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Approach to treating posttraumatic stress disorder in children and adolescents
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Approach to treating posttraumatic stress disorder in children and adolescents
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Nov 2017. | This topic last updated: Apr 25, 2017.

INTRODUCTION — Posttraumatic stress disorder (PTSD) in children and adolescents is a severe, often chronic, and impairing mental disorder. PTSD is seen in some children (and not others) after exposure to traumatic experiences involving actual or threatened injury to themselves or others. Traumatic experiences leading to PTSD can include interpersonal violence, accidents, natural disasters, and injuries.

PTSD is characterized by intrusive thoughts and reminders of the traumatic experience(s), avoidance of trauma reminders, negative mood and cognitions related to the traumatic experience(s), and physiological hyperarousal that lead to significant social, school, and interpersonal problems. PTSD can occur even in toddlers (one to two years old) [1,2]. The consequences of PTSD include elevated risk for other mental disorders and suicide, substantial impairment in role functioning, reduced social and economic opportunity, and earlier onset of chronic diseases, particularly cardiovascular disease.

This topic and an algorithm (algorithm 1) describe our approach to selecting treatment, including psychosocial interventions and pharmacotherapy, for PTSD in children and adolescents. Psychosocial interventions for PTSD in children and pharmacotherapy for PTSD in children are reviewed separately. The epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis of PTSD in children are also reviewed separately. PTSD in adults is also reviewed separately. (See "Psychosocial interventions for posttraumatic stress disorder in children and adolescents" and "Pharmacotherapy for posttraumatic stress disorder in children and adolescents" and "Posttraumatic stress disorder in children and adolescents: Epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis" and "Posttraumatic stress disorder in adults: Epidemiology, pathophysiology, clinical manifestations, course, assessment, and diagnosis" and "Psychotherapy for posttraumatic stress disorder in adults" and "Pharmacotherapy for posttraumatic stress disorder in adults".)

NEWLY DIAGNOSED PATIENTS — For most children and adolescents with posttraumatic stress disorder (PTSD) or prominent PTSD symptoms, including those with complex PTSD, we suggest first-line treatment with an evidence-based, trauma-focused psychotherapy rather than other psychosocial or medication treatments.

Multiple clinical trials have found trauma-focused psychotherapies to be efficacious in reducing PTSD symptoms in children and adolescents with the disorder [3-11]; in comparison, no medications for PTSD in this population are reliably supported by randomized clinical trial results. No medications have been approved by the US Food and Drug Administration for the treatment of PTSD in children. Serotonin reuptake inhibitors (SRIs), which are an efficacious, first-line pharmacologic treatment for adults with PTSD, have not been found to be efficacious in multiple small randomized trials in children. (See "Psychosocial interventions for posttraumatic stress disorder in children and adolescents", section on 'Trauma-focused psychotherapies' and "Pharmacotherapy for posttraumatic stress disorder in children and adolescents" and "Pharmacotherapy for posttraumatic stress disorder in adults".)

Varied trauma-focused psychotherapy models emphasize different components and/or have been customized to treat patients with specific characteristics, clinical presentations, or in certain settings. There is limited evidence available to inform selection among these therapies.

Few clinical trials have directly compared the psychotherapies, and these comparisons did not show differences in PTSD outcomes. As an example, a clinical trial randomly assigned 48 children with PTSD symptoms to receive eye movement desensitization and reprocessing (EMDR) or trauma-focused cognitive-behavioral therapy (TF-CBT) [12]. Eight sessions of each intervention resulted in large effect sizes for PTSD improvement; no difference in reduction in PTSD symptoms was seen. Parents of children treated with TF-CBT, but not those treated with EMDR, reported improvement in child depressive and hyperactivity symptoms.

Our preferences regarding trauma focused psychotherapies vary by age group and stem largely from clinical trials comparing individual therapies with inactive controls, secondary data analyses, and our clinical experience. Multiple therapies have been shown to be efficacious for youth with PTSD compared with an inactive control. The intervention should be provided by a therapist who has received appropriate training in the model used. A full course of therapy should be completed. (See "Psychosocial interventions for posttraumatic stress disorder in children and adolescents", section on 'Trauma-focused psychotherapies'.)

