TRAUMA- AND STRESSOR-RELATED DISORDERS
Trauma- and stressor-related disorders are a new category in DSM-5 (American Psychiatric Association 2013) that includes reactive attachment disorder, disinhibited social engagement disorder, posttraumatic stress disorder, acute stress disorder, and adjustment disorders.
REACTIVE ATTACHMENT DISORDER AND DISINHIBITED SOCIAL ENGAGEMENT DISORDER
Attachment disorders develop in early childhood as a result of severely deficient caregiving environments. They comprise two patterns, which DSM-5 divides into two clinical disorders. In reactive attachment disorder (RAD), young children fail to focus attachment behaviors toward a preferred caregiver. They do not seek or respond to comfort, and they have reduced social and emotional reciprocity, reduced positive affect, increased irritability or fearfulness, and disturbances of emotional regulation. Symptoms must be apparent before age 5 years. In disinhibited social engagement disorder (DSED), children show lack of wariness of strangers, will indiscriminately approach unfamiliar adults, and may interact with adults in an overly proximate or intrusive way. Attachment disorders cannot be diagnosed before the child has a developmental age of 9 months, when focused attachment is expected to occur.
In an economically deprived urban population sample in the United Kingdom, the prevalence of attachment disorders was 1.4% (Minnis et al. 2013). Prevalence of attachment disorders is highly dependent on the environment of the population studied.
RAD and DSED both arise from a background of extreme insufficient care. Abuse may have also been present. DSM-5 requires at least one of the following in the patient’s history: social neglect or deprivation with persistent unmet needs for comfort, stimulation, and affection; repeated changes of primary caregivers (as in frequent changes of foster placements or extremely disorganized families); or rearing in unusual settings that severely limit opportunities to form selective attachments (e.g., institutional settings with a high child-to-caregiver ratio). Children with Williams syndrome may exhibit a behavioral phenotype very similar to DSED, but they are not given the DSED diagnosis because the symptoms do not stem from a history of deprivation or abuse. Not all children who experience neglect or institutionalization will develop an attachment disorder. Factors that may contribute include length of time in an institution, the age at which a corrective attachment opportunity occurs, the presence of growth retardation, and genetic predisposition.
Course and Prognosis
Symptoms of RAD generally improve and may eventually resolve if affected children are placed in supportive, sensitive, and secure foster or adoptive homes. With placement in an environment where the child can develop secure attachments, some children with DSED will have marked reduction in indiscriminate behavior, but others will have continued difficulty with peer relationships. Long-term outcomes for adult interpersonal or occupational function are not known for either RAD or DSED.
Attachment disorders are diagnosed through assessment instruments completed by caregivers and by clinical observation. The history of the caretaking environment is key. The Strange Situation Procedure, in which the child is alternately exposed to his or her mother and then a stranger, is one formal way to assess the quality of attachment, although it was not designed for routine clinical use. Clinically based structured observations of attachment have been developed (see Zeanah et al. 2016 in Additional Reading).
RAD and DSED are most often diagnosed in children who have already been institutionalized or identified as victims of neglect. If the child is residing with his or her parent(s) and exhibiting symptoms of an attachment disorder, evaluation of the parent’s (parents’) capacity and willingness to provide adequate care is indicated.
RAD can be differentiated from autism spectrum disorder by improvement in cognitive and social deficits when children with RAD are placed in a caring environment and the absence in RAD of abnormalities in social communication and restricted interests and preoccupations that are characteristic of autism. Global developmental delay, depression, and posttraumatic stress disorder are in the differential diagnosis for RAD. There is overlap between symptoms of DSED and attention-deficit/hyperactivity disorder (ADHD). If criteria are met, both may be diagnosed.
For both RAD and DSED, the core feature of treatment is placing the child in a nurturing environment with the opportunity to form secure attachment. For children who will remain in their family of origin, specific parent training fosters improved attachment (Bernard et al. 2012). The therapeutic approach generally involves working with the caregiver and with the caregiver-child dyad to strengthen attachment. There is no role for psychopharmacological treatment for the core symptoms of RAD or DSED (Zeanah and Gleason 2015).
POSTTRAUMATIC STRESS DISORDER AND ACUTE STRESS DISORDER
Posttraumatic stress disorder (PTSD) encompasses the emotional, cognitive, behavioral, and physiological reactions that may occur after directly experiencing, witnessing, or learning of a loved one’s experience of a traumatic event, such as actual or threatened death, serious injury, or sexual violence. Examples of traumatic events that may affect children and adolescents include child abuse; domestic, community, or school violence; natural disasters; vehicular or other accidents; medical traumas; war, terrorism, or refugee trauma; or the traumatic death of significant others. DSM-5 no longer classifies PTSD as an anxiety disorder. The diagnostic symptom clusters have been expanded from three to four: intrusion symptoms (memories, dreams, dissociative reactions, distress or physiological reactions in response to reminders), avoidance of internal or external reminders of the event(s), negative mood or cognition symptoms, and symptoms of altered arousal (anger or irritability, reckless or self-destructive behavior, hypervigilance, exaggerated startle response, difficulty concentrating, and sleep disturbance).
