Pharmacologic treatment approaches for children and adolescents with posttraumatic stress disorder

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Posttraumatic stress disorder symptom complexity and comorbidity

Childhood and adolescent PTSD is a heterogeneous disorder typically characterized by complex symptom presentations. The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) [1] criteria set allows for at least 1750 possible symptom combinations in meeting the minimum criteria for a diagnosis of PTSD (ie, one in five B-criteria, plus three in five C-criteria, plus two in five D-criteria yields 1750 possible symptom combinations). There are at least 1750 “ways a child can look”

Neurobiology

The literature on the neurobiology of PTSD in childhood is in the early stages, and relatively little is known about the specific neurobiologic effects of early trauma on human growth and development [12], [13], [14], [15]. DeBellis [16] reviewed the psychobiology of PTSD in childhood, and more general theories of the neurobiology of stress and trauma have been reviewed extensively elsewhere [17], [18]. A body of literature is emerging, based on a synthesis of clinical and animal experimental

Special considerations in child and adolescent populations

Pharmacotherapy treatment approaches to childhood PTSD must be embedded in a broad context of assessment and treatment. Certainly the initial step in the treatment of PTSD is psychoeducation of the child, parents, and adult caregivers. This initial didactic explanation is an important but often neglected element of all types of therapy for childhood PTSD. It involves providing an explanation of the symptoms of the disorder, its natural course left untreated, and the specific rationale and

Medication use in child and adolescent posttraumatic stress disorder

This section reviews classes of medication related to their function and their effects in relation to target PTSD symptoms. Despite the lack of data, medication use in children with PTSD has become a standard of care. In a large sampling of treatment providers, Cohen et al [11] found that 95% of medical practitioners who treat pediatric PTSD use pharmacotherapy in combination with psychodynamic and cognitive-behavioral therapies. Whether to use medication for PTSD can be a deceptively complex

Specific medications for use in posttraumatic stress disorder

Table 1 provides a listing of the specific medications, dose ranges, and clinical action of the agents used in the treatment of PTSD.

Adrenergic and serotonergic agents: tricyclic antidepressants, venlafaxine

Tricyclic antidpressants, such as imipramine and desipramine, largely have been supplanted in child and adolescent psychiatry by the newer antidepressant agents because of unwanted side effects and potential cardiotoxicity. These agents may have second-line use in childhood PTSD when comorbid conditions such as ADHD, enuresis, or sleep disorders are present. Three randomized clinical trials have been conducted, and multiple case reports and open label trials with tricyclic antidepressants in

Gamma-aminobutyric acid and benzodiazepine agents

Benzodiazepine receptors are functionally linked to receptors for the inhibitory neurotransmitter gamma-aminobutyric acid. This system is clearly involved in the neurobiology of anxiety and stress. The benzodiazepines have been used to treat anxiety disorders in children and adults, although there are few, if any, data to support their effectiveness in the core symptoms of PTSD [42]. Adult studies indicate that they have little effect on core PTSD symptoms of reexperiencing, avoidance, and

Opioid antagonists

Opioid antagonists have been used with mixed results in adults with PTSD. No clinical trials with these agents have been published in children and adolescents with PTSD. Naltrexone has been used to prevent hypothesized hyperrelease in endogenous opioids as a means of blunting the tendency to self-mutilate and reducing rates of relapse in alcoholic patients who have achieved sobriety. The opioid antagonists may have limited use in treating debilitating self-mutilative behavior and perhaps

Miscellaneous agents and agents that affect multiple neurotransmitters: anticonvulsants, bupropion, psychostimulants

Trauma exposure may induce sensitization or kindling phenomena in limbic nuclei in the human central nervous system. Several successful open label trials have been conducted with antikindling and anticonvulsive agents with adult patients with PTSD. The mood stabilizers may play a role in the treatment of childhood PTSD, especially in cases of severe affective instability. Lithium, valproate, and carbamazepine may reduce extreme mood lability and anger dyscontrol. Carbamazepine has received the

Assessment and symptom monitoring

As in all psychiatric disorders, the first step in establishing a treatment program is a careful, thorough assessment that is stressor focused, as in the case of PTSD [68], [69]. Although semistructured interviews are useful for assessing psychiatric problems in children and adolescents, reliability or validity data for PTSD instruments have been slow to emerge [70], and no structured instrument can replace a well-conducted series of clinical interviews in this most complex disorder [82].

Summary

Posttraumatic stress disorder is a common cause of morbidity in children and adolescents. The disorder in youth is similar to that in adults, with high rates of psychiatric comorbidity. Children seem to be more sensitive to the effects of trauma, and early life trauma exposure may induce a complex sequence of events that leads to the development of multiple psychiatric disorders in adulthood. The state of knowledge regarding medication treatments for children and adolescents is in the earliest

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      As such, medication interventions are usually extrapolated from adult studies. A reasonable first choice of medication would be an SSRI, especially sertraline or paroxetine (as they are approved for PTSD in adults).39 Dosing should start low to prevent an exacerbation of irritability and aggressiveness, a known side effect of serotonergic agents.

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