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1. Personnel - National Child Traumatic Stress Network

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					                                                                          Cohen, Judith A.

A.Organizational Qualifications and Experience

       1.        Personnel
                 Project Director for the Child Abuse and Traumatic Loss Treatment/Services
Development Center (“Center”) will be Judith A. Cohen, M.D., Professor of Psychiatry at MCP-
Hahnemann University School of Medicine and Medical Director of the Center for Traumatic
Stress in Children and Adolescents (CTSCA) at Allegheny General Hospital in Pittsburgh. She
is a Board Certified child and adolescent psychiatrist who has a 20-year history of developing,
providing, evaluating, and training other clinicians in the treatment of sexually abused and
otherwise traumatized children. She is a nationally-recognized expert in the child trauma field,
who with Dr. Mannarino has conducted two past and two ongoing treatment trials for sexually
abused children, funded by the National Center on Child Abuse and Neglect (NCCAN) and the
National Institute of Mental Health (NIMH). These studies have focused on designing
treatments appropriate for different developmental levels: one study was designed for preschool
children (ages 3-7) (Cohen & Mannarino, 1996a), two were designed for elementary and middle
school-aged children (8-14 year olds) (Cohen & Mannarino, 1998a), and one is designed for pre-
teens and adolescents (11-18 year olds). Her current grants, conducted in collaboration with Drs.
Mannarino and Deblinger, are examining the efficacy of two different psychosocial treatments
for sexually abused children, and the impact of adding psychotropic medication to psychosocial
treatment for sexually abused pre-teens and adolescents. Drs. Cohen, Mannarino and Deblinger
have emphasized the importance of cultural competence in all of their treatment development as
discussed in their recently published article, “The importance of culture in treating abused and
neglected children” (Cohen et al., 2001b). Dr. Cohen is the Principal Author of two sets of
treatment guidelines for childhood Posttraumatic Stress Disorder (PTSD), published respectively
by the American Academy of Child and Adolescent Psychiatry (AACAP) (AACAP, 1998) and
The International Society on Traumatic Stress Studies (ISTSS) (Cohen, Berliner & March.
2000a, 2000b). With Dr. Mannarino and Ms. Berliner, Dr. Cohen also authored the Department
of Justice Office for Victims of Crime (OVC) guidelines on psychosocial and pharmacologic
interventions for child crime victims (Cohen, Berliner & Mannarino, in press) and is on the
Advisory Board to develop OVC’s guidelines for victims of intrafamilial child abuse. She is
currently serving her second term on the Board of Directors of the American Professional
Society on the Abuse of Children (APSAC), and is the past Chair and current Co-Chair of the
APSAC Research Committee. She is also a member of APSAC’s Treatment Guidelines Task
Force and Professional Education and Training Committee. She is a founding member of the
American Academy of Child and Adolescent Psychiatry’s Child Abuse Committee and is a
member of the American Psychiatric Association’s Committee on Family Violence and Sexual
Abuse. She and Dr. Mannarino founded and directed the former Child and Adolescent Sexual
Abuse Clinic (CASAC) at Western Psychiatric Institute and Clinic, and the Allegheny General
Hospital Center for Traumatic Stress in Children and Adolescents (CTSCA), which is the only
program in the tri-state (Pennsylvania-Ohio-West Virginia) region specifically dedicated to the
treatment of traumatized children. She has provided direct treatment to over 1,000 of these
children, and has supervised trainees (child psychiatry fellows, psychology and social work
interns) in the treatment of children exposed to sexual abuse or other traumatic life events.

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                                                                             Cohen, Judith A.

Through these activities, Dr. Cohen has developed longstanding collaborative relationships with
key clinical, practice and research leaders in the field of child trauma, at the local, regional and
national levels, including many who are applying to participate in the National Child Traumatic
Stress Initiative as discussed below. She is the Program Director of the only Child Psychiatry
Fellowship in the U.S. which has a specialization in the assessment and treatment of traumatized
children. The curriculum for that program has been published and widely adapted by other
training programs (Cohen & Mannarino, 1998b). As Program Director of this residency
program, Medical Director of CTSCA, and PI on several large research studies, Dr. Cohen has
had significant leadership and administrative experience, including personnel and fiscal
management experience. Dr. Cohen has provided over 150 educational presentations on the
psychosocial and pharmacologic treatment of sexually abused and other traumatized children
both locally and nationally and has had a long-standing commitment to making evidence-based
treatments more accessible and acceptable to community treatment providers and consumers. To
this end, she developed and narrated an audiotape, “Treating Trauma in Children and
Adolescents” for Sage Publications. She is a consultant on numerous grants by established and
early-career researchers in child traumatic stress, and is a PTSD treatment consultant to the
NIMH Intramural Program on Childhood Anxiety Disorders.

        Co-Director of the Center and Director of Treatment Development will be Anthony
Mannarino, Ph.D., Professor of Psychiatry, MCP-Hahnemann University School of Medicine,
and Chair, Department of Psychiatry at Allegheny General Hospital (AGH). Dr. Mannarino is
Director of the CTSCA, and has been providing treatment to traumatized children and
conducting seminal research with regard to the treatment of sexually abused children for over 20
years. He was the Principal Investigator on grants funded by NIMH and NCCAN in the 1980s
and early 1990s, which evaluated behavioral and emotional problems and mediating factors in
symptom formation in sexually abused children. This research demonstrated the importance of
children’s cognitions and attributions, and parental distress and support in symptom formation
and persistence following sexual abuse. This research contributed greatly to the development of
treatments for this population which Drs. Mannarino and Cohen published (Cohen & Mannarino,
1993) and which have subsequently been tested and found to be effective by Drs. Mannarino,
Cohen, and Deblinger. Dr. Mannarino has been a consultant to Allegheny County Children,
Youth and Families (CYF) (Child Protective Services) since 1979, conducting over 1300
forensic and clinical evaluations of abused and neglected children. In this capacity, he has
interfaced regularly with professionals in the judicial system. He is well known in Allegheny
County for advocating for greater cooperation and coordination among the various agencies and
professionals serving abused children. He was a founding member of the Allegheny County Bar
Association Roundtable on Children’s Issues, a community organization developed to improve
knowledge and communication among child advocates, Family Court judges, family attorneys,
and treating professionals, in order to better serve abused children. Dr. Mannarino has also
worked closely with community and consumer organizations such as the North Side Leadership
Conference and the Young Men and Women African Heritage Association, and has frequently
been asked to participate in community and neighborhood meetings following high profile child
molestation or murder cases. He is co-author of the OVC treatment guidelines for child crime

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                                                                            Cohen, Judith A.

victims, and is on the OVC Advisory Committee for developing treatment guidelines for
intrafamilial child abuse. Dr. Mannarino has served on the Executive Committee of the
American Psychological Association’s Section on Clinical Child Psychology, and is currently on
the Executive Committee of the American Psychological Association’s Section on Child
Maltreatment. Dr. Mannarino has conducted nearly 200 professional and community training
presentations and has authored over 60 journal articles and numerous book chapters related to the
treatment of traumatized children. As Department Chair, Dr. Mannarino has had extensive
administrative experience, and as Center Co-Director, he will share personnel and budgetary
management responsibilities with Dr. Cohen.

        David Kolko, Ph.D. will serve as Director of Services Development for the Center. He is
Professor of Psychiatry, Psychology, and Pediatrics at the University of Pittsburgh School of
Medicine, with expertise in the areas of services evaluation for abused children and treatment of
physically abused children and children with sexually aggressive behavior problems. He has
been an investigator on 17 federal and state research grants, addressing issues related to physical
abuse and offending children/youth. Dr. Kolko developed, implemented, and evaluated two
treatments for physically abused children, and has published the only randomized comparative
treatment outcome study for this population to date (Kolko, 1996a). His current work is directed
towards understanding the role and use of mental health services by child abuse victims in the
United States. He is currently Co-Investigator on the NIMH project “Mental Health Services
Across Child Welfare Agencies,” (Landsverk, 1999), and is a site Co-PI for the National
Evaluation of Child Advocacy Centers (Finkelhor, 2000). He has conducted studies of services
referral and utilization patterns for children in the child protective services system in Allegheny
County (Kolko, 1996b), and consults on a study of community-based treatment for child physical
abuse, which is evaluating both costs and outcomes (Swenson,2000). Since 1999, he has served
as a member of the OVC Advisory Committee for Guidelines for the mental health treatment of
intrafamilial child physical and sexual abuse. He was a member of the U.S. Department of
Justice Juvenile Sex Offender Focus Group, has presented to the National Academy of Science
about transporting effective treatment for abused children to community settings (Clinical
Treatment and Services Research Work Group,1999), and has consulted to the National
Academy of Science on training needs of health professionals to respond to family violence. Dr.
Kolko is also a member of the Family and Intimate Partner Violence/Sexual Assault work group
for the National Center for Injury Prevention and Control of the Centers for Disease Control. He
is currently Chair of the APSAC Research Committee, and is serving his second term on the
APSAC Board of Directors.

         Other professionals who will be closely associated with the programmatic activities of the
Center are Esther Deblinger, Ph.D., Lucy Berliner, M.S.W., Benjamin Saunders, Ph.D., Michael
DeBellis, M.D., M.P.H., David Brent, M.D., M.P.H., Katherine Shear, M.D., Walter Smith,
Ph.D., Melissa Runyon, Ph.D., Tamra Greenberg, Ph.D., and Susan Padlo, L.C.S.W. In addition
to their treatment/services development and research expertise, all of our consultants continue to
carry active treatment caseloads in their respective clinics, which serve predominantly minority
and/or low income families. Esther Deblinger, Ph.D. is Associate Professor of Psychiatry at the

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                                                                           Cohen, Judith A.

