Trauma-focused cognitive behavioral therapy with a Puerto Rican adolescent: A case study
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Published
2025-12-30
Yahaira I. Marquez
Keishalee Gomez-Arroyo
https://orcid.org/0000-0001-9205-8012
Abstract
In this article, we aim to document the application of trauma-focused cognitive behavioral therapy (TF-CBT) with an 11-year-old Puerto Rican adolescent presenting with posttraumatic stress symptoms in an outpatient clinic in the state of New Jersey. These were related to multiple traumatic experiences, including domestic violence and sexual abuse. The 25-session intervention incorporated psychoeducation, relaxation, affect regulation, and trauma narration in a culturally sensitive manner, with active caregiver involvement. Pre–post assessment demonstrated clinically significant reductions in posttraumatic stress, depression, and behavioral problems, alongside increased resiliency and coping skills. This case illustrates the clinical applicability of TF-CBT within Puerto Rican contexts.
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Keywords
case study, Puerto Rico, childhood trauma, evidence-based treatments
References
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Bernal, G., & Domenech Rodríguez, M. M. (Eds.). (2012). Cultural adaptations: Tools for evidence-based practice with diverse populations. American Psycho-logical Association.
Berríos, Y., Medina-Sustache, E., & Rodríguez-Díaz, G. (2019). Reflexión metodológica sobre los retos en la implementación con niños puertorrique-ños víctimas de abuso sexual del modelo basado en la evidencia terapia cognitiva-conductual focalizada en el trauma. Salud y Conducta Humana, 5(1), 22–34.
Cabiya-Morales, J., & Vélez, R. (2018). Informe final Consulta Juvenil IX, 2015-2017. Universidad Carlos Albizu. https://www.docs.pr.gov/files/ASSMCA/Consultas/Consulta%20Juvenil%20IX%202015-2017.pdf
Cain, J., & Canetti, Y. (2009). Así me siento yo. Parenting Press.
Child Sexual Abuse Task Force and Research & Practice Core, N. C. T. S. Network. (2004). How to implement trauma-focused cognitive behavioral therapy. National Center for Child Traumatic Stress. https://www.nctsn.org/sites/default/files/resources//how_to_implement_tfcbt.pdf
Cohen, J. A., & Mannarino, A. P. (1996). Factors that mediate treatment outcome of sexually abused preschool children. Journal of the American Academy of Child and Adolescent Psychiatry, 35(10), 1402–1410. https://doi.org/10.1097/00004583-199610000-00028
Cohen, J. A, Deblinger, E., Mannarino, A. P., & Steer, R. (2004). A multi-site, randomized controlled trial for children with abuse-related PTSD symptoms. Journal of the American Academy of Child and Adolescent Psychiatry, 43(4), 393–402. https://doi.org/10.1097/00004583-200404000-00005
Cohen, J. A., & Mannarino, A. P. (1998). Interventions for sexually abused children: Initial treatment outcome findings. Child Maltreatment, 3(1), 17–26. https://doi.org/10.1177/1077559598003001002
Cohen, J. A., Mannarino, A. P., & Deblinger, E. (2006). Treating trauma and traumatic grief in children and adolescents. The Guilford Press.
Cohen, J. A., Mannarino, A. P., & Deblinger, E. (2017). Treating trauma and traumatic grief in children and adolescents (2nd ed.). The Guilford Press.
Cohen, J. A., Mannarino, A. P., Kliethermes, M., & Murray, L. (2012). Trauma-focused CBT for youth with complex trauma. Child Abuse and Neglect, 36, 528–541. https://doi.org/10.1016/j.chiabu.2012.03.007
de Arellano, M. A., Danielson, C. K., & Felton, J. W. (2012). Children of Latino descent: Culturally modified TF-CBT. In J. A. Cohen, A. P. Mannarino, & E. Deblinger (Eds.), Trauma-focused CBT for children and adolescents: Treatment applications (pp. 253–279). The Guilford Press.
Deblinger, E., & Heflin, A. H. (1996). Treating sexually abused children and their nonoffending parents: A cognitive behavioral approach. Sage Publications.
