1

Tailoring Trauma-Focused Cognitive Behavioral Therapy for

Youth with Developmental Disabilities (TF-CBT IDD) and their
Caregivers.

This manual was prepared as part of the STRYDD Center (Supporting Trauma
Recovery for Youth with Developmental Disabilities) funded by SAMHSA
grant1H79SM05062-01
Tailoring TF-CBT for IDD 2

Contributors
Daniel W Hoover, Ph.D. ABPP- Center for Child and Family Traumatic Stress at
Kennedy Krieger Institute; Johns Hopkins School of Medicine, Baltimore, MD

Peter D’Amico, Ph.D., ABPP-Long Island Jewish Medical Center; Donald and Barbara
Zucker School of Medicine at Hofstra/Northwell, Long Island, NY

Juliet M. Vogel, Ph.D.- Long Island Jewish Medical Center; Donald and Barbara Zucker
School of Medicine at Hofstra/Northwell, Long Island, NY

Sophia Frank, Ph.D- Kennedy Krieger Institute, Baltimore, MD

Brian Tallant, LPC, NADD-CC- Neurodiverse Communities, Denver, CO

Daniel L. Hoffman, Ph.D., ABPP- Long Island Jewish Medical Center; Donald and
Barbara Zucker School of Medicine at Hofstra/Northwell; Cognitive Behavioral Therapy
Practice at Northwell Health Physician Partners, Long Island, NY

Tabitha C. Fleming, Ph.D.- Oklahoma Health Sciences University, Oklahoma City, OK

Maria Khan, Ph.D.- West Virginia University School of Medicine, Morgantown, WV

Sara Babad, Ph.D. – Long Island Jewish Medical Center, Long Island, NY

Morgan McNair, M.A.- Long Island Jewish Medical Center; Stony Brook University,
Social Competence & Treatment Laboratory
Tailoring TF-CBT for IDD 3

Table of Contents
Preface: ........................................................................................................................... 5
Chapter 1: Introduction .................................................................................................... 6
Definitions: Intellectual and Developmental Disabilities ................................................................... 6
Trauma and Maltreatment in Children with IDD ................................................................................ 7
Responses to Trauma in Youth with IDD ........................................................................................... 8
Trauma Treatment for Children with IDD.......................................................................................... 10
Chapter 2: Culture of Disability and Traumatic Stress ................................................... 11
Cultural Competency and Clinical Expertise .................................................................................... 11
Disability-Related Trauma................................................................................................................... 12
Working with Families of Youth Who Have IDD .............................................................................. 12
Systems Issues: Silos of care ............................................................................................................ 13
Chapter 3: Assessment Issues and Strategies .............................................................. 15
Using Assessment to Match the Treatment to the Client ............................................................... 17
Assessment Considerations ............................................................................................................... 17
Table 1. Potential similarities and overlap between trauma-related symptoms and commonly
observed characteristics of IDD. ........................................................................................................ 20
Chapter 4: Readiness and Preparation for Trauma Work ............................................. 21
Care Coordination and Collaboration ................................................................................................ 21
Table 2. Assessment of engagement, coordination and collaboration for treatment planning.21
Assessing Readiness and Staging for TF-CBT ............................................................................... 22
Table 3: Essential questions to determine readiness for TF-CBT: ............................................... 22
Figure 1: Sequence of services in treatment planning. .................................................................. 23
Table 4: Domains and Possible Approaches for Staging............................................................... 24
Chapter 5: Trauma Focused Cognitive Behavior Therapy (TF-CBT) ............................ 26
TF-CBT and its Components (overview) .......................................................................................... 26
Trauma Treatment Tailored for Children with IDD .......................................................................... 27
General Modifications: Relevant Research on Tailoring of Therapy with IDD Youth ................ 28
Table 5. General modifications of CBT for children with autism and developmental disorders
................................................................................................................................................................ 29
Issues in Therapeutic Engagement ................................................................................................... 30
Application of TF-CBT for Children with IDD ................................................................................... 32
Chapter 6: PRACTICE Skills Modifications- The Matrix ................................................ 34
Tailoring TF-CBT for IDD 4

Steps of TF-CBT................................................................................................................................... 34
Psychoeducation and Parenting Skills .............................................................................................. 35
Relaxation.............................................................................................................................................. 37
Affective Modulation............................................................................................................................. 38
Cognitive Coping .................................................................................................................................. 40
Trauma Narration and Processing..................................................................................................... 42
Conjoint Sessions................................................................................................................................. 43
In-Vivo Mastery ..................................................................................................................................... 44
Enhancing Safety/Social Skills ........................................................................................................... 45
Chapter 7: After TF-CBT: What Next?........................................................................... 47
Conclusions................................................................................................................... 48
REFERENCES .............................................................................................................. 49
Appendix A: Definitions of Intellectual and Developmental Disabilities ......................... 60
Appendix B: Individualized Therapy Accommodations Planning Tool ........................... 61
Appendix C: ACCOMMODATIONS CHECKLIST .......................................................... 73
Appendix D: Assessment of Adaptive Domains at Each Stage of TF-CBT ................... 76
Tailoring TF-CBT for IDD 5

Preface:
This guide is intended for clinicians who have completed basic training in TF-CBT,
including the online TFCBTWeb2.0, two-day live training conducted by a certified trainer
and follow-up consultation calls.

We have assembled this therapist guide with the hopes of enhancing clinician comfort
and flexibility in working with youth with Intellectual and Developmental Disabilities
(IDD). It is based on our practice, piloting and supervision of Trauma-Focused CBT (TF-
CBT) cases with youth who have IDD and on survey responses of certified TF-CBT
therapists about their work with this population. The category of Intellectual and
Developmental Disabilities (IDD) is a broad one encompassing many different
conditions, often with varied levels and patterns of functioning within each condition. To
tailor TF-CBT for such a varying population, we recommend considering the specific
pattern of functioning of the individual rather than prescribing distinct approaches for
each developmental condition. We provide guidance for considering each client’s
trauma reaction, their way of communicating, and their functioning in other areas that
can impact the therapy, as well as strategies for adjusting the treatment accordingly.

We begin with defining terms, introducing the special population of youth with IDD and
offering some understanding of the unique impact of trauma specific to this vulnerable
group. We suggest that gaining comfort and confidence working with these youth and
their families is akin to developing a cultural competence and we outline the systems
issues that are unique to the “IDD culture.” To assist with appropriate case evaluation
and readiness for trauma work, we offer suggestions for modifications to assessment as
well as staging guidelines for when trauma treatment should begin. We then summarize
research on successful treatment modifications for youth with IDD and present a
therapy accommodations planning tool for applying this information based on the
client’s individual IDD profile. This planning tool prepares the therapist for navigating a
detailed matrix of alternative interventions to consider as TF-CBT proceeds. The matrix
assists in tailoring each of the TF-CBT PRACTICE components according to the
individual domains of the client’s functioning. We then offer some recommendations
around case complexity, common comorbidities, adjunctive treatments, etc. Lastly, we
discuss treatment maintenance and post trauma recovery.
Tailoring TF-CBT for IDD 6

Chapter 1: Introduction

Definitions: Intellectual and Developmental Disabilities

Intellectual and developmental disabilities (IDDs) encompass chronic mental and/or
physical disabilities that begin in the developmental period and have a significant and
persistent impact on major areas of functioning. The precise criteria and the specific
sub-classifications depend on the context (see
https://www.nichd.nih.gov/health/topics/idds/conditioninfo). The three major systems
used in the United States are:

a) the federal/state entitlement categories specified by the Americans with

Disability Act of 2000;

b) the school disabilities categories specified by the federal Individuals with

Disabilities Education Act (IDEA); and

c) diagnoses of IDD by medical providers using the American Psychiatric

Association's DSM-5 (American Psychiatric Association, 2013) and the ICD-11
(World Health Organization, 2019) terminology.

The reader is referred to Appendix A for more information about these definitions and
their implications.

It is important for the therapist to be knowledgeable about these classification systems

when serving youth with IDD and their families. In order to communicate with others
involved in the child’s care or advocate for services on the child’s behalf, they will need
to understand how the child may be classified by government-sponsored programming
(e.g., state agencies), educational programming (i.e., school IEP classification) and
medical/ mental health/insurance providers.

We utilize the term IDD throughout this guide to reflect the broad set of disabilities that
result from mental and/or physical impairment characterized by early onset, a severe
and chronic (generally life-long) course and a range of functional and adaptive skill
deficits (Zablotsky et al. 2019). It is estimated that approximately 1 in 6 children in the
U.S.is affected by IDD with various causes, features, and courses (see Table 1; U.S.
Department of Health and Human Services, 2000; Zablotsky et al. 2019). Youth with
IDD are more vulnerable to trauma and to a range of behavioral, social and emotional
difficulties throughout life and many have co-occurring disorders. Thus, the IDD
designation is heterogeneous, taking into account a broad range of developmental
impact and functional presentations.

For example, IDD encompasses children on the autism spectrum with strong cognitive
and verbal comprehension skills, children with varying levels of intellectual delay, and
multiply and/or physically disabled individuals who require assistance in nearly all
activities of life. The scope of this guide is on psychosocial treatment of trauma-related
Tailoring TF-CBT for IDD 7

symptoms in children with IDD. We will focus our attention on conditions that primarily
affect cognitive and psychosocial functioning (e.g., ID, ASD, LD).

In the disability field using person-first language, (i.e., “an individual with autism”) often
has been recommended as more respectful and some individuals with disabilities prefer
this approach. However, identity and empowerment factors lead some individuals to
prefer to use identity-first language, such as identifying as an “autistic person.” Autism is
part of who they are and not something to be seen as an issue. We recommend asking
individuals for their preferences and adhering to preferences in this regard.

Key Points: The Population of Youth with IDD

• Intellectual and developmental disabilities cover a broad range
of conditions that have chronic functional impairment
• Therapists need to be familiar with the multiple systems of classification
for IDD
• IDD affects learning, thinking, language & adaptive functioning
• IDD increases vulnerability to behavioral, social, & emotional difficulties
including trauma
• Individuals and their families vary with respect to how they identify in
terms of language usage, diagnostic label and personhood

Trauma and Maltreatment in Children with IDD

Increasingly, data suggests that potentially traumatic events such as maltreatment and
exposure to violence are 2-3 times more prevalent among children with IDD compared
with the population of typically developing children (see Brendli et al 2021; Hoover,
2020; Legano et al. 2021 for reviews). Children with IDD are particularly vulnerable to
bullying, use of physical restraints and seclusion as well as maltreatment such as
physical, sexual, and emotional abuse (Hoover & Kaufman, 2018; Katsyannis et al.
2020; McDonnell et al. 2019).

Bullying is especially common for children with ASD and ADHD. Children with ASD are
bullied more often than nondisabled peers, peers with other disabilities, peers with
intellectual disabilities alone, and their typically developing siblings (Nowell, Brewton, &
Goin-Koche, 2014; Sreckovic, Hume, & Able, 2017; Zeedyk et al. 2014). A recent meta-
analysis estimates that children with ASD are bullied at a rate three times that of
typically developing children. Bullying of children with ASD has significant negative
effects on their social and academic adjustment (Adams et al. 2016), contributing to the
increased rate of suicidal ideation and attempts in youth with ASD (Mayes et al. 2016).
Bullied children with ASD and their parents also report symptoms consistent with panic
disorder, major depression, loneliness, and social anxiety (Storch et al, 2012). Physical
restraints and seclusion are applied to individuals with IDD, generally in response to
Tailoring TF-CBT for IDD 8

self-harm and aggressive, destructive challenging behavior in educational or institutional

settings. Preliminary evidence suggests that these interventions are more likely to be
experienced by individuals with disabilities than by typically developing individuals
(Katsyannis et al. 2020). While such methods may be necessary as a last resort to
prevent harm to self or others, physical restraint and isolation can be experienced as
controlling, harmful, and potentially traumatic (e.g., Embregts et al. 2019).

Adding to the concern about various forms of traumatic exposure, some children with
IDD may be unable to disclose abuse in a clear and coherent way due to language or
cognitive delays. As a result, while these children are more often the subjects of
protective services referrals, substantiation of abuse is reported as being lower at least
for some children with autism (Fisher et al. 2018). Among those who have been subject
to abuse and trauma, children with IDD have higher risk for placements in out-of-home
settings for longer periods than typically developing children. They are often placed in
more restrictive settings and in many cases, it is more difficult to find transitional family-
based placements (Hall-Lande et al. 2015; Simmel et al., 2016; Slayter, 2016).

Responses to Trauma in Youth with IDD

According to The National Child Traumatic Stress Network (National Child Traumatic
Stress Network, 2020) “child traumatic stress occurs when children and adolescents are
exposed to traumatic events and these exposures overwhelm their ability to cope with
what they have experienced.” Children show a range of responses to potentially
traumatic events (Alisic, Conroy, & Thoreson, 2020; Briggs, Nooner, & Amaya-Jackson,
2021; Cohen & Mannarino, 2017) including post-traumatic stress disorder (or partial
symptoms of this disorder), anxiety, depression, or other reactions such as increased
substance use.