Based on research that identified developmental factors affecting symptom presentation, alternative DSM-5 diagnostic criteria have been added for children 6 years and younger. Even older children may express symptoms differently than older adolescents or adults. Intrusive symptoms in children may be expressed through repetitive, trauma-themed play or trauma-themed reenactment. Children may report “scary” dreams but not be able to fully verbalize nightmares. Reminders of the trauma may trigger somatic symptoms. Avoidance of trauma cues may manifest as increased clinginess or separation anxiety fears. Negative alterations in mood or cognition may present as confusion, forgetfulness, alterations in concentration, inhibition, sense of foreshortened future, preoccupation with death of self or loved ones, self-blame (that may lead to lack of disclosure in situations of abuse), and behavioral regression. Although children may accurately remember many details of the experience, sequencing or duration of events is often distorted. Alterations in arousal may manifest as temper outbursts, irritability, physical or verbal aggression, emotional numbing, hypoactivity, sleep disturbance, and increased awareness of the environment. Perceptual distortions can occur, including tactile, olfactory, visual, and auditory misperceptions.
The diagnosis of PTSD requires symptom duration of at least 1 month. Acute stress disorder refers to trauma-reactive symptoms that last for at least 3 days but no longer than 30 days. Other than duration, acute stress disorder has diagnostic criteria similar to those for PTSD, and both disorders cause significant distress or impairment in social, occupational, or other important areas of functioning.
The rate of experiencing a traumatic event in childhood or adolescence is as high as 25% (Costello et al. 2002). Fortunately, the majority of individuals who experienced such an event do not develop PTSD. Prevalence rates of acute stress disorder range from 14% to 51% (Kassam-Adams et al. 2012). In a recent meta-analysis, the rate of childhood PTSD was estimated at 16% (Alisic et al. 2014). Rates varied with gender and type of trauma. Girls with a history of interpersonal trauma developed PTSD at rates of nearly 33%, compared with 8.4% in boys with a history of non-interpersonal trauma. Rates of both trauma exposure and PTSD are higher in girls than in boys. Risk of development of PTSD is increased with more intense or longer trauma exposure, proximity to the traumatic event, presence of potential serious injury or violence, and interpersonal violence (particularly if a parent or caregiver is the perpetrator). Risk factors identified for developing PTSD after a disaster include media exposure, peritraumatic panic symptoms, delayed evacuation, sense of endangerment, and premorbid anxiety disorder (Cohen and Mannarino 2016).
For diagnosis of PTSD and acute stress disorder, DSM-5 requires an identifiable etiological agent (i.e., the extreme traumatic event). Type of traumatic event may predict development of acute stress disorder, with higher rates in children who have experienced bodily injury, pain, or violence. Children who have experienced multiple stressors, prior loss, disturbances in family functioning, or psychiatric comorbidity are vulnerable to more severe and prolonged symptoms, but a sufficiently severe stressor can produce the disorder in a person without any predisposition. The onset of PTSD likely involves a complicated interaction of neuroendocrine dysregulation with genetic, psychological, and social factors (Caspi et al. 2002). Abuse or neglect of children may cause cognitive and developmental delays as well as increased arousal or withdrawal secondary to changes in brain physiology. Given the high degree of comorbidity with both internalizing and externalizing disorders, it is possible that trauma affects functioning in a more generalized manner.
Course and Prognosis
Whether a “natural recovery” occurs from PTSD is controversial. One meta-analysis found that without intervention, 50% of children and adolescents no longer met PTSD symptom criteria 6 months posttrauma (Hiller et al. 2016). However, other studies have found maintenance of PTSD symptoms with time (Scheeringa et al. 2005). Predictors of acute stress disorder symptom persistence in youth with severe injuries were female gender, presence of peritraumatic dissociation, and lower socioeconomic status (Brown et al. 2016). Another study found no difference in rates of acute stress disorder and PTSD rates in boys who had been traumatized in motor vehicle accidents versus assault. Presence of dissociation and hyperarousal symptoms predicted development of PTSD (Meiser-Stedman et al. 2005). In addition to the initial trauma, disasters often result in loss of home, isolation from usual social supports, and loss of parents or other family members, all of which can exacerbate the PTSD. Symptoms may be partially ameliorated by a stable, cohesive, and supportive family and safe environment. In cases of child abuse or domestic violence, potential legal and child welfare involvement, which may lead to disruption of the family unit, numerous interviews, or change in homes, may also trigger or prolong trauma-reactive symptoms.
