Psychopharmacology of pediatric posttraumatic stress disorder.

OBJECTIVE: To review the current knowledge of pharmacotherapy in the treatment of Post-traumatic Stress Disorder (PTSD) as it applies to children and adolescents and to provide a rational approach to medication use in Pediatric PTSD. METHOD: The literature on the psychopharmacology of Pediatric PTSD is reviewed. Additionally, literature is reviewed on the neurobiological systems presumptively involved in trauma as well as studies in the pharmacology of adult PTSD, as they pertain to the treatment of Pediatric PTSD. RESULTS: There are too few studies in the current Pediatric PTSD literature to confirm treatment recommendations. Downward extrapolation from the adult literature combined with an understanding of the neurobiology of PTSD and its comorbid conditions may serve as the basis for a rational pharmacotherapy of PTSD in childhood. The effectiveness of targeting pharmacological agents at PTSD symptom clusters and associated comorbid conditions remains to be verified in controlled clinical trials. CONCLUSIONS: The state of psychopharmacology for Pediatric PTSD is in its earliest stages. While there are insufficient numbers of controlled pharmacological trials to make firm recommendations, the field requires a starting point for a rational psychopharmacological approach. Pharmacotherapy may provide symptom relief of both the debilitating primary symptoms and the comorbid conditions in children suffering from PTSD.

Functional impairment and utilization of services associated with posttraumatic stress in the community.

This study describes social functioning and service utilization patterns associated with posttraumatic stress symptoms relative to nonpsychiatric controls and depressive disorder controls in a cross-sectional epidemiological survey. Data from 49 cases and 147 controls who participated in the North Carolina component of the Epidemiologic Catchment Area study were examined. Results indicate that symptoms of posttraumatic stress were associated with impairment along several domains of functioning: social, financial, physical, and psychological. Individuals with posttraumatic stress were found to have more socioeconomic disadvantages and impaired functioning. Despite this, individuals with posttraumatic stress are receiving relatively few mental health services. Further research assessing service use, treatment, and functional outcomes are indicated.

Cognitive-behavioral psychotherapy for children and adolescents with posttraumatic stress disorder after a single-incident stressor.

OBJECTIVE: To test the efficacy of a group-administered cognitive-behavioral psychotherapy (CBT) protocol for pediatric posttraumatic stress disorder (PTSD) after a single-incident stressor. METHOD: After a school-wide selection-to-treatment procedure conducted in two elementary and two junior high schools, children and adolescents with DSM-IV PTSD by structured interview were entered into an 18-week, group-administered CBT protocol using a single case across time and setting experimental design. Assessments of PTSD, anxiety, depression, trait anger, locus of control, and disruptive behavior were conducted at baseline, posttreatment, and at 6-month follow-up. RESULTS: Experimental control across time (staggered start date) and setting (school and age) was demonstrated. Fourteen of 17 subjects completed treatment. Of these, 8 (57%) no longer met DSM-IV criteria for PTSD immediately after treatment; 12 (86%) of 14 were free of PTSD at 6-month follow-up. On intent-to-treat analyses, treatment produced a robust beneficial effect posttreatment on the Clinician-Administered PTSD Scale-Child and Adolescent Version, with additional improvement accruing at follow-up (p < .001). Improvements of a similar magnitude were seen for depression (p < .001), anxiety (p < .001), and anger (p < .005). Locus of control remained external from pre- to posttreatment but became strongly internal at follow-up (p < .001). CONCLUSION: More clinical trials are required to confirm that CBT is a safe, acceptable, and effective treatment for PTSD in children and adolescents.

Effects of electroconvulsive therapy in adolescents with severe endogenous depression resistant to pharmacotherapy.

BACKGROUND: This open, prospective study examined the effects of electroconvulsive therapy (ECT) in 10 adolescents with primary, endogenous, psychotic depression who were resistant to antidepressant pharmacotherapy. METHODS: Change in symptom severity from baseline was assessed weekly with Hamilton Depression Rating Scale (HDRS) ratings, and outcome was measured additionally at 1 month, and again at 1 year, post-ECT. RESULTS: All but 1 patient demonstrated dramatic improvement, with statistically significant decreases in mean HDRS score detected after the first week of treatment. All responders maintained the benefits of their treatment. CONCLUSIONS: The results provide evidence of the clinical effectiveness of ECT in adolescents with phenomenological characteristics shown to be predictive of ECT response in adults.

