Childhood & Short-Term Trauma Responses and DSM-5-TR Diagnoses

Introduction to Trauma & Stressor-Related Disorders

• DSM-5-TR Overview

  • The Diagnostic and Statistical Manual of Mental Disorders, 5^{th} Edition, Text Revision (DSM-5-TR) includes six Trauma and Stressor-Related Disorders.

  • Key Commonality: All these disorders necessitate exposure to a traumatic or stressful event (etiological factors) as a prerequisite, rather than merely presenting with symptoms.

• Initial Discussion Points (Contextualizing Early Life Trauma vs. Acute Events, Types of Loss)

  • Consider how early caregiving disruptions (e.g., neglect, unstable placements) might manifest differently from a child's immediate reaction to a single traumatic event.

  • Reflect on the distinct emotional experience of losing a caregiver through death versus losing one through neglect or instability.

• Ethical Considerations in Classifying Grief (Gurley-Green, et al., 2024)

  • Potential Benefits and Harms of Classifying Prolonged Grief as a Psychiatric Disorder: This raises questions about whether medicalization helps or pathologizes a natural human experience.

  • Medicalization's Impact on Societal Views of Grief: How might this shift perception from grief as a human experience to a clinical condition?

  • Ecopsychosocial Approach to Grief: Authors propose this framework, suggesting it addresses dimensions (e.g., ecological, social) that biomedical models may overlook, offering a more holistic understanding.

Reactive Attachment Disorder (RAD)

• Definition and Core Features

  • A markedly disturbed and developmentally inappropriate attachment behavior. (APA, 2022, DSM-5-TR)

  • Disturbance is evident before age 5.

  • Arises from extreme emotional neglect or instability in caregiving, such as institutionalized orphans, multiple foster care placements, severe parental neglect, emotional non-responsiveness, or abusive/isolating homes.

• Diagnostic Criteria (A-G)

  • A. Consistent pattern of inhibited, emotionally withdrawn behavior toward adult caregivers, manifested by both of the following:

    • The child rarely or minimally seeks comfort when distressed.

    • The child rarely or minimally responds to comfort when distressed.

  • B. Persistent social and emotional disturbance, with at least 2 of the following:

    • Minimal social/emotional responsiveness to others.

    • Limited positive affect.

    • Episodes of unexplained irritability, sadness, or fearfulness evident even during nonthreatening interactions with caregivers.

  • C. The child has experienced a pattern of extremes of insufficient care, evidenced by at least 1 of the following:

    • Persistent social neglect or deprivation (lack of basic emotional needs for comfort, stimulation, and affection met by caregivers).

    • Repeated changes of primary caregivers that limit stable attachments (e.g., frequent foster care changes).

    • Rearing in unusual settings with severely limited attachment opportunities (e.g., institutions with high child-to-caregiver ratios).

  • D. Causal Link: The care in Criterion C must precede and explain the pattern of behavior in Criterion A (e.g., disturbances in Criterion A began following the lack of adequate care in Criterion C).

  • E. The criteria are not met for autism spectrum disorder.

  • F. The disturbance is evident before age 5 years.

  • G. The child has a developmental age of at least 9 months.

• Specifiers

  • Persistent: The disorder has been present for more than 12 months.

  • Severe: All symptoms are present at relatively high levels.

• Prevalence & Risk Factors

  • Low prevalence in community samples, not precisely established.

  • Rates are higher in high-risk contexts (e.g., institutional rearing, repeated caregiver changes).

  • No known difference in prevalence by gender.

• Differential Diagnosis (Rule Outs)

  • Intellectual disability

  • ADHD

  • PTSD

• Comorbidities

  • Developmental Delays

  • Language Delays

• Long-Term Outcomes (Untreated)

  • ADHD

  • Social relationship problems

  • Emotional dysregulation

• Treatment Considerations

  • Providing a safe, nurturing, caring, and stable environment.

  • Caregiver training and support.

  • Child-parent psychotherapy.

  • Play Therapy.

• Case Vignette: Ava

  • Ava, a 6-year-old, shows little emotional responsiveness, avoids comfort when upset, and resists physical touch after severe neglect and caregiver changes. She is socially withdrawn, with flat affect and occasional unexplained irritability, and "doesn't seem to connect." This aligns with RAD, particularly the inhibited and emotionally withdrawn patterns.

Disinhibited Social Engagement Disorder (DSED)

• Definition and Core Features

  • Core Feature: Indiscriminately social behavior and a lack of appropriate boundaries with unfamiliar adults.

  • Requires a developmental age of \geq 9 months (meaning the child has reached social-emotional milestones typical of a 9-month-old).

  • Behaviors often emerge in early childhood and can persist beyond it (no upper age cutoff).

