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Ptsd-In-Children.Pdf AACAP OFFICIAL ACTION Practice Parameter for the Assessment and Treatment of Children and Adolescents With Posttraumatic Stress Disorder This Practice Parameter reviews the evidence from research and clinical experience and highlights significant advances in the assessment and treatment of posttraumatic stress disorder since the previous Parameter was published in 1998. It highlights the importance of early identification of posttraumatic stress disorder, the importance of gathering information from parents and children, and the assessment and treatment of comorbid disorders. It presents evidence to support trauma-focused psychotherapy, medications, and a combination of interventions in a multimodal approach. J. Am. Acad. Child Adolesc. Psychiatry, 2010;49(4):414–430. Key Words: child, adolescent, posttraumatic stress disor- der, treatment, Practice Parameter ore than one of four children experiences children unless explicitly noted. Unless other- a significant traumatic event before reach- wise noted, parents refers to the child’s primary M ing adulthood.1 These traumas may in- caretakers, regardless of whether they are the clude events such as child abuse; domestic, com- biological or adoptive parents or legal guardians. munity, or school violence; disasters, vehicular or other accidents, medical traumas, war, terrorism, refugee trauma, the traumatic death of significant METHODOLOGY others; or other shocking, unexpected or terrifying A literature search was conducted on MEDLINE experiences. Although most children are resilient accessed at www.pubmed.gov using the following after trauma exposure, some develop significant Medical Subject Heading terms: stress disorders, and potentially long-lasting mental health prob- posttraumatic AND randomized controlled trials; limits lems. This Practice Parameter was written to help all child: 0–18 years, only items with abstracts, child and adolescent psychiatrists and other medi- English, randomized controlled trials. This resulted cal and mental health professionals assess and treat in 70 abstracts. A search of PsycINFO was con- one such condition, posttraumatic stress disorder ducted using the following thesaurus terms: post- (PTSD). An earlier Practice Parameter on this same traumatic stress disorder; limit 1 to treatment outcome/ subject was first published in the Journal of the randomized clinical trial; limit 2 to (childhood or American Academy of Child and Adolescent Psychiatry adolescence), resulting in 24 abstracts. A search of the in October 1998.2 Because the diagnosis of PTSD PILOTS database was conducted using the terms requires the passage of at least 1 month after clinical trials AND child AND adolescent, resulting in exposure to an index trauma, this Practice Param- 20 abstracts. The search covered the period from eter does not address the immediate psychological 1996 to 2006 and was conducted on May 7, 2007. needs of children after disasters or other acute Only abstracts that included randomized con- traumatic events, i.e., within the first month. trolled trials, instruments measuring childhood These guidelines are applicable to the evalua- PTSD symptoms, and significant results with re- tion and treatment of child and adolescent pa- gard to PTSD symptoms were included. This tients 17 years and younger. This document search was augmented by programs listed on the presumes familiarity with normal child develop- National Child Traumatic Stress Network Web site ment and the principles of child psychiatric di- (www.NCTSN.org), those nominated by expert re- agnosis and treatment. In this Parameter the viewers, and manuscripts that have recently been word child refers to adolescents and younger accepted for publication in peer-reviewed journals. JOURNAL OF THE AMERICAN ACADEMY OF CHILD & ADOLESCENT PSYCHIATRY 414 www.jaacap.org VOLUME 49 NUMBER 4 APRIL 2010 AACAP OFFICIAL ACTION CLINICAL PRESENTATION possibility of a real trauma history, has potential Posttraumatic stress disorder is the one of the risks. Children should be referred for a forensic few psychiatric diagnoses in DSM-IV-TR that evaluation if the clinician has suspicion of trauma requires the presence of a known etiologic factor, exposure but no confirmed reports. There are i.e., a traumatic event that precedes the develop- many differences between forensic and clinical ment of the disorder. For PTSD to be present, evaluations; clinicians should not attempt to con- the child must report (or there must be other duct forensic assessments in the context of a compelling evidence of) a qualifying index trau- clinical evaluation. matic event and specific symptoms in relation to Most individuals who experience truly life- that traumatic experience. Compelling evidence threatening events manifest posttraumatic