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Trauma & Post Traumatic Stress Disorder (PTSD)

Trauma & Post Traumatic Stress Disorder (PTSD)

Exposure to trauma during childhood is a major public health concern that affects children of all ages. Two thirds of US children and adolescents have experienced a potentially traumatic adverse childhood experience (ACE), and over one third have experienced two or more ACEs. The prevalence of ACEs is higher among children in low-income and urban communities. ACEs can impact brain development and affect how the body responds to stress. Posttraumatic stress disorder (PTSD) affects approximately 4% of US children and teens. This disorder can severely impact emotional and physical health, and lead to problems in school and relationships that may persist into adulthood.

Role of the Primary Care Provider

Primary care providers are often the first to detect and respond to a child’s exposure to traumatic events. They play a crucial role in minimizing the severity of traumatic experiences through early detection, timely intervention and coordination of appropriate care. Additionally, primary care providers can play an important role in preventing trauma and traumatic stress symptoms at an early age by identifying risk factors and providing guidance to caregivers.

Childhood Post Traumatic Stress Disorder (PTSD) Myths vs. Facts

Fact: In childhood, stressful events can occur and most of the time children recover quickly. However, some children who experience severe stress will be affected long-term and can develop PTSD.

Fact: PTSD does exist; it is a recognized mental health issue. Strong emotions caused by a stressful event create changes in the brain that may result in PTSD.

Fact: PTSD symptoms can develop any time after a traumatic event; they may start soon after the event or may not develop until months or years later. Additionally, symptoms may come and go throughout many years.

Fact: Not every child is able to just “get over” a traumatic event. Many factors go into determining whether a child goes on to develop PTSD, including how old the child was when the traumatic event occurred, duration and severity of the event, whether the child was believed and protected from experiencing further trauma, the type of traumatic event and whether the trauma happened in the context of a caregiving relationship.

Fact: Early diagnosis and treatment is extremely important. It can ease symptoms, enhance the child’s normal development, and improve quality of life. Treatment may include cognitive behavioral therapy, which will help the child learn skills to manage anxiety and to master the situation that led to PTSD.Additionally, medications for depression or anxiety may help some children feel calmer and more positive about life.

Prevention

Pediatric practitioners can play a vital role by identifying risk factors and strengths. Beginning at an early age, primary care providers can reduce the likelihood of exposure to trauma.

Practitioners can:

  • Assess psychosocial risk factors that are associated with maltreatment, such as parental depression, stress, substance use, and family violence. Link caregivers to appropriate support services (www.findhelp.org).
  • Assess social determinants of health (SDOH) including economic stability, education, access to health care, neighborhood, and home environment, as well as social context, all of which can impact one’s quality of life. Link caregivers to appropriate support services (www.findhelp.org).
  • Provide education on the consistent use of healthy parenting skills. Establishing regular routines, setting appropriate limits, and engaging in positive parent–child interactions, such as reading together or talking about what happened during the day at school.

Screening and Assessment

Questions about a child’s social, developmental, and medical history are important opportunities to identify risks, stressors, and strengths. A primary care practitioner (PCP) can routinely screen for traumatic exposure during well-child visits by asking children questions such as, “Since the last time I saw you, has anything really scary or upsetting happened to you or your family?” A similar question can be asked to parents of young children, “Since the last time I saw your child, has anything really scary or upsetting happened to your child or anyone in your family?” While these questions may elicit nontraumatic stressors, such as losing a pet, they may also uncover traumatic events that are associated with PTSD. For adolescents, these questions can be asked as part of the HEADSSS psychosocial interview (questions about Home environment, Education, and employment, eating, peer-related Activities, Drugs, Sexuality, Suicide/ depression, and Safety).

 

Pediatric Traumatic Stress Screening Tools (PTSST)

Primary care practices that work with populations with high rates of trauma may wish to use a screening tool as well. Several validated screening instruments are available, such as the Pediatric Traumatic Stress Screening Tool in the Intermountain Care Process Model, which was developed to identify symptoms meeting the diagnostic criteria for PTSD.

 

Pediatric Traumatic Stress Screening Tool

The severity of symptoms is determined by summing the numeric scores for items 1–12: 0–10 indicates mild or no risk; 11–20 indicates a moderate risk; scores of 21 or greater indicate a severe risk. Depending on a child or adolescent’s score on the PTSST, further steps can be taken to reduce the risk of PTSD. Continue reading for more information on how to respond to and manage exposure to trauma.

