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Kari Hancock, MD Child and Adolescent Psychiatrist PAL Program June 11, 2011 Disclosure Statement Some off label medication use will be referred to in this talk- the off label status will be noted wherever such recommendations appear No financial conflicts of interest to disclose Discussion Topics Traumatic Event Defined Epidemiology Approach After A Trauma Occurs Screening/Risk Factors PTSD At Different Developmental Levels Treatment Options What defines a traumatic event? Sudden or unexpected events Shocking nature of such events Death or threat to life or bodily injury Feeling of intense terror, horror, or helplessness Types of Trauma Child Abuse (physical, sexual, emotional, neglect) Sexual assault Domestic violence Community violence Natural disasters Terrorism Life threatening illness/accidents Death or loss of a loved one Epidemiology 68% of children experience a potentially traumatic event (Cohen, et al., Arch Pediatr Adolesc Med/Vol 162(5) May 2008) One sample of adolescents/young adults indicated overall lifetime prevalence of PTSD as 9.2% National sample of age 12-17 indicated 3.7% males and 6.3% females met criteria for PTSD (AACAP Practice Parameter, April 2010) Where To Start? “Since the last time I saw your child, has anything really scary or upsetting happened to your child or anyone in your family?” Screening question that can be used at all visits Cohen et al., “Identifying, Treating, and Referring Traumatized Children”, Arch Pediatr Adolesc Med/Vol 162 (5), May 2008 Talk with each parent and child privately Safety Measures For Any Ongoing Abuse Provide psychoeducation about symptoms to look out for – (eg. AACAP Facts For Families) Provide crisis line phone numbers for child and family Emphasize to the child that it is not their fault in cases of maltreatment or loss What If the Child Denies A Known Traumatic Event? Let them know you know Reassurance that you are not going to ask a lot about the experience, but want to know if they have any problems that many other kids have when they go through that type of thing If still avoidant, ask about hyperarousal items (sleep, concentration, irritability) first Martin, A & Volkmar, F. Lewis’s Child and Adolescent Psychiatry: A Comprehensive Textbook, 4th ed., 2007. Follow Up Visit Questions After A Trauma “Does the (event) ever bother or upset you (your child) these days?” If yes, administer the child or parent instrument again Cohen et al., “Identifying, Treating, and Referring Traumatized Children”, Arch Pediatr Adolesc Med/Vol 162 (5), May 2008 Suicide Screening Initial Response after a trauma beyond the A-B-Cs: Attend to basic needs and safety SelfActualization Maslow’s Hierarchy of Needs Personal Growth & Fulfillment Esteem Status, Reputation, Achievement, Responsibility Love Affection, Relationships, Family, Work Groups Safety Protection, Security, Order, Law, Limits, Stability Physiological Air, Food, Drink, Shelter, Warmth, Sleep General Support – Young Children Parents can provide comfort, rest, opportunity to play or draw, and return to routine Provide reassurance event is over and child is safe Help children verbalize their feelings Provide consistent caretaking and sense of security May need to tolerate regressive behavior following a traumatic event Teaching techniques for dealing with overwhelming emotions (eg. relaxation, self calming cards) Connecting caregivers to resources to address their needs (young child’s level of distress often mirrors their caregiver’s level of distress) General Support – Older Children Encouragement to discuss worries, sadness, anger Acknowledge normality of feelings and correct distortions of the event Parents can support children in school by informing teachers that the child’s thoughts/feelings may be interfering with concentration/learning General Support - Adolescent Encourage discussion of the event, feelings, and expectations of what could have been done to prevent the event Discuss expectable strain on relationships with family and peers Discuss thoughts of revenge following an act of violence, address realistic consequences of actions Help formulate constructive alternatives that lessen sense of helplessness Case Example: Case: 7 year old girl who starts to display new behaviors (eg. loss of toileting skills, sleep