Approach Considerations
Children need to feel safe before therapy can begin.
Adults often make invalidating and minimizing statements to traumatized children. Doing this is harmful.
Psychological and Behavioral Interventions
Psychological First Aid is an evidence-informed approach for assisting children, adolescents, adults, and families in the aftermath of disaster and terrorism. It involves: providing for basic needs (shelter, food, warmth); providing support, comfort, and reassurance; problem solving; and letting children know their reactions are normal. Invalidation should be avoided. False beliefs, such as that the child was at fault, should be addressed immediately.
Trauma-focused cognitive-behavioral therapy (TFCBT) has the strongest evidence for effectiveness. [26] Dialectical behavior therapy (DBT), helping children and adolescents to deal with painful feelings, may be necessary before CBT can be done. Eye Movement Desensitization and Reprocessing (EMDR) has also been found to be helpful. If symptoms persist or additional control is needed, pharmacologic therapy may be warranted. Inpatient psychiatric care should be considered in patients who are at risk of harming themselves or others. Children with PTSD are at increased risk for suicide.
Formal debriefing sessions create risk of harm, with victims flooding each other with their fears and memories. Children should not be pressured to talk about their painful memories either individually or in groups. When children feel safer and calmer, recounting what occurred and how it has affected them is generally therapeutic.
The first step in psychotherapy for PTSD is to help the child feel safe and nurtured and deal with false beliefs such as the child was at fault. Providing for the child's basic needs and creating an environment in which the child feels safe is crucial. Relaxation training and medication may be helpful in enabling the child to do this.
In younger children, play provides an opportunity to work through the trauma. However, play often breaks down in PTSD, and repetitive reenactment that is not enjoyable may be observed. If this occurs, intervention may be necessary. [27]
It is important to destigmatize the child’s symptoms in the eyes of both the child and the parents. They must be helped to understand that the repeated recollections, numbing, and hyperarousal are all natural responses to the experience of a traumatic event, not signs of serious mental illness or weakness.
Attention must be given to the multiple emotional and behavioral problems that can arise (eg, depression, anxiety, impulsive behavior, substance abuse, aggression, eating disorders, sexual acting out, labile mood, rage, panic attacks, and dissociation). Treatment of these problems may involve psychotherapy, medication, or both.
A major problem associated with PTSD in children is that the anxiety and other problems that develop interfere with a child’s ability to participate in the normal developmental experiences of childhood. The child often finds schoolwork and socializing difficult. As a result, serious secondary problems arise. Supportive therapy is needed to help keep a child on track or to get the child back on track.
The ability of the parents to remain as calm and as connected to the child as possible is crucial to the child’s ability to resolve PTSD. In particular, the parents should avoid contaminating the child with their own painful feelings and verbalizing the fear that the child is permanently damaged.
Cognitive-behavioral therapy
On the basis of empiric evidence, CBT, especially trauma-focused CBT (TF-CBT), appears to be the most efficacious of the available treatments. A 2013 review of 14 studies with a total of 758 participants found fair evidence that psychological therapies, particularly CBT, could treat PTSD effectively in children and adolescents for up to 1 month after treatment but reached no firm conclusions regarding longer-term therapy or the comparative efficacy of the various different psychological therapies. [28]
TF-CBT is a highly structured therapy that consists of a series of manual-based sessions (typically, 10-18 sessions lasting 1 hour each). 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.
TF-CBT 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. The results of a randomized, controlled trial indicated that community-provided TF-CBT successfully alleviated PTSD and anxiety in children exposed to intimate partner violence. [29]
Preliminary findings suggest that after a disaster involving many children, a school-based cognitive-behavioral 10-session intervention carried out by trained school-based mental health counselors significantly decreases future PTSD symptoms.
Other therapies
Other relaxation techniques (eg, 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, including triggered memories, reenactment, and hyperarousal symptoms (eg, sleep and appetite disruption, mood dysregulation, and exaggerated startle response). Caregivers should be instructed about the significance of these symptoms, which may warrant medical and psychological treatment.
Pharmacologic Therapy
In children who have persistent symptoms despite CBT or who need additional help with control of symptoms, pharmacologic treatment may be considered. When pharmacotherapy is undertaken, target symptoms such as insomnia, irritability, and agitation should be defined and monitored for response.
