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

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

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.

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.

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?

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

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.

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

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

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

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)

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). 

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

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

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**

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.

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.

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: http://tfcbt.musc.edu/ 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)

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

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

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

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)

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.

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).

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?

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