Approach to treating posttraumatic stress disorder in children and adolescents
- David Brent, MD
David Brent, MD
- Section Editor — Childhood Mental Disorders
- Professor of Psychiatry, Pediatrics and Epidemiology
- University of Pittsburgh School of Medicine
- Judith A Cohen, MD
Judith A Cohen, MD
- Professor of Psychiatry
- Drexel University College of Medicine
- Jeffrey Strawn, MD
Jeffrey Strawn, MD
- Associate Professor of Psychiatry
- University of Cincinnati
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 describes 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".)
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), American Psychiatric Association, Arlington, VA 2013. p.272.
- http://www.zerotothree.org/maltreatment/trauma/trauma.html (Accessed on October 20, 2015).
- Deblinger E, Mannarino AP, Cohen JA. Theory, treatment development, and research. In: Child Sexual Abuse: A Primer For Treating Children, Adolescents, and Their Non-Offending Parents, 2nd ed, Oxford Press, New York 2015. p.19.
- Cohen JA, Mannarino AP, Knudsen K. Treating sexually abused children: 1 year follow-up of a randomized controlled trial. Child Abuse Negl 2005; 29:135.
- Cohen JA, Deblinger E, Mannarino AP, Steer RA. A multisite, randomized controlled trial for children with sexual abuse-related PTSD symptoms. J Am Acad Child Adolesc Psychiatry 2004; 43:393.
- Cohen JA, Mannarino AP, Iyengar S. Community treatment of posttraumatic stress disorder for children exposed to intimate partner violence: a randomized controlled trial. Arch Pediatr Adolesc Med 2011; 165:16.
- Cohen JA, Mannarino AP. A treatment outcome study for sexually abused preschool children: initial findings. J Am Acad Child Adolesc Psychiatry 1996; 35:42.
- Deblinger E, Steer RA, Lippmann J. Two-year follow-up study of cognitive behavioral therapy for sexually abused children suffering post-traumatic stress symptoms. Child Abuse Negl 1999; 23:1371.
- Gillies D, Taylor F, Gray C, et al. Psychological therapies for the treatment of post-traumatic stress disorder in children and adolescents. Cochrane Database Syst Rev 2012; 12:CD006726.
- O'Callaghan P, McMullen J, Shannon C, et al. A randomized controlled trial of trauma-focused cognitive behavioral therapy for sexually exploited, war-affected Congolese girls. J Am Acad Child Adolesc Psychiatry 2013; 52:359.
- McMullen J, O'Callaghan P, Shannon C, et al. Group trauma-focused cognitive-behavioural therapy with former child soldiers and other war-affected boys in the DR Congo: a randomised controlled trial. J Child Psychol Psychiatry 2013; 54:1231.
- Diehle J, Opmeer BC, Boer F, et al. Trauma-focused cognitive behavioral therapy or eye movement desensitization and reprocessing: what works in children with posttraumatic stress symptoms? A randomized controlled trial. Eur Child Adolesc Psychiatry 2015; 24:227.
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- Wethington HR, Hahn RA, Fuqua-Whitley DS, et al. The effectiveness of interventions to reduce psychological harm from traumatic events among children and adolescents: a systematic review. Am J Prev Med 2008; 35:287.
- Silverman WK, Ortiz CD, Viswesvaran C, et al. Evidence-based psychosocial treatments for children and adolescents exposed to traumatic events. J Clin Child Adolesc Psychol 2008; 37:156.
- Kowalik J, Weller J, Venter J, Drachman D. Cognitive behavioral therapy for the treatment of pediatric posttraumatic stress disorder: a review and meta-analysis. J Behav Ther Exp Psychiatry 2011; 42:405.
- Jaycox LH, Cohen JA, Mannarino AP, et al. Children's mental health care following Hurricane Katrina: a field trial of trauma-focused psychotherapies. J Trauma Stress 2010; 23:223.
- Cohen JA, Mannarino AP, Murray LK. Trauma-focused CBT for youth who experience ongoing traumas. Child Abuse Negl 2011; 35:637.
