Preparation for Child Psych PRITE and Boards
This article talks about traumatic events, PTSD, and its assessment and treatments. Abuse is discussed in that context. For specific psychiatric, forensic, and medical-legal aspects of abuse and neglect, see dedicated article on maltreatment. Criminal behavior and violence are addressed elsewhere as well. Psychological and traumatic consequences of divorce are addressed here; questions of custody are mentioned in a dedicated article.
- At least 25% children and adolescents will experience a significant traumatic event during the first 17 years of life. About 30% of them will develop a form of PTSD.
- M:F distribution is about 1:1 in childhood; it increases more rapidly in female adolescents, and becomes 1:2 in teenage years.
- In the large US Survey (n=10,123) of Adolescents 13-18 yo, PTSD was found in 8% of adolescent females, and 2.3% of male teenagers. (Merikangas, JACAAP 2010)
Divorce of parents doubles a child's risk of having significant adjustment and psychosocial difficulties. (Lewis, 1007) The degree of interparental conflict is highly correlated with child's difficulty adjusting to the divorce.
Neglect, Physical and Sexual Abuse
- Neglect is the the most common form of child maltreatment.
- Of the adults caring for a child, it is the parents who are most likely to physically abuse their child. 80% of child maltreatment incidents are perpetrated by the parents. Adolescent fatalities from abuse are most often caused by the fathers (or primary male caregiver), while both parents contribute equally to death of children. Newborns (up to 3-4 weeks old) are most likely to be abused by and die at the hands of their mothers.
- Sexual abuse is a major risk factor for adolescent depression, substance use, conduct disorder, as well as suicide attempt and reattempt.
- Up to 20% of adolescent suicide attempts are attributed to sexual abuse-related PTSD; these adolescents are also eight times more likely to reattempt suicide as compared to their suicidal peers who were not sexually abused. (JACAAP PTSD parameter p.416)
DSM-IV-TR and Other Diagnostic Considerations
To be diagnosed with PTSD a patient should have symptoms in 3 categories following a significantly traumatic event, reaction to which included fear, helplessness, or, in the case of children, agitated or disorganized behavior. The three symptom categories are
- Reexperiencing the traumatic event in some way, which includes intrusive thoughts, flashbacks, specific nightmares, and physiological distress at exposure to various trauma-related cues. Children can reexperience trauma in their play, which manifests itself as trauma reenactment; this is equivalent to flashbacks in adults. Repetitive play is another form of behavioral reaction to reexperiencing trauma.
- Avoidance, numbing, and withdrawal category, from which a pt. should have at least 3 symptoms. Symptoms from this category are rarely reported by young children, but an astute parent or a teacher can sometimes pick them up. Since these symptoms require a high degree of self-awareness, it is often difficult to meet this diagnostic criteria even in clearly traumatized children.
- Increased state of arousal following the trauma, from which the patient will have at least 2 symptoms.
- If less than 1 month had passed since the traumatic experience, a diagnosis of adjustment disorder or acute stress disorder should be made.
- Acute PTSD signifies a disorder in which symptoms are still present 1mo following trauma and persist for up to 3 months from the incident.
- If symptoms persist for more than 3 months, a diagnosis of Chronic PTSD is made.
Other Diagnostic Terms
- Complex PTSD is a non-DSM-IV term that refers to symptoms that develop as a result of experiencing early, persistent, and/or severe trauma.
- Developmental trauma disorder is a term proposed to describe complex PTSD in children in adolescents (Van der Kolk). The term emphasize the fact that PTSD in children may present with different symptoms and patterns of dysregulation, depending on developmental age and chronicity of trauma; it also may have different trajectory than the PTSD described in the DSM-IV.
- Bereavement is the condition of loosing a close relative.
- Grief is the intense emotion that one feels during bereavement.
- Mourning involves various the religious, ethnic, and community practices associated with bereavement.
Uncomplicated bereavement in children resembles depression, (e.g. experiencing great sadness, grief, crying, loss of interests, withdrawing from others, loss of appetite and sleep, difficulty paying attention in school, and perhaps (especially in younger children) searching or asking for the deceased person. Just like in adults "pangs" of grief are common in children and they may surprise and scare caregivers.
Childhood traumatic grief or complicated grief is a condition that resembles childhood PTSD with inability to move through the stages of grief and accompanied by functional impairment. (Cohen and Mannarino J Clin Child Adolesc Psychol 2004)
- Treatment of complicated grief involves modified CBT and/or Child-parent psychotherapy (CPP), a relationship-based treatment developed for infants and preschoolers exposed to domestic violence (Dulcan text pp.510-12)
Additional Pediatric Considerations
- The event itself needs not to be violent or life-threatening, or at all threatening to the patient. Children may succumb to PTSD after
- experiencing an event in which their sense of security in their caregiver was compromised,
- a developmentally inappropriate sexual experience,
- experiencing neglect without violence or injury.
