Cue-Centered Treatment for Youth Exposed to Interpersonal Violence: A Randomized Controlled Trial

Abstract

This study provides preliminary evidence of the feasibility and efficacy of the Stanford cue-centered treatment for reducing posttraumatic stress, depression, and anxiety in children chronically exposed to violence. Sixty-five youth aged 8–17 years were recruited from 13 schools. Participants were randomly assigned to cue-centered treatment or a waitlist control group. Assessments were conducted at 4 discrete time points. Self-report measures assessed youth symptoms of posttraumatic stress disorder (PTSD), anxiety, and depression. Self-report ratings of caregiver anxiety and depression as well as caregiver report of child PTSD were also obtained. Therapists evaluated participants’ overall symptom improvement across treatment sessions. Hierarchal linear modeling analyses showed that compared to the waitlist group, the cue-centered treatment group had greater reductions in PTSD symptoms both by caregiver and child report, as well as caregiver anxiety. Cue-centered treatment, a hybrid trauma intervention merging diverse theoretical approaches, demonstrated feasibility, adherence, and efficacy in treating youth with a history of interpersonal violence. Traditional and Simplified Chinese Abstracts by AsianSTSS 標題 : 一個隨機對照試驗：經歷人際暴力青少年的提示為本治療。 撮要 : 史丹福提示為本治療在長期經歷暴力的青少年能否減少創傷後壓力、抑鬱和焦慮，本研究提出初步證據支持其可行性和功效。從13間學校中招募65名8至17歲的青少年，隨機分配到提示為本治療和等候對照組別，並在4個特定日子進行評核。自我報告評核包括：青少年的創傷後壓力症(PTSD) 、焦慮和抑鬱症狀，亦有照顧者焦慮和抑鬱自我報告評分，和照顧者對兒童PTSD的報告。治療師評估參與者在治療面見的綜合症狀改善程度。等級綫性模型分析指出：對比等候對照組別，提示為本治療組別有更大PTSD症狀減退(包括照顧者和兒童報告)，和更少照顧者焦慮。混合廣泛和不同理論的創傷介入治療(即提示為本治療)對治療有人際暴力經歷的青少年有著相當的可行性遵守度和效力。 标题 : 一个随机对照试验：经历人际暴力青少年的提示为本治疗。 撮要 : 史丹福提示为本治疗在长期经历暴力的青少年能否减少创伤后压力、抑郁和焦虑，本研究提出初步证据支持其可行性和功效。从13间学校中招募65名8至17岁的青少年，随机分配到提示为本治疗和等候对照组别，并在4个特定日子进行评估。自我报告评估包括：青少年的创伤后压力症(PTSD) 、焦虑和抑郁症状，亦有照顾者焦虑和抑郁自我报告评分，和照顾者对儿童PTSD的报告。治疗师评估参与者在治疗面见的综合症状改善程度。等级线性模型分析指出：对比等候对照组别，提示为本治疗组别有更大PTSD症状减退(包括照顾者和儿童报告)，和更少照顾者焦虑。混合广泛和不同理论的创伤介入治疗(即提示为本治疗)对治疗有人际暴力经历的青少年有着相当的可行性遵守度和效果。

Full text

Journal of Traumatic Stress
December 2013, 26, 654–662
Cue-Centered Treatment for Youth Exposed to Interpersonal
Violence: A Randomized Controlled Trial
Victor G. Carrion,1Hilit Kletter,1Carl F. Weems,2Rebecca Rialon Berry,1and John P. Rettger1
1Stanford Early Life Stress Program, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine,
Stanford, California, USA
2Department of Psychology, University of New Orleans, New Orleans, Louisiana, USA
This study provides preliminary evidence of the feasibility and efficacy of the Stanford cue-centered treatment for reducing posttraumatic
stress, depression, and anxiety in children chronically exposed to violence. Sixty-five youth aged 8–17 years were recruited from 13
schools. Participants were randomly assigned to cue-centered treatment or a waitlist control group. Assessments were conducted at 4
discrete time points. Self-report measures assessed youth symptoms of posttraumatic stress disorder (PTSD), anxiety, and depression.
Self-report ratings of caregiver anxiety and depression as well as caregiver report of child PTSD were also obtained. Therapists evaluated
participants’ overall symptom improvement across treatment sessions. Hierarchal linear modeling analyses showed that compared to the
waitlist group, the cue-centered treatment group had greater reductions in PTSD symptoms both by caregiver and child report, as well as
caregiver anxiety. Cue-centered treatment, a hybrid trauma intervention merging diverse theoretical approaches, demonstrated feasibility,
adherence, and efficacy in treating youth with a history of interpersonal violence.
