Kameoka et al. Int J Ment Health Syst (2015) 9:26
DOI 10.1186/s13033-015-0021-y

Open Access

SHORT REPORT

Feasibility of trauma‑focused cognitive
behavioral therapy for traumatized children
in Japan: a Pilot Study
Satomi Kameoka1*, Junko Yagi2, Yoko Arai3, Sachiko Nosaka1,4, Azusa Saito3,5, Wakako Miyake6, Saeko Takada1,
Sayaka Yamamoto1, Yasuko Asano7, Eizaburo Tanaka1 and Nozomu Asukai3,8

Abstract
Background: Trauma-focused cognitive behavioral therapy is used to treat children who have experienced traumatic
events and suffer from trauma-related disorders. Its effectiveness has been demonstrated in several randomized controlled studies. However, most of these studies have been performed in the United States, with few studies conductedin Asian countries. Therefore, we aimed to evaluate the feasibility of trauma-focused cognitive behavioral therapy inchildren who have experienced traumatic events and who suffer from trauma-related disorders in Japan.
Findings: Thirty-five traumatized children (mean age = 10.9 years; range = 3–17 years; 74.3% girls) who received
trauma-focused cognitive behavioral therapy were included. The effectiveness of the program was evaluated ineach case using the University of California at Los Angeles Post-Traumatic Stress Disorder Reaction Index for DSM-IV
for trauma-related symptoms and the Children’s Global Assessment Scale for social functioning. Pre- and post-treatment outcome measures were analyzed using two-tailed paired t tests. The results for 35 participants indicate that
post-traumatic stress symptoms were significantly improved following therapy [t(35) = 8.27; p < 0.01], whereas theassessment of social functioning supported the effectiveness of the program [t(35) = −14.68; p < 0.01]. The pre- topost-treatment effect sizes (Glass’s delta) were 1.24 for the University of California at Los Angeles Post-Traumatic Stress
Disorder Reaction Index and 1.96 for the Children’s Global Assessment Scale.
Conclusions: Our findings indicate that trauma-focused cognitive behavioral therapy is feasible for treating traumatized children of an Asian population. We discuss the implications of this result for clinical practice and future research.
Keywords: Children, Post-traumatic stress disorder, Trauma, Trauma-focused cognitive behavioral therapy, Treatment
BackgroundThe number of children in Japan that suffer trauma isincreasing. For example, the annual number of consultations at child guidance centers for child abuse andneglect increased approximately 60-fold over the past
20 years in Japan. Furthermore, the Great East Japan
Earthquake and Tsunami of March 11, 2011 resulted in
1,698 children experiencing parental death, of which 241
were orphaned. These traumatized children require emotional and practical support, and sometimes professional*Correspondence: kameoka@j‑hits.org
1
Hyogo Institute for Traumatic Stress, 1‑3‑2 Wakinohama‑kaiganndori,Chuo‑ku, Kobe, Hyogo 651‑0073, Japan
Full list of author information is available at the end of the article

treatment, to prevent the future adverse mental health or
behavioral problems.
Trauma-focused cognitive behavioral therapy (TFCBT) is a treatment that includes both the parent andchild [1], with a strong evidence base in several randomized controlled trials (RCTs) in the US [2–7]. Thesestudies have demonstrated the efficacy of TF-CBT in
reducing post-traumatic stress (PTS) symptoms andother emotional problems in children. Additional RCTs
of TF-CBT have been reported outside the US in Australia (sexually abused children [8]), the Democratic
Republic of Congo (former child soldiers [9] and sextrafficked girls [10]), and Norway (children with mixed
trauma [11]). Although dissemination is ongoing in© 2015 Kameoka et al. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License(http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium,provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license,
and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/
publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Kameoka et al. Int J Ment Health Syst (2015) 9:26

Page 2 of 5

several other countries, we are not aware of any research
on TF-CBT in Asian countries that has provided sufficient guidance for evidence-based practice.
In 2011, we began implementing TF-CBT for traumatized children and their caregivers in Japan, using a
version identical to the original US version without any
culture-related modification. In this uncontrolled pilot
study, we show the feasibility of TF-CBT in Japan.

