Acute and Posttraumatic Stress Disorders (ASD and PTSD) in Children and Adolescents

Only about 50% of PTSD cases have started with ASD (1). Pre-existing anxiety and depression are also risk factors for the development of PTSD and need to be considered in the assessment.

Other risk factors include (2):

• Severity of the trauma

• Associated physical injuries

• The underlying resiliency and temperament of children and family members

• Socioeconomic status

• Adversity during childhood (3)

• Family dysfunction

• Minority status

• Family psychiatric history

Symptoms of acute stress disorder (ASD) and posttraumatic stress disorder (PTSD) are similar and generally involve a combination of the following:

• Intrusion symptoms (eg, fear of reexperiencing the traumatic event): 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 marked physiologic reactions to 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 can also 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.

• Psychiatric assessment

• Diagnostic and Statistical Manual of Mental Disorders, Fifth edition, Text Revision (DSM-5-TR) criteria

Diagnosis of acute stress disorder (ASD) is based on a history of exposure to severely frightening and horrifying trauma followed by reexperiencing, emotional numbing, and hyperarousal (1). These symptoms must be severe enough to cause impairment or distress. Symptom duration is between 3 days and 1 month.

Diagnosis of PTSD is based on the same symptoms as ASD that lasts > 1 month. While some cases of PTSD appear to be a continuation of ASD or may manifest up to 6 months after the trauma, many cases of ASD resolve (2). Additional important diagnostic criteria include determining whether the disruption leads to notable distress or hindered performance in social, work, or other essential aspects of life. Clinicians must also exclude the physiological impact of a substance (such as medication or alcohol) or another medical condition that may be misinterpreted as PTSD.

• Timely, supportive psychosocial interventions

• Trauma-based psychotherapies

• Selective serotonin reuptake inhibitors (SSRIs) and sometimes antiadrenergic medications

For children and adolescents with acute stress disorder (ASD), the focus is on early screening and provision of brief psychosocial interventions (eg, supportive counseling, trauma-focused cognitive behavioral therapy). These measures, when implemented in a timely fashion, may promote natural recovery and prevent chronicity and progression to PTSD. 

Trauma-focused psychotherapies have been reported to be efficacious in children with PTSD (1, 2). These include cognitive therapy, child-parent psychotherapy, a blend of trauma-focused cognitive behavioral therapy and parent training, and eye movement desensitization and reprocessing (EMDR). In particular, EMDR, which refers to bilateral stimulation through guided eye movements while recalling the traumatic memory, is believed to help the brain reprocess the traumatic memory and its associated emotional charge. 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. Evaluating and treating concomitant risk factors (eg, depression, anxiety) is also important.

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 have not been conducted, and available evidence suggests that selective serotonin reuptake inhibitors (SSRIs) have limited use as first-line agents (3). However, in youths with comorbid anxiety, depression, and sleep difficulties, SSRIs can be helpful.

Antiadrenergic medications (eg, clonidine, guanfacine [Antiadrenergic medications (eg, clonidine, guanfacine [4], prazosin [], prazosin [5]) may help relieve hyperarousal symptoms, but supportive data are preliminary.

Prognosis is much better for children with acute stress disorder (ASD) than for those with posttraumatic stress disorder (PTSD), but both benefit from early treatment. Many children with ASD experience natural recovery within the first few months post-trauma, with many reporting a significant reduction in symptoms by 9 weeks (1). However, ASD can be predictive of later PTSD, especially in those who report early on more negative alterations in cognition and mood (2). Evaluating and treating anxiety and depression in PTSD is important.

Family and social support before and after the trauma moderates the final outcome.