- While DSM-IV provides some child-specific PTSD symptoms, they may not necessarily describe every traumatized child. Following trauma, youth may present with somatic symptoms, behavioral disturbances, dysregulation of mood/affect and cognition. Some children may be misdiagnosed as having a mood disorder or a disruptive behavior disorder. It is difficult for children to report avoidance/numbing/withdrawal symptoms, of which three are required, making the DSM-IV diagnosis even more difficult.
- Since Category C symptoms (withdrawal/avoindance/numbing), of which 3 are required for the diagnosis, are difficult for children to describe and for parents to report, some changes were proposed and validated in preschool children. These changes include, among others (Scheeringa MS):
- requiring only 1 symptoms from the avoidance/withdrawal/numbing category,
- recognizing constriction of play as the "diminished interests in activities" symptom,
- recognizing observable signs of social withdrawal as a symptom of "feeling of detachment and estrangement from others"
- Other associated symptoms in children include aggressive behavior which was not present before the trauma, regression, particularly in toilet training, and new separation anxiety.
- Parental distress and PTSD following a traumatic event is an important risk factor for developing PTSD in a child. Parental support, effective coping by a parent are protective factors.
Assessment of pediatric PTSD follows the principles of general assessment. Some important considerations should be noted:
- Child's pre-trauma functioning and developmental level should be established, since regression in skills, knowledge, and emotional self-regulation is very common.
- Caregivers play an important role as stress mediators in child's life, and child will reference and mirror parent's reaction to trauma. Fear for own life or well-being is not necessary for diagnosis of PTSD. In fact, witnessing a threat to, or a significant distress by, a caregiver can result in significant PTSD in children; having a caregiver who is overwhelmed or had been threatened makes for poorer outcome prognosis, particularly in younger children.
- It is important to capture the child's world following the trauma. Presence of supportive caregivers who provide attention and structure as well as absence of secondary adversities (withdrawn parent following a death, various hardships following a natural disaster, slow recovery from own injury following a car accident, etc.) signify better prognosis.
- Experiencing panic attacks shortly after experiencing trauma predict development of PTSD in children. (JAACAP)
Natural Disasters and Other Large-Scale Events
- Screening of victims for PTSD and other mental health needs is most effective when at least a few weeks had passed since the traumatic event.
- Parents and relatives, who themselves are often affected by the disaster, may not recognize the child's symptoms and needs. Thus, mere availability of services is inadequate; active, targeted outreach and follow-up are essential.
Neuropathology and Imaging
Smaller cerebral volume and a smaller corpus collosum are often seen in children exposed to domestic violence and those subjected to abuse. (De Bellis)
Smaller hippocampus is seen in adults with child abuse-related PTSD. These findings are not seen in abused children, suggesting long-term effect of abuse on neural development.
Higher NE, DA, and free cortisol are found in urine of abused and neglected children.
Treatment of Trauma and PTSD
Education (What Caregivers Should and Shouldn't Do)
A child needs to cope and process a traumatic experience. To a great detriment, parents may be tempted to avoid mentioning the traumatic event, to try and distract the child when he remembers it, or to pretend that nothing happened. Instead, caregivers should provide emotional support to the child, tolerate stress-induced regression, and help reestablish structure in child's life after the trauma, by encouraging age-appropriate activities and discussions. This is particularly true if the traumatic experience involved loss of a parent/relative who played a central role in his or her life. In a case of death of a caregiver, a child needs to grieve the loss, not unlike the rest of the family. A child should be included in family rituals (including a funeral), but not against his will.
It is important for the caregivers to be able to comfort the child following trauma, even if they themselves are distressed.
Prevention and Early Interventions
Following a communitity-level traumatic event, screening for PTSD should ideally take place a month after the incident. This is supported by the facts that symtpoms of PTSD may develop several weeks following the trauma and that early symptoms often resolve with few consequences.
Reparative drawings and similar activities are part of the process of sharing inner experiences through play and have an important role in the early stages of treatment. This can include rebuilding a house from Lego bricks after a fire at home or drawing a healthy relative after witnessing her injury. (Wiener text) Debriefing is a process commonly employed following mass disasters and other traumatic experiences; it should be facilitated by trained professionals, as there is some evidence from adult literature that debriefing can even be harmful. The optimal time between the traumatic event and the debriefing has not been established. It must be emphasized, however, that early debriefing is not sufficient for screening of affected individuals for PTSD and other future mental health needs.
Of all interventions, CBT, and specifically, trauma-focused CBT (TF-CBT), is supported by the strongest evidence in treatment of pediatric PTSD.
- Anxiety and the core symptoms of PTSD hyperarousal are best treated with thought stoping, progressive muscle relaxation, breathing, and positive imagery techniques.
- Symptoms of avoidance are addressed through gradual exposure treatments.
- CBT was also effective in treatment of preschool children, as young as 3 years of age, particularly if it involved parent-child activities in each session. Group treatments based on TF-CBT include:
- Cognitive Behavioral Intervention for Trauma in Schools (CBITS)
- Multimodal Trauma Treatment
- Seeking Safety is another CBT-based intervention developed for PTSD and comorbid substance use.
