Pediatric PTSD

David Camenisch, MD/MPH

WHAT CONSTITUTES TRAUMA?

An Experience/event: actual/threatened death or serious injury

threat to physical integrity of self/others (sexual abuse)

  A Subjective response:

intense fear, helplessness, horror (preschoolers exempt; includes disorganized or agitated behavior in school-age children)

TYPES OF TRAUMA

Child maltreatment (physical/sexual/emotional abuse,

neglect)Sexual assaultDomestic violenceCommunity violenceNatural disastersTerrorism Life threatening illness/accidents

EPIDEMIOLOGY OF CHILD TRAUMA EXPOSURE

Lifetime exposure: (at least one traumatic event) ▪ Girls: 15-43%▪ Boys: 14-43%

(Copeland W et al. Arch G Psychiatry 2007)

TYPE OF ABUSE

64% neglect 15% physical abuse 9% sexual abuse; 10% emotional abuse 

(U.S. Dept. HHS. Child Maltreatment 2006)

WHO IS ABUSING

Parents 80% (>90% bio parents) Other relatives 8%. Women 58% Men 42%

(U.S. Dept. HHS. Child Maltreatment 2006)

EPIDEMIOLOGY OF PTSD

Criteria make big difference in rates Incidence following trauma: 5-45% depending on risk/protective factors 5-9% Lifetime Prevalence of PTSD <18

yr 50 % experience trauma. 1/3 develop

PTSD Regardless of numbers, sub-threshold

symptoms can cause similar levels of functional impairment

PSYCHOLOGICAL/INTERPERSONAL VULNERABILITY

Avoidant coping style Pre-existing mental illness Poor emotional self-regulation History of trauma Heavy reliance on external locus of

control (limited coping; poor affective/behavioral regulation)

Low self-esteem Delayed social/emotional development

FAMILY AND SOCIO-ECONOMIC VULNERABILITY

Not living with nuclear family Ineffective & uncaring parenting Family dysfunction (e.g., alcoholism,

violence, child maltreatment, mental illness)

Parental PTSD/maladaptive coping with the stressor

Poverty/financial stress Social isolation/lack of support

NORMAL PSYCHOLOGICAL REACTIONS FOLLOWING TRAUMATIC EXPERIENCE

  Efforts to “make sense” and again feel that

the world is safe and understandable: “Why

me/us?” A sense of self blame and shame: “I could have…should have….” Blame self /anger towards self Blaming others/anger towards others Feeling of loss and sadness Fear/anxiety about safety of self, others, world

BIOLOGICAL AND PSYCHOLOGICAL RESPONSES TO TRAUMA

Hyperarousal (irritability, fear, startling, difficulty falling asleep)

Re-experiencing (intrusive thoughts or images, flashbacks)

Avoidance of reminders (talking, thinking, activities)

Dissociation (confusion, numbness, lost time and personal details)

Addressing Trauma and Identifying PTSD

SCREENING TIPS

Consider screening for potentially traumatic events at all well-child visits

“Since the last time I saw you,has anything really scary orupsetting happened to you oryour family?”

Discuss with parent AND child Consider Screening Tool

Trauma Screening Questionnaire(Brewin, 2002)

1. Upsetting thoughts or memories about the event that have come into your mind against your will

2. Upsetting dreams about the event

3. Acting or feeling as though the event were happening again

4. Feeling upset by reminders of the event

5. Bodily reactions (such as fast heartbeat, stomach churning,

sweatiness, dizziness) when reminded of the event6. Difficulty falling or staying asleep

7. Irritability or outbursts of anger

8. Difficulty concentrating

9. Heightened awareness of potential dangers to yourself and

others

10. Being jumpy or being startled at something unexpected

Postive Item = >2 times/weekPositive Screen = > 6 (90% PPV)

Primary Care PTSD Screen (PC-PTSD)  (Prins, Ouimette, Kimerling et al., 2003)

