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David Camenisch, MD/MPH 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) 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) 64% neglect 15% physical abuse 9% sexual abuse; 10% emotional abuse (U.S. Dept. HHS. Child Maltreatment 2006) Parents 80% (>90% bio parents) Other relatives 8%. Women 58% Men 42% (U.S. Dept. HHS. Child Maltreatment 2006) 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 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 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 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) 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?” 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 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 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 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) 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 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) 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. 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” 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.” 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 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) 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): 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): 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 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 * 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. 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 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) 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 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) 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 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 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 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) 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 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) SSRIs Adrenergic Agents (β-blockers, α1antagonists, α2-agonists) Atypical anti-psychotics Mood Stabilizers Sleep aides/hypnotics 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. 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 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) 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 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 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 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) Only 1 small RCT (Divalproex) No FDA approvals Variable side effects and monitoring required Limbic kindling model (amygdala, hippocampus) supports potential role for AEDs 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) 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 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. 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) Substance P antagonists Orexin agonists NeuropeptideY antagonists 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) Foster/reassure safety Calmness Self- efficacy Community/Family-efficacy Social connectedness Optimism