Posttraumatic stress disorder (PTSD) is described in the DSM-5 as a syndrome arising

from witnessing, directly experiencing, or being otherwise exposed to serious physical
or sexual violence, threats to bodily integrity, or death of family members (American
Psychiatric Association, 2013). PTSD symptoms are common in the immediate
aftermath of traumatic events for both neurotypical children and those with IDD. While
evidence suggests there is a heightened risk of exposure to traumatic events in children
with IDD, it is not yet clear whether this heightened risk translates into higher rates of
PTSD in this population.

There is evidence to suggest that this adult-based definition of traumatic events is too
narrow for youth in general as children may develop PTSD symptoms for a wider range
of stressful events (Copeland & McGinnis, 2021), particularly for children with IDD. For
example, research is finding that bullying and social ostracism, abandonment by a
mother or spouse, and social difficulties are associated with PTSD symptoms in
individuals with ASD (Rumball, Happe, & Grey., 2020). It is also possible that difficulties
with emotion regulation, deficits in coping abilities and sensitivities to sensory stimuli
and ASD-related reactivity may lead to greater risk of trauma-related symptoms in
individuals with ASD (Haruvi-Lamdan et at., 2018; Kerns et al., 2015).
Tailoring TF-CBT for IDD 9

It is important to note that several syndromes within the IDD designation have
symptoms in common with PTSD such as avoidance, overarousal, and idiosyncratic
fearful responses (Haruvi-Lamdan et al., 2018), which can contribute to diagnostic
confusion in children with IDD and a trauma history. There are also limited tools for
assessing trauma in this population, an area requiring more study (see Byrne, 2020;
Rumball, 2019; Stack & Lucyshyn, 2019 for recent reviews of these issues). The
problem is further complicated by diagnostic overshadowing, a frequently observed bias
in which emotional or other behavioral features in children with IDD are attributed to the
developmental disability rather than being seen as separate, treatable symptoms (Kerns
et al., 2015; Truesdale et al., 2019). Bearing in mind the increased risk of trauma and
the resulting complexity of negative mental health impact on youth with IDD, it is likely
that these children would fare no better than has been found for neurotypical peers.
They have higher rates of PTSD in cases with prior trauma and low rates of
spontaneous recovery 6 months post trauma (Alisic et al, 2021).

Consistent with the discussion above, our experience working with youngsters who
have IDD is consistent with findings with neurotypical youth, Trauma exposure
increases risk of a range of psychiatric disorders. While trauma is a specific risk factor
for PTSD, it is also a non-specific risk for a range of disorders including anxiety,
depression, prolonged grief disorder, and externalizing disorders (Alisic et al, 2021;
Briggs, Nooner, & Amaya-Jackson 2021). Furthermore, Ford and colleagues (Ford et al,
2018; Spinazzola, Kolk, & Ford, 2021) have proposed an additional diagnosis,
developmental trauma disorder (DTD, also called complex trauma), for youth who have
experienced both victimization and disruption of attachment relationships. DTD includes
but extends beyond PTSD and involves issues with self-regulation and relational
insecurity. While DTD is not currently recognized in the Diagnostic and Statistical
Manual of Mental Disorders (American Psychiatric Association, 2013), Complex PTSD
(CPTSD) is differentiated from PTSD in ICD-11 (World Health Organization, 2019).

Cohen & Mannarino (2017) report that TF-CBT is an appropriate treatment for children
with trauma-related symptoms even if the children do not meet full criteria for PTSD or
present with a predominance of other trauma-related symptoms. They note that the
course of treatment may need to be longer, and more emphasis placed on the initial
stages of treatment when developmental trauma (complex trauma) is involved. They
note that when there is high incidence of externalizing symptoms, stabilization may be
needed before TF-CBT is appropriate.

Due to the higher likelihood of language and communication challenges in youth with
IDD, clinicians need to be keen observers of a child’s behavior. New or changed
behavior is sometimes a response to a current traumatic experience or a reminder of
previous trauma. Providers should be alert to possible behavioral indicators of trauma
such as developmental regression, social withdrawal or isolation, reduced self-care, or
increase in disorganized and dysregulated behavior, aggression, and self-injury (see
Kildahl et al., 2019 for a review in children with ASD and ID).
Tailoring TF-CBT for IDD 10

Trauma Treatment for Children with IDD

The research on trauma treatment with individuals with IDD is only in beginning stages
with small sample sizes, an absence of comparison groups, and no published
randomized controlled trials at this time (e.g., Byrne, 2020). A systematic review of the
research conducted between 2008 and 2018 produced only 12 articles that investigated
trauma treatment for individuals with ID (Keesler, 2020). This review identified that four
interventions -- Child-Parent Psychotherapy (CPP), exposure therapy, TF-CBT, and eye
movement desensitization and reprocessing therapy (EMDR) -- have been studied with
this population. Of note, each treatment approach was associated with reduction in
trauma symptoms (Grosso, 2012; Harley et al, 2014; Keesler, 2020).

Another systematic review of trauma in individuals with autism identified seven papers
on treatment, all of which were case presentations (Rumball, 2019). Treatment
approaches included CPP, CBT, systematic desensitization, and EMDR. Of the six
cases providing treatment outcome data, all noted reductions in trauma symptoms
(Rumball, 2019). There is preliminary evidence that group TF-CBT (a somewhat
different European version) can be effective for adults with mild ID and trauma
symptoms (Kroese et al., 2016). The few studies that have been carried out have been
less than adequate for answering our questions about the impact of TF-CBT on youth
with intellectual and developmental disabilities.

There is a lack of current studies supporting TF-CBT effectiveness for youth and
children with ID (Byrne, 2020). However, the efficacy and flexibility of TF-CBT in many
studies of trauma treatment in children is promising and has been extended by the
authors of this treatment manual in developing interventions for traumatized youth
with IDD. As discussed further in a later section, there is now a strong evidence base for
use of CBT interventions to treat anxiety in youth with ID, and these interventions share
many elements with TF-CBT.

Key Points: Trauma in Youth with IDD

Youth with IDD:

• Are at increased risk for various forms of adverse childhood experiences

and traumatic events
• Develop PTSD and other traumatic reactions to a broad range of stressful
events (e.g., perceiving various forms of bullying as traumatic)
• Experience a range of mental health problems including trauma-related
symptoms and at a higher rate than neurotypical youth, thus higher
comorbidity is to be expected
• May have language and cognitive delays that interfere with disclosure
and/or communication about trauma
Tailoring TF-CBT for IDD 11

• Will more often utilize behavior as communication regarding trauma

expression
• Cases are often complicated by diagnostic overshadowing
• Can benefit from currently established forms of trauma treatment

Chapter 2: Culture of Disability and Traumatic Stress

Cultural Competency and Clinical Expertise

We assert that there is a significant shift needed in the way we consider professional
competency in treating trauma for youth with IDD. We see this as a cultural competency
as well as an area of clinical expertise. People with disabilities have unique
experiences, language, systems, connections and relationships, and many other
commonalities that make up their lifestyle and identities. These youth know very well
what it is like to get off the “short bus” at school. They often may know each other
through environments or provider relationships directly related to their disability. There
are people who do not have disabilities who are not directly a part of this culture but
have a familiarity or exposure to the culture of disability. It is our experience that people
who have this exposure and experience, whether personal or professional, are more
likely to have cultural competency when providing mental health treatment to people
with IDD.

The notion of healthy people with disabilities is often an oxymoron in our society. By
definition, some may consider people with dis-abilities to be “lesser-than” or broken, or
irreparably damaged. When mental health clinicians experience and become familiar
with and ultimately grasp the concept of a “healthy person with a disability,” they are
then able to identify the psychopathology when it presents itself in a clinical
assessment. The skills described in this section regarding cultural competence may
take more work for some clinicians to develop than others, but we believe that most
therapists having a reasonable degree of flexibility and openness are able to attain
them. Developing cultural competence and increased skills with this population requires
basic familiarization with the neurodiversity literature, consultation and supervision, and
clinical experience. The latter may be gained by starting with easier or less complicated
cases (e.g., higher-functioning individuals or those with less-severe symptoms) and
increasing one’s comfort with more demanding clinical needs in a stepwise fashion.

People with IDD are a disempowered minority who experience many stressors that
other disempowered minorities experience in our society. One major difference for
people with IDD is that they are the only disempowered minority group in our society
whose minority status is defined by a medical diagnosis. Collectively these youth are
shown to have higher risk and are also underserved, perhaps justifying a broad
advocacy approach toward the recognition of trauma and its recovery with this
Tailoring TF-CBT for IDD 12

vulnerable population. This guide offers this general advocacy rationale with the hope of
reducing therapist reluctance in accepting cases with IDD, instead considering the
gradual inclusion of individuals with IDD into their scope of practice as both a cultural
competency and specialized skill set. We believe this competency is basically a form of
therapist flexibility which can be learned through deliberate application of the resources
shared in this therapist guide with consultation as needed.

We have met many skilled and experienced clinicians who extend their talents to help
youth with IDD while continuing to serve typically developing children and adolescents.
The majority of these therapists do not identify themselves as IDD specialists but are
eager to learn as they already have these patients on their caseload. As therapists
become more familiar and informed regarding culturally informed practices generally,
they learn to better expand their repertoire of tailoring interventions to the individual
when required, thus broadening their comfort zone.

Disability-Related Trauma
Having a disability can in itself be traumatizing. The individual and family are faced with
daily reminders of the difference(s), stereotypes, discrimination, ill-designed physical
environments, and a host of other “micro-traumas.” These “small-T” traumas are
frequent and salient threats to feelings of safety, self-worth, self-efficacy, competency,
acceptance and attachment.

The cumulative effects of chronic trauma that come from stigma, social exclusion,
isolation, and internalized shame, paired with all kinds of other chronic and persistent
learning and social frustrations, may result in long-term physiological stress responses
and mental health sequelae such as increased suicidality. This may be compared to
racial or sexual discrimination trauma that results in persistent stress responses and
depression (see Lund, 2021 for review of this literature).

Working with Families of Youth Who Have IDD

One of the more significant challenges in working with families of youth with IDD is the
ongoing struggle of understanding the full scope of a child’s vulnerability and navigating
the balance between optimizing their potential and protecting them from harm.
Receiving a disability diagnosis for one’s child can be traumatic and a cause for grief
and mourning that may be re-opened at each developmental stage transition or
setback, though this may be moderated by parents’ acceptance and resolution
regarding the diagnosis (Barak-Levy & Atzaba-Poria, 2015). Parents may look toward
their child’s future with foreboding, not knowing what to expect. Taking care of a child
with physical, behavioral, and cognitive limitations can be a daily drain on energy,
requiring sacrifices of money and personal time that go beyond what is required for
parents of most typically developing children (Romley et al. 2017).
Tailoring TF-CBT for IDD 13

Another major aspect is the need to advocate for the disabled child’s medical,
educational, and therapy needs. The fragmented quality of the U.S. health and
education systems puts a heavy load on parents. They must learn all they can about
services necessary and available, take an active role in IEP meetings, as needed apply
for developmental disability benefits and get their child on waitlists for waiver programs,
and juggle a variety of treatment appointments, medications, and multiple team
members. This extra stress and pressure translate into costs and “spillover” into family
relationship distress with a higher divorce rate among parents who have a child with a
disability (Factor et al. 2019). Further, some caregivers can expect to take care of their
disabled child well into adulthood when most parents have shed child-rearing
responsibilities. Parents may worry whether there will be enough money and supportive
caregivers for their disabled child after they pass away. Siblings often feel responsible
to provide care themselves and may see themselves as the ultimate caregivers after
parents are no longer able.

Adding to their burden, children with IDD tend to have a greater likelihood of co-
occurring disorders such as physical disabilities and medical conditions, as well as
mental health diagnoses (Kok et al. 2016; Siegel et al. 2020).

Key Points: Working with IDD Youth and Their Families as Cultural Competency
and Professional Competency

• People with IDD are a disempowered minority defined by a medical

diagnosis.
• Competence in disability culture is essential for working with IDD families
and can be developed by most clinicians who are open to this.
• Disability-based discrimination is a form of chronic trauma with
longstanding negative impacts on mental health and well-being.
• Clinicians should have basic knowledge about definitions, developmental
profiles and characteristics of IDD.
• Families with a member who has IDD often carry extra financial, physical,
emotional, and relational burden.

Systems Issues: Silos of care

In addition to disability-based discrimination and increased financial, emotional,
physical, and medical burden, families of children with IDD often face significant gaps in
mental health services. This occurs secondary to a long-standing siloed approach to
IDD-focused services (D’Amico et al., 2021; Henderson-Smith & Jacobstein, 2015) with
little communication or interaction between mental health and IDD service systems. In
addition, often there is limited communication between IDD care providers. A child with
IDD may be receiving formal supports in their schools and communities, including an
Individualized Education Plan (IEP), Applied Behavior Analysis (ABA), Occupational
Therapy (OT), Speech Therapy (ST), and Physical Therapy (PT), among others. They
Tailoring TF-CBT for IDD 14

may be enrolled in specialized education settings, be involved with assessment

providers, followed by developmental pediatricians, and/or be receiving services
through Medicaid or other managed care programs.
Children with IDD often also receive supports from informal sources, including extended
family, friends, community members, cultural groups, and other families of children with
IDD (Ko et al., 2015). These myriad services and supports have historically been siloed,
providing services independently, individually, and without collaboration across
systems, adversely impacting care, in general. Furthermore, this parallel-systems-of-
care approach has contributed to difficulties in obtaining and providing adequate mental
health (Cervantes et al., 2022) and trauma informed care for children with IDD (National
Center for Child Traumatic Stress [NCTSN], 2020).

