In the aftermath of traumatic events like the Newtown massacre, Superstorm Sandy and Hurricane Katrina, children need to heal, just as adults do. But in turning to research to find out what approaches work best for young people, one finds little guidance, according to a research review published February 11 in Pediatrics.
The study focused on non-interpersonal trauma, such as natural disasters, terrorism and community violence, and excluded sexual abuse and domestic violence. A total of 22 trials meeting the criteria provided evidence on interventions for children exposed to trauma. The criteria required studies to have low or medium risk of bias, to compare at least two groups of children and to measure at least one outcome related to post traumatic stress symptoms that children may experience after such events, such as depression, anxiety attacks, psychosomatic symptoms (headaches, stomachaches, general pains), poor grades, nightmares and similar symptoms.
Among the 20 treatments included in those trials were various psychotherapies focusing on trauma or grief, school-based programs, group therapy and three medication trials: imipramine (Tofranil) , fluoxetine (Prozac) and sertraline (Zoloft).The results are sobering: researchers don't know if any medications help and if anything works long-term, and don't know much about possible harms from interventions.
"I thought we were going to find a lot of studies on different interventions and make clinical recommendations," says Valerie Forman-Hoffman, the study's lead researcher and a psychiatric epidemiologist for RTI International in Research Triangle Park, N.C. Many of the excluded studies failed to include comparison groups, which are important because children may recover without treatment, she added. "It's depressing. The evidence base is just lacking."
Many children do heal on their own from one-off events, especially with good support systems. Yet, about 30 percent will continue to experience nightmares, anxiety attacks, stomachaches and other post traumatic stress symptoms more than a month later, according to the American Academy of Child and Adolescent Psychiatry. Past research has also shown children can develop post-traumatic stress disorder (PTSD) symptoms simply in response to watching news coverage of traumatic events.
A variety of treatment approaches showed some evidence for effectiveness, but not enough studies compared approaches or replicated other results. "That's not saying that no treatment works," Forman-Hoffman says, "but based on the evidence, we don't know what works."
What we do know
One reason for the limited findings may be the review's exclusion of studies about relational trauma, such as sexual abuse or domestic violence. A companion review awaiting publication did review that evidence, but separating the two types of trauma may have made it harder to see a big picture.
"Had they looked at all of the research done on trauma exposure for kids, you would have seen replications for some of the intervention models," says Todd Sosna, the senior vice president in charge of program evaluation at the Children's Institute in Los Angeles. "The research does give some directions for treatments that can be helpful, and they tend to be the ones that are cognitive behavioral and involve trauma narratives."
With trauma-focused cognitive behavioral therapy (TF-CBT), clinicians spend 12 to 18 weeks with a child and parent to help them understand the effects of trauma, how to cope and how to retrain their thoughts and behavior responses. TF-CBT (pdf) also uses trauma narratives—stories children tell about an event while reprocessing it in a healthy way. Put another way, it's telling the story while getting back on the horse. This study and another recent review both found some evidence for reduced symptoms with TF-CBT, but the studies were small and short-term. TF-CBT studies also often involve only children who were sexually abused, providing less specific guidance regarding survivors of a school shooting or hurricane.