024 - Pediatric Trauma and Stress - Part 3 - Treatment

This is part 3 of a series on pediatric trauma, delving into the treatment of trauma and stress-related disorders in children. Dr. O'Leary emphasizes that therapy is always the starting point for these conditions, highlighting Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) and Eye Movement Desensitization and Reprocessing (EMDR) as highly effective, evidence-based interventions for PTSD. For attachment disorders, the focus shifts to improving the caregiver-child relationship through programs like Attachment and Biobehavioral Catch-up (ABC), while for acute stress and adjustment disorders, early CBT and psychoeducation are crucial. The discussion also addresses pharmacological interventions, noting that no medications are FDA-approved specifically for pediatric trauma, but they may be used to manage co-occurring symptoms, always with a preference for therapy as the primary approach and strong cautions against benzodiazepines and antipsychotics for routine use.

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Transcript

Welcome to PsyDactic Child and Adolescent Psychiatry Edition.  I am your host Dr. O’Leary, a fellow in Child and Adolescent Psychiatry in the National Capital region.  I started this podcast feed to help me study for my board exams and I hope it helps you as well, but anyone interested in human development or mental health may enjoy this content.  I need to let you know that everything that I say here should be considered to be my own opinion even if I am quoting or referencing someone or some institution.  Additionally, I have been learning how to use A.I. to assist me with the content creation and research.  Specifically, for this episode I used Gemini’s Deep Research tool to produce a detailed overview of Pediatric Trauma and Stressor Related Disorders and then consolidated that information into a podcast script that includes my own content merged with the A.I. content.  I use my own background knowledge as well as spot checking of the facts to make sure that the A.I. isn’t just making stuff up.  Like humans, A.I. makes mistakes, but I have found it more and more to be at least or even more reliable than human produced content.

This is part 3 of a 3 part series on Trauma and Stressor related disorders in the pediatric population.  Part one was focused on the diagnosis of things like PTSD, Acute Stress Disorder, Reactive Attachment Disorder, and Disinhibited Social Engagement disorders.  Part 2 focused on the epidemiology and etiology of these disorders.  This episode is going to focus on treatment of these disorders.

The following is the outline that was used to produce this episode and may have additional content not included in the final version of the podcast.

VII. Treatment of Pediatric Trauma- and Stressor-Related Disorders

The treatment of pediatric Trauma- and Stressor-Related Disorders (TSRDs) encompasses a range of evidence-based psychotherapeutic interventions and, in some cases, pharmacological approaches. The choice of treatment depends on the specific disorder, the child's age and developmental stage, the nature of the trauma, and comorbid conditions.

A. Evidence-Based Psychotherapeutic Interventions

Psychotherapy is generally considered the first-line treatment for most pediatric TSRDs, particularly for PTSD, RAD, and DSED.

1. Trauma-Focused Cognitive Behavioral Therapy (TF-CBT)

TF-CBT is a highly structured, components-based psychotherapy model with extensive empirical support for treating trauma symptoms in children and adolescents aged 3-18 years.78 Developed by Judith Cohen, Anthony Mannarino, and Esther Deblinger, TF-CBT has been rigorously evaluated in numerous randomized controlled trials (RCTs), establishing it as a gold-standard treatment.81 Seminal studies by Cohen, Mannarino, and Deblinger demonstrated TF-CBT's superiority over child-centered or nondirective supportive therapies in improving PTSD, depression, anxiety, and behavioral problems in children who experienced sexual abuse.80

The core components of TF-CBT are often remembered by the acronym PRACTICE:

• Psychoeducation and Parenting skills: Educating the child and caregiver about trauma and its effects, and enhancing parenting strategies.
• Relaxation skills: Teaching techniques to manage physiological arousal (e.g., deep breathing, progressive muscle relaxation).
• Affective expression and modulation: Helping children identify, express, and manage a range of emotions.
• Cognitive coping and Cognitive processing: Identifying and challenging unhelpful or distorted thoughts related to the trauma.
• Trauma narrative: Gradually developing a verbal, written, or symbolic account of the traumatic experience(s) to process thoughts and feelings and create a coherent story.
• In vivo exposure (gradual): If needed, confronting feared but safe situations or reminders associated with the trauma.
• Conjoint child-parent sessions: Facilitating communication about the trauma and strengthening the parent-child relationship.
• Enhancing future safety and development: Developing safety plans and promoting healthy future development.80