disturbance, increase frequency of tantrums) Any signs of an organic etiology for symptoms? Are there any new stressors, changes in her environment, or history of trauma? Have you been hurt by anyone? Non leading questions A Child With Externalizing Behaviors in a Chaotic Environment Multiple informants gives best estimate of child’s maltreatment experience In one study – child, parent, and CPS data indicated that each source missed a number of traumas identified by another Without CPS data – 40% of the children sexually abused, 30% of the children physically abused, and 16% of the children who witnessed domestic violence would not have been identified Martin, A & Volkmar, F. Lewis’s Child and Adolescent Psychiatry: A Comprehensive Textbook, 4th ed., 2007. PTSD Develops In Some But Not Others After A Trauma Individual child’s response to the event Inherent resiliency Learned coping mechanisms External sources of social support Short lived trauma – younger children more dependent on parent’s reaction to the trauma (eg. Israeli study – Laor, N et al, 2001) vs. chronic trauma early in life – greater risk Risk Factors For Developing PTSD Multiple traumas Greater exposure to the trauma Additional post event stressors (eg. dislocation, loss/separation from caregivers) Caregivers unable to meet child’s needs due to own distress/psychological problems Family psychiatric history Preexisting psychiatric disorder Distress Level Normal Reaction To Trauma Distress Event Time Normal Stress Response Sensory Stimuli Amygdala = Encoding, storage, retrieval memory + Emotional valence to sensory info Locus ceruleus – noradrenergic stress response Paraventricular nucleus of hypothalamus – HPA axis with negative feedback Medial prefrontal cortex (anterior cingulate) – important in extinguishing learned fear response Releases dopamine, norepinephrine, serotonin Negative feedback to amygdala dopamine releases GABA inhibitory effect on prefrontal cortex Acute Stress Disorder and PTSD Distress Level Acute Stress disorder < 1 month Distress Event Time PTSD Acute: < 3 months PTSD Chronic: > 3 months Theories of Neurobiology in PTSD Area of Dysfunction Resultant PTSD Sx Amygdala Recurrent and intrusive Sx, excessive fear associated with reminders hyperresponsiveness Increased NE (hyper- adrenergic state; tone and reactivity) – Deactivation of medial prefrontal cortex possibly due to increased dopamine– Hyperarousal Sx Unable to extinguish learned fear response, hypervigilance, paranoia Neurobiology of PTSD in Kids Reduced medial and posterior portions of corpus callosum – important in integrating perceptions, cognitive processing and responses No hippocampal changes (vs adults) HPA axis abnormalities PTSD Sx: ≥ 1 Reexperiencing the event Having frequent memories of the event, or in young children, play in which some or all of the trauma is repeated over and over Having upsetting and frightening dreams Acting or feeling like the experience is happening again Developing repeated physical or emotional symptoms when the child is reminded of the event AACAP, “Facts For Families” No. 70, Oct 1999 PTSD Sx: Avoidance & Numbing Avoiding thoughts, feelings, ≥3 conversations associated Avoiding activities, places, people that remind Unable to recall important aspects of event Diminished interest in significant activities Feeling detached from others Restricted affect Sense of foreshortened future (eg. life to short to become an adult) PTSD Sx: Increased arousal ≥2 Difficulty with sleep Irritability/anger outbursts Difficulty concentrating Hypervigilance Exaggerated startle response Primary Care PTSD Screen Used In Adults In your life, have you ever had any experience that was so frightening, horrible, or upsetting that, in the past month, you: Have had nightmares about it or thought about it when you did not want to? Tried hard not to think about it or went out of your way to avoid situations that reminded you of it? Were constantly on guard, watchful, or easily startled? Felt numb or detached from others, activities, or your surroundings? Current research suggests that the results of the PC-PTSD should be considered "positive" if a patient answers "yes" to any three items. Prins, Ouimette, Kimerling et al., 2003 Screening Scale Age Length Availability Abbreviated UCLA PTSD Reaction Index >8 self report <8 Parent form 9 