Download Childhood Anxiety Disorders for the Pediatrician

Mary Gabriel, MD FAAP
Children’s National Medical Center
Division of Psychiatry and Behavioral Sciences
March 24, 2016
Objectives
 Identify normal vs. pathological worry and fear
 Understand the development of anxiety, including risk
factors and protective elements
 List different anxiety disorders and how they present
in children vs. adults
 Understand different treatment modalities and
appropriately refer
What is worry?
 Anxious apprehension and thoughts focused on the
possibility of negative future events
What is fear?
 Response to threat or danger that is perceived as actual
or impending.
Fear and worry are common in
normal children
 Developmentally appropriate vs. significantly impaired
functioning
 Fears during childhood = normal developmental
transition
Normal fears and worries
 Infants: fear of loud noises, being startled or dropped,
and strangers (later in infancy)
 Toddlers: fear of imaginary creatures (monsters),
darkness, normative separation anxiety
 School-aged: fears about injury and natural events
 Older children and adolescents: worries about
school performance, social competence, health issues
Erikson’s psychosocial development
Stage
Basic Conflict
Important
Even
ts
Outcome
Infancy (birth to 18
months)
Trust vs. Mistrust
Feeding
Children develop a sense of trust when caregivers provide reliability, care, and affection. A lack of this will
lead to mistrust.
Early Childhood (2
to 3 years)
Autonomy vs.
Shame and
Doubt
Toilet
Children need to develop a sense of personal control over physical skills and a sense of independence.
Success leads to feelings of autonomy, failure results in feelings of shame and doubt.
Preschool (3 to 5
years)
Initiative vs. Guilt
Exploration
Children need to begin asserting control and power over the environment. Success in this stage leads to a
sense of purpose. Children who try to exert too much power experience disapproval, resulting in a
sense of guilt.
School Age (6 to 11
years)
Industry vs.
Inferiority
School
Children need to cope with new social and academic demands. Success leads to a sense of competence,
while failure results in feelings of inferiority.
Adolescence (12 to
18 years)
Identity vs. Role
Confusion
Social
Relationshi
ps
Teens need to develop a sense of self and personal identity. Success leads to an ability to stay true to
yourself, while failure leads to role confusion and a weak sense of self.
Young Adulthood
(19 to 40
years)
Intimacy vs.
Isolation
Relationshi
ps
Young adults need to form intimate, loving relationships with other people. Success leads to strong
relationships, while failure results in loneliness and isolation.
Middle Adulthood
(40 to 65
years)
Generativity vs.
Stagnation
Work and
Pare
ntho
od
Adults need to create or nurture things that will outlast them, often by having children or creating a positive
change that benefits other people. Success leads to feelings of usefulness and accomplishment, while
failure results in shallow involvement in the world.
Maturity(65 to
death)
Ego Integrity vs.
Despair
Reflection
on
Life
Older adults need to look back on life and feel a sense of fulfillment. Success at this stage leads to feelings of
wisdom, while failure results in regret, bitterness, and despair.
Train
ing
Clinical Presentation
 Crying, irritability, angry outbursts
 Misunderstood as oppositionality or disobedience
 Actually represent the child’s expression of fear or
effort to avoid the anxiety-provoking stimulus at any
cost
 Somatic complaints
 Headache
 Stomachache
 May not recognize their fears as unreasonable
Epidemiology
 Prevalence rates: 6-20%
 Strict adherence to diagnostic criteria
 Consideration of functional impairment
 Slightly higher in girls, but this is more in specific
phobia, panic disorder, agoraphobia, and separation
anxiety
 Panic disorder often emerges later in mid-teen years
Risk Factors
 Biological:
 Genetic
 Temperament
 Autonomic reactivity (cortisol dysregulation, irregular
sleep patterns, GI reactivity)
 Anxiety sensitivity
 Environmental
 Attachment styles
 Parenting behaviors
 Peer/social problems
 Negative/stressful life events
Long term
 Children may develop new anxiety disorders over time
 Higher risk of developing depression and substance
abuse disorders as well
 The more severe the disorder and the greater the
impairment, the more likely it is to persist
Pine, et al, 1998
Sequelae
 Disruption of normal psychosocial development of the
child:
 Social: poor self-esteem, underestimate their
competencies
 Family
 Academic
Anxiety Disorders in DSM5
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GAD
Separation Anxiety Disorder
Social Anxiety Disorder
Specific Phobia
Panic Disorder
Agoraphobia
Selective Mutism
SIAD/Due to MC/Other/Unspecified
Trauma- and Stressor-Related
Disorders
 PTSD– including PTSD for Children 6 Years and
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Younger
RAD
Disinhibited Social Engagement Disorder
Adjustment Disorder
Acute Stress Disorder
Other/Unspecifed
Case #1
 CC: CW is a 10yo male with h/o ADHD who returns to clinic to reestablish care and address
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anxiety sx.