TF-CBT is typically delivered over 8-25 sessions and has shown efficacy across diverse types of trauma, developmental levels, and cultural contexts.81 It is recognized as a Model Program by the Substance Abuse and Mental Health Services Administration (SAMHSA).81 While highly effective for PTSD, a formal PTSD diagnosis is not required for a child to benefit from TF-CBT if they are experiencing significant trauma-related symptoms.81

2. Eye Movement Desensitization and Reprocessing (EMDR)

EMDR, developed by Francine Shapiro, is another evidence-based psychotherapy recognized for the treatment of PTSD in adults, adolescents, and children.85 The World Health Organization (WHO) and the International Society for Traumatic Stress Studies (ISTSS) recommend EMDR for children and adolescents with PTSD.85 The therapy involves an eight-phase approach that incorporates bilateral stimulation (e.g., guided eye movements, auditory tones, or tactile tapping) while the client focuses on traumatic memories, associated thoughts, emotions, and body sensations.86 The underlying theory, the Adaptive Information Processing (AIP) model, posits that trauma can cause memories to be inadequately processed and stored dysfunctionally; EMDR aims to facilitate the reprocessing of these memories, leading to a reduction in distress and a more adaptive resolution.87

EMDR can be adapted for children of various ages, including those as young as two years, by modifying the procedures to be developmentally appropriate.86 It has demonstrated efficacy in reducing PTSD symptoms in children following both single-event traumas and cumulative or complex traumas, such as sexual abuse.89 Meta-analyses and systematic reviews suggest that EMDR achieves medium to large effect sizes, with outcomes often comparable to CBT.78 For instance, one meta-analysis found TF-CBT to be marginally more effective than EMDR overall, but concluded that both are effective treatments for pediatric posttraumatic stress symptoms.78 The UK's National Institute for Health and Care Excellence (NICE) guidelines (NG116) suggest considering EMDR for children and young people (aged 7-17) with PTSD if they present more than 3 months after a traumatic event and do not respond to or engage with trauma-focused CBT.88

3. Attachment-Based Interventions for RAD and DSED

Given that the core etiology of RAD and DSED is severe early neglect and disruptions in caregiving, interventions for these disorders primarily focus on the caregiver-child relationship and creating a stable, nurturing environment.

• Attachment and Biobehavioral Catch-up (ABC) for RAD: Developed by Mary Dozier and colleagues, ABC is a 10-session, manualized, home-visiting intervention specifically designed for infants and young children (typically 6-24 months, with an infant version and a toddler version extending up to 48 months) who have experienced early adversity, such as neglect or inconsistent care, placing them at risk for RAD.91 ABC targets three key parenting behaviors:

1. Providing nurturing care, even when children do not elicit it.
2. Following the child's lead to promote synchrony and child regulation.
3. Avoiding frightening or intrusive parental behaviors.91 Parent coaches provide in-the-moment feedback and support to parents as they interact with their children. Multiple RCTs have demonstrated ABC's efficacy in enhancing parental sensitivity, increasing rates of secure attachment in children, and improving children's behavioral and biological regulation, including more normative diurnal cortisol patterns, better executive functioning, and language development.91 ABC is a strong example of an evidence-based intervention targeting the foundational dyadic processes disrupted in RAD.

• Caregiver-Focused Interventions for DSED: While fewer manualized interventions exist specifically for DSED compared to RAD, research, particularly from the Bucharest Early Intervention Project (BEIP) led by Zeanah, Smyke, Fox, and others, underscores the critical importance of the caregiving environment.75 The BEIP, an RCT, demonstrated that placement in high-quality, specially recruited and supported foster care was significantly more effective than continued institutional care ("care as usual") in reducing signs of DSED (as well as RAD) in young children who had experienced profound early institutional deprivation.75 Key findings emphasize that earlier placement into stable, sensitive, and permanent family environments is crucial for mitigating DSED symptoms.45 Interventions also focus on minimizing placement disruptions, as frequent changes in caregivers can exacerbate DSED.45 General principles for addressing DSED involve providing consistent, responsive caregiving, establishing clear boundaries and expectations, and teaching social skills within a secure attachment relationship.27

The common thread in effective interventions for both RAD and DSED is the focus on improving the quality, consistency, and sensitivity of the caregiving relationship, thereby providing the child with opportunities to experience the type of relational environment necessary for healthy socio-emotional development.

