Psychopharmacology of pediatric posttraumatic stress disorder

Glutamate and GABA imbalance promotes neuronal apoptosis in hippocampus after stress

Background

People who experience traumatic events have an increased risk of post-traumatic stress disorder (PTSD). However, PTSD-related pathological changes in the hippocampus and prefrontal cortex remain poorly understood.

Material/Methods

We investigated the effect of a PTSD-like animal model induced by severe stress. The experimental rats received 20 inescapable electric foot shocks in an enclosed box for a total of 6 times in 3 days. The physiological state (body weight and plasma corticosterone concentrations), emotion, cognitive behavior, brain morphology, apoptosis, and balance of gamma-aminobutyric acid (GABA) and glutamate in the hippocampus and prefrontal cortex were observed. Cell damages were examined with histological staining (HE, Nissl, and silver impregnation), while apoptosis was analyzed with flow cytometry using an Annexin V and propidium iodide (PI) binding and terminal deoxynucleotidyl transferase mediated-dUTP nick end labeling (TUNEL) method.

Results

In comparison with the sham litter-mates, the stressed rats showed decreased body weight, inhibition of hypothalamic-pituitary-adrenal (HPA) axis activation, increase in freezing response to trauma reminder, hypoactivity and anxiety-like behaviors in elevated plus maze and open field test, poor learning in Morris water maze, and shortened latency in hot-plate test. There were significant damages in the hippocampus but not in the prefrontal cortex. Imbalance between glutamate and GABA was more evident in the hippocampus than in the prefrontal cortex.

Conclusions

These results suggest that neuronal apoptosis in the hippocampus after severe traumatic stress is related to the imbalance between glutamate and GABA. Such modifications may resemble the profound changes observed in PTSD patients.

The Effectiveness of Eye Movement Desensitizationand Reprocessing in the Treatment of TraumatizedChildren and Youth

This article provides a summary of all the studies that have investigated eye movement desensitization and reprocessing (EMDR) treatment of traumatized children and adolescents. The effectiveness of the treatment is revealed in more than 15 studies. This article considers the differences between Type I and Type II traumas and specifically examines the effects of EMDR on traumatic stress experienced by children and youth following Type I and Type II traumas. There is a considerable body of research evaluating EMDR treatment of Type I traumas, showing strong evidence for its efficacy, but there are few studies that have specifically investigated EMDR treatment of Type II traumas. The effect of EMDR on various symptoms and problem areas is also examined. Recommendations are made for the clinical application of EMDR and for further research.

Posttraumatic stress disorder in children and adolescents: a review of psychopharmacological treatment

PTSD in children and adolescents differs from the adult disease. Therapeutic approaches involve both psychotherapy and psychopharmacotherapy.

OBJECTIVES

The current paper aims at reviewing studies on psychopharmacological treatment of childhood and adolescent PTSD. Additionally, developmental frameworks for PTSD diagnosis and research along with an experimental model of quenching and kindling in the context of stress exposure are presented. We conducted an extensive literature search of reviews on psychopharmacotherapy as well as studies on psychopharmacological treatment for PTSD among children and adolescents. We used the database PubMed and focused on the time period of the last 10 years up to January 2009. Pertinent earlier papers were also included.There are a limited number of studies specifically assessing the psychopharmacological treatment of PTSD in children and adolescents. The vast majority of them lack verification in RCTs. Only the use of imipramine, divalproex sodium and sertraline were already evaluated in RCTs. Future studies should take into account developmental approaches to the diagnosis and treatment of PTSD in children and adolescents. In this context, different underlying neurobiological patterns, which are reflected in distinct clinical symptomatology, require a precise investigation and a symptom-orientated psychopharmacological approach.

Psychopharmacologic treatment of traumatized youth

PURPOSE OF REVIEW

To review and summarize existing literature regarding pharmacological interventions for post-traumatic stress disorder (PTSD) in children and adolescents. A literature search limited to articles focused on the pharmacological treatment of children aged 0-18 years with a history of trauma and/or PTSD was conducted through the National Library of Medicine and PsychInfo, 1967-present, and each citation manually reviewed.

