Lecture: Child Abuse and Neglect - American Academy of Child and

Child Abuse and
Shannon Wagner Simmons, MD, MPH
Child and Adolescent Psychiatry Fellow
Institute for Juvenile Research
University of Illinois at Chicago
• Review basic concepts and epidemiology of child
• 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 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
• She has a younger sister who lives at home; parents are
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
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
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
• Poverty
• Substance Abuse
• Domestic Violence
• Caregiver history of being abused
• Transient nonrelated caregivers
• Social stressors
Psychiatric Sequelae
• Maltreated children are at risk for:
o Attachment disorders
o Social/peer relationship
o Language delays
o Below-average standardized o
test scores
o Intimate Partner Violence o
o Teen parenthood
o Perpetrating abuse
o Age-inappropriate sexual
Mood disorders
Anxiety disorders
Alcohol and drug abuse
Eating disorders
Disruptive behavior
Borderline personality
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
• 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
• 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
Trauma Symptom Checklist
Anxiety Disorder Interview Schedule (ADIS) PTSD section
Sometimes children report things on rating scales that
they do not report verbally.
Treatment Planning
• The treatment should be tailored to the
• 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
• 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 schoolaged 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,
• 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
 Facts for Families
 Practice Parameters
• http://tfcbt.musc.edu/ (Trauma-Focused CBT)