Home Program

Cue-Centered Therapy (CCT)

Topic Areas
Scientific Rating
Child Welfare Relevance
Trauma Treatment - Client-Level Interventions (Child & Adolescent)
3  — Promising Research Evidence
Medium

About This Program

Target Population: Youth ages 8-18 with a chronic history of trauma, adversity, and ongoing stress

For children/adolescents ages: 8 – 18

For parents/caregivers of children ages: 8 – 18

Program Overview

CCT is a manualized protocol consisting of 15 sessions. It is an integrative approach combining elements from cognitive, behavioral, psychodynamic, expressive, and family therapies to address four core domains: cognition, behavior, emotions, and physiology. The primary goal of CCT is to build strength and resilience by empowering the child through knowledge regarding the relationship between their history of trauma exposure and current affective, cognitive, behavioral, or physiological responses. Children and parents learn about the significance of traumatic stress, how adaptive responses become maladaptive, how to cope with rather than avoid ongoing stress, and the importance of verbalizing their life experiences. The treatment process is designed to help build overall competence, reduce physical symptoms of anxiety, modify cognitive distortions, and facilitate emotional expression. In CCT, youth and caregivers are taught how to recognize and effectively manage maladaptive responses that occur in response to traumatic reminders (cues).

Program Goals

The goals of Cue-Centered Therapy (CCT) are:

For children and youth:

  • Build strength and resilience
  • Reduce negative cognitions
  • Foster emotional expression
  • Identify and change trauma-related responses
  • Learn how to be your own agent of change
  • Strengthen the relationship with your caregiver

For parents and caregivers:

  • Strengthen the relationship with your child/youth
  • Facilitate your child’s at-home practice of exposure to trauma cues
  • Coach your child in use of the learned coping skills to manage trauma reactions

Logic Model

The program representative did not provide information about a Logic Model for Cue-Centered Therapy (CCT).

Essential Components

The essential components of Cue-Centered Therapy (CCT) include:

  • CCT consists of 15 sessions divided into four phases:
    • Phase 1 (sessions 1–3) prepares youth and their caregivers for exposure through education and coping skills training.
    • Phase 2 (sessions 4–7) consists of the youth telling their life story highlighting both positive and negative events as a form of narrative exposure. The therapist identifies cognitions, emotions, cues, and memory gaps in the story and later works with the child to restructure cognitive distortions and misattributions.
    • Phase 3 (sessions 8–12) involves the therapist, youth, and caretaker working together to identify cues and reduce associated negative responses. The youth are exposed to the cues gradually in three stages: imaginary, in session, and in-vivo. Following exposure, the therapist helps youth find solutions to obstacles encountered when using the new coping strategies.
    • Phase 4 (sessions 13–15) has the youth use the skills learned to develop a coherent life narrative and the therapist, youth, and caregiver work to ensure that treatment gains are sustained after therapy.
  • Sessions generally occur weekly for 45 minutes; however the therapist may adapt the time to meet the child's individual needs.
  • Up to two additional sessions may be added to each phase if the child is having difficulty grasping the concepts in that phase. Sessions are intended to build upon one another, therefore the therapist should not advance to a later session if the child has not mastered prior material
  • It is highly advisable that therapists wishing to use CCT receive training and supervision before using the intervention.

Program Delivery

Child/Adolescent Services

Cue-Centered Therapy (CCT) directly provides services to children/adolescents and addresses the following:

  • PTSD and associated symptoms, negative cognitions and self-attributions, emotional/behavioral dysregulation

Parent/Caregiver Services

Cue-Centered Therapy (CCT) directly provides services to parents/caregivers and addresses the following:

  • Poor caregiver-child relationship

Recommended Intensity:

Once a week sessions for 45 minutes

Recommended Duration:

15–19 sessions

Delivery Settings

This program is typically conducted in a(n):

  • Hospital
  • Outpatient Clinic
  • Community-based Agency / Organization / Provider
  • Group or Residential Care
  • School Setting (Including: Day Care, Day Treatment Programs, etc.)