University of Medicine and Dentistry of New Jersey (UMDNJ) and Clinical Director of the
Center for Children’s Support, a treatment program for sexually abused children in Stratford,
N.J. She will be our Consultant for new treatment development for abused children. She is the
author of the most widely-used cognitive behavioral therapy manual for sexually abused children
(Deblinger & Heflin, 1996), and has conducted 2 past and one ongoing federally funded
randomized clinical treatment outcome studies for sexually abused children (the latter as a multi-
site study with Drs. Cohen and Mannarino). She has conducted numerous training presentations
on the treatment of abused children and has published widely in this regard. Dr. Deblinger is
currently serving her second term as an APSAC Board member and is Chair of the APSAC Task
Force on Treatment Guidelines. Lucy Berliner, M.S.W. is Clinical Associate Professor of
Psychiatry and Behavioral Sciences and Social Work at the University of Washington, and is the
Director of the Harborview Center for Sexual Assault and Traumatic Stress in Seattle. She will
serve as our Consultant on community treatments and will assist us in adapting treatments to
community settings. Ms. Berliner is an internationally known therapist, teacher and clinical
researcher in the area of child sexual abuse. She has conducted one treatment outcome study for
this population (Berliner & Saunders, 1996), and has published and presented widely in regard to
transporting protocol-driven treatments to community providers. She and Dr. Saunders are Co-
Chairs of the OVC funded project, “Treatment Guidelines for Psychosocial Interventions for
Sexually and Physically Abused Children and their Families.” Ms. Berliner is co-author of the
ISTSS Treatment Guidelines for Childhood PTSD (Cohen, Berliner & March, 2000a; 2000b),
and is a past APSAC Board and Advisory Board member. More recently, Ms. Berliner has
conducted studies of service utilization among traumatized children in community based settings
throughout Washington state (New & Berliner, 2000). Ben Saunders, Ph.D. will serve as our
Consultant on family-based treatments. Dr. Saunders is Associate Professor of Psychiatry and
Behavioral Sciences at the Medical University of South Carolina in Charleston, S.C., where he
directs the Family and Child Program of the National Violence Against Women Prevention
Research Center. Dr. Saunders’ Ph.D. is in clinical social work and he is a licensed marriage and
family therapist. He has conducted one treatment outcome study for abused children (Berliner &
Saunders, 1996) and several studies of incestuous families. He has also conducted a large scale
national survey of the prevalence and consequences of child victimization, and served on the
APSAC Board of Directors. Michael DeBellis, M.D., M.P.H. is Associate Professor of Child
Psychiatry at the University of Pittsburgh Medical Center, and Director of the Developmental
Traumatology Program at Western Psychiatric Institute and Clinic (WPIC). He will serve as our
Consultant on assessment and measurement issues for abused children. Dr. DeBellis has
conducted groundbreaking research on the endocrine, neurotransmitter, memory, IQ and
structural brain abnormalities of maltreated children (DeBellis et al., 1999) and has expertise in
assessment and measurement issues in childhood trauma. He will lend this expertise in
developing the auxiliary data set to be used for abused children. Katherine Shear, M.D. is
Professor of Psychiatry at the University of Pittsburgh School of Medicine and Director of the
WPIC Panic, Anxiety, and Traumatic Grief Program. She has developed and manualized a CBT
traumatic grief intervention for adults and is currently evaluating this treatment in an NIMH-
funded comparative treatment outcome study. She is also on a task force to evaluate the validity
of including Traumatic Grief as an Axis I diagnosis in DSM-V. Dr. Shear will serve as one of

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                                                                           Cohen, Judith A.

our Consultants on treatment development for children experiencing traumatic loss. Our second
Consultant in this regard will be David Brent, M.D., M.P.H. Dr. Brent is Professor of Child
Psychiatry and Public Health at the University of Pittsburgh Medical Center, and the Director of
the Child and Adolescent Developmental Psychopathology Research Center at WPIC. Dr. Brent
is a nationally recognized expert in the treatment of childhood depression, suicidality, and
survivors of suicide. He has conducted and published several treatment studies in this regard,
and is a consultant on Dr. Cohen’s present pharmacologic treatment grant for sexually abused
children. Dr. Brent will provide expertise in treatment manual development for children
experiencing traumatic loss. Melissa Runyon, Ph.D. is Assistant Professor of Psychiatry at The
University of Medicine and Dentistry of New Jersey and Treatment Services Director of The
Center for Children’s Support in Stratford, N.J. She will serve as a consultant for treatment
modification. Dr. Runyon has extensive experience providing and supervising treatment for
physically and sexually abused children at VOCA-funded community programs, as well as
interfacing with Child Protective Services (CPS), both in Florida and New Jersey. She and Dr.
Deblinger have implemented a partnership with CPS in New Jersey wherein Center for
Children’s Support therapists provide therapy in CPS settings rather than in the clinic. This has
contributed to Dr. Runyon’s understanding of the barriers in providing manualized treatments in
community settings and has prompted her to develop innovative ways to address these
difficulties, which will be beneficial in modifying CBT treatments for community use. Walter
Smith, Ph.D. will serve as our Consultant for cultural issues. Dr. Smith is Executive Director of
Family Resources of Pittsburgh, a community based program specializing in the prevention and
treatment of child abuse. As an African American family therapist and psychologist who has
treated abused children and their families for over 25 years, Dr. Smith will contribute leadership
regarding the importance of cultural competence in providing effective treatment to these
families. He will meet with Center staff at least monthly to address these issues in an ongoing
manner. Tamra Greenberg, Ph.D. is a clinical psychologist at CTSCA who, with Ms. Padlo, will
manualize CBT interventions for community treatment of childhood traumatic loss. Dr.
Greenberg will also participate in modification of abuse-focused CBT for use in community
settings. Her recent focus has been on integrating play therapy and CBT interventions in treating
children experiencing child abuse and traumatic loss. She is the immediate past President of the
Pennsylvania Branch of the Association for Play Therapy and a member of the Association for
Death Education and Counseling. Dr. Greenberg has presented in the community and written
about the treatment of traumatic loss in children and the adaptation of play therapy techniques
for use in CBT treatments for sexually abused children (Cohen & Greenberg, in press). Prior to
joining CTSCA, she worked in a program for HIV positive adolescents and in other community
based treatment facilities serving large numbers of sexually abused and bereaved children. She
is currently a therapist in the multi-site treatment outcome study for PTSD in sexually abused
children being conducted at CTSCA, and has expertise in providing and training other therapists
in the provision of these treatments. Susan Padlo, L.C.S.W., A.C.S.W. is a therapist at CTSCA
who, with Dr. Greenberg, will network with community therapists treating traumatic loss in
children to develop treatment manuals for children and adolescents who have experienced this
type of trauma. Ms. Padlo has been treating traumatized children for over 20 years, in a variety
of community and clinical research settings. She has worked with severely disturbed abused and

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                                                                            Cohen, Judith A.

neglected children in a state hospital inpatient program, treated abused adolescents with
substance abuse problems in two community treatment programs, and has worked as a therapist
at both CASAC and CTSCA. She has also worked extensively with children experiencing
traumatic loss and complicated bereavement, both in her current work at CTSCA and in her past
work in hospice settings. Ms. Padlo has developed an extensive network of local contacts with
community agencies and has a thorough understanding of CASSP principles. Ms. Padlo’s
community treatment perspective has been of great value to the development of Drs. Cohen and
Mannarino’s treatment protocols. She is currently a therapist in their multi-site study with Dr.
Deblinger, and has expertise in providing the treatments used in that project. She is a member of
the Association for Death Education and Counseling and the National Association of Social
Workers, and has given several presentations about traumatic loss in children. Because
community therapist involvement is critical in our proposed Center, we will also subcontract for
parts of two therapists’ time from Pittsburgh Action Against Rape (PAAR) and The Pittsburgh
Child Advocacy Center (see Letters of Agreement and Section G for details.)

       1.       Operational and Collaborative Experience
                       Operational
                The Center for Traumatic Stress in Children and Adolescents (CTSCA) is an
outpatient treatment program of the Division of Child Psychiatry, Department of Psychiatry,
Allegheny General Hospital (AGH). It is directed by Dr. Mannarino and Dr. Cohen. CTSCA is
staffed by two clinical child psychologists, one child psychiatrist, two child psychiatric fellows,
three masters level social workers (including a Research Coordinator), a post-doctoral
psychology fellow, a variable number of psychology and social work interns, and an
administrative assistant. Since its inception in 1994, CTSCA has evaluated and treated over
2500 children ages 2-18 exposed to traumatic life events, including sexual abuse and other forms
of maltreatment, traumatic loss of parent or other family member, community, school or
domestic violence, natural and man-made disasters, animal attacks, medical trauma, and motor
vehicle accidents. Approximately half of CTSCA’s >300 annual referrals are for child abuse; an
additional 50-60 annual referrals are for traumatic loss. We serve a culturally and
socioeconomically diverse population; approximately 50% of our clients are minority members
and about 50% are receiving medical assistance or are uninsured. Referral sources include the
Pittsburgh Child Advocacy Center (CAC) and A Child’s Place at Mercy Hospital (the two
forensic child abuse evaluation centers in Pittsburgh), the Allegheny County Center for Victims
of Violent Crime (CVVC, a victim advocacy agency), Pittsburgh Action Against Rape (PAAR,
one of the oldest rape crisis centers in the U.S.), Family Resources (a community treatment
program for maltreated children), The Caring Place (a community program offering peer support
groups to bereaved children), Allegheny County Children, Youth and Families Services (CYF,
the county’s Child Protective




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                                                                            Cohen, Judith A.

Services agency), Family Court judges and parole officers, police, Pittsburgh public schools and
other local school districts, pediatricians, community mental health centers, including Mercy
Behavioral Health (the Base Service Unit for Pittsburgh’s North Side) other mental health
professionals and child treatment facilities such as foster care agencies, group homes and
intensive treatment programs; and self-referrals (please refer to Appendix 2 for letters of support
from these agencies). A variety of treatments are available at CTSCA, including individual,
group and family therapies. Our staff also provide individual and group treatment and ongoing
psychotropic medication management for many traumatized children placed in residential
treatment settings. We coordinate referrals to and collaborate closely with providers of
community-based intensive in-home services (family based, intensive case management,
behavior management specialists), and regularly consult and collaborate with educational
providers (teachers, guidance counselors, school psychologists). We also provide free training to
community organizations such as churches, synagogues, school districts, preschool programs,
YWCA, pediatric organizations, parent programs and other mental health provider agencies.
CTSCA and Allegheny General Hospital have a strong and longstanding commitment to
community involvement. Located in Pittsburgh’s North Side, a neighborhood with a
predominance of poor and minority residents, AGH preferentially hires from the North Side, and
works closely with the North Side Leadership Conference to address the economic and health
care needs and concerns of minority residents.