Children who prosper in unfavorable environments: the relationship to social capital.

OBJECTIVE: Social capital describes the benefits that are derived from personal social relationships (within families and communities) and social affiliations. This investigation examined the extent to which social capital is associated with positive developmental and behavioral outcomes in high-risk preschool children. DESIGN: A cross-sectional case-control analysis of young children "doing well" and "not doing well" at baseline in four coordinated longitudinal studies. PARTICIPANTS: A total of 667 2- to 5-year-old children (mean age, 4.4 years) and their maternal caregivers who are participating in the Longitudinal Studies of Child Abuse and Neglect Consortium. At recruitment, all children were characterized by unfavorable social or economic circumstances that contributed to the identification of the children as high risk. MEASURES: Social capital was defined as benefits that accrue from social relationships within communities and families. A social capital index was created by assigning one point to each of the following indicators: 1) two parents or parent-figures in the home; 2) social support of the maternal caregiver; 3) no more than two children in the family; 4) neighborhood support; and 5) regular church attendance. Outcomes were measured with the Child Behavior Checklist, a widely used measure of behavioral/emotional problems, and with the Battelle Developmental Inventory Screening Test, a standardized test that identifies developmental deficits. Children were classified as doing well if their scores on these instruments indicated neither behavioral nor developmental problems. RESULTS: Only 13% of the children were classified as doing well. The individual indicators that best discriminated between levels of child functioning were the most direct measures of social capital-church affiliation, perception of personal social support, and support within the neighborhood. The social capital index was strongly associated with child well-being, more so than any single indicator. The presence of any social capital indicator increased the odds of doing well by 29%; adding any two increased the odds of doing well by 66%. CONCLUSIONS: Our findings suggest that social capital may have an impact on children's well-being as early as the preschool years. In these years it seems to be the parents' social capital that confers benefits on their offspring, just as children benefit from their parents' financial and human capital. Social capital may be most crucial for families who have fewer financial and educational resources. Our findings suggest that those interested in the healthy development of children, particularly children most at risk for poor developmental outcomes, must search for new and creative ways of supporting interpersonal relationships and strengthening the communities in which families carry out the daily activities of their lives.

Posttraumatic symptomatology in children and adolescents after an industrial fire.

OBJECTIVE: This investigation evaluated the extent and nature of posttraumatic symptomatology (PTS) in children and adolescents 9 months after an industrial fire at the imperial Foods chicken-processing plant in Hamlet, North Carolina, caused extensive loss of life. METHOD: Using a PTS self-report measure plus self- and teacher reports of comorbid symptoms the authors surveyed 1,019 fourth- to ninth-grade students in the community where the fire occurred. RESULTS: Three factors comprising PTS were identified: reexperiencing, avoidance and hyperarousal. Reexperiencing and avoidance were positively correlated; hyperarousal proved weakly correlated with reexperiencing, perhaps because exposure was largely indirect. Using a T score cutoff of 65 on the reexperiencing factor as indicative of PTS 9.7% of subjects met criteria for PTS; 11.9% met criteria for posttraumatic stress disorder (PTSD) using DSM-III-R PTSD criteria. Degree of exposure was the most powerful predictor of PTS. Race (African-American) and gender (female) posed significant risk factors for PTS. Self-reported internalizing symptoms and teacher-reported externalizing symptoms were positively predicted by intercurrent PTS, and independently of PTS, by degree of exposure. Comorbid symptoms showed interesting interactions with exposure, race, and gender. Lack of self-attributed personal efficacy predicted PTS but did not moderate the effects of race or gender on PTS risk. CONCLUSIONS: This study, which used a population-based sampling strategy, strengthens and extends findings from earlier literature on pediatric PTSD in showing that (1) PTS and comorbid internalizing and externalizing symptoms rise in direct proportion to degree of exposure; (2) gender and race show variable effects on risk for PTS and comorbid symptoms; and (3) comorbid symptoms are positively correlated with PTS and may represent primary outcomes of traumatic exposure in their own right.

Post-traumatic Stress Disorder in Adolescents: Risk Factors, Diagnosis, and Intervention.

Research on violent trauma and other high-magnitude threats has confirmed that exposure to severe traumatic experiences is predictive of later psychopathology in young persons, including post-traumatic stress disorder (PTSD). Here the authors summarize the literature on child and adolescent PTSD, paying particular attention to elements that diverge from the adult disorder and implications specific to prevention and treatment in the adolescent.