Ages 6-10 Years:

English: https://intermountainhealthcare.org/ckr-ext/Dcmnt?ncid=529794096

Spanish: https://intermountainhealthcare.org/ckr-ext/Dcmnt?ncid=529794105

 

Ages 11-18 Years:

English: https://intermountainhealthcare.org/ckr-ext/Dcmnt?ncid=529795279

Spanish: https://intermountainhealthcare.org/ckr-ext/Dcmnt?ncid=529795283

For additional screening and assessment tools see the International Society for Trauma Studies: ISTSS - Trauma Assessment

Symptoms and clinical findings of trauma differ by age. Regression in eating and sleeping habits is common among infants and toddlers. Physical symptoms such as stomachaches and headaches are more common among school-aged children, as are changes in academic performance and social interactions.

 
Clinical Findings of Trauma Response

Infants and toddlers: Crying, clinging, change in sleep or eating habits, regression to earlier behavior (e.g., bed-wetting, thumb-sucking), repetitive play or talk.

3- to 5-year-olds: Separation fears, clinging, tantrums, fighting, crying, withdrawal, regression to earlier behavior (e.g., bed-wetting, thumb-sucking), sleep difficulty. May have repetitive play or interaction that reenacts the trauma with or without apparent distress. May have new onset of frightening dreams or fears that do not have content with obvious links to the trauma.

6- to 9-year-olds: Anger, fighting, bullying, irritability, fluctuating moods, fear of separation or of being alone, fear that traumatic events will reoccur, withdrawal, regression to earlier behavior, physical concerns (e.g., stomachaches, headaches), school problems (e.g., avoidance, academic difficulty, difficulty concentrating).

10- to 12-year-olds: Crying, aggression, irritability, bullying, resentment, sadness, social withdrawal, fears that traumatic events will reoccur, suppressed emotions or avoidance of situations or discussions that evoke memories of the traumatic event, sleep disturbance, concern about physical health of self or others, academic problems or decline related to lack of attention.

13- to 18-year-olds: Numbing, re-experiencing, avoidance of feelings (or situations or discussions that evoke memories of the traumatic event), resentment, loss of trust or optimism about the future, depression, withdrawal, mood swings, irritability, anxiety, anger, exaggerated euphoria, acting out, substance use, fear of similar events, appetite and sleep changes, physical concerns, academic decline, school refusal.
(Wissow, 2018)

Diagnostic Features

Diagnostic features of traumatic stress include intense fear and the following:

  • re-experiencing the event, such as intrusive thoughts or repetitive play focusing on the traumatic experience;
  • emotional numbing or avoidance of people, places, or other stimuli that may be reminders of the event; and
  • increased arousal, such as sleep disturbances, startling, irritability, and difficulty concentrating.

Among children, these symptoms are sometimes accompanied by additional stress behaviors such as tantrums, aggression, and regressive behaviors.

 

Differential Diagnosis

Symptoms of traumatic stress may resemble other mental health conditions. For example, children who experience trauma may appear hyperactive and have difficulty with concentration and learning suggestive of ADHD. They may exhibit fear and helplessness that resemble anxiety or depression and disruptive, aggressive behaviors that overlap with conduct disorder. In addition, the prevalence of comorbid conditions is high among children with PTSD. Differential diagnosis involves assessment of children’s exposure to traumatic events including family environmental factors and their developmental stages. For additional information about differential diagnosis and treatment of comorbidities see: https://www.nctsn.org/sites/default/files/resources/is_it_adhd_or_child_traumatic_stress.pdf.

 

Report if Required

Trauma may result from children being in unsafe settings because of abuse, neglect, or impaired caregiving. When the practitioner suspects child maltreatment or failure of the caregiver to protect a child at any point in a health encounter, referral to child protective services is necessary and mandated. Furthermore, Social Determinants of Health such as poverty may increase a child’s risk of exposure to trauma, which may warrant mandated reporting as well.

Use the following information to report suspected child abuse or neglect: 855 O-H-CHILD (855-642-4453). An automated telephone directory that will link callers directly to a child welfare or law enforcement office in their county. Reports can be anonymous. For more information: Report Child Abuse and Neglect | Office of Families and Children | Ohio Department of Job and Family Services.

