Report Offers Guidance on Care for Maltreated Children

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Every year, over 700,000 children and adolescents experience maltreatment (abuse and/or neglect) in the United States, according to the Children’s Bureau of the Department of Health and Human Services. Yet that number, most experts agree, is probably an undercount. The actual prevalence of child maltreatment is likely much higher.

These youth need trauma-informed mental health care, but determining proper treatment can be complicated because symptoms of trauma sometimes mimic other commonly diagnosed pediatric mental disorders.

To help physicians navigate these complexities, the American Academy of Pediatrics and the American Academy of Child and Adolescent Psychiatry created a clinical report on how to best care for these vulnerable patients. The report, titled “Children Exposed to Maltreatment: Assessment and the Role of Psychotropic Medication,” appeared in the February issue of Pediatrics.

The report focuses on two key aspects of developing a care plan for youth who have been maltreated: conducting proper trauma-informed assessments and pharmacotherapy for maltreated youth.

“Kids who have been maltreated are at risk for a lot of different emotional and behavioral challenges,” said lead author Brooks Keeshin, M.D., a child abuse pediatrician and child psychiatrist at the University of Utah School of Medicine. “Recognizing that there are not enough child psychiatrists to see all the kids we’re concerned about, pediatricians are critical frontline mental health providers for children with emotional and behavioral concerns.”

Conducting Assessments

Behavior related to trauma may look like symptoms of other disorders, Keeshin said, such as depression or attention-deficit/hyperactivity disorder (ADHD), when in fact the child is experiencing traumatic stress. “We wanted to bring that to the attention of the pediatricians,” he said. If suicidality comes up while a pediatrician is screening for depression, for example, the physician might treat the child for major depressive disorder, potentially starting them on a medication. “But if you know the child has a history of maltreatment and traumatic stress symptoms, it changes completely the context of their suicidality and the next treatment steps,” Keeshin said.

Pediatricians should conduct trauma-informed evaluations before developing a treatment plan, according to the report. This includes reviewing records from child protective services or court reports whenever possible.

The Pediatrics report includes resources for questionnaires and instruments pediatricians can use to gather information on the child’s exposure to maltreatment, as well as tools to identify traumatic stress symptoms.

“It’s really about recognizing how important the child’s life experience is in terms of understanding the child’s symptoms,” Keeshin said.

Concerns Over Too Many Medications

Treating children who have been maltreated is often further complicated if they have been involved in the child welfare system.

Lack of access to appropriate interventions “may lead to underuse of trauma-informed, evidence-based psychotherapies and may be one of the many factors leading to the increased prescription of psychotropic medication among maltreated children and adolescents,” the report states. Physicians may also turn to psychotropic medications to control disruptive behaviors that might threaten the child’s foster care placement. According to the report, children and adolescents in the child welfare system are two to three times more likely to be treated with psychotropic medication.

“There’s been an incredible amount of concern regarding what is commonly considered overprescription of psychotropic medications to youth, specifically in the child welfare system,” said George Fouras, M.D., past co-chair of the Adoption and Foster Care Committee of the American Academy of Child and Adolescent Psychiatry and another author of the report.

The report suggests pediatricians keep several factors in mind when considering medications, including that children with complex trauma may be given multiple psychiatric diagnoses and that maltreated children “may not respond in predictable ways to treatments traditionally prescribed for mental health conditions.”

Anish Ranjan Dube, M.D., M.P.H., a child and adolescent psychiatrist in Orange, Calif., and a member of APA’s Council on Children, Adolescents, and Their Families, said the report “emphasizes and reinforces that we need a better understanding of how trauma and mental illness affect young people with a developing brain.” Children are not simply small adults, he added, and while it may be tempting to prescribe medications to do more for the patient, “it doesn’t necessarily translate to actual benefit.”

Discontinuing Medications

When a pediatrician sees a patient for the first time, it may be after that patient experienced a series of rapid placement changes and saw a new physician each time. “Providers often don’t know why a medication was started, and they’re generally not going to stop it because they don’t know why it’s been prescribed, and they don’t want to disrupt the treatment,” Fouras explained.

Though there is no standardized approach to discontinuing many psychotropic medications, the report details a process that pediatricians can follow, which includes steps such as determining the complete medication history, assessing each medication in light of the comprehensive assessment, and prioritizing which medication should be discontinued or decreased.

Treating youth who have been maltreated is challenging, Dube said. “There’s little continuity in these young people’s lives. I might be seeing them for a snapshot in time. They might be jumping around, and even their social workers might change. It’s a huge challenge because one of the things we know has the biggest impact and the greatest benefit is having consistent figures in their lives.” ■