Pharmacologic Treatment Considerations in Maltreated Children and Adolescents

DisorderInitial ConsiderationsOngoing Monitoring StrategySecond-Line ConsiderationsTreatments Pitfalls To Avoid
General pediatric mental health concernsStart with psychosocial treatment. Nonoffending parental involvement is essential, with involvement of other caregivers and school-based interventions as needed. In mild cases, attempt at least 12 wk of psychosocial interventions before medication.Monitor response to treatment by using reliable and valid measures. If medications are being considered, first reassess the diagnosis and diagnostic formulation. Weigh the risks and benefits of initiating treatment with psychotropic medications.When starting medication:
• Initiate with monotherapy
• When using medication, initiate at a low dose and slowly titrate (start low, go slow)
• Continue psychosocial treatment during treatment with medication
• Monitor for suicidality
• Monitor for adverse effects of medications
• Polypharmacy
• Antipsychotics should be restricted to schizophrenia, mania or bipolar disorder, psychotic depression, drug-induced psychosis, tic disorders, and severe aggression.
PTSDThe greatest level of evidence supports exposure-based therapies, of which, TF-CBT has the most data and is the most widely used.
In children <6 y, may consider TF-CBT (4 mo) or CPP (6 mo) as first-line treatment.
Monitor for treatment response.
When TF-CBT is not readily available or effective, consider:
• Prolonged exposure therapy
• Eye movement desensitization and reprocessing
• Trauma and grief components therapy for adolescents
• Child and family traumatic stress intervention (PTSD prevention therapy)
• For PTSD symptoms that impair sleep (eg, nightmares, nighttime hyperarousal), may consider psychotherapy augmentation with prazosin
• For persistent intrusive or arousal or reactivity, may consider psychotherapy augmentation with clonidine or guanfacine
• Pharmacotherapy-absent trauma-focused psychotherapy
• Polypharmacy
• Antipsychotics
• Benzodiazepines
• Multiple antihypertensive medications
DepressionPsychoeducation and psychosocial interventions including but not limited to self-help materials, active listening or relationship building, school involvement, mood monitoring, opportunities for play and recreational activities, cognitive restructuring, family conflict reduction, sleep hygiene, and exercise.• Psychotherapy for mild to moderate depression
• For moderate to severe depression, fluoxetine or combination of CBT or IPT with fluoxetine
• May consider escitalopram for patients 12 y and older
• If no clinical response to the medication in first trial, switch to other SSRI
• Reassess diagnosis or medication adverse effects
• Increase psychosocial intervention and medication dose if tolerated
• Augment with alternate psychosocial intervention (either CBT or IPT)
• Polypharmacy
• Antipsychotics
• Benzodiazepines
AnxietyInitiate treatment with exposure-based CBT. If CBT is not available, consider other evidence-based psychosocial interventions.• If moderate to severe anxiety disorder or inadequate response to CBT, initiate treatment with fluoxetine or sertraline alone or with CBT
• Treatment with CBT has been shown to be more effective than medication alone
• If first trial with fluoxetine or sertraline is not effective and/or there are treatment-limiting adverse effects, switch to the other SSRI not previously used and initiate or continue CBT• Polypharmacy
• Antipsychotics
• Benzodiazepines
ADHDWhen clinically feasible, observe for potential traumatic stress symptom overlap in children exposed to maltreatment. If unsafe, or if ADHD symptoms persist with EBTs for traumatic stress and home stabilization, proceed with ADHD treatment.• Psychostimulant monotherapy (methylphenidate class or amphetamine class, either short- or long-acting)
• If first choice is ineffective, try monotherapy with another stimulant or alpha-2 agonist
• Combination of extended-release alpha-2 agonist with psychostimulant or trial of atomoxetine• Antipsychotics
• Multiple concurrent antihypertensive medications