A recent article in the journal Pediatrics by Adam Zolotor and Valerie Forman-Hoffman found remarkably few effective mental health treatments for children who had been exposed to school shootings, looting, war, gang violence, and the like.
Or are there?
It’s easy to become alarmist when we read that of the 6,647 published articles in academic journals that were reviewed, only 25 reported enough evidence for Zolotor and Forman-Hoffman to say whether the intervention had made a positive change in a child’s life. The other 6,622 didn’t make the cut because they didn’t include a control group, showed bias, or simply didn’t include enough details to make a fair comparison of results possible.
Putting aside the sensationalist headline, what the meta-analysis of results really tells us is that it is darn difficult to do research on programs for traumatized kids in real-world settings. Good treatment is messy. Most of the studies that Zolotor and Forman-Hoffman included in their review were done in very structured environments like university-based clinics. The small community mental health centres where most of us go to get our kids treatment were not the standard research setting. Instead to reach the level of rigor necessary to be deemed an exemplary intervention, the work had to be done by academics in research hospitals and similar settings.
Does that mean nothing works? Are academics publishing useless studies by the thousands? Is there really so little that can help our kids? Or is this science at its most abstract, detached from the realities of how kids get help when they need it?
Let’s be frank….unless a treatment is designed in a way that lets it be highly controlled and measured, it is going to be difficult to assess how well it helps children heal. That usually means one kind of treatment, and one treatment only: cognitive behavioral therapy. CBT, as it’s commonly referred to, is great for researchers to study. It’s easy to spell out each step of the treatment in a manual. It has a good, simple-to-use theory. It’s time limited. It also ignores a child’s context, like whether there is still violence in the child’s life. It ignores culture. It seldom considers whether children (and their parents) attribute meaning to traumatic events in ways that are different from those doing the treatment. And it is unclear how long the results last. After all, if a child’s family, school and community haven’t changed much, but the child has, how long can we expect the child’s newly discovered mental health to be sustain?
There are likely many other therapies that work just fine for our children should the unthinkable happen and they are exposed to horrendous violence. There are practices that involve story-telling (narratives), mindfulness, play, in-home support, residential treatment, recreation, outdoor adventure, fostering attachments, and mentorship, all of which may help your child. Many of these treatments are messy. They can’t be contained to a few well-scripted sessions. Individual therapists have to think on their feet. Culture and context matter. No surprise, then, results are more difficult to prove even when there is plenty of anectodal evidence that these approaches are as or more effective as CBT.
My own model of clinical practice is called the Social Ecological Approach to counselling (S.E.A. for short, which has a nice ring to it since I live next to the ocean). Like many other approaches, it acknowledges that kids live in challenging contexts and unless we change a child’s environment we can’t sustain behavioral changes that the child makes. I like to say that S.E.A. reminds us to ask a child with a problem like attention deficit hyperactivity disorder (ADHD) to tell us what she needs her parents, educators, and counsellors to change to make it easier for her to learn, rather than insisting that change is up to the child alone. CBT is fine, but without working at the same time on adapting the child’s environment to be more supportive and resilience-promoting, change will be short-lived for children with complex needs.
The difficulty for the researcher is keeping such a dynamic, multi-level intervention simple enough to measure outcomes, especially when a child lives in a place where there is bullying, racial violence, poverty, his parent has a mental illness, or he’s been abandoned by his caregivers and placed in residential or foster care. Do the effective therapies discussed in Pediatrics account for such complexity, or were the children who live with these challenges simply ignored when the CBT studies were carried out?
Let me be clear…CBT works. It works well with populations of traumatized kids who get to see a well-trained therapist. It works well when the child returns home to a supportive environment. But it likely works even better and for much longer when change occurs at the level of the child’s environment at the same time. It is also not the only intervention that works, but it is the easiest one to assess because it fits tidily into a research paradigm that doesn’t tolerate the messiness of real life barriers to change.