Within the United States, exposure to violence represents a
significant problem, with prevalence rates ranging from 50.0%
to 96.0% for urban youth (Stein,Jaycox, Kataoka, Rhodes, &
Vestal, 2003). These rates remain constant across time (Cohen,
Deblinger,Mannarino,& Steer, 2004). Although prevalence
rates for posttraumatic stress disorder (PTSD) vary greatly in
youth exposed to violence, these rates are higher than for other
forms of trauma (Kearney, Wechsler, Kaur,& Lemos-Miller,
2010). In a sample of inner-city youth exposed to interpersonal
violence, rates were as high as 57.5% for PTSD and 42.5%
for subthreshold symptoms (Kletter, Weems, & Carrion, 2009).
Violence exposure is associated with increased anxiety, depres-
sion, aggression, and delinquency (Margolin & Gordis, 2000).
Exposure to violence has also been associated with poorer aca-
demic performance, which may be mediated by such factors as
disruptive behaviors and impairment in memory and concentra-
This research was supported by the Lucile Packard Foundation for Children’s
Health and the Evans Foundation grants to Dr. Carrion. The authors would
like to acknowledge the Early Life Stress Program staff: Laura Strom, Melissa
Hirt, Dina Frid, and Tara Hasan. We would also like to thank all the school
staff, children, and families who participated.
Correspondence concerning this article should be addressed to Victor G.
Carrion, Division of Child and Adolescent Psychiatry and Child Develop-
ment, Stanford University, Stanford, CA 94305–5719. E-mail: vcarrion@
stanford.edu
Copyright C2013 International Society for Traumatic Stress Studies. View
this article online at wileyonlinelibrary.com
DOI: 10.1002/jts.21870
tion (De Bellis, 2001). These cognitive problems may be related
to brain alterations in children who experience interpersonal vi-
olence (Carrion,Weems, Richert, Hoffman, & Reiss, 2010; De
Bellis et al., 1999). Thus, there is a compelling need for early
intervention and treatment development of youth exposed to
violence.
Recognition of the significance of youth violence exposure
has led to the development of interventions designed specifi-
cally for children and adolescents at risk for PTSD. The most
well validated of these treatments is trauma-focused cognitive–
behavioral therapy (TF-CBT; Cohen & Mannarino, 2008). Nu-
merous randomized controlled trials have demonstrated the ef-
ficacy of TF-CBT in alleviating PTSD, depression, and other
emotional and behavioral difficulties in traumatized children
(Cohen, Mannarino, & Knudsen, 2005; Scheeringa, Weems,
Cohen, Amaya-Jackson, & Guthrie, 2011). Although devel-
oped for the treatment of sexual trauma, TF-CBT has recently
proved superior to child-centered therapy in reducing PTSD
symptoms among youth exposed to intimate partner violence
(Cohen, Mannarino, & Iyengar, 2011). Multimodality trauma
treatment, a group cognitive–behavioral intervention has been
proven effective in both community mental health and school
settings (Amaya-Jackson et al., 2003). Child-parent psychother-
apy is a treatment for young children combining play with other
modalities to restore attachment and regulate traumatic stress
(Lieberman, Van Horn, & Gosh Ippen, 2011). Other treatments
that have shown promise for reducing posttraumatic stress
symptoms in trauma-exposed youth include eye-movement de-
sensitization and reprocessing and systems therapy (Chaffin
654

Cue-Centered Treatment 655
et al., 2004; Chemtob, Nakashima, & Carlson, 2002; Ellis et al.,
2012).
There is a growing interest in school-based interventions for
children exposed to violence (Wolmer, Laor, & Yazgan, 2003).
School-based approaches are more accessible, affordable, and
nonstigmatizing (Jaycox, Stein, & Amaya-Jackson, 2009). A
randomized controlled trial of a standardized 10-session CBT
school-based group intervention (cognitive behavioral interven-
tion for trauma in schools [CBITS]) was successful in reducing
PTSD symptoms and depression in children exposed to violence
(Stein et al., 2003). Furthermore, a universal classroom-based
program was successful in reducing PTSD symptoms, somatic
complaints, and anxiety in war-exposed children (Berger, Pat-
Horenczyk, & Gelkopf, 2007). In addition, studies have demon-
strated the effectiveness of teacher-delivered interventions in
reducing PTSD and enhancing adaptive coping and resiliency
in youth exposed to war and terror (Wolmer, Hamiel, & Laor,
2011).
