Transcript Lecture: Child Abuse and Neglect - American Academy of Child and

Child Abuse and
Neglect
Shannon Wagner Simmons, MD, MPH
Child and Adolescent Psychiatry Fellow
Institute for Juvenile Research
University of Illinois at Chicago
Objectives
• Review basic concepts and epidemiology of child
maltreatment
• Discuss psychiatric diagnostic issues in abused or
neglected children
• Provide an overview of the treatment of PTSD in children
and adolescents, including a brief review of the
psychopharmacology literature
• Discuss a clinical example
Jane
Jane is a 15 year old girl with a history of a learning disorder who
presents to an outpatient intake clinic with a two-month history
of generalized anxiety and panic attacks.
• She had no prior psychiatric history.
• Medical history includes only mild asthma.
• Birth, developmental, and family histories are
noncontributory.
• She has a younger sister who lives at home; parents are
divorced.
Jane, continued
• She began weekly CBT with a psychology intern.
• In the fourth session, she disclosed to her therapist that she
had been repeatedly raped by a family friend in her home
over the summer.
• This family friend still visits the home often.
• “I’m not ready to tell my mom.”
• Jane admits that she has been smoking marijuana several
times weekly to manage her anxiety symptoms.
• She also endorses nightmares, flashbacks, and
hypervigilance.
Jane – A Few Questions
• If you were the therapist, what would you do
next? What are you worried about?
• Why did she disclose this now?
• How would this information change your
treatment approach?
Some Numbers
• 3 million suspected cases reported annually
• 1 million of these are substantiated
60% neglect, 20% physical abuse, 10% sexual abuse,
10% miscellaneous
• Lifetime incidence of maltreatment:
30% in child psychiatry outpatient populations
55% in child psychiatry inpatient populations
Some Definitions
• Physical Abuse: “Intentional injury of a child by a
caretaker…that lead[s] to injury, and frequently occurs in the
context of discipline.”
• Neglect: “Caretakers fail to appropriately provide for and
protect children…failing to meet the child’s nutritional,
supervision, or medical needs.”
From Lewis’s Child and Adolescent Psychiatry: A Comprehensive Textbook
Some Definitions
• Sexual Abuse: “Sexual behavior between a child and an
adult or two children when one of them is significantly
older or uses coercion…may include exhibitionism”
• Psychological Abuse: “When an adult repeatedly conveys
to a child that he is worthless, defective, unloved, or
unwanted…it may involve threatened or actual
abandonment.”
From Lewis’s Child and Adolescent Psychiatry: A Comprehensive Textbook
Child Risk Factors for Abuse
• Prematurity
• Age under 4 years
• “Special Needs”
• Disruptive behavior
Caregiver/Family Risk Factors for
Abuse
• Poverty
• Substance Abuse
• Domestic Violence
• Caregiver history of being abused
• Transient nonrelated caregivers
• Social stressors
Psychiatric Sequelae
• Maltreated children are at risk for:
o Attachment disorders
o
o Social/peer relationship
o
problems
o
o Language delays
o
o Below-average standardized o
test scores
o
o Intimate Partner Violence o
o Teen parenthood
o Perpetrating abuse
o
o Age-inappropriate sexual
behavior
Mood disorders
Anxiety disorders
Psychosis
Alcohol and drug abuse
Eating disorders
Disruptive behavior
Borderline personality
disorder
Dissociative disorders
Predictors of More Favorable
Long-Term Outcomes
• Consistent support system after the trauma
• Limited relationship with perpetrator
• Some genetic polymorphisms:
 5HTTLPR (Serotonin Transporter Gene) and depression
 CRHR1 (Corticotropin-releasing hormone receptor)
 MAO-A (monoamine oxidase-A) and aggression
 Catechol-O-methyltransferase (COMT)
Diagnostic Issues
• “Single-blow” vs. chronic trauma
• Neglect vs. physical abuse
Internalizing vs. externalizing
• “Complex Trauma”
Diagnostic Evaluation
• Maltreated children are at risk for a wide range of
psychopathology.