Mandated Reporters are required by law to report if they suspect or know that child abuse is occurring. In Ohio, mandated reporters include attorneys, audiologists, childcare workers, children's services personnel, clergy, coroners, day care personnel, dentists, foster parents, nurses, physicians including hospital Interns and residents, podiatrists, psychiatrists, school authorities, teachers and other school employees, social workers, speech pathologists, animal control officers/agents.

Treatment

Effective support during the first few weeks after a traumatic experience may prevent the development of trauma symptoms or reduce their severity. In-office interventions can help caregivers support their child’s use of positive coping strategies to self-calm, address sleep disruptions, and remain actively engaged in positive activities. Most children and their families will benefit from education about the basics of trauma and brief interventions to develop calming skills when experiencing adverse events.

 

Clinical Pearl: Simple Interventions for Families

When primary care providers recognize that trauma is impacting a patient and family, connecting them to mental health resources may feel like the obvious next step. However, sharing basic information and simple, in-office interventions can be beneficial, especially when patients and families are unsure about seeing mental health providers and face other barriers to care.

 

Educational Resources for Families

Effective educational interventions focus on understanding what trauma is, how children may react, what to look for in trauma treatment, and how to respond and cope as a family. Specific resources for patients and families include:

 

Anticipatory Guidance

Office Based Anticipatory Guidance for Trauma Regulation

  1. Restore Safety- repeatedly assure a child or teenager that they are safe now; allow the youth to express how they feel and listen attentively.
  2. Routines- Routines or rituals also help reduce the stress response after the unpredictability and chaos of trauma by restoring a sense of order.
  3. Relaxation Techniques- Provide information verbally, with printed instructions or on phone apps that guide relaxation, meditation, and mindfulness.
  4. Special time- Caregiver chooses a time that works for them and plans to spend 10 to 30 min with the child in fun activity of child’s choosing. For infants and toddlers, reading time is a good example.
  5. Small successes- Expectations may need to be tailored to the child’s developmental level rather than actual age. It is useful to celebrate and reward small steps toward desired behaviors.
  6. Emotional Container- Caregiver needs to remain calm to model self-regulation and avoid retraumatizing the child.
  7. Cognitive triangle- Thoughts impact feelings, which then impact behavior, which then further impact thoughts. It can help to identify this cycle and break the link between thoughts and emotions
  8. Distraction- Children who are experiencing emotional dysregulation may benefit from distraction from the traumatic thoughts by suggesting a game, music, calling a friend, or deep breathing in a calm environment.
  9. Positive parenting techniques- helping children identify and name their emotions; reassuring safety and keeping the child safe both emotionally and physically; attuned, attentive listening, setting appropriate boundaries and providing guidance, offering the child positive, specific praise for good behaviors; using positive language, being a good role model, having fun together as a family. For more see (https://www.triplep-parenting.com/us/triple-p)
  10. Reinforcing cooperation, politeness, appropriate assertiveness, and kindness (Frokey Table 7)

 

Brief Interventions

Belly breathing Belly breathing (or focused breathing) involves specific methods of diaphragmatic breathing that help relax the body, calm the mood, and redirect the mind.
Guided imagery A mind exercise that helps redirect thoughts, relax the body, and calm the mood.
Routinized caregiver support Support to maintain or re-establish healthy routines, such as with mealtimes, bedtime, homework, and social activities. May include added attention from caregivers, such as playtime and daily check-ins.
Mindfulness techniques Exercises that help children ground themselves, reconnect, or become more fully present in the current moment. They include breathing exercises and practices that focus on the senses – sight, sound, taste.
Behavioral activation Behavioral activation emphasizes positive alternatives to negative behaviors that can result from trauma. Planned exercises focus on increasingly participating in school, social and extracurricular activities and decreasing avoidant behaviors. Through small steps, a patient can begin to plan and implement progressive activation goals, such as attending a few classes or participating in an outing.

 

Brief Intervention Resources for families and children

Crime Victims Reparations

Belly / focused breathing

PTSD Coach Online

PTSS Coach Phone Apps

 

Specialized Trauma-Focused Mental Health Treatment

Children with mild or moderate symptoms may benefit from referral to a mental health practitioner who routinely works with children and families. However, children with severe and/or prolonged posttraumatic stress symptoms may require specialized trauma-focused mental health treatment.

