Childhood & Short-Term Trauma Responses
Introduction to Childhood & Short-Term Trauma ResponsesTrauma & Stressor-Related Disorders in the DSM-5-TR
Overview of DSM-5-TR consisting of 6 Trauma and Stressor-Related Disorders, each requiring exposure to a traumatic or stressful event.
Definition and Etiology
Emphasis on differentiating between etiological factors and symptoms in understanding the diagnoses.
Reactive Attachment Disorder (RAD)
Key Insights:
Develops before age 5 due to extreme emotional neglect or instability in caregiving contexts.
Typical cases include institutionalized children, multiple foster placements, and homes with severe neglect.
A core feature is marked disturbance in attachment behavior (APA, 2022, DSM-5-TR).
Diagnostic Criteria for RAD
A. Consistent pattern of inhibited, emotionally withdrawn behavior towards caregivers with two behaviors required:
Rarely seeking comfort during distress.
Rarely responding to comfort during distress.
B. Persistent social and emotional disturbance with at least two symptoms of:
Minimal social/emotional responsiveness to others.
Limited positive affect.
Unexplained irritability, sadness, or fearfulness during nonthreatening interactions.
C. Documentation of extreme insufficiency in care exemplified through one or more scenarios:
Social neglect or deprivation through inadequate emotional care.
Frequent changes in primary caregivers leading to attachment disruption.
Placement in environments limiting attachment opportunities.
D. Disturbances in A must relate directly to the care deficiencies noted in C.
E. Exclusion of autism spectrum disorder as a diagnosis.
F. Symptoms must manifest before age 5.
G. The child must have a developmental age of at least 9 months.
Specifiers for RAD Diagnosis
Persistent: Duration exceeds 12 months.
Severe: All symptoms presented at high levels.
Prevalence is low in the general population but higher in high-risk contexts like institutional settings.
Rule Out Factors
Assess for alternative explanations like:
Intellectual disability
ADHD
PTSD
Early intervention may improve outcomes by promoting nurturing environments.
Comorbidities and Untreated Outcomes
Untreated conditions may lead to:
ADHD
Social relationship issues
Emotional dysregulation
Treatment Considerations for RAD
Important strategies include:
Establishing a safe and nurturing environment.
Providing caregiver training and support.
Implementing child-parent psychotherapy.
Utilizing play therapy to engage the child and promote attachment.
Disinhibited Social Engagement Disorder (DSED)
Developmental age required is at least 9 months, with behaviors often appearing in early childhood or later.
Underlying etiology includes severe neglect and caregiver instability.
Diagnostic Criteria for DSED
A. Child interacts actively with unfamiliar adults, requiring at least two behaviors:
No reticence in engaging strangers.
Overly familiar behaviors inappropriate to cultural norms.
Little or no return check with caregivers.
Readiness to accompany unknown adults without caution.
B. Symptoms are not merely impulsivity but reflect socially disinhibited behavior.
C. Manifestation of insufficient care evidenced by:
Persistent social neglect or emotional deprivation.
Repeated changes in primary caregivers.
Care settings severely limiting attachment chances.
D. Developmental age must be at least 9 months, with no upper age cutoff, supporting persistence into middle childhood/adolescence under severe conditions.
Specifiers for DSED Diagnosis
Persistent: Symptoms have existed for over 12 months.
Severe: High intensity of symptoms.
Prevalence rates are low in community settings but increase in high-risk populations.
Rule Out and Untreated Outcomes
Considerations for possible alternative diagnoses:
Intellectual disability
ADHD
PTSD
Common comorbidities include:
Developmental and language delays.
Untreated conditions can lead to similar issues as noted in RAD.
Treatment Considerations for DSED
Emphasis on:
Safe, nurturing environments.
Psychotherapy focused on safety and boundary establishment.
Social skills training to develop healthy interactions with peers and caregivers.
Case Vignettes: Ava & Leo
Ava: A 6-year-old girl in foster care showing minimal emotional engagement and significant withdrawal stemming from early neglect; resistant to comfort and interaction.
Leo: A 7-year-old boy who engages in excessive familiar behavior with strangers due to severe neglect and repeated caregiver changes; struggles with emotional regulation and pose safety risks due to impulsivity.
Discussion Points on Case Vignettes
Assess underlying behavioral origins for both children.
Identify potential diagnoses for Leo and Ava, respectively.
Discuss treatment adaptations based on differential diagnoses.
Acute Stress Disorder (ASD)
Defined as a short-term anxiety response to trauma, typically present within a 3-day to 1-month period following the event.
Diagnostic Criteria for ASD
A. Exposure to death, serious injury, or sexual violation by various means:
Direct experience or witnessing events.
Learning of violent/accidental death of a loved one.
Repeated exposure to details of traumatic events.
Core Symptoms
Symptoms categorized as follows:
Intrusion: Memories, distressing dreams, flashbacks.
Negative Mood: Difficulty experiencing positive emotions.
Dissociation: Altered reality perception.
Avoidance: Efforts to circumvent thoughts or reminders related to trauma.
Arousal: Symptoms include sleep disturbances, irritability, hypervigilance.
Additional Diagnostic Criteria
Patient must exhibit nine or more symptoms categorized as above for diagnosis.
Disturbance must cause clinically significant impairment and not be attributable to substances or other conditions.
Example Discussion of ASD in Video Reference
Behavioral observations provided in referenced video showcasing symptoms aligned with ASD following trauma exposure.
Specifics on Prevalence
ASD rates following trauma vary significantly based on type of traumatic event:
20% of individuals exposed to traumatic events may experience ASD.
Higher rates documented across specific trauma types, such as 59% in rape victims.
Comorbidities and Differentiation
Common comorbidities include:
Acute pain and brain injury symptoms.
Important to differentiate ASD from acute grief reactions and substance effects.
Treatment Strategies for ASD
Focus on providing support and normalizing symptoms.
Emphasize safety and meeting basic needs while monitoring symptoms.
Use of trauma-focused cognitive behavioral therapy (TF-CBT) to structure treatment.
Prolonged Grief Disorder (PGD)
Newly included in DSM-5-TR; characterized by intense grief lasting beyond culturally expected norms post-loss.
Diagnostic Criteria for PGD
A. Death of a close individual must occur at least 12 months prior for adults, 6 months for children.
B. Grief response must include yearning/pattern of thought focusing on the deceased nearly every day.
C. Must also exhibit at least three additional symptoms of significant emotional pain, identity disruption, or reintegration difficulties.
Core Disturbances of PGD
Identified symptoms can significantly impact functioning, encompass disbelief, avoidance of reminders, and emotional numbness.
A critical component is the duration and intensity of symptoms exceeding cultural norms.
Prevalence and Comorbidity of PGD
Estimates suggest 1-10% of bereaved adults experience PGD, with a slightly higher prevalence noted in children/adolescents.
Common comorbidities may include major depressive disorder, PTSD, sleep disturbances, and substance use issues.
Treatment Considerations for PGD
Suggested interventions include:
Complicated grief therapy (CGT)
Cognitive behavioral therapy (CBT)
Group therapy as a supportive mechanism
Pharmacotherapy for accompanying anxiety/depression symptoms.