Trauma

Introduction

This article talks about traumatic events, PTSD, and its assessment and treatments. Abuse is discussed in that context. For specific psychiatric and medical-legal aspects of abuse and neglect, see dedicated article.

Epidemiology

Physcial Abuse

Of the adults caring for a child, the parents (and particularly the mothers) are most likely to physically abuse child. Adolescent fatalities from abuse are most often caused by the fathers, while both parents contribute equally to death of children.

Natural Disasters and Other Large-Scale Events

• Screening of victims for PTSD and other mental health needs is most effective when at least a few weeks since the traumatic event had passed.
• Parents and relatives, who themselves are often affected by the disaster, may not recognize the child's symptoms and needs. Outreach and follow-up are thus essential.

Treatment of Trauma and PTSD

Education (What Caregivers Should and Shouldn't Do)

A child needs to cope and process a traumatic experience. To a great detriment, parents may be tempted to avoid mentioning the traumatic event, to try and distract the child when he remembers it, or to pretend that nothing happened. Instead, caregivers should provide emotional support to the child and help reestablish structure in child's life after the trauma, by encouraging age-appropriate activities and discussions. This is particularly if the traumatic experience involved loss of a parent/relative who played a central role in his or her life. In a case of death of a caregiver, a child needs to grieve the loss, not unlike the rest of the family. A child should be included in family rituals (including a funeral), but not against his will.

Early Interventions

Reparative drawings and similar activities are part of the process of sharing inner experiences through play and have an important role in the early stages of treatment. This can include rebuilding a house from Lego bricks after a fire at home or drawing a healthy relative after witnessing her traumatic death. (Wiener text)

Pharmacological Management of PTSD

How to Think about Medications for PTSD

As with many other disorders in child and adolescent psychiatry, the medications do not serve a curative role in PTSD treatment. Rather, they are used for two broad purposes:

• To alleviate disabling symptoms and comorbidities associated with PTSD, such as emotional hyperarrousal, sleep disturbances, anxiety, irritability, and anger outbursts, with goals to restore functioning and return to normal developmental trajectory.
• To assist the child undergoing a psychotherapeutic intervention in dealing with and processing of traumatic and emotional content.

Which Medications Are Used for PTSD

• Use of SSRIs is supported by substantial body of evidence in adult PTSD; SSRIs have been shown to improve symptoms in each of the three symptom categories. Pediatric studies of SSRIs for symptoms of PTSD are scarce, and their clinical use is extrapolated from adult literature. Thus, careful monitoring and balancing known risks and potential benefits of SSRIs use are necessary.
  
• Alpha-2 adrenergic blockers, such us clonidine and guanfacine, have been used successfully to relieve symptoms of hyperarrousal and impulsivity. Guanfacine may help with PTSD-associated nightmares.

Antipsychotics have been used in adults with PTSD. While they are used widely in many pediatric disorders, their efficacy in pediatric PTSD had not been investigated. Antiepileptics and mirtazapine may have a role in PTSD symptom relief, but research into their efficacy is lacking as well.
Nefazodone and imipramine, medications that have been used successfully in adult PTSD, are not used in children. The evidence for their efficacy is either anecdotal or contradictory. Adverse effects, particularly hepatotoxicity of nefazodone, leave little justification for the use of these drugs in pediatric PTSD. Benzodiazepines have a role in short-term adjunctive treatment of significant anxiety and agitation; the risk of paradoxical dysinhibition and potential for abuse should be weighted against anticipated benefits.

High-Yield Facts

• While flashbacks and nightmares are frequently inquired about as a clinical probing questions for PTSD, these symptoms are neither sufficient nor necessary for the diagnosis.

Further Reading

Stamatakos M, Campo JV. Psychopharmocologic treatment of traumatized youth. CurrOpinPeds 2010; 22:599
Horrigan J. Guanfacine for PTSD nightmares. JAACAP 1996; 35:1247