Elsevier

Child Abuse & Neglect

Volume 27, Issue 12, December 2003, Pages 1345-1365
Child Abuse & Neglect

Invited Review
Treating child abuse-related posttraumatic stress and comorbid substance abuse in adolescents

https://doi.org/10.1016/j.chiabu.2003.08.001Get rights and content

Abstract

Objective: Child abuse is a risk factor for developing Posttraumatic Stress Disorder (PTSD) and subsequent Substance Use Disorder (SUD). The purpose of this review is to summarize current knowledge about effective treatments for adolescent abuse-related PTSD, SUD, and the co-occurrence of these conditions.

Method: The literature on empirical treatment studies for these conditions in adolescence was reviewed, summarized, and synthesized.

Results: Randomized controlled studies of abuse-related PTSD and SUD in adolescents have supported the efficacy of cognitive behaviorally-based individual and family treatment components. Components overlap considerably in empirically supported treatments for each disorder. An integrated treatment approach is described for use in adolescents with abuse-related PTSD and SUD, with recommendations for optimizing services for this population and for future research.

Conclusions: The available evidence on effective treatments suggests that integrated PTSD- and SUD-focused cognitive-behavioral and family treatment for adolescents with comorbid abuse-related PTSD and SUD may optimize outcomes for this population.

Résumé

Objectif: Etre abusé sexuellement constiue un facteur de risque pour l’apparition de troubles postraumatiques (PTSD) et de troubles ultérieurs liés à l’usage de stupéfiants (SUD). Cette revue a pour but de résumer ce qui est admis actuellement sur le traitement des adolescents abusés présentant PTSD et SUD et sur l’occurence conjointe de ces conditions.

Méthode: On a procédé à une revue, à un résumé et à une synthèse de la littérature sur les études empiriques concernant le traitement des adolescents dans les conditions mentionnées.

Résultats: Les études randomisées et contrôlées des cas de PTSD et SUD en relation avec des abus sexuels ont montré l’efficacité des traitements à composantes comportementales et cognitives pour les individus et les familles. Ces composantes se recouvrent considérablement dans les traitements à base empirique pour chaque désordre. Une approche de traitement intégré est décrite, à utiliser pour les adolescents présentant PTSD ou SUD en relation avec des abus sexuels. Des recommandations sont faites pour améliorer les services pour cette population et pour les recherches à venir.

Conclusions: Les connaissances disponibles sur l’efficacité des traitements suggèrent que le traitement intégré comportemental et cognitif de la famille et des adolescents présentant PTSD et SUD conjointement avec des abus sexuels subis peut améliorer les résultats pour cette population.

Resumen

Objetivo: El abuso contra los niños es un factor de riesgo para desarrollar el Desorden de Estrés Post traumático (PTSD) y el Desorden de Abuso de Sustancia subsiguiente. El propósito de esta revisión es resumir los conocimientos presentes acerca de tratamientos efectivos para adolescentes relacionados con el PTSD, el SUD, y la copresencia de estas condiciones.

Método: La literatura sobre estudios empı́ricos acerca del tratamiento de estas condiciones en la adolescencia fue revisada, resumida y sintetizada.

Resultados: Estudios controlados con muestreo al azar del abuso relacionado con el PTSD y el SUD en adolescentes apoyan la eficacia de componentes de tratamiento individual y familiar con base cognitivo-conductual. Los componentes se sobreponen considerablemente en los tratamientos apoyados empı́ricamente para cada desorden. Se describe un tratamiento con enfoque integrado para el uso en adolescentes con abuso relacionado con el PTSD y el SUD, con recomendaciones para optimizar los servicios para esta población y para futuras investigaciones.

Conclusiones: La evidencia disponible sobre tratamientos efectivos sugiere que el tratamiento cognitivo-conductual y familiar integrado, dirigido a adolescentes con sı́ntomas relacionados del PTSD y el SUD, puede optimizar los resultados para esta población.

Introduction

There is a clear association between child abuse and the subsequent development of both posttraumatic stress disorder (PTSD) and substance use disorders (SUD) during adolescence and young adulthood. Both PTSD and SUD in adolescents vary in severity and duration and in some adolescents, these disorders may be self-limited. However, for many others, these conditions may become chronic and unremitting, leading to lifelong impairment. In this article, the term SUD will be used to refer to significant drug and/or alcohol abuse or dependence, rather than intermittent or experimental substance usage. Although research has demonstrated bidirectional relationships between PTSD and SUD in adolescents (Giaconia, Reinherz, Paradis, & Stashwick, 2003), this article specifically addresses treatment for those adolescents whose child abuse-related PTSD preceded the development of SUD rather than the opposite (i.e., those whose are not believed to have a primary SUD disorder).

