Violence Prevention: Psychological Harm from Traumatic Events Among Children and Adolescents – Play Therapy – Inactive

The CPSTF 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 CPSTF by a team of specialists in systematic review methods, and in research, practice, and policy related to violence prevention.

Play therapy connects concrete experience and abstract thought while allowing the child to safely express experiences, thoughts, feelings, and desires that might be more threatening if addressed directly.

Detailed results from the systematic review are available in the CPSTF finding.

Two studies were included in the systematic review.

• All of the effect sizes reported were in the desirable direction across all of the studies and outcomes.

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

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

The CPSTF identified several areas that have limited information. Additional research and evaluation could help fill remaining gaps in the evidence base. (What are 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.

• There were substantial differences between the included studies in terms of index exposure and play-therapy implementation.
• One study assessed the effectiveness of a program for children exposed to an earthquake in Taiwan; the other study assessed a program for children exposed to domestic violence who were living in women’s and homeless shelters.

Wethington HR, Hahn RA, Fuqua-Whitley DS, et al. The effectiveness of interventions to reduce psychological harm from traumatic events among children and adolescents: a systematic review. American Journal of Preventive Medicine 2008;35(3):287-313.

Task Force on Community Services. Recommendations to reduce psychological harm from traumatic events among children and adolescents. American Journal of Preventive Medicine 2008;35(3):314-6.

Effectiveness Review

Analytic Framework

When starting an effectiveness review, the systematic review team develops an analytic framework. The analytic framework illustrates how the intervention approach is thought to affect public health. It guides the search for evidence and may be used to summarize the evidence collected. The analytic framework often includes intermediate outcomes, potential effect modifiers, potential harms, and potential additional benefits.

Effectiveness Review

Summary Evidence Table
Contains evidence from reviews of individual CBT; group CBT; play therapy; art therapy; psychodynamic therapy; pharmacological therapy; psychological debriefing

The number of studies and publications do not always correspond (e.g., a publication may include several studies or one study may be explained in several publications).

Effectiveness Review

Kot S, Landreth GL, Giordano M. Intensive child-centered play therapy with child witnesses of domestic violence. Int J Play Therapy 1998;7:17 36.

Shen Y. Short-term group play therapy with Chinese earthquake victims: effects on anxiety, depression, and adjustment. Int J Play Therapy 2002;11:43 63.

Smith N, Landreth G. Intensive filial therapy with child witnesses of domestic violence: a comparison with individual and sibling group play therapy. Int J Play Therapy 2003;12:67 88.

Tyndall-Lind A, Landreth GL, Giordano MA. Intensive group play therapy with child witnesses of domestic violence. Int J Play Therapy 2001;10:53 83.

The following outlines the search strategy used for these reviews on reducing psychological harms from traumatic events: Individual CBT; Group CBT; Play Therapy; Art Therapy; Psychodynamic Therapy; Pharmacological Therapy; Psychological Debriefing.

Effectiveness Review

Electronic searches for literature were conducted in the MEDLINE; EMBASE; ERIC; NTIS (National Technical Information Service); PsycINFO; Social Sciences Abstracts; and NCJRS (National Criminal Justice Reference Service) databases for all dates up to March 2007. Search terms included the generic and specific terms for treatments, different forms of trauma, and terms such as evaluate, effective, and outcome. Also reviewed were the references listed in all retrieved articles; researchers also consulted with experts on the systematic review development team and elsewhere for additional studies. Studies published as journal articles, government reports, books, and book chapters were considered.

1. (THERAPY OR THERAPIES OR COUNSELING OR DEBRIEFING OR (CRITICAL()INCIDENT(2W)MANAGEMENT) OR SCREENING OR INTERVENTION? OR CISD OR CISM)/TI,AB
2. (CHILD? OR TODDLER? OR YOUTH? OR ADOLESCENT? OR INFANT? OR BABY OR BABIES OR PEDIATRIC? OR TEEN OR TEENS OR TEENAGER?)/TI,AB
3. (VIOLENCE OR VIOLENT OR DISASTER? OR FIRE OR CHILD()ABUSE? OR SEXUAL()ABUSE? OR RAPE OR WAR OR TRAUMA? OR TERRORIST OR TERRORISM OR CRISES OR CRISIS OR PTSD OR POST()TRAUMATIC OR POSTTRAUMATIC OR POST-TRAUMATIC OR DROWNING OR BOMBING …
4. (EVALUAT? OR EFFICACY OR EFFECTIVE? OR ASSESSMENT? OR OUTCOME?)/TI,AB
5. S1(20N)S2
6. S1(20N)S3
7. S1(20N)S4
8. S5 AND S6 AND S7
9. (ADULT? OR BLOOD OR XRAY? OR X-RAY? OR BRAIN()INJUR? OR PERSONNEL OR MANPOWER OR CRANIOCEREBRAL OR HEAD()TRAUMA OR ASTHMA OR BRONCHODILATOR OR KIDNEY? OR LUNG? OR CRIMINOLOGY OR COUPLE?()THERAPY OR CHILD()ABUSE()PREVENTION)/DE
10. 10 S8 NOT S9
11. (ADULT? OR BLOOD OR XRAY? OR X-RAY? OR BRAIN()INJUR? OR PERSONNEL OR MANPOWER OR CRANIOCEREBRAL OR HEAD()TRAUMA OR ASTHMA OR BRONCHODILATOR OR KIDNEY? OR LUNG? OR CRIMINOLOGY OR COUPLE?()THERAPY OR CHILD()ABUSE()PREVENTION OR SURGER? …
12. S8 NOT S11
13. (RISK? OR SCREEN?)/TI
14. S12 NOT S13
15. RD (unique items)
16. (ADULT? OR WOMAN OR WOMEN)/TI
17. S15 NOT S16
18. (CHILD? OR TODDLER? OR YOUTH? OR ADOLESCENT? OR INFANT? OR BABY OR BABIES OR PEDIATRIC? OR TEEN OR TEENS OR TEENAGER?)/TI
19. S17 AND S18
20. (VIOLENCE OR VIOLENT OR DISASTER? OR FIRE OR CHILD()ABUSE? OR SEXUAL()ABUSE? OR RAPE OR WAR OR TRAUMA? OR TERRORIST OR TERRORISM OR CRISES OR CRISIS OR PTSD OR POST()TRAUMATIC OR POSTTRAUMATIC OR POST-TRAUMATIC OR DROWNING OR BOMBING …
21. S19 AND S20

The CPSTF did not have enough evidence to determine whether the intervention is or is not effective. This does not mean that the intervention does not work, but rather that additional research is needed to determine whether or not the intervention is effective.