This is especially concerning given that cross-system collaboration is a crucial aspect of

effective trauma-informed care for children, in general (What is a Trauma-informed
Child and Family Service System? NCTSN), and even more so for children with IDD
(Charkowski, et al., 2022). In order to successfully work with youth with IDD, therapists
will therefore often find an increased need for multi-provider collaboration, more
consistent communication with caregivers and providers and case management
navigation. Further, therapists will find engagement in adjunctive therapies is common
for youth with IDD and their families who often have multiple treatment needs including
individual treatment for the caregiver(s), marital therapy, family therapy or collaterals
involving siblings, concomitant group therapy, etc.

Cross-system collaboration often involves multiple providers taking on multiple roles (Ko
et al., 2015). For example, when preparing to provide trauma-informed care for youth
with IDD, a mental health provider may want to collaborate with the child’s ABA
therapist, their special education teacher, the aunt who watches the child on weekends,
and the developmental pediatrician, to name a few. Although this goes beyond the
realm of what a mental health provider might typically conceptualize as their scope of
practice, when providing trauma-informed care for youth with IDD, this is as relevant to
treatment as direct provision of services. Beyond initial communication, regular contact
and collaboration will help support the child and their family and generalize skills to
different settings.

In the mental health system, there is often reluctance to treat youth with IDD such as
those with intellectual disability or autism spectrum disorder for trauma. This likely
stems from lack of knowledge that youth with IDD can benefit from trauma treatment
and the fact that these youth are sometimes excluded from community mental health
programs. In the IDD field, the tendency is to rely on behavior management or
functional skills training instead of approaches that help youth process and recover from
traumatic experiences (Xu et al. 2019).

Mental health providers may find themselves hesitant to take on these cases, in context
of a longstanding history of utilizing a behavior-management approach to trauma care
for children with IDD and personal discomfort in working with children with IDD. It has
Tailoring TF-CBT for IDD 15

long been believed that children with IDD are best – and only – treated with behavioral
management (National Child Traumatic Stress Network, 2020). This pervasive belief is
at least partially a function of the misconception that children with IDD do not
experience mental health issues like neurotypical children do (i.e., diagnostic
overshadowing; or that children with IDD will not benefit from mental health treatment.
Both are untrue, as discussed above. Furthermore, many providers do not feel
comfortable working with children with IDD (Ko et al., 2015), often citing lack of
experience or knowledge.

One way to reduce service gaps is to assist trauma trained clinicians in becoming more
comfortable in expanding their competence working with youth who have IDD and their
families. In fact, many providers who have not worked directly with children with IDD, in
a trauma-informed capacity or otherwise, already possess the requisite skills. Rather, it
is a matter of willingness, exploratory education, and flexibility. Because of the shortage
of trauma trained clinicians in the community familiar with the IDD population, we
encourage caregivers of youth with IDD to seek a provider who is open to learning how
to support their child, take the time to assess their relative strengths and weaknesses
and perhaps seek a “cultural broker” or arrange for consultation as needed.

Key Points: Systems Issues Relevant to Youth with IDD

• Youth with IDD are often involved in multiple systems of care, which
operate as independent "silos of care," adversely impacting trauma
treatment.
• Youth with IDD benefit from collaboration across systems of care, in
general, and particularly when treating trauma.
• The IDD system is more oriented toward behavior management than
mental health.
• The children’s mental health system is often trauma informed but lacking
in knowledge about IDD and sometimes systematically excludes youth
with IDD diagnoses.

Chapter 3: Assessment Issues and Strategies

Case example: Assessment of trauma in a child with autism.

Maya is an 8-year-old girl of Latino heritage who has been diagnosed with ASD as
well as a mild level intellectual disability. She has significant speech articulation
impairments making verbal communication almost impossible for most people who try
to engage her in conversation. Her mother is able to understand her and often serves
Tailoring TF-CBT for IDD 16

as an “interpreter.” Maya witnessed several instances of violence when the family

emigrated to the U.S. from a Central American country. In one episode, she was
present when a close family member was robbed and shot. Maya has always
displayed considerable anxiety and tended to avoid talking with people outside of her
family. Since the shooting, she has become more anxious and hypervigilant. She
worries about her mother’s safety when she goes to work. Maya also reports having
auditory hallucinations that began after the shooting episode. She does not speak
openly about the potentially traumatic event.

In Maya’s case, questions arise about whether and to what degree her symptoms are
related to: a) trauma; b) her long-standing developmental delays; c) generalized anxiety;
and/or d) changes in her environment. Assessing trauma symptoms in youth with IDD
can be a challenge. Differential diagnosis is difficult because of confounding aspects of
the developmental disability itself and other comorbid mental health problems.
Language impairments, limited emotional expression, and a concrete thinking style may
render the usual methods and measures invalid.

It is important to avoid the tendency for diagnostic overshadowing in which her anxiety
and hallucinations may be seen as arising from her autism or intellectual differences.
Measurement of comorbidity is complicated. Some assessment instruments have been
shown to successfully differentiate associated psychological disorders. These generally
consist of structured psychiatric interviews administered to caregivers and children and
include the K-SADS-E (Kaufman et al. 1997). The Anxiety Disorders Interview Scale,
Child and Parent (ADISIV C/P Silverman & Albano,1996) includes an addendum
assessing anxiety in autism spectrum disorders (Kerns et al. 2014). There is also an
ADIS adaptation for borderline and mild intellectual disabilities (Mevissen et al. 2016).

Other standardized questionnaire-based measures have proven useful for assessing

trauma symptoms in a typically developing population, but these have not been applied
particularly to children with IDD. These include but are not limited to the UCLA-PTSD
Reaction Index (Steinberg et al. 2013), the Trauma Symptom Checklist (Briere, 1996)
which assesses trauma symptoms and other associated problems, the Child and
Adolescent Trauma Screen (Sachser et al., 2017), and the Child PTSD Symptom Scale
(Foa et al. 2001). As with all measures, it is important to obtain input from a variety of
sources.

To address the specific concern about ability to report mental states by children with
IDD above age 6 whose cognitive functioning is at a 6-year level or below, some have
used versions of instruments that employ DSM-5 PTSD criteria for children ages six and
under when diagnosing children with IDD and such delays (Mevissen, Didden, Korzilius,
et al., 2016). Using the 6-and-under criteria under such conditions has been
recommended by two contributors to the development of the DSM-5 PTSD criteria for
young children (J.A. Cohen, personal communication, May 13, 2019; M.S. Scheeringa,
personal communication, June 5, 2019).
Tailoring TF-CBT for IDD 17

Using Assessment to Match the Treatment to the Client

Assessment is an ongoing process, not just a tool for initially diagnosing either
developmental disability or trauma related symptoms. For each TF-CBT module, the
therapist is first asked to assess the degree to which modifications are needed for the
child and family. The amount or type of modification will vary across the TF-CBT
modules depending on the clients’ personal strengths and difficulties. For some higher
functioning children and youth, very little modification may be needed to make progress
through that stage. For other children and families, significant modification may be
needed. As the clinician approaches each TF-CBT module, referencing past intellectual
and other testing combined with careful observation, questioning, and accumulating
experience with the family will inform a flexible clinical assessment of the client’s skills
and motivation. The specific accommodation or intervention follows from this
assessment and further assessment is informed by the way the client and family
responded to previous steps.

For example, in the case of Maya, the 8-year-old with ASD and intellectual delays
described above, the therapist’s review of her cognitive testing and difficulty discussing
and understanding information at the Psychoeducation stage, suggests that she will
have trouble identifying thoughts and feelings at the Affect Regulation stage. The
therapist should approach Affect Regulation using concrete visual prompts about
feelings in specific situations she often encounters (e.g., struggles with homework;
going to bed at night) and designing a “toolbox” of affective coping skills tailored to her
special interests.

Assessment Considerations

Assessing trauma in children with IDD requires attention to cognitive and functional
differences. Trauma measures for children abound but with rare exceptions (Hoover &
Romero, 2019; Kerns & Renno, 2016) none have been specifically designed and
validated for the IDD population. Assessment tools that are designed for typically
developing individuals cannot be relied upon in all cases because of the lack of
appropriate norms. There is a particular paucity of trauma measures that elicit self-
report in individuals with IDD. Most measures are administered to parents and
caregivers, assuming that children with language or intellectual differences are too
limited to comment on their own experiences. This approach leaves out a source of
information that has been found to diverge from other reports of adults in measurable
and important ways (e.g., Adams et al. 2014).

We recommend that trauma assessments include self-report measures whenever

possible. These can include developmentally appropriate screeners, structured clinical
interviews, and direct questions. As mentioned previously in this guide, there is some
Tailoring TF-CBT for IDD 18

evidence that children with intellectual differences may show regression in previously
learned skills as a result of trauma. Use of adaptive skills measures can provide a way
of tracking such changes in functioning, especially if a baseline before traumatic events
is established.

One self-report instrument currently in development is the Interactive Trauma Scale

(ITS). The ITS is a web-based diagnostic tool that is presented in a multi-modal,
interactive format, administered by tablet or smartphone. Children of most
developmental levels, beginning at approximately age 6 are prompted to select an
“avatar” from a graphic display of pictures of characters with varying skin tone, hair
styles, and gender presentations. They are then given a series of True-False trauma
exposure questions (e.g., “Were you teased or called mean names?” “Did you have
someone bigger or older than you touch your private parts?” etc.). The child is then
asked which experience troubles them the most. They are then led through a series of
symptom-based questions (e.g., “I have bad dreams,” “I feel angry,” “I blame myself for
what happened”, etc.) to which they respond in a Likert scale format: “Never,” “A little,”
“Sometimes,” “A lot,” “Always” by sliding a thermometer-like scale up and down..

The responses are scored based on DSM-5 criteria, counting symptoms of re-
experiencing, arousal, negative emotion, avoidance, dissociation, and overall trauma
response. In a pilot study with a small group of children ages 8-14, all with ASD
diagnoses and known trauma exposures, children rated the scale highly positively. Their
scores on the ITS were moderately correlated with UCLA PTSD-RI child self-report
measure and the parent report UCLA. Participants identified more trauma exposures,
mainly to bullying or teasing incidents, on the ITS, than on the UCLA self-report form
(Hoover & Romero, 2019).

The same adjustments made for therapy and other communication are applicable for
assessment. There is usually a need to establish the child’s reading and comprehension
level, read items aloud, or provide language supports for the child. These may include
the use of assistive communication devices or other ways for the child to answer non-
verbally, ASL signing for deaf children or caregivers, or an “interpreter” who
understands the child’s communication style. The use of visual items and prompts and
simplified scaling can be helpful for youth who may not intuitively or immediately grasp
Likert scales. The assessor should use simple language, a slower pace, and provide
sequencing from basic to more complex concepts when possible. Stopping and
checking for comprehension is always a good idea while proceeding through test items.

While the point has been made about obtaining direct responses from the child, the
observations of adult caregivers, teachers, and other supports are invaluable for
triangulating information about trauma and symptoms. The assessor is often left to
guess at what may have happened. A simple timeline can be valuable for clarifying
symptoms, regressions, and behaviors before and after potentially traumatic events.
Tailoring TF-CBT for IDD 19

Importance of Neurodevelopmental Assessment Data, Clinicians who have more

extensive training on how to interpret and rely on assessment data in their practice will
find they have an advantage in decision-making about the most helpful ways to tailor
treatment for youth with IDD. At times, caregivers of these youth will come to therapy
with a binder of previous testing reports and evaluations to inform the therapist of the
patient’s profile of strengths and needs, diagnostic considerations and the family’s
overall journey in procuring needed supports.

In other cases, clinicians may be waiting for evaluation data that is forthcoming or may
want to refer for more in-depth assessment when only limited information exists. In
training our therapists to approach working with youth with IDD, we encourage the use
of clinical, developmental, and educational data as a formal planning activity to identify
specific needs as well as patient strengths and to assist in learning about the patient’s
idiosyncratic ways of processing information and communicating that warrant special
consideration.

We recommend the use of an Individualized Therapy Accommodations Planning Tool

(see Appendix B) for identifying specific needs and strengths in planning for
accommodations. The tool specifies seven broad domains that often have impact on
therapy: Language, Cognitive Processing, Visual Spatial, Sensory/Motor,
Academic Skills, Willingness and Motivation, and Special Interests. For each of
these, we recommend considering three questions:
(a) What are the individual’s challenges in this area that I will to be mindful of
when implementing treatment? We provide a checklist of specific issues
to consider.
(b) What strengths does the child have that I can build on in treatment?
(c)What specific modifications will I try based on these strengths and
weaknesses?

