Child Abuse and Neglect Shannon Wagner Simmons, MD, MPH - PowerPoint Presentation

Slide1

Child Abuse and Neglect

Shannon Wagner Simmons, MD, MPH

Child and Adolescent Psychiatry Fellow

Institute for Juvenile Research

University of Illinois at ChicagoSlide2

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 exampleSlide3

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.Slide4

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. Slide5

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?Slide6

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 populationsSlide7

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 TextbookSlide8

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 TextbookSlide9

Child Risk Factors for Abuse

Prematurity

Age under 4 years

“Special Needs”

Disruptive behaviorSlide10

Caregiver/Family Risk Factors for Abuse

Poverty

Substance Abuse

Domestic Violence

Caregiver history of being abused

Transient nonrelated caregivers

Social stressorsSlide11

Psychiatric Sequelae

Maltreated children are at risk for:

Attachment disorders

Social/peer relationship problems

Language delays

Below-average standardized test scores

Intimate Partner Violence

Teen parenthood

Perpetrating abuse

Age-inappropriate sexual behavior

Mood disorders

Anxiety disorders

Psychosis

Alcohol and drug abuse

Eating disorders

Disruptive behavior

Borderline personality disorder

Dissociative disordersSlide12

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) Slide13

Diagnostic Issues

“Single-blow” vs. chronic trauma

Neglect vs. physical abuse

Internalizing vs. externalizing

“Complex Trauma”Slide14

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 issuesSlide15

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 childrenSlide16

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.Slide17

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 factorsSlide18

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/Slide19

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 idealSlide20

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!Slide21

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 slowSlide22

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)Slide23

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 teensSlide24

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).Slide25

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?Slide26

Useful Websites

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)