RECENT FINDINGS

Pharmacologic trials for pediatric PTSD are limited in scope and number, with one small double-blind, randomized controlled trial of the selective serotonin reuptake inhibitor (SSRI) sertraline. Two brief, small, double-blind, randomized controlled trials of imipramine for children and adolescents with acute stress disorder have been conducted, with mixed results. Only case reports or open-labeled trials have been conducted with alpha-adrenergic agents, other antidepressants, atypical antipsychotics, and antiepileptic agents.

SUMMARY

Data supporting the use of medications in the treatment of PTSD in children and adolescents are limited. SSRIs show promise and deserve additional study, but conclusive support for their use is not available as it is in adults. Additional research is needed, with other drugs of interest including other antidepressants, alpha-adrenergic agents, and possibly the antiepileptic agent carbamazepine.

Maternal separation modulates short-term behavioral and physiological indices of the stress response

Early-life stress produces an anxiogenic profile in adulthood, presumably by activating the otherwise quiescent hypothalamic-pituitary-adrenal (HPA) axis during the vulnerable 'stress hyporesponsive period'. While the long-term effects of such early-life manipulations have been extensively characterized, little is known of the short-term effects. Here, we compared the short-term effects of two durations of maternal separation stress and one unseparated group (US) on behavioral and physiological indices of the stress response in rat pups. Separations included 3h on each of 12days, from postnatal day (PND) 2 to 13 (MS2-13) and 3days of daily, 6-h separation from PND11-13 (MS11-13). On PND14 (Experiment 1), both MS2-13 and MS11-13 produced marked reductions in freezing toward an adult male conspecific along with reduced levels of glucocorticoid type 2 (GR) and CRF type-1 (CRF(1)) receptor mRNA in the hippocampus. Group MS2-13 but not MS11-13 produced deficits in stressor-induced corticosterone secretion, accompanied by reductions in body weight. Our results suggest that GR and/or CRF(1) levels, not solely the magnitude of corticosterone secretion, may be involved in the modulation of freezing. In a second experiment, we aimed to extend these findings by testing male and female separated and unseparated pups' unconditioned defensive behaviors to cat odor on PND26, and subsequent cue+context conditioning and extinction throughout postnatal days 27-32. Our results show that maternal separation produced reductions in unconditioned freezing on PND26, with MS2-13 showing stronger deficits than MS11-13. However, separation did not affect any other defensive behaviors. Furthermore, separated rats failed to show conditioned freezing, although they did avoid the no-odor block conditioned cue. There were no sex differences other than weight. We suggest that maternal separation may have produced these changes by disrupting normal development of hippocampal regions involved in olfactory-mediated freezing, not in mechanisms of learning and memory per se. These findings may have direct relevance for understanding the mechanisms by which early-life adverse experiences produce short-term and lasting psychopathologies.

A spiritual-hypnosis assisted treatment of children with PTSD after the 2002 Bali terrorist attack

The aim of this study was to assess the effectiveness of a spiritual-hypnosis assisted therapy (SHAT) for treatment of posttraumatic stress disorder (PTSD) in children. All children, age 6-12 years (N=226; 52.7% females), who experienced the terrorist bomb blasts in Bali in 2002, and subsequently were diagnosed with PTSD were studied, through a longitudinal, quasi-experimental (pre-post test), single-blind, randomized control design. Of them, 48 received group SHAT (treatment group), and 178 did not receive any therapy (control group). Statistically significant results showed that SHAT produced a 77.1% improvement rate, at a two-year follow up, compared to 24% in the control group, while at the same time, the mean PTSD symptom score differences were significantly lower in the former group. We conclude that the method of spiritual-hypnosis is highly effective, economic, and easily implemented, and has a potential for therapy of PTSD in other cultures or other catastrophic life-threatening events.