We recommend that this tool be used throughout therapy. Initially a therapist may
receive information from formal test data, caregiver input, and other reports. Information
should be updated as you get to know the child directly, get additional caregiver or
outside information (including new formal assessment reports), and as you work on
tailoring treatment to the specific portions of the TF-CBT model (see Chapters 5 and 6).
For therapists less familiar with the interpretation and use of formal assessment data or
with the specific subdomains of functioning in the planning tool, we recommend an
“Assessment Broker,” essentially consultation with an assessment expert such as a
neuropsychologist. Also in Appendix A is a completed example of the planning tool with
recommended therapy accommodations suggested for each domain.

A final consideration regarding assessment relates to attribution of specific symptoms to

a diagnostic classification. As discussed in chapter 1, diagnostic overshadowing can
lead to the misattribution of observed symptoms to a child’s IDD diagnosis rather than
trauma response or vice versa. Diagnostic specificity, the ability of an instrument to
detect and rule our false positives, should be a consideration in selection assessment
Tailoring TF-CBT for IDD 20

tools to help mitigate this risk. However, where this information is unavailable to the
clinician, it may be necessary for the user to rely on their comprehensive interview,
history, observation, and clinical judgment to make these distinctions. In some cases,
the distinction may not be possible to make, and this should be reflected in the
clinician’s case conceptualization and any diagnostic report. Additionally, these
categories are not mutually exclusive or exhaustive. Some symptoms related to trauma-
exposure which may overlap with or look very similar to traits seen in some IDD
diagnoses and require care are listed in Table 1.

Table 1. Potential similarities and overlap between trauma-related symptoms and

commonly observed characteristics of IDD.

Trauma Related Symptoms IDD Characteristics

Exaggerated startle response Sensory hypersensitivity

Social withdrawal Limited interest in social interaction; preferring

to be on one’s own

Depressive symptoms Limited interest in social interaction related to

functional support needs, social skills, or
personal preference; preferring to be on one’s
own; preferring to stick to specific interests;
bluntness or other differences in social
reciprocity

Repetitive play around traumatic Other repetitive behaviors

themes

Intrusive thoughts Strong or perseverative interests, sometimes

related to unusual or highly specific topics

Key Points: Assessment Issues and Strategies

• Assessment of trauma in youth with IDD is confounded by aspects of the

disability itself, diagnostic overshadowing, and high levels of comorbidity
• Standardized trauma measures are not typically normed for youth with
IDD and specially designed instruments are only now being developed
• While most rely on parent or caregiver report, it is recommended that
self-report be attempted with accommodations considering the child’s
reading and comprehension levels
• Use of adaptive skills measures can assist in assessing trauma impact
Tailoring TF-CBT for IDD 21

• Consider implementation of the Individualized Therapy Accommodations

Planning Tool
• Consider the use of an assessment broker to interpret and utilize
assessment/evaluation data

Chapter 4: Readiness and Preparation for Trauma Work

Once the need for a trauma-focused intervention has been established, it is time to
determine how to proceed with designing a treatment plan. TF-CBT treatment planning
should always include consideration of the child’s broader systems of care and lead to
logical “next steps.”

Care Coordination and Collaboration

Many children with IDD are followed by one or more medical specialist (e.g.,
psychiatrist, developmental pediatrician, neurologist), and receive multiple supportive
services such as special education, physical therapy, occupational therapy, and/or
speech and language therapy, behavioral support and/or mental health counseling.
They are likely to be receiving these services through multiple systems of care.
Examples include health, mental health, education, child welfare, and juvenile justice.
Given a particular individual’s constellation of needs and supports, it is important to
consider how TF-CBT will be integrated into the existing network of care. Information
needed and decision-making process are elaborated in Table 2.

Table 2. Assessment of engagement, coordination and collaboration for treatment

planning.

Points to assess for parent engagement and accessibility, care coordination and
collaboration with other providers:
• In which system will the child receive TF-CBT? (i.e., school, outpatient mental
health, child welfare, juvenile justice, inpatient hospitalization, etc.)
o Considerations: financing; transportation if needed to service for child
and caregiver; overcoming childcare challenges for parents with multiple
children or other parent availability issues; availability of private space to
meet; telehealth availability; time to service/waitlists; disruptions to
service
• Who is on the child’s care team?
o Considerations: prioritizing the patient’s voice and choices (e.g., a
person-centered approach); establishing ongoing communication
Tailoring TF-CBT for IDD 22

between members of the care team; leadership and delegation in care

activities; “translating” technical language for all members of the team
• What services is the child already receiving?
o Considerations: sequence of services; integration of services where
appropriate; avoiding redundancy; alignment/fit of services to the child’s
current needs, short term goals, and long-term goals
• Who coordinates care right now?
• Will some services need to be put on hold while participating in TF-CBT?

Assessing Readiness and Staging for TF-CBT

TF-CBT is designed to be a discreet and time-limited therapeutic intervention. While
there is flexibility built into the model (i.e., extended preparation time for identified
caregiver), as described in Chapter 5 of this Guide, it may be necessary to sequence
other services with TF-CBT to best support its efficacy. This is particularly the case
when the youth with IDD is exhibiting behavior that poses safety risks and there is need
for stabilization before trauma recovery can be attempted. Sometimes, TF-CBT may
need to be discontinued or paused temporarily to pursue other services. This process of
sequencing services to support the efficacy of TF-CBT is called “staging.” Staging is
different from coordinating with other services while a child is participating in TF-CBT
because staging considers when the process of trauma recovery can begin or resume
once discontinued. In addition, it is important to determine whether TF-CBT is the best
trauma-focused approach to meet your client’s needs.

Table 3: Essential questions to determine readiness for TF-CBT:

Essential Question Considerations

To what extent will this child be able Development of alternative communication modalities;
to participate in treatment verbally? availability of caregiver to participate and act as
“interpreter” for child in session;

Who are this client’s primary Availability of caregivers to participate; availability of

caregivers and are they able to act caregivers to listen to and provide support with
as active participants in services? coaching from therapist

Is this client able to sit in the Intense aggressive, self-injurious, or dangerous

treatment room and participate in disruptive behaviors such as elopement, especially if
therapy? exacerbated by discussion of trauma-related details
Tailoring TF-CBT for IDD 23

Are there safety or stabilization Active substance use; psychosis; suicidality; risk of
concerns that must be addressed? harm to others; medical conditions requiring intensive
care; pharmacological considerations

Careful evaluation of these considerations my help you to identify that your client is:

1. In need of supportive services prior to initiating TF-CBT

2. In need of services in addition to TF-CBT that may be provided concurrently or
referred to at any stage in treatment
3. In need of a trauma-focused intervention other than TF-CBT

The logic model below (Figure 1) was developed to aid in evaluating the needs of
individual clients and to determine the sequence services with consideration to TF-CBT.

Figure 1: Sequence of services in treatment planning.

Tailoring TF-CBT for IDD 24

One of the primary considerations in preparation for trauma work is to establish whether
some level of perceived safety exists or has been restored relative to the experienced
trauma. Helping the youth and caregiver recognize or co-construct a relative sense of
safety is essential to treatment progression. In our work with IDD youth and their
families, significant attention early on with the “Enhancing Safety” component of the TF-
CBT model is often needed along with clear acknowledgement of whether some aspect
of trauma is - ongoing and preventable, predictable with periods of safety, or persistent
and unpredictable (Kagan et al., 2022). Creating and/or articulating a current safety plan
already being enacted allows for a paced approach to trauma narration.

In some cases, efforts at “Enhancing Safety” within the TF-CBT model may not be
sufficient or advised given the need for stabilization. Some of the more common
stabilization domains are listed in the table below. At the patient level, significant
behavioral dysregulation in the form of significant oppositionality, conduct problems, or
aggression may preclude initial engagement in trauma treatment. An intensive parenting
approach like Parent Child Interaction Therapy (PCIT) can help stage for TF-CBT in
cases where extended time preparing caregivers within a flexible approach to TF-CBT
is not sufficient. Another stabilization domain more often encountered in youth with IDD
is psychiatric status and associated pharmacotherapy. Close monitoring of mental
status and medication effects in collaboration with the prescribing physician to
determine readiness (including transitions to and from higher levels of care) may take a
good amount of staging. Given the severity of other comorbid conditions, clinicians may
find that associated mental health concerns such as acute OCD or depression require
focused attention prior to beginning a course of TF-CBT.

At the family level, baseline functioning may not be sufficient to benefit from only a few
extended TF-CBT sessions of parenting and psychoeducation and therefore a more
inclusive family intervention like Families Overcoming Under Stress (FOCUS; Saltzman,
2016) can help create the necessary family cohesion and support. In cases where the
parent-child attachment may need bolstering, intervention at the dyadic level (such as.
ARC Grow for TIDD) may serve as a staging intervention for later TF-CBT. Lastly, as
mentioned earlier in this guide, cross system collaboration is often poorly coordinated,
even prohibitive in its structure of available supports to youth and families with IDD. In
these cases, there is likely to be importance of a more systems-oriented approach to
develop a more stable foundation for trauma treatment.

Table 4: Domains and Possible Approaches for Staging

As discussed above, the following are examples of unique circumstances that

occasionally arise working with youth with IDD (although not exclusive to the population)
where staging for trauma recovery may be necessary.
Tailoring TF-CBT for IDD 25

Domains and Possible Approaches for Staging

• Trauma Informed Behavioral Support: Parent-Child Interaction Therapy (PCIT)
• Psychiatric Status, Severity of Comorbid Condition: Pharmacotherapy,
• Family Functioning: Families Overcoming Under Stress (FOCUS)
• Parent-Child Attachment: ARC Grow for Trauma and Intellectual and
Developmental Disabilities (ARC Grow for TIDD)
• Level of Care/Service Coordination: Trauma Systems Therapy (when there is
systems commitment and availability of this approach)

Case example: Need for Family Stabilization

Manny is a 6-year-old male who was removed from his home in a mid-west state and
brought to his maternal aunt’s home in the northeast at age 5 to live with his adoptive
parents and 2 teenage cousins. Manny experienced severe neglect in his prior (bio
parent’s) home where there was significant drug abuse, domestic violence and
physical abuse and it is reported that Manny spent much time roaming the family farm
left for extended periods with only the animals. Upon intake, there were reports of
significant elopements and escalations of aggression in both home and the school
where Manny was undergoing a special education evaluation for initial impressions of
Autism and speech & language delays.

Both his adoptive family and the school were considering the need for residential
placement. While his Aunt was committed to working things out with Manny, her
husband, 14-year teenage son and 16-year-old daughter expressed much resentment
and exasperation with Manny’s intensive needs and especially his emotional-
behavioral dysregulation with accompanied interpersonal” neediness” and aggression.
Significant trauma informed consultation for all family members (and eventually school
staff) was accomplished with an adapted version of the FOCUS model (Saltzman,
2016) which facilitated stabilization by fostering family resilience through sharing
together each family member’s adoption experience in concert with Manny’s traumatic
history.

Emphasis on interpersonal safety surrounding Manny’s trauma reminders of

deprivation and personal space/touching were key features that emerged as
foundations for approaching and communicating successfully with Manny, reducing
his survival reactions of elopement and physically defending himself. Stabilization at
home led to a collaborative and trauma informed school plan as well. These efforts
which occurred across a period of approximately 3 months helped stage a successful
transition for Manny to then engage in a complete trauma recovery through
engagement in TF-CBT.
Tailoring TF-CBT for IDD 26

Key Points: Readiness and Staging for Trauma Work with IDD Youth

• Treatment planning should take into account the child’s system of care
and whether necessary support is available
• Staging of treatment may be needed
• The child’s ability to verbally participate and maintain safety and stability
is assessed in terms of readiness to participate in trauma-focused work
• Emotional and behavioral regulation need to be sufficient to allow the
child to participate in therapy but need not be perfected
• Several evidence-based treatments and other interventions are available
to promote stabilization and readiness for trauma-focused therapy

Chapter 5: Trauma Focused Cognitive Behavior Therapy (TF-

CBT)

TF-CBT and its Components (overview)

Case Example: Beginning therapy with a boy who has ID and a language
disorder

Joseph is a 12-year-old boy who was diagnosed with a mild intellectual disability and
mixed expressive-receptive language disorder at age 4. He lives with his mother,
stepfather, and two younger half-sisters in a large Midwestern city. Joseph has always
been a cheerful boy who has positive relationships with his family members and a
lifelong preoccupation with train engines, diesel trucks, and large machinery. Joseph
has been known to have occasional tantrums and “meltdowns” when frustrated or
surprised by changes to his routine. His usual bright demeanor has changed since the
family moved to another city, a major change for him. There he encountered repeated
physical and verbal bullying in his new school, and an incident on the school bus, in
which he was sexually fondled by an older boy. Since these changes and incidents,
Joseph has been increasingly isolated, refuses to leave his home or go to school, has
been wetting the bed at night, and his episodes of angry blow-ups have increased on
a daily basis. It is only with great difficulty that his parents have been able to get
Joseph to an outpatient clinic to receive evaluation and treatment for his trauma.