Deblinger, E., Lippmann, J., & Steer, R. (1996). Sexually abused children suffering posttraumatic stress symptoms: Initial treatment outcome findings. Child Maltreatment, 1(4), 310–321.
https://doi.org/10.1177/1077559596001004003
Deblinger, E., Mannarino, A. P., Cohen, J. A., Runyon, M. K., & Steer, R. A. (2011). Trauma-focused cognitive behavioral therapy for children: Impact of the trauma narrative and treatment length. Depression and Anxiety, 28, 67–75.
https://doi.org/10.1002/da.20744
Deblinger, E., McLeer, S. V., & Henry, D. (1990). Cognitive behavioral treatment for sexually abused children suffering post-traumatic stress: Preliminary findings. American Academy of Child and Adolescent Psychiatry, 29(5), 747–752. https://doi.org/10.1097/00004583-199009000-00012
Deblinger, E., Neubauer, F., Runyon, M., & Baker, D. (2006). What do you know? A therapeutic card game about child sexual abuse and physical abuse and domestic violence. CARES Institute.
Deblinger, E., Pollio, E., Runyon, M. K., & Steer, R. A. (2017). Improvements in personal resiliency among youth who have completed trauma-focused cognitive behavioral therapy: A preliminary examination. Child Abuse and Neglect, 65, 132–139.
https://doi.org/10.1016/j.chiabu.2016.12.014
Deblinger, E., Stauffer, L. B., & Steer, R. A. (2001). Comparative efficacies of supportive and cognitive behavioral group therapies for young children who have been sexually abused and their nonoffending mothers. Child Maltreatment, 6(4), 332–343.
https://doi.org/10.1177/1077559501006004006
Feiring, C., Taska, L., & Chen, K. (2002). Trying to understand why horrible things happen: Attribution, shame, and symptom development following sexual abuse. Child Maltreatment, 7(1), 26–41. https://doi.org/10.1177/1077559502007001003
Feiring, C., Taska, L., & Lewis, M. (2002). Adjustment following sexual abuse discovery: The role of shame and attributional style. Developmental Psychology, 38(1), 79–92.
https://doi.org/10.1037/0012-1649.38.1.79
Fitzgerald, M. (s.f.). Relaxation script for younger children [Manuscrito no publicado]. TF-CBT training program.
Hendricks, A., Cohen, J. A., Mannarino, A. P., & Deblinger, E. (2020). Tu libro de actividades de TF-CBT (L. Rivas-Hermina, C. Norona, L. Flores, & L. López, Trads.). (Trabajo original publicado en 2020).
Hemmings, S., Jakobowitz, S., Abas, M., Bick, D., Howard, L. M., Stanley, N., Zimmerman, C., & Oram, S. (2016). Responding to the health needs of survivors of human trafficking: A systematic review. BMC Health Services Research, 16(1), 320.
https://doi.org/10.1186/s12913-016-1538-8
Instituto de Estadísticas de Puerto Rico. (2023). Perfil del maltrato de menores en Puerto Rico.
https://estadisticas.pr/en/Perfil-Maltrato-Menores
Kovacs, M. (2012). Children’s Depression Inventory 2nd Edition (CDI-2). Multi-Health Systems.
Kraft, L., Ebner, C., Leo, K., & Lindenberg, K. (2023). Emotion regulation strategies and symptoms of depression, anxiety, aggression, and addiction in children and adolescents: A meta-analysis and systematic review. Clinical Psychology: Science and Practice, 30(4), 485–502. https://doi.org/10.1037/cps0000156
Mitlin, M., & Madden, J. (1998). Emotional Bingo. Western Psychological Services.
Murray, L. K., Skavenski, S., Kane, J. C., Mayeya, J., Dorsey, S., Cohen, J. A., Michalopoulos, L. T. M., Imasiku, M., & Bolton, P. A. (2015). Effectiveness of trauma-focused cognitive behavioral therapy among trauma-affected children in Lusaka, Zambia: A randomized clinical trial. JAMA Pediatrics, 169(8), 761–769. https://doi.org/10.1001/jamapediatrics.2015.0580
Orengo-Aguayo, R., Dueweke, A. R., Nicasio, A. V., de Arellano, M. A., Rivera, S., Cohen, J. A., Mannarino, A. P., & Stewart, R. W. (2022). Trauma-focused cognitive behavioral therapy with Puerto Rican youth in a post-disaster context: Tailoring, implementation, and program evaluation outcomes. Child Abuse & Neglect, 129, 105671.
https://doi.org/10.1016/j.chiabu.2022.105671
Orengo-Aguayo, R., Stewart, R. W., Villalobos, B. T., Hernandez Rodriguez, J., Dueweke, A. R., de Arellano, M. A., & Young, J. (2020). Listen, don’t tell: Partnership and adaptation to implement trauma-focused cognitive behavioral therapy in low-resourced settings. American Psychologist, 75(8), 1158–1174.
https://doi.org/10.1037/amp0000691
Ottenweller, J. (1991). Please tell: A child’s story about sexual abuse. Hazelden Publishing & Educational Services.