Divalproex sodium for the treatment of PTSD and conduct disordered youth: a pilot randomized controlled clinical trial

We examined the efficacy of divalproex sodium (DVP) for the treatment of PTSD in conduct disorder, utilizing a previous study in which 71 youth were enrolled in a randomized controlled clinical trial. Twelve had PTSD. Subjects (all males, mean age 16, SD 1.0) were randomized into high and low dose conditions. Clinical Global Impression (CGI) ratings for core PTSD symptoms (Intrusion, avoidance and hyper arousal) were primary outcome measures, weekly slopes of impulsivity secondary ones. Intent-to-treat analyses showed significant positive associations between receiving high dose of DVP CGI's. Parallel analyses comparing outcome by drug level achieved strengthened the results.

Risperidone treatment of preschool children with thermal burns and acute stress disorder

Pharmacologic treatment of acute stress disorder (ASD) is a novel area of investigation across all age groups. Very few clinical drug trials have been reported in children and adolescents diagnosed with ASD. Most of the available, potentially relevant, data are from studies of adults with posttraumatic stress disorder (PTSD). The atypical antipsychotic agents have been reported to be effective as an adjunctive treatment for adults with PTSD. There have been a limited number of studies published regarding atypical antipsychotic treatment of PTSD in children and adolescents, and there is no current literature available on the use of these agents for children with ASD. This report describes the successful treatment of three preschool-aged children with serious thermal burns as a result of physical abuse or neglect. Each of these children was hospitalized in a tertiary-care children's hospital and was diagnosed with ASD. In all cases, risperidone provided rapid and sustained improvement across all symptom clusters of ASD at moderate dosages. Minimal to no adverse effects were reported. These cases present preliminary evidence for the potential use of risperidone in the treatment of ASD in childhood.

Acute stress disorder symptoms in gunshot-injured youth

PROBLEM

The prevalence of acute stress disorder symptoms (ASDS) and other psychiatric comorbidities in youth with recent gunshot injuries.

METHODS

Children (n=20) admitted to an urban hospital ER for gunshot injuries over a 4-year period were evaluated for ASDS, co-morbid DSM-III-R diagnoses, legal and gang involvement, and psychiatric history; medically hospitalized children (n=36) similar in age, sex, race, and socioeconomic status served as a control group.

FINDINGS

Gunshot-injured youth reported a 75% rate of ASDS compared to a 14% rate in medically ill youth (OR 18.6; chi2 = p < .0001). Parent ratings of ASDS closely corresponded with youth ratings. Youth rated reexperiencing the event as the most frequent distressing symptom. Gunshot injury was associated with legal problems, gang involvement, marijuana/alcohol dependence, conduct disorder, social phobia, and agoraphobia compared to youth with medical illness.

CONCLUSIONS

Compared to youth with medical illness, gunshot-injured youth were 18.6 times (p = .0001) more likely to show symptoms of ASDS. Further research, developmentally appropriate assessment, prevention, and treatment are needed in this area.

Clinical perspectives on neurobiological effects of psychological trauma

Physical trauma to the brain has always been known to affect brain functions and subsequent neurobiological development. Research primarily since the early 1990s has shown that psychological trauma can have detrimental effects on brain function that are not only lasting but that may alter patterns of subsequent neurodevelopment, particularly in children although developmental effects may be seen in adults as well. Childhood trauma produces a diverse range of symptoms and defining the brain's response to trauma and the factors that mediate the body's stress response systems is at the forefront of scientific investigation. This paper reviews the current evidence relating psychological trauma to anatomical and functional changes in the brain and discusses the need for accurate diagnosis and treatment to minimize such effects and to recognize their existence in developing treatment programs.

Review of child and adolescent refugee mental health

OBJECTIVE

To review stressful experiences and stress reactions among child and adolescent refugees, as well as interventions and ethical considerations in research and clinical work, within the framework of the chronological experiences of child refugees; namely, the phases of preflight, flight, and resettlement. Highlighted are special refugee populations such as unaccompanied minors, asylum seekers, and former child soldiers. Pertinent medical findings are summarized.