Treatment strategies are needed to address trauma in the population of children dually
diagnosed with IDD and trauma-related disorders. Not only do children with IDD
respond differently, perhaps with more sensitivity to trauma than typically developing
children, but they also respond differently to treatment as well.
Tailoring TF-CBT for IDD 27

Verbal expression and processing form a key part of most therapies for trauma in
children but may be difficult or impossible for some children with IDD. Some children
with IDD are entirely non-verbal or lack receptive language comprehension. Those with
intellectual or language delays may have limited ability to understand the concepts
taught in evidence-based trauma treatments such as TF-CBT.

The core deficits and associated features of various forms of IDD make it important to
adapt treatment models to make them effective. While no evidence-based treatment
model specifically for IDD has been developed, recommendations for adjusting TF-CBT
for children with developmental disabilities have been discussed (e.g., Grosso, 2012).
Grosso highlights the need for sensitive assessment procedures using drawings, a
“Rain Cloud Likert Scale” and support for completing standard scales such as the
UCLA-PTSD Index. The TF-CBT treatment steps are discussed in detail with
accompanying suggestions for adapting them for use with children who have a variety
of disabilities. Tallant (2010) also makes many excellent recommendations for work with
children who have ASD and IDD. This treatment manual incorporates many of these
modifications. Hoover, Fleming and Khan (in review) have addressed tailoring
specifically for youth with intellectual disabilities. Peterson and colleagues (2019)
provide recommendations for treating children with autism by tailoring to key features of
TF-CBT for that population.

TF-CBT is a 12-16-session intervention designed for youth ages 3-18 and their non-
offending caregivers (Cohen, Mannarino, & Deblinger, 2017). It is the most widely used
and best validated treatment model for addressing childhood trauma. During the initial
phase of treatment, the therapist provides psychoeducation about trauma exposure and
traumatic stress and teaches a variety of stress-reduction skills such as deep breathing,
muscle-tension relaxation, emotion identification and regulation, and cognitive coping.
Caregivers also receive education and guidance on effective parenting skills and
behavior management. A central component of TF-CBT—the trauma narrative-- is
implemented following the child’s successful incorporation of the stress-reduction skills.
Trauma narration functions as a means of therapeutic exposure and facilitates
emotional and cognitive processing of the event. The narration involves identifying
thoughts and feelings related to the event and correcting distorted beliefs or
perceptions. After completion of the trauma narration, the therapist helps prepare the
child and caregiver to maintain future safety and healthy coping, and then initiates
treatment termination.

Trauma Treatment Tailored for Children with IDD

The purpose of this treatment guide is to suggest ways of tailoring TF-CBT for children
with IDD as a basis for high fidelity intervention and clinician training. The modifications
are based on a combination of clinical recommendations (e.g., Grosso, 2012) and
proven methods for treating anxiety disorders in children with autism. This will allow the
model to be tested empirically as a beginning to an evidence base that currently does
not exist.
Tailoring TF-CBT for IDD 28

To organize an effort to adapt TF-CBT to work with this population, a matrix table was
formed with the steps of TF-CBT on the horizontal axis and core needs and deficits of
IDD on the vertical axis (see Table 5). The resulting cells were completed based on
clinical experience, literature review, and supporting audiovisual, activity suggestions,
educational aids, and other materials obtained from sources designed to help children
with IDD. The matrix forms the backbone of this treatment model and is continually
being updated as materials are added from the ever-growing literature.

The manual will proceed following the PRACTICE modules of TF-CBT, providing
recommended interventions and materials to address commonly encountered
challenges unique to IDD. Many of the following points are consistent with TF-CBT
provided to typically developing children and families. In order to apply the steps to
children with IDD, it needs to be made more explicit and stepwise. During each module,
the clinician must assess how the clients’ disability impacts the use of the TF-CBT
intervention component being considered. Accommodations may be needed to fit each
client’s unique sensitivities, preferred learning modalities, and conceptual capabilities,
throughout the intervention. Further, we cannot assume that the child with IDD will
intuitively understand and volunteer to participate in what is being asked of them, and
extra motivational aids are often needed to sustain cooperation in a difficult treatment
process.

This manual is not meant to replace formal training in TF-CBT. Practitioners should first
receive training and achieve some proficiency in the overall model before attempting to
apply these modifications for a specialized population. A free online course is available
on the National Therapist TF-CBT Certification website (https://tfcbt.org/training) that
can provide a beginning; further training can be accessed through local and regional
training initiatives associated with the National Child Traumatic Stress Network
(www.nctsn.org) and the CARES Institute (https://centers.rowanmedicine.com/cares/).

General Modifications: Relevant Research on Tailoring of

Therapy with IDD Youth
Cognitive-behavioral therapy (CBT) shows promise for treating behavioral and
emotional disturbance in children who have IDD. Most of the extant work in this area is
the application of CBT to treating anxiety and challenging behaviors in children with
autism spectrum disorders. Evidence based packages with documented efficacy for
treating anxiety in children with ASD include: Coping Cat (McNally et al. 2013); Cool
Kids (Chalfant, Rapee, & Carroll, 2007); Facing Your Fears (Reaven et al.
2011);Behavioral Interventions for Anxiety in Children with Autism (BIACA; Storch et al.
2013; Wood et al. 2009); and Building Confidence (Wood et al. 2009). These
interventions are based on a CBT model of change and have many similarities. They all
explicitly speak to the adjustments that are necessary to apply established treatment
approaches to work with children on the autism spectrum.
Tailoring TF-CBT for IDD 29

CBT-based approaches to anxiety disorder treatment in autistic children have been

shown to produce outcomes that are positive in general though not as efficacious as
treatment with typically developing children (e.g., van Stensel & Bogels, 2015). Two of
these treatment interventions (Reaven et al. 2011; Storch et al. 2013; Wood et al. 2009)
have shown reliably measured and replicated efficacy in comparison with other models
(Hunsche & Kerns, 2019). In order to apply CBT models to working with children and
families with developmental delays and differences, modification is usually required.
Modifications noted in the literature consist of tailoring the structure, environment, and
intervention strategies and content of CBT treatments to best serve this population.
Though empirical support is not yet well-documented for children with ID, it is important
to note that the empirically driven modifications detailed below largely overlap with
theoretical recommendations for children with ID and the existing empirical studies in
this population (e.g., Hronis & Kneebone., 2017; Hronis et al. 2020). Table 5 highlights
the central findings and recommendations derived from studies of treating anxiety in
children with ASD and ID.

Table 5. General modifications of CBT for children with autism

and developmental disorders

• Built-in routine, predictability, visual schedules

• Slowed pace; longer treatment duration; shorter sessions
• Booster and follow-up sessions
• Reinforcement schedules for therapy-related behaviors, e.g., attendance &
engagement
• Caregiver involvement and active participation (even in treatment components
typically done by the therapist without the caregiver)
• Calm space with sensory supports or “low sensory” environment
• Slowed, simplified language
• Highly structured worksheets
• Using a child’s specific interests for engagement and reinforcement
• Presentation of material using visual aids, concrete aids
• Additional treatment targets which address ASD core deficits, such as social or
self-care skill development
• Videos to model skills and for gradual exposure
• Greater focus on in-vivo practice of skills
• Take into consideration the child’s neuropsychological profile, developmental
level, and strengths and interests to adapt appropriately

Sources: Danial & Wood, 2013; Dyson, Chlebowski, & Brookman-Frazee, 2019;
Grosso, 2012; Hronis, Roberts, & Kneebone, 2017; Moree& Davis, 2009; Moskowitz
Tailoring TF-CBT for IDD 30

et al., 2017; Ollendick et al., 2021; Reaven et al., 2009; Sofronoff, Attwood, & Hinton,
2005; Sung et al., 2011; Tallant, 2010; Ung et al., 2015

Issues in Therapeutic Engagement

Because of some of the unique qualities and circumstances of children with IDD,
particular modifications are often necessary for therapy to be successful. Things to
consider include: a) the environment of therapy; b) building therapeutic rapport and
addressing interpersonal issues with the child; c) building the alliance with the caregiver;
and d) management of risk and challenging behaviors in therapy. The following
suggestions arise from our extensive review of the literature and our own clinical
experience with this population of children and caregivers.

The therapeutic environment should provide comfort, a sense of safety and

predictability, with attention to any potentially disruptive sensory stimuli. It helps to meet
(in person or by telehealth) in a setting that is calm, quiet, removed from unnecessary
distractions, and essentially the same each time the child comes for therapy. Busy
families may present the child for telehealth treatment from the back of a parked car
outside of school, in various rooms of the house, or in front of a video-game console
proximal to the family computer. We have found that the level of distraction and sensory
overload in such settings generally overrides the best efforts of the therapist to engage
and address therapy goals. This is perhaps more true for children with organizational
and intellectual limitations, than for typically developing children, though the case could
be made that such settings are not advantageous for most clients.

We recommend bringing up such concerns with caregivers early in the treatment when
needed, communicating clearly and directly to convey expectations that will need to be
established before therapy can begin in earnest. Moving from a waiting area to the
therapy room may be difficult at first. The therapist should be ready to take it slow, meet
the client where they are, offer reinforcements of various kinds, and employ strategies
of systematic exposure and familiarization to address beginning anxiety and resistance.

Therapeutic rapport can be more difficult for children with IDD. This may arise from the
transition itself (e.g., moving from a more-preferred to less-preferred activity; meeting
and getting to know a new person). Even more than with their typically developing
peers, children with IDD may be anxious, unsettled, or stressed by meeting a new
person. This is especially the case when asked to talk about sensitive subjects, such as
traumatic memories, in relatively verbal fashion, with a therapist they do not initially
know well. It is our experience for example, with children who have autism, that they
usually resist starting therapy for multiple sessions until they have gotten more familiar
with the routine of seeing the provider. After the routine is established, however, it is our
experience that many have just as much trouble ending therapy with us as they did
starting it.
Tailoring TF-CBT for IDD 31

It is recommended that therapists enter treatment relationships focusing particular

attention on developing comfort and rapport, while recognizing that this process will
likely take some time. It is also important to set up a therapy routine from the beginning.
This often takes the form of several steps: a) greeting and conveying updates since last
session; b) exploring thoughts and feelings of child and family at the time of the session;
c) doing therapeutic tasks and skill-building (i.e., PRACTICE skill work); and d)
concluding with play or an activity related to the child’s particular interest areas. We
have found that keeping of a visual schedule (e.g., on a white board or computer
monitor) in sight can help regulate attention and participation in therapy throughout
these routines.

Caregivers and parents may be equally as difficult to engage, particularly if they have
had experiences of providers who did not understand their child or meet their needs.
Therapists ask them to be actively involved in the treatment to support learning,
generalization, and overcoming any initial avoidance by their child. Caregivers may
need some extra attention to address their own anxieties and to make sure that their
concerns are being taken seriously by the therapist.

Children with IDD are more likely to present with challenging behavior and co-occurring
mental and behavioral symptoms, than typically developing children. They commonly
present with comorbid anxiety disorders that amplify trauma reactions. Physical and
verbal aggression may be a way of communicating such anxiety or other feelings that
are difficult to communicate otherwise. They are more likely to suffer from suicidal
ideation, self-harming behavior, feelings of panic, gender identity questions, visual
and/or auditory hallucinations, interpersonal alienation and stigmatization. All of these
should be addressed directly and in a concurrent manner along with trauma focused
therapy. For more serious problems or those impacting safety, the therapist should start
with those, obtain consultation or concurrent treatment for problems not in their scope of
expertise (e.g., psychiatric consultation for medication; behavioral intervention to reduce
self-harm, etc.) and then proceed with trauma therapy when the difficulty is settled
enough to proceed safely.

It is important to remember the diversity of youth with IDD and that there will be much
variation in the extent to which specific children will need the modifications and aids
listed above. To help monitor your need for and use of specific accommodations, we
have provided a brief accommodation monitoring checklist, included as Appendix C.
More detailed information about tailoring treatment is provided in the next chapter.
Tailoring TF-CBT for IDD 32

Key Points: General Modifications to Consider from Relevant Research

• Recommendations to tailor TF-CBT are based on autism research, IDD

interventions, and clinical experience.
• Tailoring interventions are aided by a Matrix of TF-CBT PRACTICE
components and key modification needs.
• Special consideration should be given to engagement in treatment, including
environment, risk management, rapport with child, and alliance with parents.
• Adapting CBT has been studied by autism and ID researchers with resulting
recommendations including having caregivers in session, modifying language
and sequencing, adding visual-spatial prompts, and incorporating interests.