Dad reports CW seeks constant reassurance from parents.
Pt is very rigid and does not tolerate change or transitions well at all, "blow's up" when routine
changes.
Difficulty letting go of things-- will hold onto past events/experiences, especially focused on
the negative aspects. Pt has a tendency to generalize his anxieties after a while
Pt also worries about taking pills, especially on an empty stomach, and has been cheeking his
sertraline for the last few months, which father discovered
Socially, anxiety interferes with pt making friends. Pt used to have much difficulty relating to
peers due to his focus of conversation being "whatever was in his head, rather than following
what the group was discussing.
Medically, anxiety interferes with eating and at times with defecation
Pt will hit himself repeatedly in the chest when degree of anxiety is severe. Pt will also squeeze
his bunny when he is very anxious.
On interview, pt states that he is perfectionistic, gets distracted if things aren't the way he
thinks they should be. He admits he will correct his younger sister who is "bossy." Nauseated
when anxious, +muscle tension. Describes his feelings: 25% anxious, 25% happy, 25% neutral,
12/5% angry, 12.5% sad (Dad's observations of pt's feelings: 30% sad, 45% anxious, 25% happy,
12.5% angry).
Generalized Anxiety Disorder
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Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6
months, about a number of events or activities (such as work or school performance).
The individual finds it difficult to control the worry.
The anxiety and worry are associated with three (or more) of the following six symptoms (with at
least some symptoms having been present for more days than not for the past 6 months):
Note: Only one item is required in children.
Restlessness or feeling keyed up or on edge.
Being easily fatigued.
Difficulty concentrating or mind going blank.
Irritability.
Muscle tension.
Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep).
The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or
other important areas of functioning.
The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or
another medical condition (e.g., hyperthyroidism).
The disturbance is not better explained by another mental disorder (e.g., anxiety or worry about having panic attacks in
panic disorder, negative evaluation in social anxiety disorder [social phobia], contamination or other obsessions in
obsessive-compulsive disorder, separation from attachment figures in separation anxiety disorder, reminders of
traumatic events in posttraumatic stress disorder, gaining weight in anorexia nervosa, physical complaints in somatic
symptom disorder, perceived appearance flaws in body dysmorphic disorder, having a serious illness in illness anxiety
disorder, or the content of delusional beliefs in schizophrenia or delusional disorder).
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GAD: Clinical symptoms
 Excessive, unrealistic fears about day-to-day activities
 "What if" concerns that span far into the future
 Uncontrollable worry about multiple situations, performance, social, academic,
health, financial
 Physical symptoms: headaches, stomachaches, inability to unwind
 Difficulty concentrating, always thinking what's next
 Low risk-taking; Need for reassurance and approval for small steps
 Perfectionism, great fear of making mistakes, fear of criticism; unrealistic
unfavorable assessment of their grades, abilities
 Over-responsibility, feels that tragedies are preventable by worry, and if
disaster happens that it's their fault
 Any negative piece of news that happens to others, fears will happen to them;
everything is contagious by association: divorce, illness, car accidents, food
poisoning
 Reviewing events to make sure that didn't hurt anyone's feelings or do anything
wrong
 Sleep difficulties, irritability, fatigue
WorryWiseKids.org
GAD in children
 Content of anxiety:
 quality of performance or competence at school or sports
 Catastrophic events
 Perfectionistic, overly conforming
 Overzealous in seeking reassurance and approval
 Look for childhood adversities and parental behaviors
GAD: Diagnosis
 Interview
 Collateral
 Beware: an anxious child’s desire to please adults
and concerns about peformance may affect the
child’s self-report
 Consider TFT’s
 Document somatic sx before starting meds to
reduce mistaking them for medication SE’s after
initiation of meds.