         CTSCA has developed and uses effective treatments for traumatized children, including
abuse-focused cognitive behavioral treatments (CBT) for sexually abused preschoolers, school-
aged children and adolescents. Abuse-focused CBT in our practice is highly collaborative and
consumer-driven; we regularly incorporate children’s and parents’ creative ideas into their
treatment planning and we identify each parent as being the expert on his/her child. We include
each child and parent in decisions about which therapeutic or self-help activities to include in
each session. We also include a strong parental treatment component in our abuse-focused CBT,
which we have shown to be critical to children’s recovery from sexual abuse (Cohen &
Mannarino, 1996b, 1998c, 2000). Clients are encouraged to discuss concerns and problems in
implementing CBT strategies through the course of treatment and these are promptly addressed.
We have found this collaborative form of CBT to be superior to nondirective play therapy and
nondirective parental counseling in improving sexualized behaviors, PTSD symptoms, and other
behavioral and emotional difficulties in sexually abused preschoolers (Cohen & Mannarino,
1996a). We have also found this form of CBT to be superior to nondirective supportive
counseling in improving depressive symptoms and social competence in 8-14 year old sexually
abused children (Cohen & Mannarino, 1998a). Additionally, we have tested the efficacy of
Rogerian client-oriented supportive counseling for sexually abused children, and have found that
this is an effective treatment for some sexually abused children. We are currently evaluating
factors that may predict which children will respond better to which type of treatment. As noted
above, Dr. Kolko has developed and manualized two distinct treatments for physically abused
children, which he used in a study comparing abuse-focused CBT or abuse-focused Family
Therapy (FT) to Routine Community Services (RCS). Relative to RCS, CBT and FT were
associated with improvements in child-to-parent violence and child externalizing behavior,

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parental distress and abuse risk, and family conflict and cohesion. Fewer parents receiving CBT
or FT engaged in another incident of physical maltreatment than those receiving RCS (Kolko,
1996a). Effective services that we have developed and used include the routine screening of
AGH pediatric and adolescent Ob-Gyn clinic patients for traumatic exposure and presence of
PTSD symptoms. We have found that >90% of these children have experienced traumatic life
events, and almost 25% have significant and heretofore unidentified PTSD symptoms. We are
currently treating many of these children at CTSCA. With regard to promising treatment and
services approaches, Dr. Cohen has designed a pharmacologic treatment protocol for use in
conjunction with psychosocial treatment, and is currently evaluating the effectiveness of adding
medication to CBT, especially for sexually abused children with PTSD and a comorbid
depressive or anxiety disorder (Cohen, 2001). With Dr. DeBellis, we are starting to evaluate the
effect of abuse-focused CBT (with or without medication) on brain functioning and development
in sexually abused children. This is critically important, as Dr. DeBellis has documented that
PTSD due to child abuse impairs normal brain development and IQ (DeBellis et al., 1999); we
hope that treatments that are effective in improving PTSD and other psychological symptoms
will also be able to reverse these effects on the brain. We have found that there are many
commonalities between sexually abused children and children experiencing traumatic loss.
These include the loss of an important relationship (when the perpetrator of abuse is a family
member of other trusted adult); the frequency with which children experience self-blame, shame,
anger and betrayal in both types of trauma; the severity of avoidance symptoms, which are
reinforced by others (including therapists) who are often more reluctant to directly discuss sexual
abuse or death than other types of traumatic events; and the profound effects these events have
on the nonabusive or surviving parent. Because of these similarities, Dr. Greenberg and Ms.
Padlo have adapted trauma-focused CBT for use in children who have experienced the traumatic
loss of a parent or other family member. We have utilized this treatment in group settings for
treating children who lost parents in the 1994 crash of USAir Flight 427 (Stubenbort et al., in
press), and propose to manualize this treatment in collaboration with consumers and community
providers, for future use and evaluation in the community.

        CTSCA has developed assessment protocols for use in our general clinic population, and
for use in treatment outcome studies. We use a standard assessment battery (described
below)and have experience in training clinicians to administer these instruments. We have
written four treatment protocols for sexually abused children, and have implemented these in two
previous treatment outcome studies of sexually abused children. In collaboration with Dr.
Deblinger, we wrote an extensive treatment manual for Rogerian client focused counseling for
sexually abused children and their non-offending parents, which we are using, along with Dr.
Deblinger’s CBT treatment manual (Deblinger & Heflin, 1996) in our current multi-site
treatment study for sexually abused children. Dr. Kolko has developed abuse-focused CBT and
Family Therapy treatment manuals for physically abused children and their abusive parents. In
addition to conducting sophisticated treatment outcome studies, we have significant experience
in program evaluation, including conducting a Department of Justice-funded national evaluation
of professional education programs with regard to the needs of child crime victims (Cohen,


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Mannarino & McClintock, 1998), and serving as the independent program evaluator for a
NCCAN-funded program (Values for Life Parenting Center, Kingsley Association of
Pittsburgh). The latter involved working closely with a community program aimed at serving
substance abusing African American families at high risk for child abuse, to gather intervention
and evaluation data. Dr. Kolko has conducted an extensive program evaluation of CPS in
Allegheny County, and is involved in two national services evaluation projects as described
above. The Pittsburgh Services Delivery Study evaluated treatment services provided to CPS
cases and found that caseworker risk ratings describing threats to the child’s safety were virtually
unrelated to standardized measures of these domains (Kolko et al., 1999). There was also
considerable variability in the timeliness and consistency with which caseworkers’ risk
assessments were conducted. Generally, families receiving the most services upon intake were
Caucasian, with low child anxiety, high parental distress, and a parental abuse history as a child.
Those who received child treatment tended to be sexually abused, and resided with parents and
families who received concurrent services. Child treatment involvement was not associated with
any significant gains on various clinical outcomes. It will be important to evaluate if these
findings are unique to Pittsburgh or are representative of national services delivery, as the
NCTSI proposes to do.

        We have significant experience, technical expertise and administrative ability to
coordinate cross-site treatment outcome studies, gained from running a multi-site treatment
outcome study with Dr. Deblinger in New Jersey for the past four years. This has involved
multiple joint training of project coordinators on standardizing assessment techniques and
maintaining high inter-rater reliability across sites, yearly training of therapists and maintaining
>90% compliance with the assigned treatment modality through intensive supervision of
therapists and bi-weekly cross-site conference calls among therapists and supervisors,
development and implementation of reliable treatment content rating methods, development of a
common data set and data entry and management techniques, weekly conference calls with
project coordinators and Investigators, and coordination of data analyses, grant submission and
publication. Dr. Kolko has also been involved in the planning and implementation of several
multi-site treatment studies for depressed and suicidal adolescents at WPIC, including Dr.
Brent’s current multi-site study of familial pathways to early-onset suicidal attempts (Brent,
1997), and in several multi-site services evaluation programs as discussed above.

        CTSCA has been involved in collaborating with and providing training and consultation
to numerous direct service providers, on the local, regional and national levels. As noted above,
Drs. Cohen, Mannarino, and Kolko have provided more than 200 trainings to treatment and
service providers in Pittsburgh and other communities across the U.S., and have also provided
numerous intensive 1-3 day training institutes at national and international conferences
(ISPCAN, ISTSS, AACAP, APSAC, APA, etc.). We have consulted to and/or provided formal
training to almost every school district in Allegheny County, including the Allegheny County
Intermediate Unit (which provides services to disabled and developmentally challenged
children). We have consulted to the county mental health system, including participating in their
rapid response team for emergency situations. We regularly collaborate with CYF (CPS),

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juvenile court, and the county probation department. We also have ongoing collaborations with
the American Red Cross and emergency medical services at AGH, consisting of regular training
programs, consultation and cross-referrals.

        We are currently collecting, storing and analyzing clinical data for all children receiving
evaluation or treatment at CTSCA. As noted above, we administer a standard assessment battery
to children and parents at the initial evaluation, including a semi-structured clinical interview;
self- and parent-reports of trauma exposure, PTSD, depression and general emotional and
behavioral problems; and for sexually abused children, parent reports of sexual behavior
problems, parental distress and support related to the child’s sexual abuse, and child report of
abuse-related attributions and perceptions. These instruments are re-administered periodically
during the course of treatment, and are used by therapists to plan treatment and to track progress.
They are also shared with parents as clinically appropriate. We have developed and established
the psychometric properties of several of the sexual abuse instruments we use (CAPS, PERQ,
PSQ)1, as no such instruments were previously available. At the end of treatment (whether
planned or drop out), these instruments are re-administered if possible. Data are entered by the
CTSCA Research Coordinator. These data are analyzed periodically for quality assurance and
research purposes. We are also collecting, storing and analyzing clinical data from our current
multisite treatment study with Dr. Deblinger; to date this includes extensive data collected at four
time points on more than 210 children and families. We also have experience in developing,
administering and analyzing complex data sets from large national surveys. We have conducted
two such studies, one funded by the Department of Justice Office for Victims of Crime to survey
innovative training practices for professionals treating child crime victims (Cohen, Mannarino &
McClintock, 1998d), and one funded by the Jewish Healthcare Foundation of Pittsburgh, to
survey national professional practices in treating children with PTSD (Cohen et al., 2001a). As
noted above, Dr. Kolko is participating in two national studies of mental health services across
child advocacy (Finkelhor, 2000) and child welfare agencies (Landsverk, 1999) and has
substantial expertise in collecting, storing and analyzing these clinical databases.

        CTSCA has a close partnership with the forensic programs that conduct initial
evaluations of sexually abused children (Pittsburgh CAC and A Child’s Place), the primary
community treatment programs for sexual assault victims (PAAR and Family Resources), the
primary victims’ advocacy program in Pittsburgh (CVVC), and a community child bereavement
program (The Caring Place) (see Appendix 2 for letters of support from these agencies). We
also collaborate closely with other community programs which provide treatment to sexually
abused and bereaved children, and cross-refer children when this is appropriate. Drs. Cohen and
Mannarino were treatment consultants to the Erie County Rape Crisis Center (1986-1992) and
have been volunteer trainers for CVVC for over ten years. We received the 1998 Betty Elmer


       1
        CAPS=Children’s Attribution and Perception Scale (Mannarino et al., 1994);
PERQ=Parents Emotional Reaction Questionnaire (Cohen & Mannarino, 1996b); PSQ=Parent
Support Questionnaire (Cohen & Mannarino, 1996b).
                                                11
                                                                            Cohen, Judith A.

Outstanding Professional Award from Family Resources for our ongoing community activities
on behalf of abused children. For many years, we have also had formal partnerships with the
Center for

Children’s Support in Stratford, NJ and Harborview Sexual Assault & Traumatic Stress Center in
Seattle, consisting of joint research, training, and treatment development endeavors.

         Consumer input is gathered in a systematic fashion at CTSCA. All clients and parents
complete a Client Satisfaction Questionnaire at the time of the initial assessment, and at
treatment completion. Results of these questionnaires are reviewed at regular time intervals, and
problems are addressed confidentially and promptly. We propose to increase consumer input in
our treatment/services development by including 1-2 nonoffending parents of sexually abused
children and 1-2 parents of children who have experienced traumatic loss, in our Center
activities. These parents will be recruited from our former CTSCA clients, and will be invited to
review and comment upon our treatment protocols, provide suggestions for improvements in our
current treatments/services, and to participate in Center meetings on a regular basis.
Additionally, as a result of conducting several therapy groups for child and spouse survivors of
victims of the USAir Flight 427 air disaster, we have a relationship with the USAir Flight 427
Disaster Support League. Although this group’s primary goal is to provide support to survivors
of other air disasters, many of its members participated in our groups to address their children’s
traumatic loss. We propose to meet regularly with this group to solicit consumer input with
regard to developing treatment manuals for childhood traumatic loss.

        Collaborative
        The Center for Traumatic Stress in Children and Adolescents (CTSCA), its staff and
consultants agree to participate in the following NCTSI activities: 1) participate in the NCTSI
Steering Committee and implement consensus decisions made by the Committee; 2) collaborate
with other T/S Development Centers and Community Practice Centers in a comprehensive
approach to identify, improve, develop and/or evaluate child trauma treatment and services
approaches; 3) participate with other NCTSI centers in a) multi-site treatment/ services
evaluation and clinical data collection studies, b) development of clinical data and evaluation of
data collection protocols and providing such data to the NCTSI, and c) development of
professional training and community education programs in areas of child trauma; and 4) serve
as an expert resource for the NCTSI and the national resource center in knowledge development
and consultation and training with respect to areas of child trauma.