Application of TF-CBT for Children with IDD

Review of the literature suggests three central domains of functioning that have been
identified for modification of treatment (Hoover et al. in review):

1. Comprehension/Conceptual Understanding. In intellectual disabilities,

conceptual functions are affected resulting in limited ability to comprehend, learn, and
reason abstractly. Understanding of spoken and written language, and language
expression are often under-developed (Schalock et al., 2021). The heritability of ID
suggests an increased likelihood that parents and caregivers may also show
weaknesses in these areas and may require support for understanding and adhering to
treatment (LeHellerd & Steen, 2014). As compared with typically developing children,
those with ID may require slowed and repeated presentation and simpler language, with
checks for comprehension (Hronis & Kneebone, 2017). Social understanding, practical
judgment, and problem-solving may require aid, as well. These must be integrated into
trauma treatment to help patients and families maintain safety and apply tools provided
in therapy. They may be more successful if introspection is de-emphasized and the
focus is placed on skill building (Deblinger et al., 2011).

Some individuals with ID more easily understand concepts presented visually rather
than verbally; often a multi-modal presentation of new material, combining verbal,
visual, and physical engagement with tasks along with repetition, eases comprehension
challenges (Lisle, 2007). Comprehension and communication differences may affect the
child’s and caregiver’s understanding of concepts presented in trauma treatment.

2. Executive Functions and Motivation. Executive function (EF) is defined as meta-

level cognitive processing expressed in skills such as attention, planning, self-
motivating, initiating and executing behavior, problem-solving, and regulating emotions.
On average, those with intellectual disability show relatively under-developed EF
compared with typically developing peers, though the patterns of strengths and
Tailoring TF-CBT for IDD 33

weaknesses vary by individual (Spaniol & Danielsson, 2022). In children, degree of EF

weakness is correlated with intellectual capacity, and functions such as working
memory appear to improve with age and experience (Erostarbe-Perez et al., 2022). The
child and caregiver’s EF may impact trauma-focused treatment that requires sustained
motivation and working memory for psychoeducation and skills training. In ASD
particularly, a tendency has been shown for focusing on proximal details rather than
distal goals or perspectives, termed the “weak central coherence” model (Olu-Lafe et
al., 2014; Happe & Frith, 2006). Those affected by this processing difference may not
immediately or consistently grasp the metacognitively-based rationale for engaging in
treatment, especially when faced with anxiety-arousing reminders of trauma events. We
see challenges in sustaining motivation for therapy and the ability to persist in difficult
treatment as essentially arising from EF.

Perspective taking, initiation, and sustained motivation are needed to make the most of
trauma therapy, and all may need additional supports. Motivational support for both the
child and caregiver may be needed to aid engagement in therapy. Extra explanation
and demonstration of the reasoning behind systematic desensitization may be helpful.
Use of material reinforcers such as points, stickers, and a reward schedule can help
children to stay engaged in treatment work. They may only be able to tolerate relatively
shorter sessions due to difficulty sustaining treatment interactions (Hronis et al., 2017;
Ung et al., 2015).

3. Generalization of Learning. There is much evidence that individuals with ID have

greater difficulty, relative to typically developing peers, generalizing in-session learning
to situations outside of training, education, and treatment sessions (e.g., Doughty &
Kane, 2010; deMarchena et al., 2015). Generalization requires the opportunity to
practice a skill or technique in ways that lend themselves to repeating the response
after the learning has taken place. Stokes and Baer (1977) famously noted that
generalization is a key component of behavioral analysis and that “a therapeutic
behavioral change, to be effective, often (not always) must occur over time, persons,
and settings, and the effects of the change sometimes should spread to a variety of
related behaviors” (p. 350). Such generalization does not occur passively or simply as a
result of learning (described by these authors as the “train and hope” model) and must
be attended to if gains are to extend beyond the initial training.

In TF-CBT, skills (i.e., relaxation, affect regulation) are learned and practiced to replace
traumatic responses with calm and resolution. Clinical experience suggests that therapy
patients need help to recognize when to use coping skills in the “real world.” For
example, after being taught to use sensory calming strategies, a child may not be aware
of internal anxiety cues that would signal that it is time to use the strategies. Some
teaching methods such as video modeling have been shown to increase generalization,
precisely because it aids memory and attention to context (Cullen et al., 2017).
Tailoring TF-CBT for IDD 34

Key Points: Applications of TF-CBT for Children with IDD

• Comprehension/conceptual understanding, executive functioning and

motivation, and generalization of learning are key domains for
modification of treatment.
• Visual or multi-modal presentation of materials is often warranted.
• Supporting executive functions and motivation may be needed.
• Generalization of skills development should be emphasized in tailoring
treatment.

Chapter 6: PRACTICE Skills Modifications- The Matrix

Steps of TF-CBT

The following steps match specific recommendations above with stages of TF-CBT to
provide an adapted treatment. Therapists should ask themselves the following
questions, answerable based on neuropsychological assessment of the child and
informal assessment of the child and caregivers’ response to the interventions. At each
stage of treatment, therapists can obtain ideas for therapy session materials and
resources from the Matrix- Table 6. The reader is referred to Appendix D for a detailed
list of assessment questions the therapist can consider at each of the PRACTICE steps,
to inform choice of resources and aids for therapy
 35

Table 6: Matrix of TF-CBT Components and Tailoring Suggestions.

Comprehension Executive Function Generalization

• Use visual aids to orient to • Use visual aids to orient to • Consider referral to parent support
treatment structure and treatment structure and group or individual therapy for
expectations. expectations. caregivers.
• Employ Picture Exchange • Outline “Rules for Therapy” using • Provide psychoeducation about
Communication System (PECS) or simplified language. traumatic stress responses at
Psychoeducation and Parenting Skills

other language aid including • Use preferred characters to different developmental levels to
augmentative and alternative illustrate symptoms. caregivers and others who help
communication devices (AAC). • Include caregivers’ input on how with the child’s care.
• Outline “Rules for Therapy” using best to tailor treatment to their • Incorporate structured behavioral
simplified language. child. assessments and interventions
• Use developmentally appropriate • Include caregivers’ input on how (e.g., Functional Behavioral
books and games as best to tailor treatment to their Assessment) in parent training.
comprehension aids (e.g., A child. • Use reward and tracking charts
Terrible Thing Happened, ‘Please that can be shared by home,
Tell’ for sexual abuse, ‘Something school, and other team members.
is Wrong at My House’ for domestic • Provide psychoeducation about
violence, ‘Invisible String’ for social skills.
traumatic loss, ‘Maybe Day’ for • For caregivers, provide
foster placement, What Do You psychoeducation on the interaction
Know?). of the child’s diagnoses and
• Introduce and use consistent symptoms (e.g., autism and
trauma-related language, use of a PTSD).
table of language differences by
cognitive level and corresponding
vignettes.
• Use concrete, visual examples for
types of trauma and symptoms.
Tailoring TF-CBT for IDD 36

• Flash cards for key concepts (i.e.,

“trauma,” “reminders,” etc.).
 Tailoring TF-CBT for IDD 37

Comprehension Executive Function Generalization

• Use comprehension and • Teach muscle relaxation using • Involve caregivers and other
engagement aids (“pizza preferred characters (e.g., Buzz important models in practice of
breathing;” “hot air balloon” Lightyear and Woody, Sesame relaxation skills.
breathing). Street Elmo, “Head, Shoulders, • Use structured worksheets in
• Employ visual imagery/imaginal Knees and Toes song. session and at home or other
relaxation. settings, like “Schedule for
Calming and/or Relaxing
Activities.”5
Relaxation

• Deep breathing with concrete • Incorporate child’s related interests • Use sensory supports that can be
means (e.g., using bubbles). as ways to relax (e.g., drawing, employed in multiple settings
playing games with caregivers or (e.g., fidget toys).
family members.

• Make a concrete toolkit of • Make a toolkit of learned relaxation • Encourage and prompt at-home
relaxation skills (e.g., Calm Box). skills (e.g., Calm Caddy5). practice.

• Use sensory objects (e.g., bubbles, • Include strategies the parent

bubble wrap) to promote relaxation. identifies to work for the child.

• Utilize where possible, yoga • Create a reward system for using

instruction and practice relaxation strategies.
• Use structured worksheets, like
“Schedule for Calming and/or
Relaxing Activities.”4
 Tailoring TF-CBT for IDD 38

Comprehension Executive Function Generalization

• Use apps or computer programs for • Use pictures of preferred • Use caregivers and other
learning emotion facial expressions characters or interactive activities important people in role plays.
(e.g., Emotional ABCs7; Feelu: (e.g., charades, music) to teach
Emotions & Mindfulness8; I Can the emotions.
Special Needs Learning-
Feelings9).
Affective Modulation

• Use structured worksheets to learn • Use preferred subjects as • Provide visual aids of emotions
about emotions (e.g., “Words for metaphor for feelings (e.g., types and affect ratings of family to be
Worry Word Search”4). of weather). used at home.

• Use visual representations for • Use preferred subjects as a story • Encourage caregivers and other
emotions (e.g., emojis, Zones of to explore feelings (e.g., for important people to use the same
Regulation5, Feeling airplanes, people’s emotions at simplified language to discuss
Thermometers4, videos such as the airport) emotions.
Inside Out film clips).

• Use fill-in-the-blank scripts to • Charts and rewards for managing • Create a concrete toolkit or box of
improve communication skills. difficult feelings. coping skills to be used at home.

• Use videos to model emotions and • Power Cards11 to foster • SPACE (Supportive Parenting for
coping strategies. identification with preferred Anxious Childhood Emotions10)
characters modulating feelings. anxiety treatment for parents.
Tailoring TF-CBT for IDD 39

• Employ shared Power Point slides • Make use of child’s special

as a visual reminder of skills used- interests as coping skills for
collages of pictures, slogans, etc. feelings (e.g., reading, drawing,
gaming).

• Use mutual play with caregivers

as coping skill (e.g., playing
cards, engaging in common
interests as distraction or
expression modes).
 Tailoring TF-CBT for IDD 40

Comprehension Executive Function Generalization

• Use comics or stories with thought • Involve family members in using • . Have caregivers and other
bubbles (e.g., Cartoon the chosen name of the child’s important people play the Triangle
Conversations). worry. of Life mobile application game
with the child at home, school, and
community.

• Use a simplified worksheet for the • Use characters to represent • Have caregivers and other
cognitive triangle. simplified cognitive distortions important people help label the
child’s thoughts at home.
Cognitive Coping

(i.e., Power Cards, SuperFlex).

• Use movement activities (e.g., CBT • Utilize games to maintain interest- • Collaborate with caregivers and
triangle taped on floor) to illustrate these could include: the CBT other important people to generate
examples. Game (ref), Feelings matching. coping thoughts that fit the child’s
typical concerns.

• Play the Triangle of Life6 mobile • Include caregivers in sessions • Involve caregivers and other
app game. identifying thought distortions and important people as “co-
have them model cognitive errors. investigators” to challenge trauma-
related beliefs.

• Use simplified thought challenging • . Use positive sayings from

(e.g., true vs. not true). preferred media as challenges to
trauma-related beliefs.

• Use general coping • Use movement activities (e.g.,

thoughts/affirmations child can CBT triangle taped on floor) to
memorize and say to self in times of illustrate examples.
stress.
Tailoring TF-CBT for IDD 41

• Externalize worries (e.g., “my

worries are bothering me;” “my
brain lies to me.”).

• Use Worry Bugs games and

books.12, 13, 14

• Garcia-Winner Superflex Model

(ref) for identifying cognitive styles
(e.g., rigidity, catastrophizing).

• Incredible 5-point scale (ref) to

introduce cognitive flexibility.
 Tailoring TF-CBT for IDD 42

Comprehension Executive Function Generalization

• Collaborate with child on ways to • Use preferred objects/activities as • Provide psychoeducation on to

communicate needing a break (e.g., immediate rewards. whom and under what conditions
SUDS scale, red zone, break word). to share trauma history.
Trauma Narration and Processing

• Use a visual cue (e.g., timer, • Provide choices in how to use • Prepare caregivers that
schedule) and concrete parameters “cool down” or play or preferred information may not be objectively
(e.g., how many questions you will activity time following narration in and completely accurate, but the
ask that session) to structure each session. child’s perception is most
narration. important.

• Audio or video record the narration • Utilize support of caregivers in

for the child to have other forms of narration process in order to
feedback. encourage engagement, reduce
anxiety.

• Use visual representations to • . Use movement and preferred

challenge trauma-related distortions activities during breaks.
(e.g., lists for “good kids” vs “bad
kids,”, responsibility pie).

• Use metaphors for identified • Use positive sayings from

cognitive distortions (e.g., black & preferred media as challenges to
white cookie thinking, volcano trauma-related beliefs.
catastrophic thoughts).

• Provide play materials- sand tray, • Use structured worksheets for

dollhouse, a variety of figures for telling the story (e.g., Beginning,
play narration. Remote play: During, and After).
 Tailoring TF-CBT for IDD 43

onlinesandtray.com;
virtualsandtray.org
• Use a visual cue (e.g., timer,
schedule) and concrete
parameters (e.g., how many
questions you will ask that
session) to structure narration.

Comprehension Executive Function Generalization

• Encourage caregivers to use visual • Allow child to pick the format to • Use child’s regulation strategies
aids for their praise (e.g., a large share the story (e.g., recording of with caregivers when preparing
Conjoint Sessions

font letter, video format, picture). child’s voice, clinician reading for conjoint sessions.
aloud).

