Written by Rob Lusk
You just started seeing a young client who has clearly been affected by trauma. You need to diagnose them, but where do you start? Is it PTSD? An Attachment Disorder? Is there a diagnosis that can capture all of their problems?
That’s where the new DSM5® updates come in. Here are some tips that will help you wade through the new trauma diagnoses in the DSM-5® and help ensure you’re choosing the right diagnoses for your child and adolescent clients.
You’re probably aware that the DSM-5® created a new section focused on Trauma and Stressor-Related Disorders with our youth patients. There are essentially seven disorders in this new section:
- Reactive Attachment Disorder
- Disinhibited Social Engagement Disorder
- Posttraumatic Stress Disorder (PTSD; separate criteria are included for PTSD for children 6 years & younger)
- Acute Stress Disorder
- Adjustment Disorders
- Other Specified Trauma/Stressor-Related Disorders
- Unspecified Trauma/Stressor-Related Disorders
Here’s a brief overview of this section, along with some tips on using these diagnoses with your child and adolescent clients.
Reactive Attachment Disorder (RAD) and Disinhibited Social Engagement Disorder (DSED)
These both used to be subtypes of RAD. The former RAD, Inhibited Type has been expanded a bit and is now “just plain” RAD.
DSED is now used to diagnose youth who were formerly diagnosed with RAD, Disinhibited Type.
Both disorders have the same criterion that the youth must have experienced “extremes of insufficient care” in early childhood that is presumed to be responsible for their relationship problems.
In RAD, the youth tends to withdraw from caregivers, has limited social/emotional responsiveness in general, and has periods of irritability, fearfulness, or sadness. In general, these kids don’t get close to others – especially caregivers.
In contrast, in DSED (like the old RAD, Disinhibited Type) the youth has diffuse boundaries. They seem at ease with approaching and interacting with strangers, often violate others’ personal space, and don’t tend to seek security from their caregivers - who often feel like their relationship with the youth is superficial. In general, these kids seem to want closeness to as many people as possible, but often aren’t seen as having “genuinely close” relationships with others (again, especially caregivers).
These updates in the diagnoses are helpful in several ways. First, the criteria have been expanded and clarified, so it’s easier to figure out whether a child actually fits each diagnosis. Second, dividing these disorders is consistent with growing research literature that suggests that children with Disinhibited Social Engagement Disorder may be much more difficult to treat and may take somewhat different approaches, so they are probably distinct enough that it makes sense to separate them.
Posttraumatic Stress Disorder
PTSD is still pretty similar to the “old” version, although in my opinion, the criteria fit youth better than they used to – and again, there are now separate criteria for children aged six and younger.
The first three “core” criteria are:
1. Exposure to a traumatic event
2. Having intrusive/re-experiencing symptoms (like nightmares and flashbacks)
3. Avoidance of trauma reminders. Unfortunately, this often means they will want to avoid therapy with you – and kids are tough enough to engage without a symptom that makes it even harder.
The DSM-5® added a new criterion (Criterion D) - altered thoughts and mood.
This is helpful from a diagnostic perspective, since the criteria are spelled out more clearly and distinctively, making it easier to apply than the older version. However, this unfortunately means some of the most commonly used diagnostic assessments - e.g., the UCLA PTSD Index - no longer match up to the diagnostic criteria.
Finally, there are two additional criteria that carried over from the old diagnosis: alterations in arousal/reactivity and a one-month duration.
Another helpful addition is the specifier “with dissociative symptoms.” These are very common in traumatized youth, although the specifiers included – depersonalization and derealization – tend to be reported much more by older adolescents and adults in my experience.
While similar to the older version of PTSD, the new version is more helpful because it spells out the symptoms in better detail, adds the ability to include the “with dissociative symptoms” specifier, and the expanded criteria fit youth somewhat better than they used to.
PTSD 6 and Under
The PTSD criteria for ages six and under are much more developmentally appropriate for young children than the standard version’s criteria.
The main criteria are exposure to a trauma, which can include learning a caregiver was traumatized - intrusive symptoms, avoidance/negative cognitions - combined for young children - arousal/reactivity, distress/impairment, and duration of more than one month (the same specifiers are allowed as in the “older” version of PTSD (e.g., with dissociative symptoms).
