022 - Pediatric Trauma and Stress - Part 1 - Diagnosis

Dr O'Leary discusses post-traumatic stress disorder, reactive attachment disorder, disinhibited social engagement disorder along with the other diagnostic boxes defined in the DSM.  In particular, he discusses how a developmentally appropriate approach is necessary and why there are different criteria for those aged 6 and under.

Find additional case vignettes in the show transcript.

Referenced resources can be found within the show transcripts at https://psydactic_caps.buzzsprout.com

Feedback can be emailed to feedback@psydactic.com OR submitted via a form at https://psydactic.com.

This is not medical advice.  Please see a licensed physician for any personal questions regarding your own or your child's health.

Transcript

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Diagnosing Pediatric Trauma and Stressor Related Disorders

Welcome to PsyDactic Child and Adolescent Psychiatry Edition.  I am your host Dr. O’Leary, a fellow in Child and Adolescent Psychiatry in the National Capital region.  I started this podcast feed to help me study for my board exams and I hope it helps you as well, but anyone interested in human development or mental health may enjoy this content.  I need to let you know that everything that I say here should be considered to be my own opinion even if I am quoting or referencing someone or some institution.  Additionally, I have been learning how to use A.I. to assist me with the content creation and research.  Specifically, for this episode I used Gemini’s Deep Research tool to produce a detailed overview of Pediatric Trauma and Stressor Related Disorders and then consolidated that information into a podcast script that includes my own content merged with the A.I. content.  I use my own background knowledge as well as spot checking of the facts to make sure that the A.I. isn’t just making stuff up.  Like humans, A.I. makes mistakes, but I have found it more and more to be at least or even more reliable than human produced content.

The following is a script used to produce the episode and may have additional content not included in the final production.

I want to jump right into this episode with a vignette.

Vignette for PTSD (Child > 6 years)

A 10-year-old boy, Michael, was a passenger in a car involved in a serious highway collision 4 months ago, where he was uninjured, but his mother sustained significant injuries and was in the hospital for 2 weeks. At first he seemed to be doing ok, though noticeably more quite and withdrawn than he was previously.  This improved but over the past month Michael has woken up many nights screaming and often comes to sleep with his parents. He has demanded that his parents no longer watch the news because the traffic reports make him nervous.  He suddenly refused to travel by car, insisting on taking public transportation, even to school.  This has improved somewhat but he still insists that they never take the highway. In general, he has become more argumentative and there has been an increase in sibling conflict.  His teacher reports that he startles easily at loud noises in the classroom and sometimes goes into a rage and is difficult to calm down.  He once flipped over some chairs and on another occasion obsessively broke an entire box of pencils one at a time, which is something he had never done before. He is no longer completing his schoolwork, leading to a decline in his grades. He also complains of difficulty falling asleep most nights.

What is the most likely diagnosis?

I. Introduction to Pediatric Trauma- and Stressor-Related Disorders

A. Overview of Trauma- and Stressor-Related Disorders in the DSM-5-TR

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), and its subsequent text revision (DSM-5-TR), marked a significant conceptual shift by establishing a distinct diagnostic category for "Trauma- and Stressor-Related Disorders".1 This classification underscores a fundamental etiological principle: exposure to a traumatic or stressful event is a primary diagnostic criterion for all conditions included within this group.1 This was a notable departure from previous editions, where conditions like Posttraumatic Stress Disorder (PTSD) were categorized under Anxiety Disorders.4 The creation of this dedicated chapter reflects an evolved understanding that the experience of trauma or severe stress itself is a critical factor shaping the subsequent psychopathology, distinguishing these conditions from, for example, anxiety that may arise without such an explicit and severe precipitating event. This has profound implications for clinical assessment, which must prioritize a thorough trauma history, and for treatment approaches, which often need to be trauma-focused. The DSM-5-TR, published in March 2022, incorporated scientific advances since the release of DSM-5, though the diagnostic criteria for PTSD in adults remained unchanged in this update.1

B. Significance of Trauma in Child Development and Mental Health

Exposure to trauma is a distressingly common experience during childhood and adolescence. Epidemiological data suggest that a significant proportion of children encounter traumatic events; for instance, an estimated 26% of children in the United States will witness or experience a traumatic event before the age of four.5 Furthermore, studies indicate that over two-thirds of children report at least one traumatic event by the age of 16.6 These experiences are not benign. Childhood trauma, encompassing various forms such as abuse, neglect, witnessing violence, or experiencing disasters, can exert profound and enduring effects on a child's developing brain, emotional regulation capacities, attachment patterns, and overall mental and physical health.8 The consequences can be far-reaching, potentially initiating a cascade of negative outcomes that extend across an individual's lifespan.6 The sheer prevalence of such exposures, coupled with their potential for severe impact, positions childhood trauma as a major public health concern. This necessitates a broad, public health-oriented approach, where trauma-informed care principles are integrated not only within specialized mental health settings but also in more universal environments such as schools, pediatric primary care facilities, and child welfare systems. The extensive ripple effects of childhood trauma on long-term health and societal costs further underscore the critical need for comprehensive understanding, early identification, and effective intervention for these disorders.

