Acute stress disorder (ASD) and posttraumatic stress disorder (PTSD) are reactions to traumatic events. The reactions involve intrusive thoughts or dreams, avoidance of reminders of the event, and negative effects on mood, cognition, arousal, and reactivity. ASD typically begins immediately after the trauma and lasts from 3 days to 1 month. PTSD can be a continuation of ASD or may manifest up to 6 months after the trauma and lasts for >1 month. Diagnosis is by clinical criteria. Treatment is with behavioral therapy and sometimes with selective serotonin reuptake inhibitors or antiadrenergic medications.
(See also Acute Stress Disorder and Posttraumatic Stress Disorder in adults.)
ASD and PTSD are trauma- and stressor-related disorders. They used to be considered anxiety disorders but are now considered distinct because many patients do not have anxiety but have other symptoms instead.
Because vulnerability and temperament are different, not all children who are exposed to a severe traumatic event develop a stress disorder. Traumatic events commonly associated with these disorders include assaults, sexual assaults, car accidents, dog attacks, and injuries (especially burns). In young children, domestic violence is the most common cause of PTSD.
In children age 6 and below, direct experience of the traumatic event is needed. Youths age 6 and above do not have to directly experience the traumatic event; they may develop a stress disorder if they witness a traumatic event happening to others (even through media exposure; 1) or learn that one occurred to a close family member.
General reference
1. Comer JS, Kendall PC: Terrorism: The psychological impact on youth. Clin Psychol 14:179-212, 2007.
Symptoms and Signs
Symptoms of ASD and PTSD are similar and generally involve a combination of the following:
Intrusion symptoms: Recurrent, involuntary, and distressing memories or dreams of the traumatic event (in children < 6 years, it may not be clear whether their distressing dreams are related to the event); dissociative reactions (typically flashbacks in which patients reexperience the trauma, although young children may frequently reenact the event in play); and distress at internal or external cues that resemble some aspect of the trauma (eg, seeing a dog or someone who resembles a perpetrator)
Avoidance symptoms: Persistent avoidance of memories, feelings, or external reminders of the trauma
Negative effects on cognition and/or mood: Inability to remember important aspects of the traumatic event, distorted thinking about the causes and/or consequences of the trauma (eg, that they are to blame or could have avoided the event by certain actions), a decrease in positive emotions and an increase in negative emotions (fear, guilt, sadness, shame, confusion), general lack of interest, social withdrawal, a subjective sense of feeling numb, and a foreshortened expectation of the future (eg, thinking “I will not live to see 20”)
Altered arousal and/or reactivity (eg, hyperarousal): Jitteriness, exaggerated startle response, difficulty relaxing, difficulty concentrating, disrupted sleep (sometimes with frequent nightmares), and aggressive or reckless behavior
Dissociative symptoms: Feeling detached from one's body as if in a dream and feeling that the world is unreal
Typically, children with ASD are in a daze and may seem dissociated from everyday surroundings.
Children with PTSD have intrusive recollections that cause them to reexperience the traumatic event. The most dramatic kind of recollection is a flashback. Flashbacks may be spontaneous but are most commonly triggered by something associated with the original trauma. For example, the sight of a dog may trigger a flashback in children who experienced a dog attack. During a flashback, children may be in a terrified state and unaware of their current surroundings while desperately searching for a way to hide or escape; they may temporarily lose touch with reality and believe they are in grave danger. Some children have nightmares. When children reexperience the event in other ways (eg, in thoughts, mental images, or recollections), they remain aware of current surroundings, although they may still be greatly distressed.
Diagnosis
Psychiatric assessment
Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR) criteria
Diagnosis of ASD and PTSD is based on a history of exposure to severely frightening and horrifying trauma followed by reexperiencing, emotional numbing, and hyperarousal. These symptoms must be severe enough to cause impairment or distress.
Symptoms lasting ≥ 3 days and < 1 month are considered ASD. Symptoms lasting > 1 month are considered PTSD, which can be a continuation of ASD or may manifest up to 6 months after the trauma.
