• By Dartington SRU
• Posted on Tuesday 16^th September, 2014

Nipping trauma in the bud

An estimated 60 per cent of children experience some form of potentially traumatic event or circumstance at some point in their development, according to US studies, and six to 20 per cent of them go on to suffer some form of impairment or post-traumatic stress disorder.

What may provoke this includes maltreatment, exposure to violence, or serious intentional or unintentional injury. Historically, there has been no conclusive evidence about the effectiveness of interventions designed to mitigate the effects before children are traumatised.

Steven Berkovitz and Steven Marans, then based at Yale University, set out to design and rigorously evaluate a brief early intervention to nip problems in the bud and prevent post-traumatic stress disorder from developing. They knew that the window for possible intervention was narrow and that, therefore, intervention needed quickly to follow exposure to trauma and be brief in duration. Research on the development of post-traumatic stress disorder also pointed them in the right direction: poor communication between affected children and their primary caregivers has been identified as a key risk factor for the development of PTSD in children.

Berkowitz and Marans developed the Child and Family Traumatic Stress Intervention, a brief intervention for children and their caregivers provided by trained mental health professionals. They designed a randomised controlled trial to test whether or not it worked to reduce the likelihood of PTSD developing. The results tantalizingly suggest that it's effective, but that uptake was poor.

Referrals came from paediatric emergency rooms, police, and child welfare and social services departments. Potential respondents were screened for symptoms of trauma over the telephone using standardised screening instruments. Over 100 children and families were randomly allocated to receive either the CFTSI intervention or services as usual.

CFTSI offers four sessions, each lasting no more than 90 minutes. The first session takes place only between the clinician and the primary caregiver of a child. Primary caregivers complete standardised questionnaires about the child’s experiences and the symptoms of trauma. The results of these questionnaires paint a picture of the child’s experiences and areas of distress.

The second session again relies heavily upon the use of standardised PTSD questionnaires, this time completed by the child itself. As described by Berkowitz and colleagues, “the clinician, with the child and caregiver/s, facilitates a comparison of the responses as means of improving communication, which is the presumed prerequisite to enhancing caregiver emotional support.” The use of robust instrumentation thus facilitates a shared understanding of the child’s needs. “Discordance in child and caregiver responses,” say Berkowitz and colleagues, “is seen as an opportunity to increase communication.”

The clinician then proposes two main areas of concern, based upon both child and caregiver responses to questionnaires and discussion, and helps the family choose two of six possible cognitive-behavioural strategies to deal with these specific problems. The family is encouraged routinely to use these strategies in between sessions.

The third and fourth sessions review progress and center on efforts to further enhance child-caregiver communication and support, and to review, adjust and practice cognitive-behavioural strategies to support positive adjustment to trauma.

Results from the first clinical trial the results are positive. Three months after the intervention those children receiving CFTSI showed “significantly fewer full and partial PTSD diagnoses … and lower anxiety scores than the comparison group.” CFTSI thus represents a promising approach to the reduction of PTSD following traumatic events.

However, while CFTSI proved effective at treating those who received the intervention, the greatest challenge was getting needy families through the clinician’s door in the first place. Less than one in four of eligible and needy families actually agreed to participate and stay the course. According to Berkowitz and colleagues, this is because “caregivers are notoriously poor at recognizing acute post-traumatic stress symptoms in their children.” They argue that “it is incumbent upon child-serving systems such as pediatric emergency departments and child welfare agencies to facilitate the identification of exposed children in need of early intervention.”

Berkowitz, S., Smith Stover, C., and Marans, S. (2010). The Child and Family Traumatic Stress Intervention: Secondary prevention for youth at risk of developing PTSD. The Journal of Child Psychology and Psychiatry, 52(6), 676-685.