II. DSM-5-TR Diagnostic Criteria for Pediatric Trauma- and Stressor-Related Disorders

The DSM-5-TR provides specific diagnostic criteria for various Trauma- and Stressor-Related Disorders, with important developmental considerations for children.

A. Posttraumatic Stress Disorder (PTSD)

The DSM-5 introduced a significant advancement by providing distinct criteria for PTSD in children aged six years and younger, acknowledging that trauma symptomatology manifests differently based on developmental stage.1 This reflects a growing understanding within developmental psychopathology that younger children may not express their distress in the same way as older children or adults, potentially leading to underdiagnosis or misdiagnosis if adult-centric criteria were strictly applied.

1. Criteria for Children 6 Years and Younger

The diagnostic criteria for PTSD in children 6 years and younger are tailored to reflect their developmental capacities and expressions of distress.13

• Criterion A (Exposure): Requires exposure to actual or threatened death, serious injury, or sexual violence through direct experience, witnessing the event (particularly as it occurred to primary caregivers), or learning that the traumatic event occurred to a parent or caregiving figure.13 Notably, witnessing events only in electronic media, television, movies, or pictures does not qualify, unless it is work-related exposure in older individuals.4
• Criterion B (Intrusion Symptoms): At least one intrusion symptom is required. These include recurrent, involuntary, and intrusive distressing memories, which may be expressed as play reenactment rather than verbal recall.4 Recurrent distressing dreams may occur, with content that may or may not be recognizably related to the trauma.14 Dissociative reactions, such as flashbacks, may manifest as the child feeling or acting as if the event were recurring, and this can also occur during play.4 Intense or prolonged psychological distress or marked physiological reactions to reminders of the trauma are also characteristic.13
• Criterion C (Avoidance/Negative Alterations in Cognitions and Mood): At least one symptom from this category is required, representing either persistent avoidance of stimuli or negative alterations in cognitions and mood.13 This criteria combines what in older individuals would be separate categories.  Under age six, you need only one symptom and it can be either avoidance or negative cognitions or affect.
• Persistent Avoidance of Stimuli: This includes avoidance of or efforts to avoid activities, places, physical reminders, people, or conversations that arouse recollections of the traumatic event(s).13
• Negative Alterations in Cognitions and Mood: This includes a substantially increased frequency of negative emotional states (e.g. fear, guilt, sadness, shame, confusion), markedly diminished interest or participation in significant activities (including constricted play), socially withdrawn behavior, and a persistent reduction in the expression of positive emotions.4 For this age group, the criteria do not include symptoms like amnesia for the trauma or persistent, distorted blame of self or others that are seen in older individuals.4
• Criterion D (Alterations in Arousal and Reactivity): At least two symptoms are required. These include irritable behavior and angry outbursts (with little or no provocation), which may manifest as extreme temper tantrums.4 Other symptoms are hypervigilance, an exaggerated startle response, problems with concentration, and sleep disturbances (e.g., difficulty falling or staying asleep, restless sleep).4 Reckless or self-destructive behavior is not a criterion for this age group.4
• Criterion E (Duration): The disturbance (symptoms in Criteria B, C, and D) must last for more than 1 month.13
• Criterion F (Functional Impairment): The disturbance causes clinically significant distress or impairment in relationships with parents, siblings, peers, or other caregivers, or in school behavior.13
• Criterion G (Exclusion): The disturbance is not attributable to the physiological effects of a substance (e.g., medication) or another medical condition.

2. Criteria for Children Older Than 6 Years, Adolescents (and Adults)

For children older than 6 years, adolescents, and adults, the PTSD criteria are more complex, reflecting greater cognitive and verbal capacities.1

