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Acute and Posttraumatic Stress Disorders in Children and Adolescents

By Josephine Elia, MD, Professor of Psychiatry and Human Behavior, Professor of Pediatrics;Attending Physician, Sidney Kimmel Medical College of Thomas Jefferson University;Nemours/A.I. duPont Hospital for Children

Acute and posttraumatic stress disorders are reactions to overwhelming traumatic events that involve recurring, intrusive memories of the event as well as emotional numbness and increased tension or alertness (arousal). Children tend to avoid reminders of the event.

  • The disorder may develop after children witness or experience an act of violence, such as a dog attack, a school shooting, an accident, or a natural disaster.

  • Children not only reexperience the event, but they may also feel emotionally numb, extremely tense, and jittery.

  • The diagnosis is based on symptoms that occur after a traumatic event.

  • Treatment involves psychotherapy, behavioral therapy, and drugs.

Acute stress disorder (ASD) typically begins immediately after the traumatic event and lasts from 3 days to 1 month.

Posttraumatic stress disorder (PTSD) can be a continuation of ASD or may not develop until 6 months after the event.

Stress disorders may develop after children witness or experience an event that threatens their own or another’s life or health. During the event, they typically feel intense fear, helplessness, or horror. These events include acts of violence, such as child abuse, school shootings, car accidents, attacks by a dog, injuries (particularly burns), fires, wars, natural disasters (such as hurricanes, tornados, or earthquakes), and deaths. In young children, domestic violence is the most common cause. Not all children who experience a severe traumatic event develop a stress disorder.

Children do not have to directly experience the traumatic event. They may develop a stress disorder if they witness a traumatic event happening to others or learn that one occurred to a close family member.

Certain factors may affect whether children develop posttraumatic stress disorder and, if it develops, how well they do. These factors include the following:

  • How severe the traumatic event was

  • Whether physical injuries occurred during the event

  • What the temperament of the child is

  • What the social and economic status of the family is

  • Whether the child has experienced adversity (such as sexual abuse) before

  • How well the family functions

  • Whether the child has family members with mental health disorders

  • Whether the child has family and social support

Did You Know...

  • Among young children, domestic violence is the most common cause of posttraumatic stress disorder.

Symptoms

Symptoms of acute stress disorder and posttraumatic stress disorder are similar and include several different types of symptoms.

Reexperiencing of the event (intrusion symptoms)

Children may reexperience the traumatic event while they are awake (flashbacks) or asleep (as nightmares). Flashbacks are usually triggered by something associated with the original event. For example, seeing a dog may trigger a flashback in children who were attacked by a dog. During a flashback, children may be terrified and unaware of their surroundings. They may temporarily lose touch with reality and desperately try to hide or escape, acting as though they are in great danger.

Less dramatically, children can reexperience the event in thoughts, mental images, or recollections, which are nonetheless greatly distressing. Young children may frequently reenact the event in play.

Avoidance of reminders (avoidance symptoms)

Children may persistently avoid things—activities, situations, or people—that remind them of the trauma. They may even attempt to avoid thoughts, feelings, or conversations about the traumatic event. They usually fail in their attempts to avoid remembering the event.

Negative effects on thinking and mood

Feeling emotionally numb or detached from their body is common. Children may lose interest in their usual activities, withdraw from other people, and worry about dying at a young age.

Children may also feel guilty—for example, because they survived when others did not or because they could do nothing to stop the event. They may not remember important details of the event or may remember it incorrectly. For example, they may think that they were responsible for it.

Changes in alertness and reactions

Children may become excessively alert for warning signs of risk. They may feel extremely tense (called hyperarousal), making them jittery, unable to relax, and easily startled.

Controlling their reactions is difficult, resulting in reckless behavior or angry outbursts. They may have difficulty relaxing, falling asleep, or concentrating.

Dissociative symptoms

Children feel detached from their body as if in a dream. They also feel that the world is unreal.

Diagnosis

  • History of a traumatic event

  • Symptoms

Diagnosis of a stress disorder is based on a history of a frightening, horrifying traumatic event followed by characteristic symptoms.

For acute stress disorder or posttraumatic stress disorder to be diagnosed, the symptoms must cause substantial distress or prevent children from functioning normally.

Acute stress disorder is diagnosed if symptoms last 3 days up to 1 month. Posttraumatic stress disorder is diagnosed if symptoms last more than 1 month.

Treatment

  • Psychotherapy

  • Behavioral therapy

  • Sometimes drugs

Supportive psychotherapy may help. Therapists reassure children that their response is valid but encourage them to face their memories (as a form of exposure therapy). Exposure therapy (see What Is Exposure Therapy?), a type of behavioral therapy, can be used to systematically desensitize children to situations that cause them to reexperience the event.

Children with acute stress disorder usually fare better than those with posttraumatic stress disorder, but children with either disorder benefit from early treatment.

A type of antidepressant called selective serotonin reuptake inhibitors (SSRIs) may help relieve some symptoms.

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