        Drs. Cohen, Mannarino, and Kolko have a long history of collaborating with others
prominently involved in child traumatic stress. In addition to our long collaborations with Drs.
Deblinger and Saunders and Ms. Berliner, we have longstanding collegial relationships with
most of the other child maltreatment researchers in the U.S. Through our leadership roles in
APSAC and child trauma committees of AACAP, ISTSS, and both APAs, we have worked
closely with other prominent researchers and practitioners in the child trauma field. Matthew
Friedman, M.D., Ph.D., Executive Director of the National Center for PTSD, is a current

                                                12
                                                                          Cohen, Judith A.

collaborator on Dr. Cohen’s pharmacologic treatment grant and has agreed to consult regarding
the experience of that Center as it may contribute to the NCTSI. We have collaborated closely
on multiple projects with Drs. John March, Lisa Amaya-Jackson, John Fairbank at Duke
University, and Bob Pynoos at UCLA, who are applying jointly to become the National Center.
We have provided ongoing trainings for, and otherwise collaborated with the Center for Child
Protection of San Diego Children’s Hospital, which is also applying to participate in the NCTSI.
Drs. Cohen and Mannarino have also consulted and collaborated with Drs. Claude Chemtob,
Julian Ford, Glenn Saxe, Frank Putnam, and Lisa Jaycox, whose organizations are applying to
become T/S Development Centers, and with Jon Conte, Ph.D., Ms Berliner (Harborview Sexual
Assault and Trauma Center), Jeff Wherry, Ph.D. and Patricia Resick, Ph.D. (Children’s
Advocacy Center of St. Louis), Lisa Amaya-Jackson, M.D. and David Corwin, M.D., who are
applying to become CPCs. We anticipate ongoing productive collaborative relationships if any
or all of these organizations are involved in the SAMHSA-funded network. Please refer to
Appendix 2 for Letters of Agreement from several of these programs. We recognize that the
NCTSI will likely include programs with which we have had no previous relationship; we look
forward to new collaborations and anticipate working collegially and productively with all
programs in the NCTSI.

        Drs. Cohen and Mannarino have longstanding collaborative relationships with
community service providers including local Base Service Units (please see Appendix 2 for
Letter of Support from Mercy Behavioral Health, the BSU for Pittsburgh’s North Side) and their
wrap-around and in-home programs, county -funded foster care and group home agencies, and
non-profit family- and faith-based treatment agencies. These programs follow the CASSP
principles of providing child-centered, family focused, community-based treatments which are
multi-system, culturally competent and as unintrusive and unrestrictive as possible. We are
familiar with and supportive of these principles and work closely with direct providers of these
services. CTSCA is the preferred provider of child trauma treatment for the county’s managed
medicaid program (Community Care Behavioral Health). As noted above, CTSCA has a
relationship with the USAir Flight 427 Disaster Support League, an advocacy group whose
members experienced traumatic loss of a family member and many of whom participated in our
child and parent groups in the past. We meet regularly with community advocacy groups such as
the North Side Leadership Conference, and with consumer groups such as the North Shore
Foster Care Association (which includes foster parents caring for abused children and children
who have lost a parent) to obtain community and consumer input.

         As described above, CTSCA has the experience, technical expertise and administrative
ability to conduct multi-site treatment and evaluation program projects. We are successfully
conducting a multi-site treatment study with Dr. Deblinger, which has currently recruited and
treated over 210 sexually abused children and their families. We have also conducted two cross-
site program evaluations funded by the Department of Justice and the Jewish Healthcare
Foundation, as described above. Additionally, Dr. Kolko has conducted an extensive program
evaluation of CYF in Allegheny County, and has experience collaborating on large multi-site
treatment studies for depressed and suicidal adolescents and two national services evaluation

                                               13
                                                                             Cohen, Judith A.

projects; Ms. Berliner has conducted a state-wide evaluation of OVC-funded agencies providing
treatment and services to traumatized children and Dr. Saunders has evaluated the
implementation of victims’ rights and services in a state-wide South Carolina project.

B.     Implementation Plan

1.               Coordination and Program Support
                 The participation of the Center for Traumatic Stress in Children and Adolescents
(CTSCA) will contribute to achieving the overall aims of the NCTSI in a number of ways. We
and our consultants have conducted almost all of the published treatment outcome research for
abused children; we will contribute expertise in treatment development to the NCTSI along with
our longstanding commitment to improving the quality and effectiveness of treatment and
services for these children. Dr. Shear and Dr. Brent are strongly committed to contributing their
expertise to the NCTSI to help us develop manualized CBT treatments for community-based
treatment of childhood traumatic loss. Ms. Berliner, Drs. Kolko, Greenberg and Runyon have
experience in adapting protocol-driven treatments for community implementation, and Ms.
Berliner and Dr. Smith will contribute community provider and cultural competence perspectives
to the NCTSI treatment and services development efforts. We are all committed to strengthening
the ties among treatment researchers, providers and advocates throughout the U.S., and will
continue to expand our efforts in collaboration with the National Center network. We also
believe it is critical to involve professional organizations not specifically identified with child
traumatic stress in the overall aims of the NCTSI. Our activities in the American Academy of
Child and Adolescent Psychiatry, American Psychological Association, American Psychiatric
Association and National Association of Social Workers will facilitate inclusion and
coordination of these organizations in NCTSI activities. Some of the critical treatment/services
issues for traumatized children that must be addressed by the NCTSI, and that we have the
necessary experience and expertise to address are:

              Improving early screening and identification of traumatized children in routine
               settings such as schools, pediatric and community settings
       e       Identifying current child trauma treatments/services provided in community
               settings, and evaluating these treatments as they are currently delivered
              Identifying effective treatments/services for traumatic events which have received
               less attention than child abuse or disasters (i.e., currently have no proven effective
               treatment)
              Developing and evaluating new potentially effective treatments for traumatized
               children
              Developing and testing optimal treatments for “difficult to treat” traumatized
               children, i.e., those with psychiatric comorbidities, severe behavioral problems
               (violence to others, sexual aggression, self-injurious behaviors), and children in
               out-of-home placements, who typically have multiple problems, multiple traumas,
               and poorly developed support systems
              Identifying cultural, ethnic, gender and/ or developmental factors which affect

                                                14
                                                                             Cohen, Judith A.

               optimal access to, acceptance of, and response to currently available treatments,
               and modifying treatments to address these barriers to optimal treatment

              Improving implementation of effective treatment strategies in community
               settings, including adapting existing treatment models for greater acceptability
               and deliverability
              Improving awareness (among parents, educational and health care providers,
               insurance providers, and the general public) of the detrimental impact of
               childhood traumatization, and the importance of prevention, early identification
               and treatment for these children

         The proposed staff and Consultants have the expertise and commitment to substantially
contribute to NCTSI’s efforts to address these and related issues. We will depend on The
National Center to provide overall direction and coordination of our efforts with other programs
in the network. We will work closely with other T/S Development Centers to share current
effective screening, evaluation, and treatment strategies, incorporate successful elements of each
others’ treatments and services into our own interventions, and when appropriate, jointly develop
new treatment and services strategies. We are confident that effective treatments can be
successfully adapted for use in community settings within the National Center structure. We
hope to benefit particularly from the input of Community Practice Center (CPC) staff in
modifying, implementing, and evaluating our existing treatments, and in developing new ones.
We are aware that community providers see multi-problem children and families, have large
caseloads, and often consider manualized treatments to be inflexible “cookbooks” that diminish
the importance of their therapeutic relationships and creativity (Barlow et al., 1999; Kolko et al.,
2001). We have had success in addressing many of these issues in our community training
efforts and by providing ongoing consultation and supervision for treatment cases at community
treatment sites. We will make our treatment manuals available to the network and will provide
consultation, collaboration and training in treatment development and implementation as needed.
We will provide the opportunity for CPCs to access these if desired. We also propose to
contribute to network development by including local community agencies in Pittsburgh in our
training, treatment implementation and evaluation plans, as discussed below. Treatment
development for abused children is more advanced than for other types of trauma. Several
treatment manuals have been designed for various ages, and have been evaluated in randomized
clinical trials. Trauma-focused CBT has been shown in several such trials to be superior to
routine community treatment or supportive counseling (Cohen & Mannarino, 1996a, 1998a;
Deblinger et al., 1996; Kolko, 1996). Therefore, in order to advance optimal treatments for
traumatized children, we are proposing three primary activities for our T/S Center. We believe
this multi-pronged approach will optimally contribute to improved treatment and services for
children traumatized by child abuse or traumatic loss. We propose to 1) participate in NCTSI
efforts to evaluate current community treatment/services practices for children experiencing
child abuse or traumatic loss; 2) in collaboration with community providers, develop CBT
treatment manuals for children experiencing traumatic loss, and gather evaluation data on using
this treatment model in community settings; and 3) work with CPCs in the NCTSI, as well as

                                                15
                                                                           Cohen, Judith A.

with two community programs in Pittsburgh (CAC and PAAR) to modify our current CBT
manuals for abused children for use in these community settings. We will then train therapists in
these programs in the community-revised CBT model, and evaluate the impact of implementing
this model in these community settings.

       Short-term goals for our participation include the following:

1)             Link, network and collaborate with other centers in the network during the
               Organizational Phase to coordinate goals with other NCTSI Centers. We will
               accomplish this through scheduled meetings (Steering Committee, Grantee’s
               Meeting), and regular telephone and/or e-mail contact with each of the other T/S
               and Community Practice Centers.
2)             Make at least one trip within the first year of the project to each of 3-5
               Community Practice Centers in order to establish specific treatment and services
               goals during the Organizational Phase.
3)             Formulate and implement a plan to evaluate current treatment practices and child
               outcomes for child abuse and traumatic loss at CPCs, in collaboration with the
               network.
1)             Train staff at 3-5 CPCs, and at two Pittsburgh sites (CAC and PAAR), in abuse-
               focused CBT, conduct focus groups to modify this treatment for community use,
               and prepare community-modified CBT treatment manuals for abused children.
2)             In collaboration with community providers, develop trauma-focused CBT
               treatment manuals for children and adolescents who have experienced traumatic
               loss.

       Long term goals include the following:

       1)      In collaboration with 3-5 selected Community Practice Centers, PAAR, and the
               Pittsburgh CAC, intensively train staff at these programs in the provision of
               community-modified CBT for abused children, provide ongoing consultation, and
               evaluate of the impact of this training on therapist practices and child outcomes.
       2)      Conduct an evaluation study of 20 children who have experienced traumatic loss,
               using the newly developed treatment manuals in community settings.