3.5 Neurosequential Model of Therapeutics (NMT).

It's important to note that the NMT is not a specific type of therapy or a single intervention technique. Instead, it is a developmentally sensitive, neurobiology-informed approach to clinical problem-solving.

Here’s how the Neurosequential Model of Therapeutics works:

• Framework, Not a Technique The NMT provides a way to organize a child's history (including developmental and trauma history) and assess their current functioning. It integrates core principles of neurodevelopment and traumatology to create a holistic picture of the child's needs.
• Assessment and Brain Mapping An NMT-certified clinician conducts a comprehensive assessment of the child's developmental history and current functioning. This information is used to generate an "NMT Metric Report," which includes a "Functional Brain Map". This map helps to identify areas of the brain that may be underdeveloped or functioning poorly due to the impact of trauma and stress.
• Sequenced and Individualized Interventions Based on the brain map, the NMT provides specific recommendations for the selection and sequencing of therapeutic, educational, and enrichment activities.5 The goal is to apply interventions that match the child's specific neurological needs, targeting the lower, less complex parts of the brain before moving to more complex, relational, and cognitive therapies.

In essence, Dr. Perry's model helps clinicians and caregivers understand how trauma has affected a child's brain development and then create a personalized treatment plan that applies the right interventions in the right order to facilitate healing.

4. Other Psychotherapies for ASD and Adjustment Disorders

• Acute Stress Disorder (ASD): Early intervention is considered important.50 Trauma-focused CBT principles, adapted for the acute phase, can be beneficial in preventing the progression to PTSD.17 This may involve psychoeducation, anxiety management techniques, and initial processing of the traumatic experience in a supportive context.
• Adjustment Disorders: Treatment for adjustment disorders often involves supportive psychotherapy that focuses on enhancing coping skills, problem-solving abilities, communication, and stress management.20 Cognitive behavioral techniques can be useful in addressing maladaptive thoughts and behaviors related to the identified stressor. Family therapy may also be indicated, particularly if family dynamics are contributing to or affected by the child's difficulties.22 In many cases, especially with adequate social support from family and friends, symptoms of adjustment disorder may improve naturally over a few months as the child adapts to the stressor or the stressor resolves.21

5. Table: Evidence-Based Psychotherapies for Pediatric Trauma- and Stressor-Related Disorders

 | Therapy | Target Disorder(s) | Key Components/Principles | Age Range | Evidence Level (Examples) | Key Researchers/ Developers
| Trauma-Focused Cognitive Behavioral Therapy (TF-CBT)80 | PTSD, trauma-related depression, anxiety, behavioral problems | Psychoeducation, relaxation, affect regulation, cognitive coping/processing, trauma narrative, in vivo exposure (if needed), conjoint sessions, safety planning (PRACTICE) | 3-18 years | Strong RCT support | Cohen, Mannarino, Deblinger
| Eye Movement Desensitization and Reprocessing (EMDR)87 | PTSD | 8-phase protocol, bilateral stimulation, adaptive information processing (AIP) model, processing traumatic memories | Children (adapted, e.g., from age 2) to adults | RCT support; WHO, ISTSS recommended | Shapiro
| Attachment and Biobehavioral Catch-up (ABC)91 | RAD, effects of early adversity on attachment and regulation | 10 home-visiting sessions, in-the-moment parent coaching on providing nurturance, following child's lead, avoiding frightening behavior | Infants & Toddlers (e.g., 6-48 months) | Strong RCT support | Dozier
| High-Quality Foster Care / Family-Based Interventions75 | DSED, RAD (effects of institutionalization/neglect) | Placement in stable, sensitive family environments; caregiver support and training; minimizing placement disruptions | Early childhood onwards | RCT support (BEIP) | Zeanah, Smyke, Fox (BEIP)
| Supportive Psychotherapy / CBT for Adjustment Disorders20 | Adjustment Disorders | Enhancing coping skills, problem-solving, stress management, emotional expression, cognitive restructuring | Children & Adolescents | General clinical support, component evidence | N/A (general approach)
| Trauma-Focused CBT (adapted) for ASD17 | Acute Stress Disorder | Psychoeducation, anxiety management, early trauma processing | Children & Adolescents | Emerging support, based on PTSD Tx | N/A (adaptation)

B. Pharmacological Treatments

Pharmacological interventions for pediatric TSRDs are generally considered adjunctive to psychotherapy, particularly for PTSD, or are used to target severe comorbid symptoms. There is a notable scarcity of FDA-approved medications specifically for most pediatric TSRDs, leading to frequent off-label prescribing.

