1. Child Abuse and Neglect
Shannon Wagner Simmons, MD, MPH Child and Adolescent Psychiatry Fellow
Institute for Juvenile Research
University of Illinois at Chicago

2. Objectives
Review basic concepts and epidemiology of child maltreatment
Discuss psychiatric diagnostic issues in abused or neglected children
Provide an overview of the treatment of PTSD in children and adolescents, including a brief review of the psychopharmacology literature
Discuss a clinical example

3. Jane
Jane is a 15 year old girl with a history of a learning disorder who presents to an outpatient intake clinic with a two-month history of generalized anxiety and panic attacks.
She had no prior psychiatric history.
Medical history includes only mild asthma.
Birth, developmental, and family histories are noncontributory.
She has a younger sister who lives at home; parents are divorced.

4. Jane, continued She began weekly CBT with a psychology intern.
In the fourth session, she disclosed to her therapist that she had been repeatedly raped by a family friend in her home over the summer.
This family friend still visits the home often.
“I’m not ready to tell my mom.”
Jane admits that she has been smoking marijuana several times weekly to manage her anxiety symptoms.
She also endorses nightmares, flashbacks, and hypervigilance.

5. Jane – A Few Questions
If you were the therapist, what would you do next? What are you worried about?
Why did she disclose this now?
How would this information change your treatment approach?

6. Some Numbers 3 million suspected cases reported annually
1 million of these are substantiated
60% neglect, 20% physical abuse, 10% sexual abuse, 10% miscellaneous
Lifetime incidence of maltreatment:
30% in child psychiatry outpatient populations
55% in child psychiatry inpatient populations

7. Some Definitions
Physical Abuse: “Intentional injury of a child by a caretaker…that lead[s] to injury, and frequently occurs in the context of discipline.”
Neglect: “Caretakers fail to appropriately provide for and protect children…failing to meet the child’s nutritional, supervision, or medical needs.”
From Lewis’s Child and Adolescent Psychiatry: A Comprehensive Textbook
Sexual abuse: “It is important to think about context and developmental factors in determining whether sexual behaviors between two children are abusive.”
Psychological abuse usually co-occurs with other forms.

8. Some Definitions
Sexual Abuse: “Sexual behavior between a child and an adult or two children when one of them is significantly older or uses coercion…may include exhibitionism”
Psychological Abuse: “When an adult repeatedly conveys to a child that he is worthless, defective, unloved, or unwanted…it may involve threatened or actual abandonment.”
From Lewis’s Child and Adolescent Psychiatry: A Comprehensive Textbook

9. Child Risk Factors for Abuse
Prematurity
Age under 4 years
“Special Needs”
Disruptive behavior
Special needs = intellectual or physical disabilities

10. Caregiver/Family Risk Factors for Abuse
Poverty
Substance Abuse
Domestic Violence
Caregiver history of being abused
Transient nonrelated caregivers
Social stressors
- Abuse is 22x more likely in families with an annual income of <$15K compared to >$30k

11. Psychiatric Sequelae Maltreated children are at risk for:
Attachment disorders
Mood disorders
Social/peer relationship problems
Anxiety disorders
Psychosis
Language delays
Alcohol and drug abuse
Below-average standardized test scores
Eating disorders
Disruptive behavior
Intimate Partner Violence
Borderline personality disorder
Teen parenthood
Perpetrating abuse
Dissociative disorders
Age-inappropriate sexual behavior
- Interesting literature coming out about early adverse events and long-term health sequelae (heart disease etc)

12. Predictors of More Favorable Long-Term Outcomes
Consistent support system after the trauma
Limited relationship with perpetrator
Some genetic polymorphisms:
5HTTLPR (Serotonin Transporter Gene) and depression
CRHR1 (Corticotropin-releasing hormone receptor)
MAO-A (monoamine oxidase-A) and aggression
Catechol-O-methyltransferase (COMT)
- 5httplr: Short allele confers a greater risk for depression in the presence of stressful life conditions (Mushtag et al, 2012; Rundell et al, 2011).
- CRHR1: haplotype is associated with adult depression, if there is exposure to childhood adverse events such as abuse (Bradley et al 2008; Grabe, 2010). 
A lower level of monoamine oxidase-A (MAO-A) expression, in the setting of mild to moderate trauma, has been linked with higher levels of aggressive behavior and conduct disorder (Ferguson et al, 2011; Foley et al, 2004). 
COMT: certain polymorphisms predispose women to impulsive aggression in borderline personality disorder, dissociation and/or schizotypal personality traits (Savitz et al, 2010; Savitz et al, 2008; Wagner et al, 2010). 

