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Few Answers on How to Effectively Help Children Cope with Trauma
Evidence supports the effectiveness of some cognitive behavioral therapies, but barriers to research make it hard to offer specific recommendations in treating children exposed to traumatic events
By Tara Haelle
In the aftermath of traumatic events like the Newtown massacre , Superstorm Sandy and Hurricane Katrina, children need to heal, just as adults do. But in turning to research to find out what approaches work best for young people, one finds little guidance, according to a research review published February 11 in Pediatrics.
The study focused on non-interpersonal trauma, such as natural disasters, terrorism and community violence, and excluded sexual abuse and domestic violence. A total of 22 trials meeting the criteria provided evidence on interventions for children exposed to trauma. The criteria required studies to have low or medium risk of bias, to compare at least two groups of children and to measure at least one outcome related to post traumatic stress symptoms that children may experience after such events, such as depression, anxiety attacks, psychosomatic symptoms (headaches, stomachaches, general pains), poor grades, nightmares and similar symptoms.
Among the 20 treatments included in those trials were various psychotherapies focusing on trauma or grief, school-based programs, group therapy and three medication trials: imipramine (Tofranil) , fluoxetine (Prozac) and sertraline (Zoloft).The results are sobering: researchers don't know if any medications help and if anything works long-term, and don't know much about possible harms from interventions.
"I thought we were going to find a lot of studies on different interventions and make clinical recommendations," says Valerie Forman-Hoffman, the study's lead researcher and a psychiatric epidemiologist for RTI International in Research Triangle Park, N.C. Many of the excluded studies failed to include comparison groups, which are important because children may recover without treatment, she added. "It's depressing. The evidence base is just lacking."
Many children do heal on their own from one-off events, especially with good support systems. Yet, about 30 percent will continue to experience nightmares, anxiety attacks, stomachaches and other post traumatic stress symptoms more than a month later, according to the American Academy of Child and Adolescent Psychiatry. Past research has also shown children can develop post-traumatic stress disorder (PTSD) symptoms simply in response to watching news coverage of traumatic events.
A variety of treatment approaches showed some evidence for effectiveness, but not enough studies compared approaches or replicated other results. "That's not saying that no treatment works," Forman-Hoffman says, "but based on the evidence, we don't know what works."
多种治疗方法都有证据显示了其有效性，但是没有研究把不同的疗法做比较，或者试图山寨已经发布的结果。 “这并不能说明没有有效的治疗，” Forman-Hoffman 说，“但是基于现有证据，我们我不知道哪一种治疗是有效的.”
What we do know
One reason for the limited findings may be the review's exclusion of studies about relational trauma, such as sexual abuse or domestic violence. A companion review awaiting publication did review that evidence, but separating the two types of trauma may have made it harder to see a big picture.
"Had they looked at all of the research done on trauma exposure for kids, you would have seen replications for some of the intervention models," says Todd Sosna, the senior vice president in charge of program evaluation at the Children's Institute in Los Angeles. "The research does give some directions for treatments that can be helpful, and they tend to be the ones that are cognitive behavioral and involve trauma narratives."
"如果他们阅读了所有曝光于创伤的儿童的研究，你就会发现其中一些介入模式的反复出现，" 负责项目评估的洛杉矶儿童协会高级副主席Todd Sosna说。“研究确实指明了一些有效的治疗方式，而且这些治疗倾向于那些涉及叙述出创伤的认知行为治疗.”
With trauma-focused cognitive behavioral therapy (TF-CBT), clinicians spend 12 to 18 weeks with a child and parent to help them understand the effects of trauma, how to cope and how to retrain their thoughts and behavior responses. TF-CBT (pdf) also uses trauma narratives—stories children tell about an event while reprocessing it in a healthy way. Put another way, it's telling the story while getting back on the horse. This study and another recent review both found some evidence for reduced symptoms with TF-CBT, but the studies were small and short-term. TF-CBT studies also often involve only children who were sexually abused, providing less specific guidance regarding survivors of a school shooting or hurricane.
) 同时使用创伤叙述 --- 让儿童讲述关于某个事件的故事，同时用健康的思维方式来重新处理这个事件。换句话说，通过讲故事来试图帮助他们康复。这项课题和最近的另一个研究评论同时发现了TF-CBT疗法减轻了症状的一些证据，但是这些研究范围都很小并且都是短期研究。TF-CBT疗法的课题通常需要牵涉被性虐待的独生子女，和校园枪击事件或者飓风的幸存者相比，提供了更少的具体指导。
Excluding studies involving abuse also leaves out the most common trauma children experience, though, so the new findings were unsurprising, says Ryan Herringa, at University of Wisconsin School of Medicine and Public Health. "There's clearly a great need for research," he says. "It's just really difficult to do."