Treatment
Trauma-based psychotherapies
Supportive psychotherapy
Selective serotonin reuptake inhibitors (SSRIs) and sometimes antiadrenergic medications
Trauma-based psychotherapies have been reported to be efficacious in children with PTSD (1–4). Trauma-based psychotherapy involves short-term interventions that use cognitive-behavioral techniques to modify distorted thinking, negative reactions, and behavior. It can also include teaching parents stress reduction and communication skills.
Supportive psychotherapy may help children who have adjustment issues associated with trauma, as may result from disfigurement due to burns. Behavioral therapy can be used to systematically desensitize children to situations that cause them to reexperience the event (exposure therapy). Behavioral therapy is clearly effective in reducing distress and impairment in children and adolescents with PTSD.
There are no medications approved for PTSD in children because adequate clinical trials remain to be conducted. However, in youths with comorbid anxiety, depression, sleep difficulties, selective serotonin reuptake inhibitors (SSRIs) can be helpful (5).
67]) may help relieve hyperarousal symptoms, but supportive data are preliminary.
Treatment references
1. Kowalik J, Weller J, Venter J, et al: Cognitive behavioral therapy for the treatment of pediatric posttraumatic stress disorder: A review and meta-analysis. J Behav Ther Exp Psychiatry 42(3):405-413, 2011. doi: 10.1016/j.jbtep.2011.02.002
2. Kataoka SH, Stein BD, Jaycox LH, et al: A school-based mental health program for traumatized Latino immigrant children. J Am Acad Child Adolesc Psychiatry 42(3):311-318, 2003. doi: 10.1097/00004583-200303000-00011
3. McMullen J, O'Callaghan P, Shannon C, et al: Group trauma-focused cognitive-behavioural therapy with former child soldiers and other war-affected boys in the DR Congo: A randomised controlled trial. J Child Psychol Psychiatry54(11):1231-1241, 2013. doi: 10.1111/jcpp.12094
4. Deblinger E, Steer RA, Lippmann J: Two-year follow-up study of cognitive behavioral therapy for sexually abused children suffering post-traumatic stress symptoms. Child Abuse Negl 23(12):1371-1378, 1999. doi: 10.1016/s0145-2134(99)00091-5
5. Strawn JR, Keeshin BR, DelBello MP, et al: Psychopharmacologic treatment of posttraumatic stress disorder in children and adolescents: A review. J Clin Psychiatry 71(7):932-941, 2010. doi: 10.4088/JCP.09r05446blu
6. Connor DF, Grasso DJ, Slivinsky MD, et alJ Child Adolesc Psychopharmacol 23(4):244-251, 2013. doi: 10.1089/cap.2012.0119
7. Keeshin BR, Ding Q, Presson AP, et alNeurol Ther 6(2):247-257, 2017. doi: 10.1007/s40120-017-0078-4
Prognosis
Prognosis is much better for children with ASD than for those with PTSD, but both benefit from early treatment.
Risk factors include (1)
Severity of the trauma
Associated physical injuries
The underlying resiliency and temperament of children and family members
Socioeconomic status
Adversity during childhood (see Adverse Childhood Experience (ACE) Response)
Family dysfunction
Minority status
Family psychiatric history
Family and social support before and after the trauma moderates the final outcome.
Prognosis reference
1. Trickey D, Siddaway AP, Meiser-Stedman R, et al: A meta-analysis of risk factors for post-traumatic stress disorder in children and adolescents. Clin Psychol Rev 32(2):122-138, 2012. doi: 10.1016/j.cpr.2011.12.001
Key Points
ASD typically begins immediately after the trauma and lasts from 3 days to 1 month; PTSD lasts for > 1 month and can be a continuation of ASD or may manifest up to 6 months after the trauma.
Stress disorders may start after children directly experience a traumatic event, if they witness one, or learn that one happened to a close family member.
Symptoms of ASD and PTSD are similar and usually involve a combination of intrusion symptoms (eg, reexperiencing the event), avoidance symptoms, negative effects on cognition and/or mood (eg, emotional numbing), altered arousal and/or reactivity, and dissociative symptoms.
Treat with trauma-based psychotherapy and, in children with comorbid anxiety, depression and/or sleep difficulties, SSRIs; sometimes antiadrenergic medications may be helpful.