Table 1 Description of sample

Range

3–17

Method

Mean

10.9

SD

3.6

Participants and procedures

Between June 2012 and February 2014, participants
were recruited from four sites in Japan: a child-trauma
center in Morioka, a trauma care center in Kobe, a
victim support center in Tokyo, and a child guidance
center in Osaka. We recruited children with mixed
trauma between the ages of 3 and 17 years and theircaregivers. For inclusion in the study, children wererequired to meet at least five criteria for post-traumaticstress disorder (PTSD) as defined in the Diagnostic andStatistical Manual of Mental Disorders, Fourth Edition(DSM-IV), including at least one symptom in each of
the three PTSD clusters (re-experiencing, avoidance,and hyperarousal). In addition, children were required
to have a caregiver who was willing and able to participate every week in the parental treatment included in
TF-CBT. Informed child assent and parental consent
were required for admission to the study. We excluded
patients with psychosis, history of suicide attempt, or
any significant behavioral problems, including thosewith aggressive and/or antisocial behaviors that causesignificant impairment in social, academic, or otherimportant areas of functioning. Child psychiatrists
or clinical psychologists screened 187 children andidentified 35 children and their caregivers to be eligible for treatment in this study. Among these participants, 3 dropped out during the treatment; 32 children
completed all TF-CBT components. Of these, 74.3%(n = 26) of the children were girls and their mean age
was 10.9 years [standard deviation (SD), 3.6]. Most
cases of trauma were because of sexual abuse inside oroutside the family (42.9%, n = 15). Table 1 summarizes
the demographic data, type of traumatic experience,and relationship between child and caregiver for theparticipants.
Therapists

Therapists delivered the treatment at each site. They
comprised three child psychiatrists and four clinical psychologists. All therapists were women and underwent
a 2-day introductory training session by the program
developers and/or were certified TF-CBT trainers.

Demographics of child sample (N = 35)
and participating caregivers (N = 35)
Gender (N = 35)

n (%)

Girls

26 (74.3)

Boys

9 (25.7)

Age (N = 35)

Most traumatic experience—total (N = 35)

Natural disaster (earthquake and/or tsunami)

9 (25.7)

Sexual abuse outside the family

10 (28.6)

Sexual abuse inside the family

5 (14.3)

Physical abuse inside the family

5 (14.3)

Bullying

3 (8.6)

Kidnap2 (5.7)

Traffic accident

1 (2.9)Total number of trauma experiences (N = 35)
Range

1–4

Mean

1.8

SD

0.8

Identity of participating caregiver (N = 35)
Biological mother16 (45.7)

Biological father

2 (5.7)

Both biological mother and father

8 (22.9)Grandmother2 (5.7)Aunt

2 (5.7)

Nursery home careworker

5 (14.3)

TF‑CBT

The TF-CBT program uses a component-based cognitive
behavioral approach over 12–25 sessions. Each component, as shown in Table 2, is offered to the child and caregiver in both parallel and joint sessions [1]. In this study,
all sessions were discussed with peer consultation andsupervised by the first author, and 30% of the sessions
were audio recorded. In 33% of the sessions, ongoing
consultation was provided by the program developers ora certified trainer. All sessions were coded using the Brief
Practice Checklist (BPC) and were confirmed to meetfidelity standards by a certified TF-CBT trainer. The BPC,
created by the program developers, tracked the timing
and implementation of specific TF-CBT components to
help therapists and supervisors determine whether fidelity was adequately maintained.
Measures

The traumatic events and PTS symptoms of children
were evaluated using the University of California at Los

Kameoka et al. Int J Ment Health Syst (2015) 9:26

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Table 2 PRACTICE components

considered statistically significant. Intention-to-treat(end-point) analyses were performed in which pretest
scores were used to replace missing post-test scores.
Effect sizes for the two primary outcomes were calculated using Glass’s delta.

Psychoeducation about child trauma and trauma reminders
Parenting component including parenting skills
Relaxation skills individualized to youth and parent
Affective modulation skills tailored to youth, family and culture
Cognitive coping: connecting thoughts, feelings and behaviors

