Evidence-Based Reviews

Traumatized children: Why victims of violence live out their nightmares

Current Psychiatry. 2003 January;2(1):30-39

References

1. American Psychiatric Association. Diagnostic and statistical manual of mental disorders (4th ed). Washington, DC: American Psychiatric Association, 1994

2. Frederick CJ. Children traumatized by catastrophic situations. In: Eth S, Pynoos RS (eds). Posttraumatic stress disorder in children. Washington, DC: American Psychiatric Press, 1985;71-100.

3. Garrison CZ, Bryant ES, Addy CL, Spurrier PG, Freedy JR, Kilpatrick DG. Posttraumatic stress disorder in adolescents after Hurricane Andrew. J Am Acad Child Adolesc Psychiatry 1995;34:1193-1201.

4. Scheeringa MS, Zeanah CH. Symptom expression and trauma variables in children under 48 months of age. Infant Ment Health J 1995;16:259-70.

5. Scheeringa MS, Zeanah CH, Drell MJ, Larrieu JA. Two approaches to diagnosing post-traumatic stress disorder in infancy and early childhood. J Am Acad Child Adolesc Psychiatry 1995;34:191-200.

6. American Academy of Child and Adolescent Psychiatry. Practice parameters for the assessment and treatment of posttraumatic stress disorder in children and adolescents. J Am Acad Child Adolesc Psychiatry 1998;37(10,suppl):4S-26S.

7. Carrion VG, Weems CF, Ray R, Reiss AL. Toward an empirical definition of pediatric PTSD: the phenomenology of PTSD symptoms in youth. J Am Acad Child Adolesc Psychiatry 2002;41(2):166-73.

8. Silva RR, Alpert M, Munoz DM, Singh S, Matzner F, Dummit S. Stress and vulnerability to posttraumatic stress disorder in children and adolescents. Am J Psychiatry 2000;157(8):1229-35.

9. Foy DW, Madvig BT, et al. Etiologic factors in the development of posttraumatic stress disorders in children and adolescents. J Sch Psychol 1996;34:133-45.

10. Famularo R, Fenton T, Augustyn M, Zuckerman B. Persistence of pediatric posttraumatic stress after two years. Child Abuse Negl 1996;20:1245-8.

11. De Bellis MD, Baum A, Birmaher B, Keshavan MS, Eccard CH, et al. Developmental traumatology part I: Biological stress systems. Biol Psychiatry 1999;45(10):1259-70.

12. De Bellis MD, Keshavan M, Clark DB, Casey BJ, Giedd JN, Boring AM, et al. Developmental traumatology Part II: Brain development. Biol Psychiatry 1999;45:1271-84.

13. Hart J, Gunnar M, Cicchetti D. Altered neuroendocrine activity in maltreated children related to symptoms of depression. Dev Psychopathol 1996;8:201-14.

14. King JA, Madasky D, King S, Fletcher KE, Brewer J. Early sexual abuse and low cortisol. Psychiatry Clin Neurosci 2001;55:71-4.

15. Carrion VG, Weems CF, Ray RD, Glaser B, Hessl D, Reiss AL. Diurnal salivary cortisol in pediatric posttraumatic stress disorder. Biol Psychiatry 2002;51(7):575-82.

16. De Bellis MD, Keshavan M, Frustaci K, Shifflett H, et al. Superior temporal gyrus volumes in maltreated children and adolescents with PTSD. Biol Psychiatry 2002;51:544-52

17. Carrion VG, Weems CF, Eliez S, Patwardhan A, Brown W, et al. Attenuation of frontal asymmetry in pediatric posttraumatic stress disorder. Biol Psychiatry 2001;50:943-51

18. De Bellis MD, Keshavan MS, Spencer S, Hall J. N-acetylaspartate concentration in the anterior cingulate of maltreated children and adolescents with PTSD. Am J Psychiatry 2000;157:1175-7.

19. Cohen JA, Mannarino AP. Treatment outcome study for sexually abused preschool children: initial findings. J Am Acad Child Adolesc Psychiatry 1996;35(1):42-50.

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21. Deblinger ES, Cohen JA. Cognitive behavioral treatment for sexually abused children and their nonoffending parents (workshop) Chicago: American Professional Society on the Abuse of Children, sixth national colloquium,1998.

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23. Cohen JA, Mannarino AP. Treatment outcome study for sexually abused preschool children: initial findings. J Am Acad Child Adolesc Psychiatry 1996;35 (1):42-50.