1. Have had nightmares or thought about [what happened] when you did not want to?

2. Tried hard not to think about it or went out of your way to avoid situations that reminded you of it?

3. Were constantly on guard, watchful, or easily startled?

4. Felt numb or detached from others, activities, or your surroundings?

Positive Screen = 3/4

ADDRESSING CHILDHOOD TRAUMA: GENERAL STRATEGIES

Include parents in assessment Address immediate safety in

home/community Identify supports and resources Consider developmental level of patient Consider cultural issues that may impact

families use of services Keep it “Trauma-focused” – give

permission to talk about what happened Plant seed that this is manageable and

skills can be learned that will help

ADDRESSING CHILDHOOD TRAUMA: PARENTS AND CARETAKERS

Encourage parents to access/seek mental health support for themselves

Remind parents they (can be) key to child’s resiliency

Encourage parents to re-establish a sense of safety/security and get back to routine

Encourage basic self-care (sleeping, eating, recreation, exercise)

Psycho-education about trauma and PTSD in children

Build in regular follow-up sessions with parents

ADDRESSING CHILDHOOD TRAUMA: CHILDREN

Re-establish sense of safety and security Permit regression temporarily Attempt to re-establish routines Encourage social and school connections

(participation in sports, etc) Provide education (and reassure) about trauma

and PTSD (normalize response and symptoms) Encourage self-care (sleep, eat, exercise, etc) Education about strategies to address

hyperarousal (e.g. relaxation, yoga, exercise, meditation, etc.)

Education about effective mental health treatment

ADDRESSING CHILDHOOD TRAUMA: THE SCHOOL

Psycho-education with school about impact of trauma

School safety plan and supports (“go to” person)

Reconsider academic expectations, schedule and accommodations (consider 504/IEP)

Support parents advocacy (offer to talk with school personal)

Developmental Considerations: Pre School

Clingy Disordered attachment Separation anxiety Hyperactive/impulsivity Tantrums/aggression Stubborn/oppositional Regression Somatic complaints Re-experiencing may manifest as repetitive play If advanced verbally, still likely concrete and

limited cognitively in ability to undertand/process

Developmental Considerations: School Age

Anger/irritability (“behavioral” expression of difficulty) School refusal Poor attention Somatic complaints Separation anxiety Avoidance symptoms more closely related to

event/trauma Trauma related play (becomes more complex and

elaborate). More challenging to assess loss of interest/pleasure Better able to understand concepts of future, past

more realistically Nightmares (may change from event specific to

generalized over time)

Developmental Considerations: Adolescent

Shame/blame Oppositional/aggressive behaviors to regain a

sense of control School avoidance/refusal/truancy Drugs/alcohol Self-injurious urges and behavior Revenge fantasies (especially with

developmental issues/social delays/victims of bullying)

Detachment Self conscious Sense of foreshortened future may take form of

belief that they will not reach childhood or don’t need to plan for future.

Big Picture

Many children experience trauma Most have transient symptoms More symptoms immediately

following trauma and subside with time

Most recover with use of available supports and resources

Majority do NOT develop PTSD

Diagnostic Criteria and Issues

DSM and CHILDHOOD PSYCHOPATHOLOGY

“If you suspect it, treat it”

PTSD is good example of challenges in applying DSM to childhood psychopathology. 1) Generated debate about how diagnostic

algorithms need to be modified for different age groups

2) Highlights challenges of defining diagnosis that accounts for effects of trauma in different age groups

3) Attempts to guide use of multiple informants.  

DSM and CHILDHOOD PSYCHOPATHOLOGY

“If you miss, you miss big.”

Predictive value of diagnosis especially important because of rapid development in all areas.

Evidence that psychopathology can be more enduring. (Fewer defenses and resources, impact of neurophysiologic change on developing brain.)