Result
The number of TF-CBT sessions for those who completed the program ranged from 9 to 26 [mean(M) = 14.31; SD = 3.60]. The length of the sessions
ranged from approximately 60 to 90 min in this study.
The pre- and post-treatment means and standard
deviations are presented in Table 3. Pre- and post-treatment outcome measures were analyzed using two-tailed
paired t tests. The post-treatment RI scores (M = 12.69;
SD = 11.46; range = 0–26) were significantly lower thanthe pretreatment RI scores (M = 29.06; SD = 13.21;
range = 6–56; t = 8.27; p < 0.01) for the 35 children thatwere assessed. Furthermore, post-treatment C-GAS
scores (M = 73.74, SD = 11.48, range = 61–91) weresignificantly higher than pretreatment C-GAS scores(M = 53.31, SD = 10.43, range = 38–70; t = −14.68;
p < 0.01) for the 35 children that were assessed. The RI
and the C-GAS scores were well correlated pretreatment(r = −0.66; p < 0.01) and post-treatment (r = −0.74;
p < 0.01). The Cronbach’s alpha for the RI was 0.85
(n = 35) pretreatment, and 0.80 (n = 31) post-treatment.
A reliable cut-off value for a single incident traumatic
event in the English version of the RI is considered to be
38 [12]. In this sample, 25.7% of the participants wereabove this level and 74.3% were below this level on theirpretreatment RI scores. Of those who completed all components of the program, 71.9% (n = 23) exhibited at least
a 50% reduction in their RI score. Though only one childexperienced an increase in their post-treatment RI score(pre–post; 12–17), her post-treatment C-GAS score washigher than her pretreatment score (pre–post; 55–65).
The pre- to post-treatment effect sizes (Glass’s delta)
were 1.24 for RI and 1.96 for the C-GAS.
The characteristics of the three children who dropped
out were as follows: a 10-year-old girl who experienced
sexual abuse by a stranger, a 13-year-old boy who experienced an earthquake and sexual abuse, and a 17-year-old
girl who experienced physical abuse. Their pretreatment

Trauma narrative and processing
In vivo mastery of trauma reminders
Conjoint youth-parent sessions
Enhancing safety and future developmental trajectoryAngeles PTSD Reaction Index for DSM-IV (i.e., the RI)[12], which is a widely used, well-validated, and reliablemeasure. The RI is a child- and parent-reported questionnaire that evaluates the exposure to traumatic events andall DSM-IV PTS symptoms that occurred between ages
7 and 18 years. This test has been translated by Akashi
et al. and examined for reliability by Fujimori et al. [13]in Japan. In this study, the child scores were adopted andanalyzed without the data for a 3-year-old girl; the score
for her was provided by her mother only.
The Children’s Global Assessment Scale (C-GAS) wasused to assess the social functioning of the children [14].
The C-GAS is a well-validated and reliable measure thatis equivalent to the adult Global Assessment of Functioning score; we used its Japanese version in this study[15]. TF-CBT therapists conferred with an independent
evaluator to determine each child’s C-GAS score. This
independent evaluator decided the final C-GAS scoreby reviewing each child’s social functioning, but was not
involved in the treatment.
Ethical considerations

This study was approved by the institutional review
board of each institute or facility. Furthermore, after the
study procedure had been completely explained to them,written assent and consent to participate were obtained
from children and their caregivers, respectively.
Statistical analysis

Paired t tests were performed to determine the pre- andpost-treatment effect. Two-tailed p values <0.05 wereTable 3 Descriptions of outcome variables: means and standard deviations by treatment time
MeasureRI (N = 35)

CGAS (N = 35)

Pre-treatment

Post-treatmentp

Effect size

M

SD

M

SD

Pre–post

29.06

13.21

12.69

11.46

<0.01

1.24

53.31

10.43

73.74

11.48

<0.01

1.96

RI UCLA PTSD Index for DSM-IV, CGAS Children’s Global Assessment Scale, M mean, SD standard deviation, N number of cases, Effect size glass’s delta.

Kameoka et al. Int J Ment Health Syst (2015) 9:26

RI scores were 19, 40, and 56, and their pretreatment
C-GAS scores were 70, 45, and 38, respectively. They
dropped out at a session of 20, 8, and 7, respectively.