The new criteria is easier to “fit” traumatized young children in this diagnosis, but it also means that two young children with a PTSD diagnosis can have very different specific symptoms. Overall, I think it’s an important addition because it recognizes that trauma symptoms show themselves differently in young children, and the flexible criteria make it much easier to fully apply a PTSD diagnosis to them.
Acute Stress Disorder
Acute Stress Disorder hasn’t changed much. It’s characterized by the development of severe anxiety, dissociative, and other symptoms that occurs within one month after exposure to an extreme traumatic stressor.
It’s essentially the short-term version of PTSD, but it’s diagnosed from three days to one month after the traumatic event. The main reason the disorder isn’t diagnosed before three days is that many people - including youth - have PTSD-like symptoms for up to two days after a trauma, but in most people the symptoms fade after a day or two.
While the new update isn’t much of an improvement over the old version, it still fits the immediate/short-term aftermath of youth pretty well.
The diagnosis of Adjustment Disorders in the DSM-5® is very similar to the older version of the disorder, and typically doesn’t create issues for clinicians who are used to the “old” version.
Adjustment Disorders refer to when a youth develops clinically significant emotional or behavioral symptoms after experiencing identifiable stressor(s) that happened in the last three months. Functionally, the youth must either have distress that is clearly out of proportion to the stressor (this is often a judgment call) or significantly impaired functioning. Normal grief (bereavement) isn’t considered an Adjustment Disorder, and the symptoms can’t last more than six months after the stressor or its consequences have ended (so it’s time-limited in a sense).
The same “specifiers” are present in the newer version; the youth can show depressed mood, anxiety, mixed emotional symptoms, behavior (“conduct”) problems, or a mixed disturbance of both emotions and behavior.
Again, the criteria haven’t changed much from the older version, but this diagnosis is still useful for kids who haven’t had the “extreme” traumas usually needed for a PTSD or similar diagnosis, but are clearly reacting to a stressful event in their life.
Other Specified Trauma- and Stress-Related Disorder
This diagnosis is used when a client has trauma-related symptoms that cause significant distress or impaired functioning, but don’t meet the criteria for another listed disorder.
I want to emphasize that this is a perfectly legitimate diagnosis, and should not be confused with terms like “not otherwise specified” or “provisional”. According to National Child Traumatic Stress Network data on youth in treatment for trauma, it appears that only around 25% of youth who receive trauma-focused treatment in the U.S. have ever met criteria for PTSD.
Many trauma professionals believe that PTSD – and other specific trauma diagnoses, for that matter – usually don’t fit youth that well – especially those with chronic or complex trauma.
Other Specified Trauma-Related Disorder is a valid way of dealing with this issue. It allows you to give a diagnosis for your trauma victims who simply don’t meet criteria for another disorder, but are clearly dealing with trauma-related problems.
For communication purposes, I recommend noting what the problems are in parentheses after the diagnosis. In my experience, as long as you have the right code and name first, this doesn’t cause any issues with billing Medicaid or insurance companies.
For example, a youth at my agency is diagnosed with Other Specified Trauma- and Stressor-Related Disorder (Features of PTSD and Disinhibited Social Engagement Disorder).
As I’ve noted, this new diagnosis is extremely helpful; it allows you to make a “legitimate” diagnosis of a problem that’s clearly trauma-related, but simply doesn’t meet PTSD or other more specific criteria.
Unspecified Trauma/Stressor-Related Disorder
This option is used when you don’t have enough information to make a more specific diagnosis (e.g., in an emergency room). This should be specified further by the clinician in charge of the case as soon as possible.
When I learned that the new edition of the DSM® was going to have a section devoted to Trauma- and Stressor-Related Disorders, I was both hopeful and worried about what this new section would bring.
While there are still plenty of issues being debated about this section, in my experience (as well as that of the therapists I supervise and work with) it’s a significant improvement over the older versions. The addition of the “Other Specified” diagnosis in particular has made the practice of diagnosing youth easier – and arguably more valid – than it used to be.
The biggest concern about the current section among trauma professionals is probably that “Developmental Trauma Disorder” was not included. This term is probably the most common unofficial language used to describe the host of symptoms often seen in complex or chronic trauma victims. As a result, kids with complex trauma histories will often still meet criteria for multiple disorders in other areas (e.g., ADHD, Depressive Disorders, and Anxiety Disorders), even when these issues seem clearly trauma-related. Hopefully the next edition of the DSM® will address this.
Interested in learning more from Rob Lusk? See more of his courses here.