Higher rates of development of chronic PTSD in younger cohorts

NOSOLOGIC CHALLENGES OF PTSD

Evolving diagnosis Relatively “young” diagnosis Very polymorphic/heterogenous

symptoms The “great mimicker” Trying to capture complex response to

wide range of experiences across full developmental spectrum

Attempts to capture affects of a particular trauma at many different points in time

DSM-IVTR: Post Traumatic Stress Disorder

Criterion A : Event/Response

Event: actual/threatened death or serious injury OR threat to physical integrity of others OR sexual abuse

Subjective Response: intense fear, helplessness, horror; disorganized OR agitated behavior in children

DSM-IVTR: Post Traumatic Stress Disorder Criterion B : Re-experiencing (≥ 1)

Intrusive memories/repetitive play/drawing

Recurrent dreams/nightmares Flashbacks or behavioral re-enactment Psychological distress or physiological

reactivity in response to trauma-related cues

DSM-IVTR: Post Traumatic Stress Disorder

Criterion C : Avoidance/Numbing (≥ 3;1 for preschoolers):

Avoiding thoughts/feelings/conversations Avoiding activities/places/people Loss of recall of details Diminished interests Feelings of detachment Restricted range of affect Sense of foreshortened future Preschoolers: loss of previously acquired

developmental skills

DSM-IVTR: Post Traumatic Stress Disorder

Criterion D: Hyperarousal (≥ 2; 1 for preschoolers):

Sleep problems Irritability/anger Difficulty concentrating Hypervigilance Exaggerated startle

DSM-IVTR: Post Traumatic Stress Disorder

Criterion E: Duration >1 monthCriterion F: Significant distress or

impairment

Modifiers: Acute: sx <3 months durationChronic: sx >3 months durationDelayed onset: >3 months after trauma

DSM-IVTR: Post Traumatic Stress Disorder

Proposed Preschool Cluster (≥1):

Loss of developmental skills New onset separation anxiety New onset aggression New non-trauma related fears

(ScheeringaM et al JAACAP 2003)

COMPLEX PTSD

Attempts to better account for developmental impact of trauma

Unique Components of Trauma: Chronic and pervasive pattern of

severe, early and interpersonal trauma Occurs Early (0-6 yrs) Maltreatment (abuse or neglect) Within a care-giving relationship *

COMPLEX PTSD

Disordered attachment Biological changes (↑ NE, ↑ cortisol) Emotional Dysregulation (affective

reactivity or constriction) Behavioral Dyscontrol/Aggression Cognitive Delays and/or Functional

Deficits Impaired Self-concept/Interpersonal

functioning

DSM-V: Disorders of Extreme Stress, NOS

Includes symptoms related to - affect dysregulation, - inattention - awareness/consciousness (e.g.

dissociation), - disturbances of self-perception, relations with others, - somatization - disturbances in systems of

meaning.

Why Look for PTSD?

High rates of psychiatric co-morbidity Increased suicide risk (20% of SA related to

trauma, 8x risk in childhood sexual abuse) Chronic, progressive, debilitating Treatable Can impact all developmental domains Frequently overlooked Masquerades as many other somatic,

cognitive and behavioral disorders

PSYCHIATRIC COMORBIDITIES (60 %)

Depressive disorders Anxiety disorders (Separation Anxiety,

GAD) Disruptive behavior disorders (ADHD,

ODD, CD) Substance abuse/dependence Increased risk of developing personality

disorder Increased risk of suicidality

(independent of mood disorder)

Behavioral and Medical Consequences

Adverse health outcomes (asthma, GI, headaches)

Poor school performance/disciplinary issues

Appetite disturbances Sleep disturbances Disturbance in attention and focus Social withdrawal Increased anger and aggression

NEUROBIOLOGY

Increased NE (hyper-adrenergic state; tone and reactivity)

Abnormal cortisol ↑acutely = neurotoxicity↓chronically = ↓neurogenesis, ↓myelination

Decreases in corpus callosa and cerebral volume

No hippocampal changes (vs adults) “Limbic kindling” (amygdala, hippocampus) Loss of anterior cingulate integrity

(supported by clonidine studies and fMRI)

What can I expect?

Highly variable course (waxing and waning course, relapsing and remitting, gradual improvement)

Untreated, decreases slowly with time 30 % develop chronic PTSD Less natural remission in younger

populations Episodic difficulties with new stressors High rates of psychiatric co-morbidities,

social and interpersonal problems, family conflict and academic issues

Treatment of Pediatric PTSD

EBT FOR PTSD

Level 1 (Best Support) Trauma-focused CBT (3-17)CBT with parents

Level 2 (Good Support) CBT (with child) Level 3 (Moderate Support) None Level 4 (Minimal Support) Play therapy

PsychodramaLevel 5 (No support) CBT with parents only

Client Centered TherapyEMDRCBT and medicationInterpersonal TherapyRelaxation(State of Hawaii, CAMHD. “Blue Menu.” 2010.)

