Evidence-Based Reviews

Traumatized children: Why victims of violence live out their nightmares

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

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Confronting Steven’s demons. Steven was treated with paroxetine, 15 mg/d, targeting both his depressive and PTSD symptoms; clonidine, 0.05 mg at bedtime, targeting hyperarousal symptoms and ADHD; and risperidone, 0.5 mg bid, which was added last to target his severe aggression and violent behavior.

He also received speech therapy, milieu treatment with the structured setting at the day program, and individual play therapy from the day program’s interns. At home, wrap-around services—including a behavioral specialist and a therapeutic staff support worker—were provided to help his foster family deal with his aggression and difficult behavior.

Conclusion

Current approaches to diagnosis, assessment, and treatment of PTSD in children and adolescents depend in large part on the few available studies conducted in adults, which may not necessarily apply to younger patients. We need more clinical trials involving children and adolescents, better diagnostic instruments, and accurate symptom severity rating scales.

Box 5

DSM-IV-TR: POSTTRAUMATIC STRESS DISORDER Criterion E: Duration of symptoms

Duration of the disturbance (symptoms in Criteria B, C, and D) is more than 1 month.

PROPOSED CHANGE FOR YOUNG CHILDREN

The disturbance has been present for 1 month

Appearance of new symptoms (only one is needed)

new aggression
new separation anxiety
fear of toilet training alone
fear of darkness
any new fears not related to the trauma

Criterion F: Impairment in functioning

The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

PROPOSED CHANGE FOR YOUNG CHILDREN

Function impairment is not needed for the diagnosis

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

Research is leading to new understandings of PTSD in childhood, from more refined diagnostic criteria to observations of changes in brain volume and secretion of stress hormones in maltreated children. Case reports are exploring the safety and efficacy of drug and psychotherapeutic treatments.

Acceptable treatment and management—as indicated by case reports and recommended by the American Academy of Child and Adolescent Psychiatry—includes CBT or dynamic psychotherapy, group therapy, and drug treatment, especially for PTSD’s comorbidities.

Related resources

National Center for PTSD. www.ncptsd.org
International Society for Traumatic Stress Studies. www.istss.org
The PTSD Alliance. http://www.ptsdalliance.org
National Center for Children Exposed to Violence (NCCEV) http://www.nccev.org

Drug brand names

Carbamazepine • Tegretol
Citalopram • Celexa
Clonidine • Catapres
Fluvoxamine • Luvox
Imipramine • Tofranil
Mirtazapine • Remeron
Nefazodone • Serzone
Paroxetine • Paxil
Propranolol • Inderal
Risperidone • Risperdal

Disclosure

Dr. Elizabeth Weller reports that she receives research/grant support from Forest Pharmaceuticals, Organon, and Wyeth Pharmaceuticals, and serves as a consultant to Johnson & Johnson, GlaxoSmithKline, and Novartis Pharmaceuticals Corp.

Dr. Shlewiet reports no affiliation or financial arrangement with any of the companies whose products are mentioned in this article, or with manufacturers of competing products.

Dr. Ronald Weller reports that he receives research/grant support from Wyeth Pharmaceuticals, Organon, and Forest Pharmaceuticals.