Introduction
In this essay, we examine the mental health interventions provided to US children who have experienced trauma and developed psychiatric sequelae. We highlight one highly vulnerable group, children in foster care. Children with trauma histories have high rates of mental health problems, but they rarely receive recommended, evidence-based, psychosocial treatments and too often receive high-risk, unapproved, pharmaceutical treatments, such as antipsychotic medications and polypharmacy.
Childhood trauma and its resulting psychiatric morbidity are common in the USA. One-quarter to one-half of children and youth under the age of 18 years (hereafter referred to as children) experience at least one traumatic event during childhood (Finkelhor et al., Reference Finkelhor, Turner, Hamby and Ormrod2011; Adams et al., Reference Adams, McCart, Zajac, Danielson, Sawyer, Saunders and Kilpatrick2013; Kilpatrick et al., Reference Kilpatrick, Resnick, Milanak, Miller, Keyes and Friedman2013). Childhood trauma refers to extremely stressful events such as physical or sexual abuse, or witnessing violence. Children who experience trauma tend to show developmental, social, and educational difficulties that extend into adulthood (Felitti et al., Reference Felitti, Anda, Nordenberg, Williamson, Spitz, Edwards, Koss and Marks1998; De Bellis and Zisk, Reference De Bellis and Zisk2014; Kerker et al., Reference Kerker, Zhang, Nadeem, Stein, Hurlburt, Heneghan, Landsverk and McCue Horwitz2015). The US child protection system substantiates approximately 700 000 unique child victims of abuse or neglect each year (US Department of Health and Human Services and Administration for Children and Families Children's Bureau, 2017). When a case is substantiated and the child is placed in foster care, he or she not only bears the abuse and neglect that led to placement but also the trauma of removal from family, and is predisposed to mental health and behavioural problems.
Researchers estimate that roughly half of children in foster care have at least one mental health diagnosis (Burns et al., Reference Burns, Phillips, Wagner, Barth, Kolko, Campbell and Landsverk2004; Landsverk et al., Reference Landsverk, Burns, Stambaugh and Rolls-Reutz2006). Those in foster care commonly have diagnoses of adjustment disorder or post-traumatic stress disorder (PTSD) (1–21% prevalence), attention-deficit/hyperactivity disorder (ADHD) (10–21%), oppositional defiant or conduct disorder (2–18%), attachment disorders (4–17%), depression (5–15%), anxiety (3–12%), developmental disorders (10%) and substance use disorders (5%) (dosReis et al., Reference dosReis, Zito, Safer and Soeken2001; Zeanah et al., Reference Zeanah, Scheeringa, Boris, Heller, Smyke and Trapani2004; Oswald et al., Reference Oswald, Heil and Goldbeck2010). Rates of attachment disorders are much higher (40%) in samples of very young children in foster care (Zeanah et al., Reference Zeanah, Scheeringa, Boris, Heller, Smyke and Trapani2004), as are rates of substance use disorders (15%) in samples of older adolescents in foster care (Narendorf and McMillen, Reference Narendorf and McMillen2010).