Antidepressants
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)—a proven therapy for PTSD in adults—are helpful. These agents are considered the medications of choice for managing anxiety, depression, avoidance behavior, and intrusive recollections.
The 2 SSRIs that have been approved by the US Food and Drug Administration (FDA) for treatment of PTSD in adults are sertraline and paroxetine. Currently, no SSRIs are FDA-approved for the treatment of PTSD in the pediatric population.
Although SSRIs have not been evaluated for efficacy in children with PTSD in randomized clinical trials, they are believed to improve social and occupational functioning and to decrease core PTSD symptoms, 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 is especially pertinent in cases of overdose. Suicide risk must always be considered in the treatment of a child or adolescent with mood disorder.
Special concerns in children
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.
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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, the agency decided that the risks SSRIs pose to pediatric patients outweighed the benefits of treatment, except for fluoxetine, which appears to have a positive risk-benefit ratio in the treatment of depressive illness in patients younger than 18 years
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In October 2003, the FDA issued a public health advisory regarding reports of suicidality in pediatric patients treated with antidepressants for major depressive disorder; the advisory reported suicidality (both ideation and attempts) in clinical trials of various antidepressant drugs in pediatric patients, and the FDA asked that additional studies be performed because suicidality occurred in both treated and untreated patients with major depression and thus could not be definitively linked to drug treatment
However, a study of more than 65,000 children and adults treated for depression between 1992 and 2002 by the Group Health Cooperative in Seattle found that suicide risk declined, rather than rose, with the use of antidepressants. [30] .
Numerous authors have addressed the controversy concerning when and how to use SSRIs in children. In 2007, Cuffe summarized the literature in an update available from the American Academy of Child Adolescent Psychiatry. [31] When SSRIs are used, consultation with a child psychiatrist and close monitoring for suicidal ideation are important.
If the decision has been made to use an SSRI in a child and appropriate informed consent (including information about the FDA black box warning concerning suicidality) has been obtained, the agent should be started at a low dose, with gradual dose escalation. Specific dosing depends on the medication and the age and weight of the child. Adverse effects of SSRIs include anxiety or agitation, behavioral activation, hypomania, headaches, hyperhidrosis, somnolence, gastrointestinal upset, diarrhea, and anorexia.
Other agents
Additional pharmacologic agents have been used clinically to treat PTSD symptoms in children and adolescents; however, the evidence supporting the use of these agents is not as robust as that supporting the use of antidepressants.
Beta-blockers and alpha-adrenergic agonists (eg, guanfacine [32] and clonidine) are helpful in reducing arousal, decreasing forced reexperiencing of the trauma, and avoiding the neurophysiologic kindling that can contribute to chronic illness. These medications are most helpful if used very soon after the onset of symptoms.
Mood stabilizers can be helpful in dealing with increased arousal, impulsivity, and already established kindling once the illness has become chronic. The mood stabilizers are not interchangeable: Carbamazepine may ameliorate persistent reexperiencing of the event, whereas valproic acid may ameliorate symptoms of avoidance.
Compared with the aforementioned medications, atypical antipsychotics are infrequently used. They should be considered only when the patient is unresponsive to other medications or when marked agitation or psychosis is present.
Consultations
Consultation with therapists and child psychiatrists with particular expertise in the treatment of PTSD in children is generally warranted.
Long-Term Monitoring
Most of the treatment of psychologically traumatized children is conducted on an outpatient basis. Monitoring and educating the child and parents is important because symptoms may recur even after resolution, especially during new developmental stages. The impact on self image and views of the world are especially persistent.
In addition to treatment of the presenting diagnostic symptoms (eg, reexperiencing, avoidance, changes in cognition, and hyperarousal/reactivity), children with PTSD require treatment of all associated problems (eg, depression, anxiety, and destructive acting out) and ongoing support of participation in the normal developmental experiences of childhood.
Long-term educational support and social skills training may be needed on a remedial basis to help a child gain the skills that were not developed during a period of months or years of withdrawal, especially if PTSD is not effectively treated shortly after the incident.