Trauma-focused psychotherapy can be provided to individual patients or to groups. Group models are useful where there are resource constraints, an absence of trained therapists, or other barriers to access that preclude individual therapy, eg, Cognitive Behavioral Intervention for Trauma in Schools (CBITS) [13-15]. The choice between individual and group modalities may also be influenced by family preference, by specific population needs (eg, trauma and grief component therapy for teens with both PTSD and maladaptive grief symptoms), or by clinical presentation. We favor individual rather than group therapy for children with severe PTSD symptoms [15] Specific therapies are suggested for population subgroups, including:

Children seven years and older — For most children seven years and over with PTSD or PTSD symptoms, TF-CBT is the intervention most strongly supported by evidence from clinical trials. These findings have been replicated in diverse populations of children with diverse types of trauma [16-18]. (See "Psychosocial interventions for posttraumatic stress disorder in children and adolescents", section on 'Individual trauma-focused CBT'.)

A clinical trial comparing CBITS and TF-CBT in youth following Hurricane Katrina [19] found that the group model CBITS provided greater access but the two interventions had comparable efficacy. The trial randomly assigned 118 schoolchildren with PTSD symptoms identified by screening to receive CBITS at their schools or TF-CBT at community clinics. Students assigned to the school-based intervention were more likely to access treatment than students assigned to the clinic-based intervention (98 versus 37 percent). Both groups experienced reductions in PTSD symptoms, but no differences were seen between groups. (See "Psychosocial interventions for posttraumatic stress disorder in children and adolescents", section on 'Cognitive-Behavioral Intervention for Trauma in Schools (CBITS)'.)

For some patients, the choice among therapies may be influenced by individual or family preference, specific population needs (eg, Trauma Affect Regulation: Guide for Education and Therapy for juvenile justice-involved youth) and/or local availability. (See "Psychosocial interventions for posttraumatic stress disorder in children and adolescents", section on 'Trauma affect regulation: Guide for education and therapy (TARGET)'.)

Children three to six years — For children three to six years old with PTSD or PTSD symptoms, we suggest child-parent psychotherapy (CPP) rather than other psychotherapies, particularly for children with (see "Psychosocial interventions for posttraumatic stress disorder in children and adolescents", section on 'Child-Parent Psychotherapy'):

Significant developmental or cognitive delays, since this model does not require participation in cognitive-based interventions

Severe attachment-related difficulties, due to the dyadic, attachment-based nature of CPP and its longer duration

We suggest TF-CBT rather than CPP for children with (see "Psychosocial interventions for posttraumatic stress disorder in children and adolescents", section on 'TF-CBT for Preschoolers'):

Sexualized behavior problems, based on findings of positive outcomes in a clinical trial [7]

Higher levels of general internalizing or externalizing problems, based on the findings from a meta-analysis of multiple clinical trials [18]

Supporting the use of CPP and TF-CBT in this population are clinical trials showing improvement compared with active comparison conditions, and the availability of well-established training protocols and fidelity guidelines [16,17]. CPP and TF-CBT have not been compared in head-to-head clinical trials, nor have they been compared with other psychosocial interventions in this population. (See "Psychosocial interventions for posttraumatic stress disorder in children and adolescents", section on 'Therapies for preschool children'.)

Children under three years — For children under three years old with PTSD symptoms, we suggest the use of CPP rather than TF-CBT or Preschool PTSD Treatment. Children under three are typically too young to participate in cognitive-based interventions and would benefit more from attachment-based therapy. To date, no empirical data are available to guide decision making for this age group. (See "Psychosocial interventions for posttraumatic stress disorder in children and adolescents", section on 'Child-Parent Psychotherapy'.)

Children with severe co-occurring conditions — Contraindications to trauma-focused psychotherapies include:

Comorbidities presenting in acute clinical states that require immediate stabilization (eg, acute suicidality, psychosis, mania, or drug intoxication)

For cognitive-based therapies, severe developmental or cognitive impairment

For group therapies, conditions that would interfere with participation (eg, severe behavioral dysregulation, severe attention deficit disorder)

Youth with apparent comorbid conditions should be carefully assessed for the presence of complex trauma, which is often mistaken for comorbid illness. (See 'Complex trauma' below.)

