July 2020 NEWS Post-Traumatic Stress Disorder (PTSD) Assessment and Treatment In this Issue: Guidelines for Pediatric Primary Upcoming Clinical Care Conversations 5 Clinical Conversation: May 26, 2020 Presented by Sylvia Krinsky, MD, Tufts Medical Center For some children, childhood is far from a carefree time; they Leadership: experience trauma which can disrupt development and lead John Straus, MD to post-traumatic stress disorder (PTSD). At the May Clinical Founding Director Conversation, Sylvia Krinsky, MD, MCPAP site director at Tufts Barry Sarvet, MD Medical Center, discussed how to address PTSD in the primary Medical Director care setting. Beth McGinn Types of trauma Program Manager There are three major types of trauma: Elaine Gottlieb • Discrete Trauma – examples include a car accident, injury, Contributing Writer medical procedure, or a single episode of physical or sexual assault, when life is filled with otherwise helpful and supportive people • Complex Trauma – series of repeated traumas usually in close interpersonal contexts, such as childhood abuse or neglect, witnessing domestic or community violence, or racism and chronic social adversities • Adverse Childhood Event – a term from the Adverse Childhood Experiences (ACE) study, referring to potentially traumatic events that can have an impact on physical and psychological health Discrete trauma is most recognized in the DSM-5, while ACE is more familiar to the medical community, says Dr. Krinsky. 1000 Washington St., Suite 310 One study reported in the Journal of the American Medical Boston, MA 02118 Association (JAMA) found that more than 90 percent of pediatric Email: [email protected] patients seen in a primary care pediatric clinic had experienced a traumatic exposure, and 25 percent met full or partial criteria for www.mcpap.org PTSD. Continued on page 2 MCPAP is funded by the Massachusetts Department of Mental Health. 2 PTSD Assessment and Treatment Guidelines for Pediatric Primary Care Continued from page 1

When trauma occurs in early childhood, from • Two alterations in arousal and reactivity infancy to age three, it has a major impact on – irritable/angry outbursts, reckless/self- brain development. “At this stage, there is so destructive behavior, hypervigilance, high much cognitive maturation. The child is entirely startle reflex, concentration problems, sleep dependent on the caregiver, so trauma can difficulty disrupt secure, normal attachment. It also has a long-lasting impact on the biologic system, Differential diagnoses and abuse and neglect are linked to somatizing Differential diagnoses following a traumatic event conditions” says Dr. Krinsky. can include: Of course, children vary greatly in their response • Adjustment disorder to trauma; what may be traumatic for one child isn’t for another. • Acute Stress Disorder • PTSD • Anxiety • Depression “Patients should be assessed for PTSD immediately after a traumatic event or during an assessment of mental health complaints during a well-child visit,” says Dr. Krinsky. Acute stress disorder Acute stress disorder has similar symptoms as DSM-5 definition of PTSD PTSD but they last less than a month, whereas PTSD persists; when it lasts longer than three According to the DSM-5, which has more narrow months, it will require treatment. criteria, PTSD is an exposure to a traumatic event and can include: Adjustment disorder • One re-experiencing symptom – intrusive • Development of emotional/behavioral thoughts/memories, nightmares, flashbacks, symptoms due to an identifiable stressor(s) intense distress at reminders, physiological and occurring within three months of the re-experiencing onset of the stressor • One avoidance symptom – avoiding • Marked by distress that is in excess of what memories, thoughts, or specific places/ would be expected within the context, given experiences associated with trauma the nature of the stressor, and/or marked by significant impairment in social, occupational, • Two negative alterations in cognition or mood or other important areas of functioning – inability to remember parts of the trauma, negative beliefs about self/others/world, self- • Exclude if the disturbance meets criteria blame for the trauma, persistent negative for another condition or is an exacerbation emotional state, inability to experience of another condition or results from positive emotions, diminished interest and bereavement participation in activities • Does not persist longer than six months

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MCPAP News July 2020 3 PTSD Assessment and Treatment Guidelines for Pediatric Primary Care Continued from page 2 Consider whether the patient’s coping is normal. difficulty relating to others. “Adjustment disorder is not a mental illness, just difficulty adjusting for six months or less,” says ADHD – consider the time course of symptoms. Dr. Krinsky. Did the inattention start after a traumatic event? PTSD can disrupt concentration and Depression cause hyperarousal, hypervigilance and an exaggerated startle reflex. • Sad, irritable mood with difficulty or inability to enjoy things that used to give pleasure Bipolar disorder – very rare before puberty; usually there’s a family history. Bipolar disorder • Hopeless and guilty ruminations can cause irritability, anger, and mood instability. • Decreases in energy, interest, and Consider if PTSD is a differential diagnosis in concentration these cases. • Changes in sleep (early morning awakenings) Screening for trauma and appetite (typically lower) Patients should be screened for trauma at well- Anxiety disorders child visits and at mental health evaluations. Start with general questions about stress and • Intrusive level of worry • Frequently accompanied by somatic symptoms (stomachaches and headaches), especially in younger kids • Misperception of situations as overly threatening or dangerous • An urge to avoid that results in functional impairment Distinguishing trauma from other mental health conditions Trauma is a risk factor for mental health then more specific questions about trauma, disorders and can complicate treatment: patients using clinical interviewing and rating scales. may meet criteria for more than one condition. “Focus on what happened and how to stabilize Also, pre-existing major depression and anxiety the situation. The priority is safety and affirming disorders are risk factors for PTSD after a the therapeutic relationship,” says Dr. Krinsky. traumatic event. According to Dr. Krinsky, it’s Assessing impact on patient and family important to consider how the patient was doing before the traumatic event and any subsequent Trauma affects the entire family. During the changes. Diagnostic clarity is greatest in the assessment, find out how the child and family context of a known single discrete trauma. are functioning, including parental anxiety and ability to provide support. “Parents need to be Misdiagnosis able to soothe the child,” says Dr. Krinsky. PTSD can be misdiagnosed as: Assess the child’s symptoms, including Autism – consider early developmental history. separation difficulties, sleep problems, frequent Pediatric patients with PTSD can be withdrawn tearfulness, tantrums, changes in play, and shut down, but they have better social skills withdrawal, hopelessness and suicidal ideation. than children with autism, who always have Continued on page 4