• Criterion A (Exposure): Requires exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways: directly experiencing the event(s); witnessing, in person, the event(s) as it occurred to others; learning that the event(s) occurred to a close family member or close friend (in cases of actual or threatened death, the event must have been violent or accidental); or experiencing repeated or extreme indirect exposure to aversive details of the event(s), usually in the course of professional duties (e.g., first responders, police officers repeatedly exposed to details of child abuse).1 The DSM-5 narrowed qualifying traumatic events, for instance, by no longer including the unexpected death of family or a close friend due to natural causes.1
• Criterion B (Intrusion Symptoms): Presence of one (or more) of the following: recurrent, involuntary, and intrusive distressing memories; recurrent distressing dreams related to the trauma; dissociative reactions (e.g., flashbacks); intense or prolonged psychological distress at exposure to traumatic reminders; and marked physiological reactivity to traumatic reminders.1
• Criterion C (Avoidance): Persistent avoidance of stimuli associated with the trauma, requiring one (or more) of the following: avoidance of distressing memories, thoughts, or feelings about the trauma; or avoidance of external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about the trauma.1 The DSM-5 made it a requirement that a PTSD diagnosis includes at least one avoidance symptom.1
• Criterion D (Negative Alterations in Cognitions and Mood): Two (or more) of the following that began or worsened after the trauma: inability to remember an important aspect of the trauma (typically dissociative amnesia); persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., "I am bad," "No one can be trusted") (a new symptom in DSM-5); persistent, distorted cognitions about the cause or consequences of the trauma leading to self-blame or blaming others; persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame) (a new symptom in DSM-5); markedly diminished interest or participation in significant activities; feelings of detachment or estrangement from others; or persistent inability to experience positive emotions.1
• Criterion E (Alterations in Arousal and Reactivity): Two (or more) of the following that began or worsened after the trauma: irritable behavior and angry outbursts; reckless or self-destructive behavior (a new symptom in DSM-5); hypervigilance; exaggerated startle response; problems with concentration; or sleep disturbance.1
• Criterion F (Duration): Duration of the disturbance (Criteria B, C, D, and E) is more than 1 month.1
• Criterion G (Functional Significance): The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.1
• Criterion H (Exclusion): The disturbance is not attributable to the physiological effects of a substance or another medical condition.1
• Specifications: [Not for children under 6]
• With dissociative symptoms: The individual meets full PTSD criteria and experiences persistent or recurrent symptoms of either depersonalization (feeling detached from oneself) or derealization (experiencing unreality of surroundings).1
• With delayed expression: Full diagnostic criteria are not met until at least 6 months after the traumatic event(s), although onset of some symptoms may be immediate.1

3. Key Differences and Developmental Considerations

The primary differences between the PTSD criteria for younger children (≤6 years) and older individuals highlight the importance of a developmentally sensitive diagnostic approach. You have to know how a child would express things depending on their developmental level.  Younger children are more likely to express their traumatic experiences and re-experiencing symptoms through behavior and play (e.g., trauma-specific reenactment) rather than through direct verbalization of complex thoughts or feelings.4 Just because a child re-enacts violence doesn;t mean they were abused.  They may just have parents that are permissive about what videos they watch.  

Cognitive symptoms, such as distorted blame or pervasive negative self-perceptions, are less elaborated or absent in the criteria for younger children.4 It is not uncommon for children to blame themselves for their circumstances because they are necessarily so egocentric, so including this in the criteria would make them overly broad. Similarly, certain arousal symptoms, like reckless or self-destructive behavior, are not included in the preschool PTSD criteria.4 Little kids may participate in behaviors that others characterize as reckless because they are poor at predicting future outcomes.  The "witnessing" criterion for younger children places a specific emphasis on trauma occurring to primary caregivers, underscoring their unique vulnerability related to the security of their attachment figures.13

B. Acute Stress Disorder (ASD)

Acute Stress Disorder (ASD) captures severe stress reactions that occur within a month of a traumatic event and lasts at least 3 days, and falls outside of a typical human stress response.15

1. Diagnostic Criteria (including pediatric considerations)

The diagnostic criteria for ASD are largely similar for children and adults, with specific notes for how symptoms might manifest in children, akin to those for PTSD.18

• Criterion A (Exposure): Exposure to actual or threatened death, serious injury, or sexual violation, similar to PTSD Criterion A (direct experience, witnessing, learning about trauma to a close family member/friend [violent or accidental death], or repeated/extreme exposure to aversive details of the event for professionals).18
• Criterion B (Presence of Symptoms): Requires the presence of nine or more symptoms from any of the following five categories, beginning or worsening after the traumatic event(s): intrusion, negative mood, dissociation, avoidance, and arousal.17
• Intrusion Symptoms: Recurrent, involuntary, and intrusive distressing memories (in children, repetitive play with trauma themes may occur); recurrent distressing dreams related to the event (in children older than 6, dreams may be frightening without recognizable content); dissociative reactions (e.g., flashbacks, where the individual feels the event is recurring; in children, trauma-specific reenactment may occur in play); intense or prolonged psychological distress or marked physiological reactions to trauma cues.18
• Negative Mood: Persistent inability to experience positive emotions (e.g., happiness, satisfaction, loving feelings).17 People often describe a numbness or report that pleasure cannot be sustained past the good experience itself.
• Dissociative Symptoms: An altered sense of the reality of one's surroundings or oneself (e.g., feeling in a daze, time slowing); inability to remember an important aspect of the traumatic event(s) (typically dissociative amnesia, not due to head injury, alcohol, or drugs).17
• Avoidance Symptoms: Efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the event; efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings.17
• Arousal Symptoms: Sleep disturbance; irritable behavior and angry outbursts (with little or no provocation); hypervigilance; problems with concentration; exaggerated startle response.17
• Criterion C (Duration): The duration of the disturbance (symptoms in Criterion B) is 3 days to 1 month after trauma exposure.17 Symptoms typically begin immediately after the trauma. This duration criterion is the primary feature distinguishing ASD from PTSD.15
• Criterion D (Functional Significance): The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.17
• Criterion E (Exclusion): The disturbance is not attributable to the physiological effects of a substance (e.g., medication or alcohol) or another medical condition (e.g., mild traumatic brain injury) and is not better explained by brief psychotic disorder.17