 

Clinical Pearl: Finding Specialized Treatment

Just like not all therapists have experience working with young children, not all therapists have experience dealing with patients and families who have been severely impacted by trauma. Primary care providers can help families to expect that more specialized mental health care may be needed in those cases. Primary care providers can help empower families to ask if the therapist has experience working with young people with a history of trauma when contacting a therapist’s office to schedule an initial appointment or at the time of the initial appointment.

 

Trauma Focused Cognitive Behavioral Therapy For children and adolescents ages 3-18 and their non-offending caregivers. The model includes psychoeducation, parenting skills, relaxation, affect expression and modulation, cognitive coping, and processing, and developing and sharing a trauma narrative.
Parent-Child Interaction Therapy Positive parenting skills for nonoffending caregivers or caregivers at elevated risk of engaging in physical abuse with children ages 2-7.
Child and Family Traumatic Stress Intervention Early intervention designed for youth (ages 7-18). Engages youth and their non-offending caregivers in psychoeducation, symptom monitoring, symptom-specific coping mechanisms, and parent-child communication.
Child-Parent Psychotherapy Promotes development of healthy parent–child relationships for young children and their non-offending caregivers (ages 0 – 6 years).
Alternatives for Families: A Cognitive Behavioral Therapy For treatment of trauma symptoms from physical abuse and/or physical discipline in children and adolescents (5 – 18 years). Engages offending caregivers in treatment.

 

Clinical Pearl: Trauma and Suicide

Sometimes the emotional toll of trauma is so great that it overwhelms a young person’s ability to cope and remain safe. Youth who have experienced severe trauma are at higher risk for suicidal thoughts and behaviors and death by suicide. A history of trauma is often comorbid with depression and, with or without symptoms of major depressive disorder, increases both suicide risk and the likelihood that suicidal thoughts may progress more rapidly to suicidal behaviors. Providers should anticipate this and screen for suicidal ideation and behaviors in youth experiencing mental health symptoms in the context of trauma.

Learn More

Medication

To date, no medication is approved by the US Food and Drug Administration for trauma-specific symptoms or PTSD in children and adolescents. Medications may be judiciously considered for specific symptoms that are interfering with a child’s ability to function normatively in specific ways. Readers are referred to the AAP clinical report “Children Exposed to Maltreatment: Assessment and the Role of Psychotropic Medication” for discussion of medication use in identified comorbid mental health conditions. (Frokey page 14)

 

Clinical Pearl: Non-Pharmacological Interventions First

Sometimes patients, families, and even providers can expect that because a young person is suffering, psychiatric medications can help. It is important to know that the evidence base for using pharmacotherapy to treat PTSD is weak. For this reason, it is important to emphasize the central role of non-pharmacologic interventions and to use medications for comorbid disorders and targeted symptomatic relief. Additionally, patients and families may interpret a primary care provider’s reluctance to prescribe as dismissive or a sign that they do not think the patient and family are suffering. In these cases, reflective listening (e.g., “I hear you saying this has had a huge impact on school”) and empathic statements (e.g., “this has been very scary, and extremely hard on everyone in the family”) can help patients and families feel confident that they are heard, before pivoting to discussing a treatment plan that emphasizes psychotherapy rather than pharmacotherapy.

Ongoing Management

Frequent Follow-Ups

Frequent follow up with patients is of vital importance to best monitor symptom severity and response to interventions. It is also important to continue to ensure that patients are safe and well cared for, as these patients can be at elevated risk for repeated exposure to traumatic experiences. Patients should be seen within 2-4 weeks following initial assessment and r with a determination made at that time regarding referral to specialized mental health care. During this short-term follow up visit, if a screening instrument was used at the initial visit, this can be repeated, as this is a useful way to track symptoms. After short term follow up, patients should follow up as often as appears necessary based on the clinician’s assessment of distress and need.

 

Brief Interventions

During these follow up visits, clinicians can help the patient by insuring the child is in a safe environment and further trauma is not being experienced, completing brief interventions. completing brief interventions and evaluating the patient’s overall functioning. Often, sleep disturbances can impede the patient’s ability to participate in treatment and adversely affect quality of life. Clinicians are encouraged to provide education around sleep, sleep hygiene, and relaxation techniques such as guided imagery and belly breathing. If nonpharmacologic interventions are unsuccessful it can be appropriate to consider certain medications at night, particularly when high levels of traumatic stress or severe sleep disturbances are present.