1. FDA-Approved Medications for Pediatric TSRDs

A review of available information indicates a lack of specific FDA approvals for medications to treat pediatric PTSD, RAD, DSED, ASD, or Adjustment Disorder for these primary indications.96 While sertraline (Zoloft) and paroxetine (Paxil) are FDA-approved for adult PTSD 98, this approval does not extend to pediatric PTSD.

For other conditions often comorbid with or sharing symptoms with TSRDs in children, some FDA approvals exist:

• Pediatric Depression: Fluoxetine (Prozac) is approved for children aged 8 years and older, and escitalopram (Lexapro) is approved for adolescents aged 12 to 17 years.100
• Pediatric Anxiety Disorders (e.g., GAD, Social Anxiety, OCD): Duloxetine (Cymbalta), an SNRI, is FDA-approved for GAD in children 7 years and older.101 Several SSRIs like fluoxetine, sertraline, and fluvoxamine have FDA approval for pediatric OCD.
• Irritability associated with Autistic Disorder: Risperidone (Risperdal) and aripiprazole (Abilify) are FDA-approved for this indication in children aged 5 years and older.103 This landscape means that clinicians treating pediatric TSRDs often rely on off-label use of medications, guided by evidence from adult studies, studies in related pediatric conditions, or emerging pediatric research for the TSRD itself.

2. Evidence-Based Pharmacotherapy for Pediatric TSRDs

• PTSD: Despite the lack of specific FDA approval for pediatric PTSD, Selective Serotonin Reuptake Inhibitors (SSRIs) such as sertraline, fluoxetine, and paroxetine are commonly used as first-line pharmacological agents, particularly when psychotherapy alone is insufficient or when comorbid depression or anxiety is prominent.96 Alpha-2 adrenergic agonists like clonidine and guanfacine have shown some preliminary promise in open-label studies and case reports for targeting PTSD-associated symptoms such as hyperarousal, nightmares, aggression, and sleep disturbances in children and adolescents, but robust RCT evidence is still lacking.96
• Acute Stress Disorder (ASD): There is very limited data on pharmacotherapy for pediatric ASD. Benzodiazepines are sometimes used for acute anxiety in procedural settings but are not recommended for the ongoing management of ASD or other anxiety disorders in children due to risks and lack of efficacy data.105
• Adjustment Disorders: Medications are typically not indicated or prescribed for adjustment disorders unless there are severe comorbid symptoms of anxiety or depression that warrant pharmacological intervention.21 The primary approach is psychotherapy and supportive care.
• Reactive Attachment Disorder (RAD) and Disinhibited Social Engagement Disorder (DSED): There are no specific pharmacotherapies established for the core features of RAD or DSED. Treatment for these disorders is centered on interventions that improve the caregiving environment and foster secure attachment.70 Medications, if used, would be to target comorbid conditions such as severe anxiety, depression, or significant behavioral problems (e.g., ADHD symptoms, aggression).102

3. SSRIs in Pediatric TSRDs: Efficacy and Safety Concerns

SSRIs are the most studied and frequently used class of psychotropic medications for anxiety and depressive symptoms that often accompany or define aspects of pediatric TSRDs.96