Questions for self report 6 Questions for parent form Found in an article by Judith Cohen “Identifying, Treating, and Referring Traumatized Children” in Archives of Pediatric Adolescent Medicine vol 162 (5) May 2008 or AACAP PTSD Practice Parameters UCLA PTSD Reaction Index 7-18 48 Questions Email: [email protected] Child PTSD Symptom Scale 8-18 26 Questions Email: [email protected] Child Stress 2-18 Disorders Checklist 4 Questionsshort form 36 Questions – long form www.nctsnet.org/nctsn_assets/acp/hosp ital/CSDC-Screening%20Form2.pdf - for the short form Preschool Cases 4 year old Bobby Cries inconsolably when dropped off at preschool Appears to have a speech delay Frequent tantrums with loud noises, transitions Bangs head on table Aggressive toward others What You Might See In A Preschooler Loss of previously acquired developmental skills (eg. difficulty separating from parent, falling asleep on their own, losing speech or toileting skills) Traumatic play – repetitive and less imaginative form of play Changes in behavior (eg. appetite, sleep, withdrawal, frequent tantrums, aggression) Over or under reacting to physical contact, bright lights, sudden movements, loud noises Increased distress (unusually whiny, irritable, moody) Anxiety, fear and worry about safety of self/others Statements/questions about death and dying School Age Cases 10 year old Lisa Normally developing girl Complains of stomachaches, normal physical exam Having difficulty with schoolwork and completing tasks Appears tired throughout the day Hears a voice at night calling her name Has become oppositional at home What You Might See In A School Age Child Egocentric view of the world normally at this stage: Lead to self blame for the event – possible guilt, shame, diminished self esteem, feelings of worthlessness Cause and Effect Search for an explanation – irrational belief may develop Come to believe that bad things happen to them because they are bad (world remains fair, predictable) Generalize their experience No one is trustworthy What You Might See In A School Age Child Worry about safety of self/others and recurrence of violence Changes in behavior (eg. aggression, school performance) Distrust of others Change in ability to interpret and respond to social cues Somatic complaints – headaches, stomachaches Difficulty with authority, redirection or criticism Recreating the event (talking, playing out, drawing) Adolescent Cases 14 year old James Previously good student Appears more irritable, defiant to adults Withdrawing from friends Bloodshot eyes What You Might See In An Adolescent Self conscious about their emotional responses to the event – concern about being labeled “abnormal” Withdraw from peers/family due to concern of being different Express shame/guilt, may express fantasies about revenge and retribution Self fulfilling prophecy Increased risk for substance abuse Distrust of others, heightened difficulty with authority Over or under reacting to loud noises, sudden movements Complex PTSD Multiple, chronic traumatic events from early childhood Impaired affect modulation Self destructive/impulsive behavior Dissociative Sx Feeling permanently damaged Loss of previous sustained beliefs Feeling constantly threatened Impaired relationships with others Change of previous personality traits Confusion With Other Diagnoses MDD – distinguish by having a unique symptom associated with MDD (eg. depressed mood, suicidal ideation) ADHD – distinguish by its existence before age 7, before trauma Extreme irritability can be misattributed to Mania or ODD (in PTSD irritability is worse with triggers, less evident in non emotionally charged environments) Martin, A & Volkmar, F. Lewis’s Child and Adolescent Psychiatry: A Comprehensive Textbook, 4th ed., 2007. Confusion With Other Diagnoses Other Anxiety Disorders Trauma related hallucinations sometimes mistaken for a primary psychosis (9% of abused children from juvenile court/pediatric clinics, 20% of child sexual abuse victims on inpt psych units have trauma related hallucinations) Developmental Delays Martin, A & Volkmar, F. Lewis’s Child and Adolescent Psychiatry: A Comprehensive Textbook, 4th ed., 2007. Trauma Related Behaviors Growing up in a violent home and/or community: Observe and learn maladaptive behaviors and coping strategies Those behaviors may be rewarded repeatedly