Trauma-focused cognitive behavioural therapy (TF-CBT) is one of the best-supported psychological treatments for children and adolescents with post-traumatic stress symptoms. Yet the existence of an evidence-based treatment does not mean that children and families can access it in routine care. Pfeiffer et al. (2024) examine this research-to-practice gap by exploring how TF-CBT has been disseminated and implemented across seven European countries, highlighting a central challenge for child and adolescent mental health services: effective treatments can remain unavailable unless health systems invest in training, translation, supervision, policy support, and implementation infrastructure.
Why Trauma-Focused CBT Isn’t Reaching Children with PTSD in Europe
Children and adolescents are at significant risk of experiencing traumatic events, and a substantial minority develop post-traumatic stress disorder (PTSD) after trauma exposure (Alisic et al., 2014). Evidence-based psychological interventions for child and adolescent PTSD have been developed and tested over recent decades, with strong support for trauma-focused CBT approaches (Cohen et al., 2016; Morina et al., 2016; Smith et al., 2019). However, efficacy evidence does not automatically translate into routine care. Many children and adolescents who could benefit from TF-CBT do not receive it, reflecting a broader implementation gap in mental health services, where treatments shown to work in research trials are not consistently delivered in everyday practice (Harvey & Gumport, 2015; Kratz et al., 2022). Without implementation strategies, trauma-exposed children may receive no trauma-focused intervention, receive non-specific support, or encounter long delays before accessing appropriate care.
How TF-CBT is being implemented across Europe
Pfeiffer et al. (2024) used a mixed-method approach to capture implementation from the perspective of European TF-CBT experts. The first component was an online survey of certified TF-CBT trainers working in Europe. The second involved country-based narratives from experts describing the dissemination and implementation context in Finland, Germany, Italy, the Netherlands, Norway, and Sweden. Implementation is not only a matter of individual clinician competence; it depends on national health systems, reimbursement models, professional training routes, policy structures, language resources, and organisational culture. Country narratives allowed the authors to describe these contextual differences in more detail than survey data alone could provide. The study does not claim to offer a fully representative map of all trauma-focused care in Europe. Rather, it presents expert perspectives from countries with varying levels of TF-CBT dissemination. This makes the paper especially useful for identifying shared barriers and practical strategies.
Key barriers to TF-CBT implementation
- At the trauma-related level, the authors highlight difficulties around routine trauma screening and assessment. Some countries reported that trauma exposure and post-traumatic stress symptoms are not consistently assessed in child and adolescent mental health services. Without systematic identification, children who might benefit from TF-CBT may never be referred.
- At the therapist level, barriers include limited training, lack of confidence, and uncertainty about using trauma-focused methods. Some clinicians may prefer familiar non-trauma-specific approaches or feel concerned about destabilising children by directly addressing traumatic memories. These concerns are consistent with broader implementation literature showing that therapist beliefs and preferences can affect uptake of evidence-based practices (Harvey & Gumport, 2015; Kratz et al., 2022).
- At the treatment level, the study identifies barriers related to manuals, language, materials, and certification. Several countries lacked translated manuals, workbooks, or web-based training resources. Others lacked agreed certification structures or clear criteria for who could provide TF-CBT training. This matters because dissemination without quality assurance risks diluting the model.
- At the organisational and government levels, barriers include funding, workforce capacity, waiting lists, lack of national policies, and fragmented healthcare structures. These levels were especially important in the study’s conclusions. Pfeiffer et al. (2024) argue that the strongest barriers to broader European implementation were found at government and treatment levels, particularly around funding, certification, and integration into policies and guidelines.
What we learn from TF-CBT implementation across Europe
The country narratives show how implementation varies across Europe. Norway stands out as one of the strongest examples of national-scale TF-CBT implementation. The paper reports that TF-CBT has been implemented there since 2012 and is now present in a high proportion of outpatient child and adolescent mental health clinics. This implementation has been supported by national funding, structured training, and research infrastructure (Jensen et al., 2014; Skar et al., 2022). Germany has conducted major TF-CBT research, including a randomised controlled trial in eight mental health clinics (Goldbeck et al., 2016), and has also developed large implementation projects such as BEST FOR CAN and BETTERCARE (Rosner et al., 2020a, 2020b).