13. Diagnostic Issues “Single-blow” vs. chronic trauma
Neglect vs. physical abuse
Internalizing vs. externalizing
“Complex Trauma”
- Single blow = more associated with PTSD
Recurrent = chronic mood dysregulation, dissociation, character identity problems, and rage (often self-directed).
Neglect = more strongly associated with internalizing disorders, physical abuse = more commonly associated with externalizing behaviors such as aggression and other disruptive behavior.
- Complex trauma = white paper by NCTSN explores complex trauma in depth, asserting that our current diagnostic system does not account for its range of impact on a developing child. Complex trauma is defined here multiple simultaneous or sequential traumas within the caretaking environment, beginning in childhood, as well as the multi-domain impairment and symptomatology that often results

14. Diagnostic Evaluation
Maltreated children are at risk for a wide range of psychopathology.
Developmental state at the time of trauma and at presentation is key.
A thorough diagnostic assessment is indicated.
We must ask the questions, sometimes several times.
Mandated reporting issues

15. PTSD
Three symptom clusters: re-experiencing, avoidant, and hyperarousal
Some DSM criteria allow for developmental differences, but others do not.
There is some controversy about how accurately these criteria capture the disorder in children, especially young children
For example, instead of recurrent/intrusive memories or re-experiencing, children may display repetitive trauma-themed play
Examples of criteria that are difficult to apply to kids: sense of foreshortened future, efforts to avoid trauma reminders
**Developmental stage of child at the time of the trauma and of treatment is key**

16. PTSD Screening Tools UCLA PTSD index Trauma Symptom Checklist
Anxiety Disorder Interview Schedule (ADIS) PTSD section
Others
Sometimes children report things on rating scales that they do not report verbally.

17. Treatment Planning
The treatment should be tailored to the symptoms/disorder.
Safety First: Be vigilant for ongoing maltreatment or re-traumatization
Treatment often requires working with a larger multidisciplinary team and focusing on family and environmental factors
E.g. may need to work with child protective services, adult mental healthcare providers or substance abuse treatment providers, other social services, legal system, schools, etc.

18. Trauma Focused CBT
Considered best practice for children or teens who have experienced trauma
Intervenes with both the child and caregivers
Psychoeducation, relaxation skills, affective modulation, cognitive coping related to the trauma
Creation of a trauma narrative
Free web training:
Goals = exposure to traumatic memories, gaining mastery of the trauma, learning skills to manage triggers and understand how the trauma fits in your life story (meaning making)

19. Pharmacotherapy of PTSD
Indications:
Severe symptoms
Suboptimal response to psychotherapy
Comorbidity with a disorder amenable to pharmacotherapy (e.g. MDD)
Combined approach (therapy + meds) is ideal

20. SSRIs in Pediatric PTSD
Double-blind, placebo-controlled RCT: sertraline was comparable to placebo (Robb et al, 2010)
Addition of placebo or citalopram to TF-CBT: no additional benefit in treatment group (Cohen et al, 2007)
Open trial of citalopram in 8 patients: improvements seen (Seedat et al, 1999). 
That’s all!
- SSRis are well studied in adults, effective at targeting all 3 symptom clusters, considered first line
- It should be noted that these studies included a total of <200 participants TOTAL, so it is difficult to draw too many conclusions

21. SSRIs: Things to Consider
Black-box warning regarding suicidal ideation
Children, especially those with severe mood dysregulation, may find SSRIs too activating
The other usual side effects
Start low, go slow

22. Other Agents in PTSD: Adrenergic Agents
Clonidine reduced some PTSD symptoms in a small open trial of preschoolers (Harmon and Riggs, 1996).
Guanfacine reduced nightmares in a case report involving a 7 year old (Horrigan, 1996).
Prazosin reduced nightmares and hyperarousal in two adolescent case reports (Strawn et al, 2009; Fraleigh et al, 2009)
Propranolol reduced PTSD symptoms in 11 school-aged children (Famularo et al, 1988)
Clonidine reduced aggression in all children, and reduced emotional outbursts, hyperarousal and hypervigilance, generalized anxiety, and oppositionality in the majority of children. Clonidine was added only after a month of family-based therapy did not result in sign. Improvements
These meds can be used in combo with others (e.g. SSRI)
These meds require cardiovascular monitoring (vitals)

23. Other Agents in PTSD: Atypical Antipsychotics
Risperidone reduced hypervigilance and aggression in a teen (Keeshin and Strawn, 2009).
When added to escitalopram, aripiprazole decreased nightmares in a teen (Yeh et al, 2010). 
Quetiapine decreased dissociation, anxiety, and depression in a series of 6 teens with PTSD (Stathis et al, 2005). 
Clozapine reduced aggression and improved sleep in a case series of six treatment-resistant teens
- First two are case reports, third is a case series
Quetiapine trial was teens in a juvenile detention center
Needless to say with clozapine, it is reserved for severe cases in which the patient has failed numerous other trials. Co-occurring psychosis was seen in many cases in this study. The ability to have regular blood draws is another key factor.
All of these medications carry metabolic risks and require monitoring.

24. Other agents in PTSD: Mood Stabilizers
Divalproex sodium caused a greater reduction of PTSD symptoms when given in high vs. low doses in 12 juvenile-detention teens (Steiner et al, 2007). 
In a case series of 28 children and teens with severe abuse history, most responded very well to carbamazepine (Looff et al, 1995).

25. Jane Revisited – A Few Questions
If you were the therapist, what would you do next? What are you worried about?
Why did she disclose this now?
How would this information change your treatment approach?

26. Useful Websites http://tfcbt.musc.edu/ (Trauma-Focused CBT)
(National Child Traumatic Stress Network)
(American Academy of Child and Adolescent Psychiatry)
Facts for Families
Practice Parameters
(Trauma-Focused CBT)