For example: Child may conclude that anger and abuse are accepted ways of coping with frustration Abusive parent has control, battered parent repeatedly injured and powerless – conclusion: battering is an acceptable and even advantageous behavior Sexualized Behaviors after being Abused Reexperiencing/Reenactment of the abuse exhibiting adult like sexual behaviors sharing sexual knowledge beyond their years Child may develop ongoing sexualized behaviors Learned behavior that is rewarding (eg. power gained or physically stimulating) Traumatic Grief Trauma sx in the context of the death of a loved one Need to address trauma sx and also cope with interference of typical grieving process Sequential Tx – address trauma sx first, then grieving process Symptoms of Childhood Trauma that Impact Physical Health New somatic symptoms with no clear underlying medical cause Symptoms that mimic the deceased person’s cause of death in traumatic grief Significant worsening of existing chronic medical conditions (diabetes, asthma, and so forth) Noncompliance or decreased compliance with usual medication regimens Self-injurious or suicidal behaviors Comorbid Diagnoses Major Depressive Disorder Substance Related Disorders Anxiety Disorders (Panic Disorder, Generalized Anxiety Disorder, Social Anxiety, OCD, Specific Phobia) Bipolar Disorder Disruptive Behavior Disorders Developmental Delay From website developed by the Center for Pediatric Traumatic Stress at The Children's Hospital of Philadelphia: www.healthcaretoolbox.org Referral Treatment Options Psychotherapy is the primary mode of treatment in childhood PTSD You might suggest to a parent that they ask prospective therapists questions such as: Do you have experience working with children after trauma? What is your approach in working with this type of problem? How do you work with parents? Trauma Focused Cognitive Behavioral Therapy Most empirical support with randomized control trials Psychoeducation and parenting skills Relaxation skills Affective modulation skills Cognitive coping and processing Trauma narrative In vivo mastery of trauma reminders Conjoint child-parent sessions Enhancing future safety and development Practice Parameter for the Assessment and Treatment of Children and Adolescents with Posttraumatic Stress Disorder, JAACAP, 49(4), April 2010 Other Evidence Based Psychotherapies CBITS (Cognitive Behavioral Intervention for Trauma in Schools): group based CBT, PRACTICE and teacher component Child Parent Psychotherapy (usually children under age 7): joint sessions of modeling protective behavior, interpretation of feelings/actions, crisis intervention, emotional support, family narrative NO CLEAR EVIDENCE IN KIDS: Psychological debriefing Nondirective play or non structured child directed therapy EMDR (Eye Movement Desensitization and Reprocessing) NOT RECOMMENDED: Restrictive rebirthing or holding techniques that bind, restrict, coerce or withhold food/water Psychopharmacology Limited studies, limited evidence for kids Adult data does not always translate into the child world No FDA approved medications for PTSD in children and adolescents SSRI Effectively decreases adult PTSD symptoms Child studies indicate no significant advantages compared to placebo PTSD Practice Parameters: “SSRIs can be considered for treatment of children and adolescents with PTSD” Practice Parameter for the Assessment and Treatment of Children and Adolescents with Posttraumatic Stress Disorder, JAACAP, 49(4), April 2010 Used to treat comorbidity anxiety/depression – evidence base to treat these disorders in children If an SSRI is used: monitor for possible activation or agitation (eg. sleep changes, irritability, restlessness, increased anxiety and suicidal ideation/self harm), start low and go slow Antiadrenergic Medications Theory: modify dysregulated noradrenergic system in pts with PTSD = intrusive/hyperarousal symptoms Prazosin (alpha 1 antagonist) – only adult studies in combat veterans treating nightmares/flashbacks Clonidine and Guanfacine (central acting alpha 2 agonists) – no dbl blind trials in pediatric ptsd Propranolol (central acting beta blocker) – only case studies in kids Alpha 2 Agonists in Clinical Practice Dosing strategies extrapolated from ADHD parameters: Clonidine: start 0.05 mg po qhs, increase by 0.05 mg every 3 days. Max dosing 