• Efficacy: Meta-analyses have shown SSRIs to be generally superior to placebo and other medication classes for pediatric anxiety disorders broadly.101 The Child/Adolescent Anxiety Multimodal Study (CAMS) found sertraline to be effective for pediatric anxiety disorders (separation anxiety, GAD, social anxiety), although the combination of sertraline and CBT yielded superior outcomes.101 For pediatric major depressive disorder, fluoxetine and escitalopram have demonstrated efficacy over placebo.101 However, direct RCT evidence for SSRIs in treating core PTSD symptoms specifically in children and adolescents is less robust than in adults; a NICE review, for example, noted the inclusion of only two RCTs for SSRIs in the treatment of pediatric PTSD.110
• Safety Concerns: The use of SSRIs in pediatric populations is accompanied by significant safety considerations:
• Suicidality: In 2004, the FDA issued a "black box" warning regarding an increased risk of suicidal thoughts and behaviors (suicidality) in children, adolescents, and young adults (up to age 25) treated with antidepressant medications, including SSRIs.100 The increased risk is estimated to be around 2% over placebo (4% on active drug vs. 2% on placebo), with no completed suicides reported in the pooled analyses of short-term trials.108 The risk appears highest during the initial weeks of treatment or following dosage changes, and also in the month prior to starting medication.108 Close monitoring for worsening mood, agitation, or emergent suicidality is imperative.
• Activation Syndrome: Some children and adolescents may experience an "activation syndrome," characterized by agitation, disinhibition, insomnia, irritability, or akathisia.101
• Other Common Adverse Effects: These include gastrointestinal distress (nausea, diarrhea), headache, sleep disturbances (insomnia or somnolence), weight changes, and dry mouth.101 Sexual dysfunction (e.g., decreased libido, anorgasmia) is a common side effect in adults, but its prevalence and impact are less well-documented in pediatric populations, though it can occur.108
• Growth: There is some concern that long-term SSRI use in adolescents might be associated with a reduction in expected growth, warranting monitoring.108
• Pharmacokinetic Differences: Children and adolescents metabolize medications differently than adults due to developmental changes in liver enzyme activity (e.g., cytochrome P450 systems) and other physiological factors.101 For example, peripubertal children may metabolize some SSRIs more rapidly than adults, potentially requiring different dosing strategies to achieve equivalent exposure and therapeutic effect.101 These differences can affect both efficacy and tolerability.

4. Benzodiazepines: Role in Pediatric Acute Stress/Anxiety (Risks and Benefits)

Benzodiazepines have a very limited and specific role in pediatric populations due to concerns about their risk-benefit profile.99

• Benefits: Meta-analyses have shown that benzodiazepines can be effective and generally well-tolerated as short-term anxiolytics for acute procedural anxiety in children (e.g., before dental work or minor medical procedures).105
• Risks and Limitations:
• Current practice guidelines generally do not recommend benzodiazepines for the acute or ongoing management of anxiety disorders (including those related to trauma or stress) in pediatric patients.105 The VA/DoD Clinical Practice Guideline explicitly recommends against the use of benzodiazepines for the treatment of PTSD.99
• There is a lack of robust evidence supporting their efficacy for pediatric anxiety disorders from RCTs; the few existing trials have generally failed to show superiority over placebo.107
• Significant concerns include the potential for dependence, withdrawal symptoms upon discontinuation, cognitive impairment (e.g., memory problems), sedation, and paradoxical reactions such as disinhibition, agitation, or increased aggression in some children.105

5. Antipsychotics: Off-Label Use, Efficacy, and Adverse Effects in Children

The use of antipsychotic medications, particularly second-generation antipsychotics (SGAs), in children and adolescents has increased dramatically over the past two decades, with a substantial proportion of this use being off-label.103

• Off-Label Use: Common off-label indications in youth include ADHD (especially with aggression), mood disorders not otherwise specified, conduct problems, and severe irritability or aggression that may be associated with various underlying conditions, including trauma.103
• Efficacy: While some SGAs like risperidone and aripiprazole have FDA approval and demonstrated efficacy for treating irritability associated with autistic disorder in children 104, their efficacy for the core symptoms of pediatric TSRDs is not well established. They may be considered for severe, treatment-resistant aggression, agitation, or psychotic-like symptoms that can sometimes accompany complex trauma presentations. Some older case series or open-label trials in adults have suggested potential benefits of certain atypical antipsychotics (e.g., olanzapine, risperidone) or trazodone (an antidepressant with sedative and alpha-adrenergic blocking properties) for PTSD-related nightmares or sleep disturbances, but these findings are not robust and pediatric data are scarce.113
• Adverse Effects: The use of antipsychotics in children is associated with a significant burden of potential adverse effects. SGAs are particularly known for causing metabolic side effects, including substantial weight gain, hyperglycemia (and increased risk of type 2 diabetes), dyslipidemia, and hyperprolactinemia.19 Other common side effects include sedation and drowsiness. While SGAs generally have a lower risk of extrapyramidal symptoms (EPS) compared to first-generation antipsychotics, EPS can still occur.19 Given these risks, antipsychotics should be used cautiously in pediatric populations, typically after other interventions have failed for severe behavioral symptoms, and with careful monitoring.

