When Valerie Forman-Hoffman heard about the shootings at Sandy Hook Elementary School in Newtown, CT, on December 14, she reacted like a parent. She picked up her five-year-old daughter Romy from school earlier than usual and then hugged her closer and longer. But when Hoffman thinks about the mental health needs of the surviving children affected by the horrific violence, she responds as the researcher she is. She knows too well that we know too little.
Hoffman, a psychiatric epidemiologist, was part of a team of eight investigators at RTI International Evidence-based Practice Center who reviewed interventions for children and adolescents exposed to traumatic events other than maltreatment or family violence such as accidents, natural disasters, school shootings, and war. RTI is one of 11 centers supported by AHRQ that systematically review scientific findings to examine treatment options.
The AHRQ research review, Child and Adolescent Exposure to Trauma: Comparative Effectiveness of Interventions Addressing Trauma Other Than Maltreatment or Family Violence revealed that more research is needed on the effectiveness and comparative effectiveness of psychotherapeutic and pharmacological interventions. But the authors did find that certain psychotherapeutic interventions may benefit children exposed to trauma. Ultimately, the report is call to action.
"It's a very important problem," says Hoffman. "How do we help these children?"
Promising school-based interventions
School-based treatments with elements of cognitive behavior therapy appear promising based on the magnitude of their impact on children's PTSD, anxiety, depression, or anger symptoms.
"The field is so new," says RTI investigator and child clinical psychologist Joni McKeeman, Ph.D., who also worked on the review. "We've learned some really basic things."
She cites an example from a young person who was a child when the 9/11 terrorist attacks occurred. "In his school, they wheeled televisions into the classrooms so students could watch the news all day. Now, we know not to expose children to visual media all day long. We didn't know that then."
McKeeman says that although there needs to be more literature and more research. "There are some good strategies found to be effective—Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) and the CFTSI (Child and Family Traumatic Stress Intervention) and CBITS (Cognitive Behavioral Intervention for Trauma in Schools)."
Scope of the problem
Approximately two-thirds of children and adolescents under the age of 18 will experience at least one traumatic event, according to a 2007 article in the Archives of General Psychiatry. Although many children exposed to trauma do not experience long-term difficulties, other children go on to develop traumatic stress syndromes, including post-traumatic stress disorder (PTSD).
The RTI researchers, supported by AHRQ, examined the efficacy of interventions that target traumatic stress symptoms and syndromes among children and adolescents exposed to trauma and those already experiencing symptoms after trauma. When they began their research, Hoffman expected to discover more studies.
"I worked on this project for a year and a half. It was so intense. I initially thought we were going to find all of these interventions that would need synthesis and meta-analysis. I was really looking forward to finding out what works," Hoffman told Research Activities. Ultimately, Hoffman said, "I was surprised that there were so few studies. There were only about 20 studies and they were all single studies. There weren't other studies to confirm the findings."
Hoffman understands the challenges of research involving children and trauma. "You don't know when these types of events are going to occur and the last thing you want to do is go in there as a researcher and ask, 'Do you mind if I research your child?' Getting consent to do any type of study especially on a traumatized child is very, very difficult," she says. "The gold standard of doing intervention research is a randomized control trial. Maybe we're not going to be able to do that. Maybe the solution is do some very well designed observational studies perhaps using registry data or the like in terms of looking at a cohort of kids and following them forward to see what kind of treatments they got."
Fellow investigator and family physician Adam Zolotor, M.D., Dr.P.H., shares Hoffman's concerns. "When we put the science under the microscope, we found the majority of the studies didn't meet our inclusion criteria. They had a brief duration of followup, or weren't randomized, or didn't use standardized measures."
As Zolotor points out, knowing more about which treatments are effective would not only be helpful for children, it would be helpful for payers too to "get a better handle on what types of therapies to reimburse for." "It is striking how common trauma is in kids and how little science there is," says Zolotor. "The lifelong consequences are tremendous. I see kids and adults. Lots of psychiatric illness due to trauma emerges through the lifespan. Would it be true if all these kids got treatment? We don't really know. There are lots of things we do in medicine where our best practice precedes the evidence, but we often change best practices as evidence emerges." "It is striking how common trauma is in kids and how little science there is."
Call to action
The investigators interpret their findings as a call to action for more research.
"We need strategies for intervening that are available and easier to disseminate to a wider range of practitioners in the community so more practitioners have access to learning about and training in these methods," says McKeeman. "There are a lot of people out there doing good work, but I'd like to see more practitioners with the skills and knowledge to implement the interventions that have been found to be most helpful in working with traumatized children."
Researchers, clinicians, policymakers and the public share a need to know more about how to help traumatized children—before a traumatic event occurs. As a parent, Hoffman hopes she'll never have to know.
Editor's note: The Evidence Report Child and Adolescent Exposure to Trauma: Comparative Effectiveness of Interventions Addressing Trauma Other Than Maltreatment or Family Violence was one of four reviews on child trauma and adult PTSD supported and funded by AHRQ. All four reviews and others by AHRQ's Effective Health Care Program can be found at www.effectivehealthcare.ahrq.gov.