Jaycox et al. (2010) suggest that structured interventions such
as TF-CBT have adequate treatment effects, but that in real-
world settings these effects may be diminished compared to
modified CBT interventions such as CBITS that specifically
include elements targeting ease of implementation and adher-
ence. The availability of interventions such as TF-CBT and
CBITS has had a significant impact on the successful treatment
of traumatized children. The development of new modalities,
however, continues to be necessary because not all children
respond to available treatments. In particular, children who ex-
perience traumatization within a context of ongoing adversity
may derive limited benefit from processing an isolated trau-
matic event. More efforts need to be developed to empower
this group of children through knowledge (insight) into their
condition. The emphasis on multiple or recurring traumas, the
gained insight into the connection between history, feelings,
and behaviors, the acknowledgment that parents may not be
available for treatment in all sessions are a few of the charac-
teristics that the Stanford cue-centered treatment shares with
CBITS; however, unlike CBITS, cue-centered treatment em-
phasizes individual treatment rather than group prevention. Al-
though group intervention is a cost-effective approach, many
youth may not respond to group interventions or may need
an individual focus to their own cues, history, feelings, and
behaviors.
Cue-centered treatment was developed in recognition of the
growing need for a manualized treatment aiming to increase
youth insight into how an individual’s history of exposure
to trauma may relate to current emotional experiences and
how these in turn may be linked to maladaptive behaviors.
Although authors have called for the inclusion of insight
oriented techniques for the treatment of traumatized youth
(Osofsky, 2003) and have implemented them in broadbased
community intervention models (Osofsky et al., 2007), ran-
domized trials have yet to show that their inclusion (within
CBT protocols) is feasible and linked to reductions in PTSD
symptoms. The cue-centered treatment protocol helps (a) in-
corporate evidence-based treatments for childhood trauma; (b)
educate the child on how to become his or her own agent
of change; (c) increase the child’s understanding of his or
her traumatic experiences and symptoms, as well as effective
methods to counteract them; and (d) increase the child’s in-
sight into the relationship between trauma history, current emo-
tions, and behavioral responses to unconscious trauma-mimetic
cues.
Cue-centered treatment incorporates several unique compo-
nents that render it a distinguishable intervention for trauma-
exposed youth. First, through the use of a life timeline, cue-
centered treatment aims to address the impact of their allostatic
load, examining the direct influence of circumscribed traumatic
events as well as other daily or life stressors. Second, several
cue-centered treatment sessions focus on teaching youth and
caregivers about the conditioning process that occurs through
repeated exposure to trauma, resulting in increased sensitiv-
ity of fear and anxiety networks. As the child identifies cues
associated with this conditioning and develops more adaptive
responses to the cues, the child develops self-efficacy. Third,
through the use of insight-oriented strategies and visual icons
linking history, emotions, and behaviors, the child is challenged
to avoid compartmentalization of these constructs while cur-
rent behaviors are placed in an empathic context. Finally, in
addition to utilizing behavioral, cognitive, and emotional ap-
proaches to develop new responses, cue-centered treatment in-
cludes a physiological approach (how the child feels physically)
recognizing that many children who experience trauma are
sensitive to their interoceptive cues (e.g., increased heart rate,
sweating).
The purpose of the current study was to examine the effi-
cacy of cue-centered treatment as a short-term, manual-based
intervention for youth with interpersonal violence exposure un-
dergoing concurrent and chronic environmental adversity. We
hypothesized that cue-centered treatment would demonstrate
feasibility and efficacy in reducing symptoms of PTSD and
that these symptoms would steadily decrease from session to
session. Rates of comorbidity in individuals with PTSD are
as high as 80.0% for mood and anxiety disorders (Pfeffer-
baum, 1997). Therefore, we chose to also evaluate anxiety
and depression in youth, and it was hypothesized that cue-
centered treatment would result in a reduction in both. Addi-
tionally, based on the work of Silverman and colleagues, we
reasoned that as youth symptoms improved, caregivers’ symp-
toms might also benefit from reduced stress associated with
a symptomatic child (Silverman, Kurtines, Jaccard, & Pina,
2009).
Method
Participants
Youth were considered appropriate for the study if they were
between 8–17 years old, had a history of exposure to violence,
a nonabusing caretaker willing to participate in the study, and
Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.

656 Carrion et al.
Figure 1. CONSORT flow diagram of enrollment.
no current exposure to perpetrators of violence. Youth were
excluded from the study if they had significant medical illness,
documentation of a diagnosis of autism or schizophrenia, his-
tory of mental retardation or an intelligence quotient (IQ) less
than 70, substance dependency, and lack of proficiency in En-
glish. A diagnosis of PTSD or minimum symptom level was
not required for participation as treatment was also intended
to be preventive for those youth currently not exhibiting sig-
nificant symptoms. Sixty-nine youth met inclusion criteria and
were scheduled for a diagnostic evaluation during which they
and their caregiver completed assessment measures and signed
assent and consent forms approved by an institutional review
board. Of these 69, four participants failed to show for the intake
evaluation.