6. Medications Effective in Adults but Not (or Differently) Effective in Children (RCT findings)

A critical consideration in pediatric psychopharmacology is that efficacy and safety data from adult studies cannot be directly extrapolated to children and adolescents. Developmental differences in brain maturation, neurochemistry, and drug metabolism (pharmacokinetics and pharmacodynamics) can lead to different responses.101

• Tricyclic Antidepressants (TCAs): While TCAs are effective for adult depression, multiple RCTs have shown them to be generally ineffective for treating depression in children and adolescents.108 They also carry a higher risk of side effects, including cardiotoxicity in overdose, compared to SSRIs.
• SSRIs for PTSD: As noted, sertraline and paroxetine are FDA-approved and considered first-line for adult PTSD.98 While SSRIs are used off-label for pediatric PTSD and show efficacy for comorbid anxiety and depression in youth 101, the strength of direct RCT evidence for core PTSD symptom reduction in children is less compelling than in adults, and no SSRI holds an FDA indication specifically for pediatric PTSD.96
• Prazosin: This alpha-1 adrenergic antagonist has historically been recommended for PTSD-associated nightmares in adults (VA/DoD CPG 99, AASM Level A recommendation 113). However, it is not FDA-approved for pediatric PTSD 96, and while there is emerging interest and some supportive case reports or small studies, robust RCT evidence in children is still limited.
• Venlafaxine (SNRI): Venlafaxine is a recommended treatment for adult PTSD.98 In adolescents with depression who did not respond to an initial SSRI, the TORDIA study found that switching to another SSRI resulted in less suicidal ideation and fewer adverse events compared to switching to venlafaxine extended-release (ER).101 This suggests a potentially different risk-benefit profile in youth for this specific context.
• Benzodiazepines for Anxiety Disorders: Benzodiazepines have established efficacy for various anxiety disorders in adults.105 However, as previously discussed, they have largely failed to demonstrate efficacy over placebo in the few available trials for pediatric anxiety disorders and are not recommended for this use.107

These examples highlight the necessity of conducting pediatric-specific trials for psychotropic medications rather than relying on adult data. The unique developmental context of childhood and adolescence significantly influences how medications work and the types of adverse effects that may occur.