Treatments for disorders common in traumatised children
Several psychosocial treatments for childhood disorders related to trauma are effective (evidence-based according to research). The American Academy of Child and Adolescent Psychiatry recommends specific evidence-based psychosocial interventions (e.g. trauma-focused psychotherapy) as first-line treatment for nearly every childhood mental health disorder (Lee et al., Reference Lee, Fouras and Brown2015). These recommendations reflect robust research on psychosocial interventions for specific mental health disorders. For example, 41 randomised controlled trials have examined the efficacy of trauma- or attachment-focused psychotherapies for children with PTSD, showing large and medium effect sizes compared with wait-list and active treatment controls, respectively (Morina et al., Reference Morina, Koerssen and Pollet2016). Evidence-based psychosocial treatments for behavioural disorders and ADHD (Eyberg et al., Reference Eyberg, Nelson and Boggs2008; Fabiano et al., Reference Fabiano, Pelham, Coles, Gnagy, Chronis-Tuscano and O'Connor2009), depression (Hetrick et al., Reference Hetrick, Cox, Witt, Bir and Merry2016) and anxiety (Wang et al., Reference Wang, Whiteside, Sim, Farah, Morrow, Alsawas, Barrionuevo, Tello, Asi, Beuschel, Daraz, Almasri, Zaiem, Larrea-Mantilla, Ponce, LeBlanc, Prokop and Murad2017) similarly demonstrate efficacy. Further, some evidence-based psychotherapies for children exposed to trauma have positive effects on comorbid symptoms, including depression, anxiety and disruptive behaviours (Cohen et al., Reference Cohen, Deblinger and Mannarino2018)
Psychotropic medications that are often used for disorders common in children exposed to trauma have also been studied extensively, but the findings and recommendations are more negative and cautious (McLaren et al., Reference McLaren, Barnett, Concepcion Zayas, Lichtenstein, Acquilano, Schwartz, Woloshin and Drake2018). No psychotropic medications have demonstrated efficacy and received US Food and Drug Administration approval for childhood PTSD, attachment disorders or disruptive behaviour disorders (e.g. oppositional defiant disorder, conduct disorder), with the single exception of ADHD. Psychotropic medications are efficacious for childhood ADHD and anxiety, but psychotropic medications are recommended only after psychosocial treatment has failed or in combination with psychosocial treatment, with the exception of ADHD in older children (Chan et al., Reference Chan, Fogler and Hammerness2016; Wang et al., Reference Wang, Whiteside, Sim, Farah, Morrow, Alsawas, Barrionuevo, Tello, Asi, Beuschel, Daraz, Almasri, Zaiem, Larrea-Mantilla, Ponce, LeBlanc, Prokop and Murad2017). The evidence for efficacy of psychotropic medications for childhood depression is mixed and highly controversial (Cox et al., Reference Cox, Callahan, Churchill, Hunot, Merry, Parker and Hetrick2014).
A major caveat concerns serious side effects of antipsychotics, antidepressants, anxiolytic medications, stimulants and mood-stabilising medications in children. Different medicines can have major negative impacts on metabolism, weight gain, growth, cognitive function and neurological function – especially when used in combination with other medications and over long periods of time. Nearly all studies have examined the safety and efficacy of a single medication for children with a single diagnosis. Guidelines also address single diagnoses. In real-world practice, however, mental health comorbidities are the norm, not the exception, among traumatised children (Finkelhor et al., Reference Finkelhor, Turner, Hamby and Ormrod2011); and multiple medications (polypharmacy) are often used for comorbid diagnoses and symptoms. Few studies have examined the safety and efficacy of two or more psychotropic medications used concurrently in children. What is known, however, is that each additional medication increases the risks for adverse drug interactions and additional side effects, such as weight gain (Jureidini et al., Reference Jureidini, Tonkin and Jureidini2013).
Antipsychotic medications present significant risks for children when not monitored appropriately. The common side effects include somnolence and sedation, weight gain, metabolic syndrome, hyperprolactinemia and accompanying galactorrhoea and gynaecomastia, irregular menses, potentially irreversible neurological effects and direct cardiovascular effects (Zuddas et al., Reference Zuddas, Zanni and Usala2011; Cohen et al., Reference Cohen, Bonnot, Bodeau, Consoli and Laurent2012). Across trials, numbers needed to harm begin at one or two for somnolence and sedation, weight gain and neurological effects (Zuddas et al., Reference Zuddas, Zanni and Usala2011). Receiving an antipsychotic medication doubles or triples the risk of obesity among those in foster care; receiving two or more antipsychotics increases the risk of obesity five-fold (Allaire et al., Reference Allaire, Raghavan and Brown2016). The effects on academic and social functioning, as well as the long-term effects (e.g. neuro-cognitive) on development, are unknown. Further, children receiving antipsychotics should receive regular monitoring, including blood tests, but monitoring is remarkably poor (Delate et al., Reference Delate, Kauffman, Botts, Wong and Gaughan2014; McLaren et al., Reference McLaren, Brunette, McHugo, Drake and Daviss2017).