GAD: diagnostic scales
 MASC (Multidimensional Anxiety Scale for Children)
 SCARED (Screen for Child Anxiety Related Emotional

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
Disorders)
GAD 7
Severity Measure for Generalized Anxiety Disorder—
Child Age 11–17
ADIS-IV-C (Anxiety Disorders Interview Schedule for
DSM-IV: Child Version) Child and Parent Interview
Schedules
Family assessment
GAD: Treatment
 CBT
 Facilitates modification of negative thought patterns that lead to
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emotional distress– Cognitive restructuring
Facilitates development of emotional regulation to modulate
excessive arousal
Shaping and strengthening adaptive behavior patterns– Problem
solving
Relaxation techniques
May include parent training component and psychoeducation
 Pharmacotherapy
 SSRIs, venlafaxine*
 Parent-Child and Family Interventions
GAD: Help for kids and caregivers
SSRIs: the skinny
 Fluoxetine*
 5-80mg daily
 Can be activating
 Long half-life  no tapering needed
 Sertraline
Drug Counseling
 12.5-200mg daily
1. Side effects:
 Divide BID for patients under 14yo
HA,
 Citalopram
abdominal
 5-40mg daily
pain,
 Can be sedating  HS dosing if needed
activation
 QTc prolongation
2. Serotonin
 Escitalopram*
syndrome
 2.5-20mg daily
 Fewer side effects theoretically, but same as citalopram
*FDA approved in children
SSRIs: what NOT to do
 NO Paroxetine
 Very short half-life withdrawal symptoms
Agitation or restlessness
 Serotonin syndrome
Confusion
Rapid heart rate and high blood
 dextromethorphan
pressure
Dilated pupils
Loss of muscle coordination or
 SNRIs: trazodone (!), SSRIs, TCAs,
twitching muscles
rigidity
MAOIs, St. John’s Wort, lithium, SGAs Muscle
Heavy sweating
Diarrhea
Headache
 Tramadol
Shivering
Goose bumps
 Triptans
---------------------High fever
Seizures
 linezolid
Irregular heartbeat
Unconsciousness
 Withdrawal syndrome
SSRI Withdrawal Syndrome
F
I
N
I
S
H
Flu-like symptoms
Fatigue
Lethargy
General malaise
Muscle aches/headaches
Diarrhea
Insomnia
Nausea
Imbalance
Gait instability
Dizziness/lightheadedness
Vertigo
Sensory disturbances
Paresthesia
“Electric shock” sensations– “brain zaps”
Visual disturbance
Hyperarousal
Anxiety
Agitation
Case #2
CC: “She is always up my ass.”
6 yo JE is brought in by her mother due to tantrums and not being able to
do anything by herself. She incessantly asks about mom, needing
reassurance constantly, and refuses to go anywhere or do anything
without mom. She “freaks out” when mom is late from work or
separated from her: crying, hyperventilating, and refusing to go to
sleep until mom returns from work at 9:30-11:30 PM. JE follows mom
around the house, even into the bathroom, and will wait outside on the
sidewalk with her blanket until mom returns home from work that
night, regardless of the weather, including in snow and rain. She
refuses to go to school regularly and will “clock-watch.”
