Child Abuse and Neglect

1. Child Abuse and Neglect Shannon Wagner Simmons, MD, MPHChild 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

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

10. Caregiver/Family Risk Factors for Abuse • Poverty • Substance Abuse • Domestic Violence • Caregiver history of being abused • Transient nonrelated caregivers • Social stressors

11. 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 disorders

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)

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

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

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

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: http://tfcbt.musc.edu/

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!

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)

23. Other Agents in PTSD: Atypical Antipsychotics • Risperidone reduced hypervigilance and aggression in a teen (Keeshinand Strawn, 2009). • When added to escitalopram, aripiprazole decreased nightmares in a teen (Yehet al, 2010).  • Quetiapine decreased dissociation, anxiety, and depression in a series of 6 teens with PTSD (Stathiset al, 2005).  • Clozapine reduced aggression and improved sleep in a case series of six treatment-resistant teens

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 (Looffet 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 • 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)