MCPAP News July 2020 4 PTSD Assessment and Treatment Guidelines for Pediatric Primary Care Continued from page 3 In adolescents, look for self-injurious behavior Treatment options and substance abuse. Evidence-based treatments for trauma include: CATS assessment • Trauma-focused cognitive behavioral therapy Dr. Krinsky recommends using CATS (Child (CBT) – ages 3-21, focuses on building skills and Adolescent Trauma Screen) for ages 7-17 for emotional and behavioral regulation, and the PTSD Checklist for DSM-5 (PCL-5) for strengthening relationships, and processing patients over age 18. traumatic events CATS includes three types of questions: • Child Parent Psychotherapy (CPP) – ages 0-5, focuses on strengthening the parent- • A checklist of traumatic events, such as a child attachment serious accident, sudden death, and physical abuse • Parent-Child Interaction Therapy (PCIT)– ages 2-7, therapists coach parents on • Symptoms experienced, such as upsetting changing parent-child interactional patterns thoughts and bad dreams, and frequency • Attachment Regulation and Competency • Areas of life affected by symptoms, such as (ARC) – ages 2-21, provides a framework school or work and family relationships for working with children and adolescents • Score 21 or higher – probable PTSD who have experienced multiple or prolonged traumas Scoring CATS To find a provider of trauma-focused care, visit A score of 6-7: avoidance symptoms the state Child Trauma Training Center or call (855-Link-Kid). A score of 8-14: negative alteration in cognition; scoring less than 15 indicates no clinically Medication related problem, normal response Consider medication when the: A score of 15-20: hyperarousal, such as anger and inattention; may have moderate, trauma- • Patient has comorbid depression and/or related stress anxiety requiring medication treatment (see appropriate MCPAP algorithm) Responding to disclosures • Symptoms are causing significant distress or In discussing a sensitive area like trauma with functional impairment despite an adequate the patient and family, a calm demeanor and trial of an evidence-based psychotherapy for empathy are important. Just talking about PTSD trauma shouldn’t be re-traumatizing. If parents are going into too much detail, speak with them • Symptom severity is limiting engagement in alone. If sexual abuse may have occurred, refer psychotherapy for PTSD the child for a forensic evaluation. There are currently no FDA-approved Encourage parent-child quality time, self- medications for PTSD, but the following can be soothing, and good sleep hygiene. used to treat symptoms that are causing the greatest impairment: MCPAP algorithm • Sleep difficulties – melatonin or clonidine MCPAP has developed an algorithm that provides ways to respond to the different CATS • Severe nightmares – a trial of prazosin in categories. consultation with MCPAP Continued on page 5

MCPAP News July 2020 5 PTSD Assessment and Treatment Guidelines for Pediatric Primary Care Continued from page 4 • Hyperarousal with anger and irritability – clonidine or guanfacine What’s Happening • Negative alterations of cognition – an SSRI for you at MCPAP trial; monitor for suicidal ideation; follow-up for four weeks. If you need guidance in prescribing medications, Clinical Conversations contact MCPAP. We invite you to log in Follow up on the fourth Tuesday of each month from 12:15 Following up is critical for patients who have experienced trauma. The CATS includes a - 1:15 p.m. to learn more six-question form to monitor how the patient is about managing pediatric doing. behavioral health issues Addressing family issues with treatment in your practice. If the family is resistant to getting help, perhaps because of the stigma around mental health Next Clinical Conversations: care, use motivational interviewing to probe their concerns. Emphasize the need for parental Look for information on our next Clinical involvement and build accountability. Refer to Conversation in September 2020. the following for certain concerns: • A Mobile Crisis Intervention (MCI) team or the ER – for acute safety concerns If you are interested in receiving monthly • Partial hospital program – if the family is Clinical Conversation invitations, updates, stable but the child’s functioning is impaired and newsletters please email us at • Community-Based Acute Treatment (CBAT)/ [email protected]. inpatient admission – if the child has severe For any questions regarding Clinical difficulty functioning, including school Conversations, please contact Beth at refusal; usually requires MCI or ER evaluation [email protected]. Resources MCPAP PTSD algorithm Sample parent interview Sample child interview National Child Traumatic Stress Network

MCPAP News July 2020