Child Exposure to Trauma: Comparative Effectiveness of Interventions Addressing Maltreatment

Goldman Fraser J, Lloyd SW, Murphy RA, Crowson MM, Casanueva C, Zolotor A, Coker-Schwimmer M, Letourneau K, Gilbert A, Swinson Evans T, Crotty K, Viswanathan M. Child Exposure to Trauma: Comparative Effectiveness of Interventions Addressing Maltreatment. Comparative Effectiveness Review No. 89. (Prepared by the RTI-UNC Evidence-based Practice Center under Contract No. 290-2007-10056-I.) AHRQ Publication No. 13-EHC002-EF. Rockville, MD: Agency for Healthcare Research and Quality. April 2013.



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(1) To assess the comparative effectiveness of interventions (psychosocial and/or pharmacological) for children age 0 to 14 exposed to maltreatment in addressing child well-being outcomes (mental and behavioral health; caregiver-child relationship; cognitive, language, and physical development; school-based functioning) and child welfare outcomes (safety, placement stability, and permanency); (2) To assess the comparative effectiveness of interventions (a) with different treatment characteristics, (b) for child and caregiver subgroups, and (c) for engaging and retaining children and/or caregivers in treatment; and (3) To assess harms associated with interventions for this population.

Data Sources

MEDLINE®, PsycINFO®, Social Science Citation Index®, and the Cochrane Library. Additional studies were identified from reference lists and technical experts

Review Methods

A team of reviewers, including clinicians specializing in child trauma treatment, independently reviewed, extracted data from, and rated the risk of bias of relevant trials. Decisions required agreement between two independent reviewers, with disagreements regarding inclusion or exclusion resolved by a third. We qualitatively synthesized results; quantitative analysis was not appropriate due to clinical heterogeneity, insufficient numbers of similar studies, and wide variation in outcome reporting.


We found a total of 24 trials and 1 cohort study of either medium or low risk of bias from our review of 6,282 unduplicated abstracts. Although pharmacotherapy was included in our definition of interventions for this review, we did not identify any eligible studies for inclusion. Our main finding was that the literature in this field is strikingly limited due to numerous substantive and methodological gaps. These limitations include (a) the predominance of single trials conducted by the treatment developers testing unique interventions which often employ strategies very similar to those of other approaches, (b) usual care, wait-list, or derived controls rather than head-to-head comparisons with bona fide alternative treatments, (c) short-term outcomes, (d) inadequate reporting of attrition, and (e) wide heterogeneity in type and psychometric soundness of outcome measurement across studies. Given the nascent state of the field, it is too early to make strong recommendations based on the available comparative effectiveness research. However, our review suggests that several interventions show promising child well-being and child welfare benefits and summarizes these findings by salient population subgroups including child age, type of maltreatment, and caregiving context (maltreating parents or foster/kinship parents).


This review serves as an urgent call for improving and building the evidence base for interventions to promote the well-being of maltreated children. A multisite research network is a powerful platform that could facilitate the conduct of large, methodologically rigorous comparative efficacy and effectiveness trials needed to move the field forward. More broadly, a paradigm shift is required on the part of researchers and funders alike to galvanize the commitment and resources necessary for conducting collaborative clinical trials with these particularly vulnerable children and families.