Download Pediatric PTSD - PAL Wyoming: Partnership Access Line

David Camenisch, MD/MPH
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An Experience/event:
actual/threatened death or serious injury threat to
physical integrity of self/others (sexual abuse)
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A Subjective response:
intense fear, helplessness, horror (preschoolers
exempt; includes disorganized or agitated
behavior in school-age children)
Child maltreatment
(physical/sexual/emotional abuse, neglect)
Sexual assault
Domestic violence
Community violence
Natural disasters
Terrorism
Life threatening illness/accidents
Lifetime exposure: (at least one traumatic
event)
▪ Girls: 15-43%
▪ Boys: 14-43%
(Copeland W et al. Arch G Psychiatry 2007)
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64% neglect
15% physical abuse
9% sexual abuse;
10% emotional abuse
(U.S. Dept. HHS. Child Maltreatment 2006)
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Parents 80% (>90% bio parents)
Other relatives 8%.
Women 58%
Men 42%
(U.S. Dept. HHS. Child Maltreatment 2006)
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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
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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
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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
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
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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)
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Consider screening for potentially traumatic
events at all well-child visits
“Since the last time I saw you,
has anything really scary or
upsetting happened to you or
your family?”
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Discuss with parent AND child
Consider Screening Tool
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 event
6.
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
1.
Postive Item = >2 times/week
Positive Screen = > 6 (90% PPV)
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
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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
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
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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
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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)
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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
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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)
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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.
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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
“If you suspect it, treat it”
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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.
“If you miss, you miss big.”
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Predictive value of diagnosis especially important
because of rapid development in all areas.
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Evidence that psychopathology can be more
enduring. (Fewer defenses and resources, impact of
neurophysiologic change on developing brain.)
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Higher rates of development of chronic PTSD in
younger cohorts
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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
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
Criterion B : Re-experiencing (≥ 1)
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Intrusive memories/repetitive play/drawing
Recurrent dreams/nightmares
Flashbacks or behavioral re-enactment
Psychological distress or physiological
reactivity in response to trauma-related cues
Criterion C : Avoidance/Numbing (≥ 3;1 for
preschoolers):
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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
Criterion D: Hyperarousal (≥ 2; 1 for
preschoolers):
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Sleep problems
Irritability/anger
Difficulty concentrating
Hypervigilance
Exaggerated startle
Criterion E: Duration >1 month
Criterion F: Significant distress or impairment
Modifiers:
Acute: sx <3 months duration
Chronic: sx >3 months duration
Delayed onset: >3 months after trauma
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Loss of developmental skills
New onset separation anxiety
New onset aggression
New non-trauma related fears
(ScheeringaM et al JAACAP 2003)
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 *
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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
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.
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High rates of psychiatric co-morbidity
Increased suicide risk (20% of SA related to trauma,
8x risk in childhood sexual abuse)
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Chronic, progressive, debilitating
Treatable
Can impact all developmental domains
Frequently overlooked
Masquerades as many other somatic,
cognitive and behavioral disorders
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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)
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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
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Increased NE (hyper-adrenergic state; tone and
reactivity)
Abnormal cortisol
↑acutely = neurotoxicity
↓chronically = ↓neurogenesis, ↓myelination
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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)
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
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Level 1 (Best Support)
Level 2 (Good Support)
Level 3 (Moderate Support)
Level 4 (Minimal Support)
Level 5 (No support)
Trauma-focused CBT (3-17)
CBT with parents
CBT (with child)
None
Play therapy
Psychodrama
CBT with parents only
Client Centered Therapy
EMDR
CBT and medication
Interpersonal Therapy
Relaxation
(State of Hawaii, CAMHD. “Blue Menu.” 2010.)
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
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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
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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)
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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 nonmedication treatments
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Goal: Evaluate safety and efficacy of sertraline vs placebo for
treatment of pediatric PTSD
Design: Multi-site DB-RCT. N=131. 3 sessions of psychoed/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”
Severe symptoms causing impaired functioning
Prolonged symptoms (> 1 mos)
Failure of psychological, supportive and family
interventions
 Patient/family unable or unwilling to participate in
psychological and social treatments
 Co-morbid depression or anxiety disorder
(especially adolescents)
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SSRIs
Adrenergic Agents (β-blockers, α1antagonists, α2-agonists)
Atypical anti-psychotics
Mood Stabilizers
Sleep aides/hypnotics
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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 can be considered for the treatment of children
and 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.
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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
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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)
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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
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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)
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quetiapine (Seroquel) – No RCTs
 Case series (n=6) - adolescents; improvement in
PTSD symptoms, anxiety, depression and anger
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ziprasidone (Geodon) – no reports or studies
olanzapine (Zyprexa) – no reports or studies
aripiprazole (Abilify) – no reports or studies
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
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Carbamazepine (Tegretol) – OT; n=28; ages 817 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)
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Only 1 small RCT (Divalproex)
No FDA approvals
Variable side effects and monitoring required
Limbic kindling model (amygdala,
hippocampus) supports potential role for
AEDs
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Propranolol - negative pediatric DBRCT, n=29
(Nugent. 2007)
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Fluoxetine – negative pediatric RCT; study
duration 1 week; treatment of ASD (Tcheung et al.
2008)
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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)
Medication
Level of Evidence
Adrenergics
Prazosin
IV
Cloinidine
IV
Guanfacine
IV
Propranolol
IV
SGAs
Quetiapine
IV
Risperidone
IV
AEDs
Carbamazepine
IV
Divalproex
IV
SSRIs
Sertraline
2 negative RCTs
Citalopram
IV
Others
Cyproheptadine
IV
Benzodiazepines
No Evidence
Notes
↓ Intrusive/hyper-arousal
↓ Re-enactment
↓ Intrusive
↓ Hyper-arousal
↓ Anxiety, Depression, Anger
↓ Intrusive/hyper-arousal
↓ Intrusive/hyper-arousal
I=Sys Review or RCTs; II=RCT; III=Case-Control Studies; IV=case-series; V=expert opinion
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2 PCRT do NOT support use of SSRIs in
treatment of pediatric PTSD
Role for SSRIs related to treatment of comorbid 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
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.
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.
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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.
National Childhood Traumatic Stress Network
http://www.nctsnet.org/nccts/nav.do?pid=ctr_aud_prof
American Academy of Child and Adolescent Psychiatry
www.aacap.org
National Center for PTSD
http://www.ptsd.va.gov/professional/pages/assessments/childtrauma-ptsd.asp
Sesame Street
http://www.sesameworkshop.org/initiatives/emotion
Trauma Focused CBT Web Resource
http://tfcbt.musc.edu/
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 PlaceboControlled 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)
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Substance P antagonists
Orexin agonists
NeuropeptideY antagonists
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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)
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Foster/reassure safety
Calmness
Self- efficacy
Community/Family-efficacy
Social connectedness
Optimism