Only cognitive-behavioral therapy, of all the major interventions being used to reduce psychological harm in children and adolescents who have witnessed or been victims of trauma or violence, has strong evidence to show it is effective, according to a review.
Evidence was scant for the effectiveness of play therapy, art therapy, psychodynamic therapy, pharmacologic therapy, or psychological debriefing–the other interventions that were reviewed–in reducing depressive disorders, anxiety, posttraumatic stress disorder (PTSD), and other adverse sequelae in this population, said Holly R. Wethington, Ph.D., and associates of the task force on community preventive services at the Centers for Disease Control and Prevention.
“Children and adolescents in the United States and worldwide are commonly exposed to traumatic events, yet practitioners treating these young people to reduce subsequent psychological harm may not be aware of–or use–interventions based on the best available evidence,” the authors wrote (Am. J. Prev. Med. 2008;35:287-313). The task force is a project that has been in place since 1995. Funded by the CDC and the Department of Health and Human Services, it reviews major interventions in multiple arenas of public health–such as tobacco control, motor vehicle safety, sexual behavior, diabetes control, and mental health–to determine what measures work, what might be harmful, and what areas need new research.
For this report, electronic searches for literature used databases including Medline and PsycINFO, and looked for articles written in English on the particular treatments up to March 2007. Types of trauma included physical or sexual abuse, community violence, suicide of a family member, juvenile cancer and treatment, traffic accidents, and natural disasters. Eleven studies were deemed appropriate for consideration for individual cognitive-behavioral therapy (CBT) and 10 for group CBT. Four studies were identified for play therapy, one for art therapy, two each for psychodynamic and pharmacologic therapy, and one for psychological debriefing.
Task force member Robert A. Hahn, Ph.D., said that children and adolescents in the United States are exposed to multiple trauma rates that were surprising to him because they were so high.
Not all children will go on to experience harmful psychological consequences, but a proportion will, and this can lead to risky behaviors–such as smoking, drinking, and criminal behavior–in the adult years, he said in an interview.
It is important that clinicians treat these children appropriately, with therapy that is effective. “Except for cognitive-behavioral therapy, the evidence was lacking for all the other interventions we reviewed, even for pharmaceutical therapy, which is important because it is used by many psychiatrists,” said Dr. Hahn, who is also coordinating scientist for the violence prevention review team and the excessive alcohol prevention review team at the CDC.
One of the interventions reviewed, psychological debriefing, may even be harmful, Dr. Hahn noted. “This has been found to have some harm, at least in adults, because it is administered to people in a group, right after an event, whether they have symptoms or not. They sit around in a group and listen to each other's traumatic experience, so in a sense they are exposed to another version of the trauma they themselves suffered. This psychological debriefing may not provide an opportunity for them to get referrals and subsequent treatment, and we therefore urge caution and more research [regarding this intervention] in children and adolescents.”
A “major challenge is that children and adolescents who have been traumatized and may need treatment for PTSD or other psychological conditions generally do not receive that treatment,” according to the task force.
The work of Dr. Wethington and two other members of the task force was supported by funding from the Oak Ridge Institute for Science and Education. No other financial disclosures were reported by the authors of the report.
The evidence was lacking for all the other interventions reviewed, even for pharmaceutical therapy. DR. HAHN