The final sample consisted of 65 youth who were ran-
domly assigned by the study coordinator to either the Stan-
ford cue-centered treatment manual-based treatment (n=38)
or a waitlist (n=27) and to one of two therapists using
a computer-generated number series. Twenty-four individuals
(13 assigned to cue-centered treatment, 11 to waitlist) did not
complete treatment (see reasons in Figure 1) and were included
in the intent-to-treat analysis (see below). Forty-one youths
completed all phases of the treatment. Nonsignificant differ-
ences were found between treatment completers and noncom-
Table 1
Participant Characteristics
CCT intervention Waitlist control Total
Demographics (n)(n)(n)
Gender
Female 16 10 26
Male 22 17 39
Ethnicity
African American 16 17 33
Hispanic/Latino 15 11 26
Mixed ethnicity 4 1 5
Pacific Islander 1 0 1
Note. CCT =cue-centered treatment.
pleters with regard to age, gender, ethnicity, and pretreatment
scores across measures. A flowchart of participation is shown in
Figure 1.
Demographic data for youth who completed the study are
depicted in Table 1. Mean age was 11.56 years (range =8–
17 years). There were slightly more boys (60.0%, n=39) than
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Cue-Centered Treatment 657
girls (40.0%, n=26). Two participants (3.1%) were taking
psychotropic medication.
Measures
Youth self-report inventories. The UCLA PTSD Reaction
Index for DSM-IV-Child Version (UCLA PTSD-RI) is a 48-
item semistructured interview evaluating children’s exposure
to 26 types of traumatic events and PTSD diagnostic criteria
according to the Diagnostic and Statistical Manual of Mental
Disorders (4th ed., DSM-IV; American Psychiatric Associa-
tion, 1994; Pynoos, Rodriguez, Steinberg, Stuber, & Frederick,
1998). It shows good internal consistency (α=.90) and test-
retest reliability (r=.84; Roussos et al., 2005). Youth provided
PTSD-RI ratings following every treatment session. The PTSD-
RI has been used in several treatment outcome studies includ-
ing the evaluation of symptom changes per session (Taylor &
Weems, 2011).
The revised Children’s Manifest Anxiety Scale (RCMAS;
Reynolds & Richmond, 1985) consists of 37 yes or no items
that assess the level and nature of anxiety. The RCMAS has
been shown to have good internal consistency (α=.87), test-
retest reliability (r=.68), and concurrent validity (e.g., r=
.85).
The Children’s Depression Inventory is a 27-item self-report
measure of youth depression symptoms (Kovacs, 1992). The
Children’s Depression Inventory has adequate internal consis-
tency (α=.71 to .89), test-retest reliability, and concurrent
validity (e.g., r=.55; Kovacs, 1992).
The Violence Exposure Scale for Children-Revised is a 21-
item, cartoon-based interview of community violence exposure.
Responses are measured on a thermometer type rating scale
ranging from never to lots of times. Internal consistency for the
Violence Exposure Scale for Children-Revised ranges from .80
to .86 (Shahinfar, Fox, & Leavitt, 2000).
Caregiver inventories. The UCLA PTSD Reaction Index
for DSM-IV-Parent Version (UCLA PTSD-RI) was completed
by caretakers at each of the four assessment points.
The Beck Anxiety Inventory (BAI) is a 21-item self-report
measure of common anxiety symptoms with high internal con-
sistency (α=.92 to .94) and convergent validity (r=.85to.93;
Beck, Epstein, Brown, & Steer, 1988). The Beck Depression
Inventory (BDI-II) is a 21-item self-report measure of somatic
and psychological aspects of depression The BDI-II has high
internal consistency (α=.91), test-retest reliability (α=.93),
and convergent validity (r=.93; Beck, Steer, & Brown, 1996).
A medical and developmental history form and a demographics
form were also completed by caretakers.
Therapist ratings. The Children’s Global Assessment
Scale is a numeric scale (1–100) used by mental health pro-
fessionals to rate the general functioning of children under the
age of 18. The Children’ Global Assessment Scale has adequate
reliability (α=.83 to .91) and acceptable concurrent and dis-
criminant validity (Schaffer et al., 1983). The Children’s Global
Assessment Scale has been used in a number of treatment out-
come studies (e.g., Cohen, Mannarino, Perel, & Staron, 2007).
Procedure
Recruitment began in October 2009 and ended in July 2011.
Follow-ups occurred between December 2009 and September
2011. Participants were recruited from 13 urban low-income
schools. The first author conducted workshops for approxi-
mately 50 school staff members on the symptoms and impair-
ment associated with trauma and violence exposure, and asked
them to refer students who appeared at risk for these experi-
ences. The counselor or wellness coordinator of each school
gathered all referrals and provided them to the study’s research
coordinator.