Homework

Cue-Centered Therapy (CCT) includes a homework component:

Take-home activities are an essential component of CCT. Youth and their caregivers are given take-home activities during certain sessions to reinforce the skills learned in treatment and to allow caregivers practice in coaching the youth in using these skills.

Languages

Cue-Centered Therapy (CCT) has materials available in a language other than English:

Spanish

For information on which materials are available in this language, please check on the program's website or contact the program representative (contact information is listed at the bottom of this page).

Resources Needed to Run Program

The typical resources for implementing the program are:

  • Private space to conduct the sessions
  • Waiting area/supervision for children when caregivers are seen alone
  • Therapy manual and worksheets

Manuals and Training

Prerequisite/Minimum Provider Qualifications

Master's level with experience working with traumatized youth and families and training on the treatment intervention

Manual Information

There is a manual that describes how to deliver this program.

Program Manual(s)

English Version: Carrion, V. G. (2016). Cue-Centered Therapy for youth experiencing posttraumatic symptoms: A structured multimodal intervention, therapist guide. Oxford University Press.

The manual can be ordered at the Oxford University Press website.

Spanish Version: Carrion, V. G. (2018). Terapia de claves traumáticas: Manual de intervención para niños y adolescentes con síntomas postraumáticos. Editorial Gedisa.

The Spanish version can be ordered through the Gedisa Editorial website.

Training Information

There is training available for this program.

Training Contacts:
Training Type/Location:

Training for becoming a rostered CCT therapist or trainer is available. Training can occur either in-person (Stanford University or onsite by request) or via Zoom.

Number of days/hours:

The following three steps are required to become a rostered CCT clinician:

  • Foundations of CCT: Online, self-paced course that takes 6-8 hours to complete
  • Theory and Practice of CCT: Two half days for a total of 8 hours
  • Applications of CCT: Case Consultations: Must complete a minimum of 2 CCT cases with ongoing case consultation provided by an approved CCT trainer bi-weekly for 15-18 weeks

To become a rostered CCT trainer:

  • Must complete all steps for a rostered CCT clinician
  • Must lead two Theory and Practice courses under observation of an approved CCT trainer
  • Must lead one Case Consultation under observation of an approved CCT trainer

For further information: https://med.stanford.edu/elspap/Cue-Centered-Therapy/education.html or contact CCT-Training@stanford.edu

Implementation Information

Pre-Implementation Materials

There are no pre-implementation materials to measure organizational or provider readiness for Cue-Centered Therapy (CCT).

Formal Support for Implementation

There is no formal support available for implementation of Cue-Centered Therapy (CCT).

Fidelity Measures

There are fidelity measures for Cue-Centered Therapy (CCT) as listed below:

A fidelity checklist outlining the goals of each session is available upon request by contacting Dr. Hilit Kletter at hkletter@stanford.edu.

Implementation Guides or Manuals

There are no implementation guides or manuals for Cue-Centered Therapy (CCT).

Implementation Cost

There are no studies of the costs of Cue-Centered Therapy (CCT).

Research on How to Implement the Program

Research has not been conducted on how to implement Cue-Centered Therapy (CCT).

Relevant Published, Peer-Reviewed Research

Child Welfare Outcome: Child/Family Well-Being

Carrion, V. G., Kletter, H., Weems, C. F., Berry, R. R., & Rettger, J. P. (2013). Cue-Centered Treatment for youth exposed to interpersonal violence: A randomized controlled trial. Journal of Traumatic Stress, 26(6), 654–662. https://doi.org/10.1002/jts.21870

Type of Study: Randomized controlled trial
Number of Participants: 65

Population:

  • Age — 8–17 years
  • Race/Ethnicity — 33 African American, 26 Hispanic/Latino, 5 Mixed Ethnicity, and 1 Pacific Islander
  • Gender — 39 Male and 26 Female
  • Status — Participants were youth with a history of exposure to violence.

