CHILD ABUSE & NEGLECT
Primary Care Interventions for Traumatic Stress in Children
Source: Flynn AB, Fothergill KE, Wilcox HC, et al. Primary
care interventions to prevent or treat traumatic stress in child-
hood: a systematic review. Acad Pediatr. 2015;15(5):480-492;
doi:10.1016/j.acap.2015.06.012
R
esearchers from Johns
Hopkins University
PICO
Question: Among children seen in
conducted a systematic primary care settings, what is the
review of published studies to evidence for effectiveness of interventions
identify the types of interven- that prevent or treat childhood traumatic
stress?
tions that have been implement-
Question type: Intervention
ed in primary care settings to
Study design: Systematic review
prevent and/or treat traumatic
stress, and to assess their effec-
tiveness on provider behavior and/or patient outcomes. The authors
used a systematic search strategy to identify relevant studies. Articles
selected for inclusion were peer-reviewed research articles, pub-
lished in English, that described a primary-care-based intervention
to prevent or treat traumatic stress in children. The authors used a
standardized data extraction tool and assessed each selected article
for bias using the Cochrane “Risk of Bias” tool. Included studies
were both randomized controlled trials and observational studies in
which the effect of the intervention on either health care professional
attitudes and behaviors and/or parents/children was assessed.
A total of 1,735 articles were initially identified by the search
strategy. After applying inclusion criteria, 12 articles encompassing
10 studies were included in the final review. Of those 10 studies, 5
reported behavioral or attitude outcomes among health care profes-
sionals, 3 reported outcomes among parents and/or children, and
2 reported outcomes among both health care professionals and
parents/children. In 4 studies, the intervention included teaching
clinicians to use a specific model or screening questionnaire with as-
sociated follow-up based on screen answers. These included the Safe
Environment for Every Kid (SEEK) Parent Screening Questionnaire
(PSQ), the Pediatric Symptom Checklist (PSC), and the WE CARE
family psychosocial screening tool. Other studies detailed interven-
tions such as referrals to parenting programs, a telephone-based
parenting curriculum, and referrals to nurse case management,
among others. Most interventions had multiple components, making
evaluations of the specific components difficult.
Among primary care providers, the interventions increased
screening rates and clinician confidence to carry out screening,
improved self-assessments by clinicians, and increased awareness
of community resources. Among parents and children, 4 of 5 stud-
ies provided evidence of reduced risk or occurrence of trauma or
increases in referrals to community resources. One identified an
improvement in Child Behavior Checklist scores 9 months after
baseline assessment. In another study, lower rates of maltreatment
in both high- and low-risk populations 1 year or more after baseline
were found in children exposed to the intervention. Outcomes dem-
onstrated in other studies included increased referrals to social work,
less harsh punishment reported by parents, and fewer child injuries
resulting from fights with peers.
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Risk of bias for the included studies was generally low; however,
2 of the 4 randomized trials reporting clinical outcomes did have
high risk of bias. Additionally, the diversity of studies precluded the
possibility of conducting a meta-analysis, and cost-effectiveness and
sustainability were not addressed in the included studies.
The authors conclude that interventions in primary care settings
are feasible, and these interventions can positively affect clinical
practices and family outcomes.
Commentary by
James Anderst, MD, MSCI, FAAP, Child Abuse Pediatrics, Children’s Mercy
Hospital, UMKC School of Medicine, Kansas City, MO
Dr Anderst has disclosed no financial relationship relevant to this commentary. This commentary does not contain a
discussion of an unapproved/investigative use of a commercial product/device.
There is increasing interest in the prevention and treatment of
psychological and physical trauma in children, often termed toxic
or traumatic stress.1,2 Traumatic stress in childhood occurs when
children are exposed to traumatic situations that overwhelm their
ability to cope.3 Many of the studies identified in this systematic
review provide evidence for some benefit of primary care interven-
tions to parents/children. However, none of these interventions were
evaluated for true feasibility and outcomes in larger numbers and
various types of practices. Additionally, many of the studies focused
on process measures, such as increased referrals or improved clini-
cian confidence. Only a few detailed true patient outcomes.
As medicine, particularly pediatrics, drifts away from drugs and
procedures as its primary means of intervention, more studies evalu-
ating the impacts of psychosocial interventions are needed. The chal-
lenges of today and tomorrow are less likely to be fixed by procedural
or medication-based interventions, and more likely to be addressed
by the types of studies described within this systematic review. The
lack of studies of this nature (only 10 were identified by the search
strategy) indicates that the science behind the approach to solving
psychosocial problems lags behind the seriousness of the problems.
References
1. Flaherty EG, et al. Pediatrics. 2010;126(4):833-841; doi:10.1542/peds.2010-2087
2. Garner AS, et al. Pediatrics. 2012;129(1):e224-e231; doi:10.1542/peds.2011-2662
3. National Child Trauma Stress Network. Defining trauma and child traumatic stress. Avail-
able at: www.nctsnet.org/content/defining-trauma-and-child-traumatic-stress. Accessed
November 30, 2015
Key words: traumatic stress, prevention, children
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 Primary Care Interventions for Traumatic Stress in Children
AAP Grand Rounds 2016;35;21
DOI: 10.1542/gr.35-2-21

The online version of this article, along with updated information and services, is located on
the World Wide Web at:
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