        The overall fit between CTSCA and the NCTSI is outstanding because from our
inception our clinical, services and research efforts have been dedicated to improving treatment




                                                16
                                                                           Cohen, Judith A.

effectiveness and availability for all traumatized children, improving understanding of the
impact, treatment and prevention of child traumatization, and reducing the negative impact of
these events on children, their families and communities. We stand to benefit from collaboration
with other treatment and service developers and providers, particularly by receiving input about
how our treatments are not currently adequate for certain children, providers or communities,
and how we can improve treatments and services in this regard. We do not see any potential
problems for CTSCA with our participation in the NCTSI.


        Potential challenges that we foresee are the likelihood that different programs may have
very different specific goals and ideas about how to achieve these. An open-minded,
collaborative approach will be critical in resolving these differences. In particular, T/S
Development Centers will have to be attentive to criticisms of their treatments given by
community providers, and need to be flexible in adapting protocol-driven treatments to these
settings. We will hire a full-time Community Provider Liaison staff member to facilitate open
and ongoing communication with the CPCs in the network, and will conduct focus groups with
CPC providers as described below. We will maintain at least bi-weekly e-mail and/or phone
contact with other T/S Development Centers and The National Center, to facilitate cross-center
collaboration and coordination. The initial selection of sites will hopefully incorporate programs
with compatible views of how to move the field forward., but if this is not the case, the NCTSI
Steering Committee will need to resolve these differences in as inclusive a fashion as possible.

       2.       Network Participation
                In addition to the activities described above (networking with other Centers,
sharing treatment expertise and already-developed treatment manuals; collaborating on
development of new treatments for different types of trauma and incorporating needs of specific
populations based on gender, developmental level, and/or cultural factors; collaborating with
CPCs to modify abuse-focused CBT and to develop traumatic loss treatment manuals for use in
community settings), we also propose to contribute to the network by evaluating
treatments/services for child abuse and traumatic loss in our own community where we have
already established strong collaborative relationships. We believe that we can further the goals
and objectives of the NCTSI most optimally by capitalizing on existing relationships in addition
to establishing new ones with the funded NCTSI Centers. As noted above, we will also utilize
our existing committee memberships and relationships in national professional organizations to
promote the goals and objectives of the NCTSI.

        Network participation will enhance our efforts to develop effective treatment and services
approaches by allowing us to benefit from the expertise of other T/S Development Centers which
may have more experience in treating types of traumas that we have treated less frequently (ex:
medical and war/refugee traumas). Integrating elements of treatments used by these programs
will enhance the services we can provide to such children, and also potentially enhance our
current treatment models for children exposed to abuse and traumatic loss. Additionally,
although we have strong collaborative relationships with community programs in Pittsburgh,

                                                17
                                                                              Cohen, Judith A.

CPCs in other geographic areas are likely to be serving children from different cultural
backgrounds than those we have typically treated and included in our treatment studies. For
example, Latino, Asian and Native American children are less represented than Caucasian and
African American children in our clinic and treatment studies, due to the demographics of
Pittsburgh and Stratford , N.J. where these studies have been conducted. It is essential that we
evaluate whether these treatments (as well as new treatments that we develop in the future) are
acceptable and effective among these populations. Additionally, therapist training, attitudes and
philosophies as well as child and family attitudes toward mental health treatment in general and
child abuse or traumatic loss in particular, may vary widely in different geographic settings.
Participation in the network will allow us to determine what impact these factors have on the
effectiveness of our current treatments and modify these treatments accordingly, as well as help
us to develop more optimal treatments in the future. We also hope to benefit from successful
experiences other programs have had in transporting effective trauma treatments to community
settings. Finally, designing effective treatments for “hard-to-treat” children will likely be
optimally accomplished by pooling the expertise of the most accomplished treatment/services
developers in the child trauma field. The NCTSI network will greatly facilitate this process.

         We hope to utilize our expertise in treatment development, training, implementation, and
evaluation to provide better treatments for all traumatized children. If the NCTSI is successful in
meeting its goals, the model of developing a national treatment/services development network
will be of great value to the wider child services field, by providing a successful network model
for improving quality and availability of treatment in community settings (a primary focus of
services research). Improving the availability and quality of child trauma treatment will have a
positive effect on mental health care consumers by making optimal treatments more accessible,
and will likely be beneficial to the public, as it will result in decreasing the potentially negative
consequences of child trauma (discussed in detail in AACAP, 1998 and DeBellis et al., 1999).
Initiatives we would like to see included are expanding the network to include agencies within
the communities where the T/S Development Centers are located, and a focus on developing a
wider network of knowledgeable child trauma treatment/services trainers throughout the United
States. We would also like to see development of a web-based consultation service to CPC
providers whereby they can receive immediate personalized feedback on specific treatment
situations regarding how to implement CBT or other effective treatments.

        Operationalizing interactions between NCTSI centers will require regular communication
via phone, fax, e-mail (including establishment of a listserv for participating programs and
individuals), teleconferencing, and face-to-face meetings. A process for resolving potential
conflicts should be agreed upon, as well as a method for including in decision making those
CPCs which do not have direct representation on the Steering Committee. Other details of
operationalization should be worked out in collaboration with the participating programs.

        CTSCA can supply several resources which will contribute to the development of the
network. We will provide our treatment manuals, which have already been developed, tested,
and in some cases published, to the NCTSI, and provide training and consultation in their

                                                 18
                                                                             Cohen, Judith A.

application. We will contribute assessment instruments we have developed and standardized,
along with scoring guidelines and information on psychometric properties, for use by the NCTSI.
Dr. Kolko has developed/modified two questionnaires for services evaluation (described below)
which he will also supply to the NCTSI. We have strong collaborative relationships with several
additional treatment/services programs both in Pittsburgh and nationally, which we can recruit
for participation in the network. Specifically, we have agreements with the Pittsburgh Child
Advocacy Center (CAC) and Pittsburgh Action Against Rape (PAAR) to serve as local
community sites at which we can evaluate current and new treatments for child abuse and
traumatic loss. We can also recruit the USAir Flight 427 Air Disaster Support League and
facilitate recruitment of child abuse committees of the AACAP and both the APAs for
participation in the NCTSI. This has the potential to significantly expedite and expand the
operation of the NCTSI network.

3.               Knowledge Development
                 We plan to collect, analyze and use clinical, service and clinical research data on
children and adolescents experiencing trauma using the following procedures. We anticipate that
the National Center and Steering Committee will discuss and agree upon a core data set to be
collected at all Center sites. Each T/S Development Center may add auxiliary data sets, which
are relevant to specific types of trauma, developmental levels, or treatments, but not included in
the core data set. When considering such protocols, it is important to balance research needs (the
use of reliable and valid instruments that measure several critical variables) with
service/treatment needs (not overburdening treatment providers or clients with lengthy or overly
intrusive instruments; sensitivity to culture and the possibility of limited literacy, etc.).

1)             Development of clinical data collection protocols from T/S Centers and CPCs
               providing treatment/services for child abuse or traumatic loss will be
               accomplished in close collaboration with those centers. Information to be
               collected from participating CPC and other treatment sites might include ages,
               genders, ethnicity/culture of clients, gender, ethnicity/culture, training and years
               of experience of agency therapists, numbers of children referred for each type of
               trauma, insurance status and referral sources.
2)             With regard to clinical case-level treatment outcome data for children
               experiencing child abuse and traumatic loss, instruments might include self-and
               parent-report measures of traumatic exposure to other stressors (TESI-C)2, PTSD
               ( UCLA PTSD Index for DSM-IV), general trauma symptoms (TSC-C),


       2
       TESI-C=Traumatic Exposure Structured Interview for Children; TSC-C=Trauma
Symptom Checklist for Children; MFQ=Multiple Functioning Questionnaire; BDI=Beck
Depression Inventory; SCARED=Screen for Child Anxiety Related Emotional Disorders;
MASC=Multiaxial Anxiety Scale for Children; CSBI=Child Sexual Behavior Inventory;
PCTGQ=Prigerson Child Traumatic Grief Questionnaire; PPQ=Parent Practices Questionnaire;
CAP=Child Abuse Potential Questionnaire.
                                                19
                                                                  Cohen, Judith A.

     depressive symptoms (MFQ ; BDI), general anxiety symptoms (SCARED;
     MASC), the child’s trauma-related attribution and perceptions (CAPS), sexual
     behavior problems (CSBI), psychological symptoms related specifically to
     traumatic loss in children (PCTGQ), parental distress and support related to the
     child’s trauma (PERQ; PSQ), and/parenting practices (PPQ; CAP). All of these
     instruments can be completed by the child or parent, and do not require significant
     staff training to be administered. Data will be collected at the CPCs and other
     sites where treatment is being provided, at intervals agreed upon by the Steering
     Committee (ex: pre-treatment, every 4 weeks of treatment and at treatment
     completion), and be sent to CTSCA (in a uniform and secure manner which
     maintains anonymity of participating children and parents) for data entry and
     analysis. CTSCA will also transmit the data set to the National Center for
     program evaluation analyses.
3)   Collection of program data regarding intervention development and
              implementation experiences may include what treatments are currently
     being provided, number of sessions attended and missed, length of treatment,
     demographic information about participating families and therapists, and auxiliary
     types of treatment provided (ex: medication, in-home services, etc.). We
     developed a brief questionnaire of treatment practices for traumatized children
     which we used in a national survey (Cohen et al., 2001a). This instrument will be
     made available to the NCTSI for use in this regard. Dr. Kolko has administered
     the Therapy Process Checklist (TPC; Weersing & Weisz, 2000) to service
     providers to determine what treatment techniques they use and what orientation
     best describes their practice. Dr. Kolko has developed the Agency Questionnaire,
     which asks about client numbers, providers, supervision, services, evaluation and
     theoretical orientation. He has also modified The Survey for Service Providers
     (SPP) (Atkins et al., 1999), to include interventions for abused children.
     Providers rate the extent to which they are likely to use a particular intervention,
     their confidence that it would be helpful, importance and availability of
     manualized treatments, agency supports and resources, how likely they would be
     to request alternative interventions, and their confidence that if the interventions
     were carried out they would be helpful, and how often they experience different
     obstacles and strengths when working with families of abused children. These
     instruments will be available for use by the NCTSI. Data analyses will address
     what treatment practices are currently utilized, and in conjunction with clinical
     case data (#2 above), may indicate the relative efficacy of different types of
     treatments/services as currently provided.
4)   We will collaborate with the National Center in collecting data with regard to the
     availability, accessibility and quality of services in communities in which NCTSI
     Centers are located and will facilitate this process in Pittsburgh, potentially using
     instruments and methods similar to those used by Dr. Kolko in his recent analysis
     of service utilization by children in the CPS system (Kolko et al., 1999).
5)   We have demonstrated our ability to support and perform clinical research with

                                      20
                                                                              Cohen, Judith A.

               regard to risk factors for developing traumatic stress reactions. For example, we
               have conducted a series of studies which empirically evaluated demographic,
               cultural, family, abuse-related and child cognitive factors which predict symptom
               formation in sexually abused children (Mannarino et al., 1994; 1996a; 1996b;
               1996c; Cohen & Mannarino, 1996b;1998c; 2000). We have also conducted
               clinical research on the consequences of traumatic stress (Mannarino & Cohen,
               1986; Cohen & Mannarino, 1988; Mannarino et al., 1989; 1991) and treatment
               and
               services approaches for traumatized children and adolescents (Cohen &
               Mannarino, 1996a; 1997; 1998a; Kolko, 1996a, b; Kolko et al., 1999).

