Excluding studies involving abuse also leaves out the most common trauma children experience, though, so the new findings were unsurprising, says Ryan Herringa, at University of Wisconsin School of Medicine and Public Health. "There's clearly a great need for research," he says. "It's just really difficult to do."
Barriers to research
The biggest research obstacle is the population itself. Researchers need to get involved with children early after an event. Without knowing what will happen or when, arriving in time to enroll children in trials can be tough, not to mention lag times in getting ethics approval. "Ideally, you would have some sort of rapid-response team that would fly into a tragedy and begin enrolling people in a study on the spot," Herringa says. "Then, ethically, is it appropriate to be approaching someone for research just as they're trying to cope?"
Forman-Hoffman says lack of funding and the sensitivity of working with traumatized children may also be limiting research. "As a researcher, I wouldn't want to go running to Sandy Hook and say, 'Can I study your kid and see if this works?'—to add to what they're already going through and without knowing if any of these treatments could potentially be harmful," she says. In fact, some PTSD therapies have shown harm in adults recovering from sexual abuse, such as retraumatization, but only five studies in this review even looked for harm. No harm was found in two psychotherapy trials, but among the three medication trials, none showed benefit and one showed possible harm. The placebo group in the sertraline study showed more improvement in quality of life measures than those receiving the medication showed, and those taking sertraline experienced side effects from the medication and more suicidal thoughts.
Katey Smith, coordinator of the Trauma Response Team at Family Centers in Fairfield County, Conn., worked with Newtown families right after the shooting. She is not involved in ongoing interventions in Newtown, but she uses TF-CBT in her own practice—without having much information about long-term effectiveness. "We have to follow these kids over time to know if this model is working," she says, because research shows that experiencing trauma before age 18 can increase adults' risk of depression, suicide and other problems. It is also difficult to control for differences between children that may influence recovery. "We're talking about human beings here, and there's so much variability between subjects," Smith says.
A growing body of research points to the importance of "protective factors" in helping children cope with trauma and develop resilience. Protective factors include how engaged children are with their communities, schools and faith; how well they regulate their emotions; what their support systems are; and how attached they are to a caregiver.
The Children's Institute's Sosna says protective factors are part of a multi-faceted solution to treatment. "We think research will advance, and we think therapy will be part of a larger solution to helping kids recover from trauma," he says.
Another approach entirely is to view these children's experiences through the lens of loss and grief, says Robert Lucia, a pediatric counseling specialist at Children's Hospital of Illinois. Both Lucia and the study authors pointed out that discussing PTSD in children is controversial because children may not show the full constellation of symptoms that garner a diagnosis. "I would challenge researchers and clinicians to switch the lens," says Lucia, who treats children coping with death. "You need to treat the grief too, and there is no pathology to grief. Everyone does it differently. Look at the impact of the loss that traumatic event has on the child," he says, whether it's loss of home, community, friends or a way of life.