Ever since the horrific shootings at Connecticut's Sandy Hook Elementary School in December, Mary Jo Barrett has been getting a steady stream of phone calls from therapists treating the schoolchildren who survived.
How should they proceed, they ask Ms. Barrett, an internationally renowned expert in child trauma. With parent-child interaction therapy? Cognitive behavioral therapy? Art therapy? Yoga therapy?
One child is going home to a mother "who is completely fragmented and derailed," noted Ms. Barrett, executive director of the Center for Contextual Change in Chicago, an integrative trauma center. "So in that case, I told the therapist that the focus has to be on doing some work with the mother."
There is, she notes, "no one-size-fits-all."
But in an article published in the journal Pediatrics earlier this month, some researchers said that's exactly the problem. Because of inadequate research, there is no consensus about what works and what doesn't.
"Based on the evidence, we can make very few recommendations about what the best treatment is for children," said Valerie Forman-Hoffman, a psychiatric epidemiologist at RTI International, a research institute in North Carolina and one of the authors of the study. It was commissioned by the federal Agency for Healthcare Research and Quality as part of a regular "comparative effectiveness review" of federally funded research.
However, trauma-focused cognitive behavior therapy -- developed in part by Judith Cohen and Anthony Mannarino at Allegheny General Hospital -- did get good marks in the Pediatrics study for its step-by-step approach of relaxing the child, teaching coping strategies and visualization to control disturbing thoughts and helping the child construct a personal story about what happened.
But Dr. Cohen isn't returning the favor. She noted that the Pediatrics study made an unnecessary distinction between "nonrelational" trauma -- one-time events such as shootings, accidents or natural disasters -- and the far more common "relational" traumas experienced by children in homes with domestic violence or sexual abuse.
"There is this presumption that there are critical differences between these different kinds of trauma, when in fact there is no evidence to back up that premise. Our current understanding of trauma is that there are many more commonalities than there are differences in how children respond to treatment for multiple types of traumas."
Indeed, the researchers in the journal article seemed to be aiming at a particular audience, perhaps on Capitol Hill, said David Kolko, professor of psychiatry, psychology and pediatrics at the University of Pittsburgh School of Medicine, "which perhaps is a prudent approach to stimulating financial support for additional research on trauma from a political viewpoint."
Dr. Kolko has been the lead developer of another widely used therapy for family conflict, called Alternative For Families: A Cognitive Behavioral Therapy, which involves skills training with caregivers and their children. Work focuses on helping children learn to self-regulate their emotional responses -- "to adjust the thermostat" -- when they have distressing or upsetting reactions to traumatic events.
The researchers in the Pediatrics study issued "a call to action" for more funding and research, an appeal perhaps aimed at those members of Congress who might hesitate to fund studies of children traumatized by frequent gun violence in Chicago or Philadelphia -- but jump at the opportunity to do something for victims of school shootings such as those in Newtown, Conn., where Adam Lanza killed 20 first-graders and six staff members before killing himself.
"With Sandy Hook, some of those kids will do just fine with a debriefing, while others may require completely different measures," said Ms. Barrett. "The model I use is organizational therapy -- which means, quite simply, to organize therapies and responses around the needs of the patient, whether it's art or play therapy, or cognitive therapy. I suppose we don't know what really works best, except from what the clients tell us."
Ms. Forman-Hoffman, Adam Zolotor and other members of the federal research team waded through a database containing more than 6,000 study abstracts and found only 25 that were relatively large, randomized and controlled -- but nonetheless relatively inconclusive.
This silo approach to child trauma, "in which each treatment is studied individually rather than recognizing commonalities that unify children's trauma experiences and responses," is wrongheaded, Dr. Cohen said. "More recently the field has recognized therapies that work for multiple types of traumas so it is really disheartening to see the previous silo approach perpetuated in the current study."
Cognitive behavioral therapy is well tested, and the AGH studies have been replicated 13 times, she added. It's a step-by-step, gradual approach, rather than the old "debriefing" method, in which victims of traumatic events were herded into a room and told to talk.
"Say it's a school shooting and you're a 7-year-old. In my first meeting, I might explain that your brain puts out certain chemicals that make you jumpy, or if you hear something that sounds like thunder, your whole body reacts as if the shooting were happening all over again. It feels dangerous although part of your brain knows it's not. We retrain your brain so it knows the difference," she said.
Cognitive behavioral therapy does that through relaxation techniques and then "we teach them to change the channel. When a bad thought comes into their mind, we show them how to stop that thought, and think of something else. They realize they have control over their feelings."
Then comes the trauma narrative, where, "through the telling of it, they master their fears of it. There are no longer these memories controlling them. They make the unspeakable, speakable."
This process can take four to five months, depending on the age and how many traumas have been suffered. "Some will draw a picture, although a 3-year-old may just play."
It's not clear what method will be used in Connecticut but the AGH researchers' training has been adopted across the country.
"We've had many kids who have experienced school violence in our studies, and we know it's going to work with kids like those in Newtown," Dr. Cohen said.
Ms. Barrett, a family therapist and social worker, agreed with Dr. Cohen's criticism of the Pediatrics study's decision to focus only on nonrelational trauma. "The child is always in a relational situation. A young adult came to me the other day and said his friend had just committed suicide. That was one event, but it brought up all sorts of other traumas he had suppressed."
Dr. Zolotor, co-author of the Pediatrics study, is a family physician and a researcher based in North Carolina, but not a psychologist. Still, he says combining relational and nonrelational traumas doesn't make as much developmental sense to him as a treatment that focuses on what caused the trauma symptoms to develop. "If I have depressed symptoms because my mom beat me, or somebody I don't know got shot and I saw it, the treatments are probably going to be different."
The problem is trying to unify the people from different fields, he added.
"No one really owns this topic," said Denise Dowd, an emergency physician and research director at Children's Mercy Hospitals and Clinics in Kansas City, Mo., who wrote an editorial about the study in Pediatrics. "We need to get all of these people -- criminologists, educators, psychologists, psychiatrists, social workers, physicians -- together to come up with some consensus."
Sometimes a single event does seem easier to treat, said Cindy Snyder, a child and family therapist in Pittsburgh who does clinical consultations for the Center for Victims of Violence and Early Head Start. "When it's one isolated episode, the work tends to be fairly straightforward and moves smoothly," she said.
Little is known about what treatment the children at Sandy Hook Elementary are receiving, but recent media reports say that they have been transferred to another school in another area that is nonetheless retrofitted to look exactly like Sandy Hook -- down to the scrawled crayoned pictures on the wall to the backpacks in the locker.
"My prediction is that the effects of Sandy Hook will vary across the board and for lots of reasons," said Ms. Snyder. "It depends on whether there are healthy attachments and also the response by the family -- what happens if the parents are so wrapped up in their own responses that they are not be able to meet the child's emotional needs." Indeed, she said, "Everybody's trying to come up with a simple approach to what will always be a complex problem."
Mackenzie Carpenter: email@example.com or 412-263-1949.