        We anticipate that the process for developing clinical data will be agreed upon during the
Organizational Phase of the project. We will collaborate regularly with the National Center
during this initial phase to discuss selection of appropriate instruments, and offer our expertise in
instrumentation for children experiencing abuse or traumatic loss in this regard. We agree to use
the core data set decided upon by the Steering Committee, and to develop auxiliary abuse- and
traumatic loss-specific data sets in collaboration with the National Center. We anticipate that
there may be tension between CPCs, which are already over-burdened with paperwork from
managed care/medicaid and other regulatory requirements, and the National Center or T/S
Centers, which are responsible for developing, analyzing and interpreting useful, objective
databases. We will clearly need to streamline the data collection protocol in close collaboration
with these Centers.

       Preliminary goals and objectives for successfully performing research activities include:

       Short term objectives and supporting activities

1)             Identify the most pressing research questions to be answered, in collaboration
               with the National Center and Steering Committee.
2)             Develop core data set and auxiliary data sets for abused children and children
       experiencing traumatic loss, taking into account the service and clinical needs of CPCs
       which will be implementing them; develop data base and data entry/analysis procedures
       to be used across the network.
3)             Identify 3-5 CPCs treating significant numbers of abused children and children
       with traumatic loss, educate their staff and therapists about the data set and how/when
       instruments should be administered.
4)             Develop procedures consistent across sites for data transmittal to CTSCA and
       other T/S Development Centers, and to the National Center, which maintain
       security/confidentiality.
5)             Collect data, analyze it, and summarize treatments/services currently being
       provided at the CPCs, utilizing methods described above.
       6)      Provide training in identified effective treatments for abused children to
               supervisors and treatment providers at CPCs; in collaboration with these CPCs,

                                                 21
                                                                          Cohen, Judith A.

              modify these treatments to be acceptable and appropriate for use by therapists in
              each CPP, while maintaining core ingredients of the treatment model; agree upon
              procedures to maintain treatment integrity and to measure outcomes of children
              treated by trained vs. untrained therapists at these CPCs.




       Long term goals and objectives:

       1)     Train therapists at CPCs, PAAR, and the Pittsburgh CAC in community-
              modified CBT, implement this treatment at these sites, and conduct evaluations of
              treatment effectiveness using the agreed upon treatment models and core and
              auxiliary data sets; collect and analyze data and prepare reports of results.
       2)     Evaluate difficulties in implementing these treatments in CPC settings, and
              modify treatments accordingly.
       3)     Conduct an evaluation study treating 20 children who have experienced traumatic
              loss using the newly-developed CBT treatment manual in community settings.

        In order to coordinate research efforts across T/S Development sites and among CPCs, it
will be necessary to agree upon the most pressing research questions to be addressed, identify
which T/S Center will focus on which populations, issues or questions, and agree upon a
coordinated plan of action. This will likely involve identifying which T/S Centers and CPCs
have the most compatible goals/populations, and matching these programs to work together.
Although some research questions need to be addressed across all populations and sites (for
example, the effects of culture on treatment utilization, acceptability and outcome), some
questions may pertain specifically to certain types of trauma or other factors (for example,
evaluation of medical services utilization may be most relevant for children exposed to medical
traumas, whereas treatment referral patterns of CPS agencies may be most relevant to abused
children). Thus, matching of T/S sites and CPCs will aid in achieving the goals of the network.
Close collaboration among T/S Centers (discussing clinical experience, sharing screening and
assessment instruments, treatment manuals and outcome data) will also facilitate the optimal
development of treatments for diverse populations of traumatized children. Please refer to
Letters of Agreement (Appendix 2) for details of plans to collaborate with potential T/S and CPC
programs.
        Plans to collect service data from NCTSI clinical sites and other child trauma treatment
include the following:

       Short term plans:

       4)     Adapting an existing instrument or creating a new one to collect these data in
              collaboration with other NCTSI Centers. Type of data may include
              treatment/services referral patterns, who actually receives services, the

                                              22
                                                                             Cohen, Judith A.

               type/intensity/length of services provided, and impact of receiving services on
               child/family outcomes. As noted above, Dr. Kolko has successfully used the
               Agency Questionnaire for Service Providers and Therapy Process Checklist to
               collect these data in the past.
       5)      In collaboration with the NCTSI, determining and putting in place appropriate
               methods of collecting these data.


       6)      Identifying other programs which should be surveyed. This should include
               collaborating with researchers such as Drs. Landsverk (1999) and Finkelhor
               (2000) who are already collecting this type of data nationally.

       Long term plans:

1)             Distributing surveys to selected programs; collecting and entering data.
2)             Data analysis and evaluation of significance of findings, including implications
               for T/S development needs.

       It is essential that issues of culture, race, ethnicity, developmental level, gender and other
population differences be considered in developing optimal treatment and services models for
traumatized children. In a recent article we addressed the importance of culture in child
maltreatment research (Cohen et al., 2001b) and determined that inadequate attention has been
devoted to these factors in most published treatment studies to date. We will urge the network to
include these factors in the core data set, and attend to the impact of these factors in
treatment/services acceptability, utilization and response.

       4.       Developing Effective Treatment and Service Delivery Approaches
                As noted above, we have already begun to a) collect, analyze and publish data
regarding treatments, screenings, assessment and services that traumatized children receive both
in our community (Kolko, 1998; Kolko et al., 1999) and nationally (Cohen et al., 2001a;
Landsverk, 1999; Finkelhor, 2000). In collaboration with the national network, we will further
identify treatments, assessments, screening and services that traumatized children currently
receive, whether by surveying the NCTSI CPC treatment practices, by national or targeted
surveys, use of managed care treatment data, or other methods. We also propose plans to
b) support implementation of interventions with proven or promising effectiveness, c) develop
screening and service models to improve effectiveness of interventions received, and d) enhance
identified effective treatments, as described below.

       We propose the following plan for developing, improving and providing intervention
approaches in the areas of child abuse and traumatic loss:

       Short term objectives and supporting activities:



                                                 23
                                                                      Cohen, Judith A.

1)          Modify proven CBT treatments for abused children for use in community settings.
            We will provide intensive training in our current abuse-focused CBT models, and
            conduct a series of focus groups with community providers both at selected CPCs
            and at PAAR and the Pittsburgh CAC, in order to modify our current CBT
            treatment manuals. Focus groups elicit information about training interests,
            attitudes toward research and manualized treatment, and the process of choosing
            intervention methods (Krueger, 1994), and demonstrate to service providers that
            their input is important for successful treatment and research. A series of focus
            groups will be held at 3-5 CPCs, PAAR and the Pittsburgh CAC in accordance
            with accepted focus group methodology (Richter, Bottenberg, & Roberto, 1991).
            CTSCA will provide a group facilitator for these groups. Questioning will follow
            the general format suggested by Krueger (1994). We will use Informed Consent
            procedures (see Section I). After conducting these focus groups, we will
            integrate the information gathered from them to modify the CBT treatment
            manuals from our prior efficacy studies. Although many of the content areas
            from the original manuals may remain the same, modifications will be made to
            improve the ease with which the sessions can be implemented by community
            clinicians and their acceptability to therapists and clients from diverse
            backgrounds. Once the first revision of these manuals has been completed, they
            will be presented to CPC providers for review and further feedback. This input
            will be incorporated into final community-modified manuals for abuse-focused
            CBT.
1)          Develop treatment manuals for children and adolescents experiencing traumatic
            loss. Dr. Greenberg and Ms. Padlo will complete and publish a literature review
            on the published treatment interventions for childhood traumatic grief. In
            consultation with Drs. Shear and Brent, and in collaboration with community
            providers, we will develop trauma-focused CBT treatment manuals for use in
            children and adolescents experiencing traumatic loss. If adequate numbers of
            CPCs are treating such children, we will convene focus groups in the manner
            described above.

     Long term objectives and supporting activities:

     1)     Train CPC, PAAR, and Pittsburgh CAC providers in community-modified CBT,
            implement and evaluate this treatment at these sites. Half of the counselors at
            each CPC will receive training and ongoing supervision in the community-
            modified CBT and then be asked to implement the revised manual with eligible
            cases. Throughout the course of the effectiveness trial, CPC therapists will
            continue to receive training as needed by a designated supervisor. Prior to the
            intensive training sessions, all counselors will be asked to complete a
            questionnaire regarding their knowledge of the core aspects of community-
            modified abuse-focused CBT. They will also complete questions about their
            perceptions of manualized treatment. All counselors, both those receiving

                                            24
                                                                              Cohen, Judith A.

               training and those not receiving training, will then complete questions in both
               areas following the three-month training period. If agreed upon by the NCTSI,
               we will conduct a randomized clinical trial (RCT) at NCTSI CPCs, comparing our
               community-modified manualized CBT to treatment-as-usual for abused children,
               using methods similar to those utilized in our previous RCTs. Outcomes for the
               two treatment groups will be compared on symptom severity, functional
               impairment, environmental context, consumer satisfaction, and service
               participation/use (Burns, 1999; Hoagwood, Jensen, Petti & Burns, 1996).
       2)      Conduct an evaluation study of trauma-focused CBT for children experiencing
               traumatic loss, using newly developed treatment manuals. This will involve
               recruitment of 20 eligible children referred to identified community providers,
               provision of the manualized treatment by these therapists, and collection of
               outcome data pre- and post-treatment and at a 6-month follow-up.

        We recognize that the purpose of the NCTSI is to deliver optimal treatment/services to
more traumatized children, rather than to support research activities. We therefore have not
included conventional treatment outcome studies in this NCTSI protocol. However, we will
continue to conduct such studies and because we believe these efforts will also contribute to the
long-term success of the NCTSI, we mention them briefly here.

       1)      Identifying the “critical ingredients” of abuse-focused CBT for young children (4-
               10 year olds), and the optimal length of treatment for children with different types
               and severity of symptoms. We are submitting a study to examine these issues.
       2)      Determining the benefits of adding antidepressant medication (sertraline) to
               abuse-focused CBT for sexually abused 10-18 year olds with PTSD. Dr. Cohen is
               currently funded to conduct this study. The issue of medication use in
               traumatized children is a critical one to empirically evaluate. A recent national
               survey (Cohen et al., 2001a) indicated that 95% of physicians treating childhood
               PTSD use medication, and almost 20% of these physicians identify medication
               alone as their first-line treatment choice, despite the fact that no controlled studies
               have indicated the effectiveness of medication in treating childhood PTSD.