• Plan a flexible schedule (e.g., • Reinforce the conjoint narration

longer session time with several with preferred activity/object for
built-in breaks) to share the both caregiver and child (e.g.,
narration. play).

• Encourage caregiver to serve as • Use white boards, written

“interpreter” to facilitate timelines, or other visual aids to
explanations. explain narratives and other family
processes.
Tailoring TF-CBT for IDD 44

Comprehension Executive Function Generalization

In-Vivo Mastery

• Provide a concrete visual • Use examples from child’s interests • Practice in-vivo mastery in
example of a fear hierarchy to illustrate fear habituation (e.g., settings beyond those in which
(e.g., ladder, mountain). roller coasters, storms, spiders, etc.). the trauma was experienced.

• Incorporate disorder-informed • Use preferred objects/activities as • Involve caregivers and other

difficulties in the hierarchy. immediate rewards or safety important people in exposures
features. and to facilitate practice
across contexts.
 Tailoring TF-CBT for IDD 45

Comprehension Executive Function Generalization

• Use visuals for safety rules. • Use preferred characters in safety • Actively involve caregivers and
Enhancing Safety/Social Skills

rules and boundaries (Power Cards). other important people (e.g.,

siblings, teachers) throughout
the course of treatment to
support skill practice across
contexts.

• Use a hula hoop to teach “hula • Reward child consistently for use of • Actively involve other
space” (i.e., personal safe behaviors. therapists (e.g., occupational,
boundaries). speech) for wraparound care.

• Use games (e.g., Simon Says) • Actively involve caregivers and

to identify various body parts. other important people in
reinforcing therapy-related
behaviors (e.g., engagement,
skill practice).

• Use structured steps for safety • Actively involve caregivers and

seeking (e.g., No, Go, Tell). other important people in role
plays and behavioral
rehearsals.

• Incorporate social skills training • Conduct follow-up or booster

and apply to safety sessions in-person.
enhancement (e.g., Circles
Curriculum7).
Tailoring TF-CBT for IDD 46

• Teach and encourage use of

Social Stories to normalize
safe interactions.

Note. See Therapy Materials for resource citations. These recommendations are based on the literature on adapted CBT
for individuals with IDD and clinical experience from the authors (see Hoover et al. in review).
 47

Chapter 7: After TF-CBT: What Next?

While TF-CBT may reduce trauma-specific anxiety and depression, these symptoms
may persist and require further treatment after TF-CBT. As previously discussed, youth
with ASD and ID may have already been symptomatic and/or diagnosed with other
mental health conditions prior to recognizing that trauma was a factor. Trauma can also
be a risk factor in developing additional mental health conditions and exacerbate pre-
existing symptoms. Common additional diagnoses include generalized anxiety disorder
(GAD), social anxiety disorder (SAD), attention deficit hyperactivity disorder (ADHD),
and major depressive disorder (MDD). Some children develop obsessive-compulsive
disorder (OCD), or trauma might add a subtype (e.g., obsessions of contamination and
compulsions of hygiene; self/other harm obsessions with checking/reassurance seeking
compulsions) to prior OCD subtypes (e.g., symmetry/ordering/arranging).

Children who have developmental disorders and trauma are at risk for numerous other
developmental crises, family stressors, further traumas, and clashes with educational
and treatment environments. Following even the most successful TF-CBT treatment,
children and families often continue to require therapy to address additional mental
health problems and adversities to which IDD may predispose them. As a result, the
therapist may feel a pull to provide long-term care for a variety of treatment issues that
go well beyond the initial trauma-focused therapy request. What should clinics and
providers do in this situation? We recommend four possibilities depending on the nature
of clinical needs and providers’ availability:

a. Clarify new treatment goals and continue to provide individual and/or family therapy
consistent with the therapist’s expertise, availability, and funding for ongoing treatment.
b. Refer for specialty care to address particular behavioral and emotional treatment
needs (see below for interventions specific to diagnoses).
c. Provide monitoring or refer for episodic care in which patients discharge or pause
therapy sessions when current treatment concerns are met, and then return as needed
across time and development when issues come up.
d. Co-treatment may be beneficial when the child requires certain specialty services
(e.g., behavioral supports, wraparound care, occupational therapy, speech-language
therapy, etc.) and these can be offered in addition to ongoing treatment individual and
family work with the primary therapist.

In borrowing from work with adult patients, appropriate treatment goals post-intervention
include teaching new cognitive and behavioral skills yet unlearned, teaching
compensatory strategies for deficits (core problems of the developmental -condition)
that cannot be changed, facilitating self-acceptance, and expanding coping skills to
decrease or prevent symptoms of comorbid mental health problems such as anxiety
and depression (Gaus, 2018). As discussed earlier, a traditional (CBT) approach shows
promise for treating behavioral and emotional disturbance in children who have IDD.
Tailoring TF-CBT for IDD 48

Key Points: Post Trauma Recovery

• Trauma can also be a risk factor in developing additional mental health
conditions and exacerbate pre-existing symptoms.
• Children and families affected by IDD often continue to require therapy
after completing TF-CBT, to address additional mental health targets and
other support needs.
• Establish “postvention” treatment goals or plan for referral/co-treatment in
the client’s next phase of care.

Conclusions
This therapy guide is meant to provide the most up-to-date information for adapting TF-
CBT for traumatized children with developmental disorders. The suggestions in this
guide are based on the small but growing research literature and our own clinical
experience. While this work may seem complex in its specialized recommendations,
much remains to be researched and written as we move forward with renewed hope
and determination to serve children and families. TF-CBT for children with IDD requires
flexibility and creativity to customize it for each individual. It is our experience that even
children with significant developmental differences can heal from trauma and thereby
resume their developmental trajectory. We wish you the best as you press forward in
this important work.
Tailoring TF-CBT for IDD 49

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Appendix A: Definitions of Intellectual and Developmental

Disabilities

1.For resources and entitlements specified by the Americans with Disability Act of 2000
(PL-106-402), including services through Social Security and state agencies for persons
with developmental disabilities, the definition provided above pertains with additional
specification that three or more (listed) significant areas of functioning must be affected.
For young children up to age 9 the law covers developmental conditions that are likely
to result in significant future impairment without services and supports.

2. Educational supports offered by states and local school districts under the federal
Individuals with Disabilities Education Act (IDEA) follow the IDEA requirement that a
child be assessed as having one of 13 qualifying categories of disabilities (e.g., autism,
blind, learning disability) and also offers states the option of including the general
category of “developmental delay” for children ages 3 to 9 or any subset of those ages.
The disability must have an impact on functioning in the educational setting that is
assessed as leading to a need for special education
services https://sites.ed.gov/idea/regs/b/a/300.8IDEA part C requires states to provide
early intervention services for infants and toddlers (birth to 3 years) who have
developmental delays or developmental disorders putting them at significant risk of
delays (See https://www.parentcenterhub.org/ei-overview/).

3. Diagnoses of IDD by medical providers, including mental health providers, generally

use the developmental disability categories specified by the diagnostic system of mental
disorders of the American Psychiatric Association and by the international classification
of disorders. With the publication of the DSM-5 (2013), the American Psychiatric
Association changed the umbrella term for the group of disorders originating in the
developmental period from developmental disorders to “neurodevelopmental disorders”
(see Morris-Rosendahl & Crocq, 2020).
Tailoring TF-CBT for IDD 61

Appendix B: Individualized Therapy Accommodations Planning

Tool

Age/
Issues Strengths in each of the Grade Therapy
Areas Level* Accommodations

Language issues Language strengths

__ Limited expressive vocabulary

__ Limited ability to express ideas in

words

__ Speech unclear/hard to
understand

__ Limited receptive vocabulary

__ Limited understanding of complex

language forms (e.g., multi-phrase
sentences, etc.)

__ Limited pragmatic skills

(understanding and use of verbal and
nonverbal cues for interpersonal
communication)

Cognitive issues Cognitive strengths

__ Difficulty with abstract concepts

(more difficult than expected for age)

__ Difficulty with generalizing

__ Difficulty with immediate memory

(e.g., ability to remember multiple
instructions)
Tailoring TF-CBT for IDD 62

__ Difficulty with long-term memory

retrieval on demand

__ Limited attention span for at least

some kinds of materials (specify)

__Limited visual/spatial skills—may

affect organizing of information

__ Uneven skills (specify—e.g., visual

spatial skills much stronger than
verbal or the opposite)

Sensory/motor issues Visual/spatial & motor

strengths

__Low vision (for near, far, both?)

__Hearing issues (any aids?)

__Fine motor issues (e.g., affecting

writing, drawing)

__ Gross motor issues

__ Sensory sensitivities (specify)

Academic skills that can impact Academic strengths

treatment

___Reading decoding

___Reading comprehension

___Writing skills

___Understanding basic numbers

Tailoring TF-CBT for IDD 63

Other issues Special characteristics

___Willingness and Motivation ___ Special interests

___Obsessive about sameness ___ Tends to follow clear

routines
___Hyperfocus on
______________________________ ___ Has mastered coping
______ strategies of
_________________________
___Difficulty with transitions ______

___ Limited emotional coping ___Other_________________

strategies ______

*If available
Tailoring TF-CBT for IDD 64

Appendix B (Continued): Individualized Therapy

Accommodations Planning Tool
Completed Example

Issues Strengths in each of the areas Age/Gra Therapy

de Accommodation
s
Level*

Language issues Language strengths

_X_ Limited expressive Checks for comprehension (“You 4 or 5

th th
·Pt uses drawings
vocabulary said…?”) to express
emotions,
situations

·Pt given sufficient

time to answer
therapist
questions and
prompts

_X_ Limited ability to express Can express simple, concrete 4 or 5

th th
·Pt uses drawings
ideas in words ideas to express
emotions,
situations

·Pt asked to point

to or circle things
when possible

·Therapist writes
out pt’s words
when necessary

__ Speech unclear/hard to Pt can express himself/articulate

understand
Tailoring TF-CBT for IDD 65

_X_ Limited receptive vocabulary Can learn new words with 4 or 5

th th
·Therapist
repetition carefully selects
words to
streamline/reduce
psychology jargon

·Use of pictures
whenever
possible instead
of/in addition to
words

·Use of slides and

visuals to present
content

_X_ Limited understanding of Can understand simple, concrete 4 or 5

th th
·Therapist
complex language forms (e.g., language simplifies
multi-phrase sentences, etc.) language in
session and on
hw

·Therapist
matches words
and pictures when
possible

_X_ Limited pragmatic skills Pt understands use of facial 2 or 3

nd rd
·Therapist
(understanding and use of verbal expressions in others and in constantly reviews
and nonverbal cues for himself but does not often exhibit and exaggerates
interpersonal communication) them own facial
expressions when
practicing emotion
recognition
Pt is very social – wants friends,
wants to treat people kindly ·Therapist
emphasizes
behaviors (facial,
hand, body
expressions)
associated with
emotions

·Rapport-building
emphasized at
start of session by
spending several
sessions with
caregiver
Tailoring TF-CBT for IDD 66

understanding
pt’s:

·Interests
(including
restricted ones)

·Strengths

·Reward systems
already in place

·Collaterals
involved in care

·Preferred mode
of communication

Cognitive Processing Issues Cognitive Processing

Strengths

_X_ Difficulty with abstract With repetition, personalization, 3 or 4

rd th
·Slower pacing of
concepts (more difficult than and simplification, can treatment to allow
expected for age) understand more abstract for more review of
concepts content

·Breaking down
session content in
to smaller, more
concrete pieces

·Always bringing
content back to
personal
experiences

·Review previous
session content at
start of every
session
Tailoring TF-CBT for IDD 67

_X_ Difficulty with generalizing Pt can offer examples pertaining 3 or 4

rd th
·Therapist reviews
to his personal life hw with pt at start
of session and
brings his
answers into the
review of last
session,
generalizing skills
to things that
happened to him

·Therapist always
ties examples
back to things pt
has
said/experiences
he has had

_X_ Difficulty with immediate Pt wants to focus but cannot 3 or 4

rd th
·Therapist
memory (e.g., ability to remember always do so without prompting coaches caregiver
multiple instructions) how to prompt
without nagging

·Therapist breaks
instructions down
into small pieces,
checks for
comprehension in
between

·Therapist puts
everything on
slides/visuals
when possible
and matches
verbal language
to slide content
Tailoring TF-CBT for IDD 68

_X_ Difficulty with long-term Pt does hw in between sessions, 5 or 6

th th
·Therapist reviews
memory retrieval on demand with prompting from caregiver at start of every
and setting alarm (together with session
therapist in session)
·HW each week is
based directly off
of session content
(therapist created
content specially
for pt)

·First pg. of hw is
a pictorial
summary of
session content

·Pt teaches back

session content to
caregiver at end
of every session

·Therapist uses
hw responses to
check pt’s
comprehension
and know what to
emphasize or
focus on next

_X_ Limited attention span for at Pt is very motivated to perform 3 or 4

rd th
·Therapist
least some kinds of materials well and very responsive to shortened
(specify) positive reinforcement sessions to 30
minutes/week

·Therapist
maintains
engagement
through active
learning (games,
questions,
activities)
Tailoring TF-CBT for IDD 69

__Limited visual/spatial skills— Area of strength – cognitively 4 or 5

th th
·All session
may affect organizing of and pt’s preference content is
information presented visually

·Pt is asked to
draw responses
whenever
possible

·Abstract
concepts, chain
analyses, cause
and effect are
explained with
diagrams and
pictures

_X_ Uneven skills (specify—e.g., Pt is relatively stronger in visual 5 or 6

th th
·Therapist utilizes
visual spatial skills much stronger vs verbal skills visual content
than verbal or the opposite) whenever
possible

·Therapist
matches verbal
words to visual
content

·Therapist
streamlines and
simplifies verbal
content/psycholog
ical jargon
Tailoring TF-CBT for IDD 70

_X_ Slowed processing speed or Pt does process information but 4 or 5 y/o ·Therapist waits
working memory needs 30 seconds longer than 30 seconds after
most to do so saying something
to give pt time to
respond

·Therapist allows
pt to check for
comprehension
(“You said…?”)

