Child and Adolescent Exposure to Trauma: Comparative Effectiveness of Interventions Addressing Trauma Other Than Maltreatment or Family Violence
Forman-Hoffman V, Knauer S, McKeeman J, Zolotor A, Blanco R, Lloyd S, Tant E, Viswanathan M. Child and Adolescent Exposure to Trauma: Comparative Effectiveness of Interventions Addressing Trauma Other Than Maltreatment or Family Violence. Comparative Effectiveness Review No. 107. (Prepared by the RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center under Contract No. 290-2007-10056-I.) AHRQ Publication No. 13-EHC054-EF. Rockville, MD: Agency for Healthcare Research and Quality. February 2013.
To assess the effectiveness of interventions that target traumatic stress symptoms and syndromes among children exposed to trauma other than maltreatment or family violence (Key Question 1 [KQ 1]), or children exposed to trauma other than maltreatment or family violence who already have symptoms (KQ 2); to identify subgroup characteristics that moderate the effect of an intervention on outcomes (KQ 3); and to assess harms associated with interventions (KQ 4).
MEDLINE®, The Cochrane Library, Embase, PsycInfo, Cumulative Index to Nursing and Allied Health Literature, International Pharmaceutical Abstracts, and Web of Science. Additional studies were identified from reference lists and technical experts.
Two trained reviewers independently selected, extracted data from, and rated the risk of bias of relevant trials and systematic reviews. We did not quantitatively analyze our data because of statistical heterogeneity, insufficient numbers of similar studies, or variation in outcome reporting; thus, we synthesized the data qualitatively. KQ 1, KQ 2, and KQ 4 present outcomes categorized by intervention type. KQ 3 presents outcomes of interventions categorized by child characteristics.
We found a total of 21 trials and 1 cohort study (reported in 25 articles) of either medium or low risk of bias from our review of 6,647 unduplicated abstracts. We did not find studies that attempted to replicate findings of effective interventions; rather, studies tested unique interventions. No pharmacotherapy intervention demonstrated effectiveness. Studies demonstrating improvement in outcomes generally compared results of interventions with waitlist controls. With a single exception, studies comparing interventions with active controls did not show benefit. Some psychotherapy interventions targeting children exposed to trauma appear promising based on the magnitude and precision of effects found. These interventions were school-based treatments with elements of cognitive behavioral therapy (CBT). We found less compelling evidence regarding potentially promising interventions targeting already existing symptoms, each of which also had elements of CBT.
Authors typically evaluated short-term outcomes. The body of evidence provides no insight into how interventions targeting children exposed to trauma, some of whom already have symptoms, might influence healthy long-term development. We found little evidence on how effectiveness might vary by child characteristics and no evidence on how effectiveness might vary by treatment characteristics or setting. We also found almost no evidence on harms associated with psychological treatments. Only pharmacological interventions attempted to assess harms in this vulnerable population.
Our findings may be interpreted as a call to action. Psychotherapeutic intervention may be beneficial relative to no treatment, but far more research is required to produce definitive guidance on the comparative effectiveness of psychotherapeutic or pharmacological interventions targeting children exposed to trauma, some of whom already have symptoms.