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ten arose concurrently with or after the PTSD, suggesting a link between the trauma and various psychopathologies. Common comorbid disorders in this population included substance abuse, conduct disorder, depression, psychosis, and generalized anxiety disorder. Suicide attempts were more likely in girls with PTSD (Dixon, Howie, & Starling, 2005). Though this study was of a specialized population, it highlights the variety and extent of comorbid psychopathology that can accompany PTSD. NEUROBIOLOGY OF CHILD ABUSE Child abuse causes changes in the brain. Technological advances have led to an improved but still evolving understanding of these changes on a structural and neurochemical level. Children who are traumatized have higher levels of peripheral sympathetic nervous system activity, such as circulating norepinephrine (Pervanidou, 2008). Cortisol, a hormone that is released in response to stress, has a variety of physiological effects, such as mobilizing glucose stores and suppressing immune function. In children, the cortisol response to trauma is perhaps even more complicated than in adults, and study findings have not been completely consistent . Child maltreatment is known to have long-term effects on the developing hypothalamic-pituitary-adrenal axis that are mediated by a variety of individual biological and environmental risk and protective factors (Tarullo & Gunnar, 2006). A functional MRI study of adults who experienced childhood trauma showed increased amygdala responsiveness when exposed to threatening facial expressions. Reduced gray matter in the hippocampus and other brain regions was also seen (Dannlowski et al., 2012). Notably, these adults were studied decades after the traumatic events, suggesting long-lasting structural and functional brain changes. GENERAL CONSIDERATIONS Childhood abuse and neglect are associated with a range of emotional and behavioral disturbances. In some cases, pharmacotherapy to treat posttraumatic psychiatric symptoms is a significant element of the treatment plan. This chapter describes the link between child maltreatment and mental illness , the underlying neurobiological and neuroendocrine changes that may occur following abuse (and which may increasingly serve as targets for medicines as our knowledge base expands), and indications for medications. The scientific data on various classes of medications used to treat childhood posttraumatic stress disorder (PTSD) are summarized , followed by a brief discussion of the treatment of acute stress disorder and medications used for prevention of PTSD. Special considerations related to the use of medications for foster children are also presented. The chapter concludes with a summary of outstanding questions in the understudied area of pharmacotherapy of childhood PTSD. Child abuse and neglect are associated with a variety of psychiatric and behavioral disturbances. PTSD can be a direct outcome of abuse. Studies have also shown a link between childhood abuse and anxiety and mood disorders (such as major depressive disorder and bipolar disorder) and psychosis—including schizophrenia (Alvarez et al., 2011; Bebbington et al., 2011; Schafer & Fisher, 2011; Sugava et al., 2012). Abused children have a greater risk of developing an eating disorder or abusing drugs and alcohol, with earlier and more severe drug use, compared with nonmaltreated youths (Cisler et al., 2011; Douglas et al., 2010; Nomura, Hurd, & Pilowsky, 2012; Rayworth, Wise, & Harlow, 2004). Children who develop PTSD are at risk of developing other comorbid conditions. A study of female juvenile offenders showed that girls with PTSD had more psychiatric diagnoses than those without. The comorbid conditions ofPsychopharmacology SHANNON W. SIMMONS, M.D., M.P.H. MICHAEL W. NAYLOR, M.D. 32 314 New Directions tured in current descriptions of PTSD diagnostic criteria” (American Academy of Child and Adolescent Psychiatry, 2010, p. 416). Children with these symptoms might be misdiagnosed as having bipolar disorder or other psychiatric illnesses if the examiner does not consider the role of trauma. Conversely, all emotional or behavior problems in a child with trauma may erroneously be attributed to PTSD when, in fact, the youngster has another mental illness (Griffin et al., 2011). The timing of the symptoms—in particular, if their onset coincides with a traumatic event—may aid with diagnosis; however, in cases of chronic trauma, a discrete timeline might not be possible. A child’s developmental stage may affect PTSD symptom presentation. The Diagnostic and Statistical Manual of Mental Disorders (4th edition, text revision; DSM-IV-TR) provides some modifications of criteria for children. For example , instead of intrusive traumatic recollections (which may be difficult for a child to describe), repetitive traumathemed play is acceptable evidence of re-experiencing the traumatic event (American Psychiatric Association, 2000). Other PTSD criteria, however, do not provide specific guidance or allowances for young children. For example, studies have shown that traumatized youths may demonstrate a wide range...

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