Discussion
In this pilot study, we found that TF-CBT was feasible forchildren suffering from PTS symptoms because of mixed
trauma in Japan. PTS symptoms and general social functioning significantly improved in participants by the endof treatment, with considerable effect sizes: 1.24 and 1.96
for RI and C-GAS, respectively.
The pre–post effect sizes of our study were smaller thanthose of previous TF-CBT studies in the West, which are
as follows: they range from 2.13 to 2.80 using the Kiddie Schedule for Affective Disorders and Schizophrenia
in the US studies for sexually abused children [3, 5, 16];
1.92 using the Child PTSD Symptom Scale in a Norwegian study of children subjected to mixed traumatic
events [11]; and 1.86 using the Anxiety Disorder Interview Schedule, Child Version, in an Australian study forsexually abused children [8]. Although these differences
may be caused by the different assessment scales used, it
was noteworthy that most therapists in our study werebeing trained and that their treatment skills were consequently immature. Furthermore, 60% of participants inour study were victims of single trauma, such as crime or
the Great East Japan Earthquake and Tsunami. Therefore,
we assume that the total number of trauma experiencesin our study (M = 1.8) was markedly lower than that of
the studies in the US, Norway, or the Democratic Republic of Congo (M = 3.56–11.79) [7, 10, 11].
Three children failed to complete the TF-CBT program because they showed strong resistance to creatingor processing trauma narratives. Moreover, one of thosepatients had the highest RI score in our study. We believethat the further experience and skill acquisition by ourtherapists will help overcome this issue in the future.
In the original version of TF-CBT, therapists areencouraged to modify their interventions specific toeach child. However, the requirement for culture-specific modifications to the treatment program has been
discussed when seeking to disseminate TF-CBT to nonEnglish speaking countries. Although culture-specificmodification was not required for the implementation of
TF-CBT in Norway [11], dissemination in low-resource
African countries required modifications because of cultural differences and the limited availability of trained
therapists [9, 10, 17, 18]. We found that no culturerelated modifications were required in Japan, suggestingthat TF-CBT may be successfully applied according tothe original US version in Asian settings.
There are several limitations to this study. First, thiswas an uncontrolled pilot study in Japan. Therefore, thePage 4 of 5effectiveness of TF-CBT has not yet been established.
Second, we measured treatment outcomes with a selfrating questionnaire of PTS symptoms and the therapist’s
evaluation of social functioning. Although this could
cause a bias in the results, the self-rating and therapistrating scores were well correlated before and after treatment. Third, the therapists received ongoing consultationin one-third of cases by program developers or a certified
trainer in the US because it was a part of their TF-CBT
training. Therefore, ongoing consultation probably contributed to the success observed.
Despite the limitations of the study, we believe that our
preliminary findings demonstrate the feasibility of TFCBT in Japan. Moreover, they suggest that TF-CBT in
Japan is a promising treatment for traumatized children
and their caregivers. Following this study, a randomizedcontrolled trial with independent assessments is required
to evaluate the effectiveness of TF-CBT for traumatizedchildren in Japan.
Authors’ contributions
Conception and design: SK, NA. Implementation of TF-CBT and acquisition of
data: SK, JY, YA, SN, AS, WM, ST, SY, YA. Analysis and interpretation of the data:
ET, SK, NA. Drafting of manuscript: SK. Critical revision of the manuscript forimportant intellectual content: ET, NA, SK. All authors read and approved thefinal manuscript.
Author details
1
Hyogo Institute for Traumatic Stress, 1‑3‑2 Wakinohama‑kaiganndori,Chuo‑ku, Kobe, Hyogo 651‑0073, Japan. 2 Department of Neuropsychiatry,
Iwate Medical University, 19‑1 Uchimaru, Morioka‑shi, Iwate 020‑8505, Japan.
3
Victim Support Center of Tokyo, 3‑18‑1, Toyama, Shinjuku‑ku, Tokyo 169‑0052,
Japan. 4 Graduate School of Human Sciences, Osaka University, 1‑2 Yamadaoka, Suita, Osaka 565‑0871, Japan. 5 Faculty of Human Sciences, Mejiro University, 4‑31‑1, Naka‑Ochiai, Shinjuku‑ku, Tokyo 161‑8539, Japan. 6 Osaka Medical
Center and Research Institute for Maternal and Child Health, 840 Murodo‑cho,
Izumi, Osaka 594‑1101, Japan. 7 Osaka Prefectural Child Guidance Center, 28‑5
Yasaka‑tyou, Neyagawa, Osaka 572‑0838, Japan. 8 Tokyo Metropolitan Instituteof Medical Science, 2‑1‑6 Kamikitazawa, Setagaya‑ku, Tokyo 156‑8506, Japan.
Acknowledgements
We wish to thank all the participants and staff members of the facilities
who participated in the study. Furthermore, we wish to thank Dr. Cohen, Dr.
Mannarino, Dr. Deblinger, and Dr. Fitzgerald for their consultation support.
This work was supported by Health Labor Sciences Research Grant and JSPS
KAKENHI Grant Number 25461796.
Compliance with ethical guidelines
Competing interests
The authors declare that they have no competing interests.
Received: 2 May 2015 Accepted: 26 June 2015

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