Over-treatment with psychotropic medications
Mitigating the health problems stemming from childhood trauma should be a top priority for public health (Lowe et al., Reference Lowe, Blachman-Forshay, Koenen, Schnyder and Cloitre2015), but US children with mental health needs related to trauma tend to receive inappropriate or no mental health services (Burns et al., Reference Burns, Phillips, Wagner, Barth, Kolko, Campbell and Landsverk2004; Romanelli et al., Reference Romanelli, Landsverk, Levitt, Leslie, Hurley, Bellonci, Gries, Pecora and Jensen2009). The treatments they do receive have limited evidence. Our index group, children in foster care, are more likely to receive a psychotherapy that is not evidence-based than one that is (Landsverk et al., Reference Landsverk, Burns, Stambaugh and Rolls-Reutz2006). Further, children with disorders related to trauma often receive inappropriate mental health treatment with high-risk pharmacological practices that are not supported by the evidence and have strong potential to cause harm (Zito et al., Reference Zito, Safer, Sai, Gardner, Thomas, Coombes, Dubowski and Mendez-Lewis2008; Kutz, Reference Kutz2011; Vanderwerker et al., Reference Vanderwerker, Akincigil, Olfson, Gerhard, Neese-Todd and Crystal2014).
The most concerning practices are the use of two or more psychotropic medications concurrently (polypharmacy) and the use of antipsychotic medications for non-approved conditions (only psychosis, bipolar disorder, aggression with autism and Tourette's disorder are approved by the Food and Drug Administration for use in children). Among the many children in foster care receiving at least one psychotropic medication (Raghavan and McMillen, Reference Raghavan and McMillen2008; Leslie et al., Reference Leslie, Raghavan, Zhang and Aarons2010; Kutz, Reference Kutz2011), 41% receive three different classes of medications and 16% receive four or more (Zito et al., Reference Zito, Safer, Sai, Gardner, Thomas, Coombes, Dubowski and Mendez-Lewis2008). The use of antipsychotic medications is also common among children in foster care (Zito et al., Reference Zito, Safer, Sai, Gardner, Thomas, Coombes, Dubowski and Mendez-Lewis2008). In one study, nearly one-third of children in foster care who received any antipsychotic received two or more concomitantly (dosReis et al., Reference dosReis, Yoon, Rubin, Riddle, Noll and Rothbard2011).
In sum, concerns about over-treatment of children with trauma sequelae are several. First, contrary to recommendations, many of these children receive medications before they receive psychosocial treatments or without receiving effective psychosocial treatments concurrently. Second, many of the medications they receive have neither research support nor Food and Drug Administration approval for the specific conditions for which they are used. Third, medications that are approved are often used over months and years, not for the brief time periods for which they have been tested. Fourth, medications are often used in combinations (polypharmacy) that have not been tested for efficacy or safety. Fifth, many psychotropic medications, including antipsychotics, antidepressants, mood stabilisers and antianxiety medications, have serious side effects, which are often not monitored.
What has been done?
Concerns about over-treatment with psychotropic medications of US children in foster care have led to federal legislation mandating that state foster care systems and their Medicaid (health insurance) partners create policies to promote oversight of prescribing to children (US Department of Health and Human Services Administration for Children Youth and Families Children's Bureau, 2012). Some states have successfully implemented oversight programmes, both within their general Medicaid programme and specifically focused on children in foster care. These programmes include increased education and training for families and clinicians, audit and feedback processes for clinicians, expert consultation systems for clinicians and prior authorisations or second opinions for certain medications (Mackie et al., Reference Mackie, Hyde, Palinkas, Niemi and Leslie2017).