METHOD

The authors reviewed articles from 1990 to 2003 addressing the topics above. Literature was gathered from databases including PsycINFO, Medline, and SocioFile. Pertinent earlier papers and those from other disciplines cited in database-identified articles were also included.

RESULTS

Child and adolescent refugees suffer from significant conflict-related exposures. Reactions to stress may be mediated by coping strategies, belief systems, and social relations.

CONCLUSIONS

More research is needed on interventions, specifically on efficacy and cultural relevance. Interventions that have an impact on multiple ecological levels need further development and evaluation.

Our-component model for counseling clients with traumatic childhood abuse

To treat the effects of traumatic childhood abuse effectively, we propose a model which incorporates information from neurophysiological, psychoeducational, cognitive, and social work literature. The four components of the model reflect the broad range of explanations for pathology posed by researchers and also support the breadth of interventions available for use with survivors of childhood abuse. The model relies on individualized assessment and treatment related to the physiological response to abuse, faulty learning, cognitive and psychological problems, and social effects of abuse. This model contributes to the literature by providing a comprehensive framework complementary to many theoretical orientations, is useful across the helping disciplines, and appropriate in multidisciplinary settings.

Pharmacologic treatment approaches for children and adolescents with posttraumatic stress disorder

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 stages of development. There are no well-conducted, randomized clinical trials to guide practitioners. Medication may play an important role in reducing debilitating symptoms of PTSD and providing a buffer for children while they confront difficult material in therapy and may help to improve their general functioning in day-to-day life. Given the various medications with potential usefulness in PTSD, it is helpful to use a stepwise approach to treatment. As a general principal, broad-spectrum agents, such as the SSRIs, are a good first choice. The SSRIs have efficacy in treating the core symptoms of PTSD and conditions such as the anxiety disorders and depression that commonly co-occur with PTSD. These agents also improve social and occupational functioning and an individual's perception of improved quality of life [41, 45, 46]. Although the SSRIs are generally effective for a broad spectrum of problems, clinicians should systematically monitor for the persistence of symptoms that do not respond to these agents. For example, despite significant improvements in core PTSD symptoms in one study that used sertraline, little improvement was seen in patients' comorbid anxiety and depressive symptoms [41]. This finding demonstrates the value of continuous symptom monitoring and shows that residual or comorbid symptoms may require a different medication to augment effective SSRI treatment for PTSD. A reasonable approach is to begin with a broad-spectrum agent, such as an SSRI, which should target anxiety, mood, and reexperiencing symptoms. Adrenergic agents, such as clonidine, used either alone or in combination with an SSRI may be useful when symptoms of hyperarousal and impulsivity are problematic. Supplementing with a mood stabilizer may be necessary in severe affective dyscontrol. Similarly, introduction of an atypical neuroleptic agent may be necessary in cases of severe self-injurious behavior, dissociation, psychosis, or aggression. Comorbid conditions such as ADHD should be targeted with pharmacotherapy known to be effective, such as psychostimulants or newer agents such as atomoxetine. Pharmacologic treatment of PTSD in childhood is one approach to alleviating the acute and chronic symptoms of the disorder. Despite the lack of well-designed, randomized, controlled trials that support efficacy, medication can be used in a rational and safe manner. Reduction in even one disabling symptom, such as insomnia or hyperarousal, may have a positive ripple effect on a child's overall functioning. Pharmacotherapy is typically used as one component of a more comprehensive multiple modality treatment package, including psychoeducation of the parent and child, focused exposure-based psychotherapy with adjunctive family therapy when indicated, and long-term booster interventions that use an admixture of psychodynamic, cognitive-behavioral, and pharmacologic interventions.

Psychosocial and pharmacological interventions for child crime victims

Children may develop a variety of difficulties following victimization, including posttraumatic stress disorder (PTSD), other anxiety symptoms, depressive disorders, externalizing symptoms, or substance use disorders. Some children appear to be resilient in the face of victimization and do not report significant difficulties. A growing number of treatment studies for child abuse victims has supported the efficacy of trauma-focused cognitive-behavioral therapy (CBT); however, more research is needed to determine the critical components and optimal dosage of CBT, and to evaluate the efficacy of this approach for other groups of child crime victims. Psychopharmacological treatments are widely used for childhood PTSD, but little research has evaluated such treatments. Treatment guidelines and future directions are discussed.