Caregivers of youth identified as at risk for trauma exposure
completed a brief telephone interview to determine whether
youth met inclusion/exclusion criteria. The telephone inter-
view consisted of providing caregivers information regarding
the study’s purpose, design, and compensation. Caregivers were
asked their child’s age, history of medical and psychiatric con-
dition, history of educational or psychological testing, history
of trauma exposure and relationship to trauma perpetrator. Ther-
apy sessions were conducted at the child’s school. Parents were
required to participate in four of the 15 sessions. Participants in
the cue-centered treatment group began treatment immediately
while treatment for the waitlist control group occurred 3 months
following initial assignment to waitlist (the time it takes to com-
plete the treatment). Youth were evaluated at preintervention,
midintervention (session 8), posttreatment, and at a 3-month
follow-up. After preintervention youth were only assessed on
symptom measures. Caregivers received a $25 grocery gift card
for the completion of assessments at each time point.
Two licensed therapists (PhD and MFT) with experience in
the treatment of childhood trauma were trained in the admin-
istration of the cue-centered treatment protocol over 3 months
by the study’s principal investigator (VGC). Therapists also
had weekly supervision on the manual, phone consultation,
and case conferences. Fidelity to the treatment protocol was as-
sessed by two independent research assistants utilizing a fidelity
form (available upon request). The raters randomly listened to
25.0% of all audiotapes and used the form to check yes or no on
whether session objectives were met. Fidelity was established
to be 91.2%.
The Stanford cue-centered treatment is a manualized pro-
tocol designed for implementation in clinic or school settings
for youth who have experienced repeated exposure to trau-
matic events and adverse circumstances. Cue-centered treat-
ment consists of 15 weekly, individual sessions, designed to
last approximately 50 minutes. Cue-centered treatment is an
integrative approach, combining elements from cognitive, be-
havioral, psychodynamic, expressive, and family therapies to
address four core domains (cognition, behavior, emotions, and
physiology). Psychoeducation is a keystone in cue-centered
Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.

658 Carrion et al.
treatment. The primary goal of cue-centered treatment is to
build strength and resilience by empowering the child through
knowledge regarding the relationship between their history of
trauma exposure, and current affective, cognitive, behavioral,
or physiological responses. Children and parents learn about
the significance of traumatic stress, how adaptive responses be-
come maladaptive, how to cope with rather than avoid ongoing
stress, and the importance of verbalizing their life experiences.
The treatment process involves overall competence building,
reduction of physical symptoms of anxiety, modification of
cognitive distortions, and facilitation of emotional expression.
In cue-centered treatment, youth and caregivers learn to recog-
nize and effectively manage maladaptive responses that occur
in response to traumatic reminders (cues).
Although cue-centered treatment is a structured program in
terms of specific session requirements and goals, it is also de-
signed to be flexible, and can be adapted to each child’s devel-
opmental level and therapists’ strengths. The manual contains
numerous pictorial tools intended to help youth understand dif-
ficult therapeutic concepts; such as intensity or severity. The
manual describes each session’s goals and specific objectives,
the role of the therapist in facilitating these, a breakdown of ac-
tivities and a list of materials (i.e., visual icons, questionnaires,
handouts) required during the session. A background section
describes in greater detail the session’s objectives and theoret-
ical and research underpinnings, and provides brief illustrative
case examples. The manual is available upon request to the
corresponding author.
Data Analysis
Planned sample size was calculated based on expected medium
to large effect sizes and actual sample size was a function of
participant recruitment during the project period. The main out-
come comparisons (treatment vs. waitlist) were analyzed with
hierarchical linear models (using the program HLM 7; Rau-
denbush, Bryk, Cheong, Congdon, & du Toit, 2011; see also
Bryk & Raudenbush, 1987, 1992). In the first stage of the
analysis, hierarchical linear modeling (HLM) was used to es-
timate the within-subject change (random effects, Level 1) to
test if change was linear or curvilinear in nature. The second
stage (fixed effects, Level 2) HLM was used to test if there
were differential effects of treatment condition on trends of the
within-subject slopes for each outcome. Specifically, the HLM
analyses nested pre- to postchange (Level 1) in outcomes as a
function of treatment group (immediate treatment vs. waitlist).
The linear values were squared to create the quadratic curvilin-
ear trend similar to previous research and as suggested by Bryk
and Raudenbush (1992). A significant linear slope suggests
gradual change across treatment and a significant quadratic
slope suggests strong initial gains followed by a leveling off.
Changes across individual sessions were also tested via trend
analyses of PTSD-RI scores using HLM. Again, in first stage
of the analysis, HLM was used to estimate the within-subject
change (random effects, Level 1) to test if change was linear or
curvilinear in nature. The second stage HLM was used to test if
there were any effects of age or gender on these trends (fixed ef-
fects, Level 2) on the within-subject slopes for the PTSD scores
across the sessions. Treatment maintenance was examined us-
ing a series of paired sample ttests comparing posttreatment
with follow-up.
