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Child Abuse & Neglect, Posttraumatic Stress Disorder: Treatment & Medication

Author: Angelo P Giardino, MD, PhD, Clinical Associate Professor, Department of Pediatrics, Baylor College of Medicine; Medical Director, Texas Children's Health Plan, Inc
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; Eileen R Giardino, PhD, RN, MSN, FNP-BC, ANP-BC, Associate Professor of Nursing, Department of Acute and Continuing Care, University of Texas Health Sciences Center Houston School of Nursing
Contributor Information and Disclosures

Updated: Jul 28, 2009

Treatment

Medical Care

The first step of treatment in posttraumatic stress disorder (PTSD) is to provide a safe environment and to attend to urgent medical needs.

Immediately after a traumatic event, children are likely to be frightened and distressed. A sense of security can be achieved with a combination of respect, compassion, containment, assistance with helping the child experience consistency in their daily routines, and provision of opportunities for relaxation and positive experiences.

The role of formal debriefing sessions after a traumatic event is not entirely clear, but the discussion of trauma in asymptomatic individuals may increase the long-term risk of PTSD symptoms, possibly because the child becomes sensitized through exposure without having adequate treatment to process this stress.

Interventions with children

  • Cognitive behavioral therapy
    • Of all treatments, cognitive behavioral therapy (CBT), especially CBT with a trauma focus (TF-CBT), is most efficacious based on empirical evidence. It seems to help children with both acute and chronic PTSD with PTSD symptoms, as well as those with depression, shame, social skills, and behavioral disturbances. The improvements have been shown to persist for at least 2 years after treatment.
    • TF-CBT is a highly structured therapy that consists of manual-based sessions (eg, 10-18 sessions, each 1 h). The intervention focuses on stress management, education about symptoms, creating a narrative of the trauma (as a means of exposure), and cognitive reprocessing of the trauma and resultant symptoms.
    • Preliminary findings suggest that, after a disaster involving many children, a school-based cognitive-behavioral 10-session intervention by trained school-based mental health counselors significantly decreases future PTSD symptoms.
    • Other relaxation techniques, such as biofeedback, yoga, deep relaxation, self-hypnosis, or meditation, may be suitable in some children, but clinical evidence concerning their efficacy or use is unavailable.

Interventions with caregivers

Involving caregivers in treatment has been effective, particularly in reducing the child's comorbid depressive symptoms and improving the caregiver's own depressed mood, abuse-related distress, and ability to support the child. Caregivers and parents must be aware of the symptoms of PTSD, such as triggered memories, re-enactment, and hyperarousal symptoms (eg, sleep and appetite disruption, mood dysregulation, startle response). Caregivers should be instructed about the significance of these symptoms, which may warrant medical and psychological treatment.

 

Consultations

  • Consider consultation with a therapist to establish cognitive behavior treatments.
  • A child psychiatrist may also be helpful and can provide assessment and pharmacologic management for PTSD, as well as comorbid psychiatric conditions.
  • Physical complications may require the attention of physicians who specialize in orthopedic injuries or burns, depending on the nature of the concern (see Burns, Thermal). These issues are described in corresponding sections of this pediatric journal.

Diet

No restrictions are necessary in children with PTSD, unless clinically indicated.

Activity

No restrictions are necessary in children with PTSD, unless clinically indicated.

Medication

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.

Antidepressive agents

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.


Fluoxetine (Prozac)

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

Adult

20 mg/d PO every am and increase after several wk by 20 mg/d; not to exceed 80 mg/d

Pediatric

Younger children: 2-4 mg/d PO (liquid)
Older children: 10-20 mg/d PO depending on the response

Inhibits CYP450 isoenzymes 2C9, 2C19, 2D6, and 3A4; increases toxicity of diazepam and trazodone by decreasing clearance; also increases toxicity of MAOIs and highly protein-bound drugs; serotonin syndrome (ie, myoclonus, rigidity, confusion, nausea, hyperthermia, autonomic instability, coma, eventual death) occurs with simultaneous use of other serotonergic agents (eg, anorectic agents, tramadol, buspirone, trazodone, clomipramine, nefazodone, tryptophan), discontinue other serotonergic agents at least 2 wk prior to SSRIs

Documented hypersensitivity; concurrent administration of MAOIs or administration in the last 2 wk; fluoxetine must be discontinued for at least 4 wk before starting MAOI; coadministration with thioridazine

