Pediatricians and Child Psychiatrists Suggest Comprehensive Approach in Caring for Children who Have Been Maltreated

The American Academy of Pediatrics (AAP) and the American Academy of Child and Adolescent Psychiatry (AACAP) offer evidence-based recommendations to care for children who have been maltreated

More than 700,000 U.S. children are confirmed victims of physical, sexual or psychological abuse each year, and many of these children suffer emotional, behavioral and developmental problems as a result. In a new, joint report, the American Academy of Pediatrics (AAP) and the American Academy of Child and Adolescent Psychiatry (AACAP) recommend a comprehensive approach to diagnosis and treatment that includes therapy and other interventions.

Children who have been maltreated or neglected are more likely to develop mental health conditions that are complicated or difficult to identify and treat. A comprehensive assessment of the child is important to guide a plan for follow-up care and treatment, according to the joint report, “Children Exposed to Maltreatment: Assessment and the Role of Psychotropic Medicine,” published in the February 2020 Pediatrics (published online Jan. 21).

In the clinical report, the AAP and the AACAP describe methods for identifying children and teens with mental health problems within the context of maltreatment and review the role and impact of the child welfare system on mental health assessments and treatment. The organizations recommend that treatment plans consider a broad range of interventions, including psychotherapy, and avoid an over-reliance on medications that are likely over-prescribed to children who have been abused.

“Children who have been abused or who have undergone multiple traumatic experiences may not show symptoms that easily fit into diagnostic categories, and they may not respond in predictable ways to traditional treatments,” said Brooks Keeshin, MD, FAAP, coauthor of the report. “Many factors must be taken into account before we consider the use of psychotropic drugs that affect thinking, mood or behavior.”

The AAP and AACAP recommend that a clinician trained in child maltreatment assess a child before any psychosocial or medication intervention is initiated. Children may show a variety of emotional, behavioral and developmental problems as a result of maltreatment, including changes in mood, anxiety, sleep or eating. Often, they show more than one commonly associated conditions, such as post-traumatic stress disorder (PTSD).

Research shows that children who are involved in the child welfare system are 2 to 3 times more likely to be prescribed psychotropic medications, suggesting overtreatment. Among Medicaid-eligible children, 10% of foster children receive three or more psychotropic medications at any given time.

“Children are best served when we take a comprehensive approach to treatment, by first assessing if a child has experienced trauma and getting a clear picture of how the child has been affected,” said George Fouras, MD, DFAACP. “Treatments such as psychotherapy may be more appropriate and effective than medications in some cases.”

In the clinical report, AAP and AACAP emphasize the need to obtain an accurate diagnosis with a thorough assessment that takes the child’s social history into account. Before prescribing, changing or discontinuing any medications, the organizations recommend shared decision-making and the informed consent by the child’s parent or caregiver.

The AAP and AACAP also recommend:

• Pediatricians should let children and families know that they want to hear about past and present events, including any trauma or violence.
• They must emphasize safety and make it clear that if a child or family is unsafe at any time, the child welfare system will be contacted.
• Children who have experienced abuse and who are having emotional and behavioral difficulties should receive evidence-based psychotherapies and treatments with demonstrated effectiveness.
• Pediatric providers should offer resources to bridge the period until the evidence-based treatment can begin. Those resources may include family education, relaxation training and parent-child communication.

“Ideally, pediatricians work closely with therapists and psychiatrists when treating children who have been maltreated, but we know this is not always possible,” Dr. Keeshin said. “This report offers pediatricians some tools to help children and families address mental health problems that stem from maltreatment. Healing begins with a stable home environment with a responsive and nurturing caregiver.”

More information is available in these AAP reports:

• “Clinical Considerations Related to the Behavioral Manifestations of Child Maltreatment”
• “Addressing Early Childhood Emotional and Behavioral Problems”

###

The American Academy of Pediatrics is an organization of 67,000 primary care pediatricians, pediatric medical subspecialists and pediatric surgical specialists dedicated to the health, safety and well-being of infants, children, adolescents and young adults. For more information, visit www.aap.org and follow us on Twitter @AmerAcadPeds