C. Adjustment Disorders

Before we move on, let me tell you about

Vignette for Adjustment Disorder:

An 8-year-old boy, Jamal, recently moved to a new city and started a new school 6 weeks ago due to his father's military move. His parents report that since the move, Jamal, who was previously outgoing and a good student, has become increasingly withdrawn, often cries before school, and expresses worries about not having friends. His grades have dropped, and he has started refusing to participate in class activities.  Once he eloped from the school during lunch and the police had to be called to help find him.  He frequently states he misses his old friends and school and has threatened to run away.  During the encounter you determine that he does not meet criteria for major depressive disorder.

What is the most likely diagnosis?

(A) Acute Stress Disorder

(B) Social Anxiety Disorder

(C) Adjustment Disorder with Mixed Anxiety and Depressed Mood

(D) Generalized Anxiety Disorder

Correct Answer: (C) Adjustment Disorder with Mixed Anxiety and Depressed Mood. Jamal's symptoms (withdrawal, crying, worry, academic decline) developed within 3 months of an identifiable stressor (moving and new school) (Criterion A). The distress and impairment are clinically significant (Criterion B). His symptoms do not meet criteria for another specific mental disorder like GAD or MDD (Criterion C), are not normal bereavement (Criterion D), and are expected to remit if the stressor's impact lessens or he adapts (Criterion E). The symptoms reflect both anxiety and depressed mood.

Adjustment Disorders are characterized by emotional or behavioral symptoms in response to an identifiable stressor that are clinically significant, but the stressor itself is not necessarily of the severity or type required for PTSD or ASD.20 Adjustment disorders do not get enough clinical attention, because they aren’t something the insurance companies like to pay for.  Therefore, children with adjustment disorders are very likely to get a diagnosis of major depressive disorder or some kind of anxiety disorder because that will justify to the insurance company that they need treatment.

1. Diagnostic Criteria and Subtypes in Children

• Criterion A: The development of emotional or behavioral symptoms in response to an identifiable stressor(s) occurring within 3 months of the onset of the stressor(s).20 Stressors can be diverse, including events like parental divorce, moving, school difficulties, bullying, or the illness of a family member.20
• Criterion B: These symptoms or behaviors are clinically significant, as evidenced by one or both of the following:

1. Marked distress that is out of proportion to the severity or intensity of the stressor, taking into account the external context and the cultural factors that might influence symptom severity and presentation.20
2. Significant impairment in social, occupational (or academic for children), or other important areas of functioning.20

• Criterion C: The stress-related disturbance does not meet the criteria for another mental disorder and is not merely an exacerbation of a preexisting mental disorder.20
• Criterion D: The symptoms do not represent normal bereavement.20
• Criterion E: Once the stressor or its consequences have terminated, the symptoms do not persist for more than an additional 6 months.20
• Subtypes: Adjustment disorders are specified based on the predominant symptoms 20:
• With depressed mood: Predominant symptoms include low mood, tearfulness, or feelings of hopelessness.
• With anxiety: Predominant symptoms include nervousness, worry, jitteriness, or (in children) separation anxiety.
• With mixed anxiety and depressed mood: A combination of depressive and anxious symptoms predominates.
• With disturbance of conduct: The predominant symptom is a disturbance in conduct (e.g., violating societal norms or the rights of others, such as truancy or vandalism).
• With mixed disturbance of emotions and conduct: Both emotional symptoms (e.g., depression, anxiety) and a disturbance of conduct are present.
• Unspecified: For maladaptive reactions to stressors that are not classifiable as one of the specific subtypes (e.g., social withdrawal without significant depressed or anxious mood). It is noted that children with adjustment disorders tend to exhibit more behavioral symptoms, such as acting out, whereas adults more commonly present with depressive symptoms.22 The explicit acknowledgment of cultural context in Criterion B1 is important, as what constitutes an "out of proportion" reaction can be culturally mediated. This necessitates clinical cultural humility and potentially adapted assessment and intervention approaches.

Now let’s revisit that case about 10 year old Michael:

Michael, was a passenger in a car involved in a serious highway collision 4 months ago

He was uninjured but his mom required two weeks in the hospital before she was stable enough to go home. At first he seemed to be doing ok, but over the past month Michael appeared to be having nightmares. He actively avoided things like traffic reports and riding in cars or going onto the highway.  He also became uncharacteristically argumentative with siblings and had raged in school and stopped completing his homework.  What is the most likely diagnosis?