7. Table: Pharmacological Treatments for Pediatric Trauma- and Stressor-Related Disorders

 | Medication Class | Specific Drugs (Examples) | FDA Approval Status (Pediatric TSRD-specific) | Common Off-Label Use in Pediatric TSRDs | General Efficacy Notes (Pediatric) | Key Safety Concerns (Pediatric)
| Selective Serotonin Reuptake Inhibitors (SSRIs) | Fluoxetine, Sertraline, Paroxetine, Escitalopram, Citalopram, Fluvoxamine | None specifically for pediatric PTSD, RAD, DSED, ASD, or AdjD. <br> Fluoxetine (8+), Escitalopram (12+) for MDD. 100 <br> Some for pediatric OCD/Anxiety. | PTSD symptoms, comorbid anxiety/depression with any TSRD. 96 | Moderate for anxiety/depressive symptoms; less direct evidence for core PTSD symptoms vs. adults. Combination with CBT often superior. 101 | Increased suicidality risk (black box warning), activation syndrome, GI upset, sleep disturbance, headache, sexual dysfunction, potential growth effects. 108
| Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) | Venlafaxine, Duloxetine | Duloxetine for GAD (7+), MDD (some indications). 101 <br> None specifically for pediatric TSRDs. | PTSD symptoms (less common than SSRIs), comorbid anxiety/depression. | Limited pediatric data for TSRDs. TORDIA suggests SSRIs may be better tolerated than venlafaxine as second-line for adolescent depression. 101 | Similar to SSRIs (suicidality risk, activation). Venlafaxine: potential for blood pressure increase, more AEs in TORDIA. 98
| Alpha-2 Adrenergic Agonists | Clonidine, Guanfacine | None specifically for pediatric TSRDs. <br> Approved for ADHD. 96 | PTSD-associated hyperarousal, nightmares, aggression, sleep disturbance. 96 | Preliminary evidence from open-label studies/case reports suggests potential benefit; RCTs lacking. 96 | Sedation, dizziness, hypotension, dry mouth. Generally well-tolerated in ADHD studies. 96
| Antipsychotics (Second Generation) | Risperidone, Aripiprazole, Olanzapine, Quetiapine | None specifically for pediatric TSRDs. <br> Risperidone, Aripiprazole for irritability in autism (5+); some for pediatric schizophrenia/bipolar. 103 | Severe aggression, agitation, mood instability, or psychotic-like symptoms in complex trauma. 103 | Limited evidence for core TSRD symptoms. May reduce specific behavioral disturbances. [113 (adult data for nightmares), 103] | Significant weight gain, metabolic syndrome (diabetes risk, dyslipidemia), sedation, hyperprolactinemia, EPS (less than FGAs but possible). 103
| Benzodiazepines | Diazepam, Lorazepam, Alprazolam, Clonazepam, Midazolam | None for pediatric TSRDs or anxiety disorders. Some for pediatric seizures. | Historically used for acute anxiety, sleep. Now strongly discouraged for these uses in TSRDs. | Effective for short-term procedural anxiety only. Not effective/not recommended for anxiety disorders or PTSD. 105 | Dependence, withdrawal, sedation, cognitive impairment, disinhibition/paradoxical agitation. Not recommended for PTSD. 99
| Other Antidepressants (e.g., TCAs) | Amitriptyline, Imipramine | None for pediatric TSRDs. | Rarely used now for TSRDs due to side effects and poor efficacy in pediatric depression. | Generally ineffective for pediatric depression. 108 | Significant side effects (anticholinergic, cardiotoxicity in overdose). 108

C. Practice Guidelines and Recommendations

Several organizations provide guidelines and recommendations for the assessment and treatment of pediatric trauma and stress.

• American Academy of Child and Adolescent Psychiatry (AACAP): AACAP develops Practice Parameters and Clinical Practice Guidelines to inform clinical practice. While some older parameters exist for PTSD (revised 2010) 115 and for RAD/DSED (2016) 54, these may be outdated. Newer Clinical Practice Guidelines focus on broader categories like anxiety or depression but contain relevant information.115 AACAP generally emphasizes psychotherapy as a primary intervention, with medication considered for moderate to severe symptoms or when psychotherapy is insufficient.50 For RAD/DSED, the focus is on ensuring a safe and stable caregiving environment and interventions that support the caregiver-child relationship.54
• National Institute for Health and Care Excellence (NICE) (UK): NICE guideline NG116 (updated 2018) provides comprehensive recommendations for PTSD in children, young people, and adults.88
• For children and young people (CYP) with PTSD (or clinically important symptoms >1 month post-trauma):
• Individual trauma-focused CBT is recommended as the first-line treatment.90 This should be adapted for age and development, typically 6-12 sessions, and involve parents/carers.
• EMDR is considered for CYP aged 7-17 with PTSD (>3 months post-trauma) only if they do not respond to or engage with TF-CBT.88
• Drug treatments are not recommended for the prevention or treatment of PTSD in CYP under 18.90
• For acute stress disorder (or symptoms <1 month post-trauma), active monitoring or individual TF-CBT is considered.90
• Substance Abuse and Mental Health Services Administration (SAMHSA): SAMHSA promotes evidence-based practices for child traumatic stress through initiatives like the National Child Traumatic Stress Network (NCTSN).7 They disseminate information on effective interventions (like TF-CBT, recognized as a model program) and emphasize trauma-informed care principles.124 SAMHSA's Treatment Improvement Protocols (TIPs) also address issues related to trauma, abuse, and neglect, although often with a focus on co-occurring substance use.125

The consistent theme across guidelines is the primacy of evidence-based, trauma-focused psychotherapies for pediatric TSRDs. Pharmacological interventions are viewed as adjunctive, for specific symptom targets, or when psychotherapy is not sufficiently effective or available, always with careful consideration of the limited pediatric-specific approvals and the distinct risk-benefit profiles in youth.

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