  • Arises from severe neglect and instability.

• Diagnostic Criteria (A-D)

  • A. Child actively approaches and interacts with unfamiliar adults and exhibits at least 2 of the following:

    • Reduced or absent reticence in approaching unfamiliar adults (i.e., no shyness or fear of strangers).

    • Overly familiar verbal or physical behavior that is not culturally or developmentally appropriate (e.g., hugging or sitting on the lap of strangers).

    • Diminished or absent "checking back" with caregiver after venturing away, even in unfamiliar settings.

    • Willingness to go off with an unfamiliar adult with little or no hesitation.

  • B. The behaviors in Criterion A are not limited to impulsivity (as in ADHD) but specifically include socially disinhibited behavior.

  • C. The child has experienced a pattern of extremes of insufficient care as evidenced by at least one of the following:

    • Social neglect or deprivation (persistent lack of basic emotional needs for comfort, stimulation, and affection met by caregiving adults).

    • Repeated changes of primary caregivers that limit opportunities to form stable attachments (e.g., frequent changes in foster care).

    • Rearing in unusual settings that severely limit opportunities to form selective attachments (e.g., institutions with high child-to-caregiver ratios).

  • D. The child has a developmental age of at least 9 months (no upper age cutoff) (Zeanah & Gleason, 2015). These behaviors can persist into middle childhood/adolescence, especially after institutional rearing.

• Specifiers

  • Persistent: Present for more than 12 months.

  • Severe: Child exhibits all symptoms of the disorder at high levels of intensity.

• Prevalence & Risk Factors

  • Low prevalence in community samples, not precisely established.

  • Rates are higher in high-risk contexts (e.g., institutional rearing, repeated caregiver changes).

• Differential Diagnosis (Rule Outs)

  • Intellectual disability

  • ADHD

  • PTSD

• Comorbidities

  • Developmental Delays

  • Language Delays

• Long-Term Outcomes (Untreated)

  • ADHD

  • Social relationship problems

  • Emotional dysregulation

• Treatment Considerations

  • Providing a safe, nurturing, caring, and stable environment.

  • Psychotherapy with a focus on safety and boundary setting.

  • Social Skills Training.

• Case Vignette: Leo

  • Leo, a 7-year-old, frequently hugs unfamiliar adults, seeks physical affection from new acquaintances, and shows little "checking back" with caregivers. He has tried to leave with strangers, and these behaviors are not explained by impulsivity. This indiscriminately social and boundary-less behavior is characteristic of DSED.

Acute Stress Disorder (ASD)

• Definition and Core Features

  • A short-term reaction to a traumatic event.

  • Core Features: Severe anxiety and stress response occurring immediately after a traumatic experience.

• Duration

  • Symptoms must last a minimum of 3 days and a maximum of 1 month post-event.

  • Must cause significant distress or impairment in functioning and cannot be attributed to substance abuse, medical illness, or a brief psychotic disorder.

• Diagnostic Criteria (A-E)

  • A. Exposure to actual or threatened death, serious injury, or sexual violation in one (or more) of the following ways:

    • Directly experiencing the traumatic event(s).

    • Witnessing, in person, the event(s) as it occurred to others.

    • Learning that the traumatic event(s) occurred to a close family member or close friend (in cases of actual or threatened death, the event(s) must have been violent or accidental).

    • Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting human remains, police officers repeatedly exposed to details of child abuse). Note: Criterion A4 does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work-related.

  • B. Presence of nine (or more) of the following symptoms from any of the five categories:

    • Intrusion:

      • Recurrent, involuntary, and intrusive distressing memories of the event(s).

      • Recurrent distressing dreams related to the event(s).

      • Dissociative reactions (e.g., flashbacks).

      • Intense or prolonged distress/physiological reactions to reminders.

    • Negative Mood:

      • Persistent inability to experience positive emotions (e.g., happiness, satisfaction, loving feelings).

    • Dissociation:

      • Altered sense of reality (e.g., feeling in a daze, time slowing, detached from self).

      • Inability to remember an important aspect of the trauma (not due to head injury, alcohol, or drugs).

    • Avoidance:

      • Efforts to avoid distressing memories, thoughts, or feelings about the trauma.

      • Efforts to avoid external reminders (people, places, conversations, activities, objects, situations).

    • Arousal:

      • Sleep disturbance.

      • Irritable behavior/angry outbursts.

      • Hypervigilance.

      • Problems with concentration.

      • Exaggerated startle response.

  • C. Duration of the disturbance (symptoms in Criterion B) is 3 days to 1 month after trauma exposure.

  • D. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

  • E. The disturbance is not attributable to the physiological effects of a substance (e.g., medication or alcohol) or another medical condition and is not better explained by a brief psychotic disorder.