(A) Acute Stress Disorder

(B) Posttraumatic Stress Disorder

(C) Adjustment Disorder with Anxiety

(D) Generalized Anxiety Disorder

(E) Conduct Disorder

(F) Obsessive Compulsive Disorder

Correct Answer: (B) Posttraumatic Stress Disorder. Note first that Michael is over 6 years old, so we are using the same PTSD criteria as we would in adults.  Michael meets Criterion A (exposure to serious injury of mother, direct experience of threatened serious injury). He exhibits intrusion symptoms (Criterion B: nightmares, distress at reminders), avoidance (Criterion C: avoids highway travel), negative alterations in mood/cognition (Criterion D: irritability, rage), and arousal/reactivity symptoms (Criterion E: exaggerated startle, difficulty concentrating on school work, sleep disturbance). Symptoms have persisted for more than 1 month (Criterion F) and cause functional impairment (Criterion G: school).

Now let's discuss two very different cases.

Vignette for Reactive Attachment Disorder (RAD):

A 3-year-old child, Anna, was adopted 1 year ago from an Eastern European orphanage where she spent the first 2 years of her life with a high child-to-caregiver ratio and minimal individualized attention. Her adoptive parents report that Anna rarely seeks comfort from them when she is hurt, scared, or upset. When they attempt to comfort her, she often stiffens or shows minimal response. She rarely smiles or laughs during interactions, and often appears sad or irritable, even when safe at home with her parents.  Assuming we have ruled out Autism Spectrum Disorder,  What is the most likely diagnosis?

Correct Answer: (C) Reactive Attachment Disorder. Anna exhibits a consistent pattern of inhibited, emotionally withdrawn behavior toward caregivers (Criterion A: rarely seeks/responds to comfort). She shows persistent social/emotional disturbance (Criterion B: minimal responsiveness, limited positive affect, unexplained irritability/sadness). There is a history of pathogenic care (Criterion C: institutional rearing with limited attachment opportunities). Her behavior is presumed linked to this care (Criterion D), she does not have ASD (Criterion E), the disturbance was evident before age 5 (Criterion F), and she is developmentally older than 9 months (Criterion G).

Vignette for Disinhibited Social Engagement Disorder (DSED):

A 4-year-old boy, Tom, has been in the foster care system since infancy and has experienced five different placements. His current foster parents report that Tom is overly friendly with strangers. At the park, he will readily approach unfamiliar adults, start conversations, and even attempt to sit on their laps or ask for hugs. He often wanders away from his foster mother in public places without checking back and has, on one occasion, attempted to get into a car with an unfamiliar woman who had spoken kindly to him. Assuming we have ruled out ADHD, what is the most likely diagnosis?

Correct Answer: (D) Disinhibited Social Engagement Disorder. Tom displays a pattern of actively approaching and interacting with unfamiliar adults (Criterion A: reduced reticence, overly familiar behavior, diminished checking back, willingness to go off with stranger). This behavior is not solely impulsivity but includes social disinhibition (Criterion B). He has a history of pathogenic care (Criterion C: multiple foster placements). His behavior is presumed linked to this care (Criterion D), and he is developmentally older than 9 months (Criterion E).

D. Reactive Attachment Disorder (RAD)

Reactive Attachment Disorder (RAD) is a condition of early childhood characterized by markedly disturbed and developmentally inappropriate attachment behaviors, resulting from a history of grossly inadequate or pathogenic care.23

1. Diagnostic Criteria

• Criterion A (Core Feature): A consistent pattern of inhibited, emotionally withdrawn behavior toward adult caregivers, manifested by both of the following:

1. The child rarely or minimally seeks comfort when distressed.
2. The child rarely or minimally responds to comfort when distressed.23

• Criterion B (Persistent Social and Emotional Disturbance): Characterized by at least two of the following:

1. Minimal social and emotional responsiveness to others.
2. Limited positive affect.
3. Episodes of unexplained irritability, sadness, or fearfulness that are evident even during nonthreatening interactions with adult caregivers.23

• Criterion C (Etiology - Pathogenic Care): The child has experienced a pattern of extremes of insufficient care as evidenced by at least one of the following:

1. Social neglect or deprivation in the form of persistent lack of having basic emotional needs for comfort, stimulation, and affection met by caring adults.
2. Repeated changes of primary caregivers that limit opportunities to form stable attachments (e.g., frequent changes in foster care).
3. Rearing in unusual settings that severely limit opportunities to form selective attachments (e.g., institutions with high child-to-caregiver ratios).23

• Criterion D (Causal Link): The care in Criterion C is presumed to be responsible for the disturbed behavior in Criterion A (e.g., the disturbances in Criterion A began following the lack of adequate care in Criterion C).23
• Criterion E (Exclusion Criteria): The criteria are not met for autism spectrum disorder.23
• Criterion F (Age of Onset): The disturbance is evident before age 5 years.23
• Criterion G (Developmental Age): The child has a developmental age of at least 9 months (the age by which selective attachments are typically formed).23
• Specifications:
• Persistent: The disorder has been present for more than 12 months.23
• Current severity: Specified as severe when a child exhibits all symptoms of the disorder, with each symptom manifesting at relatively high levels.23