Prince-Embury, S. (2007). Resiliency Scales for Children and Adolescents: A Profile of Personal Strengths. Harcourt Assess-ment.
Sachser, C., Berliner, L., Holt, T., Jensen, T. K., Risch, E., Rosner, R., & Goldbeck, L. (2022). The Child and Adolescent Trauma Screen 2 (CATS-2): Development and validation of an instrument for children and adolescents to self-rate posttraumatic stress disorder according to both DSM-5 and ICD-11. European Journal of Psycho-traumatology, 13(1), 2131816.
https://doi.org/10.1080/20008066.2022.2105580
Saunders, B. E., Berliner, L., & Hanson, R. F. (2003). Child physical and sexual abuse: Guidelines for treatment, final report. https://eric.ed.gov/?id=ED472572
Scott, L. (1983). Jenga [Juego de mesa]. Hasbro; Pokonobe Associates.
Silverman, W. K., Ortiz, C. D., Viswesvaran, C., Burns, B. J., Kolko, D. J., Putnam, F. W., & Amaya-Jackson, L. (2008). Evidence-based psychosocial treat-ments for children and adolescents exposed to traumatic events. Journal of Clinical Child & Adolescent Psychology, 37(1), 156–183. https://doi.org/10.1080/15374410701818293
Stewart, R. W., Orengo-Aguayo, R., Villalobos, B. T., Nicasio, A. V., Dueweke, A. R., Alto, M., Cohen, J. A., Mannarino, A. P., & de Arellano, M. A. (2021). Implementation of an evidence-based psychotherapy for trauma-exposed children in a lower-middle income country: The use of trauma-focused cognitive behavioral therapy in El Salvador. Journal of Child & Adolescent Trauma, 14, 433–441.
https://doi.org/10.1007/s40653-020-00327-9
Whitham, C. (2004). Gana la guerra de los berrinches y otras contiendas: Un plan de paz familiar. Perspective Publishing.
Bass, J., Bearup, L., Bolton, P., Murray, L., & Skavenski, S. (2011). Implementing Trauma Focused Cognitive Behavioral Therapy (TF-CBT) among formerly trafficked-sexually exploited and sexually abused girls in Cambodia: A feasibility study. Phnom Penh, Cambodia: World Vision.
Bernal, G., & Domenech Rodríguez, M. M. (Eds.). (2012). Cultural adaptations: Tools for evidence-based practice with diverse populations. American Psycho-logical Association.
Berríos, Y., Medina-Sustache, E., & Rodríguez-Díaz, G. (2019). Reflexión metodológica sobre los retos en la implementación con niños puertorrique-ños víctimas de abuso sexual del modelo basado en la evidencia terapia cognitiva-conductual focalizada en el trauma. Salud y Conducta Humana, 5(1), 22–34.
Cabiya-Morales, J., & Vélez, R. (2018). Informe final Consulta Juvenil IX, 2015-2017. Universidad Carlos Albizu. https://www.docs.pr.gov/files/ASSMCA/Consultas/Consulta%20Juvenil%20IX%202015-2017.pdf
Cain, J., & Canetti, Y. (2009). Así me siento yo. Parenting Press.
Child Sexual Abuse Task Force and Research & Practice Core, N. C. T. S. Network. (2004). How to implement trauma-focused cognitive behavioral therapy. National Center for Child Traumatic Stress. https://www.nctsn.org/sites/default/files/resources//how_to_implement_tfcbt.pdf
Cohen, J. A., & Mannarino, A. P. (1996). Factors that mediate treatment outcome of sexually abused preschool children. Journal of the American Academy of Child and Adolescent Psychiatry, 35(10), 1402–1410. https://doi.org/10.1097/00004583-199610000-00028
Cohen, J. A, Deblinger, E., Mannarino, A. P., & Steer, R. (2004). A multi-site, randomized controlled trial for children with abuse-related PTSD symptoms. Journal of the American Academy of Child and Adolescent Psychiatry, 43(4), 393–402. https://doi.org/10.1097/00004583-200404000-00005
Cohen, J. A., & Mannarino, A. P. (1998). Interventions for sexually abused children: Initial treatment outcome findings. Child Maltreatment, 3(1), 17–26. https://doi.org/10.1177/1077559598003001002
Cohen, J. A., Mannarino, A. P., & Deblinger, E. (2006). Treating trauma and traumatic grief in children and adolescents. The Guilford Press.