·Therapist slows
pace and rate of
speech, uses
shorter
sentences, and
pauses often to
allow pt to
process

·Therapist talks
only 30% of time
– pt engaged in
activities rest of
time

Sensory/motor issues Visual/spatial & motor

strengths

__Low vision (for near, far, both?) Intact

__Hearing issues (any aids?) Intact

__Fine motor issues (e.g., Intact (immature pencil grasp but

affecting writing, drawing) readable drawing and writing)

__ Gross motor issues Intact (poor coordination)

__ Sensory sensitivities (specify) Not impairing

Tailoring TF-CBT for IDD 71

Academic skills that can impact Academic strengths 4 or 5

th th
·Minimal reading
treatment comprehension
required
___Reading decoding
Very hard working ·Simplification of
__X_Reading comprehension content across UP
Very positive sessions
___Writing skills
·Therapist praises
___Understanding basic numbers pt’s work and
effort

·Therapist helps
caregiver to
implement reward
systems when
needed

Other issues Special characteristics 3 or 4

rd th
·Likes drawing –
therapist and pt
_X__Willingness and Motivation __X_ Special interests draw together
every session – pt
___Obsessive about sameness __X_ Tends to follow clear drawing what
routines happened during
___________________________ situation of high
_____ ___ Has mastered coping emotional
strategies of intensity, therapist
___Difficulty with transitions __________________________ drawing diagram,
_____ etc.
_X__ Limited emotional coping
strategies (i.e., frustration __X_Other__Increased ·Same routine
tolerance) engagement of collaterals every session –
Review HW,
review previous
session content,
and “Listening
Eyes and Ears”

·Minimal materials
that pt has to
read. Most
content is visually
presented

·Therapist
engages regularly
with: caregiver,
sibling,
community hab
care providers,
school social
Tailoring TF-CBT for IDD 72

worker,
psychiatrist day
hab workers
Tailoring TF-CBT for IDD 73

Appendix C: ACCOMMODATIONS CHECKLIST

Identify nature of IDD involved (check multiple if pertinent, e.g., ASD and ID)

☐Learning disabled

☐Speech/language impaired

☐Autism spectrum disorder

☐Intellectually disabled

☐Multiple handicap

☐Other (include sensory impairment) ____________________

ACCOMMODATIONS USED DURING THIS BLOCK OF SESSIONS:

Increased attention to engagement strategies

☐More play time

☐Use of special interests and/or skills

☐Other:__________________

Flexible session and treatment length and pacing

☐Shorter sessions

☐More sessions

☐Adjust pacing of content

☐Other _______________________

Adjustment of parental/caregiver involvement

Tailoring TF-CBT for IDD 74

Mechanism:

☐Increased time in child session

☐Increase in parent/caregiver sessions or between-session

contact

Goal:

☐Skill reinforcement

☐Help deal with child anxiety

☐For interpretation purposes

Adjustment of session content

☐Clarifying session structure/aids for marking structure

Strategies for presentation adjusted depending on dd needs:

☐Simplify language

☐Simplify some content (e.g., choice of PRAC skill strategies)

☐Additional comprehension check

☐Increased use of visual cues

☐Use of materials/strategies developed for youth with

disabilities (e.g., social stories)

☐Building on child’s special interests or areas of

talent/relative strength[J3]

☐Other ______________ (e.g., increased use of technology/apps or

materials for younger age)

☐Attention to generalization of PRAC skills

☐Attention to modality/type of narration based on child’s skills

☐Other: _______________ (includes attention to any sensory issues—e.g.,

sensory sensitivities of youth with ASD, sensory issues of youth with low vision,
hearing impairment, etc.)
Tailoring TF-CBT for IDD 75
Tailoring TF-CBT for IDD 76

Appendix D: Assessment of Adaptive Domains at Each Stage of

TF-CBT
Psychoeducation and Caregiver ASSESS:
Training- Domain
Comprehension/Conceptual • Does the child/caregiver know key
Understanding terms inherent in this step (e.g.,
“trauma,” “trigger,” “physical, sexual,
psychological abuse,” “rewards and
reinforcement”)?
• Will the child/caregiver benefit from
pictures and other visual and activity-
based illustrations of trauma and its
effects and parenting skills?
• Does the child/caregiver understand
the connection between having
traumatic experiences and the signs
and symptoms present in the child?
• Does the child/caregiver understand
how the child’s trauma might impact
adult caregivers?
• Does the child/caregiver have good
conceptual connections between
descriptions and actual experiences
and events (grasping concepts related
to trauma and potential feelings,
consequences, outcomes,
interpersonal implications)?
• How much do the participating
parents/caregivers know and
understand specific behavioral
interventions including FBA, use of
antecedents, behavioral intervention
plans, and social skills training?

Executive Function/Motivation • How willing and motivated are the

child/caregiver to engage in therapy
with an unfamiliar adult?
• How willing is the child to stop, think,
and use relaxation skills before,
during, or after a stressful trigger?
• What is the level of the caregivers’
willingness to change parenting styles
if needed?
Tailoring TF-CBT for IDD 77

Generalization of Learning • Are the child/caregiver able to

recognize potentially traumatic
situations or reminders of past
traumas?
• Can the child/caregiver remember
information that was presented in
psycho-education?
• How able are caregivers to implement
recommendations for parenting skills
including tracking, rewarding, and
consistency skills?

Relaxation Assess:
Comprehension/Conceptual • Does the child/caregiver understand
Understanding key terms inherent in this step? (e.g.,
“deep breathing,” “relaxation,” “tense,”
“stressed,” and ”breath”)?
• Are the child/caregiver able to name
parts of the body that might
experience tension, and identify how
tension or body states “feel”?
• Will the child/caregiver benefit from
pictures and other visual and activity-
based illustrations of tension and
relaxation?
• Does the child/caregiver understand
the connection between relaxation
and reduced feelings of stress and
anxiety?

Executive Function/Motivation • How willing is the caregiver to teach

and reinforce relaxation skills at home
and in the community?
• How willing is the child to stop, think,
and use relaxation skills before, during
and after a stressful trigger?

Generalization of Learning • Does the child/caregiver have the

ability to remember skills taught in
session?
• Does the child/caregiver have the
ability to read cues that it is time to
use relaxation?
• What is the caregiver’s ability to
remember, remind, prompt, carry out
Tailoring TF-CBT for IDD 78

thoughts-related plans at home and in

the community?

Affect Expression and Modulation Assess:

Comprehension/Conceptual • Does the child/caregiver understand
Understanding central key terms including names of
feelings (happy, sad, disappointed,
scared…)?
• Would the child/caregiver be helped
by visual illustrations of emotions and
emotion management?
• How well do the child/caregiver
identify feelings in themselves and
others?
• What is the child/caregiver's
understanding of emotional
expression, emotional response, body
response, and the positive effects of
managing one’s emotions?

Executive Function/Motivation • How willing are the caregivers to

teach and reinforce relaxation skills at
home and in the community?
• How willing is the child to stop, think,
and use relaxation skills before,
during, or after a stressful trigger?
Generalization of Learning • How able are the child/caregiver to
remember affect regulation skills?
• Ability to apply techniques to manage
self when they may believe that their
response is justified or impossible to
manage?
• What is the level of the caregivers’
ability to remember, remind, prompt,
carry out affect regulation plans at
home and in the community?
Cognitive Coping ASSESS:
Comprehension/Conceptual • Does the child/caregiver understand
Understanding key terms inherent in this step?
(“thoughts vs. feelings,” “mind,”
“brain,” “thought glitches,” “thought
challenging,” “negative thoughts,”
“positive thoughts”)
Tailoring TF-CBT for IDD 79

• Will the child/caregiver respond best

to verbal explanations, visual
illustrations, or a combination of both?
• At what level do the child and
caregiver understand the connection
between thoughts, feelings, and the
purposes of cognitive coping?
• Child/caregiver’s’ awareness of their
own thoughts
• The relationship between thoughts,
feelings, and actions
• Theory of mind concepts- accuracy of
self-reflection about thoughts
• Ability to challenge client’s own
thought process
• Understanding of the thought/reality
distinction (i.e., just because we have
thoughts does not mean they are
“real” or “true”)?
Executive Function/Motivation • How able is the caregiver to teach and
reinforce cognitive coping skills at
home?
• How willing is the child to “stop and
think”?
• Are there impulse control problems
that preclude cognitive reflection in the
moment?
Generalization of Learning • Ability to remember skills taught in
session
• Ability to read cues that it is time to
use cognitive techniques
• Caregiver’s ability to remember,
remind, prompt, carry out thoughts-
related plans at home and in the
community.
Therapeutic Narration ASSESS:
Comprehension/Conceptual • Will the client be better able to
Understanding complete narration in verbal or visual
format?
• What kinds of support will the client
require to complete a narrative?
(translator, keyboard, art materials,
breaking task into small pieces,
dictating to therapist)
Tailoring TF-CBT for IDD 80

• Is the client able to tell a personal

story?
• Does the child/caregiver understand
the purpose and helpfulness of
producing a trauma narrative?
Executive Function/Motivation • Does the caregiver support the idea of
narration and encourage the child to
do this step-in treatment?
• Does the caregiver have personal
trauma or other issues that reduce
willingness to support or listen to the
narrative?
In-Vivo Desensitization ASSESS:
Comprehension/Conceptual • Does the child/caregiver understand
Understanding key terms inherent in this step (e.g.,
“fear,” “worry,” “anxiety,” “exposure,”
“face your fears”)?
• Will the child/caregiver best respond
to visual explanations, diagrams,
prompts?
• Does the child/caregiver readily
understand the applicability of gradual
exposure?
• Reality-fantasy distinction?
• Difference between thoughts and
feelings?
Executive Function/Motivation • Are the child/caregiver able to see the
“big picture” about how in-vivo
practice might be helpful?
• How does the child respond to
reinforcers?
• How able is the caregiver to reinforce
the child’s follow-through on difficult
in-vivo practice?
Generalization of Learning • Does the child/caregiver remember to
carry out “homework” assignments?
• Will the child/caregiver remember and
respond to visual schedules,
calendars, and prompts?
Conjoint Child-Caregiver Sessions ASSESS:
Comprehension/Conceptual • Will the child need help- i.e., extra
Understanding time, verbal assistance, visual-spatial
prompts- to share narration with their
caregiver?
Tailoring TF-CBT for IDD 81

• Does the child require the caregiver to

“interpret” in order to share
information including the narration?
• Is the caregiver able to follow along
verbally or will they require visual or
interpretive aids?
Executive Function/Motivation • Will the child/caregiver benefit from
conjoint explanation about purposes
and outcomes of narration?
• Is the caregiver prepared to provide
emotional support and regulate own
feelings when the narrative is shared?
• Do the child/caregiver need extra
support to maintain
emotional/behavioral regulation in
narration?
Generalization of Learning • Will the child/caregiver need guidance
for when and where to share the
narrative outside of therapy sessions?
Enhancing Safety Skills ASSESS:
Comprehension/Conceptual • Does the child/caregiver understand
Understanding key words inherent in this step (e.g.,
“safe,” “tell someone,” “danger,”
“boundaries,” etc.)?
• Are the child/caregiver able to read
written safety signals in the
environment (stop signs…)?
• Will these child/caregivers remember
and respond to visual schedules,
calendars, reminders, prompts?
• Are the child/caregiver able to
recognize unsafe environments (e.g.,
situations in which re-victimization
might occur) and the difference
between safe and unsafe?
• Does the child/caregiver recognize the
need to promote safety?
• Does the child/caregiver expose
themselves to unsafe situations
through behavior?
• Are the child/caregiver able to
anticipate possible unsafe situations
before they have happened?
• Able to identify safe and unsafe
people?
Tailoring TF-CBT for IDD 82

Executive Function/Motivation • Does the child/caregiver believe that it

is important to maintain safety?
• How motivated are the child/caregiver
to improve their situation or their
child’s situation?
Generalization of Learning • Does the child/caregiver remember
psycho-education?
• Will the child/caregiver make use of
charts and reminders?
• Will the client recognize situations
outside of therapy that require the use
of coping skills?