3.1 Cross-cultural adaptation of TF-CBT in China
This study developed a TF-CBT intervention with a combination of 7 group sessions (50-60 minutes each) and 3 individual sessions (40-50 minutes each). Each session had a similar structure: participants began with an activity review, worked through a series of games, interactive discussions, or exercises; and ended with family time. The adapted interventions are described in Table 3.
3.1.1 Group session 1: Psychoeducation. The goals of this session were building relationships, introducing trauma knowledge, normalizing children's response to trauma and instilling hope for recovery. The adaption was reflected in the way trauma knowledge was imparted and by injecting hope. By letting children read a picture book that described five injured animals being treated together, the facilitators guided the TEs and trauma reactions. Then, the children were required to add a happy ending to the picture book to convey the hope of healing. Finally, the children's hopes were reinforced through a one-minute applause game.
3.1.2 Group session 2: Relaxation. The purpose of this session was to teach the children relaxation techniques to cope with stressful situations. The modifications were mainly reflected in the content and delivery mode. First, because left-behind children could not receive extra support outside the group, the imagery and mindfulness techniques, which both required guidance from others, were deleted in this session. Second, with regard to the form of delivery, the study adopted guessing riddles that described the four animals’ responses to stress and relaxation methods to let the children list their common stress scenarios and responses. Then, the facilitator taught the children relaxation methods and guided them to apply relaxation methods to different stress scenarios.
3.1.3 Group session 3: Affect expression and modulation. This session aimed to guide the children to recognize, express, monitor and regulate their emotions. The study adapted the original delivery method to be more interesting, diverse, intuitive and operable. For example, several pictures and games, such as stickers (identifying various emotional features on the stickers), emotion camp maps (smashing the different emotions with a small ball; when an emotion was hit, the children needed to express "I felt......when"), emotion thermometers (using a "thermometer" to measure the degree of emotion) and emotional jar games (shaking the emotional bottle until the emotion was calm), were used to help the children understand what different emotional characteristics were, what emotions they had in different situations, and how to express their emotions and realize that the emotions were adjustable.
3.1.4 Group session 4: Cognitive coping. This session was mainly to help children distinguish between thoughts, emotions, and behaviours and to understand the impact of unreasonable thoughts. The adaptations in this session were mainly reflected in the use of storytelling and metaphor to embody abstract concepts. For example, "little angel" and "little devil" were used as metaphors for "reasonable thought" and "unreasonable thought", and the children were asked, "What does the little angel/little devil say to you in this case?" to make it easier for the children to think and understand reasonable/unreasonable thoughts.
3.1.5 Group session 5: Cognitive coping. This session required the most modification in the study. It aimed to teach the children to replace unreasonable thoughts with reasonable thoughts. The abstract replacement method was adapted to be more operative, practical and acceptable. The study adopted a four-step method of “defeating the little devil” (pausing, realizing the existence of the little devil, thinking about what the little devil said to you, and looking for the little angel to defeat the little devil) to replace unreasonable thoughts. Subsequently, four common reasonable thoughts, "little angels" (enthusiasm, affirmativeness, empathy and communication), were introduced to help children master using reasonable thoughts to replace unreasonable thoughts.
3.1.6 Group session 6: Trauma narrative. This session enabled the children to accept and learn the methods of trauma narrative. We adapted the content of picture books and follow-up activities. The session began by reading a trauma storybook and summarizing the eight elements of the trauma narrative (time, place, character, cause, process, outcome, emotion and thought). Afterwards, the children were asked to complete the "bear’s picture book" and record their unforgettable events and to write a "catalogue" for their stories. Finally, one of the happiest things was chosen to be filled in according to the eight elements to exercise the method of trauma narrative.
3.1.7 Individual sessions 1, 2 & 3: Trauma narrative and processing. The first individual session was to allow the children to tell their own trauma memories. The eight elements were used to help children gradually write/draw trauma stories with the guidance of facilitators. The second and third individual sessions were to address the children's unreasonable or reasonable but useless thoughts and to formulate the action strategy. Several techniques, such as in vivo mastery (if needed), responsibility circle, Socratic questioning, miracle question, exception question and problem solving therapy, were used to solve the children's problems in a targeted and in-depth way and to rewrite the children's trauma storybooks.