E. Disinhibited Social Engagement Disorder (DSED)

Disinhibited Social Engagement Disorder (DSED), like RAD, stems from early experiences of social neglect but is characterized by a pattern of overly familiar and culturally inappropriate behavior with unfamiliar adults.25 The DSM-5 separated DSED from RAD, recognizing them as distinct disorders with different behavioral manifestations despite similar etiological backgrounds of pathogenic care.25

1. Diagnostic Criteria

• Criterion A (Core Feature): A pattern of behavior in which a child actively approaches and interacts with unfamiliar adults and exhibits at least two of the following:

1. Reduced or absent reticence in approaching and interacting with unfamiliar adults.
2. Overly familiar verbal or physical behavior (that is not consistent with culturally sanctioned and age-appropriate social boundaries).
3. Diminished or absent checking back with an adult caregiver after venturing away, even in unfamiliar settings.
4. Willingness to go off with an unfamiliar adult with minimal or no hesitation.27

• Criterion B (Behavioral Nature): The behaviors in Criterion A are not limited to impulsivity (as in Attention-Deficit/Hyperactivity Disorder) but include socially disinhibited behavior.27
• Criterion C (Etiology - Pathogenic Care): The child has experienced a pattern of extremes of insufficient care as evidenced by at least one of the following (similar to RAD Criterion C):

1. Social neglect or deprivation in the form of persistent lack of having basic emotional needs for comfort, stimulation, and affection met by caring adults.
2. Repeated changes of primary caregivers that limit opportunities to form stable attachments.
3. Rearing in unusual settings that severely limit opportunities to form selective attachments.27

• Criterion D (Causal Link): The care in Criterion C is presumed to be responsible for the disturbed behavior in Criterion A.
• Criterion E (Developmental Age): The child has a developmental age of at least 9 months.
• Specifications:
• Persistent: The disorder has been present for more than 12 months.
• Current severity: Specify if the child exhibits all symptoms of the disorder, with each symptom manifesting at relatively high levels.

The distinction between RAD and DSED, despite both originating from similar conditions of severe early neglect, highlights divergent maladaptive social-emotional pathways. RAD manifests as an inhibited, withdrawn pattern and a failure to seek or respond to comfort, suggesting a profound disruption in the formation of attachment behaviors themselves.23 In contrast, DSED is characterized by an indiscriminate, overly familiar approach to strangers, indicating an aberrant pattern of social engagement rather than a complete lack of it.27 This divergence implies potentially different underlying impacts on the developing social brain and may necessitate distinct intervention strategies, even though the foundational cause—pathogenic care—is shared.

One way to think about this is using an attractor landscape metaphor.  During development there is a balance between engagement and avoidance or disengagement.  Both are necessary.  If you think of a set of space where the x access is engagement on the positive side and lack of engagement progressing to active avoidance on the negative side and the y axis is the strength of effect where negative numbers are stronger attractors (imagine a ball rolling down a hill into a valley) and positive are repellers (imagine a ball trying to roll up hill).  You might have a attractors on both sides, and the strength of these is dependent upon the circumstances.

Imagine that someone sees a familiar face that they haven’t seen in a long time.  The attractor space would shift from being relatively neutral (near the origin) to being deep on the engagement side.  The ball would roll downhill toward the deep engagement attractor.  The opposite could be said when a stranger approaches.  The typically developing kid’s attractor landscape should shift toward either neutral or avoidant.

RAD can be characterized by an overly stable attractor state near the origin and toward the negative end of the landscape, whereas in DSID, there is an overly stable attractor on the positive side of the graph.  These diagnosis suggest that there can be only one overly stable attractor, either overly engaged or under engaged.  Kids who have experienced trauma may have two stable attractor states, one on each side of the landscape and some kind of reminder or trigger could provide the energy needed to shift from overly engaged to overly avoidance and they get stuck in each state for too long.  

Trauma can reduce the variability or malleability of the attractor states toward being more rigid, less flexible.  Trauma could also result in these attractors becoming pathologically unstable which can result in things that look like borderline personality disorder or in the extreme, might fracture someone's identity into distinct parts that are dissociated from each other.  We call this dissociative identity disorder and the vast majority of cases are associated with significant, sustained trauma or neglect, especially in early childhood… but that is a topic for a future podcast.

F. Other Specified Trauma- and Stressor-Related Disorder

This diagnostic category is used when symptoms characteristic of a trauma- and stressor-related disorder cause clinically significant distress or impairment in social, occupational, or other important areas of functioning but do not meet the full criteria for any of the specific disorders in this class.30

1. Criteria and Examples Relevant to Children

When this diagnosis is used, the clinician must specify the reason that the presentation does not meet the criteria for any specific trauma- and stressor-related disorder (e.g., "adjustment-like disorder with delayed onset of symptoms").30 This allows for a more precise description of presentations that are subthreshold or atypical.