Separation Anxiety Disorder
 Excessive anxiety or worry about being separated from attachment
figures or home something bad will happen to them or caregiver that
results in permanent separation
 Developmentally inappropriate
 Causing significant disturbance in important areas of functioning
 At least 4 weeks of symptoms in children
 Early onset is onset > 6 yo
 **School refusal is the most common behavior and occurs 75% of the time**
Separation Anxiety Disorder:
Diagnostic Criteria
Three (or more) of the following:
 recurrent excessive distress when separation from home or major attachment
figures occurs or is anticipated
 persistent and excessive worry about losing, or about possible harm befalling,
major attachment figures
 persistent and excessive worry that an untoward event will lead to separation
from a major attachment figure (e.g., getting lost or being kidnapped)
 persistent reluctance or refusal to go to school or elsewhere because of fear of
separation
 persistently and excessively fearful or reluctant to be alone or without major
attachment figures at home or without significant adults in other settings
 persistent reluctance or refusal to go to sleep without being near a major
attachment figure or to sleep away from home
 repeated nightmares involving the theme of separation
 repeated complaints of physical symptoms (such as headaches, stomachaches,
nausea, or vomiting) when separation from major attachment figures occurs or
is anticipated
Separation Anxiety Disorder:
What does it look like?
 Crying or hiding from parents
 Shadowing parents and refuse to go anywhere without
them
 Nightmares of being kidnapped or taken away
 Somatic sx
 See risk factors for GAD, especially insecure
attachment
Separation Anxiety Disorder:
Outcomes
 Longitudinal studies: some pt’s have resolution of sx,
some don’t
 Predictors of persistence of sx:
 Comorbid ODD, ADHD
 Maternal marital dissatisfaction
 Starting with SAD makes you more likely to have
anxiety d/o as an adult
Separation Anxiety Disorder:
Treatment
 Parent training
 Particularly helpful with younger children
 Focus on teaching strategies to help manage anxiety, and identify and
shape adaptive coping skills
 CBT
 Facilitates modification of negative thought patterns that lead to emotional
distress
 Facilitates development of emotional regulation to modulate excessive
arousal
 Shaping and strengthening adaptive behavior patterns
 May include parent training component and psychoeducation
 Pharmacotherapy
 SSRIs
Case #3
 A.P is a 14yo female with history of anxiety who is referred by her PCP for
worsening school anxiety. Mom reports A.P. used to be “friendly,” has always
been shy but able to make and keep friends. Now she avoids being around any
peers at all, even family and cousins. She states people don't like her and don't
care about her.
 She attends a girls group for group therapy in Winchester-- sometimes cannot
even get out of car to go into building and attend. Pt then beats herself up after
group for not being able to talk or speak like the other girls.
 Pt avoids going to school-- thinks everyone is against her and hates her. Level
of functioning has decreased significantly since end of 2013: prefers not to got
out, and is now in homebound schooling.
 Pt worries about what others think, afraid of “getting it wrong,” very sensitive
and takes things very personally.
 On interview, she wants to be able to go to school and "be normal, and do
things" such as have friends, go out and socialize, and feel happier.
 On exam A.P. is reluctant and reticent but cooperative, has
intermittent-poor eye contact, withdrawn and guarded. Affect is constricted,
tearful, severely anxious
Social Anxiety Disorder–
DSM5-Style
A.
B.
C.
D.
E.
Marked fear or anxiety about one or more social situations in
which the individual is exposed to possible scrutiny by others.
 (Note: In children, the anxiety must occur in peer settings and
not just during interactions with adults)
The individual fears that he or she will act in a way or show
anxiety symptoms that will be negatively evaluated
The social situations almost always provoke fear or anxiety.
 Note: In children, the fear or anxiety may be expressed by
crying, tantrums, freezing, clinging, shrinking, or failing to
speak in social situations.
The social situations are avoided or endured with intense fear or
anxiety.
The fear or anxiety is out of proportion to the actual threat posed
by the social situation and to the sociocultural context.
