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Treatment of PTSD in Children

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(1)

Treatment of PTSD in

Children

(2)

Why Treat PTSD in Kids ?

Distress & Disabling

Impairs Functioning

Development Affected

Co- morbid Problems

Chronicity

(3)

Limited research on Child PTSD Treatment

Combined approach to treatment

Cognitive Behavioural Therapy

Psychotherapy Drugs

(4)

Aim of PTSD Treatment

z

Relieve Distress

Reduce Impairment

Resume Development

Prevent Co-morbidities

Prevent Chronic Disorders

(5)

Essential Components of Treatment

¾ Psycho-education

¾ Stress Management

¾ Direct Exploration of Trauma

¾ Exploration & Correction of inaccurate attributions

¾ Parental Involvement

¾ Drug Treatment

(6)

Psychoeducation

Symptoms of PTSD

Course of Untreated PTSD

Rationale of Treatment

Treatment Goals

Treatment Components

(7)

Relaxation Techniques

Gain control over thoughts &

feelings

Give confidence & Increase capacity to explore trauma Handle Re-experiencing

phenomena

(8)

Direct Exploration of Trauma Encourage child to relax &

describe event with diminished hyper-arousal and negative

affective states.

Expose child to the phobic stimulus in a safe and

supportive environment & help gain mastery over trauma

(9)

Identify, Challenge and Reconsider negative cognitive attributions

related to trauma such as “It was

my fault ” , “The world is not a safe place”

(10)

Parental involvement

Parents’ issues & distress

resolved so they are perceptive

& responsive to child’s emotional needs.

Parents learn behavioural

strategies to help child deal with trauma.

(11)

Drug Treatment

In Paediatric PTSD

(12)

Studies have shown that stress or trauma affects different

neurotransmitter, neuro-endocrine systems and neuroanatomical

structures

(13)

Why Drugs for PTSD ?

Evidence of medication efficacy in adults

Comorbid conditions respond well to drugs

Failed Response to CBT

Neurobiological abnormalities noted in Child PTSD

(14)

No randomized , double blind,

placebo-controlled clinical trials in drug treatment of Childhood PTSD.

Cohen et al – 95 % who treat

childhood PTSD use drugs together with psychodynamic and cognitive behavioural therapy

(15)

Drugs for PTSD

Drugs treat symptom clusters of PTSD and and co-morbid disorders

Usually adjunct

No / Partial response to Psychotherapy Severe Symptoms ( agitation,

aggression, anxiety, insomnia, depression or self mutilation)

(16)

Chronic, Disabling PTSD

Disabling Co-morbid conditions

No Access to Psychosocial Treatments Treating even 1 disturbing, disabling

PTSD symptom can bring great relief

& improve child’s functioning

(17)

Drug Treatment

Alleviate distressing symptoms that interfere with daily

functioning and / hinder psychotherapy

Treat co-morbid disorders such as depression, anxiety, panic, ADHD

(18)

Choice of drug tailored to patient’s needs, concerns & preferences

Broad-spectrum drugs to target a range of symptoms Specific drugs targeting

specific co-morbid conditions Drug Combinations

(19)

Drugs in Childhood PTSD Adrenergic Agents

Dopiminergic Agents Serotonergic Agents Mood Stabilisers

(20)
(21)

Amydala & Normal stress

Integrate multimodal sensory information & attaches

emotional valence to it

Triggers stress response

Amydala hyper-responsiveness in veterans in response to fear stimuli compared to controls

(22)

HPA & PTSD

Increased cortisol levels in Child PTSD

Stress stimulates HPA Axis &

increases cortisol levels Cortisol helps in Stress

Excess Cortisol Toxic to Hippocampus

(23)

Trauma & Neuroanatomical Damage Hippocampal damage – affects

emotional regulation, learning, memory

Trauma affects Prefrontal Cortex

PFC Damage – Poor Judgement, Impulsivity, Fear response

(24)

Children with PTSD

- Lower intracranial, corpus callosum volume than carefully matched

controls

- Co-related with age & duration of abuse ( DeBellis et al ,1999)

Trauma Toxic to Brain Development Early , Effective Intervention Vital

(25)

Noradrenaline / Adrenaline &

Normal Stress

NE Release from Amydala, Locus Coerulus, PFC, Hypothalamus &

Hippocampus

Sympathetic arousal, anxiety, frontal lobe activation, mood

regulation, thinking & perception.

(26)

Activates “Flight or Fight” Response Increases Cortisol production

In PTSD, sustained ,increased adrenergic tone & reactivity

Hyperarousal symptoms in PTSD

(27)

Adrenergic Agents

Alpha 2 agonist – Clonidine , Guanfacine

Beta antagonist – Propranalol

Adrenergic agents mainly target Re-experiencing and

Hyperarousal symptoms

(28)

Perry et al – 17 PTSD children had

improvement in anxiety, concentration, mood & impulsivity with low doses of clonidine

Famularo et al – Propranolol reduced symptoms significantly in 8/11 abused children with PTSD.