 

Encourage Health Habits

It is also important that during follow up visits, patients are encouraged to engage in healthy habits to promote brain health. Encourage exercise, outdoor play, balanced and consistent diet, sleep (critically important to mental health), special time with parents, frequent acknowledgment of the child’s strengths, and open communication with a trusted adult about worries. Children, particularly younger ones, should be shielded from certain types of media, such as television (TV) news, when there are violent or disturbing images or stories, especially without an adult available and attentive to put this information in context and emphasize current safety. Likewise, some TV shows and video games, even some cartoons, may contribute to a child feeling anxious. For preteens and teens, media messages about unattainable standards of appearance and social media exchanges may contribute to or exacerbate anxiety.

 

Continue to Asses Family Needs

Lastly, clinicians should continue to assess the needs of the family to improve resilience and decrease exposure to future traumatic events. Addressing the social determinants of health such as food insecurity and homelessness can dramatically improve the lives of patients and families. Referral to case management and other resources such as legal aid and food banks has been associated with increased employment, use of childcare, and a decrease in the use of homeless shelters.

 

Clinical Pearl: Trauma and Comorbidity

PTSD is frequently comorbid with other mental health conditions, particularly depression and anxiety disorders. For this reason, when a child and family are significantly impacted by trauma, providers should obtain history and elicit symptoms that touch on a wide range of functions and symptoms. For instance, the “HEADSSS” assessment mentioned above is used in adolescents to understand social functioning and elicit areas of difficulty and risk. Screening tools such as the PHQ-9 for depression (see section on depression) can also be useful to detect comorbid conditions. These conditions can then be incorporated into the treatment plan, with interventions that may overlap (e.g., psychotherapy) or represent a new direction (e.g., pharmacotherapy with an SSRI medication). Mental health conditions and symptoms seen comorbidly with trauma are, in general, more challenging to treat than when there is no significant trauma.

 

Meet Rebecca

Rebecca, a 15-year-old female with history of mild depression, presents to the PCP's office for difficulty sleeping and low mood. Rebecca’s mom reports that she has not been herself for the last two months and notes high levels of irritability and jumpiness. When interviewed alone, Rebecca states that she witnessed her best friend’s brother die after he was attacked by a group of boys in the front yard of his home. She now avoids her friend and refuses to walk near the block that her friend’s house is on. Rebecca also admits to constant worrying about her own safety and has difficulty staying asleep most nights due to recurrent nightmares. Sometimes she will suddenly find herself back in the moment when the boy was attacked (i.e., flashback). These episodes happen sporadically but are sometimes triggered by loud noises or violent scenes in movies. She scored an 8 on the PHQ-9 administered in office.

During Rebecca’s appointment, the PCP discussed interventions including fostering emotional intelligence and promoting positive peer relationships, both of which were set as goals for Rebecca. The PCP suggested these goals as reasonable targets to investigate with a therapist. Rebecca returns to the PCP's office for a follow-up appointment six weeks after starting with her new therapist.

Rebecca’s mom reports that she has been sleeping better and appears less irritable. Furthermore, she has been talking to her best friend again, and is less on edge in response to loud noises or violent movie scenes. Rebecca no longer has flashbacks either. When given the PHQ-9 again, she scored a 4. Both Rebecca and her mom report that her new therapist is empathic and teaches useful skills.

Meet Noah

Noah, a 5-year-old male with no past medical or psychiatric history, presents to the PCP's office for behavioral outbursts. His mom reports that he is “fine” one minute and then seems to explode with rage. These episodes, which include Noah yelling, hitting others, and crying, occur multiple times per week. His mom reports that he has also started to wet the bed at night and has not been sleeping well, as he wakes from nightmares. When asked if there have been any recent changes in the home, Noah’s mom reports that the family moved two months ago due to three episodes of domestic violence between Noah’s grandmother and grandfather, which occurred in the family’s previous home.

The PCP recognized that Noah’s loving relationship with his mother was a strength in the family system. The PCP discussed with his mom how the events that Noah witnessed could be influencing his current symptoms. Furthermore, the PCP discussed how working with a therapist could help, and suggested implementing the following three principles: (1) think about ways to ensure that his environment is and remains safe, (2) recognize the value of routines and consistency to create a holding environment for him, and (3) prioritize time for him and a parent to engage in positive child-directed play every day.