         We envision collaborating very closely with Community Practice Centers in modifying
our existing treatments for use in community settings, and in developing new treatments. We
propose to provide CPC therapists and supervisors with training in treatments that have proven
efficacy (abuse-focused CBT) and ask them in a series of focus groups to address concerns or
problems they foresee in using these treatments in their practice. Through detailed discussions
of possible modifications, we will collaborate to revise these treatments to be appropriate and
acceptable for use by these therapists for their client populations, incorporating elements that
they have found to be helpful in their current practice. We have already begun to see the benefits
of this type of input; for example, information/educational handouts for parents, and activity
worksheets for children have frequently been requested by community therapists during our
community presentations. In response, we have incorporated a number of these into our CBT

                                                 25
                                                                           Cohen, Judith A.

manuals and found them to be very helpful. Use of the core and auxiliary data set will also be
discussed at length with CPC staff, and CPC requests for modification of this assessment
protocol will be considered seriously, in collaboration with the National Center. We will also
solicit suggestions from CPCs about developing new treatments, i.e., what populations, traumas,
symptoms, etc, are not being adequately addressed by currently available treatments. We will
attempt to address these issues in our ongoing treatment development efforts.

        We envision collaborating with the other T/S Development Centers by sharing
information about current treatment practices in our communities, and treatment needs that we
believe are not currently being addressed. We anticipate that each T/S Center will have unique
strengths, and that we will be able to utilize each others’ expertise to improve all of the
treatments we have developed, are developing, or are attempting to evaluate in community
settings. It is likely that some T/S Centers will have more expertise in treatment development,
whereas others will have more in services research. We hope to benefit from the expertise of the
other T/S Centers while sharing ours with regard to treatment development, monitoring,
implementation and evaluation. Regular phone conference calls (at least bi-weekly) will occur to
address these issues. We will also maintain at least bi-weekly contact with the National Center,
to assure that our activities are addressing the overarching needs and aims of the project, and to
request guidance when needed. By capitalizing on each others’ strengths, and collaborating
rather than competing with other programs, the network will have a greater impact on improving
treatment quality and availability for all traumatized children.

         As noted earlier, in our recent review of treatment outcome studies for abused children,
we determined that inadequate attention has been given to the impact of race, ethnicity and
cultural diversity in evaluating treatment response. We have included evaluation of these factors
in all of our treatment outcome studies, and will strongly urge the National Center to require all
programs in the network to systematically collect data which can address these issues. One of
the instruments we developed, the Children’s Attributions and Perceptions Scale has been
translated into Spanish and is currently being validated for use in a variety of diverse Latino
populations. We will encourage the National Center to collaborate in similar efforts in order to
support treatment evaluation in non-English speaking children. In terms of our own treatment
development, we will regularly meet with Dr. Smith to assure that our treatments are culturally
sensitive. We have designed treatments specifically for children of different developmental
stages, and propose to continue to design treatments that are developmentally appropriate (for
example, we will develop separate treatment manuals for children and adolescents experiencing
traumatic loss).

       5.      Child Traumatic Stress Resource Center
               We plan to participate in the following components of the planned resource center
as described below:

               1)     We have a long history of providing expert consultation, references,
                      assessment instruments, treatment manuals, compliance checklists (for

                                                26
                                                                             Cohen, Judith A.

                       monitoring fidelity to specific treatment models), Client Satisfaction
                       Questionnaires, and other assistance without charge to researchers and
                       providers who have requested these resources, and we will continue these
                       efforts as part of our participation in the National Center.
               2)      We have also provided training to professionals throughout the U.S. about
                       the nature, impact and treatment of child and adolescent trauma, and will
                       participate, in conjunction with the National Center, in the development of
                       a national program to expand these efforts, including sharing all of our
                       training and educational materials and training new trainers. We have
                       developed a 220-page training curriculum for child psychiatry fellows
                       which integrates child traumatic stress into all aspects of training. We will
                       contribute this curriculum to the National Center.
               3)      We have already developed educational materials on child trauma which
                       we have provided at public presentations; we will provide these to the
                       National Center, assist it in developing more comprehensive educational
                       programs, and continue to respond to media inquiries regarding child
                       trauma, as we have been doing for many years in Pittsburgh. During the
                       Organizational Phase of the project we will also assist the National Center
                       in utilizing already existing resource centers such as the National
                       Clearinghouse on Child Abuse.

        Goals, objectives and activities for successfully participating in the development of a
national child trauma resource center (“Resource Center”) include the following goals: 1)
develop an accessible, user-friendly national child traumatic stress resource center for research,
clinical and services data on child trauma; 2) provide training, consultation and technical
assistance on effective treatments and services for traumatized children and their families; and
3) support publication and electronic dissemination of information to professionals and the
public on child traumatic stress.

       Short term objectives and supporting activities:
1)             Develop an infrastructure at the National Center to collect, catalog, and make
               available via publication or electronic transmission, information about the types,
               prevention, impact and treatment of child trauma, and service needs/resources for
               these children. We will contribute expertise about what information should be
               included in the Resource Center and how it might be optimally accessed.
       2)      Identify existing resource centers or data bases (ex: PILOTS; National Data
               Archive on Child Abuse and Neglect) which can be utilized or referenced to
               optimize the efficiency of the Resource Center. We will contribute our
               knowledge of existing resources on child abuse, traumatic loss, childhood PTSD,
               and child trauma, and assist in negotiating information-sharing with these
               programs.
3)             Identify needs with regard to training, consultation and technical assistance in
               child traumatic stress. We will provide input from our clinical and training

                                                27
                                                                              Cohen, Judith A.

               experience, and contribute to efforts initiated by the National Center to identify
               these needs.

       Long term objectives and supporting activities:

       3)      Collect, catalog and disseminate information about child traumatic stress. We
               will contribute the resources described above, and assist in identifying and
               obtaining other relevant resources to be added to the Resource Center on an
               ongoing basis.
       4)      Develop a national program to train professionals about child traumatic stress.
               We will contribute our educational and training materials as described above,
               provide direct training and train other trainers.
       5)      Develop educational programs on child traumatic stress for the public and a
               media-response process. We will contribute educational materials as discussed
               above, and will be available for media interviews at the discretion of the National
               Center.

       Potential collaborations, consultations and interactions with the following agencies and
organizations should be employed to develop the Resource Center. We have established
professional relationships with leaders in each of these, and will facilitate collaboration with the :
National Center for PTSD, OCAN, APSAC, ISTSS, ISPCAN, National Clearinghouse on Child
Abuse, National Center for the Prevention of Child Abuse, AACAP, American Psychiatric
Association, American Psychological Association, National Data Archives on Child Abuse and
Neglect (Cornell University), National Association of Social Workers, and the Association for
Death Education and Counseling.

C.      Monitoring/Evaluation
        The evaluation plan for this T/S Development Center will be finalized in collaboration
with the National Center, other T/S Centers and CPCs, in order to assure that specific data sets,
data collection and analysis procedures are consistent among programs. The preliminary plan for
evaluating our T/S Center includes the following:

       1)      During the Organizational Phase, the Steering Committee and National Center
               will determine whether our proposed goals/objectives and activities are
               appropriate for and consistent with the scope of functions of a T/S Center as
               specified in the GFA. If not, we will revise these to be more responsive to the
               GFA. These revised goals/objectives and activities will serve as the basis for
               evaluating the functioning of our T/S Center.
       2)      We propose the following indicators for success of each goal:
               a)      One hundred percent compliance with expected meetings/trips to various
                       Centers.
               b)      Finalize core data set elements and auxiliary data sets for child abuse and
                       traumatic loss (in collaboration with the NCTSI network) by end of

                                                 28
                                                                 Cohen, Judith A.

            Year 1.
     c)     Finalize agreements for intensive collaboration with 3-5 CPCs by end of
            Year 1.
     d)     Complete evaluation of current treatment/services practices at T/S Centers
            and CPCs by end of Year 3.
     e)     Complete treatment manuals for child and adolescent traumatic loss by
            end of Year 2.

     f)      Complete training, focus groups, and community modification of CBT
             treatment manuals for sexually and physically abused children, in
             conjunction with CPCs, PAAR, and Pittsburgh CAC by end of Year 3.
     g)      Begin pilot community evaluation study of CBT treatment for 20 children
             experiencing traumatic loss by middle of Year 3..
     h)      Finalize implementation and evaluation plans for testing community-
             modified CBT at CPCs, Pittsburgh CAC, and PAAR by end of Year 3.
3)   Methods for evaluating these activities will include the following for each
     indicator listed above:
     a)      Written documentation of all meetings held with NCTSI Centers.
     b)      Written documentation (by National Center and/or Steering Committee) of
             agreed-upon core data set and approval of our T/S Center’s recommended
             auxiliary data sets for child abuse and traumatic loss.
     c)      Written documentation (ex: e-mail communication) of agreement to
             directly collaborate with 3-5 CPCs in data collection/training/treatment
             development.
     d)      Data on current treatment practices at T/S Centers and CPCs be gathered,
             as documented by raw data received from each T/S Center and CPC;
             entered and analyzed as documented by data entry and analysis printouts;
             written summary results to be completed and provided to CPCs and
             National Center.
     e)      Completed treatment manuals, to be provided to evaluator and National
             Center.
     f)      Documentation of focus groups and intensive (>6 hours) training at
             identified sites, including attendance sheet for trainees and copies of
             training materials; community-modified treatment manuals for sexually
             and physically abused children, to be provided to evaluator and National
             Center.
     g)      Documentation of IRB approval for traumatic loss community treatment
             study and number of subjects entered in treatment at end of Year 3.
     h)      Documentation of procedures agreed upon for conducting an evaluation of
             community-modified CBT in CPCs, Pittsburgh CAC and PAAR.
4)   Data analysis (item d above) may include analysis of impact of therapist gender,
     ethnicity and age on treatment types provided, length and treatment perceived
     satisfaction with each treatment type; impact of client demographic characteristics

                                     29
                                                                            Cohen, Judith A.

               on treatment type, length of treatment and perceived satisfaction and clinical
               response by treatment type and length of treatment. Correlational, step-wise
               regression, and other statistical analyses will be utilized as appropriate to
               optimally interpret these data. Goals will be to identify current treatment/services
               and clinical outcomes of these practices; impact of therapist and child
               characteristics on treatment response; and effectiveness of current
               treatment/services.
       5)      Results of the data evaluation (item d) will be used to determine CPC treatment
               strengths and needs (e.g., which, if any current treatment practices are achieving
               outcomes comparable to proven treatments, identify specific child populations or
               symptoms needing improved treatments). For other evaluation items, failure to
               meet goals set will be used to identify and correct problems in implementation so
               that overall project goals are attained by the end of Year 3.

         The National Center and T/S Development Centers should collaborate to develop an
evaluation protocol for the T/S Centers. This should begin by agreeing upon specific goals and
measurable activities for each T/S Development Center to achieve within a defined period of
time. We have maintained written minutes of weekly meetings that our multi-site study has
convened over the past four years and recommend this as a method for describing and
documenting events, processes and difficulties which have occurred, as well as a specific plan
for proceeding or addressing problems. During the Organizational Phase, frequent (at least
biweekly) written documentation of each T/S Center’s meetings and activities will facilitate early
identification of progress made in establishing ties throughout the network, and will also
facilitate correction of difficulties. During the Operational Phase, documentation will also
indicate biweekly progress made towards evaluation, implementation and data collection and
analysis.