Cohen, J. A., Mannarino, A. P., & Deblinger, E. (2017). Treating trauma and traumatic grief in children and adolescents (2nd ed.). The Guilford Press.
Cohen, J. A., Mannarino, A. P., Kliethermes, M., & Murray, L. (2012). Trauma-focused CBT for youth with complex trauma. Child Abuse and Neglect, 36, 528–541. https://doi.org/10.1016/j.chiabu.2012.03.007
de Arellano, M. A., Danielson, C. K., & Felton, J. W. (2012). Children of Latino descent: Culturally modified TF-CBT. In J. A. Cohen, A. P. Mannarino, & E. Deblinger (Eds.), Trauma-focused CBT for children and adolescents: Treatment applications (pp. 253–279). The Guilford Press.
Deblinger, E., & Heflin, A. H. (1996). Treating sexually abused children and their nonoffending parents: A cognitive behavioral approach. Sage Publications.
Deblinger, E., Lippmann, J., & Steer, R. (1996). Sexually abused children suffering posttraumatic stress symptoms: Initial treatment outcome findings. Child Maltreatment, 1(4), 310–321.
https://doi.org/10.1177/1077559596001004003
Deblinger, E., Mannarino, A. P., Cohen, J. A., Runyon, M. K., & Steer, R. A. (2011). Trauma-focused cognitive behavioral therapy for children: Impact of the trauma narrative and treatment length. Depression and Anxiety, 28, 67–75.
https://doi.org/10.1002/da.20744
Deblinger, E., McLeer, S. V., & Henry, D. (1990). Cognitive behavioral treatment for sexually abused children suffering post-traumatic stress: Preliminary findings. American Academy of Child and Adolescent Psychiatry, 29(5), 747–752. https://doi.org/10.1097/00004583-199009000-00012
Deblinger, E., Neubauer, F., Runyon, M., & Baker, D. (2006). What do you know? A therapeutic card game about child sexual abuse and physical abuse and domestic violence. CARES Institute.
Deblinger, E., Pollio, E., Runyon, M. K., & Steer, R. A. (2017). Improvements in personal resiliency among youth who have completed trauma-focused cognitive behavioral therapy: A preliminary examination. Child Abuse and Neglect, 65, 132–139.
https://doi.org/10.1016/j.chiabu.2016.12.014
Deblinger, E., Stauffer, L. B., & Steer, R. A. (2001). Comparative efficacies of supportive and cognitive behavioral group therapies for young children who have been sexually abused and their nonoffending mothers. Child Maltreatment, 6(4), 332–343.
https://doi.org/10.1177/1077559501006004006
Feiring, C., Taska, L., & Chen, K. (2002). Trying to understand why horrible things happen: Attribution, shame, and symptom development following sexual abuse. Child Maltreatment, 7(1), 26–41. https://doi.org/10.1177/1077559502007001003
Feiring, C., Taska, L., & Lewis, M. (2002). Adjustment following sexual abuse discovery: The role of shame and attributional style. Developmental Psychology, 38(1), 79–92.
https://doi.org/10.1037/0012-1649.38.1.79
Fitzgerald, M. (s.f.). Relaxation script for younger children [Manuscrito no publicado]. TF-CBT training program.
Hendricks, A., Cohen, J. A., Mannarino, A. P., & Deblinger, E. (2020). Tu libro de actividades de TF-CBT (L. Rivas-Hermina, C. Norona, L. Flores, & L. López, Trads.). (Trabajo original publicado en 2020).
Hemmings, S., Jakobowitz, S., Abas, M., Bick, D., Howard, L. M., Stanley, N., Zimmerman, C., & Oram, S. (2016). Responding to the health needs of survivors of human trafficking: A systematic review. BMC Health Services Research, 16(1), 320.
https://doi.org/10.1186/s12913-016-1538-8
Instituto de Estadísticas de Puerto Rico. (2023). Perfil del maltrato de menores en Puerto Rico.
https://estadisticas.pr/en/Perfil-Maltrato-Menores
Kovacs, M. (2012). Children’s Depression Inventory 2nd Edition (CDI-2). Multi-Health Systems.