• Developmental state at the time of trauma and at
presentation is key.
• A thorough diagnostic assessment is indicated.
• We must ask the questions, sometimes several times.
• Mandated reporting issues
PTSD
• Three symptom clusters: re-experiencing,
avoidant, and hyperarousal
• Some DSM criteria allow for developmental
differences, but others do not.
• There is some controversy about how accurately
these criteria capture the disorder in children,
especially young children
PTSD Screening Tools
•
•
•
•
•
UCLA PTSD index
Trauma Symptom Checklist
Anxiety Disorder Interview Schedule (ADIS) PTSD section
Others
Sometimes children report things on rating scales that
they do not report verbally.
Treatment Planning
• The treatment should be tailored to the
symptoms/disorder.
• Safety First: Be vigilant for ongoing
maltreatment or re-traumatization
• Treatment often requires working with a larger
multidisciplinary team and focusing on family
and environmental factors
Trauma Focused CBT
• Considered best practice for children or teens
who have experienced trauma
• Intervenes with both the child and caregivers
• Psychoeducation, relaxation skills, affective
modulation, cognitive coping related to the
trauma
• Creation of a trauma narrative
• Free web training: http://tfcbt.musc.edu/
Pharmacotherapy of PTSD
• Indications:
Severe symptoms
Suboptimal response to psychotherapy
Comorbidity with a disorder amenable to
pharmacotherapy (e.g. MDD)
• Combined approach (therapy + meds) is ideal
SSRIs in Pediatric PTSD
• Double-blind, placebo-controlled RCT: sertraline
was comparable to placebo (Robb et al, 2010)
• Addition of placebo or citalopram to TF-CBT: no
additional benefit in treatment group (Cohen et
al, 2007)
• Open trial of citalopram in 8 patients:
improvements seen (Seedat et al, 1999).
• That’s all!
SSRIs: Things to Consider
• Black-box warning regarding suicidal ideation
• Children, especially those with severe mood
dysregulation, may find SSRIs too activating
• The other usual side effects
• Start low, go slow
Other Agents in PTSD:
Adrenergic Agents
• Clonidine reduced some PTSD symptoms in a small
open trial of preschoolers (Harmon and Riggs, 1996).
• Guanfacine reduced nightmares in a case report
involving a 7 year old (Horrigan, 1996).
• Prazosin reduced nightmares and hyperarousal in
two adolescent case reports (Strawn et al, 2009;
Fraleigh et al, 2009)
• Propranolol reduced PTSD symptoms in 11 schoolaged children (Famularo et al, 1988)
Other Agents in PTSD:
Atypical Antipsychotics
• Risperidone reduced hypervigilance and aggression
in a teen (Keeshin and Strawn, 2009).
• When added to escitalopram, aripiprazole
decreased nightmares in a teen (Yeh et al, 2010).
• Quetiapine decreased dissociation, anxiety, and
depression in a series of 6 teens with PTSD (Stathis
et al, 2005).
• Clozapine reduced aggression and improved sleep in
a case series of six treatment-resistant teens
Other agents in PTSD:
Mood Stabilizers
• Divalproex sodium caused a greater reduction of
PTSD symptoms when given in high vs. low doses
in 12 juvenile-detention teens (Steiner et al,
2007).
• In a case series of 28 children and teens with
severe abuse history, most responded very well
to carbamazepine (Looff et al, 1995).
Jane Revisited –
A Few Questions
• If you were the therapist, what would you do
next? What are you worried about?
• Why did she disclose this now?
• How would this information change your
treatment approach?
Useful Websites
• www.nctsn.org (National Child Traumatic Stress Network)
• www.aacap.org (American Academy of Child and Adolescent
Psychiatry)
 Facts for Families
 Practice Parameters
• http://tfcbt.musc.edu/ (Trauma-Focused CBT)