Social Anxiety Disorder: Development
and Course
 Median age of onset: 13yo
 Sometimes emerges out of a history of shyness
 Onset may follow a stressful or humiliating experience or
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insidious and slow
First onset in adulthood is rare
Younger patients = high levels of anxiety over specific
situations
Older patients = lower levels of anxiety over broader range
of situations
Remission: 30% remit in 1 yr, 50% in a few years, 60%-without treatment– takes several years or longer
Separation Anxiety Disorder:
Treatment
 Therapy:
 CBT
 psychodynamic
 graduated exposure therapy
 Pharmacological:
 SSRI’s
 hydroxyzine
Case #4
CC: “My bad behavior”
V.L. is a 9 yo adopted female who was referred in by her
therapist for ongoing out of control behavior. Pt was
adopted at 3½ yo and has always been defiant,
manipulative, physically aggressive with significant
tantrums, and impulsive. She is alternately overlyaffectionate and untrusting of her parents– cheating,
stealing (esp food), lying. Past history is significant for
severe neglect, “deplorable living conditions,” removal from
home at 2yo, placement with 4 foster families within
18mos, and finally placement with current family.
Reactive Attachment Disorder (DSM 5)
A. 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. A persistent social and emotional disturbance
characterized by at least two of the following:
 Minimal social and emotional responsiveness to others.
 Limited positive affect.
 Episodes of unexplained irritability, sadness, or fearfulness that are
evident even during nonthreatening interactions with adult
caregivers.
RAD: Pathogenic Care
 Social neglect or deprivation in the form of persistent lack
of having 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).
Disinhibited Social Engagement
Disorder
1. A pattern of behavior in which a child actively approaches and interacts
with unfamiliar adults and exhibits at least two of the following:
 Reduced or absent reticence in approaching and interacting with
unfamiliar adults.
 Overly familiar verbal or physical behavior (that is not consistent with
culturally sanctioned and with age-appropriate social boundaries).
 Diminished or absent checking back with adult caregiver after venturing
away, even in unfamiliar settings.
 Willingness to go off with an unfamiliar adult with minimal or no
hesitation.
****not limited to impulsivity (as in attention-deficit/hyperactivity disorder)
but include socially disinhibited behavior. ****
2. Pathogenic care is the same as RAD.
Conclusions
 Not all worry and fears are pathological. Many are
developmentally appropriate and reflect typically
developing children
 While some risk factors are innate, many are not, and
targeting these environmental influences can affect
the trajectory of anxiety
 Specific anxiety disorders can morph into each other,
making complete resolution difficult but possible.
 Therapy is the mainstay of anxiety treatment.
Medications can enhance the process.
Fine
Case #3
CC: Mood swings
16 yo AB was referred from pediatric neurology following multiple ED visits for
nonepileptic sz, which began 1 yr ago. Pt admits that 1 yr ago, she disclosed to
her friend that her older brother had sexually abused repeatedly at age 6yo.
Friend told the VP, who told pt’s uncle-guardian, after which pt began “acting
out”: defiant, outbursts, breaking rules; alternating with quiet and withdrawn.
Pt admits to having nightmares every night and was admitted for SI 3 mos ago.
Pt also reports that she sees the abuse happening in her mind and feels numb.
She sleeps in the same room the abuse occurred and feels terrified in her room.
PGM-guardian reports that pt subsequently started therapy and, during one of
these therapy sessions, pt had an episode in which she seemed to suddenly
behave differently, “like a completely different persona,” for 10 minutes,
followed by abrupt fatigue and amnesia of the episode.
Post Traumatic Stress Disorder
 T rauma
 R e-experiencing
 A voidance
 U nable to function
 M onth
 A rousal
PTSD: Risk factors in children
 Girls > boys
 Poorer performance on neurocognitive tests prior
to trauma = ↑ vulnerability to developing PTSD
 Emotional problems before 6yo
 Childhood adversity
 Lots of comorbidities: MDD, anxiety, ADHD,
ODD, CD, substance use
 ***Social support is protective***
Post Traumatic Stress Disorder
 T rauma
 R e-experiencing
 A voidance
 U nable to function
 M onth
 A rousal
PTSD: Trauma
DSM IV
 the person experienced, witnessed, or
was confronted with an event or events
that involved actual or threatened death
or serious injury, or a threat to the
physical integrity of self or others
 the person's response involved intense
fear, helplessness, or horror.
