* This is the Professional Version. *
Acute and Posttraumatic Stress Disorders (ASD and PTSD) in Children and Adolescents
Acute stress disorder (ASD—see page Acute Stress Disorder (ASD)) and posttraumatic stress disorder (PTSD—see page Posttraumatic Stress Disorder (PTSD)) are reactions to traumatic events (see page Overview of Trauma and Stressor-Related Disorders). 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 mo. PTSD can be a continuation of ASD or may manifest up to 6 mo after the trauma and lasts for > 1 mo. Diagnosis is by clinical criteria. Treatment is with behavioral therapy and sometimes with SSRIs or antiadrenergic drugs.
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.
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.
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 yr, 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
Altered 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: 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 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 mo are considered ASD. Patients must have a number of manifestations in different symptom areas; specific criteria for ASD and PTSD in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) differ slightly.
Prognosis is much better for children with ASD than for those with PTSD, but both benefit from early treatment. Risk factors include severity of the trauma, associated physical injuries, the underlying resiliency and temperament of children and family members, socioeconomic status, adversity during childhood, family dysfunction, minority status, and family psychiatric history. Family and social support before and after the trauma moderates the final outcome.
SSRIs often help reduce emotional numbing and reexperiencing of symptoms but are less effective for hyperarousal. Antiadrenergic drugs (eg, clonidine, guanfacine, prazosin) may help relieve hyperarousal symptoms, but supportive data are preliminary.
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. Behavioral therapy is clearly effective in reducing distress and impairment in children and adolescents with PTSD.
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* This is the Professional Version. *