Results
The average age of participants was 11.56 years (SD =1.90)
with no differences between cue-centered treatment (M=
11.67, SD =2.06) and waitlist (M=11.46, SD =1.66). Par-
ticipants reported an average of 5.03 (SD =1.88) total traumas
with no differences between cue-centered treatment (M=5.25,
SD =2.34) and waitlist (M=4.81, SD =1.42). Nonsignifi-
cant differences were also observed between groups in terms
of gender and ethnicity comparisons (Table 1). All participants
reported exposure to at least two traumatic events; the most
common traumas reported included separation/loss (75.0%),
witnessing violence (61.5%), homicide (51.9%), physical abuse
(25.0%), and bullying (25.0%). No significant differences were
found between the waitlist and treatment groups on amount of
violence exposure, t(59) =.801, p=.426 with both groups
reporting moderate levels of exposure, waitlist (n=23; M
=27.65, SD =14.12); treatment (n=38, M=25.00, SD
=11.48). Additionally, there were no baseline differences be-
tween groups on child and parent reports on any of the measures
(Table 2; ns varied somewhat across time and measures).
Child Self-Report Inventories
The mean changes in child symptoms by treatment versus wait-
list are presented in Table 2. The results of the HLM analysis
of the overall within-subject PTSD-RI scores (child reported)
change curves indicated significant linear, t(98) =−4.67, p
<.001 and quadratic, t(98) =3.72, p<.001, components
for PTSD symptoms. The significant curvilinear pattern is
consistent with the larger declines from pre- to midtreatment
followed by smaller decreases from midtreatment to posttreat-
ment. Level 2 analyses on PTSD-RI scores indicated that there
was a significant effect of treatment group (wait vs. immedi-
ate treatment) on both the linear (B=−21.41, SE =9.87),
t(96) =−2.17, p=.033 and quadratic (B=4.62; SE =2.28),
t(96) =2.02, p=.046, terms suggesting larger and quicker
reductions in the immediate treatment group. Follow-up anal-
yses were consistent with this and indicated a larger (based on
η2effect size) reduction in PTSD-RI scores from pre- to post-
treatment in the intervention group (partial η2=.58), than in
the wait group (partial η2=.27). At posttreatment, individuals
who received the intervention had lower PTSD-RI scores than
those in the wait group, independent sample t(41) =3.10, p=
.004, 90% confidence interval for the mean difference [4, 19],
d=0.97.
The HLM analyses for the RCMAS and Children’s De-
pression Inventory indicated significant linear, t(90) =−3.21,
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Cue-Centered Treatment 659
Table 2
Pretreatment, Midtreatment, and Posttreatment Outcome Measures
Pretreatment Midtreatment Posttreatment
Measure MSDMSDMSDη2
Children’s Global Assessment Scale
UCLA PTSD Reaction Index-Child*
55.70 10.78 64.26 10.38 70.96 10.63 .73
Treatment 22.70 14.30 8.96 7.96 7.50 9.10 .58
Waitlist 25.80 18.90 20.86 17.83 19.20 15.50 .27
Revised Children’s Manifest Anxiety Scalea
Treatment 11.60 6.00 7.67 5.34 5.40 5.40 .46
Waitlist 12.00 6.60 8.09 7.65 8.60 7.90 .18
Children’s Depression Inventory
Treatment 11.80 7.30 7.18 6.29 6.20 7.10 .30
Waitlist 9.90 6.40 8.14 8.74 7.40 7.30 .11
UCLA PTSD Reaction Index-Parent**
Treatment 23.30 14.50 17.12 12.27 16.10 11.00 .20
Waitlist 19.20 10.80 20.15 15.15 21.70 12.40 .01
Beck Anxiety Inventory**
Treatment 12.40 11.80 9.48 9.79 9.00 7.90 .21
Waitlist 8.50 10.10 7.33 9.47 9.80 11.30 .12
Beck Depression Inventory
Treatment 13.90 10.50 12.33 9.28 9.10 9.50 .25
Waitlist 12.10 11.40 8.89 11.37 7.20 6.40 .16
PTSD =posttraumatic stress disorder.
ap=.08.
*p<.05. **p<.01.
p=.002, and quadratic, t(90) =2.29, p=.025, effects on Level
1 for the RCMAS and a linear trend for the Children’s Depres-
sion Inventory, t(93) =1.78, p=.078. On Level 2, the effect of
treatment (wait vs. no wait) on RCMAS scores approached
significance on the linear trend (B=−1.47; SE =0.83),
t(93) =−1.77, p=.079, suggesting a steeper linear reduction
in RCMAS scores in the immediate treatment group. Follow-up
analyses on the RCMAS indicated a larger (based on η2effect
size) reduction in RCMAS scores from pre- to posttreatment
in the intervention group (partial η2=.46), than in the wait
group (partial η2=.18). At posttreatment the difference be-
tween treated and wait was not statistically significant, but com-
parison suggested a medium effect size, independent sample
t(42) =1.60, p=.117, d=0.49. There was not a significant
effect of treatment on Children’s Depression Inventory scores
(B=−1.18, SE =0.87), t(93) =−1.36, p=.177.