Location/Institution: Not specified

Summary: (To include basic study design, measures, results, and notable limitations)
The purpose of the study was to test the efficacy of the Stanford Cue-Centered Treatment [now called Cue-Centered Therapy (CCT)] for reducing posttraumatic stress, depression, and anxiety in children chronically exposed to violence. Participants were randomly assigned to the Stanford Cue-Centered Treatment or a waitlist control group. Measures utilized include the UCLA PTSD Reaction Index for DSM-IV-Child Version (UCLA PTSD-RI), the Children’s Manifest Anxiety Scale (RCMAS), the Children’s Depression Inventory, the Violence Exposure Scale for Children-Revised, the UCLA PTSD Reaction Index for DSM-IV-Parent Version (UCLA PTSD-RI), the Beck Anxiety Inventory (BAI), and the Children’s Global Assessment Scale. Results indicate that compared to the waitlist group, the Stanford Cue-Centered Treatment group had greater reductions in PTSD symptoms both by caregiver and child report, as well as caregiver anxiety. Limitations include small sample size and limited length of follow-up.

Length of controlled postintervention follow-up: 3 months.

Espil, F. M., Balters, S., Li, R., McCurdy, B. H., Kletter, H., Piccirilli, A., Cohen, J. A., Weems, C. F., Reiss, A. L., & Carrion, V. G. (2022). Cortical activation predicts posttraumatic improvement in youth treated with TF-CBT or CCT. Journal of Psychiatric Research, 156, 25–35. https://doi.org/10.1016/j.jpsychires.2022.10.002

Type of Study: Randomized controlled trial
Number of Participants: 73

Population:

  • Age — 7–17 years (Mean=12.97)
  • Race/Ethnicity — 56% White, 25% African American, 13% Other, 8% Asian, 5% American Indian/Alaskan, 5% Pacific Islander/ 24% Hispanic/Latino, 52% Not Hispanic/Latino, and 24% Missing
  • Gender — 63% Female and 37% Male
  • Status — Participants were recruited from treatment-seeking families referred through Sacramento County.

Location/Institution: Sacramento County, CA

Summary: (To include basic study design, measures, results, and notable limitations)
The purpose of the study was to examine youths’ post traumatic stress disorder (PTSD) symptom change following treatment and test if previously identified activation patterns would predict treatment response. Participants were randomized to trauma-focused cognitive behavioral therapy (TF-CBT), Cue-Centered Therapy (CCT), or treatment as usual (TAU). Measures utilized include the UCLA Child/Adolescent PTSD Reaction Index (UCLA PTSD-RI), the Multiaxial Anxiety Scale for Children, Second Edition (MASC), the Child Depression Inventory (CDI), and the Wechsler Abbreviated Scale of Intelligence, Second Edition (WASI-2). Results indicate that overall, PTSD symptoms decreased from pre-intervention through follow-up across conditions, with some evidence of relative benefit of TF-CBT and CCT over TAU but significant individual variation in treatment response. Cortical activation patterns were correlated with PTSD symptom improvement slopes. In particular, cortical responses to fearful and neutral facial stimuli in six functional near-infrared spectroscopy (fNIRS) channels in the bilateral dlPFC were important predictors of PTSD symptom improvement. Limitations include small sample size, loss of data due to drop out at post-intervention and follow-up lowered the statistical power and ability to draw conclusions about treatment outcomes, and length of follow-up.

Length of controlled postintervention follow-up: 3 months.

Additional References

No reference materials are currently available for Cue-Centered Therapy (CCT).

Contact Information

Hilit Kletter, PhD
Agency/Affiliation: Stanford University Early Life Stress and Resilience Program
Website: med.stanford.edu/elspap/patients-and-families.html
Email:
Phone: (650) 721-3582

Date Research Evidence Last Reviewed by CEBC: June 2023

Date Program Content Last Reviewed by Program Staff: March 2023

Date Program Originally Loaded onto CEBC: June 2016