Noah returns to the PCP's office two months after starting with a therapist who specializes in young children exposed to trauma. His mom reports that he still has occasional outbursts, but they are much less frequent. His nightmares are gone, but he still wets the bed about once per week. Noah’s mom also reports that he seems much more like himself.

Frequently Asked Questions (FAQs)

PTSD in children is not common. According to the National Center for Post-Traumatic Stress Disorder, 15 – 43% of girls and 14 – 43% of boys have experienced a traumatic event in their lifetimes. However, only 3 – 15% of girls and 1-6% of boys are diagnosed with PTSD.

The symptoms and feelings associated with PTSD are similar in kids and adults. However, adults are usually better at verbalizing how they are feeling and what they are experiencing. Children also have a more difficult time recognizing that the flashbacks and memories of the trauma are not actually the trauma happening again. A child with PTSD is more likely to physically react (screaming, hiding, fighting) to traumatic thoughts and feelings than an adult.

A traumatic event that triggers PTSD may include something that happened to the child; something that happened to someone close to the child; or something the child saw. Some examples of these traumatic events include bad car accidents; invasive medical procedures; animal bites; natural disasters; experiencing war; violent personal attacks; physical abuse; sexual assault; sexual abuse; emotional abuse or bullying; or neglect.

A child’s risk for PTSD is often affected by: how close the child was to the traumatic event; how bad the event was; how long the event lasted; if the event happened more than once; how well the child can recover quickly from difficult things (resiliency); how well the child copes; and how supportive a child’s family and community are after the event.

Children with PTSD may experience: reliving the event over and over in thought or in play; nightmares and sleep problems; becoming very upset when something causes memories of the event; lack of positive emotions; intense ongoing fear or sadness; irritability and angry outbursts; constantly looking for possible threats; being easily startled; acting helpless, hopeless or withdrawn; denying that the event happened or feeling numb; avoiding places or people associated with the event; having problems in school; acting younger than their age, such as thumb-sucking or bedwetting; and having physical symptoms, such as headaches or stomachaches.

Exposure to trauma is one of the criteria necessary to diagnose PTSD, but not every child who goes through a trauma develops PTSD. It is not known why some children develop PTSD after experiencing traumatic events and others do not. Many factors may play a role, including biology and temperament. As described above, hyperarousal, intrusive experiences and avoidance or emotional numbing related to the trauma are features of the diagnosis, and PTSD is diagnosed only if symptoms persist for more than 1 month and are negatively affecting the child’s life and functioning. These symptoms do not always look the same in individuals of different developmental stages (e.g., preschoolers, school age children, adolescents, and adults) and may look different even within siblings in the same family who experience the same trauma. A child mental health expert can diagnose PTSD by completing a mental health evaluation.

References

  1. California Evidence Based Clearinghouse for Child Welfare. (n.d.). Welcome to the CEBC: California Evidence-Based Clearinghouse for Child Welfare. https://www.cebc4cw.org/
  2. Forkey, H., Szilagyi, M., Kelly, E. T., Duffee, J., Council on Foster Care, Adoption, and Kindship Care, Council on Committee Pediatrics, Council on Child Abuse and Neglect, & Committee on Psychosocial Aspects of Child and Family Health. (2021). Trauma-informed care. Pediatrics, 148(2). https://doi.org/10.1542/peds.2021-052580
  3. Foy, J. M. (Ed.). (2018). Mental Health Care of Children and Adolescents: A Guide for Primary Care Clinicians. American Academy of Pediatrics. https://doi.org/10.1542/9781610021517
  4. Intermountain Health Care. (2020). Diagnosis and treatment of traumatic stress in pediatric patients. https://intermountainhealthcare.org/ckr-ext/Dcmnt?ncid=529796906
  5. Keeshin, B., Forkey, H. C., Fouras, G., MacMillan, H. L., American Academy of Pediatrics, Council on Child Abuse and Neglect, Council on Foster Care, Adoption, and Kinship Care, American Academy of Child and Adolescent Psychiatry, Committee on Child Maltreatment and Violence, & Committee on Adoption and Foster Care. (2020). Children exposed to maltreatment: Assessment and the role of psychotropic medication. Pediatrics, 145(2). https://doi.org/10.1542/peds.2019-3751