There is growing evidence that both PTSD and SUD are associated with significant functional and structural brain abnormalities in adolescents, which appear to worsen with the length of time either disorder has been present (DeBellis et al., 1999, DeBellis et al., 2000). Additionally, both SUD and trauma history place children, adolescents, and young adults at increased risk of suicide attempts (Brent et al., 2002). Thus, there are compelling reasons to develop and provide effective treatments for these conditions, particularly when they coexist. This article will describe the relationships between child abuse, PTSD, and SUD in youth, examine evidence-based models of how each of these disorders influence the other in adolescents, describe randomized controlled treatment studies for youth with these disorders, and describe an integrated treatment approach to address the needs of adolescents with comorbid abuse-related PTSD and SUD.

Section snippets

The association between childhood trauma, PTSD, and SUD

Associations between childhood physical or sexual abuse, PTSD, and subsequent SUD have been documented repeatedly in adolescence and young adulthood (Briere & Zaidi, 1989; Cohen, Spirito, & Sterling, 1996; Herman, Russell, & Trocki, 1986; Miller, Downs, Gondoli, & Keil, 1987). Conversely, studies of youth with SUD have demonstrated that these samples have very high rates of past child abuse and concurrent PTSD (Clark et al., 1995; Van Hasselt, Ammerman, Glancy, & Bukstein, 1992). Recent

Models of interactions between child abuse-related PTSD and SUD in adolescents

Why are there such consistent connections between child abuse-related PTSD and the subsequent development of SUD? It is likely that there are neurobiological interactions between these conditions which have yet to be completely elucidated (DeBellis, 2002). Sophisticated structural equation modeling studies of child sexual abuse response provide important insights into these connections, although they have not explicitly included substance abuse as an outcome (Barker-Collo & Read, 2003). These

Trauma-focused cognitive-behavioral therapy

Since randomized controlled trials (RCTs) are the most scientifically rigorous method of evaluating treatment efficacy, only RCTs utilizing well-defined manualized treatments are included in the following sections. At least five RCTs have demonstrated superiority of trauma-focused cognitive behavioral therapy (TF-CBT) in treating PTSD and related symptoms in sexually abused children and adolescents when compared to nondirective play or supportive therapy, child centered therapy, standard

Empirical treatment studies for SUD in adolescents

A small but growing number of randomized controlled treatment studies using well-defined treatments have evaluated improvement in SUD and other mental health outcomes for substance abusing adolescents (Bruner & Fishman, 1998). Such research has indicated that the most important variables in predicting successful treatment response in adolescent SUD are the specific therapeutic components provided in treatment (i.e., family and/or cognitive behavioral interventions), and the training and

Models of integrated treatment for PTSD and SUD

A few research groups have designed and tested TF-CBT interventions for adults with comorbid PTSD and SUD (Back, Dansky, Carroll, Foa, & Brady, 2001; Najavits, 1998, Najavits, 2002; Najavits, Weiss, Shaw, & Meunz, 1998). In adult populations, these treatments have been found to improve PTSD symptoms, social adjustment, problem-solving abilities, depression, and to decrease both substance abuse and suicidality (Najavits et al., 1998). One of these treatment models, Seeking Safety (Najavits, 2002

Components of integrated treatment for abuse-related PTSD and SUD in adolescents

The specific treatment components common to empirically supported treatments for adolescent abuse-related PTSD and adolescent SUD, and elements of integrated treatments shown to improve outcome in adults with comorbid PTSD and SUD suggest potentially effective integrated interventions for adolescents with comorbid abuse-related PTSD and SUD. These include the following:

  • 1.

    Establishment of a consistent and trusting therapeutic relationship which includes collaborative empiricism (working together

Optimizing use of integrating treatments

Improved assessment strategies, reconciliation of divergent treatment philosophies, increased adoption of empirically supported treatments and changes in therapist attitudes may facilitate the use of optimal integrated treatment for adolescents with comorbid abuse-related PTSD and SUD.

The need for more treatment research

Finally, expanding the available empirical knowledge base requires additional research into the treatment of abused and otherwise traumatized youth with SUD. To our knowledge, only one treatment study has explicitly evaluated any treatment specifically for this population (Najavits, 1998). The potential for serious, life-long impairment should compel researchers to devote greater attention and funding agencies to devote more resources to evaluating optimal treatments for abused and otherwise

Recommendations for treating adolescents with abuse-related PTSD and SUD

The following recommendations attempt to synthesize the above information into practical guidelines for optimizing current treatment for adolescents with abuse-related PTSD and SUD.

  • 1.

    Adolescents presenting for mental health or substance abuse treatment should receive comprehensive assessments which include evaluation of child abuse and other trauma exposure, PTSD symptomatology, and SUD.

  • 2.

    Parents or other informed caretakers should be included in the assessment and treatment process in a respectful

Conclusions

Child maltreatment predisposes adolescents to developing both PTSD and SUD. The broader use of integrated, empirically derived treatments for these disorders and an increase in treatment research for youth with both disorders will greatly enhance the ability to provide the best possible treatment to adolescents with abuse-related PTSD and SUD.

Acknowledgements

The authors gratefully acknowledge the assistance of Ann Marie Kotlik in the preparation of this paper.

References (89)

  • P.D Riggs et al.

    A clinical approach to integrating treatment for adolescent depression and substance abuse

    Journal of the American Academy of Child and Adolescent Psychiatry

    (2002)
  • R Robert et al.

