Children and adolescents who have experienced maltreatment can struggle even after they are physically safe. They might be bothered by memories of traumatic experiences or impacted by secondary adversities common among those who experience maltreatment. Add changes in relationships and social supports (including possible placement in foster care), challenges with development and academics, and an increased risk for medical problems, and it is no surprise that these children and adolescents require expert, trauma-informed pediatric care.
Due to the complexity of traumatic and adverse experiences, and the near-limitless responses to trauma, knowing how to clinically approach maltreated youths when they are struggling can be challenging. Their struggles may result from the emergence of traumatic stress or other common mental health conditions. But developmental, social, adversity, transition and relationship challenges also may explain the symptoms of concern.
When a family, foster or otherwise, has concerns about new, worsening or changing emotional and behavioral difficulties, how should pediatricians proceed?
The new clinical report Children Exposed to Maltreatment: Assessment and the Role of Psychotropic Medication provides a pathway. The report, from the AAP Committee on Child Abuse and Neglect and Council on Foster Care, Adoption and Kinship Care, along with the American Academy of Child and Adolescent Psychiatry, is available at https://doi.org/10.1542/peds.2019-3751 and will be published in the February issue of Pediatrics.
Critical issues
The emotional and behavioral challenges that maltreated children face are not new to the general pediatrician. For years, pediatricians have been tasked with identifying and determining the underlying etiology of the emotional, behavioral and cognitive challenges experienced by maltreated youths — all on the fly and often with incomplete information.
Evidence-based trauma-focused and -informed therapies are a cornerstone of care for maltreated youths. However, before determining challenges and making preliminary diagnoses, consider the following when addressing the emotional and behavioral changes in maltreated children and adolescents:
- how to assess patients in an efficient, systematic and trauma-informed manner;
- how to thoughtfully apply evidence-based psychiatric principles to post-traumatic stress disorder (PTSD) and other commonly diagnosed psychiatric conditions in maltreated youths; and
- how to de-escalate psychopharmacologic care in maltreated youths when appropriate.
The report highlights how trauma reactions can mimic common pediatric mental health concerns such as depression, anxiety and attention-deficit/hyperactivity disorder (ADHD). It emphasizes that among maltreated youths, ruling in or ruling out trauma-related reactions is critical before proceeding in a treatment direction. Accurate, trauma- informed assessment among this population is critical to decrease psychopharmacologic trials with limited chance of success.
Furthermore, for youths who have experienced unhelpful, harmful and/or overly complex psychotropic polypharmacy, the report offers pediatricians concrete steps adopted from the deprescribing literature to collaborate with families or child welfare when youths are in foster care.
Providing trauma-informed, evidence-based treatment can feel overwhelming in the context of the busy pediatric practice. The clinical report aims to streamline the trauma-informed assessment process and provide objective guidance on the risks and benefits of initiation and discontinuation of psychotropic medications among maltreated youths.
Guidance for pediatricians
- Obtain a comprehensive social history. Communicate an openness to hearing about past and present events.
- Emphasize safety and be alert to ongoing trauma and violence. Do not assure children or caregivers of absolute confidentiality; explain that if a child or family is unsafe at any time, a report will be made to child protective services.
- A clinician trained in the assessment of children exposed to maltreatment should conduct a focused assessment before psychosocial or medication interventions are initiated.
- Maltreated children with emotional and behavioral difficulties should receive evidence-based psychotherapies and treatments.
- First- and second-generation antipsychotics and benzodiazepines should not be used for sleep problems and generally are not indicated for the most common disorders found among maltreated children (PTSD, anxiety, depression and ADHD).
- When considering discontinuation of medications, use evidence-based protocols that incorporate principles of optimizing the medication regimen.
- Refer children to child psychiatry, if available, when there is diagnostic uncertainty, when multiple medication trials have failed or when patients are taking two or more psychotropic medications (or one antipsychotic medication).
Dr. Keeshin is a lead author of the clinical report. He is a liaison from the American Academy of Child and Adolescent Psychiatry to the AAP Council on Child Abuse and Neglect.
