves exclusively young people with a history of foster care, which is very relevant to the population of the research question. The authors analyzed the electronic health records of 46 foster care youngsters who received TF-CBT using telehealth during the period of March 2020 to April 2021. They also held a focus group consisting of 7 mental health providers in the clinic to seek qualitative feedback on barriers and facilitators. Among the 14 youth who were given the complete treatment, the results showed that the post-traumatic stress symptom was significantly decreased, with the pre-treatment score of 25.64 dropped to 13.57 at the end of the treatment, which is a significant change. Provider focus group themes included home environment barriers, involvement of caregivers and system-level barriers to completion. The completion rate was low (approximately 30%), but clinical outcomes of completers were encouraging. This paper contributes to the notion that TF-CBT has the potential to alleviate trauma symptoms in foster care youth, even in the case of remote delivery. It provides significant real-world information regarding access barriers and the importance of caregiver involvement in ensuring that TF-CBT is effective with this population.

Reference Trubey, R., Evans, R., McDonald, S., Noyes, J., Robling, M., Willis, S., Boffey, M., Wooders, C.,

Vinnicombe, S., & Melendez-Torres, G. J. (2024). Effectiveness of Mental Health and Wellbeing Interventions for Children and Young People in Foster, Kinship, and Residential Care: Systematic Review and Meta-Analysis. Trauma, Violence, & Abuse, 25(4). https://doi.org/10.1177/15248380241227987

This systematic review and meta-analysis, tested the effectiveness of mental health and wellbeing interventions in children and young people who were in foster care, kinship care and residential care environments. The authors conducted an extensive search of different databases and chose 44 randomized controlled trials to be included in the final analysis that covered a wide range of interventions to help in dealing with mental health disorders, emotional wellbeing, and behavioral outcomes. The findings indicated that trauma-oriented interventions such as TF-CBT yielded the most plausible and most credible mental health results improvement relative to other

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forms of interventions in all the three care settings. The meta-analysis demonstrated small to medium pooled effect sizes in support of the use of trauma-oriented approaches versus standard or minimal treatment conditions. The other factor that was identified during the review was the participation of caregivers as a consistent contributor to improved treatment outcomes. The source is very much pertinent to the research question since it directly compared the trauma- focused therapy with other strategies in a foster care population, which gives extensive cross- national evidence. It gives a strong argument that trauma-focused therapy is more effective than standard counseling in enhancing the mental health of children placed in care by welfare services.

Reference Onsjö, M., Axberg, U., Hultmann, O., & Strand, J. (2025). A mixed-methods evaluation of long-

term outcomes after trauma-focused cognitive behavioural therapy for children subjected to family violence. Psychotherapy Research, 1–15. https://doi.org/ 10.1080/10503307.2025.2469256 Onsjo et al. carried out mixed-methods research to determine what long-term outcomes

occurred following the TF-CBT exposure to family violence in children. The researchers contacted and interviewed 17 of the former child patients, aged 12-25 years, and they were able to obtain quantitative data of the symptoms as well as the personal stories of how the treatment influenced their lives over the years. The findings revealed that the TF-CBT was largely effective in reducing trauma in respondents to treatment. However, the non-responsive children to TF- CBT had chronic symptoms of trauma and persistent psychiatric disorders. The continued exposure to a violent parent who refused or downplayed the abuse was among the obstacles of effective treatment that hampered the processing of trauma and narrative work that are the two essential elements of TF-CBT. The study confirms the idea that TF-CBT is an effective intervention, which is long-term, yet also indicates that not all children enjoy the same benefits. It is relevant to the research question because it addresses the issue of whether or not trauma- focused therapy may lead to long-term mental health outcomes within children with traumatized experiences, and it also provides useful background information as to what circumstances may render TF-CBT most and least effective.

Reference Thielemann, J. F. B., Kasparik, B., König, J., Unterhitzenberger, J., & Rosner, R. (2023).

Stability of treatment effects and caregiver-reported outcomes: A meta-Analysis of trauma-focused cognitive behavioral therapy for children and adolescents. Child Maltreatment, 29(2), 375–387. https://doi.org/10.1177/10775595231167383

Thielemann et al. (2023) performed a meta-analysis to determine whether the gains of TF-CBT treatment were maintained in the follow-up by up to 12 months of treatment, and whether self-reports of children and caregiver reports of symptom change were consistent. The researchers used several major databases and eventually identified 33 studies among which 21 studies were randomized controlled trials and the total number of participants was 4,523. The results suggested that TF-CBT showed a significant difference between the symptoms of post- traumatic stress at the pre-treatment and 12 months follow-up with an effect size of g = 1.71. Tf- CBT was also found to have positive results relative to active interventions and treatment as

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usual at the 12-month follow-up with an effect size of g = 0.35. Surprisingly, the caregiver reports and the self-reports showed a high level of consistency in most outcomes and at most time points, a fact that warrants the reliability of the results. The meta-analysis assists in answering the research question because it demonstrates high-quality extensive evidence that TF- CBT is not only capable of reducing the symptoms of trauma but also is able to sustain the results in the long-term, which is a sufficient argument to support the use of the trauma-focused therapy in the case of traumatized children and adolescents.

References Esterer, M., Carlson, J. S., Roschmann, S., Kim, H., Cowper, A., Cranmer-Fosdick, H., Ludtke,

M., & DeCicco, B. (2023). Exploring early termination patterns and effectiveness of trauma-focused cognitive behavioral therapy for children in foster care. Children and Youth Services Review, 147, 106841. https://doi.org/10.1016/j.childyouth.2023.106841

Hultmann, O., Broberg, A. G., & Axberg, U. (2023). A randomized controlled study of trauma focused cognitive behavioural therapy compared to enhanced treatment as usual with patients in child mental health care traumatized from family violence. Children and Youth Services Review, 144, 106716. https://doi.org/10.1016/j.childyouth.2022.106716

Martin, A. N., McLeigh, J. D., & Lamminen, L. M. (2023). Examining the feasibility of telehealth trauma-focused cognitive behavioural therapy (TF-CBT) with young people in foster care. Journal of Child & Adolescent Trauma, 16. https://doi.org/10.1007/ s40653-023-00538-w

Onsjö, M., Axberg, U., Hultmann, O., & Strand, J. (2025). A mixed-methods evaluation of long- term outcomes after trauma-focused cognitive behavioural therapy for children subjected to family violence. Psychotherapy Research, 1–15. https://doi.org/ 10.1080/10503307.2025.2469256

Thielemann, J. F. B., Kasparik, B., König, J., Unterhitzenberger, J., & Rosner, R. (2023). Stability of treatment effects and caregiver-reported outcomes: A meta-Analysis of trauma-focused cognitive behavioral therapy for children and adolescents. Child Maltreatment, 29(2), 375–387. https://doi.org/10.1177/10775595231167383

Trubey, R., Evans, R., McDonald, S., Noyes, J., Robling, M., Willis, S., Boffey, M., Wooders, C., Vinnicombe, S., & Melendez-Torres, G. J. (2024). Effectiveness of Mental Health and Wellbeing Interventions for Children and Young People in Foster, Kinship, and Residential Care: Systematic Review and Meta-Analysis. Trauma, Violence, & Abuse, 25(4). https://doi.org/10.1177/15248380241227987