Symptoms of anxiety (especially separation anxiety disorder) or depression may be prominent. Impulsivity, difficulty concentrating, and decreased motivation may interfere with school performance. Many traumatized children develop a chronic sense of pessimism and hopelessness about the future. For the subset of youth with persistent PTSD, prognosis is poor if untreated. PTSD in childhood is a significant risk factor for adult suicide attempts, major depression, dissociation, and impaired overall functioning (Warshaw et al. 1993). Maltreatment in childhood significantly increases the risk of adult depression and anxiety (Li et al. 2016). A history of sexual or physical abuse during childhood is associated with increased risk of lifetime psychopathology, particularly for women (MacMillan et al. 2001).
Evaluation and Differential Diagnosis
At the time of clinical presentation, a traumatic event may or may not be known. Acute stress disorder or PTSD should be suspected in any child or adolescent who has had a significant change in behavior or emotional state. Multiple informants should be interviewed, as avoidance can lead to underreporting, the child may have difficulty describing trauma and symptoms, and caregivers may not know about or wish to disclose the trauma and may not be aware of the child’s emotional reaction. The developmental history may suggest increased vulnerability. The Child PTSD Symptom Scale (Foa et al. 2001) and the Child Stress Disorders Checklist (Saxe et al. 2003) are potentially useful rating scales. Teacher observations regarding changes in school behavior or achievement can contribute to the evaluation.
Comorbidity is common in PTSD and frequently includes mood, anxiety, and/or behavioral disorder diagnoses. Acute stress disorder and PTSD are distinguished from adjustment disorder by the severity and type of the stressor and the distinctive trauma-related symptoms, such as repetitive re-experiencing. PTSD can mimic many other disorders (any of which could be comorbid), such as ADHD, oppositional defiant disorder, panic disorder, social anxiety disorder, depression, substance use, bipolar disorder, psychotic disorders, or a variety of physical conditions.
Established by Congress in 2000, the National Child Traumatic Stress Network (www.nctsn.org) serves as a resource for developing and disseminating evidence-based treatment and education.
Early identification of at-risk youth following a traumatic event can greatly lessen psychological morbidity. A preventative approach that includes screening and rapid referral to appropriate services is particularly applicable to traumas that affect many children (i.e., natural disasters). The Child and Family Traumatic Stress Intervention (CFTSI; Berkowitz et al. 2011), a four-session intervention that incorporates psychoeducation, relaxation training, and coping skills training, was more effective than care-as-usual in preventing progression to PTSD.
Evidence-based psychotherapy treatment models for youth with PTSD symptoms (described in Cohen and Mannarino 2016) share the following components: developmental and cultural sensitivity; informed by the neurobiological impact of trauma on children; inclusion of parents/caretakers/families; and aims of reestablishing safety and trust and addressing trauma reminders and significant areas of dysfunction. Selection among the evidence-informed treatments for an individual child is influenced by developmental level, treatment setting, acceptance by the family, type of trauma, and other individual factors. Trauma-focused cognitive-behavioral therapy (TF-CBT) has the strongest empirical support. TF-CBT treatment components are summarized by PRACTICE: Psychoeducation and Parenting skills, Relaxation, Affective modulation, Cognitive processing, Trauma narrative, In vivo mastery of trauma memories, Conjoint child-parent sessions, and Enhancing safety. Cognitive-Behavioral Intervention for Trauma in Schools (CBITS) is a model that adapts TF-CBT to group therapy during the school day with limited parental involvement. Child-Parent Psychotherapy (CPP), a relationship-based model with some empirical support, is designed to improve interactions between young children and parents. Individual trauma-focused CBT for single-episode traumas, called Cognitive-Based CBT, has been developed and studied. More specialized modalities include the Surviving Cancer Competently Intervention Program (SCCIP), Trauma Grief Component Therapy for Adolescents (TGCT-A), Trauma Systems Therapy (TST), and Narrative Exposure Therapy for Children (KidNET; for youth exposed to war and refugee experiences). Other models, designed to address complex trauma or trauma with comorbidity, have shown some promising results. Trauma Affect Regulation: Guidelines for Education and Therapy (TARGET; Ford et al. 2012) was shown to be effective for girls in the juvenile justice system with complex trauma. The adolescent adaptation of Seeking Safety, a treatment curriculum for youth with PTSD and substance use disorders, is promising (Najavits et al. 2006). Web-based curricula have been developed to enhance dissemination of evidence-based treatments. It is important to screen for trauma-reactive symptoms in the parent or caregiver, who may have had shared or prior trauma, and refer for treatment if needed. Parental trauma-related symptoms predict greater symptoms in children.
