Posttraumatic Stress Disorder due to Child Abuse and Neglect Medication

  • Author: Angelo P Giardino, MD, PhD; Chief Editor: Caroly Pataki, MD   more...
 
Updated: Aug 23, 2011
 

Medication Summary

CBT, discussed in Medical Care, is the first-line treatment for posttraumatic stress disorder (PTSD) in children. In children with persistent symptoms despite CBT or those who need additional help with control of symptoms, pharmacologic treatment may be considered. When medication treatment is undertaken, target symptoms such as insomnia, irritability, and agitation should be defined and monitored for response.

No large-scale randomized clinical trials are available to guide choices for the treatment of PTSD in children. Clinical experience suggests that selective serotonin reuptake inhibitors (SSRIs) are helpful; SSRIs are a proven therapy for PTSD in adults. Additional pharmacologic agents have been used clinically to treat PTSD symptoms in children and adolescents; they include alpha-agonists (eg, clonidine, guanfacine), beta-adrenergic blocking agents (eg, propranolol), mood stabilizers (eg, carbamazepine, valproic acid), and atypical antipsychotic medications. However, the evidence supporting the use of these agents is not as robust as that for antidepressant medications. Medications that have been approved for children by the US Food and Drug Administration can be viewed here.

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Antidepressive agents

Class Summary

SSRIs inhibit CNS neuronal uptake of serotonin (5HT). Some have a weak effect on norepinephrine and dopamine neuronal reuptake. They have also been used to treat anxiety, phobias, and obsessive-compulsive disorders. Two SSRIs are FDA-approved for the treatment of PTSD in adults: sertraline (Zoloft) and paroxetine (Paxil). Currently, no SSRIs are FDA-approved for the treatment of PTSD in the pediatric population. While randomized clinical trials are not available to test their efficacy in children with PTSD, SSRIs are thought to improve social and occupational functioning and to decrease core symptoms of PTSD, such as avoidance, numbing, and dissociation. They have the added benefit of treating comorbid conditions. However, using SSRIs for the treatment of PTSD in the pediatric population would be an off-label use.

SSRIs do not carry the risk of cardiac arrhythmia associated with tricyclic antidepressants (TCAs). One randomized trial of imipramine and chloral hydrate proved imipramine to be efficacious in reducing PTSD symptoms in children. However, the risk of arrhythmia makes the use of TCAs problematic and especially pertinent in overdose. Suicide risk must always be considered when treating a child or adolescent with mood disorder.

Physicians are advised to be aware of the following information and to use appropriate caution when considering treatment with SSRIs in the pediatric population. Informed consent regarding the FDA black box warning concerning the risk of suicidality must be obtained.

  • In December 2003, the UK Medicines and Healthcare Products Regulatory Agency (MHRA) issued an advisory that most SSRIs are not suitable for use in persons younger than 18 years for treatment of depressive illness. After review, this agency decided that the risks to pediatric patients outweigh the benefits of treatment with SSRIs, except fluoxetine (Prozac), which appears to have a positive risk-benefit ratio in the treatment of depressive illness in patients younger than 18 years.
  • In October 2003, the US Food and Drug Administration issued a public health advisory regarding reports of suicidality in pediatric patients being treated with antidepressant medications for major depressive disorder. This advisory reported suicidality (both ideation and attempts) in clinical trials of various antidepressant drugs in pediatric patients. The FDA has asked that additional studies be performed, as suicidality occurred in both treated and untreated patients with major depression, thus could not be definitively linked to drug treatment.

Numerous authors have addressed the controversy concerning when and how to use SSRIs in children. Cuffe (2007) has summarized the literature in a recent update available from the American Academy of Child Adolescent Psychiatry.[15] When SSRIs are used, consultation with a child psychiatrist and close monitoring for suicidal ideation is important.

If the decision has been made, with appropriate informed consent (including information about the FDA black box warning concerning suicidality), to use an SSRI in a child, it should be started at a low dose with gradual dose escalation. Adverse effects include anxiety or agitation, behavioral activation, hypomania, headaches, hyperhidrosis, somnolence, GI upset, diarrhea, and anorexia. Dosing depends on the medication and the age and weight of the child.

View full drug information

Fluoxetine (Prozac)

 

Selectively inhibits presynaptic serotonin reuptake with minimal or no effect on reuptake of norepinephrine or dopamine.

View full drug information

Paroxetine (Paxil)

 

Potent selective inhibitor of neuronal serotonin reuptake. Also has a weak effect on norepinephrine and dopamine neuronal reuptake.