Examples relevant to children include 30:

• Adjustment-like disorders with delayed onset of symptoms: Symptoms begin more than three months after the stressor has occurred.
• Adjustment-like disorders with prolonged duration: Symptoms of an adjustment disorder persist for more than six months after the stressor (or its consequences) has terminated.
• Ataque de nervios: A cultural syndrome observed in individuals of Latino descent, often triggered by a stressful family-related event (e.g., death in the family, family conflict). Symptoms can include intense emotional upset, screaming, crying, trembling, sensations of heat rising in the chest and head, dissociative experiences, and verbal or physical aggression.
• Other cultural syndromes: The DSM-5 acknowledges various cultural concepts of distress that might fall under this category if related to trauma or stress. Examples include Kufungisisa ("thinking too much," characterized by excessive worry and rumination, recognized in several African, Caribbean, Latin American, East Asian, and Native American cultures) and Susto (a Latin American cultural syndrome where a frightening event is thought to cause the soul to leave the body, resulting in symptoms similar to PTSD).  This last one sounds like a dissociative disorder.
• Presentations where, for example, a child exhibits some core PTSD symptoms following a significant stressor but does not meet the full number of symptoms in each cluster, or the duration criterion.

G. Unspecified Trauma- and Stressor-Related Disorder

This category is applied when symptoms characteristic of a trauma- and stressor-related disorder that cause clinically significant distress or impairment are present, but the criteria are not met for any specific disorder within this class, and the clinician chooses not to specify the reason why the criteria are not met.31

1. Criteria and Clinical Application in Pediatrics

This diagnosis is typically used in situations where there is insufficient information to make a more specific diagnosis, such as in emergency room settings where a full assessment may not be feasible.31 The symptoms are broad and may overlap with other trauma disorders, including anxiety, irritability, intrusive memories, difficulty concentrating, hypervigilance, avoidance, or dissociative symptoms, but they do not align with the full criteria for a specific disorder.31 The primary utility of this category is to ensure that individuals experiencing significant trauma-related distress receive clinical attention and access to treatment even when a precise diagnosis cannot be immediately established.31

The "Other Specified" and "Unspecified" categories fulfill a critical clinical role by acknowledging the full spectrum of trauma's impact. Not all children who suffer trauma and exhibit significant impairment will fit neatly into the more defined diagnostic boxes. These residual categories ensure that subthreshold or atypical presentations, or situations with incomplete information, are not dismissed, thereby facilitating access to care. The "Other Specified" category, in particular, encourages clinicians to document the specific reasons for not meeting full criteria, which can be valuable for clinical understanding and research.

H. Table: DSM-5-TR Diagnostic Criteria for Pediatric Trauma- and Stressor-Related Disorders

 | Feature | PTSD (≤ 6 years) | PTSD (> 6 years, Adolescents, Adults) | Acute Stress Disorder (ASD) | Adjustment Disorder | Reactive Attachment Disorder (RAD) | Disinhibited Social Engagement Disorder (DSED)
| Criterion A Exposure | Actual/threatened death, serious injury, sexual violence: Direct, Witnessing (esp. to caregivers), Learning (to parent/caregiver). No media (unless work-related). | Actual/threatened death, serious injury, sexual violence: Direct, Witnessing (in person), Learning (to close other, violent/accidental), Repeated/extreme indirect (professional). No natural causes death. | Actual/threatened death, serious injury, sexual violence: Direct, Witnessing (in person), Learning (to close other, violent/accidental), Repeated/extreme indirect (professional). No media (unless work-related). | Identifiable stressor(s) (not necessarily life-threatening or severe trauma). | Pattern of extremes of insufficient care (social neglect/deprivation, repeated caregiver changes, institutional rearing). | Pattern of extremes of insufficient care (social neglect/deprivation, repeated caregiver changes, institutional rearing).
| Key Symptom Clusters | 1+ Intrusion: Memories (play reenactment), dreams (unclear content), flashbacks (in play), distress to cues, physiological reactivity. <br> 1+ Avoidance/Negative Alterations: Avoidance of reminders (places, people); OR Increased negative emotions, decreased interest (constricted play), social withdrawal, reduced positive emotions. (No amnesia, blame). | 1+ Intrusion: Memories, dreams, flashbacks, distress to cues, physiological reactivity. <br> 1+ Avoidance: Of thoughts/feelings OR external reminders. <br> 2+ Negative Cognitions/Mood: Amnesia, negative beliefs (self/world), distorted blame, negative emotional state, decreased interest, detachment, anhedonia. | 9+ Symptoms from 5 categories: <br> Intrusion: Memories (play reenactment in children), dreams (frightening, unclear content in children >6), flashbacks (play reenactment in children), distress/reactivity to cues. <br> Negative Mood: Inability to experience positive emotions. <br> Dissociative: Altered reality, amnesia. <br> Avoidance: Of memories/thoughts/feelings OR external reminders. | Emotional or behavioral symptoms (e.g., depressed mood, anxiety, disturbance of conduct, or mixed). | Inhibited/Withdrawn Behavior (Both required): Rarely seeks comfort; Rarely responds to comfort. <br> Social/Emotional Disturbance (2+ required): Minimal social/emotional responsiveness, limited positive affect, unexplained irritability/sadness/fearfulness with caregivers. | Disinhibited Social Behavior (2+ required): Reduced reticence with strangers, overly familiar behavior, diminished checking back with caregiver, willingness to go off with strangers. (Not just impulsivity).
|
| 2+ Arousal/Reactivity: Irritability/tantrums, hypervigilance, startle, concentration problems, sleep disturbance. (No reckless behavior). | 2+ Arousal/Reactivity: Irritability/aggression, reckless/self-destructive behavior, hypervigilance, startle, concentration problems, sleep disturbance. | Arousal: Sleep disturbance, irritability/outbursts, hypervigilance, concentration problems, startle. | Distress out of proportion to stressor OR significant functional impairment. |
|