For the general child Medicaid population, several strategies have been successful. An education, audit and feedback initiative targeting high-prescribing clinicians demonstrated significant decreases in the use of multiple antipsychotics, prescriptions to young children and polypharmacy (defined as four or more psychotropic medications used concomitantly) (Thackeray et al., Reference Thackeray, Crane, Fontanella, Sorter, Baum and Applegate2018). At least two other strategies – a peer-review partnership with clinical pharmacists and child psychiatrists (Pennap et al., Reference Pennap, Burcu, Safer and Zito2018), and an expert consultation programme (Barclay et al., Reference Barclay, Penfold, Sullivan, Boydston, Wignall and Hilt2017) – have demonstrated significant reductions in the use of antipsychotics in children.
In a study of the foster care population, seven states developed and evaluated psychotropic oversight programmes with partial success between 2011 and 2015 (Center for Health Care Strategies, 2018). Research in progress compares the effectiveness of various oversight programmes within the foster care population (Patient Centered Outcomes Research Institute, 2018).
Additional recommendations
Monitoring interventions may be helpful but will likely be only partially effective without more fundamental changes. Clinicians, families and children need access to accurate information (not advertising from industry) and greater involvement in decision-making; researchers need to study real-world practice, including discontinuance of unnecessary medications; and policy makers need to listen to consumers and providers and protect public health.
Workforce
Clinicians in training and those already working with children need to be prepared to provide trauma-informed, evidence-based care. They must be able to assess for exposure to traumatic events and other adverse childhood experiences as well as evaluate mental health symptoms and functioning in order to conceptualise treatment holistically. All clinicians should receive training in providing evidence-based interventions to children who have experienced trauma.
Children and families
Children and caregivers should participate in what is called shared decision-making. Evidence-based medicine in fact assumes that children and caregivers have valuable information on history, goals and preferences that should be included in clinical decisions. But children and their caregivers, including parents and those caring for children in foster care, often lack accurate information about trauma and evidence-based interventions that would help them participate in treatment decisions (Brinkman et al., Reference Brinkman, Hartl Majcher, Poling, Shi, Zender, Sucharew, Britto and Epstein2013; Barnett et al., in press). Further, they may experience pressure from clinicians, schools and the pharmaceutical industry (false advertising) to improve a child's behaviour rapidly with medications. They therefore need to know that effective psychosocial treatments are available, and that no psychotropic medications have been approved by the Food and Drug Administration for children with PTSD, attachment disorders and most disruptive behaviour disorders. They need to understand the dangers of psychotropic medications, and to understand and accept their role in careful monitoring when a medication is used.
Research
Researchers need to study psychosocial treatments and medication practices in real-world conditions. What is needed to increase access to evidence-based interventions and to decrease the use of potentially harmful medications? If excessive medications are being added in hospital settings (a common complaint), outpatient prescribers need to know how to taper and discontinue the most dangerous ones – a procedure called deprescribing (Bellonci and Carlson, Reference Bellonci and Carlson2016). Researchers should study ways to ensure that parents, caregivers and youth understand the potential benefits and risks, and necessary monitoring, for various interventions. Researchers could also examine how systems could support the monitoring of high-risk medications.
Policy
Patients, providers and policy makers have been misled again and again by the pharmaceutical industry. Policy makers need to listen to consumers and providers and address implementing evidence-based practices and eliminating harmful practices. Unlike European countries, the USA has not instituted universal health insurance and registry based quality improvement. But policy makers could inject more transparency and accountability into mental health policies that affect our most vulnerable children (Noonan and Miller, Reference Noonan and Miller2013). Further, families and other stakeholders need easy access guidelines and procedures to follow when they are receiving poor care (Noonan and Miller, Reference Noonan and Miller2013).
Conclusions
Childhood trauma can have profound effects on all aspects of development and lead to long-term mental and physical health problems. Our most vulnerable children too often become our most troubled adults. These children need access to effective treatments as well as protection from harmful treatments. Doing so in the USA will require major investments in training the workforce, empowering children and families, enhancing research and creating effective policies.
Data
Not applicable.
Acknowledgements
We are grateful to our colleagues in the Vulnerable Children Research Group for their continued support and encouragement.
Financial support
This research received no specific grant from any funding agency, commercial or not-for-profit sectors.
Conflict of interest
None.
Ethical standards
Not applicable.