symp- 3,4 might include sexually transmitted infection in a tomatology immediately. However, only about young child, a reliable eyewitness report (e.g., a 30% on average tend to manifest enduring symp- 5 police report that a child was rescued from the tomatology beyond the first month. Therefore, scene of an accident), or a forensic evaluation PTSD is not diagnosed until at least 1 month has confirming the likelihood that the child experi- passed since the index traumatic event occurred. enced a traumatic event. An inherent contradic- After large-scale disasters, vehicular accidents, or tion exists in that avoidance of describing trau- medical trauma, children may be seen very soon matic experiences is a core feature of PTSD, as after traumatic exposure by medical personnel, indicated below; yet diagnosing PTSD requires mental health professionals, or paraprofession- that the child describe the traumatic event. als. Acute stress disorder, adjustment disorder, In the absence of child report or other compel- or another disorder may be diagnosed within the ling evidence of a qualifying index trauma, a first month of exposure. Transient moderate psy- PTSD diagnosis should not be made. There may chological distress may be a normative reaction be situations where children or adolescents to traumatic exposure. Recent data have sug- present with symptoms suggestive of PTSD (e.g., gested that panic symptoms in the immediate general anxiety symptoms, nightmares and im- aftermath of trauma exposure are predictive of pairment; or in an older youth, self-injurious subsequent PTSD in children and this may be an behavior such as repeated cutting, substance important symptom to evaluate in this acute abuse, and indiscriminant sexualized behavior) period.6,7 Little is known about the efficacy of early in the absence of a disclosure of trauma exposure. interventions that are typically provided in the In this situation the clinician should not presume immediate aftermath of disasters, and whether that trauma has occurred. Clinicians are wise to they may cause harm to children as they have been ask in nearly all routine evaluations whether found to do in some adult studies.8 One random- traumatic events (e.g., maltreatment, acute inju- ized controlled study demonstrated that providing ries, disasters, and witnessed violence to loved an early mental health intervention, psychological ones) have occurred. However, if children and debriefing, was neither better nor worse than a caregivers cannot confirm that a traumatic event control group in improving PTSD symptoms for has occurred, then clinicians ought not to imply children in road-traffic accidents.9 that symptomatology is a consequence of forgot- Acute PTSD is diagnosed if the symptoms are ten trauma. Conversely, some children may be present after the first month and for less than 3 afraid, ashamed, embarrassed, or avoidant of months after the index trauma; chronic PTSD is disclosing traumatic experiences, particularly in diagnosed if the symptoms persist beyond 3 an initial clinical interview. Avoidance may take months. Debate is ongoing a to whether or not an the form of denial of trauma exposure and as alternative condition alternatively referred to as such may be an indication of the severity of the “complex PTSD” (also known as disorders of child’s avoidance symptoms rather than lack of extreme stress not otherwise specified or devel- trauma exposure. Parental denial of the child’s opmental trauma disorder) exists in severely, exposure to trauma may occur because the par- early, or interpersonally traumatized children or ent is unaware of the child’s trauma exposure, adolescents.10 An alternative view with substan- because the parent is a perpetrator or for a tial support is that complex PTSD is chronic variety of other reasons. An error in either direc- PTSD occurring with or without other comorbid tion, i.e., mistakenly attributing symptoms to DSM-IV-TR conditions.11 In either perspective, trauma that did not occur or disregarding the there is clinical consensus that children with severe JOURNAL OF THE AMERICAN ACADEMY OF CHILD & ADOLESCENT PSYCHIATRY VOLUME 49 NUMBER 4 APRIL 2010 www.jaacap.org 415 AACAP OFFICIAL ACTION PTSD may present with extreme dysregulation of Young children also manifest new aggression, physical, affective, behavioral, cognition, and/or oppositional behavior, regression in develop- interpersonal functioning that is not adequately mental skills (toileting and speech), new separa- captured in current descriptions of PTSD diagnos- tion anxiety, and new fears not obviously related tic criteria. Some of these children may be misdiag- to the traumatic event (usually fear of the dark or nosed with bipolar disorder because of severe fear of going to the bathroom alone)
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