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Known or suspected history of mania or hypomania; hepatic impairment and history of seizures


Paroxetine (Paxil)

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

Adult

40 mg/d PO qd

Pediatric

<18 years: Not established
>18 years: Administer as in adults

Inhibits CYP450 2D6, thus may increase toxicity of 2D6 substrates (eg, phenothiazines, propafenone, flecainide and encainide, other SSRIs, tricyclic antidepressants); phenobarbital and phenytoin decrease effects of paroxetine; alcohol, cimetidine, sertraline, phenothiazines, and warfarin increase toxicity of paroxetine; serotonin syndrome (ie, myoclonus, rigidity, confusion, nausea, hyperthermia, autonomic instability, coma, eventual death) occurs with simultaneous use of other serotonergic agents (eg, anorectic agents, tramadol, buspirone, trazodone, clomipramine, nefazodone, tryptophan), thus discontinue other serotonergic agents at least 2 wk prior to using other SSRIs

Documented hypersensitivity; concurrent administration with MAOIs or administration within 14 d of discontinuing MAOIs; coadministration with thioridazine or pimozide

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Newborn infants exposed to SSRIs during the third trimester of pregnancy have developed complications requiring prolonged hospitalization, respiratory support, and tube feeding; preliminary analysis of a retrospective study shows increased congenital malformations as a whole, particularly for cardiovascular malformations, with paroxetine compared to other antidepressants with exposure during the first trimester
Known or suspected history of mania or hypomania; caution with history of seizures, renal disease, and cardiac disease


Sertraline (Zoloft)

Selectively inhibits presynaptic serotonin reuptake.

Adult

50 mg/d PO every am, may increase by 50 mg/d increments q2-3d to 100 mg/d, if tolerated; not to exceed 200 mg/d

Pediatric

<6 years: Not established
6-12 years: 6.25 mg PO qd, may increase gradually qwk; not to exceed 100 mg/d
>12 years: 12.5 mg PO qd, may increase gradually qwk; not to exceed adult dose

Inhibits CYP450 isoenzymes 3A3/4, 2C9, 2C19, and 2D6, resulting in possible decreased clearance of isoenzyme substrates (eg, metoprolol, thioridazine, imipramine, haloperidol, phenytoin, barbiturates, glyburide, warfarin)
Increases toxicity of MAOIs, diazepam, tolbutamide, and warfarin; serotonin syndrome (ie, myoclonus, rigidity, confusion, nausea, hyperthermia, autonomic instability, coma, eventual death) occurs with simultaneous use of other serotonergic agents (eg, anorectic agents, tramadol, buspirone, trazodone, clomipramine, nefazodone, tryptophan), discontinue other serotonergic agents at least 2 wk prior to SSRIs

Documented hypersensitivity; do not use concurrently or within 2 wk of MAOIs

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Known or suspected history of mania or hypomania; caution with preexisting seizure disorders and in patients who have experienced a recent myocardial infarction, have unstable heart disease, and have hepatic or renal impairment; dampening of sexual libido

More on Child Abuse & Neglect, Posttraumatic Stress Disorder

Overview: Child Abuse & Neglect, Posttraumatic Stress Disorder
Differential Diagnoses & Workup: Child Abuse & Neglect, Posttraumatic Stress Disorder
Treatment & Medication: Child Abuse & Neglect, Posttraumatic Stress Disorder
Follow-up: Child Abuse & Neglect, Posttraumatic Stress Disorder
References
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Further Reading

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Keywords

posttraumatic stress disorder, post-traumatic stress disorder, traumatic stress disorder, child abuse, child neglect, child maltreatment, acute traumatic reaction, chronic or delayed traumatic disorder, PTSD, psychological trauma, physical trauma, acute stress reaction

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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: Nothing to disclose.

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, PhD, RN, MSN, 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, PhD, RN, MSN, 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.

Medical Editor

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.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

CME Editor

Carrie Sylvester, MD, MPH, Director of Education in Child and Adolescent Psychiatry, Professor, Departments of Psychiatry and Pediatrics, Northwestern University Medical School
Carrie Sylvester, MD, MPH is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, American Academy of Pediatrics, American Medical Women's Association, American Psychiatric Association, and American Society for 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, Director of Training, Child and Adolescent Psychiatry Residency Program, University of Southern California Keck School of Medicine
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.

 
 
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