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DSM 5
Exposure to actual or threatened death, serious
injury, or sexual violence in one (or more) of
the following ways:



Note: In children, this may be expressed
instead by disorganized or agitated
behavior

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 of a family
member or friend, 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.
PTSD: Trauma in Children
 Child abuse (physical, sexual)
 Violence: community, domestic, school
 Disasters
 War or terrorism
 Medical traumas
 Serious accidents
 Sudden or violent death of someone close to the
child
Post Traumatic Stress Disorder
 T rauma
 R e-experiencing
 A voidance
 U nable to function
 M onth
 A rousal
PTSD: Re-experiencing
 Recurrent, involuntary, and intrusive distressing memories of the traumatic
event(s).
 Note: In children older than 6 years, repetitive play may occur in which themes or
aspects of the traumatic event(s) are expressed.
 Recurrent distressing dreams in which the content and/or affect of the dream are related
to the traumatic event(s).
 Note: In children, there may be frightening dreams without recognizable content.
 Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the
traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the
most extreme expression being a complete loss of awareness of present surroundings.)
 Note: In children, trauma-specific reenactment may occur in play.
 Intense or prolonged psychological distress at exposure to internal or external cues that
symbolize or resemble an aspect of the traumatic event(s).
 Marked physiological reactions to internal or external cues that symbolize or resemble an
aspect of the traumatic event(s).
Post Traumatic Stress Disorder
 T rauma
 R e-experiencing
 A voidance
 U nable to function
 M onth
 A rousal
PTSD: Avoidance
DSM IV
 efforts to avoid thoughts, feelings, or
conversations associated with the trauma
 efforts to avoid activities, places, or people
that arouse recollections of the trauma
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inability to recall an important aspect of the
trauma
markedly diminished interest or participation
in significant activities
feeling of detachment or estrangement from
others
restricted range of affect (e.g., unable to have
loving feelings)
sense of a foreshortened future (e.g., does not
expect to have a career, marriage, children, or a
normal life span)
Continued…
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DSM 5
Avoidance of or efforts to avoid distressing
memories, thoughts, or feelings about or
closely associated with the traumatic event(s).
Avoidance of or efforts to avoid external
reminders (people, places, conversations,
activities, objects, situations) that arouse
distressing memories, thoughts, or feelings
about or closely associated with the traumatic
event(s).
PTSD: DSM 5 Cognitive and Mood
Changes
DSM IV
 inability to recall an important aspect of
the trauma
 markedly diminished interest or
DSM 5
Negative alterations in cognitions and mood associated with the
traumatic event(s), beginning or worsening after the traumatic
event(s) occurred, as evidenced by two (or more) of the
following:

Inability to remember an important aspect of the traumatic
event(s) (typically due to dissociative amnesia and not to other
factors such as head injury, alcohol, or drugs).

Persistent and exaggerated negative beliefs or expectations about
oneself, others, or the world (e.g., “I am bad,” “No one can be
trusted,” “The world is completely dangerous,” “My whole
nervous system is permanently ruined”).

Persistent, distorted cognitions about the cause or consequences
of the traumatic event(s) that lead the individual to blame
himself/herself or others.

Persistent negative emotional state (e.g., fear, horror, anger,
guilt, or shame).

Markedly diminished interest or participation in significant
activities.

Feelings of detachment or estrangement from others.

Persistent inability to experience positive emotions (e.g.,
inability to experience happiness, satisfaction, or loving
feelings).
participation in significant activities
 feeling of detachment or estrangement
from others
 restricted range of affect (e.g., unable to
have loving feelings)
 sense of a foreshortened future (e.g., does
not expect to have a career, marriage,
children, or a normal life span)
Post Traumatic Stress Disorder
 T rauma
 R e-experiencing
 A voidance
 U nable to function
 M onth/Mood
 A rousal
Post Traumatic Stress Disorder
 T rauma
 R e-experiencing
 A voidance
 U nable to function
 M onth/ Mood
 A rousal
PTSD: Arousal
Marked alterations in arousal and reactivity associated with the traumatic event(s),
beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or
more) of the following:
 Irritable behavior and angry outbursts (with little or no provocation) typically
expressed as verbal or physical aggression toward people or objects.