Treatment of PTSD in youth should start with psychotherapy (rather than pharmacotherapy) unless there is a compelling reason to add medication, such as a comorbid diagnosis that requires medication, clear dangerousness requiring immediate medication, or severe symptoms that persist despite psychotherapy. No randomized control trials have demonstrated efficacy of medication in pediatric PTSD. Limited evidence suggests that selective serotonin reuptake inhibitors, propranolol, clonidine, prazosin (for nightmares), morphine (for pain in burn victims), or risperidone can benefit traumatized youth (Cohen and Mannarino 2016). However, because of weak empirical support and the high placebo response in youth, medications should be used only if necessary.
Adjustment disorder is characterized by the development of emotional and/or behavioral symptoms within 3 months of the onset of a stressor. Diagnosis requires marked distress that is out of proportion to the severity or intensity of the stressor and/or significant functional impairment. In DSM-5 (American Psychiatric Association 2013), adjustment disorders are classified as stressor-related disorders, instead of the prior residual category for subdiagnostic threshold clusters of symptoms. An adjustment disorder may be diagnosed in a person with another mental disorder only if an identifiable stressor leads to the development of symptoms that are not characteristic of the original disorder. Adjustment disorders have six subtypes, classified by patterns of symptoms of depression, anxiety, and behavior (conduct).
Common stressors in childhood and adolescence include parental divorce, change in schools, physical illness, the birth of a sibling, parental unemployment, and abuse or neglect. Adolescents may be particularly vulnerable to disruptions in a relationship with a boyfriend or girlfriend. Normal bereavement is exclusionary.
The prevalence of adjustment disorders in community samples of youth is between 2% and 8%. Populations with particularly severe stressors (i.e., surgical patients) have high rates of adjustment disorder. Children and adolescents usually have mixed presentations, with symptoms that are not exclusively emotional (mood, anxiety) or behavioral.
The adjustment disorder is presumed to be precipitated by the identified stressor. The child’s reaction to the stressor rather than the characteristics of the stressor determine whether the diagnosis is present. Even if the patient’s emotional response to the stressor is developmentally expected, if the symptom presentation is causing significant impairment, a diagnosis of adjustment disorder is made.
Course and Prognosis
Symptoms of adjustment disorder will typically remit when the stressor is removed or when a new level of adaptation is reached. By definition, if the disorder lasts for more than 6 months after the stressor or its consequences have stopped, then a different diagnosis is warranted. The prognosis depends on the severity and duration of the stressor and its meaning to the child; the vulnerability of the individual; and the response of the family, school, and peers to both the stressor and the young person’s reaction. In general, the prognosis is assumed to be benign, although patients can present with suicidal ideation and/or behavior, substance abuse, or recurrent somatic complaints. Patients with adjustment disorder are more frequently seen in medical emergency rooms and admitted to inpatient units than are control groups without psychiatric symptoms.
Follow-up of adolescents 5 years after receiving a clinical diagnosis of adjustment disorder found that 57% were well, although 23% of these patients had qualified for another psychiatric diagnosis during the intervening period. Research diagnoses at follow-up included schizophrenia, affective disorders, antisocial personality disorder, and substance abuse disorders. One patient had committed suicide (Andreasen and Hoenk 1982). Another study found a 25% rate of suicidal ideation, suicide threats, or suicide attempts in clinic-referred adolescent outpatients diagnosed with adjustment disorder (Pelkonen et al. 2005).
Evaluation and Differential Diagnosis
The clinician should obtain reports from the child, parent, and teacher to identify all stressors, rather than assuming that the first reported or obvious stressor is the crucial one. Other psychiatric diagnoses should be sought, and if diagnostic criteria are met, the diagnosis of adjustment disorder is precluded. In the past, overuse of the diagnosis of adjustment disorder (in an effort to avoid “labeling” children) has often obscured another psychiatric diagnosis. If the reaction to the death of a loved one exceeds what might be expected in intensity, quality, or persistence, then persistent complex bereavement disorder (included in DSM-5 under Conditions for Further Study) should be considered. If specific psychological aspects (emotional symptoms and behaviors) exacerbate a medical condition (e.g., asthma or diabetes), then psychological factors affecting other medical conditions should be considered. In contrast, adjustment disorder is descriptive of the reaction to the illness. If the stressor is sudden and catastrophic or potentially so, and the other diagnostic criteria are met, then acute stress disorder or PTSD should be considered.
Crisis intervention and time-limited psychotherapy techniques may be useful for treatment of adjustment disorder. Cognitive therapy to improve coping skills and problem-solving abilities and to reduce dysfunctional thoughts and beliefs in reaction to the stressor may be beneficial. Environmental intervention may be indicated to remove or ameliorate the stressor and to mobilize family and community support systems. Explanations to parents and teachers of the child’s or adolescent’s reactions may reduce impairment and shorten the course of the disorder. Treatments established for similar diagnoses may be useful. For example, if adjustment disorder with depressed mood is debilitating, the same treatments as for major depression may be indicated.
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