Transcript Post Traumatic Stress Disorder in Children

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

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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
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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.
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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
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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
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– 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
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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.