Pediatric PTSD

1. David Camenisch, MD/MPH Pediatric PTSD

2. WHAT CONSTITUTES TRAUMA? • 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)

3. TYPES OF TRAUMA Child maltreatment (physical/sexual/emotional abuse, neglect) Sexual assault Domestic violence Community violence Natural disasters Terrorism Life threatening illness/accidents

4. EPIDEMIOLOGY OF CHILD TRAUMA EXPOSURE Lifetime exposure: (at least one traumatic event) • Girls: 15-43% • Boys: 14-43% (Copeland W et al. Arch G Psychiatry 2007)

5. TYPE OF ABUSE • 64% neglect • 15% physical abuse • 9% sexual abuse; • 10% emotional abuse (U.S. Dept. HHS. Child Maltreatment 2006)

6. WHO IS ABUSING • Parents 80% (>90% bio parents) • Other relatives 8%. • Women 58% • Men 42% (U.S. Dept. HHS. Child Maltreatment 2006)

7. EPIDEMIOLOGY OF PTSD • 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

8. PSYCHOLOGICAL/INTERPERSONAL VULNERABILITY • 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

9. FAMILY AND SOCIO-ECONOMIC VULNERABILITY • 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

10. NORMAL PSYCHOLOGICAL REACTIONS FOLLOWING TRAUMATIC EXPERIENCE • 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

11. BIOLOGICAL AND PSYCHOLOGICAL RESPONSES TO TRAUMA • 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)

12. Addressing Trauma and Identifying PTSD

13. SCREENING TIPS • 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

14. Trauma Screening Questionnaire(Brewin, 2002) • Upsetting thoughts or memories about the event that have comeinto your mind against your will • Upsetting dreams about theevent • Acting or feeling as though the event were happeningagain • Feeling upset by reminders of the event • Bodily reactions(such as fast heartbeat, stomach churning,sweatiness, dizziness)when reminded of the event • Difficulty falling or staying asleep • Irritability or outbursts of anger • Difficulty concentrating • Heightened awareness of potential dangers to yourself andothers • Being jumpy or being startled at something unexpected Postive Item = >2 times/week Positive Screen = > 6 (90% PPV)

15. Primary Care PTSD Screen (PC-PTSD)  (Prins, Ouimette, Kimerling et al., 2003) 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

16. ADDRESSING CHILDHOOD TRAUMA: GENERAL STRATEGIES • 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

17. ADDRESSING CHILDHOOD TRAUMA: PARENTS AND CARETAKERS • 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

18. ADDRESSING CHILDHOOD TRAUMA: CHILDREN • 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

19. Addressing Childhood Trauma: The School • 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)

20. Developmental Considerations: Pre School • 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

21. Developmental Considerations: School Age • 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)

22. Developmental Considerations: Adolescent • 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.

23. Big Picture • 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

24. Diagnostic Criteria and Issues

25. DSM and CHILDHOOD PSYCHOPATHOLOGY “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.  

26. DSM and CHILDHOOD PSYCHOPATHOLOGY “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

27. NOSOLOGIC CHALLENGES OF PTSD • 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

28. DSM-IVTR: Post Traumatic Stress Disorder Criterion A : Event/Response Event: actual/threatened death or serious injury ORthreat to physical integrity of others OR sexual abuse Subjective Response: intense fear, helplessness, horror; disorganized OR agitated behavior in children

29. DSM-IVTR: Post Traumatic Stress Disorder 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

30. DSM-IVTR: Post Traumatic Stress Disorder 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

31. DSM-IVTR: Post Traumatic Stress Disorder Criterion D: Hyperarousal(≥2; 1 for preschoolers): • Sleep problems • Irritability/anger • Difficulty concentrating • Hypervigilance • Exaggerated startle

32. DSM-IVTR: Post Traumatic Stress Disorder 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

33. DSM-IVTR: Post Traumatic Stress DisorderProposed Preschool Cluster (≥1): • Loss of developmental skills • New onset separation anxiety • New onset aggression • New non-trauma related fears (ScheeringaM et al JAACAP 2003)

34. COMPLEX PTSD 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 *

35. COMPLEX PTSD • 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

36. DSM-V: Disorders of Extreme Stress, NOS 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.

37. Why Look for PTSD? • 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

38. PSYCHIATRIC COMORBIDITIES (60 %) • 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)

39. Behavioral and Medical Consequences • 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

40. NEUROBIOLOGY • 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)

41. What can I expect? • 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

42. Treatment of Pediatric PTSD

43. EBT FOR PTSD Level 1 (Best Support) Trauma-focused CBT (3-17) CBT with parents Level 2 (Good Support) CBT (with child) Level 3 (Moderate Support) None Level 4 (Minimal Support) Play therapy Psychodrama Level 5 (No support) CBT with parents only Client Centered Therapy EMDR CBT and medication Interpersonal Therapy Relaxation (State of Hawaii, CAMHD. “Blue Menu.” 2010.)

44. What is TF-CBT? • Approach that helps patients understand and change how they think and react to their trauma and its aftermathby 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

45. TRAUMA-FOCUSED COGNITIVE BEHAVIORAL THERAPY (TF-CBT) • 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

46. COMPONENTS OF EFFECTIVE TF-CBT • 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)

47. Cohen et al study (JAACAP, 46:7, July 2007) • 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 non-medication treatments

48. Robb et al (Journal of Child and AdolPsychopharm, 20:6, 2010) • Goal: Evaluate safety and efficacy of sertralinevs placebo for treatment of pediatric PTSD • Design: Multi-site DB-RCT. N=131. 3 sessions of psycho-ed/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”

49. WHEN SHOULD MEDICATIONS BE CONSIDERED? • 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)

50. What are my options? • SSRIs • Adrenergic Agents (β-blockers, α1-antagonists, α2-agonists) • Atypical anti-psychotics • Mood Stabilizers • Sleep aides/hypnotics