0.2 mg for 20-40 kg, 0.3 mg for 40-45 kg, 0.4 mg for >45 kg Guanfacine: start 0.5 mg qhs if <45 kg, 1 mg has if >45 kg. Max dosing 2 mg for 20-40 kg, 3 mg for 40-45 kg, 4 mg for >45 kg Monitor heart rate, blood pressure Rebound hypertension can occur if abruptly discontinued Second Generation Antipsychotics No dbl blind placebo control trials in kids with PTSD May be used to treat comorbid diagnoses FDA approved in children for irritability in autism, bipolar and schizophrenia in adolescents Multiple side effects: EPS, tardive dyskinesia, NMS, obesity, hyperlipidemia, diabetes mellitus Mood Stabilizers, Benzodiazepines Only adult studies with modest improvement No clear evidence based data to treat PTSD in children/adolescents Reasons For Therapy + Meds Need for acute Sx reduction in severe PTSD Comorbid disorder that requires medication treatment Unsatisfactory or partial response to psychotherapy Potential improved outcome with combined Tx Practice Parameter for the Assessment and Treatment of Children and Adolescents with Posttraumatic Stress Disorder, JAACAP, 49(4), April 2010 Long Term Consequences of Trauma Increased Risk of: Depression Suicide Substance abuse Oppositional and aggressive behaviors Eating disorders Medical problems and somatic complaints Lower IQ scores Early pregnancy Course of PTSD Waxing and Waning 30% on average tend to manifest enduring symptomatology beyond the first month of the trauma Approx half of cases of PTSD have complete recovery within 3 months Many have persisting symptoms longer than 12 months after the trauma Symptom reactivation may occur with reminders, life stressors Culturally Sensitive Trauma-Informed Care From website developed by the Center for Pediatric Traumatic Stress at The Children's Hospital of Philadelphia: www.healthcaretoolbox.org Collaboration with School Monitor any decline with child’s academic functioning Work with school personnel to meet child’s needs (eg. frequent somatic complaints – develop a plan with the school nurse to gently reassure the child and to minimize class time missed) Recommend school testing if academic struggles persist Modifications to academic work for a short time Bright Futures in Practice: Mental Health—Volume I, Practice Guide: Child Maltreatment, 2002 Providing Strategies For Parents Refer to our discussion earlier about general support Other tips to help caregivers: Take a deep breath, count to 10 Call someone close to you for emotional support Help parents talk to their children about how to get help when they are having a difficult time (eg. how to contact parents or a trusted adult) Awareness of triggers, their child’s clues of discomfort Engage community supports: referral for the parent’s own treatment, social work services, support groups, respite services (eg. trusted relative, friend) Bright Futures in Practice: Mental Health—Volume I, Practice Guide: Child Maltreatment, 2002 Helpful Resources www.NCTSN.org – The National Child Traumatic Stress Network www.aacap.org – American Academy of Child and Adolescent Psychiatry website provides practice parameters and fact sheets for families www.tfcbt.musc.edu –web based training course for trauma focused cbt www.healthcaretoolbox.org –Center for Pediatric Traumatic Stress at The Children's Hospital of Philadelphia- helps deal with a child’s traumatic stress in injury/illness Helpful Resources Cohen, J.A., Mannarino, A.P., & Deblinger, E. Treating Trauma and Traumatic Grief in Children and Adolescents. (2006) Perry, B and Maia Szalavitz, The Boy Who Was Raised as a Dog: And Other Stories from a Child Psychiatrist's Notebook-- What Traumatized Children Can Teach Us About Loss, Love, and Healing by (2007) Useful References Practice Parameter for the Assessment and Treatment of Children and Adolescents with Posttraumatic Stress Disorder, JAACAP, 49(4), April 2010 (www.aacap.org) Cohen et al., “Identifying, Treating, and Referring Traumatized Children”, Arch Pediatr Adolesc Med, 162 (5), May 2008 (can be found at: http://archpedi.amaassn.org/cgi/content/abstract/162/5/447) Martin, A & Volkmar, F. Lewis’s Child and Adolescent Psychiatry: A Comprehensive Textbook, 4th ed., 2007. Strawn, J. et al., “Psychopharmacologic Treatment of Posttraumatic Stress Disorder in Children and Adolescents: A Review”. Journal of Clinical Psychiatry 2010; 71(7):932-941.