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.
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.
The authors said their findings should serve as a call to action. "We hear so much about gun control and mental health coverage following Newtown, and those are important in terms of prevention, but there's no easy solution," Forman-Hoffman says. "These kinds of traumas and natural disasters are going to keep happening, so we really do need to turn attention to determining what works best for these kids."