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Violence: Psychological Harm from Traumatic Events Among Children and Adolescents – Pharmacological Therapy

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What the CPSTF Found

About The Systematic Review

The Task Force finding is based on evidence from a systematic review of 2 studies (search period through March 2007). The review was conducted on behalf of the Task Force by a team of specialists in systematic review methods, and in research, practice, and policy related to violence prevention.

Context

Pharmacological therapies for symptomatic youth are administered on the assumption that exposure to trauma causes neurochemical disruptions in mechanisms controlling arousal, fear, memory, and other aspects of emotional processing, and that medications can correct these disruptions.

Summary of Results

Detailed results from the systematic review are available in the Task Force finding pdf icon [PDF - 127 kB].

Two studies were included in the systematic review.

  • In one study, children and adolescents aged 2–19 years who had suffered substantial burns and manifested symptoms of acute stress disorder were given either imipramine or chl oral hydrate (the control). They were assessed for symptoms of acute stress disorder prior to 1 week of drug administration and at three points during treatment.
    • Patients given imipramine were 1.2 times more likely (p=0.04) to show a reduction in symptoms than patients given the control treatment.
    • However, post-drug and longer-term outcomes were not assessed.
  • A second study examined the effect of pharmacotherapy on children with a PTSD diagnosis. The beta-adrenergic antagonist, propranolol, was administered for 4 weeks.
    • Subjects showed a significant improvement in PTSD symptoms during treatment, followed by a return to baseline-symptom levels after treatment ended, indicating symptomatic relief while on the medication.

Summary of Economic Evidence

An economic review of this intervention was not conducted because the Task Force did not have enough information to determine if the intervention works.

Applicability

Applicability of this intervention across different settings and populations was not assessed because the Task Force did not have enough information to determine if the intervention works.

Evidence Gaps

Each Community Preventive Services Task Force (Task Force) review identifies critical evidence gaps—areas where information is lacking. Evidence gaps can exist whether or not a recommendation is made. In cases when the Task Force finds insufficient evidence to determine whether an intervention strategy works, evidence gaps encourage researchers and program evaluators to conduct more effectiveness studies. When the Task Force recommends an intervention, evidence gaps highlight missing information that would help users determine if the intervention could meet their particular needs. For example, evidence may be needed to determine where the intervention will work, with which populations, how much it will cost to implement, whether it will provide adequate return on investment, or how users should structure or deliver the intervention to ensure effectiveness. Finally, evidence may be missing for outcomes different from those on which the Task Force recommendation is based.

Identified Evidence Gaps

The following outlines evidence gaps from these reviews on reducing psychological harms from traumatic events: Individual CBT; Group CBT; Play Therapy; Art Therapy; Psychodynamic Therapy; Pharmacological Therapy; Psychological Debriefing.

  • Identification of robust predictors of transient and enduring symptoms following traumatic events would allow for better screening of exposed children and adolescents and more efficient allocation of treatment resources.
  • The optimal timing of cognitive behavioral therapy (CBT) intervention following the exposure and the onset of symptoms is important to assess.
  • It would be useful to stratify the outcomes of CBT treatment by the severity of patient PTSD symptoms and history. For example, it would be useful to know whether children and adolescents with multiple traumatic exposures require more intensive or longer treatment.
  • One study with long term follow-up indicates that it may take a year after the end of the intervention for benefits to appear. This outcome should be replicated. If confirmed, it suggests that follow-up periods of less than one year are not adequate and may erroneously indicate intervention ineffectiveness.
  • The cost effectiveness and differential cost effectiveness of individual and group CBT among children and adolescents should be explored.
  • The effectiveness of individual and group CBT among minority populations, especially in communities in which violence is prevalent, should be further explored.
  • Adaptations of CBT involving the recruitment, training, deployment, and supervision of nonprofessionals should be evaluated, and their applicability to low-income countries should also be explored.

Furthermore, the finding of insufficient evidence to determine the effectiveness of several of the interventions reviewed highlights the need for additional well-controlled studies of these interventions. Because CBT has been found to be an effective intervention, and because research funds are limited, it would be useful to adopt CBT as a comparison in future evaluations. Because of harms reported for psychological debriefing among adults, caution should be taken in research on this intervention with children and adolescents.

Study Characteristics

  • In one study, children and adolescents aged 2–19 years who had suffered substantial burns and manifested symptoms of acute stress disorder were given either imipramine or choral hydrate (the control).
  • In another study, children with PTSD were given beta-adrenergic antagonist, propranolol for 4 weeks.

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