What is TF-CBT?

Approach that helps patients understand and change how they think and react to their trauma and its aftermath by directly addressing the trauma with child AND caregivers.

The goal is to understand how certain thoughts about the trauma cause the patient stress and make their symptoms worse.

In addition to symptom improvement, focus is on improved functioning and resiliency in the face of future stress

TRAUMA-FOCUSED COGNITIVE BEHAVIORAL THERAPY (TF-CBT)

Combines trauma-sensitive interventions with cognitive behavioral therapy

Clinic-based Increasingly available (but not universally) Short-term (12-16 weeks) 80 % show some improvement Tested alone and with medication Effective following wide-range of traumas

COMPONENTS OF EFFECTIVE TF-CBT

  Psychoeducation (reduce stigma/shame by “normalizing”;

common reactions to stress; epidemiology) Parenting skills (PMT – praise, positive attention, contingency

reinforcement) Relaxation skills (diaphragmatic breathing, PMR) Affective modulation (feeling identification, positive-self talk,

thought stopping, problem solving, social skills) Cognitive coping and processing (rec link b/t thoughts > feelings

> behavior; challenging unhelpful/inaccurate thoughts) Trauma narrative (create narrative; correct cog distortions; put

in perspective) In vivo mastery of reminders (graduated exposure) Conjoint parent sessions Enhancing safety planning (incl skills/confidence to manage

future stress)

Cohen et al study (JAACAP, 46:7, July 2007)

Goal: Examine potential benefit of adding an SSRI (sertraline) vs placebo to TF-CBT

Design: pilot RCT; n = 24, 10-17 yrs, female; 12 weeks, tf-cbt + sertaline OR tf-cbt + placebo

Results: Both groups improved (CGAS, wk 3→5 in CBT + sertraline)

Conclusion: minimal benefit to adding SSRI Significance: established gains related to

non-medication treatments

Robb et al (Journal of Child and Adol Psychopharm,

20:6, 2010)

Goal: Evaluate safety and efficacy of sertraline vs placebo for treatment of pediatric PTSD

Design: Multi-site DB-RCT. N=131. 3 sessions of psycho-ed/CBT during screening phase. No significant therapy during treatment phase.

Results: No improved efficacy over placebo in 10 wk treatment phase. Both groups experienced significant improvement (UCLA PTSD Scale, CGAS)

Conclusion: “minimal evidence” supports adding sertraline; sertraline well-tolerated but little benefit

Significance: “Negative” industry study; SSRIs w/o therapy of little value; “unusually high placebo response rate”

WHEN SHOULD MEDICATIONS BE CONSIDERED?

Severe symptoms causing impaired functioning

Prolonged symptoms (> 1 mos) Failure of psychological, supportive and

family interventions Patient/family unable or unwilling to

participate inpsychological and social treatments

Co-morbid depression or anxiety disorder (especially adolescents)

What are my options?

SSRIs Adrenergic Agents (β-blockers, α1-

antagonists, α2-agonists) Atypical anti-psychotics Mood Stabilizers Sleep aides/hypnotics

SSRIs – The Evidence

Sertraline - Negative multi-site DB-RCT. N=131. No improved efficacy over placebo in 10 wk treatment phase.(UCLA PTSD Index) 3 sessions of psycho-ed/CBT during screening phase. No significant therapy during treatment phase. (Robb et al. 2010)

Sertraline – Negative pilot RCT. N=24. 12 weeks. Little benefit over placebo when added to TF-CBT. Both groups demonstrated improvement, but no significant between group differences. Sertraline not recommended until after therapy alone. (Cohen et al. 2007)

Citalopram – Open-label trial. 8 weeks. n=24. Compared pediatric vs adult improvement (CAPS, CGI-I); >50% reduction in symptom severity in both groups.(Seedat et al. 2002)

Citalopram - Open-label trial. 12 weeks. n=8. Adolescents. (CAPS) >50% reduction in symptom severity. (Seedat et al. 2001)

Fluoxetine – Open-label trial. N=26. Improved earthquake related PSTD in 7-17 yrs. (Yorbik et al. 2001)

No studies looking at escitalopram (Lexapro), fluvoxamine (Luvox) or paroxetine (Paxil).