Kraft, L., Ebner, C., Leo, K., & Lindenberg, K. (2023). Emotion regulation strategies and symptoms of depression, anxiety, aggression, and addiction in children and adolescents: A meta-analysis and systematic review. Clinical Psychology: Science and Practice, 30(4), 485–502. https://doi.org/10.1037/cps0000156
Mitlin, M., & Madden, J. (1998). Emotional Bingo. Western Psychological Services.
Murray, L. K., Skavenski, S., Kane, J. C., Mayeya, J., Dorsey, S., Cohen, J. A., Michalopoulos, L. T. M., Imasiku, M., & Bolton, P. A. (2015). Effectiveness of trauma-focused cognitive behavioral therapy among trauma-affected children in Lusaka, Zambia: A randomized clinical trial. JAMA Pediatrics, 169(8), 761–769. https://doi.org/10.1001/jamapediatrics.2015.0580
Orengo-Aguayo, R., Dueweke, A. R., Nicasio, A. V., de Arellano, M. A., Rivera, S., Cohen, J. A., Mannarino, A. P., & Stewart, R. W. (2022). Trauma-focused cognitive behavioral therapy with Puerto Rican youth in a post-disaster context: Tailoring, implementation, and program evaluation outcomes. Child Abuse & Neglect, 129, 105671.
https://doi.org/10.1016/j.chiabu.2022.105671
Orengo-Aguayo, R., Stewart, R. W., Villalobos, B. T., Hernandez Rodriguez, J., Dueweke, A. R., de Arellano, M. A., & Young, J. (2020). Listen, don’t tell: Partnership and adaptation to implement trauma-focused cognitive behavioral therapy in low-resourced settings. American Psychologist, 75(8), 1158–1174.
https://doi.org/10.1037/amp0000691
Ottenweller, J. (1991). Please tell: A child’s story about sexual abuse. Hazelden Publishing & Educational Services.
Prince-Embury, S. (2007). Resiliency Scales for Children and Adolescents: A Profile of Personal Strengths. Harcourt Assess-ment.
Sachser, C., Berliner, L., Holt, T., Jensen, T. K., Risch, E., Rosner, R., & Goldbeck, L. (2022). The Child and Adolescent Trauma Screen 2 (CATS-2): Development and validation of an instrument for children and adolescents to self-rate posttraumatic stress disorder according to both DSM-5 and ICD-11. European Journal of Psycho-traumatology, 13(1), 2131816.
https://doi.org/10.1080/20008066.2022.2105580
Saunders, B. E., Berliner, L., & Hanson, R. F. (2003). Child physical and sexual abuse: Guidelines for treatment, final report. https://eric.ed.gov/?id=ED472572
Scott, L. (1983). Jenga [Juego de mesa]. Hasbro; Pokonobe Associates.
Silverman, W. K., Ortiz, C. D., Viswesvaran, C., Burns, B. J., Kolko, D. J., Putnam, F. W., & Amaya-Jackson, L. (2008). Evidence-based psychosocial treat-ments for children and adolescents exposed to traumatic events. Journal of Clinical Child & Adolescent Psychology, 37(1), 156–183. https://doi.org/10.1080/15374410701818293
Stewart, R. W., Orengo-Aguayo, R., Villalobos, B. T., Nicasio, A. V., Dueweke, A. R., Alto, M., Cohen, J. A., Mannarino, A. P., & de Arellano, M. A. (2021). Implementation of an evidence-based psychotherapy for trauma-exposed children in a lower-middle income country: The use of trauma-focused cognitive behavioral therapy in El Salvador. Journal of Child & Adolescent Trauma, 14, 433–441.
https://doi.org/10.1007/s40653-020-00327-9
Whitham, C. (2004). Gana la guerra de los berrinches y otras contiendas: Un plan de paz familiar. Perspective Publishing.
How to Cite
Trauma-focused cognitive behavioral therapy with a Puerto Rican adolescent: A case study. (2025). Puerto Rican Journal of Psychology, 36(2), 234-249. https://doi.org/10.55611/reps.3602.08
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How to Cite
Trauma-focused cognitive behavioral therapy with a Puerto Rican adolescent: A case study. (2025). Puerto Rican Journal of Psychology, 36(2), 234-249. https://doi.org/10.55611/reps.3602.08