In 2012, the blog weekly features a summary or discussion of a recent scientific article on traumatic stress in children. This week: Kramer & Landolt (Dec 2011) about early interventions.

When children are exposed to a single traumatic event such as a car accident, a violent incident, or a disaster, many of them will recover naturally. However, a significant minority has difficulty getting back on track: 10 to 30% of the exposed children develop chronic symptoms, including Posttraumatic Stress Disorder (PTSD).

Can we intervene early to help children recover? Systematic reviews on the efficacy of early single interventions in adults have shown either no or even harmful effects so far. In particular psychological debriefing, where survivors are asked to ventilate their emotions, cause concerns. For example, Rose et al. (2009) concluded in their meta-analysis that compulsory psychological debriefing of adults should cease.  

Even though this suggests that we shouldn’t encourage the expression of negative emotions shortly after a traumatic event, there is still (a lot of) room for research to explore what we could do instead. I don’t think we should necessarily refrain from early interventions altogether. We ‘ just’ need to study the effects of different elements, such as providing social support and calming (see Hobfall et al., 2007 for ‘essential elements’ of interventions after disaster). And potentially better target people who could benefit from an intervention, since many people will show resilience. 

The evidence of what works for children and adolescents is even less clear than for adults. Therefore, Kramer and Landolt conducted a systematic review, aiming a) to describe the characteristics of early psychological interventions for children and b) to statistically summarize to what extent children in intervention groups improved more or less than children in control conditions.

The authors retrieved 7 trials in the literature, which were almost all based on behavioral and cognitive theory. Most of the interventions included psycho-education, a reconstruction of the event (‘trauma narrative’), coping skills, and social support as main elements. Three studies included ‘debriefing’. The length ranged from 1 to 4 sessions, including two internet-based approaches. The authors identified several methodological shortcomings in the studies, with quality ranging from moderate to very high. All trials focused on children aged 6 to 18 years.

None of the statistics indicated harmful effects of early interventions for children. The mean overall effect, including several outcomes (e.g., PTSD symptoms, anxiety, dissociation, anger) was not significant. However, the effects showed a trend towards being beneficial. In addition, the effects for anxiety and dissociation indicated a statistically significant reduction in symptoms for children receiving the intervention relative to children in the control group.

The authors concluded that the results were encouraging for early interventions with children but that the meta-analysis could not yet provide definitive answers regarding their efficacy. As with adults, we need more studies and the isolation of intervention-elements to get a more comprehensive idea of what works to facilitate recovery. Kramer & Landolt point out that interventions should probably include age-appropriate psycho-education (and those younger than 6 deserve attention!), teaching of individual coping skills, parental involvement, possibly some form of a trauma narrative, and a stepped procedure which starts with screening children for risk of developing symptoms.

Articles:

Kramer, D., & Landolt, M. (2011). Characteristics and efficacy of early psychological interventions in children and adolescents after single trauma: a meta-analysis European Journal of Psychotraumatology, 2 DOI: 10.3402/ejpt.v2i0.7858

 
Rose, S.C., Bisson, J., Churchill, R., & Wessely, S. (2009). Psychological debriefing for preventing post traumatic stress disorder (PTSD) Cochrane Database of Systematic Reviews, 1

Hobfoll SE, Watson P, Bell CC, Bryant RA, Brymer MJ, Friedman MJ, Friedman M, Gersons BP, de Jong JT, Layne CM, Maguen S, Neria Y, Norwood AE, Pynoos RS, Reissman D, Ruzek JI, Shalev AY, Solomon Z, Steinberg AM, & Ursano RJ (2007). Five essential elements of immediate and mid-term mass trauma intervention: empirical evidence. Psychiatry, 70 (4) PMID: 18181708