Acute stress disorder in children related to violence

TOPIC

Unidentified and untreated acute stress responses in children may result in chronic posttraumatic stress disorder (PTSD), other serious psychiatric disorders, and/or developmental arrest.

PURPOSE

To review and identify gaps in current literature on acute stress disorder (ASD) in children and examine current treatments.

SOURCES

Review of the

CONCLUSIONS

More developmentally appropriate, standardized measurement instruments are needed. Future research must focus on prospective studies of children exposed to trauma in order to better understand the association between ASD and PTSD. Future studies must include children at different developmental stages.

Current pharmacotherapy for the treatment of severe burns

The pharmacotherapy of burn care has evolved from the first topical antibiotics instituted > 30 years ago. These have helped greatly to reduce the incidence of burn wound sepsis, but a better understanding of the principles of burn care has resulted in earlier burn wound excision and complete coverage with autograft, cadaver skin, synthetic dressings, and amnion. This has markedly reduced septic complications and ameliorated the hypermetabolic response to burn injury. The hypermetabolic response, which is mediated by hugely increased levels of circulating catecholamines, prostaglandins, glucagon and cortisol, causes profound skeletal muscle catabolism, immune deficiency, peripheral lipolysis, reduced bone mineralisation, reduced linear growth, and increased energy expenditure. Supportive therapy and pharmacological manipulation, acutely and during rehabilitation, with growth hormone, insulin and related proteins, oxandrolone and propranolol can ameliorate the hypermetabolic response, improving survival and long-term outcome. Despite judicious use of topical and systemic antibiotics, opportunistic nosocomial bacterial resistance threatens to annul the improved survival of patients with severe burns. Patterns of emerging resistance encountered in burn units need to be considered, in light of a decreasing antibiotic armamentarium. A holistic approach to pharmacotherapy of severely burned patients including current practice in antimicrobial control, analgesia, sedation, and anxiety management is required. Current therapy of frequently encountered problems, such as post-burn pruritus, prophylaxis of deep venous thrombosis and peptic ulceration, and pharmacological manipulation of inhalation injury in the burned patient is described. Current pharmacotherapy to ameliorate psychosocial problems associated with burns such as acute stress disorder, depression and post traumatic stress disorder are discussed. Better analgesics, newer antibiotics and immune stimulating drugs are required to reduce mortality and morbidity in large burns.

Efficacy of newer antidepressants for childhood anxiety disorders

Anxiety disorders as a whole are the most common psychiatric disorders in children and adolescents, with a reported prevalence ranging from 6 to 18%. Childhood anxiety disorders predict adult disorders and the majority of adult anxiety disorders are antedated by childhood anxiety. Furthermore, social dysfunction may result from misdiagnosis of these early-onset disorders. Anxiety disorders can be managed using nonpharmacological and pharmacological options, or a combination of them. Different classes of medications have been used in pediatric anxiety disorders, including benzodiazepines, tricyclics and buspirone. Newer antidepressants (SSRIs and beyond) have fewer side effects, lower toxicity in overdose and a broader range of indications. This review will focus on the efficacy of these new drugs in the management of anxiety disorders in children and adolescents (obsessive-compulsive disorder, panic disorder, separation anxiety disorder/school refusal, generalized anxiety disorder, social phobia, post-traumatic stress disorder).

New directions in the pharmacotherapy of posttraumatic stress disorder

Advances in psychopharmacology of PTSD are presented, focusing on antidepressants, adrenergic agents, antianxiety agents, and mood stabilizers. Treatment recommendations are related to recent advances in the understanding of the biology of PTSD. Pharmacotherapy of PTSD in children and adolescents is discussed, including recommended dose ranges. Recommendations are specified for pharmacotherapy of trauma survivors in the immediate aftermath of traumatic exposure, and for those with acute and chronic posttraumatic stress disorders.