(29)

Serotonin System and PTSD Involved in satiety, mood,

aggression, anxiety, impulsive compulsive behaviours

PTSD - aggression, obsessive, intrusive thoughts , substance abuse , panic, dissociative

symptoms, flashbacks may be due to serotonin disturbance

(30)

Serotonin System and PTSD Comorbid conditions of PTSD ( depression, suicidality ) also mediated by serotonin

SSRIs - Prozac, Sertraline, Paroxetine Most commonly used first line drug in Childhood PTSD

(31)

SSRI Drugs & Trauma

Have broad-spectrum action on mood, anxiety & obsessive,

compulsive symptoms Safe & well tolerated

Reduce re-experiencing, anxiety, panic, mood symptoms

Side effects – GIT symptoms, headache, insomnia, sleepiness

(32)

Dopamine System in Stress

Amydala excitation increases Dopamine release from PFC &

other sites

Sexually abused girls,abused

children with PTSD have increased urinary DA & DA metabolites

( Debellis et al , 1999)

(33)

Stress & Dopamine

Dopamine excess causes Prefrontal Cortex under-activity & failure to

extinguish conditioned fear responses, hyper-vigilance & paranoia

Dopamine blocking drugs help

hyper-vigilant, agitated & paranoid PTSD patients

(34)

Dopaminergic agents Olanzepine

Olanzepine,, RisperidoneRisperidone & &

quetiapine

quetiapine used in severe PTSD used in severe PTSD cases

cases

Horrigan

Horrigan & Barnhill, 1999& Barnhill, 1999

13 /18 kids with PTSD & high 13 /18 kids with PTSD & high

rates of co

rates of co--morbid psychiatric morbid psychiatric disorders, had remission of

disorders, had remission of symptoms with

symptoms with Risperidone Risperidone

..

(35)

Side Effects

Side Effects –– Rigidity, Rigidity, BradykinesiaBradykinesia Acute

Acute dystoniadystonia, , AkathesiaAkathesia, , Tardive Tardive dyskinesia

dyskinesia

Limited to severe PTSD

Limited to severe PTSD -- psychotic psychotic

symptoms, severe aggression, intense symptoms, severe aggression, intense

flashbacks ,self destructive

flashbacks ,self destructive behaviourbehaviour

(36)

Anticonvulsants – Carbamazepine, Sodium valproate

Carbamazepine – labile mood, anger , flashbacks, nightmares, intrusive

memories, sleep disturbance

Sodium Valproate – avoidance, numbing, hyperarousal , sleep difficulties, anger, rage

(37)

Tricyclic antidepressants &

Venlafaxine

Benzodiazepines - addictive potential, rebound effects

Lithium

Methylphenidate & Bupropion ( ADHD)

(38)

Endogenous Opiate System

Stress releases endorphins from substantia nigra & mesolimbic

regions

Causes pain analgesia

In PTSD, excessive endorphins may lead to psychic numbing

Endorphins raised in combat veterans with PTSD

(39)

Opiate Antagonists

Glower , 1992 – Naltrexone reduced numbing but not PTSD symptoms, worsen in some others

In Child PTSD, self injurious behaviour ( SIB ) common

Naltrexone may be helpful in reducing SIB

(40)

Drug Treatment in Childhood PTSD Assess Target PTSD &

Comorbid symptoms

Treat & Monitor response &

Progress

Add Additional Drugs if necessary

(41)

Drug Treatment in Childhood PTSD May need to treat Comorbid

conditions prior to or

concurrent with CBT for PTSD Consider pre-morbid history, medical conditions

(42)

Stress & Amydala

Locus Coerulus – Noradrenaline Hypothalamus – Hypothalamo- Pituitary Axis

Ventral Tegmentum – Dopamine release to Prefrontal cortex

Central Grey Matter – Conditioned “ freezing ”

(43)

4 criteria to make a DSM IV diagnosis of PTSD

Exposure to major stressor Re-experiencing of the event Avoidance of stimuli or

Numbing of general responsiveness

Persistent Hyperarousal

(44)

DSM IV Criteria for PTSD

A. Person has been exposed to

traumatic event in which both of the following were present :

(45)

Person experienced, witnessed or was confronted with an event/events that involved actual or threatened death or serious injury, or a threat to the

physical integrity of other

Person’s response involved intense fear, helplessness, horror ( Agitation, disorganization in children )

(46)

B. Traumatic event persistently

re-experienced in 1 or more of the following ways:

Recurrent, intrusive distressing

recollections of the event (images, thoughts or perceptions, repetitive play with themes or aspects of

trauma)

(47)

Recurring distressing dreams of the event

Acting or feeling as if traumatic event were recurring ( sense of reliving the experience, illusions, hallucinations, dissociative flashbacks, trauma

specific reenactment in children)

(48)

Intense psychological distress at

exposure to internal / external cues that symbolize or resemble an aspect of traumatic event.

Physiological reactivity on exposure to internal or external cues that

symbolize or resemble an aspect of traumatic event.

(49)

C. Persistent avoidance of stimuli

associated with trauma & numbing of general responsiveness,as indicated by 3 (or more) of the following

Efforts to avoid thoughts, feelings, or conversations associated with trauma Efforts to avoid activities, places or

people that arouse recollections of the trauma

(50)

Inability to recall an important aspect of the trauma

Markedly diminished interest or

participation in significant activities Feelings of detachment or

estrangement from others Restricted range of affect

Sense of foreshortened future

(51)

D. Persistent symptoms of increased arousal as indicated by 2 (or more) of the following:

Difficulty falling or staying asleep Irritability or anger outbursts

Difficulty concentrating Hyper-vigilance

Exaggerated startle response

(52)

E. Duration of disturbance is more than 1 month

F. The disturbance causes clinically significant distress or impairment in

social, occupational or other important areas of functioning

References

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