View full drug information

Sertraline (Zoloft)

 

Selectively inhibits presynaptic serotonin reuptake.

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Contributor Information and Disclosures
Author

Angelo P Giardino, MD, PhD  Clinical Associate Professor, Department of Pediatrics, Baylor College of Medicine; Medical Director, Texas Children's Health Plan, Inc

Angelo P Giardino, MD, PhD is a member of the following medical societies: Academic Pediatric Association, American Academy of Pediatrics, American Professional Society on the Abuse of Children, Harris County Medical Society, Helfer Society, and International Society for Prevention of Child Abuse and Neglect

Disclosure: Bayer Honoraria Review panel membership; Pfizer Grant/research funds Independent contractor; MedImmune Honoraria Review panel membership; Teva Pharmacutical travel & honoraria Managed Care Advisory Panel; CIGNA Honoraria Physician Advisory Council

Coauthor(s)

Toi Blakley Harris, MD  Assistant Professor and Director of Diversity and Education, Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine; Founder and Director, Texas Regional Psychiatry Minority Mentor Network

Toi Blakley Harris, MD, is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, American Psychiatric Association, and Association for Academic Psychiatry

Disclosure: Nothing to disclose.

Eileen R Giardino, RN, MSN, PhD, FNP-BC, ANP-BC  Associate Professor of Nursing, Department of Acute and Continuing Care, University of Texas Health Sciences Center Houston School of Nursing

Eileen R Giardino, RN, MSN, PhD, FNP-BC, ANP-BC is a member of the following medical societies: American Academy of Nurse Practitioners, American College Health Association, American Nurses Association, American Professional Society on the Abuse of Children, and International Society for Prevention of Child Abuse and Neglect

Disclosure: Nothing to disclose.

Specialty Editor Board

Carol Diane Berkowitz, MD  Executive Vice Chair, Department of Pediatrics, Professor, Harbor-University of California at Los Angeles Medical Center

Carol Diane Berkowitz, MD is a member of the following medical societies: Alpha Omega Alpha, Ambulatory Pediatric Association, American Academy of Pediatrics, American College of Emergency Physicians, American Medical Association, American Pediatric Society, and North American Society for Pediatric and Adolescent Gynecology

Disclosure: Nothing to disclose.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Carrie Sylvester, MD, MPH  Senior Child and Adolescent Psychiatrist, Sound Mental Health

Carrie Sylvester, MD, MPH is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry

Disclosure: Nothing to disclose.

Chief Editor

Caroly Pataki, MD  Professor of Clinical Psychiatry and Behavioral Sciences, Department of Psychiatry, Division Chair, Child and Adolescent Psychiatry, Keck School of Medicine of the University of Southern California

Caroly Pataki, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, New York Academy of Sciences, and Physicians for Social Responsibility

Disclosure: Nothing to disclose.

Acknowledgments

The authors acknowledge the encouragement and support of Dr. John Sargent, who has taught us much and who has set a standard for us in terms of his being an excellent mentor and modeling for us the highest degree of professionalism as a colleague who works tirelessly to ameliorate the effects of child abuse and neglect among the children and families we serve.

References

  1. Child Maltreatment 2006. Washington DC: US Department of Health and Human Services Administration for Children and Families, Administration on Children Youth and Families Children's Bureau; 2008. 1-194. [Full Text].

  2. Spinazzola J, Ford JD, Zucker M, van der Kolk B, Silva S, Smith SF, et al. Survey evaluates complex trauma exposure, outcome, and intervention among children and adolescents. Psychiatr Ann. May 2005;35(5):433-9.

  3. van der Kolk BA. From the Guest Editor: Child Abuse & Victimization. Psychiatric Annals. 2005/05;35:5:374-378.

  4. Terr LC. Chowchilla revisited: the effects of psychic trauma four years after a school-bus kidnapping. Am J Psychiatry. Dec 1983;140(12):1543-50. [Medline].

  5. Plattner B, Karnik N, Jo B, Hall RE, Schallauer A, Carrion V, et al. State and trait emotions in delinquent adolescents. Child Psychiatry Hum Dev. Aug 2007;38(2):155-69. [Medline].

  6. Martin A, Volkmar FR. Lewis's Child and Adolescent Psychiatry: A Comprehensive Textbook. 4th ed. Philadelphia, PA: Wolters Kluwer, Lippincott Williams & Wilkins; 2007.

  7. Collishaw S, Pickles A, Messer J, Rutter M, Shearer C, Maughan B. Resilience to adult psychopathology following childhood maltreatment: evidence from a community sample. Child Abuse Negl. Mar 2007;31(3):211-29. [Medline].