Caregiver Report of Child PTSD Symptoms
Means are reported in Table 2; HLM analyses on the parent
reported PTSD-RI-Parent Version indicated only a significant
effect of treatment group (wait vs. no wait) on a linear trend,
(B=−4.79; SE =1.72), t(101) =−2.78, p=.006, suggesting
a steep linear reduction in PTSD symptoms in the immedi-
ate treatment group. Again follow-up indicated a much larger
(based on η2effect size) reduction in UCLA PTSD-RI-Parent
Version scores from pre- to posttreatment in the intervention
group (partial η2=.20), and little or no change in the wait
group (partial η2=.01).
Caregiver Self-Report of Anxiety and Depression
Symptoms
Means are reported in Table 2 and HLM analyses for the BAI
and BDI indicated linear trend effects on Level 1 for the BAI,
t(102) =−1.79, p=.080; however, on Level 2, there was a
significant effect of treatment group (wait vs. no wait) on BAI
scores for the linear trend (B=−3.84, SE =1.37), t(102) =
−2.80, p=.006, suggesting a steep linear reduction in BAI
scores in the immediate treatment group but increases in the
wait group. Follow-up indicated a (based on η2effect size)
reduction in BAI scores from pre- to posttreatment in the in-
tervention group (partial η2=.21), and an increase in the wait
group (partial η2=.12). There was no significant effect of
treatment on the BDI (B=−1.27, SE =1.18), t(102) =−1.07,
p=.287.
Therapist Ratings of Overall Improvement
Analyses of the Children’s Global Assessment Scale combined
youth initially randomized to treatment and also the waitlist
Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.

660 Carrion et al.
Figure 2. Reductions in UCLA PTSD Reaction Index (PTSD-RI) scores across
treatment sessions. PTSD =posttraumatic stress disorder.
youth after they had received treatment, as has been done in
previous research (Cohen & Mannarino, 2008). Mean scores at
pre-, mid-, and post-treatment are reported in Table 2. The
results of the HLM analysis of the overall within-subject Chil-
dren’s Global Assessment Scale change indicated significant
linear (B=8.53, SE =2.53), t(83) =3.37, p<.001, but not
quadratic, t(83) =−0.37, p=.711, components for PTSD
symptoms. The significant linear pattern is consistent with
steady increases in therapist-reported functioning from pre- to
midtreatment and from mid- to posttreatment.
Symptom Changes per Session
Analyses of session-level change in PTSD symptoms also com-
bined youth initially randomized to treatment and also the wait-
list youth after they had received treatment. HLM analyses indi-
cated significant decreases on PTSD symptoms across sessions
(Figure 2; ns varied across sessions). Level 1 HLM analyses
indicated a significant linear (B=−2.84, SE =0.42), t(500) =
−6.72, p<.001, and curvilinear (quadratic) change (B=0.13,
SE =0.02), t(500) =5.60, p<.001. The significant curvilinear
pattern is consistent with sharper declines early in treatment
followed by smaller decreases later in treatment with a general
leveling off near the end of treatment. The results of the Level 2
HLM analyses on the effect of age, gender, or initial assignment
to treatment versus wait indicated no significant effects of age,
gender, or initial assignment on the decrease trends.
Follow-Up Analyses
Treatment maintenance was examined using a series of paired
sample ttests comparing posttreatment symptoms with symp-
toms reported at follow-up. There were no significant differ-
ences between posttreatment and 3-month follow-up for the
PTSD-RI-Child (Mdifference =−1.05, SE =0.92), t(36) =
−1.15, p=.259. Additionally, there were no significant dif-
ferences for the Children’s Depression Inventory (Mdifference =
0.50, SE =0.71), t(37) =0.70, p=.487, RCMAS (Mdifference =
0.19, SE =0.47), t(36) =0.41, p=.686, BAI (Mdifference =
2.14, SE =1.33), t(28) =1.60, p=.120, and BDI (Mdifference =
−0.24, SE =1.69), t(28) =−0.14, p=.887. There was a
significant decrease on the PTSD-RI-Parent completed about
their child’s symptoms (Mdifference =5.37, SE =1.42), t(34)
=3.78, p=.001, suggesting continued improvement from the
perspective of the caregiver.