Barriers to research
The biggest research obstacle is the population itself. Researchers need to get involved with children early after an event. Without knowing what will happen or when, arriving in time to enroll children in trials can be tough, not to mention lag times in getting ethics approval. "Ideally, you would have some sort of rapid-response team that would fly into a tragedy and begin enrolling people in a study on the spot," Herringa says. "Then, ethically, is it appropriate to be approaching someone for research just as they're trying to cope?"
Forman-Hoffman says lack of funding and the sensitivity of working with traumatized children may also be limiting research. "As a researcher, I wouldn't want to go running to Sandy Hook and say, 'Can I study your kid and see if this works?'—to add to what they're already going through and without knowing if any of these treatments could potentially be harmful," she says. In fact, some PTSD therapies have shown harm in adults recovering from sexual abuse, such as retraumatization, but only five studies in this review even looked for harm. No harm was found in two psychotherapy trials, but among the three medication trials, none showed benefit and one showed possible harm. The placebo group in the sertraline study showed more improvement in quality of life measures than those receiving the medication showed, and those taking sertraline experienced side effects from the medication and more suicidal thoughts.
Katey Smith, coordinator of the Trauma Response Team at Family Centers in Fairfield County, Conn., worked with Newtown families right after the shooting. She is not involved in ongoing interventions in Newtown, but she uses TF-CBT in her own practice—without having much information about long-term effectiveness. "We have to follow these kids over time to know if this model is working," she says, because research shows that experiencing trauma before age 18 can increase adults' risk of depression, suicide and other problems. It is also difficult to control for differences between children that may influence recovery. "We're talking about human beings here, and there's so much variability between subjects," Smith says.
A growing body of research points to the importance of "protective factors" in helping children cope with trauma and develop resilience. Protective factors include how engaged children are with their communities, schools and faith; how well they regulate their emotions; what their support systems are; and how attached they are to a caregiver.
The Children's Institute's Sosna says protective factors are part of a multi-faceted solution to treatment. "We think research will advance, and we think therapy will be part of a larger solution to helping kids recover from trauma," he says.
Another approach entirely is to view these children's experiences through the lens of loss and grief, says Robert Lucia, a pediatric counseling specialist at Children's Hospital of Illinois. Both Lucia and the study authors pointed out that discussing PTSD in children is controversial because children may not show the full constellation of symptoms that garner a diagnosis. "I would challenge researchers and clinicians to switch the lens," says Lucia, who treats children coping with death. "You need to treat the grief too, and there is no pathology to grief. Everyone does it differently. Look at the impact of the loss that traumatic event has on the child," he says, whether it's loss of home, community, friends or a way of life.
另一种治疗方法则是完全从缺失(译者注:造成心理创伤的原因,比方说失去了亲人, 朋友等)与悲痛(译者注:心理创伤产生的结果)的角度来观察这些受创伤儿童的经历，伊利诺斯州儿童医院的儿科质询专家Robert Lucia说道。Lucia和研究的作者都指出，与儿童讨论PTSD是件颇有争议的事，因为儿童也许并不会表现出需要确定某个诊断的所有症状(译者注:full constellation...还全星座,所以雅典娜的圣斗士才是创伤的祸根吗冏, 冥斗士们请尽情毁灭这些小强吧!)。“我会通过让研究者和临床医生更换看问题的视角来挑战他们,” Lucia说，他治疗与死亡打过交道的孩子。“你也需要治疗儿童的悲痛，而且我们都知道没有用于治疗悲痛的病理学. 每个人面对悲痛的反应都是不同的. 关注这些缺失对儿童产生的的影响, 不管是失去了家, 集体, 朋友还是生活的某一部分."
The authors said their findings should serve as a call to action. "We hear so much about gun control and mental health coverage following Newtown, and those are important in terms of prevention, but there's no easy solution," Forman-Hoffman says. "These kinds of traumas and natural disasters are going to keep happening, so we really do need to turn attention to determining what works best for these kids."
研究评论的作者们说他们的发现只是抛砖引玉. “在Newtown事件之后我们听到了诸多关于枪支管理里和精神健康的报道，这些对于防止类似悲剧发生是很重要的，但是仅仅这样是无法解决根本问题的.” Forman-Hoffman说. “将来仍然会有经历过各种人际创伤和自然灾害的孩子出现，我们非常有必要把注意力集中到决定怎样做才是对这些孩子最好的.”
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