  8. Caspi A, Sugden K, Moffitt TE, Taylor A, Craig IW, Harrington H, et al. Influence of life stress on depression: moderation by a polymorphism in the 5-HTT gene. Science. Jul 18 2003;301(5631):386-9. [Medline].

  9. Kim-Cohen J, Caspi A, Taylor A, Williams B, Newcombe R, Craig IW, et al. MAOA, maltreatment, and gene-environment interaction predicting children's mental health: new evidence and a meta-analysis. Mol Psychiatry. Oct 2006;11(10):903-13. [Medline].

  10. How common is PTSD. Washington, DC: National Center for PTSD. Department of Veterans Affairs; accessed January 2009. [Full Text].

  11. National Institute of Justice. Youth Victimization: Prevalence and Implications. Washington, D.C.: US Department of Justice; 2003.

  12. Mitchell KJ, Finkelhor D, Wolak J. Risk factors for and impact of online sexual solicitation of youth. JAMA. Jun 20 2001;285(23):3011-4. [Medline].

  13. Wolak L, Mitchell K, Finkelhor D. Online Victimization of Youth: Five Years Later. National Center for Missing & Exploited Children; 2006. [Full Text].

  14. Hepp U, Gamma A, Milos G, Eich D, Ajdacic-Gross V, Rössler W, et al. Prevalence of exposure to potentially traumatic events and PTSD. The Zurich Cohort Study. Eur Arch Psychiatry Clin Neurosci. Apr 2006;256(3):151-8. [Medline].

  15. Cuffe SP. Suicide and SSRI Medications in Children and Adolescents: An Update. American Academy of Child & Adolescent Psychiatry:Accessed January 27, 2009. [Full Text].

  16. Ackerman PT, Newton JE, McPherson WB. Prevalence of post traumatic stress disorder and other psychiatric diagnoses in three groups of abused children (sexual, physical, and both). Child Abuse Negl. Aug 1998;22(8):759-74. [Medline].

  17. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association Press; 1994.

  18. Baum A. Stress, intrusive imagery, and chronic distress. Health Psychol. 1990;9(6):653-75. [Medline].

  19. Beers SR, De Bellis MD. Neuropsychological function in children with maltreatment-related posttraumatic stress disorder. Am J Psychiatry. Mar 2002;159(3):483-6. [Medline].

  20. Carrion VG, Weems CF, Ray R, Reiss AL. Toward an empirical definition of pediatric PTSD: the phenomenology of PTSD symptoms in youth. J Am Acad Child Adolesc Psychiatry. Feb 2002;41(2):166-73. [Medline].

  21. Cohen JA. Treating acute posttraumatic reactions in children and adolescents. Biol Psychiatry. May 1 2003;53(9):827-33. [Medline].

  22. Cohen JA, Deblinger E, Mannarino AP, Steer RA. A multisite, randomized controlled trial for children with sexual abuse-related PTSD symptoms. J Am Acad Child Adolesc Psychiatry. Apr 2004;43(4):393-402. [Medline].

  23. Cohen JA, Mannarino AP. Predictors of treatment outcome in sexually abused children. Child Abuse Negl. Jul 2000;24(7):983-94. [Medline].

  24. Cohen JA, Mannarino AP, Knudsen K. Treating sexually abused children: 1 year follow-up of a randomized controlled trial. Child Abuse Negl. Feb 2005;29(2):135-45. [Medline].

  25. Cortes AM, Saltzman KM, Weems CF, Regnault HP, Reiss AL, Carrion VG. Development of anxiety disorders in a traumatized pediatric population: a preliminary longitudinal evaluation. Child Abuse Negl. Aug 2005;29(8):905-14. [Medline].

  26. Costello EJ, Erkanli A, Fairbank JA, Angold A. The prevalence of potentially traumatic events in childhood and adolescence. J Trauma Stress. Apr 2002;15(2):99-112. [Medline].

  27. Davidson JR, Stein DJ, Shalev AY, Yehuda R. Posttraumatic stress disorder: acquisition, recognition, course, and treatment. J Neuropsychiatry Clin Neurosci. Spring 2004;16(2):135-47. [Medline].

  28. De Bellis MD, Keshavan MS, Shifflett H, Iyengar S, Beers SR, Hall J, et al. Brain structures in pediatric maltreatment-related posttraumatic stress disorder: a sociodemographically matched study. Biol Psychiatry. Dec 1 2002;52(11):1066-78. [Medline].