Youth with confirmed comorbidities may benefit from medication treatment for PTSD symptoms as well as for the co-occurring disorders. (See "Posttraumatic stress disorder in children and adolescents: Epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis", section on 'Comorbidity'.)

Some co-occurring disorders can be treated concurrently, while others require clinical judgment to determine priorities for treatment. (See 'Medication treatment' below.)

RESPONSE TO PSYCHOTHERAPY

Robust response — After a robust response to psychotherapy, patients and parents should be encouraged to continue to implement skills learned during therapy, particularly in response to reminders of the trauma, which can prompt symptom recurrence. Booster sessions may be helpful in patients who experience symptom recurrence.

Inadequate response — For children with posttraumatic stress disorder (PTSD) who respond inadequately to trauma-focused psychotherapy, the following steps are suggested:

Optimizing psychotherapy — Research to date has not identified consistent predictors of nonresponse to trauma-focused psychotherapy in children. When children with PTSD do not respond to psychotherapy, the clinician should reevaluate the therapy and the patient’s clinical presentation in view of the considerations below:

Treatment fidelity — Treatment nonresponse may occur when an evidence-based treatment is provided with low fidelity, ie, the model is not provided as intended. If core treatment components are provided incorrectly or not at all, the treatment will likely be ineffective. In such cases, improved fidelity and outcomes can often be attained by ensuring that therapists receive appropriate training and consultation in the selected model, receive ongoing, model-specific supervision, and monitor their treatment fidelity over time. Certification or other documentation (when available) that therapists have completed all recommended training requirements for the chosen model can enhance the likelihood of children receiving treatment with high fidelity.  

Trauma reminders — Lack of response to cognitive-behavioral therapy (CBT) in children with PTSD should prompt more careful exploration of potential trauma reminders or triggers, further development of different coping strategies for these triggers, and/or helping the child to master the coping strategies identified (eg, during in-session practice). (See "Psychosocial interventions for posttraumatic stress disorder in children and adolescents", section on 'Mechanisms of treatment' and "Psychosocial interventions for posttraumatic stress disorder in children and adolescents", section on 'Phases and components'.)

Ongoing trauma — Even with appropriate treatment, some PTSD symptoms may persist when trauma recurs during treatment; in this situation some trauma responses (eg, increased vigilance) might be adaptive. Clinical strategies include, for example, increasing the focus on child safety early in treatment, helping children differentiate between real danger and trauma reminders, and helping nonoffending parents collaborate with children to develop effective strategies for enhancing the child’s safety [6,20]. These strategies have been effective in reducing PTSD and anxiety symptoms in a clinical trial [6]. (See "Psychosocial interventions for posttraumatic stress disorder in children and adolescents", section on 'Phases and components'.)

Complex trauma — Poor or delayed response to trauma-focused psychotherapy may suggest the presence of complex PTSD. Complex PTSD presents with additional symptoms of severe dysregulation in multiple domains of functioning that include affect, attachment, biology, self-concept, cognitions, perceptions [21]. Complex PTSD is often observed in response to early and prolonged interpersonal trauma occurring during crucial developmental periods [22,23]. These children are particularly vulnerable to interpersonal trauma reminders (eg, arguments, real or perceived rejection or threatened attachment loss) [24,25]. The dissociative subtype of PTSD is one form of complex PTSD. (See "Dissociative aspects of posttraumatic stress disorder: Epidemiology, clinical manifestations, assessment, and diagnosis".)

Since youth with complex PTSD experience trauma within the context of close relationships, initiating a therapeutic relationship often serves as a trauma reminder for these youth. It is useful to contextualize these responses within a trauma framework rather than viewing such difficulties as "treatment nonresponse." Most treatments with efficacy for child PTSD have been successfully applied to the subgroup with complex trauma [26]. These youth typically need somewhat lengthier treatment, with a longer initial stabilization phase, during which they can be expected to test the trustworthiness of the new therapist. Other treatments have been developed specifically for these youth [27-29].

Complex PTSD is not yet included in the DSM or the International Classification of Diseases, and controversy remains over how to optimally assess this construct in children and adolescents.

Co-occurring mental disorders — Co-occurring disorders are often seen in children with PTSD, including depression, generalized anxiety disorder, and obsessive-compulsive disorder. (See "Posttraumatic stress disorder in children and adolescents: Epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis", section on 'Comorbidity'.)

