Acute Stress Disorder (ASD) and Post-Traumatic Stress Disorder (PTSD) are reactions to traumatic events. These reactions involve intrusive thoughts or dreams, avoidance of reminders of the event, and negative impacts on mood, cognition, arousal, and response. ASD typically begins immediately after the trauma and lasts from 3 days to 1 month. PTSD can be a continuation of ASD or may manifest up to 6 months after the trauma and last for more than 1 month. Diagnosis is based on clinical criteria. Treatment involves behavioral therapy and sometimes selective serotonin reuptake inhibitors or adrenergic antagonists.

ASD and PTSD are disorders related to trauma and stressors. They were once considered anxiety disorders but are now viewed as distinct because many patients do not experience anxiety but have other symptoms instead.

Due to varying vulnerabilities and temperaments, not all children exposed to a significant traumatic event develop stress disorders. Traumatic events often associated with these disorders include assaults, sexual abuse, car accidents, dog attacks, and injuries (especially burns). In younger children, domestic violence is the most common cause of PTSD.

For children under 6 years old, there must be direct exposure to the traumatic event. Children aged 6 and older do not need to directly experience the traumatic event; they can develop stress disorders if they witness a traumatic event occurring to someone else (even through media exposure) or if they learn that the event has happened to a close family member.

Symptoms and Signs

The symptoms of ASD and PTSD are similar and often involve a combination of the following:

Intrusive Symptoms:

• Recurrent, involuntary, and distressing memories or dreams of the traumatic event (in children < 6 years old, it may be unclear whether their distressing dreams relate to the event).
• Dissociative reactions (often flashbacks, where the individual relives the trauma, although younger children may frequently reenact the event during play).
• Distress at cues that are internally or externally similar to aspects of the trauma (e.g., seeing a dog or a person resembling the perpetrator).

Avoidance Symptoms:

• Persistent avoidance of memories, feelings, or external reminders of the trauma.

Negative Impact on Cognition and/or Mood:

• Inability to remember important aspects of the traumatic event, distorted thoughts about the cause and/or consequences of the trauma (e.g., blaming themselves or thinking they could have avoided the event through certain actions), diminished positive emotions, and increased negative emotions (fear, guilt, sadness, shame, embarrassment), general disinterest, social withdrawal, a subjective feeling of emotional numbness, and a pessimistic outlook for the future (e.g., thinking “I won’t live to see 20”).

Alterations in Arousal and/or Reactivity:

• Hyperarousal, exaggerated panic responses, difficulty relaxing, difficulty concentrating, disrupted sleep (sometimes with frequent nightmares), aggressive or reckless behavior.

Non-Specific Symptoms:

• A sense of detachment from the body as if in a dream and a feeling that the world is unreal.

Typically, children with ASD may appear dazed and seem detached from their everyday surroundings.

Children with PTSD experience intrusive recollections that make them re-experience the traumatic event. The most vivid type of recollection is the flashback. Flashbacks can be spontaneous but are often triggered by something related to the original trauma. For example, seeing a dog may trigger a recollection in a child who has experienced a dog attack. During a flashback, the child may be in a state of fear and unaware of their current surroundings while attempting to escape; they may temporarily lose touch with reality and believe they are in serious danger. Some children have nightmares. When children re-experience the event in other ways (e.g., through thoughts, mental images, or recollections), they remain aware of their current surroundings, although they may still be very distressed.

Diagnose

Mental Health Assessment

Criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR)

Diagnosis of Acute Stress Disorder (ASD) and Post-Traumatic Stress Disorder (PTSD) is based on a history of exposure to traumatic and terrifying events, followed by symptoms such as re-experiencing, emotional numbing, and hyperarousal. These symptoms must be severe enough to cause impairment or distress.

Symptoms lasting ≥ 3 days and < 1 month are classified as ASD. Symptoms lasting > 1 month are classified as PTSD, which may be a continuation of ASD or may manifest up to 6 months after the trauma.

Treatment

Trauma-Focused Psychotherapy

Supportive Psychotherapy

Selective serotonin reuptake inhibitors (SSRIs) and sometimes adrenergic antagonists.

Trauma-focused psychotherapies have been reported to be effective in children with PTSD. These therapies include short-term interventions that utilize cognitive-behavioral techniques to modify distorted thoughts, negative responses, and behaviors. They may also involve guiding parents on how to reduce stress and improve communication skills.

Supportive psychotherapy can assist children with adjustment issues related to trauma, such as those resulting from burn injuries. Behavioral therapy may be used systematically to reduce situations that trigger the child to re-experience the event (exposure therapy). Behavioral therapy has shown significant effectiveness in alleviating distress and impairment in children and adolescents with PTSD.

No medications are currently approved for PTSD in children, as full clinical trials are still ongoing. However, in adolescents with co-occurring anxiety, depression, or sleep difficulties, selective serotonin reuptake inhibitors (SSRIs) may be effective.

Adrenergic antagonists (e.g., clonidine, guanfacine, prazosin) may help alleviate symptoms of hyperarousal, but the supporting data is still preliminary.