- TARGET psychotherapy is geared towards juvenile offenders with PTSD
Psychodynamic psychotherapy for PTSD can be used with children and adolescents. Parent-child relationship is central in treatment of young children, since the traumatic experience is often shared in some way by the caregiver, most often the mother. (AACAP)
Eye movement desensitization and reprocessing (EMDR) is effective in treatment of adult PTSD; there is some evidence to support its use in pediatric population.
Pharmacological Management of PTSD
It is important to identify targets for treatment when considering medication. As with many other disorders in child and adolescent psychiatry, the medications do not serve a curative role in PTSD treatment. Rather, they are used for two broad purposes:
- To alleviate disabling symptoms and comorbidities associated with PTSD, such as emotional hyperarrousal, sleep disturbances, anxiety, irritability, and anger outbursts, with goals to restore functioning and return to normal developmental trajectory.
- To assist the child undergoing a psychotherapeutic intervention in dealing with and processing of traumatic and emotional content.
Which Medications Are Used in PTSD
- Use of SSRIs is supported by substantial body of evidence in adult PTSD; SSRIs have been shown to improve symptoms in each of the three symptom categories. Pediatric studies of SSRIs for symptoms of PTSD are scarce, and their clinical use is extrapolated from adult literature. Thus, careful monitoring and balancing known risks and potential benefits of SSRIs use are necessary. In pediatric population, trauma-focused psychotherapies should be first-line treatments of PTSD; it is appropriate to add an SSRI, particularly in treatment of comorbid depression, anxiety, or OCD.
- Imipramine, valproate, and carbamezapine may have a role based on small trials.
- Alpha-2 adrenergic blockers, such us clonidine and guanfacine, have been used successfully to relieve symptoms of hyperarrousal and impulsivity, but there are no placebo-controlled trials. Guanfacine may help with PTSD-associated nightmares. Propranolol may help with hyperarrousal and reexperiencing symptoms.
Antipsychotics have been used in adults with PTSD. While they are used widely in many pediatric disorders, their efficacy in pediatric PTSD had not been investigated. Antiepileptics and mirtazapine may have a role in PTSD symptom relief, but research into their efficacy is lacking as well.
Nefazodone and imipramine, medications that have been used successfully in adult PTSD, are not used in children. The evidence for their efficacy is either anecdotal or contradictory. Adverse effects, particularly hepatotoxicity of nefazodone, leave little justification for the use of these drugs in pediatric PTSD. Benzodiazepines have a role in short-term adjunctive treatment of significant anxiety and agitation; the risk of paradoxical dysinhibition and potential for abuse should be weighted against anticipated benefits.
- >25% of children and adolescents experience a significant traumatic event (before adulthood).
- While flashbacks and nightmares are frequently inquired about as a clinical probing questions for PTSD, these symptoms are neither sufficient nor necessary for the diagnosis. (They are from the list of Category B symptoms, of which you only need one).
- Reaction of the caregiver to a traumatic event bears great importance in child's risk for developing PTSD. Witnessing a threat to the caregiver is a poor prognostic factor in preschoolers' treatment, while having a close relationship with a well-coping parent is most protective. A distressed caregiver, who is not too overwhelmed to provide some form of comfort to a traumatized child should do so.
- RCT had not shown that debriefing shortly following the traumatic exposure is either beneficial or harmful. However individuals not trained in debriefing should not perform thos form of intervention.
- Panic symptoms following the traumatic exposure predict development of PTSD in children.
- Trauma-focused psychotherapies are first line treatment of pediatric PTSD and are supported by substantial emperical evidence; SSRI can reduce symtpoms, but there is insufficient emperical evidence of favorable risk/benefit ratio in PTSD and no clinical consensus on their role in treatment.
~ Stamatakos M, Campo JV. Psychopharmocologic treatment of traumatized youth. CurrOpinPeds 2010; 22:599
~ Horrigan J. Guanfacine for PTSD nightmares. JAACAP 1996; 35:1247
~ Cohrn, J. Practice Parameter for the Assessment and Treatment of Children and Adolescents With Posttraumatic Stress Disorder. JAACAP, 2010;49(4):414
~ Cohen JA, Mannarino AP, Staron V: Modified cognitive behavioral therapy for childhood traumatic grief (CBT-CTG): a pilot study. J Am Acad Child Adolesc Psychiatry 45:1465–1473, 2006b
~ De Bellis MD. The Psychobiology of Neglect. Child Maltreatment 2005, 10:2 (150)
~ Van der Kolk BA. Developmental trauma disorder. Psychiatr Ann 2005, 35:401–408
~ Scheeringa MS. Developmental Considerations for Diagnosing PTSD and Acute Stress Disorder in Preschool and School-Age Children. Am J Psychiatry 2008 165:10.
~ Merikangas et.al Lifetime Prevalence of Mental Disorders in US Adolescents: Results from the National Comorbidity Survey Replication - Adolescent Supplement (NCS-A) JACAAP, 2010;49(10)980-9.
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