No Long-term Benefit of Trauma Treatments in Kids

Deborah Brauser

February 12, 2013

Treating children after they have been exposed to a traumatic event is challenging, especially because many interventions show very little long-term efficacy, new research suggests.

In fact, an evidence review of 22 studies assessing traumatic stress disorders in children and adolescents showed that no type of psychotherapeutic intervention used provided significant long-term benefits.

Although some psychological treatments with elements of cognitive behavioral therapy (CBT) did help these patients in the short-term — no pharmacotherapy intervention demonstrated efficacy.

"Our findings serve as a call to action," write Valerie L. Forman-Hoffman, PhD, from RTI International in Research Triangle Park, North Carolina, and colleagues.

Although "psychotherapeutic intervention may be beneficial relative to no treatment," the investigators add that "far more research" is needed for definitive guidance on providing effective treatment to these children.

The study was published online February 11 in Pediatrics.

According to the researchers, almost two thirds of all individuals younger than 18 years will experience at least 1 traumatic event. This can include an accident, natural disaster, school shooting, or war-related event.

In addition, previous research has shown that childhood posttraumatic stress disorder (PTSD) can increase the risk for comorbid psychiatric disorders, such as substance abuse, depression, and even suicidality.

However, little evidence exists on the best way to help these children to recover and avoid long-term, negative consequences, report the investigators. Therefore, they sought to conduct a comparative effectiveness review (CER) that examined these issues.

From an initial review of 6647 unduplicated citations published through July 2012, 22 English-language studies were chosen for this analysis.

No case reports, case series, or retrospective cohort studies were included. Also, "traumatic events" did not include those in relation to personal events.

Low-Rated Evidence

In 7 studies of 6 interventions, trauma-focused CBT and child and family traumatic stress intervention (CFTSI) showed some short-term improvement for patients for at least 1 outcome, as did 2 school-based interventions with elements of CBT: ERASE Stress and Overshadowing the Threat of Terrorism.

All of these treatments except for CFTSI showed significant evidence of short-term benefit compared with no intervention and compared with "wait-list controls."

Use of an early psychological intervention or of propranolol showed no improvement with regard to any outcomes.

In 5 of the studies that assessed PTSD diagnosis, CFTSI and ERASE Stress showed some improvement in symptoms; and 4 studies that assessed PTSD severity showed evidence of improvement with both school-based treatments.

Two studies also assessed comorbid anxiety and reported symptom improvement after the children underwent 1 of the interventions. All 3 of the studies that evaluated comorbid depression also reported improvements.

However, "we rated the evidence as low for all these outcomes, based on the limited number of studies...and small sample sizes," report the investigators.

No Benefit

The researchers also evaluated 15 studies that examined treatments only for already-occurring symptoms of trauma. Of the 13 interventions used, 3 focused on the following medications:

  • Sertraline vs placebo,

  • Imipramine vs chloral hydrate, and

  • Imipramine vs fluoxetine and placebo.

These studies showed no evidence of benefit for any of the pharmacologic interventions. In addition, "the sertraline study suggested that children in the intervention arm fared worse than those in the control arm."

All of the nonpharmacotherapies (except for narrative exposure therapy, grief- and trauma-focused intervention (GTFI), and GTFI with coping skills) showed "some evidence of benefit" for at least 1 outcome compared with wait-list controls. All of these contained elements of CBT.

However, none of the studies attempted to replicate findings of the effective interventions — and none provided insight into how any of the interventions may influence children's long-term development.

The investigators also note that beneficial outcomes were usually shown when results were compared with wait-list controls instead of with active controls.

"With a single exception (CFTSI vs supportive therapy), studies comparing interventions with active controls did not show benefit," write the investigators, adding that more research is needed to provide definitive treatment guidance.

Call to Action

"The most important conclusion derived from this rigorous review is: when it comes to empirical evidence to prevent or treat symptoms from traumatic events, we don't know much of anything," writes M. Denise Dowd, MD, from the Division of Emergency and Urgent Care at Children's Mercy Hospitals and Clinics in Kansas City, Missouri, in an accompanying editorial.

Dr. Dowd notes that there are many different barriers to improving knowledge on this topic.

"Rigor in research is clearly lacking. Of 6647 abstracts reviewed, a mere 21 trials and 1 cohort study with low or medium risk of bias were identified," she writes, adding that nearly all evaluated only short-term symptoms.

"Although this CER may be criticized for using too strict inclusion criteria resulting in a predictably large number of exclusions, the return is indeed paltry," writes Dr. Dowd.

Yet, "understanding of the impact of childhood exposure to trauma has grown exponentially."

In addition, several protective factors have been shown to counterbalance these adverse experiences, including healthy attachment relationships, motivation/ability to engage with the community, and supportive environmental systems.

"A trauma exposure prevention and treatment research agenda can and should focus on resilience," said Dr. Dowd. "This review serves as a call to action to bring together stakeholders from multiple disciplines to create a consensus-based research agenda."

The study was funded by the Agency for Healthcare Research and Quality. The study authors and Dr. Dowd have disclosed no relevant financial relationships.

Pediatrics. Published online February 11, 2013. Abstract, Editorial