Discussion
The current investigation supports the use of cue-centered
treatment to treat youth exposed to interpersonal violence in
school settings. Cue-centered treatment resulted in significant
reduction in youth posttraumatic symptoms by both parent and
child report and therapist ratings showed improvement in over-
all functioning. Furthermore, treatment gains were maintained
over time. Effect sizes were strongest for PTSD-RI symptoms
and the significant curvilinear pattern is consistent with the
larger declines from pre- to midtreatment followed by smaller
decreases from midtreatment to posttreatment. In addition, the
HLM on session-level analyses indicated that PTSD symptoms
decreased across sessions, with larger symptom reductions ob-
served earlier in treatment followed by less substantial reduc-
tions later on. The explanation for the significant symptom
reduction in the earlier phase of treatment is unclear, and the
critical role of each treatment component cannot be examined
in the current design. However, it is possible that psychoeduca-
tion and coping skills received in the initial sessions provided
youth with knowledge and hope imperative to symptom relief,
and accounted for the sharp decline in PTSD symptoms.
Cue-centered treatment was also associated with improve-
ment in youth overall functioning as rated by the therapists
on the Children’s Global Assessment Scale. As symptoms de-
creased, functioning improved across time points. Improving
function in youth with PTSD symptoms is pivotal because these
symptoms can have a deleterious effect on social, emotional,
and academic development. Although Children’s Global As-
sessment Scale scores indicate overall improvement in func-
tioning, it is possible that these changes are due to time alone.
The specificity of cue-centered treatment efficacy to PTSD,
rather than depression, was consistent for both children and
caregivers. This may reflect cue-centered treatment’s direct ap-
proach to responses to trauma-mimetic cues, and lower empha-
sis in mood-related items. Of interest, even though cue-centered
treatment does not emphasize the caregivers’ experience or re-
quires caregivers to come to every session, those caregivers in
the treatment group had a significant decrease of anxiety. A
number of explanations could account for this change, such as
psychoeducation into the child’s condition, improvement in the
child’s behavior and mood, their own participation in a number
of sessions, and feeling supported in terms of getting help for
Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.

Cue-Centered Treatment 661
their child. Future work should research these possibilities, as
well as the anxiety specificity. Notably, these treatment gains
were maintained at follow-up evaluation for both children and
caregivers.
The results of this trial contribute to the extant literature by
demonstrating the benefits of a hybrid intervention, combining
core elements of different theoretical approaches, for reducing
psychiatric symptoms in youth exposed to chronic adversity.
The data provide support for the notion (Osofsky, 2003) that
the inclusion of insight-oriented techniques in the treatment of
traumatized youth is feasible and linked to reductions in PTSD.
Based on the results, the use of cue-centered treatment appears
feasible in school settings that provide easy access to youth,
dedicated time for sessions, and a supportive, structured envi-
ronment. The cue-centered treatment approach represents just
the second protocol to help reduce nondisaster-related PTSD in
a school setting. This study presents with a number of signif-
icant strengths relative to other trauma-focused interventions
performed in school settings, including random assignment,
inclusion of caregiver data, and clinical evaluation of child
symptoms by therapists. Though emphasis on the development
of skillful coping behaviors appears consistent across similar
treatments for youth trauma, cue-centered treatment specifi-
cally emphasizes the connection between environmental ex-
periences, traumatic responses, and trauma-mimetic cues (i.e.,
vis-a-vis a classical conditioning paradigm). The results of the
present initial feasibility trial of cue-centered treatment further
suggests that processing traumatic events and adverse experi-
ences across the lifespan, gaining self-empowerment through
knowledge, and developing competency may provide an effica-
cious approach for youth who would find it difficult to process
isolated traumatic events while experiencing ongoing adversity.
Study limitations included a relatively small sample size. The
groups were similar in pretreatment scores on most measures,
and the data suggest that while the waitlist group demonstrated
reduced symptomatology between pre- and postintervention
assessments, the reductions were larger in the group receiving
the intervention across measures. However, larger samples are
needed to produce more statistically robust conclusions for the
comorbid anxiety and depression. Follow-up could be improved
by lengthening its time and assessing recurrent trauma and
health service utilization.
Future studies should examine the utility of the Stanford cue-
centered treatment protocol in other treatment settings. Cogni-
tive and personality measures should be added to future trials
to learn which individuals will benefit most from which cue-
centered treatment components. Reduced symptomatology has
been shown to have a strong impact on academic functioning
such as grades and attendance (Stein et al., 2003), thus future
studies should incorporate both behavioral and academic out-
come measures. Comparisons are needed between cue-centered
treatment and other active psychosocial treatments to determine
specificity for different types of traumas and populations. Fi-
nally, outcome studies integrating biological markers will in-
form potential mechanisms of action, helping future treatment
development. Cue-centered treatment may provide an alterna-
tive intervention for youth who do not respond to available
treatments.
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