 Reckless or self-destructive behavior.
 Hypervigilence.
 Exaggerated startle response.
 Problems with concentration.
 Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).
PTSD: Specifiers
DSM 5
 With dissociative symptoms: in addition, in response to the stressor, the individual
experiences persistent or recurrent symptoms of either of the following:
 Depersonalization: Persistent or recurrent experiences of feeling detached from,
and as if one were an outside observer of, one’s mental processes or body (e.g.,
feeling as though one were in a dream; feeling a sense of unreality of self or body or
of time moving slowly).
 Derealization: Persistent or recurrent experiences of unreality of surroundings
(e.g., the world around the individual is experienced as unreal, dreamlike, distant, or
distorted).
 Note: To use this subtype, the dissociative symptoms must not be attributable to the
physiological effects of a substance (e.g., blackouts, behavior during alcohol
intoxication) or another medical condition (e.g., complex partial seizures).
Specify if:
 With delayed expression: If the full diagnostic criteria are not met until at least 6
months after the event (although the onset and expression of some symptoms may be
immediate).
PTSD: DSM 5-- for Children 6 Years
and Younger
Trauma
 Witnessing does not include events
that are witnessed only in electronic
media, television, movies, or
pictures.
Re-experiencing/Intrusive
sx
 Spontaneous and intrusive
memories may not necessarily
appear distressing and may be
expressed as play reenactment.
 Dreams: it may not be possible to
ascertain that the frightening
content is related to the traumatic
event.
Avoidance +
Cognitive/Mood changes
 Markedly diminished interest or
participation in significant
activities, including constriction of
play.
 Includes socially withdrawn
behavior
Arousal sx
 Including extreme temper tantrums
****The disturbance causes clinically
significant distress or impairment in
relationships with parents, siblings,
peers, or other caregivers or with
school behavior. ****
PTSD in kids: More of what it looks
like
 In young children, developmental regression, such as loss of language
 Children may not manifest fearful reactions (may focus on imagined interventions in
their play or story-telling)
 In addition to avoidance, children may become preoccupied with reminders
 Children may experience co-occurring traumas (physical abuse and witnessing domestic
violence)
 In chronic circumstances, may not be able to identify onset of sx
 Avoidance can also look like:
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exploratory behavior in young children
reduced participation in new activities in school-aged children
reluctance to pursue developmental opportunities in teens (dating, driving)
older kids and teens may judge themselves as cowardly
 Teens: may harbor beliefs of being changed in ways that make them socially undesirable
and estrange them from peers or lose aspirations for the future.
PTSD: Diagnosis
 The challenge: how do you make a child talk about
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something that their condition is making them avoid or
who are not developmentally capable of describing their
experiences
Collateral: pediatrician, forensic evaluator, police, CPS,
child advocacy centers
UCLA PTSD Reaction Index (for DSM IV)
CPSS (Child PTSD Symptom Scale)
PsySTART (13-item questionnaire for rapid triage)
Zero to Three
PTSD: Treatment
*****Trauma-Focused CBT*****
 P sychoeducation, parenting skills
 R elaxation
 A ffective modulation
 C ognitive Processing
 T rauma narrative
 I n vivo mastery of trauma memories
 C onjoint child-parent sessions
 E nhancing safety
PTSD: Treatment
 CBITS (Cog-Behavioral Interventions for Trauma in
Schools)
 Same as TF-CBT but done in groups at school
 So no parents
 CPP (Child-Parent Psychotherapy)
 For very young children
 Cognitive-based CBT
 TST (Trauma Systems Therapy)
 More intensive
 Wrap-around services
 Medications– NO GOOD EVIDENCE FOR ANY