PTSD should not be considered nonresponsive to psychotherapy until the after the comorbid disorder is adequately treated. Many of these co-occurring conditions are treatable with CBT. (See "Overview of prevention and treatment for pediatric depression" and "Pharmacotherapy for anxiety disorders in children and adolescents" and "Psychotherapy for anxiety disorders in children and adolescents" and "Treatment of obsessive-compulsive disorder in children and adolescents".)

Environmental factors — Many features of a traumatized child’s daily life (eg, family, health, educational, community, faith, legal, and child welfare) are likely to influence treatment response [30]. Examples include changes in foster family placement or the arrest/incarceration or illness/death of a family member. These issues emphasize the critical importance of working collaboratively with caregivers to be proactively aware of potential changes that may occur in the child’s life and address perceived or real threats to the child’s safety that may occur as a result of these changes.

Changes to psychotherapy — If after addressing these factors the clinician is convinced that the patient has not responded to an adequate trial of the first-line psychotherapy, the following steps may be helpful:

Switching to another evidence-based psychotherapy that may be more helpful. As an example, a child who has not responded to trauma-focused group CBT may benefit from trauma-focused individual CBT [19].

Tailoring the psychotherapy to the child’s specific PTSD symptoms, such as:

For hyperarousal symptoms (eg, angry outbursts, irritability, and sleep disturbance) – A systematic CBT focus on parenting skills and behavioral regulation skills.

For ongoing symptoms of re-experiencing, avoidance, fear, or anxiety – Trauma narration and/or cognitive processing of maladaptive cognitions that includes [8,31]:

-Emotional expression

-Increased coherence of trauma memories as the narrative progresses

-Focus on integrating meaning of past trauma experiences into more positive present and future

Medication treatment — Adjunctive medication can be useful for children with PTSD when the clinical response to trauma-focused psychotherapy is not adequate. Youth with PTSD may also benefit from medication when trauma-focused psychotherapy is not available or when clinical factors preclude its use. (See 'Children with severe co-occurring conditions' above.)

Few comparative or placebo-controlled trials of medication, adjunctive or as monotherapy, evaluate the efficacy of medications for general or specific symptoms of pediatric PTSD.

PTSD symptoms — Based uncontrolled trials and case reports [32-37], as well as our clinical experience, we favor treatment of pediatric PTSD symptoms (under the limited circumstances described above) with one of the antiadrenergic medications, clonidine, guanfacine, or prazosin, the latter of which may be particularly helpful for nighttime intrusive symptoms (eg, nightmares). (See "Pharmacotherapy for posttraumatic stress disorder in children and adolescents".)

An uncontrolled trial suggested that guanfacine extended release may reduce pediatric PTSD symptoms [33]. Used to treat children with other disorders, the antiadrenergic medication appears to be generally well tolerated. The most common side effects in children are dry mouth and sedation [38].

Guanfacine (extended-release) is typically initiated at 1 mg each evening and increased by 1 mg each week until effective to a maximum of 0.08 mg/kg/day. In our clinical experience, the onset of improvement occurs within several days of reaching the effective dose. (See "Pharmacotherapy for posttraumatic stress disorder in children and adolescents", section on 'Clonidine and guanfacine'.)

Similarly limited reports have suggested that some reduction of PTSD symptoms may be obtained from second-generation antipsychotics and anticonvulsants; however, the relative tolerability and side effect profiles of these medication classes lead us to favor antiadrenergic medications for the treatment of PTSD symptoms in youth.

Sleep disruption — Based on limited research and our clinical experience, we favor treatment of sleep disturbances in pediatric PTSD with prazosin (under the limited circumstances described above), particularly in cases where prazosin is being used adjunctively with a trauma-focused psychotherapy.

Case reports and a retrospective case series suggested that prazosin may be effective and well tolerated in treating sleep disturbances in youth with PTSD [32,34-37]. In our clinical experience, improving the child’s sleep can greatly improve daytime functioning, reduce daytime symptoms, and increase the child’s ability to engage in evidence based trauma psychotherapy. (See "Pharmacotherapy for posttraumatic stress disorder in children and adolescents", section on 'Prazosin'.)