SSRIs - The Message

SSRIs can be considered for the treatment of childrenand adolescents with PTSD BUT “ insufficient data to support the use of SSRI medication alone (i.e., in the absence of psychotherapy) for the treatment of childhood PTSD.” (AACAP PP, 2010. Rec 7)

Not FDA approved. Identify target symptoms and track response. When

demonstrated to be effective in adult studies, symptoms decreased in all three symptom clusters.

Monitor for sleep changes, irritability, agitation, anxiety and suicidal ideation. SSRIs are more often activating in pediatric patients. Proceed with caution.

Adrenergic Agents – The Rationale

Adult and pediatric literature supports adrenergic hyperactivity in PTSD

β-blockers (propranolol) attenuate effects of NE post-synaptically and dampen sympathetic tone

α-1 antagonists (Prazosin) attenuate effects of NE post-synaptically and dampen sympathetic tone

α-2 agonists (clonidine, guanfacine) decrease NE release

Adrenergic Agents – The Evidence

No DBRCTs in pediatric populations Case reports, case series, open-trials:

Prazosin - 2 case reports; adol females (n=2); improved sleep, cessation of nightmares, decr intrusive symptoms

Clonidine - 3 OTs; decreased re-enactment symptoms in very young children; decreased basal HR, anxiety, impulsivity and hyper-arousal

Guanfacine - may reduce nightmares (2) Propranolol - children with abuse related PTSD

(n=11); fewer symptoms (on-off-on design)

Adrenergic Agents – The Message

β-blockers - may be useful in decreasing hyper-arousal and re-experiencing symptoms

α-1 antagonist (Prazosin) – helpful in decreasing trauma related nightmares, sleep disruption and intrusive symptoms.

α-2 agonist (clonidine) - may be useful in decreasing hyper-arousal, intrusive thoughts, and impulsivity

SGAs - The Evidence

risperidone (Risperdal) – No RCTs Case series (n=3) - reduced all symptoms

clusters in thermal burns Open label (n=18) - improved remission in 13/18

adolescent male PTSD (high rates of comorbidity) quetiapine (Seroquel) – No RCTs

Case series (n=6) - adolescents; improvement in PTSD symptoms, anxiety, depression and anger

ziprasidone (Geodon) – no reports or studies olanzapine (Zyprexa) – no reports or studies aripiprazole (Abilify) – no reports or studies

SGAs - The Message

No pediatric PTSD studies No FDA approvals for PTSD Most effective for intrusive and

hyperarousal symptoms Meta-analysis of 7 adult studies: “may be

beneficial”, “particularly effective in reducing intrusive symtpoms”

side effects must be recognized and managed (wt gain, glucose/lipid metabolism, prolactin, TD, EPS, QTc)

generally lower doses are effective

Mood Stabilizers – The Evidence

Carbamazepine (Tegretol) – OT; n=28; ages 8-17 yrs; sexual abuse related PTSD; 22/28 asymptomatic at therapeutic levels (10-11.5 μg/mL) (Loof et al. JAACAP. 1995)

Divalproex – pilot RCT; n=12; male adol; high dose > lose dose; based on CGI. (Steiner et al. Child Psych Human Dev. 2007)

Mood Stabilizers - The Message

Only 1 small RCT (Divalproex) No FDA approvals Variable side effects and monitoring

required Limbic kindling model (amygdala,

hippocampus) supports potential role for AEDs

Preventing PTSD

Propranolol - negative pediatric DBRCT, n=29 (Nugent. 2007)

Fluoxetine – negative pediatric RCT; study duration 1 week; treatment of ASD (Tcheung et al. 2008)

Morphine - decrease arousal symptoms α dose of morphine. (Stoddard et al.2009, Saxe et al.2001)

