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Traumatic Stress in Childhood: Minimal Guidance for Primary Care Providers :

February 24, 2016

Despite valiant efforts by this group of investigators, primary care providers have little guidance in implementing screening measures to identify and treatment traumatic stress in children.

Despite valiant efforts by this group of investigators, primary care providers have little guidance in implementing screening measures to identify and treatment traumatic stress in children.

Source: Flynn AB, Fothergill KE, Wilcox HC, et al. Primary care interventions to prevent or treat traumatic stress in childhood: a systematic review. Acad Pediatr. 2015;15(5):480-492; doi:10.1016/j.acap.2015.06.012. See AAP Grand Rounds commentary by Dr. James Anderst (subscription required).

PICO Question: Among children seen in primary care settings, what is the evidence for effectiveness of interventions that prevent or treat childhood traumatic stress?
Question type: Intervention
Study design: Systematic review
Although this study provides no practical advice to front-line healthcare providers, it's interesting to note how these researchers conducted their analysis. It provides the rest of us with a glance at how difficult it is to develop management strategies for important health issues.

The term "systematic review" simply means that a literature review was conducted in a standardized method, and that the method is described well enough that anyone reading the article could perform the same strategy. But that's where the simplicity ends. In this instance, researchers had modest aims: identify primary care interventions for childhood traumatic stress and see how those interventions impacted various outcomes such as ease of implementation in a primary care setting or benefit to patients and families. To do this, they constructed a search methodology that was anything but simple. They searched 8 different literature databases with a strategy focused on 4 topics; the listing of that strategy took up 1/2 page of tiny print. The 4 topics to be combined included "child," which required 22 different search terms, "abuse/trauma," (82 terms!), "mental health," (35 terms), and "primary care" (21 terms). They also searched 3 other web sources, including Google, as well as the reference lists of the articles that made the cut as pertinent studies. They searched only English language studies (a potential limitation - good studies are published in other languages!) and did not require that studies had a control group or any random allocation of intervention.

After all that, they came down to only 10 studies (covered in 12 articles) that were appropriate for further analysis, out of over 1700 identified through their massive literature search. Six of these were randomized controlled trials and 4 were observational studies. The studies were disparate enough that they couldn't perform a formal quantitative synthesis of outcomes, also known as a meta-analysis. Thus, the study is basically a good review of what's been published so far, but nothing to point to a preferred strategy in primary care settings.

The authors spent a bit of space discussing limitations of their study, and I was pleased that they noted that none of the articles went into great attempts to see how screening strategies for traumatic stress impacted/displaced all the other screening and anticipatory guidance activities that child healthcare providers value. It's great if the screening tool can be administered in the waiting room, but that still doesn't take into account analyzing and acting on the results.

The authors also noted that 9 of the 10 articles had favorable outcomes (i.e. there was net benefit to the screening interventions). This is strongly suggestive of publication bias, where studies with negative results (e.g. no benefit of screening) are less likely to be accepted for publication in high quality journals, and finally the authors just give up trying to get the data published.

Overall, the authors did a good job of pointing out the gaps in our knowledge about this subject, but I wouldn't recommend this article to front line providers looking for a tool to implement in their practices tomorrow.
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