Pediatric patients hospitalized for physical injury who received an online therapist-assisted trauma-focused intervention had lower posttraumatic stress symptom scores compared with usual care at 10 weeks following randomization, with improvements maintained at 6 months, according to a randomized clinical trial published in JAMA Pediatrics.
The findings offer early evidence toward addressing a growing gap in pediatric trauma care as more trauma systems adopt screening protocols for psychological sequelae following injury but have limited evidence-based guidance regarding treatment after a positive screen.
“Current [American College of Surgeons] standards stop short of defining what evidence-based care should entail once a child screens positive or meets criteria for clinically significant posttraumatic stress,” wrote Shawn J. Rangel, MD, MSCE, of Boston Children’s Hospital and Harvard Medical School, in an accompanying editorial.
Researchers evaluated the Reducing Stress After Trauma (ReSeT) program among 93 pediatric patients aged 8 to 17 years who had persistent posttraumatic stress symptoms 4 weeks following injury. Patients were recruited from inpatient wards, pediatric intensive care units, surgical units, and short-stay units at 4 level 1 pediatric trauma centers between July 2021 and September 2024.
Of 1,653 potential participants identified, 722 agreed to initial screening, 271 completed symptom screening assessments at 1 and 4 weeks following injury, and 93 ultimately underwent randomization.
Eligibility for randomization required a combined parent- and child-reported Child Posttraumatic Stress Disorder Scale score of at least 11 at the 4-week assessment. Researchers determined the combined score using the higher parent or child response for each symptom item.
Patients were randomly assigned 1:1 to the ReSeT intervention or usual care. The primary outcome was the combined parent- and child-reported symptom score at 10 weeks following randomization, and the secondary outcome was the score at 6 months.
At 10 weeks, adjusted mean symptom scores were 10.5 in the ReSeT group and 14.7 in the usual-care group. At 6 months, adjusted mean scores were 8.0 and 13.5, respectively. Researchers reported moderate effect sizes at both time points, with treatment effects appearing somewhat larger at 6 months compared with 10 weeks.
The Child Posttraumatic Stress Disorder Scale ranges from 0 to 51, with scores of at least 11 used to identify elevated symptoms in this study. Researchers noted that by 6 months, the mean score in the ReSeT group had fallen below both the enrollment threshold and a more stringent cutoff score of at least 15 that has shown strong sensitivity and specificity in injured pediatric patients.
The ReSeT program included 8 online psychoeducational modules containing interactive videos followed by telehealth sessions with a therapist to practice cognitive behavioral skills, cognitive reframing, coping strategies, relaxation techniques, and trauma narrative desensitization exercises.
Therapists delivering the intervention were advanced graduate students in clinical psychology supervised by licensed clinical psychologists, a model that may have implications for scalability and workforce implementation.
Optional caregiver modules addressed stress management, positive caregiving strategies, and sleep concerns. Among patients assigned to ReSeT, 81% completed all 8 sessions, with average therapist contact time totaling approximately 5 hours across sessions.
Researchers also reported that parental engagement in therapy sessions declined with increasing patient age, suggesting implementation challenges may differ between younger pediatric patients and adolescents.
Usual care varied substantially across participating centers and ranged from no formal psychological screening to referral information for behavioral health services or brief trauma-focused cognitive behavioral therapy. This heterogeneity may complicate interpretation of treatment effect size relative to a standardized comparison condition.
In addition, patients assigned to usual care were permitted to receive outside psychological support during the study period, introducing the possibility of control-group contamination.
Exploratory analyses using separate child- and parent-reported symptom scores also favored the ReSeT intervention. Researchers additionally evaluated outcomes using a more stringent prerandomization symptom cutoff score of at least 15; approximately 76% of enrolled patients met that threshold, and findings remained consistent with the primary analysis.
Per-protocol analyses also produced results consistent with the intention-to-treat findings, suggesting treatment effects were not solely attributable to protocol nonadherence.
Subgroup analyses suggested larger treatment-associated reductions in symptom scores among male patients compared with female patients. Male patients in the intervention group demonstrated an approximately 7-point treatment difference, whereas female patients demonstrated little difference between groups. Researchers cautioned that the confidence interval surrounding the male subgroup estimate was broad.
The researchers further emphasized that the study was not powered for subgroup analyses, sex was not included as a stratification variable during randomization, and older female patients were disproportionately assigned to usual care, limiting confidence in the subgroup findings.
The researchers noted several limitations that may affect generalizability. The trial excluded patients with moderate to severe traumatic brain injury, severe developmental disorders, severe preexisting psychiatric illness requiring hospitalization, current psychotherapy, injuries related to abuse or interpersonal violence, hospitalization longer than 30 days, or lack of broadband internet access. Non–English-speaking families also were excluded.
In addition, the enrolled population appeared relatively socioeconomically advantaged, with most families reporting commercial insurance coverage or household income at least twice the federal poverty level.
Researchers also used symptom-scale assessments rather than structured clinical interviews to evaluate posttraumatic stress symptoms, and follow-up was limited to 6 months. Adverse events were collected nonsystematically, and none were reported, limiting conclusions regarding safety monitoring.
Dr. Rangel also emphasized that the enrolled cohort may not reflect the higher-risk pediatric patients and families who face the greatest barriers to mental health care access, including socioeconomic strain, language barriers, housing instability, and caregiver burden.
The study was funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development.
Lead study researcher Linda Ewing-Cobbs, PhD, of the Children’s Learning Institute and Department of Pediatrics at McGovern Medical School at UTHealth Houston, reported receiving grants from the National Institutes of Health and the Department of Defense during the study. Several co-researchers reported support from the National Institutes of Health, the Centers for Disease Control and Prevention, the Patient-Centered Outcomes Research Institute, the National Institute on Disability, Independent Living, and Rehabilitation Research, and the Toyota Way Forward Fund outside the submitted work. Dr. Rangel reported no conflicts of interest.
Source: JAMA Pediatrics