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31. Domon S, Anderson M. Nefazodone for PTSD. J Am Acad Child Adolesc Psychiatry 2000;39(8):

attenuation in frontal lobe asymmetry and smaller total brain and cerebral volumes in children with PTSD, compared with controls¹⁷
a lower N-acetylaspartate/creatine ratio in children with PTSD, which suggests altered anterior cingulate neuronal metabolism.¹⁸

These apparent changes in brain architecture and metabolism may have functional implications. Children with PTSD have been found to perform more poorly than do controls on measures of attention, abstract reasoning, and executive functioning.¹⁶

PTSD treatment in children

Treatment of PTSD in children is strongly influenced by the adult literature and practice guidelines. Most psychiatrists who treat children endorse drug therapy as the first line of treatment, followed by psychodynamic psychotherapy and cognitive-behavioral therapy (CBT). In a recent survey of treatment practices in childhood PTSD, 95% of psychiatrists endorsed the use of medications such as selective serotonin reuptake inhibitors (SSRIs) (47 to 49%), alpha-agonists (16 to 38%), tricyclic antidepressants (11 to 15%), and anxiolytics (12%).

Nonmedical therapists who were included in the survey endorsed the use of eye movement desensitization and reprocessing, CBT, family therapy, and nondirective play therapy.¹⁹

Psychotherapy. Preliminary evidence from five controlled trialsindicates that CBT may be an effective first-line treatment for children and adolescents with PTSD:

In a study of 100 sexually abused children, PTSD symptoms improved significantly more when children received CBT alone or with their parents, compared with when only their parents received CBT.²⁰ Externalizing and depressive symptoms improved greatly when a parent was included in the child’s treatment, and this improvement was maintained 2 years later.²¹
A randomized study of 80 sexually abused children found little difference between those who received traditional group therapy and others who received group therapy plus CBT.²²
CBT was found more effective than nondirective supportive therapy in sexually abused preschool children, both initially and at 6- and 12-month intervals, as well as in children ages 7 to 14.^23,24
After an earthquake in Armenia, children treated with school-based, grief/trauma-focused CBT showed significant improvement on self-reported measures of PTSD and depressive symptoms, compared with children who received no such treatment.²⁵

Pharmacotherapy

Open-label case reports and case series have examined a variety of pharmacotherapies in childhood PTSD, but no double-blind, placebo-controlled studies have been published.

Propranolol. Eleven children with histories of sexual and/or physical abuse exhibited significantly fewer PTSD symptoms during a 5-week regimen of the beta blocker propranolol than either before or after they received the medication.²⁶

Carbamazepine was given to 28 children and adolescents ages 8 to 17 with a primary diagnosis of PTSD. Complete symptom remission was observed in 22 children, and the other 6 had significant improvement—reporting only abuse-related nightmares. Carbamazepine dosages of 300 to 1,200 mg/d yielded serum levels of 10 to 11.5 mcg/ml.

Subjects with comorbid conditions (one-half the sample) required additional medications. Four children with ADHD received stimulants, three with major depressive disorder received SSRIs, and one patient was given imipramine.²⁷

Clonidine treatment resulted in moderate or greater improvement in target symptoms of PTSD in seven preschool children ages 3 to 6 with a history of severe sexual and/or physical abuse. Clonidine dosages ranged from 0.1 mg at bedtime to 0.05 bid plus 0.1 at bedtime.²⁸

SSRIs and other antidepressants. Citalopram was given in a comparison study to 24 children and adolescents and 14 adults with PTSD, with symptoms assessed every 2 weeks based on Clinician Administered PTSD Scale (CAPS) and Clinical Global Impression (CGI) scores. Mean CAPS total score, symptom cluster score, and CGI ratings were significantly reduced in both age groups. Children and adolescents showed greater improvement than adults in hyperarousal symptoms but less in re-experiencing and avoidance symptoms.²⁹

An 8-year-old girl with PTSD and comorbid anxiety disorder initially responded to fluvoxamine. When she relapsed, mirtazapine was added and her overall symptoms improved.³⁰

An adolescent with PTSD treated with nefazodone, up to 600 mg/d, showed improvement in hyperarousal symptoms and anhedonia.³¹

Summary. In the absence of conclusive scientific evidence—i.e., double-blind, placebo-controlled studies—these case reports reflect common practices in treating PTSD in children and adolescents. American Academy of Child and Adolescent Psychiatry practice guidelines defer to the psychiatrist’s judgment to determine the best pharmacologic approach.⁶ In most cases, evidence from the adult literature influences treatment decisions, and in some cases treatment targets comorbidities such as depression, panic disorder, ADHD, and anxiety.

Box 4

DSM-IV-TR: POSTTRAUMATIC STRESS DISORDER Criterion D: Hyperarousal

Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following:

difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response

PROPOSED CHANGE FOR YOUNG CHILDREN

night terrors
difficulty going to sleep
night awakening
decreased concentration
hypervigilance
exaggerated startle response

Source: Adapted from DSM-IV-TR and Scheeringa et al. J Am Acad Child Adolesc Psychiatry 1995;34:191-200.