  29. Deblinger E, Steer RA, Lippmann J. Two-year follow-up study of cognitive behavioral therapy for sexually abused children suffering post-traumatic stress symptoms. Child Abuse Negl. Dec 1999;23(12):1371-8. [Medline].

  30. Donnelly CL. Pharmacologic treatment approaches for children and adolescents with posttraumatic stress disorder. Child Adolesc Psychiatr Clin N Am. Apr 2003;12(2):251-69. [Medline].

  31. Donnelly CL, Amaya-Jackson L. Post-traumatic stress disorder in children and adolescents: epidemiology, diagnosis and treatment options. Paediatr Drugs. 2002;4(3):159-70. [Medline].

  32. Donnelly CL, Amaya-Jackson L, March JS. Psychopharmacology of pediatric posttraumatic stress disorder. J Child Adolesc Psychopharmacol. 1999;9(3):203-20. [Medline].

  33. Famularo R, Fenton T, Kinscherff R, Augustyn M. Psychiatric comorbidity in childhood post traumatic stress disorder. Child Abuse Negl. Oct 1996;20(10):953-61. [Medline].

  34. Foa EB, Meadows EA. Psychosocial treatments for posttraumatic stress disorder: a critical review. Annu Rev Psychol. 1997;48:449-80. [Medline].

  35. Gaensbauer T, Chatoor I, Drell M. Traumatic loss in a one-year-old girl. J Am Acad Child Adolesc Psychiatry. Apr 1995;34(4):520-8. [Medline].

  36. Garbarino J. The stress of being a poor child in America. Child Adolesc Psychiatr Clin N Am. Jan 1998;7(1):105-19, ix. [Medline].

  37. Harmon RJ, Riggs PD. Clonidine for posttraumatic stress disorder in preschool children. J Am Acad Child Adolesc Psychiatry. Sep 1996;35(9):1247-9. [Medline].

  38. Kaplow JB, Dodge KA, Amaya-Jackson L, Saxe GN. Pathways to PTSD, part II: Sexually abused children. Am J Psychiatry. Jul 2005;162(7):1305-10. [Medline].

  39. King NJ, Tonge BJ, Mullen P, Myerson N, Heyne D, Rollings S, et al. Treating sexually abused children with posttraumatic stress symptoms: a randomized clinical trial. J Am Acad Child Adolesc Psychiatry. Nov 2000;39(11):1347-55. [Medline].

  40. Lewis DO, Bard JS. Multiple personality and forensic issues. Psychiatr Clin North Am. Sep 1991;14(3):741-56. [Medline].

  41. Lovett J. Small Wonders. Healing childhood trauma with EMDR. New York, NY: The Free Press; 1999.

  42. March JS, Amaya-Jackson L, Murray MC, Schulte A. Cognitive-behavioral psychotherapy for children and adolescents with posttraumatic stress disorder after a single-incident stressor. J Am Acad Child Adolesc Psychiatry. Jun 1998;37(6):585-93. [Medline].

  43. McCloskey LA, Walker M. Posttraumatic stress in children exposed to family violence and single-event trauma. J Am Acad Child Adolesc Psychiatry. Jan 2000;39(1):108-15. [Medline].

  44. Mitchell KJ, Wolak J, Finkelhor D. Police posing as juveniles online to catch sex offenders: is it working?. Sex Abuse. Jul 2005;17(3):241-67. [Medline].

  45. Perkonigg A, Pfister H, Stein MB, Höfler M, Lieb R, Maercker A, et al. Longitudinal course of posttraumatic stress disorder and posttraumatic stress disorder symptoms in a community sample of adolescents and young adults. Am J Psychiatry. Jul 2005;162(7):1320-7. [Medline].

  46. Perrin S, Smith P, Yule W. The assessment and treatment of Post-traumatic Stress Disorder in children and adolescents. J Child Psychol Psychiatry. Mar 2000;41(3):277-89. [Medline].

  47. Perry BD, Azad I. Posttraumatic stress disorders in children and adolescents. Curr Opin Pediatr. Aug 1999;11(4):310-6. [Medline].

  48. Perry BD, Pollard R. Homeostasis, stress, trauma, and adaptation. A neurodevelopmental view of childhood trauma. Child Adolesc Psychiatr Clin N Am. Jan 1998;7(1):33-51, viii. [Medline].

  49. Pfefferbaum B, Allen JR. Stress in children exposed to violence. Reenactment and rage. Child Adolesc Psychiatr Clin N Am. Jan 1998;7(1):121-35, ix. [Medline].

  50. PTSD in Children and Adolescents. Washington, DC: National Center for Post Traumatic Stress Disorder. Department of Veterans Affairs; 2004.

