Separating traumatic stress from other mental health issues

Many patient visits are well-visits or for a sick child and can be easy to resolve. However, some families will come in with a concern about the child’s behavior, perhaps even at the request of the child’s school. Deciding the course of treatment depends on whether the child is suffering from anxiety, depression, attention-deficit/hyperactivity disorder (ADHD), or traumatic stress. As posttraumatic stress disorder (PTSD) is rarely seen as a main complaint in children, it can be difficult to discover that traumatic stress is the cause of the child’s problem, said Brooks Keeshin, MD, FAAP, associate professor of pediatrics at the University of Utah in Salt Lake City, during his presentation “Teasing out trauma: How to assess, how to treat” at the 2020 virtual American Academy of Pediatrics National Conference & Exhibition.

Separating traumatic stress from anxiety, ADHD, and depression can be difficult, but it can be important to ensuring that the child gets proper care. Symptoms of trauma can overlap with several ADHD symptoms, including some that are considered hallmarks of ADHD, such as being easily distracted, hyperactivity, difficulty concentrating and learning, and restlessness. However, the stimulants that are frequently used to treat ADHD have not been shown to be effective for treating trauma. Behavioral therapy does help for both, but it needs to be geared to trauma to be effective. Depression and traumatic stress also have a number of overlapping symptoms including loss of interest, detachment, and sleep disturbances. Anxiety can be particularly difficult to separate because many forms of anxiety such as panic attacks and separation anxiety can be similar. As with ADHD, the treatments for depression and anxiety have limited to no effect on treating traumatic stress.

One of the best ways to discover trauma is to use structured screening and assessments. Keeshin presented a roadmap to care, which utilized a 13 question pediatric traumatic stress screening tool, to determine if reporting the incident was required (abuse vs traumatic event, such as a fire), if there was a risk of suicide, and how to respond with treatment. The question about suicide risk can trigger use of the Columbia Suicide Severity Rating Scale to determine the necessary response. The response to treatment helps determine if the issues are centered around sleep, arousal/intrusion, or avoidance/negative mood.

Once assessed, the child can be treated by either trauma-focused cognitive behavioral therapy that helps the child learn coping skills, process the trauma, and then provide safety and stability. Numerous studies have proven this form of treatment to be very successful. If medication is deemed necessary, the clinician should avoid benzodiazepines, significant polypharmacy, and second generation antipsychotics.