However, the paper notes that even where trauma-focused treatments are available, it can be difficult to know whether routine providers are delivering evidence-based trauma-focused interventions. The Netherlands has developed translated materials and training structures, while Finland, Sweden, and Italy each show different stages of dissemination. Italy, for example, had begun TF-CBT training only relatively recently and had no published TF-CBT research at the time of the country narrative. Sweden reported regional variation in access to evidence-based trauma treatments, alongside broader workforce and waiting-time pressures. These narratives make clear that implementation depends heavily on local context. A strategy that works in one country may need adaptation elsewhere. Nevertheless, several common facilitators appear across settings.
What helps TF-CBT dissemination and uptake?
Pfeiffer et al. (2024) identify several successful dissemination and implementation strategies.
First, translation matters. Materials need to be available in local languages, including manuals, workbooks, training resources, and therapist supports. Without translated resources, clinicians may struggle to deliver TF-CBT with fidelity, and families may be less able to engage.
Second, trainer networks are central. Countries that developed certified trainers, training institutes, or national centres were better positioned to scale up implementation. The study emphasises that treatment developers often played an important role as consultants, helping build local trainer capacity.
Third, learning collaboratives appear particularly valuable. The authors argue that European regional learning collaboratives could strengthen implementation by allowing countries to share resources, funding models, certification processes, and research methods. This is consistent with broader implementation frameworks emphasising leadership, organisational support, and implementation infrastructure (Aarons et al., 2011; Fixsen et al., 2009).
Fourth, funding is an overarching factor. Translation, training, supervision, certification, and evaluation all require resources. The paper highlights TF-CBT Ukraine as an example of international collaboration supporting training and translation during war, demonstrating how cross-national effort can support dissemination in high-need contexts (Pfeiffer et al., 2023).
Why policy and commissioning are critical for TF-CBT access
Implementation cannot be left to individual clinicians alone. If health systems do not prioritise evidence-based trauma-focused treatments, access will remain uneven. Pfeiffer et al. (2024) argue that future dissemination efforts should incorporate TF-CBT into national treatment policies and guidelines. This could include clearer eligibility criteria for training, requirements that training be delivered by certified trainers, national certification processes, and public-facing information about evidence-based trauma treatments. Commissioning and policy decisions shape what services are funded, which clinicians are trained, how supervision is organised, and whether trauma screening becomes routine. Without these structures, TF-CBT may remain available only in specialist pockets rather than becoming a reliable part of child and adolescent mental health care.
Practical implications for child mental health services
The paper offers several practical implications. Services need routine trauma screening so that children and adolescents with post-traumatic stress symptoms are identified. Training should include not only TF-CBT techniques but also confidence in assessment, engagement, and trauma-focused formulation. Organisations should protect time for supervision and consultation, as implementation is unlikely to be sustained through one-off training alone. At a system level, countries can learn from one another. Norway’s national model, Germany’s implementation projects, the Netherlands’ translated materials, and Ukraine’s international training collaboration each illustrate different implementation strategies. Rather than each country developing isolated solutions, European collaboration could accelerate access to evidence-based trauma care.
Conclusion: Turning TF-CBT evidence into accessible care
The challenge is no longer simply whether TF-CBT is effective. The central challenge is whether children and adolescents can access these treatments in routine services. There are multiple barriers across different levels, from trauma assessment and therapist confidence to translated materials, certification, funding, and national policy. Practical solutions are needed: trainer networks, translated resources, learning collaboratives, implementation research, and coordinated European funding. Implementation is difficult because child mental health systems are heterogeneous and under pressure. Yet progress is possible when evidence-based treatment is supported by infrastructure. For trauma-exposed children and adolescents, dissemination is not an academic extra; it is the route through which evidence becomes care.
Where next?
For a more extensive understanding join us on 30 June for our much anticipated webinar – Trauma: Evidence, Practice, and Implementation Challenges. Jack Tizard International Online Conference
The sessions dive into the practical challenges of identifying and treating trauma in children and young people, with an emphasis on implementation issues, barriers to delivering evidence-based treatments, and work with specific populations. Confirmed speakers; Professor Rachel Hiller, Dr. Jess Richardson, Dr. Connor Kerns, Dr. Stephanie Lewis, and Professor Dr. Elisa Pfeiffer.
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