- Cook A, Spinazzola J, Ford J, et al. Complex trauma in children and adolescents. Psychiatr Ann 2005; 35:390.
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- Herman JL. Sequelae of prolonged and repeated trauma: evidence for a complex posttraumatic syndrome (DESNOS). In: Posttraumatic Stress Disorder: DSM-IV and Beyond, Davidson, JRT, Foa, EB (Eds), American Psychiatric Press, Washington, DC 1993. p.213.
- National Child Traumatic Stress Network. Understanding child traumatic stress. http://nctsn.org/resources/audiences/parents-caregivers/understanding-child-traumatic-stress (Accessed on October 27, 2015).
- NCTSN Core Curriculum on Childhood Trauma Task Force. The 12 core concepts: Concepts for understanding traumatic stress responses in children and families. Core Curriculum on Child Trauma. http://nctsn.org/resources/audiences/parents-caregivers/what-is-cts/12-core-concepts (Accessed on October 27, 2015).
- Trauma-focused CBT for children and adolescents: Treatment applications, Cohen JA, Mannarino AP, Deblinger E (Eds), Guilford Press, New York 2012.
- Ford JD, Steinberg KL, Hawke J, et al. Randomized trial comparison of emotion regulation and relational psychotherapies for PTSD with girls involved in delinquency. J Clin Child Adolesc Psychol 2012; 41:27.
- Cohen JA, Mannarino AP, Kliethermes M, Murray LA. Trauma-focused CBT for youth with complex trauma. Child Abuse Negl 2012; 36:528.
- Blaustein ME, Kinniburgh KM. Treating traumatic stress in children and adolescents: how to foster resilience through attachment, self-regulation and competence, Guilford Press, New York 2010.
- Saxe GN, Ellis BH, Kaplow JB. Collaborative treatment of traumatized children and teens: The trauma systems therapy approach, Guilford Press, New York 2007.
- Mundorf ES, Paivio SC. Narrative quality and disturbance pre- and post-emotion-focused therapy for child abuse trauma. J Trauma Stress 2011; 24:643.
- Keeshin B, Presson A, Berkowitz S, Strawn JR. Prazosin in children and adolescents with post traumatic stress disorder and nightmares: a retrospective chart review of 34 cases. J Am Acad Child Adolesc Psychiatry 2016; 55:S112.
- Connor DF, Grasso DJ, Slivinsky MD, et al. An open-label study of guanfacine extended release for traumatic stress related symptoms in children and adolescents. J Child Adolesc Psychopharmacol 2013; 23:244.
- Strawn JR, Keeshin BR. Successful treatment of posttraumatic stress disorder with prazosin in a young child. Ann Pharmacother 2011; 45:1590.
- Strawn JR, Delbello MP, Geracioti TD. Prazosin treatment of an adolescent with posttraumatic stress disorder. J Child Adolesc Psychopharmacol 2009; 19:599.
- Brkanac Z, Pastor JF, Storck M. Prazosin in PTSD. J Am Acad Child Adolesc Psychiatry 2003; 42:384.
- Fraleigh LA, Hendratta VD, Ford JD, Connor DF. Prazosin for the treatment of posttraumatic stress disorder-related nightmares in an adolescent male. J Child Adolesc Psychopharmacol 2009; 19:475.
- Keeshin BR, Strawn JR. Treatment of Children and Adolescents with Posttraumatic Stress Disorder (PTSD): A Review of Current Evidence. Child Adolesc Psychopharmacol News 2010; 17:5.
- NEWLY DIAGNOSED PATIENTS
- Children seven years and older
- Children three to six years
- Children under three years
- Children with severe co-occurring conditions
- RESPONSE TO PSYCHOTHERAPY
- Robust response
- Inadequate response
- - Optimizing psychotherapy
- Treatment fidelity
- Trauma reminders
- Ongoing trauma
- Complex trauma
- Co-occurring mental disorders
- Environmental factors
- - Changes to psychotherapy
- - Medication treatment
- PTSD symptoms
- Sleep disruption
- SUMMARY AND RECOMMENDATIONS