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

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

Caregiver/Family Risk Factors for Abuse

• Poverty • Substance Abuse • Domestic Violence • Caregiver history of being abused • Transient nonrelated caregivers • Social stressors

Psychiatric Sequelae

o o o o o o o o • Maltreated children are at risk for: Attachment disorders o Social/peer relationship o problems Intimate Partner Violence o Language delays test scores o Below-average standardized o o o Teen parenthood Perpetrating abuse Age-inappropriate sexual behavior o Mood disorders Anxiety disorders Psychosis Alcohol and drug abuse Eating disorders Disruptive behavior Borderline personality disorder Dissociative disorders

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)

Diagnostic Issues

• “Single-blow” vs. chronic trauma • Neglect vs. physical abuse  Internalizing vs. externalizing • “Complex Trauma”

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

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

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/

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: 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)

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

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

• • 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)