• Prevalence

  • About 20%_\text{ of people exposed to traumatic events}.

  • Rates vary based on trauma type: 13\%-21\%\text{ for car accident survivors}, 14\%\text{ for traumatic brain injuries}, 24\%\text{ for assault}, 59\%\text{ for rape victims}.

  • Interpersonal traumas tend to yield higher ASD rates.

  • Note: These rates are based on DSM-IV ASD criteria and may differ with DSM-5 criteria.

• Comorbidities

  • Acute pain from injuries and mild traumatic brain injury (concussion) symptoms often overlap.

  • Panic Attacks.

  • Elevated Risks: Developing PTSD, depression, substance abuse.

• Differential Diagnosis

  • Acute grief reactions.

  • Brief psychotic disorder.

  • TBI effects.

  • Intoxication/withdrawal.

• Treatment Considerations

  • Emphasis on support, normalization of symptoms, psychoeducation, and monitoring patient progress.

  • Ensuring safety and basic needs are met.

  • Trauma-Focused Cognitive Behavioral Therapy (TF-CBT), including psychoeducation, anxiety management, and gradually processing trauma.

  • Exposure-based interventions, helping the person safely revisit the trauma memory or cues.

Prolonged Grief Disorder (PGD)

• Core Features & Recent Addition to DSM-5-TR

  • Just added in the DSM-5-TR, recognizing an intense, persistent grief response to loss, far beyond the "expected social/cultural norms of grieving."

  • Must cause significant distress or impairment in functioning.

• Ethical/Societal Considerations

  • The inclusion of PGD in the DSM-5-TR prompts discussion on the medicalization of grief, a natural human experience.

  • Albert Gyorgy's "Melancholy" sculpture, representing the void felt after losing someone, metaphorically illustrates the profound nature of grief that PGD attempts to clinically define.

• Diagnostic Criteria (A-F)

  • A. The individual experienced the death of a person who was close to them, at least 12 months ago for adults (at least 6 months ago for children and adolescents).

  • B. Since the death, the individual experiences, on more days than not, to a clinically significant degree, and nearly every day for at least the last month:

    • Intense yearning/longing for the deceased (in children, may be expressed through play and behavior, such as a desire to be reunited). OR

    • Preoccupation with thoughts or memories of the deceased (in children, preoccupation may focus on the circumstances of the death).

  • C. In addition, at least three (or more) of the following symptoms must be present, nearly every day, to a clinically significant degree, and for at least the last month:

    • Identity disruption (e.g., feeling as though part of oneself has died).

    • Sense of disbelief about the death.

    • Avoidance of reminders that the person is dead (in children, may include avoidance of situations that remind them of loss).

    • Intense emotional pain (e.g., anger, bitterness, sorrow) related to the death.

    • Difficulty with reintegration into life (e.g., problems engaging with friends, pursuing interests, planning for the future).

    • Emotional numbness.

    • Feeling that life is meaningless as a result of the death.

    • Intense loneliness (feeling alone or detached from others).

  • D. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

  • E. The duration and severity of the bereavement reaction clearly exceed expected social, cultural, or religious norms for the individual’s culture and context.

  • F. The symptoms are not better explained by another mental disorder (e.g., major depressive disorder, posttraumatic stress disorder) and are not attributable to the physiological effects of a substance or another medical condition.

  • Note: The timing differs significantly for children (\geq 6 months) versus adults (\geq 12 months).

• Prevalence

  • 1\%-10\%_\text{ of bereaved adults} (Lundorff et al., 2017).

  • 5\%-10\%_\text{ in children and adolescents}.

  • Note: There is a lack of culturally-specific research on these criteria; most measures used for PGD were created in the US (Hilberdink et al, 2023).

• Comorbidities

  • Major Depressive Disorder (MDD)

  • PTSD

  • Anxiety Disorders

  • Sleep Disturbances

  • Substance Use

  • Physical Symptoms

  • Suicidal Ideation

• Treatment Considerations

  • Complicated Grief Therapy (CGT) (Shear et al., 2016).

  • Cognitive Behavioral Therapy (CBT).

  • Group therapy.

  • Pharmacotherapy for comorbid depression/anxiety.

  • Sleep aids (on a case-by-case basis) (Anchor with Shear et al., 2016).

Wrap-Up: Clinical Practice & Systemic Factors

• Discussion Points on Diagnosis in Real-World Care:

  • Consider which of these disorders (RAD, DSED, ASD, PGD) is most likely to be over- or under-diagnosed.

  • Analyze the systemic factors (e.g., time pressure, reimbursement policies, clinician training, cultural considerations) that might contribute to such diagnostic errors in practice.

  • Reflect on how this information on trauma and stressor-related disorders will be applied in future clinical or professional settings.