Imipramine - Imipramine > chloral hydrate; PTSD @ 6 mos in burn victims (Robert et al. 1999)

Current Evidence (J Clin Psych 71:7, 2010)

Medication Level of Evidence NotesAdrenergics

Prazosin IV ↓ Intrusive/hyper-arousal Cloinidine IV ↓ Re-enactment Guanfacine IV ↓ Intrusive Propranolol IV ↓ Hyper-arousal

SGAsQuetiapine IV ↓ Anxiety, Depression, AngerRisperidone IV ↓ Intrusive/hyper-arousal

AEDsCarbamazepine IVDivalproex IV

SSRIsSertraline 2 negative RCTsCitalopram IV

OthersCyproheptadine IV ↓ Intrusive/hyper-arousalBenzodiazepines No Evidence

I=Sys Review or RCTs; II=RCT; III=Case-Control Studies; IV=case-series; V=expert opinion

Medication Summary

2 PCRT do NOT support use of SSRIs in treatment of pediatric PTSD

Role for SSRIs related to treatment of co-morbid anxiety or depression

Adult literature and pediatric OTs support use of anti-andrenergic agents

Need for more studies looking at Quetiapine and Risperidone

Need for more studies looking at carbamazepine

HOW HARD SHOULD I WORK TO GET A PSYCHIATRIC ASSESSMENT?

Consider: Your comfort with the diagnosis Severity of symptoms and level of impairment Presence of co-morbidities

Remember: Best if patient and family are comfortable with

“psychiatric” assessment Most important is having someone help you

follow symptoms and functional impairment on regular basis.

Evidence is better for psychological and social interventions.

PTSD Treatment Summary Children who remain seriously symptomatic for

more than 1 month after a traumatic event should be referred for child mental health treatment.

Best Evidence base is for psychotherapy that involves skill-based symptom management and encourages direct discussion about the trauma.

Medications may play an auxiliary role in treating symptoms, especially in the acute situation but should be used with caution.

Reasonable to get psychiatric OR psychological assessment for help in diagnosis and directing treatment.

The PCP and PTSD

First-line for identifying children who develop symptoms after a traumatic experience and develop functional impairment to abnormal degree. Screen as often as possible.

First-line for providing education and support should a child/family experience trauma.

Essential role in deciding when to refer and preparing family for what to expect.

Targeted pharmacotherapy with assistance of PAL or other consulting child psychiatrist.

WEB RESOURCES

National Childhood Traumatic Stress Network http://www.nctsnet.org/nccts/nav.do?pid=ctr_aud_prof

American Academy of Child and Adolescent Psychiatrywww.aacap.org

National Center for PTSDhttp://

www.ptsd.va.gov/professional/pages/assessments/child-trauma-ptsd.asp

Sesame Street http://www.sesameworkshop.org/initiatives/emotion

Trauma Focused CBT Web Resource http://tfcbt.musc.edu/

Selected Bibliography

1. Practice Parameter for the Assessment and Treatment of Children and Adolescents with Posttraumatic Stress Disorder (JAACAP, 49:4, April 2010)

2. Psychopharmacologic Treatment of Posttraumatic Stress Disorder in Children and Adolescents: A Review (J.Strawn, et al. J Clin Psychiatry, 71:7, July 2010)

3. Sertraline Treatment of Children and Adolescents with Posttraumatic Stress Disorder: A Double-Blind Placebo-Controlled Trial (Robb et al. Journal of Child and Adolescent Psychopharmacology, 20:6, 2010)

4. A Pilot RCT of Combined Trauma-focused CBT and Sertraline for Childhood PTSD Symtpoms (Cohen et al. JAACAP 46:7, July 2007)

In Development

Substance P antagonists Orexin agonists Neuropeptide Y antagonists

Cyproheptadine

Antihistamine/5HT-2 antagonism Adjunctive use may be useful in

decreasing intrusive symptoms and nightmares

Adults –several case reports Peds - Retrospective study looking

at adjunctive use in abuse victims (Gupta et al. 1998)

PRINCIPLES OF PSYCHOLOGICAL FIRST AID

Foster/reassure safety Calmness Self- efficacy Community/Family-efficacy Social connectedness Optimism