Are
the current approaches to treating traumatized kids actually making them
better?
Intro
More and more research is telling us about
the long-term negative consequences of trauma and adversity in childhood with correlations between childhood trauma and poor mental and physical health
outcomes across the lifespan. So, it makes sense that there should be a good
evidence base for treating the effects of childhood trauma.
In February this year, researchers in the
United States undertook a Comparative Effectiveness Review (CER) examining the
evidence for interventions that target traumatic stress symptoms and syndromes
associated with nonrelational trauma, such as exposure to war, disasters and
accidents. The review was sponsored by the Agency for Healthcare Research and
Quality (AHRQ). CER’s are designed to guide health care decisions by providing
evidence on the effectiveness, benefits and harms of different types of interventions.
The authors noted in their paper – although several guidelines on the treatment
of PTSD in childhood and adolescence exist, the recommendations are
inconsistent and largely not based on evidence from high-quality clinical
trials or comparative effectiveness reviews (CER’s).
Method
· The literature, including the
grey literature, was systematically reviewed to identify 21 trials and 1
observational study that evaluated 6 different types of interventions. These
studies included 7 studies that targeted children identified as exposed to
trauma and 15 studies targeting children with trauma exposure who already had
symptoms. These interventions included psychological as well as pharmacological
treatments.
· The researchers used
qualitative rather than quantitative analysis methods, which they stated was
due to there being insufficient numbers of similar studies, variation in
outcome reporting and statistical heterogeneity (the level of differences
present in the data).
· At least 1 outcome in the
studies included in this CER had to relate to the assessment of traumatic
stress symptoms or syndromes.
Results
· Interventions that included
trauma-focused CBT, child and family traumatic stress intervention and 2
different school interventions with elements of CBT reported some improvement
in outcomes.
· Studies that included early
psychological intervention and medication with propanonol showed no improvement
in any outcomes.
· The child and family traumatic
stress intervention was the only study that showed evidence of benefit with an
active group comparator.
· School based interventions with
elements of CBT were promising based on the magnitude and precision of effects.
Overall the study found that there was very
little evidence to support the current interventions that are being used to
treat children presenting with adverse symptoms as a result of nonrelational
trauma.
Conclusion
In their systematic review of the literature
the authors were able to identify many more studies assessing interventions
than those that were included here. Most of these studies were not included in
this review as they did not meet the inclusion criteria for the CER or the
interventions had only been trialed with children exposed to relational
traumas, such as child maltreatment or sexual abuse. This raises the obvious
point that there is a need for a more consistent and evidence based approach
and also the need for research that is embedded in practice in order to collate
evidence about those interventions that are being used to treat trauma in
children. However, as the authors note, studying traumatized children is a
particularly sensitive area and one that can be difficult to recruit participants
into.
The authors concluded that:
Psychotherapeutic
intervention may provide benefit relative to no treatment in children with
traumatic stress symptoms or exposed to traumatic events and appears not to
have associated harms.
For practitioners working with children who
have been exposed to trauma, it is worth noting that the CER found that
interventions with components of CBT were amongst those that demonstrated some
efficacy. A review and meta-analysis of CBT for the treatment of posttraumatic
stress disorder (PTSD) in children (Kowalk et al) also found that interventions
that incorporated CBT were the most effective in treating trauma in children.
Another point to note is that many of the
current interventions and much of the research only focuses on the short to
medium term outcomes of trauma in children, when we know that the experience of
traumatic is likely to have long term negative impacts on development. This
leaves us with a large gap of knowledge about what actually helps children and
young people over time.
Given what we now know regarding the poor
outcomes of many children and young people who are exposed to trauma, it is
essential that the knowledge base continues to be developed in order ensure the
wellbeing of children, young people and their families.
This article has also appeared on The Mental Elf blog.
Valerie L. Forman-Hoffman, Adam J. Zolotor,
Joni L. McKeeman, Roberto Blanco, Stefanie R. Knauer, Stacey W. Lloyd, Jenifer
Goldman Fraser , Meera Viswanathan. Comparative
effectiveness of interventions for children exposed to nonrelational traumatic
events. Peadiatrics; originally published online February 11, 2013.
Joanna Kowalik, Jennifer Weller, Jacob
Venter, David Drachman. Cognitive
behavioral therapy for the treatment of pediatric posttraumatic stress
disorder: A review and meta-analysis. Journal of Behavior Therapy and
Experimental Psychiatry. 2011 42 405 – 413.