  51. Pynoos RS, Frederick C, Nader K. Life threat and posttraumatic stress in school-age children. Arch Gen Psychiatry. Dec 1987;44(12):1057-63. [Medline].

  52. Pynoos RS, Steinberg AM, Piacentini JC. A developmental psychopathology model of childhood traumatic stress and intersection with anxiety disorders. Biol Psychiatry. Dec 1 1999;46(11):1542-54. [Medline].

  53. Roy CA, Russell RC. Case study: possible traumatic stress disorder in an infant with cancer. J Am Acad Child Adolesc Psychiatry. Feb 2000;39(2):257-60. [Medline].

  54. Ruggiero KJ, McLeer SV, Dixon JF. Sexual abuse characteristics associated with survivor psychopathology. Child Abuse Negl. Jul 2000;24(7):951-64. [Medline].

  55. Runyon MK, Faust J, Orvaschel H. Differential symptom pattern of post-traumatic stress disorder (PTSD) in maltreated children with and without concurrent depression. Child Abuse Negl. Jan 2002;26(1):39-53. [Medline].

  56. Sack WH, Clarke G, Him C. A 6-year follow-up study of Cambodian refugee adolescents traumatized as children. J Am Acad Child Adolesc Psychiatry. Mar 1993;32(2):431-7. [Medline].

  57. Sapp MV, Vandeven AM. Update on childhood sexual abuse. Curr Opin Pediatr. Apr 2005;17(2):258-64. [Medline].

  58. Scheeringa MS, Zeanah CH, Drell MJ. Two approaches to the diagnosis of posttraumatic stress disorder in infancy and early childhood [published erratum appears in J Am Acad Child Adolesc Psychiatry 1995 May;34(5):694]. J Am Acad Child Adolesc Psychiatry. Feb 1995;34(2):191-200. [Medline].

  59. Seng JS, Graham-Bermann SA, Clark MK, McCarthy AM, Ronis DL. Posttraumatic stress disorder and physical comorbidity among female children and adolescents: results from service-use data. Pediatrics. Dec 2005;116(6):e767-76. [Medline].

  60. Shapiro F. Eye Movement Desensitization and Reprocessing (EMDR) and the anxiety disorders: clinical and research implications of an integrated psychotherapy treatment. J Anxiety Disord. Jan-Apr 1999;13(1-2):35-67. [Medline].

  61. Shapiro F. Eye movement desensitization: a new treatment for post-traumatic stress disorder. J Behav Ther Exp Psychiatry. Sep 1989;20(3):211-7. [Medline].

  62. Sidran Institute. PTSD Alliance: Post Traumatic Stress Disorder Fact Sheet. Sidran Institute. Available at http://www.sidran.org/sub.cfm?contentID=76&ionid=4. Accessed September 24, 2004.

  63. Simon GE, Savarino J, Operskalski B. Suicide risk during antidepressant treatment. Am J Psychiatry. Jan 2006;163(1):41-7. [Medline]. [Full Text].

  64. Stein BD, Jaycox LH, Kataoka SH, Wong M, Tu W, Elliott MN, et al. A mental health intervention for schoolchildren exposed to violence: a randomized controlled trial. JAMA. Aug 6 2003;290(5):603-11. [Medline].

  65. Steiner H, Garcia IG, Matthews Z. Posttraumatic stress disorder in incarcerated juvenile delinquents. J Am Acad Child Adolesc Psychiatry. Mar 1997;36(3):357-65. [Medline].

  66. Sugar M. Toddler's traumatic memories. Infant Mental Health Journal. 1992;13:245-251.

  67. Sutherland SM, Davidson JR. Pharmacotherapy for post-traumatic stress disorder. Psychiatr Clin North Am. Jun 1994;17(2):409-23. [Medline].

  68. Thabet AA, Vostanis P. Post traumatic stress disorder reactions in children of war: a longitudinal study. Child Abuse Negl. Feb 2000;24(2):291-8. [Medline].

  69. Thomas LA, De Bellis MD. Pituitary volumes in pediatric maltreatment-related posttraumatic stress disorder. Biol Psychiatry. Apr 1 2004;55(7):752-8. [Medline].

  70. Walker JL, Carey PD, Mohr N, Stein DJ, Seedat S. Gender differences in the prevalence of childhood sexual abuse and in the development of pediatric PTSD. Arch Womens Ment Health. Apr 2004;7(2):111-21. [Medline].

  71. Yehuda R. Post-traumatic stress disorder. N Engl J Med. Jan 10 2002;346(2):108-14. [Medline]. [Full Text].

 
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