Prazosin can be initiated at 1 mg, 30 minutes before bedtime due to concern for first dose hypotension, and increased gradually to minimize side effects, to at least 5 mg over the course of four to eight weeks prior to concluding that the medication trial has been ineffective. Blood pressure and pulse should be monitored at baseline and at medication management appointments, especially if side effects are reported. If prazosin is effective, but morning dizziness or other orthostatic symptoms are present, prazosin may be administered 30 to 60 minutes earlier in the evening and/or the dose can be slowly reduced.

In our experience, prazosin can be continued through the duration of evidence-based trauma-focused psychotherapy. At the termination of psychotherapy, prazosin should be re-evaluated and titrated as clinically appropriate.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Anxiety disorders in children".)

SUMMARY AND RECOMMENDATIONS

For most children and adolescents with posttraumatic stress disorder (PTSD) or prominent PTSD symptoms, including those with complex PTSD, we suggest first-line treatment with an evidence-based, trauma-focused psychotherapy rather than other psychosocial or medication treatments (Grade 2B). The intervention should be provided by a therapist who has received appropriate training in that model. A full course of therapy should be completed. (See 'Newly diagnosed patients' above.)

Contraindications to trauma-focused psychotherapies include acute clinical states that require immediate stabilization (eg, acute suicidality, psychosis, mania, or drug intoxication); for cognitive-based therapies, severe developmental or cognitive impairments. (See 'Children with severe co-occurring conditions' above.)

We favor specific types of trauma-focused psychotherapy for subgroups of patients with PTSD or PTSD symptoms:

Children seven years and older – Trauma-focused cognitive-behavioral therapy (TF-CBT); reasonable alternatives include combined parent-child cognitive-behavioral therapy and Trauma Affect Regulation: Guide for Education and Therapy. (See 'Children seven years and older' above and "Psychosocial interventions for posttraumatic stress disorder in children and adolescents", section on 'TF-CBT for Preschoolers'.)

-Severe PTSD symptoms and severe co-occurring disorders that prevent participation in groups – Individual rather than group therapy.

-Resource constraints, absence of trained therapists, or other barriers to access – Group rather than individual therapy (specifically, Cognitive-Behavioral Intervention for Trauma in Schools rather than other psychotherapies). (See "Psychosocial interventions for posttraumatic stress disorder in children and adolescents", section on 'Cognitive-Behavioral Intervention for Trauma in Schools (CBITS)'.)

Children three to six years (see 'Children three to six years' above)

-Developmental or cognitive delays, or severe attachment-related difficulties – Child-parent psychotherapy (CPP) rather than TF-CBT. (See "Psychosocial interventions for posttraumatic stress disorder in children and adolescents", section on 'Child-Parent Psychotherapy'.)

-Sexualized behavior problems or greater internalizing or externalizing problems – TF-CBT rather than CPP.

Children under three years – CPP rather than TF-CBT adapted to preschool children or other therapies. (See 'Children under three years' above and "Psychosocial interventions for posttraumatic stress disorder in children and adolescents", section on 'Child-Parent Psychotherapy'.)

Strategies for optimizing psychotherapy for patients who respond inadequately include evaluating the fidelity of therapy to the evidence-based model, more careful exploration of potential trauma reminders or triggers, and addressing unaddressed clinical needs such as ongoing trauma, complex trauma, co-occurring conditions, and environmental stressors. (See 'Inadequate response' above.)

If the clinician is convinced that the patient has not responded to an adequate trial of the first-line psychotherapy, options include (see 'Inadequate response' above):

Tailoring intervention to child’s specific PTSD symptoms

Switching to another evidence-based, trauma-focused therapy

Adding adjunctive medication. (See 'Medication treatment' above.)

For children with PTSD who continue to have significant PTSD symptoms following a complete course of trauma-focused psychotherapy (or for whom trauma-focused therapy was not indicated), we suggest treatment with guanfacine or clonidine (Grade 2C). (See 'PTSD symptoms' above and "Pharmacotherapy for posttraumatic stress disorder in children and adolescents", section on 'Clonidine and guanfacine'.)

For children with PTSD who have significant sleep disruption (or for whom trauma-focused therapy is not indicated), we suggest treatment with prazosin (Grade 2C). (See 'Sleep disruption' above and "Pharmacotherapy for posttraumatic stress disorder in children and adolescents", section on 'Prazosin'.)

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