| Duration | More than 1 month. | More than 1 month. | 3 days to 1 month after trauma. | Symptoms within 3 months of stressor; do not persist >6 months after stressor/consequences terminate. | Disturbance evident before age 5. Child developmental age at least 9 months. Persistent: >12 months. | Child developmental age at least 9 months. Persistent: >12 months.
| Impairment | Clinically significant distress or impairment in relationships or school behavior. | Clinically significant distress or functional impairment (social, occupational, etc.). | Clinically significant distress or impairment (social, occupational, etc.). | Clinically significant distress or impairment (social, occupational/academic, etc.). | Care in Criterion C presumed responsible for behavior in Criterion A. Not autism spectrum disorder. | Care in Criterion C presumed responsible for behavior in Criterion A.
| Exclusion | Not due to substance/medication or other medical condition. | Not due to substance/medication or other medical condition. | Not due to substance/medication, other medical condition, or brief psychotic disorder. | Not another mental disorder, not normal bereavement. |
|

| Pediatric Notes | Specific criteria for expression (e.g., play reenactment, non-specific dreams). Different symptom thresholds/exclusions (e.g., no amnesia, no reckless behavior). | Standard criteria apply. Dissociative and delayed expression specifiers applicable. | Notes for child expression (play reenactment, frightening dreams). | Children may show more behavioral symptoms (acting out) vs. adult depressive symptoms. Cultural factors considered. | Requires history of pathogenic care. Disturbance evident before age 5. | Requires history of pathogenic care.

Vignette for PTSD (Child ≤ 6 years):

A 4-year-old girl, Lily, was rescued from a house fire 2 months ago. Her parents report that she now frequently engages in repetitive play where her dolls are "stuck in the hot house" and "can't get out." She becomes extremely distressed, crying and screaming, when she hears fire engine sirens. She avoids talking about the fire and refuses to go near the street where their old house was. Her parents also note a significant increase in temper tantrums, especially at bedtime, and she often wakes up crying from what they assume are bad dreams. She has also become more withdrawn and shows less interest in playing with her usual friends.

What is the most likely diagnosis?

(A) Separation Anxiety Disorder

(B) Acute Stress Disorder

(C) Posttraumatic Stress Disorder, Preschool Subtype

(D) Adjustment Disorder with Mixed Disturbance of Emotions and Conduct

Correct Answer: (C) Posttraumatic Stress Disorder, Preschool Subtype. Lily meets Criterion A (direct exposure to threatened death/serious injury). She shows intrusion symptoms (Criterion B: play reenactment, distress at reminders - sirens), avoidance/negative alterations (Criterion C: avoids street, withdrawn, diminished interest), and arousal/reactivity symptoms (Criterion D: temper tantrums, sleep disturbance/nightmares). Symptoms have lasted over 1 month and cause distress/impairment.

Vignette for Acute Stress Disorder (ASD):

A 16-year-old girl, Sariah, was physically assaulted while walking home from school 10 days ago. She presents to the emergency department reporting that she constantly feels like someone is behind her and is checking again and again and again, even in her own home. She states she often loses track of time and every once in a while it seems as if things around her are "not real." She also noted that she hasn’t been able to enjoy being with friends.  She is not sad, just, “Blah.” She has actively avoided walking past the location of the assault and today refused to go to school. Mom notes that Sariah startles at any sudden movement, and has been unable to sleep for more than a few hours each night since the event.

What is the most likely diagnosis?

(A) Posttraumatic Stress Disorder

(B) Panic Disorder

(C) Acute Stress Disorder

(D) Adjustment Disorder with Anxiety

(E) OCD

(F) Delusional disorder

Correct Answer: (C) Acute Stress Disorder. Sariah meets Criterion A (exposure to physical assault). She exhibits more than 9 symptoms from the five categories (Criterion B: intrusive images, emotional numbness, derealization, avoidance of location/school, hypervigilance, exaggerated startle, sleep disturbance, concentration difficulty, anxiety). The symptoms began after the trauma and have been present for 3 days to 1 month (Criterion C: 10 days). They cause significant distress and impairment (Criterion D).

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