3.1.8 Group session 7: Enhancing safety and future development. This session integrated the last two sessions of the original group TF-CBT. Its purpose was to review all interventions and explore standard safety preparedness skills so that the children could respond to similar incidents that might occur in the future. The main adaptations in this session were the method of teaching security techniques and the content of farewell ceremonies. The study set up a situation in which Pinocchio had a stress response and unreasonable thoughts due to his parents' migrant work, and the children were asked to help Pinocchio solve the problem. In this way, relaxation, emotional regulation, cognitive processing and other skills were integrated and exercised together. Then, the facilitators could guide the children to use these methods to solve different problems in the future. Finally, at the farewell ceremony, the TE notes written by the children were turned away by magic so that the children could say goodbye to the TEs.
3.2 Feasibility and acceptability of adapted TF-CBT
3.2.1 Retention of children. All 58 children completed 10 sessions of intervention, and the average retention rate was maintained above 97%. As shown in Figure 2, the participation rate of the children in the first group session and three individual sessions was 100%. Of 58 children, 98.28% (n = 57) attended the 2nd, 3rd, and 5th group sessions, 1 child was on leave, 96.55% (n = 56) attended the 6th session, 94.83% (n = 55) attended the 4th and 7th sessions, and 1 child was on sick leave. A total of 99.13% (n = 114) of the children completed the posttreatment, and 1 child was not evaluated because he was on sick leave. All children completed the follow-up assessment.
3.2.2 Acceptance and satisfaction of children. A total of 98.28% (n = 57) of the children completed the CSQ-8 posttreatment. A total of 78.95% (n = 45) and 19.30% (n = 11) of the children had high or medium levels of satisfaction, respectively. A total of 89.48% (n = 51) of the children said that they "will" or "definitely will" recommend that their friends receive our intervention.
The results of the focus groups also showed that the children had a high degree of satisfaction and acceptance of the adapted TF-CBT. When asked about their acceptance of the group format, the children expressed their support: "I made good friends in the group," "The group was relatively open, and I became more outspoken than before." With regard to their acceptance of the individual format, a girl expressed that she liked the individual sessions very much: "I think the group leader can help me, and I will feel better after speaking out, and nothing will hinder me anymore. I feel safe with one-on-one." In addition, children thought that the games in the programme were very interesting. Compared with competitive games, the children preferred cooperative games. "Because there are so many people in games, we can help each other and solve problems together." When talking about the growth and change produced by the intervention, the children said that they had gained a lot: "I feel that the intervention has given me support, and I am more confident to face difficulties"; "The group let me learn a lot of knowledge. For example, when I am sad, I can use some methods to adjust my mood. I feel very happy.”
3.2.3 Acceptance and satisfaction of facilitators. The results of the semi-structured interviews indicated that the facilitators had strong satisfaction and acceptance of the intervention. With regard to the inclusion of multiple types of TEs, the facilitators said that it did not have much impact on the project because the details of TEs were not involved in the group sessions. In addition, the facilitators highly accepted the combination of group and individual formats, and they felt that this created a transition of relationships, emotions, and knowledge that helped to quickly establish a relationship and sense of trust between the facilitator and the child and helped to save the investment of the facilitators' time and resources.
In terms of acceptance of content, the facilitators generally believed that Chinese elements, such as games, picture books and music, were very popular with the children. "They can increase the interest of the project, help children integrate into the group more quickly and relax to accept the knowledge." At the same time, it was useful to use the children’s language style to control discipline: "Every time they hear ‘one, two, three, sit on the side’, the scene will immediately calm down." When asked whether the training knowledge could be implemented substantially, the facilitators said that they did not have much difficulty with this because the project provided standardized materials, which were helpful to remind them of the overall designs and priorities of intervention and to effectively deal with emergencies. Moreover, the facilitators were satisfied that the project had made a difference to the children and themselves: "After the programme, the child's relationship always becomes more harmonious and active"; "The intervention provides good problem-solving methods and skills for children with sudden traumatic events";"I also gain the method of how to provide treatment for children, and I feel a sense of trust and value."
3.2.4 Challenges for the facilitators and children. Both the children and the facilitators reported difficulties in completing family time. The children said this was mainly because school work was so stressful that they did not have enough time to complete family time. However, the facilitators thought this problem was created by the high frequency of the intervention; two sessions a week caused the children to lack practice time. Another facilitator believed that another reason was the lack of a reward mechanism, which made the children less motivated to finish it.
The facilitators also noted some challenges in the implementation of the intervention. First, children in different grades had different cognitive and comprehension abilities, which slowed the progress of the group. When the programme developed to the later stage, it often took a long time to maintain discipline. Additionally, more mature elements should be adopted for children in the upper grades. Moreover, the individual sessions were located in the second half of the group, making it difficult for facilitators to monitor the use of skills and action strategies.