       We will hire a full time Evaluator to assess our progress in meeting our goals and in
contributing to the NCTSI aims. This evaluator, who has not yet been selected, will meet or
exceed the qualification and experience requirements in the Evaluator job description, which is
included in Section H (Biographical Sketches and Job Descriptions).

        As noted above, we propose to continue to use client satisfaction questionnaires for all
children and parents receiving treatment as part of the proposed NCTSI activities. We also
propose to include 1-2 parents of abused children and 1-2 parents of children experiencing
traumatic loss, to participate in our regular Center meetings as discussed above. They will
review our evaluation plans and have input regarding additional consumer-focused factors we
should include in our evaluation. They will review our treatment protocols and data collection
plans and provide suggestions for modification. They will also review and comment on written
reports of results, and their comments will be considered and incorporated prior to dissemination
of these results.

D.     Project Management - Organizational, Equipment/Facilities and Other Support

                                                30
                                                                           Cohen, Judith A.


       A project schedule and activity centered time line is attached as Appendix 1.

         We believe the staffing and management plans, project organization and other resources
are optimal to carry out all aspects of the proposed project. In particular, our Directors have
expertise in both child abuse and traumatic loss treatment development (Drs. Mannarino and
Cohen) and services research (Dr. Kolko). Our staff and consultants have expertise in the needs
of diverse cultural (Dr. Smith), age, gender and developmental populations (Drs. Deblinger,
Cohen and Greenberg), family treatment (Drs. Saunders and Smith), services/community trauma
treatment (Dr. Smith, Ms. Berliner, Dr. Runyon), and different types of traumatic events (child
sexual and physical abuse and traumatic loss). With specific regard to cultural competence,
CTSCA since its inception has served a diverse population in terms of age (2-18 year olds),
gender and ethnicity (approximately 45% of our patients are African American and 5% are
biracial, reflecting the ethnicity of our community). All CTSCA staff receive required training in
gender/age/cultural competence, and all of our staff and consultants have extensive experience
treating diverse populations. We do not serve a multi-linguistic population. Our educational
materials reflect the diversity of the children we see and were developed to be gender/age/
culturally appropriate. Proposed instruments to be used for evaluation have been normed on
children of diverse cultures, ages, and both genders. We will make every attempt to hire new
staff, including our Evaluator, Community Liaison, and Trainer, to reflect the cultural diversity
of our target population. Our Consultant for Cultural Issues, Dr. Walter Smith, is African
American, and we have carefully considered the client satisfaction responses of families from
diverse cultures in designing our treatment models. We will include input from community
organizations in the cities where the CPCs are located in modifying our treatments for use in
those communities.

        The facilities and equipment at CTSCA include therapy rooms (including two-way mirror
observation), examining rooms, individual offices for all CTSCA staff and five desktop
computers. We have requested an additional computer for the Program Evaluator. Additional
office space will be made available for project activities as needed. We have requested funds to
purchase additional assessment instruments and copyrighted treatment manuals which will be
needed to carry out the proposed Center activities. Our facilities and equipment will therefore be
adequate to carry out all of the proposed functions of the T/S Center.

        The budget plan reflects the resources required for optimal coordination and
collaboration called for in the GFA, including adequate travel funds, consultant time, and e-mail
access for all project staff and consultants. Additionally, we will add two new positions to our
current staff to optimize coordination and collaboration. Our Community Provider Liaison will
be devoted to facilitating communication and collaboration between our Center and the
Community Provider Centers, as well as with community providers in Pittsburgh. Our
Treatment Trainer will be devoted to providing training in effective treatments for traumatized
children and will interact closely with CPCs, community providers in Pittsburgh, and with other
T/S Development Center trainers. S/he will also be available to conduct trainings for the

                                               31
                                                                         Cohen, Judith A.

National Resource Center. The amount of time budgeted for Drs. Mannarino and Cohen reflects
in part their responsibility to maintain regular contact with the other T/S Development Centers
and the National Center, respectively. We believe the proposed budget will allow our Center to
optimally carry out the proposed activities.




                                              32
                                                                          Cohen, Judith A.


F.     Literature Citations

AACAP (1998). Practice parameters for the assessment and treatment of children and
adolescents with posttraumatic stress disorder. Judith A. Cohen, Principal Author. American
Academy of Child and Adolescent Psychiatry, 37(10) Supplement, 4S-26S.

Atkins MS, Letendre J, Graczyk, P, McCoy J, Kim J, Baumann B, Jackson M, Harley R, Sykes
K, & McKay M (1999). Urban educators’ attitudes about mental health services for students
with ADHD. Paper presented at the 12th Annual Research Conference: A System of Care for
Children’s Mental Health, Clearwater, FL.

Barlow DH, Levitt JT, & Bufka LF (1999). The dissemination of empirically supported
treatments: A view to the future. Behaviour Research and Therapy, 37:S147-S162.

Berliner L, Saunders B (1996). Treating fear and anxiety in sexually abused children: Results of
a controlled two-year follow-up study. Child Maltreatment, 1(4):294-309.

Brent DA (1997). Familial pathways to early-onset suicide attempt. Multisite grant application
funded by NIMH (R10 MH56612).

Burns BJ (1999). A call for a mental health services research agenda for youth with serious
emotional disturbance. Mental Health Services Research, 1:5-20.

Clinical Treatment and Services Research Workgroup (1999). Bridging science and service: A
report by the National Advisory Council’s Mental Health Clinical Treatment and Services
Research Workgroup (99-4353). Bethesda, MD: National Institute of Mental Health.

Cohen JA (2001a). Pharmacologic treatment of traumatized children. Trauma, Violence &
Abuse, 2(2):155-171.

Cohen JA, Berliner L, & Mannarino AP (in press). Psychosocial and pharmacologic
interventions for child crime victims. Journal of Traumatic Stress.

Cohen JA, Berliner L, & March JS (2000a). Guidelines for treatment of PTSD: Treatment of
Children and Adolescents. Journal of Traumatic Stress, 13(4):566-568.

Cohen JA, Berliner L, & March JS (2000b). Treatment of children and adolescents. In Foa EB,
Keane TM, & Friedman MJ (Eds.), Effective treatments for PTSD. New York: Guilford Press,
pp. 106-138.


Cohen JA, Deblinger E, Mannarino AP & De Arellano, MA (2001b). The importance of culture

                                               33
                                                                         Cohen, Judith A.

in treating abused and neglected children: An empirical review. Child Maltreatment, 6(2):148-
157.

Cohen JA, Greenberg, TA (in press). Psychosocial treatment of sexually abused children. In
Conte J (Ed.), Encyclopedia of trauma and abuse. Thousand Oaks, CA: Sage Publication.

Cohen JA, Mannarino AP (1988). Psychological symptoms in sexually abused girls. Child
Abuse and Neglect: An International Journal, 12:571-577.

Cohen JA, Mannarino AP (1993). A treatment model for sexually abused preschool children.
Journal of Interpersonal Violence, 8(1):115-131.

Cohen JA, Mannarino AP (1996a). A treatment outcome study for sexually abused preschooler
children: Initial findings. Journal of the American Academy of Child and Adolescent Psychiatry,
35(1):42-50.

Cohen JA, Mannarino AP (1996b). Factors that mediate treatment outcome of sexually abused
preschool children. Journal of the American Academy of Child and Adolescent Psychiatry,
35(10):1402-1410.

Cohen JA, Mannarino AP (1997). A treatment study of sexually abused preschool children:
Outcome during one year follow-up. Journal of the American Academy of Child and Adolescent
Psychiatry, 36(9):1228-1235.

Cohen JA, Mannarino AP (1998a). Interventions for sexually abused children: Initial treatment
findings. Child Maltreatment, 3(1):17-26.

Cohen JA, Mannarino AP (1998b). Creating a curriculum on childhood traumatic stress. Child
Maltreatment, 3(1):53-62.

Cohen JA, Mannarino AP (1998c). Factors that mediate treatment outcome in sexually abused
preschoolers: 6- and 12-month follow-ups. Journal of the American Academy of Child and
Adolescent Psychiatry, 37(1):44-51.

Cohen JA, Mannarino AP (2000). Predictors of treatment outcome in sexually abused children.
Child Abuse and Neglect, 24(7):983-994.

Cohen JA, Mannarino AP, & McClintock T (1998). Promising practices in professional
education. OVC Bulletin, U.S. Department of Justice.

Cohen JA, Mannarino AP, & Rogal SS (2001a). Treatment practices for childhood PTSD.
Child Abuse and Neglect, 25(1):123-136.
DeBellis, M.D., Baum, A.S., Birmaher, B., Keshavan, M.S., Eccard, C.H., Boring, A.M.,

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                                                                           Cohen, Judith A.

Jenkins, F.J., & Ryan, N.D. (1999). Developmental traumatology part I: Biological stress
systems. Biological Psychiatry, 45:1259-1270.

DeBellis, M.D., Keshavan, M.S., Clark, D.B., Casey, B.J., Giedd, J.N., Boring, A.M., Frustaci,
K., & Ryan, N.D. (1999). Developmental traumatology part II: Brain development. Biological
Psychiatry, 45:1271-1284.

Deblinger E, Heflin AH (1996). Treating sexually abused children and their non-offending
parents: A cognitive behavioral approach. Thousand Oaks, CA: Sage Publication.

Deblinger E, Lippman J, & Steer R (1996). Sexually abused children suffering posttraumatic
stress symptoms: Initial treatment outcome findings. Child Maltreatment, 1:310-321.

Finkelhor D (2000). National evaluation of child advocacy centers. Multisite grant application
funded by OJJDP.

Hoagwood K, Jensen PS, Petti T, & Burns BJ (1996). Outcomes of mental health care for
children and adolescents: I. A comprehensive conceptual model. Journal of the American
Academy of Child and Adolescent Psychiatry, 35:1055-1063.

Kolko DJ (1996a). Individual cognitive behavioral treatment and family therapy for physically
abused children and their offending parents: A comparison of clinical outcomes. Child
Maltreatment, 1(4):322-342.

Kolko DJ (1996b). Clinical monitoring of treatment course in child physical abuse:
Psychometric characteristics and treatment comparisons. Child Abuse and Neglect, 20:23-43.

Kolko DJ, Berliner L, Chaffin M, Cohen J (2001). Research symposium: Bridging the gap
between practice and research: Enhancing effectiveness and dissemination of treatment. Mini-
plenery presented at the APSAC 9th Annual Colloquium, Washington, D.C., June.

Kolko DJ, Selelyo J, & Brown EJ (1999). The treatment histories and service involvement of
physically and sexually abusive families: Description, correspondence, and clinical correlates.
Child Abuse and Neglect, 23:459-476.

Krueger RA (1994). Focus groups: A practical guide for applied research (2nd edition).
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