    Imipramine treatment in pediatric burn patients with symptoms of acute stress disorder: A pilot study

    Journal of the American Academy of Child and Adolescent Psychiatry

    (1999)
  • V.V Ruchkin et al.

    Violence exposure, posttraumatic stress, and personality in juvenile delinquents

    Journal of the American Academy of Child and Adolescent Psychiatry

    (2002)
  • H Steiner et al.

    Posttraumatic stress disorder in incarcerated juvenile delinquents

    Journal of the American Academy of Child and Adolescent Psychiatry

    (1997)
  • V.B Van Hasselt et al.

    Maltreatment in psychiatrically hospitalized dually diagnosed adolescent substance abusers

    Journal of the American Academy of Child and Adolescent Psychiatry

    (1992)
  • AACAP. (1998). Practice parameters for the assessment and treatment of children and adolescents with posttraumatic...
  • AACAP. (2002). New practice parameters for children and adolescents with substance use disorders [On-line]. Available...
  • N.H Azrin et al.

    Youth drug abuse treatment: A controlled outcome study

    Journal of Child and Adolescent Substance Abuse

    (1994)
  • Azrin, N. H., Donohue, B., Teichner, G., Crum, T., Howell, J., & DeCato, L. (in press). A controlled evaluation and...
  • S Barker-Collo et al.

    Models of response to childhood sexual abuse

    Trauma, Violence & Abuse

    (2003)
  • Barnett, N. P., Monti, P. M., & Wood, M. D. (2001). Motivational interviewing for alcohol-involved adolescents in the...
  • M.E Barrett et al.

    Behavioral changes of adolescents in drug abuse intervention programs

    Journal of Clinical Psychology

    (1988)
  • D.M Berwick

    Disseminating innovations in health care

    Journal of the American Medical Association

    (2003)
  • K.T Brady et al.

    Sertraline treatment of comorbid PTSD and alcohol dependence

    Journal of Clinical Psychiatry

    (1996)
  • D.A Brent et al.

    Familial pathways to early-onset suicide attempt

    Archives of General Psychiatry

    (2002)
  • J Briere et al.

    Sexual abuse histories and sequelae in female psychiatric emergency room patients

    American Journal of Psychiatry

    (1989)
  • A.E Bruner et al.

    Adolescents and illicit drug use

    Journal of the American Medical Association

    (1998)
  • Bry, B. H., & Attaway, N. M. (2001). Community based interventions. In E. F. Wagner & H. B. Waldron (Eds.), Innovations...
  • Bukstein, O. G., & Kithas, J. (2002). Pharmacological treatment of substance use disorders. In D. A. Rosenberg, P. A....
  • A Cartwright

    Group work with substance abusers: Basic issues and future research

    British Journal of Addictions

    (1987)
  • R.F Catalano et al.

    Evaluation of the effectiveness of adolescent drug abuse treatment, assessment of risks for relapse, and promising approaches for relapse prevention

    International Journal of Addictions

    (1990–1991)
  • D.B Clark et al.

    Identifying anxiety disorders in adolescents hospitalized for alcohol abuse or dependence

    Psychiatric Services

    (1995)
  • Cloitre, M., Davis, L., & Mirvis, S. (2002). A phase-based treatment for adolescent trauma survivors of childhood...
  • J.A Cohen

    Pharmacologic treatments for childhood PTSD

    Trauma, Violence & Abuse: A Review Journal

    (2001)
  • Cohen, J. A. (2001b). Pharmacologic treatment of PTSD in sexually abused children and adolescents. Grant application...
  • Cohen, J. A., Berliner, L., & March, J. S. (2000). Treatment of children and adolescents. In E. B. Foa, T. M. Keane, &...
  • J.A Cohen et al.

    The importance of culture in treating abused and neglected children: An empirical review

    Child Maltreatment

    (2001)
  • Cohen, J. A., Deblinger, E., Mannarino, A. P., & Steer, R. (in press). A multisite randomized controlled trial for...
  • J.A Cohen et al.

    Interventions for sexually abused children: Initial treatment findings

    Child Maltreatment

    (1998)
  • J.A Cohen et al.

    Trauma-focused cognitive behavioral therapy: An empirical update

    Journal of Interpersonal Violence

    (2000)
  • J.A Cohen et al.

    Treatment practices for childhood posttraumatic stress disorder

    Child Abuse & Neglect

    (2001)
  • J.A Cohen et al.

    Treating traumatized children: Clinical implications of the psychobiology of PTSD

    Journal of Trauma, Violence and Abuse

    (2002)
  • Y Cohen et al.

    Physical and sexual abuse and their relation to psychiatric disorder and suicidal behavior among adolescents who are psychiatrically hospitalized

    Journal of Child Psychology and Psychiatry

    (1996)
  • J.K Connor-Smith et al.

    Applying treatment outcome research in clinical practice: Techniques for adapting interventions to the real world, Child

    Child & Adolescent Mental Health

    (2003)
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