Trauma & Stressor-Related Disorders

The trauma and stressor related disorders include 

  • Post-traumatic Stress Disorder (PTSD)
  • Acute Stress Disorder 
  • Reactive Attachment Disorder
  • Disinhibited Social Engagement Disorder and
  • Unclassified and unspecified trauma disorders.

We will focus on PTSD here. The primary difference between PTSD and Acute Stress Disorder is that the duration of PTSD is greater than 1 month, and that of Acute Stress Disorder 1 month or less.

PTSD has been recognized in adults and children of all ages as symptomatic responses to the experience or witnessing of a traumatic event. The diagnostic criteria for PTSD have evolved in subsequent editions of the DSM to better describe the varied ways in which children respond to trauma, and DSM-5 includes a section on diagnosis of PTSD in children under the age of 6 years.  

Symptoms

The core symptom clusters that make up a PTSD diagnosis include:

  • Exposure to a traumatic event
  • Recurrent intrusive, involuntary memories or dreams, dissociative reactions, and/or prolonged psychological or physiological reactions to internal or external cues that symbolize or represent an aspect of the traumatic event
  • Avoidance of stimuli associated with the traumatic events
  • Negative alterations in mood and cognitions, including inability to remember an important aspect of the event, exaggerated negative beliefs or expectations about oneself, others or the world, distorted cognitions associated with blame, diminished interest in activities, detachment or estrangement, inability to experience positive emotions
  • Alterations in arousal and reactivity, including irritable behavior or angry outbursts, reckless or self-destructive behavior, hypervigilance, exaggerated startle response, problems with concentration, or sleep disturbance.

Risk Factors & Prognosis

Not all children who are exposed to traumatic events will develop a stressor-related disorder. Risk factors include more severe, prolonged, or interpersonal trauma, pre-existing anxiety disorder, perceived threat to life, prolonged evacuation from a dangerous situation, and panic symptoms during the traumatic event. These are also risk factors for prolonged PTSD symptomatology.

Evaluation

PTSD is a challenging diagnosis to make. It involves talking about events that the child would rather avoid talking about, and internal responses which the child may not have the cognitive skills to describe. The symptom clusters associated with PTSD overlap with other psychiatric disorders which may be comorbid to the stressor response.  

Freely available rating scales include the Child PTSD Symptom Scale for DSM-5.

Treatment

Psychotherapeutic treatments

Trauma-focused Cognitive Behavioral Therapy (TF-CBT) has the strongest evidence base for the treatment of pediatric PTSD.  The core elements of TF-CBT include work with children and their caregivers, learning relaxation and affective modulation, and creation of and processing the trauma narrative.  Children learn to master reminders of the trauma through this process, and work with their parents to build safety and control.

Child-Parent Psychotherapy is used with very young traumatized children and their often-traumatized parents to improve interactions, correct unhelpful cognitive processes and create a joint trauma narrative. 

Psychopharmacologic treatments

There are no randomized controlled trials supporting the use of any pharmacologic agent in the treatment of pediatric PTSD.  That said, medications are often prescribed to target comorbid disorders (such as anxiety or depression) or salient symptom clusters (irritability and aggression).  Such medications should be used thoughtfully and not continued indefinitely. 

Trauma-Informed Care

Trauma-informed care is a model of care that recognizes the impact of traumatic stress on the physical and psychological health of children, their families, and medical staff who work with them.  More information is available in the Toolbox section.

References

Cohen, J. A. & Mannarino, A. P. Posttraumatic Stress Disorder and Persistent Complex Bereavemennt Disorder.  In Dulcan's Textbook of Child and Adolescent Psychiatry, Third Edition.  American Psychiatric Publishing, Inc: Washington DC. 2022.