BHIPP Bulletin

Volume 10, Issue 7

January 2025

Differentiation and Comorbidity of Diagnosis for Youth who have Experienced Trauma

This month's BHIPP Bulletin is a contribution from

Rheanna Platt, MD, Associate Professor in the Department of Psychiatry and Behavioral Sciences at Johns Hopkins University School of Medicine and BHIPP Consultant.

It is estimated that more than two thirds of children report at least one traumatic event by age 16.1 However, the sequelae and/or impact of trauma exposure on any given patient is highly variable; some children recover with minimal signs of psychological distress, while for others, trauma exposure can result in more significant sequelae. In this newsletter, we will describe common sequelae of trauma, including Post-Traumatic Stress Disorder (PTSD) and other diagnoses among youth experiencing trauma. 

As demonstrated in studies such as the Adverse Childhood Experiences study,2 exposure to childhood adversity and trauma is a risk factor for psychopathology. Overall, children who have experienced trauma are about twice as likely to develop/meet criteria for any mental health diagnosis compared to those who have not experienced trauma.3 There is also evidence that certain forms of trauma (e.g., child maltreatment) are associated with impaired ability to regulate or manage challenging emotions.4 Exposure to trauma has been associated with mood, anxiety, and disruptive behavior disorders, substance use, psychotic experiences, and suicidal ideation and attempts. Conversely, social support seems to be a broad protective factor against the development of psychopathology and trauma-related disorders.


Research has found several potential mechanisms that help explain the link between trauma exposure and mental health disorders, including: 


1.  Experiences of trauma can contribute to the way a child perceives and interprets social cues. For example, a child may be more likely to perceive social cues as threatening and/or have increased sensitivity to emotions such as anger (e.g., being more likely to attribute facial expressions as angry). This may lead to an aggressive response (increasing the risk for disruptive behavior) or may increase levels of anxiety disorders (which are characterized by increased attention to cues that are perceived as threatening) and may also relate to increased risk for later development of psychotic disorders.


2. Experiences of trauma can lead to difficulties identifying and regulating emotions. These difficulties may increase later risks of maladaptive coping responses (e.g., self-injurious behavior, substance use).


3. Accelerated biological aging. For example, trauma exposure is associated with earlier pubertal timing which may hasten onset of associated risk-taking behaviors (e.g., substance use disorders).

Trauma and Posttraumic Stress Disorder

Despite the high prevalence of youth having experienced traumatic events, studies of children and adolescents estimate prevalence of PTSD to be about 5-10%, with a higher prevalence among females compared to males. Risk of developing PTSD appears to be highest among youth experiencing interpersonal trauma (e.g., rape, sexual assault, physical assault, kidnapping) and exposure to war/armed conflict.5 Additionally, psychological distress/symptoms prior to a traumatic event may increase the risk of PTSD following trauma.6 Finally, family characteristics (e.g., poor family functioning, parental PTSD symptoms) are also associated with increased risk of PTSD amongst those exposed to trauma.7 


PTSD, Trauma, and ADHD:

A common challenge is assessing for ADHD in the context of trauma. It is important to note that there appears to be a bidirectional relationship between ADHD and PTSD  whereby youth with ADHD have a greater likelihood of developing PTSD (which may in part be due to an increase in impulsivity/risk-taking behaviors), and youth with PTSD have a greater likelihood of having symptoms of ADHD (which may in turn increase risk for exposure to additional traumatic events).8 Of note, in addition to psychotherapy, there is some evidence for the use of alpha-2 agonists (e.g., guanfacine) to treat symptoms of both ADHD and PTSD.9

Trauma and Anxiety Disorders/Symptoms10

Trauma and anxiety are closely linked, as anxiety is a natural (and in some cases, adaptive) response to threat, and anxiety and PTSD share common features (e.g., avoidance). Perhaps not surprisingly, pre-existing anxiety is associated with an increased risk of developing PTSD in youth exposed to trauma. The presence of comorbidities such as anxiety may influence pharmacologic treatment in particular. For example, while there is a lack of evidence for the use of SSRIs to treat PTSD in the pediatric population,11 SSRIs do have a role in the treatment of anxiety and depressive disorders. 


Conclusion

Given the association of trauma exposure with the development of a range of other disorders in addition to PTSD, consider screening or assessing for the presence of other disorders in addition to PTSD. For additional information on assessment of trauma and PTSD, check out these two previous BHIPP newsletters: Trauma and Adverse Childhood Experiences (ACEs) and Culturally Responsive, Trauma-Informed Practices for Pediatric Primary Care Providers. Conversely, consider the potential for trauma exposure as a contributor to other symptoms/behaviors (e.g., disruptive behavior, substance use).


Importantly, bolstering social support and other protective factors (e.g., positive childhood experiences) can play an important protective role for children and families.


Resources:


1. Center for Youth Wellness Adverse Childhood Experiences Questionnaire (ACE-Q)

2. The Pediatric ACEs and Related Life Events Screener (PEARLS)

3. Child Stress Disorder Checklist - Short Form (CSDC-SF)

4. Child Trauma Screening Questionnaire (CTSQ)

5. BHIPP Quick Tips for Providers: Educating Families about Traumatic Stress

6. Is it ADHD or Traumatic Stress? A Guide for Clinicians

As always, if you have questions about the behavioral health needs of your patients, we encourage you to call the BHIPP consultation line at 

855-MD-BHIPP (632-4477), open 9am-5pm Monday-Friday, for resource/referral networking or consultation support.


We will keep you informed about all our services and training events through our website (www.mdbhipp.org) and monthly e-newsletters. Additionally, BHIPP is on LinkedIn, X, and Facebook. We invite you to follow us there to stay up-to-date on upcoming training events, pediatric mental health research, and resources for providers, families and children.

References

BHIPP Announcements

There is still time to register for this week's BHIPP Webinar!

Register for the next BHIPP Webinar on January 30th at 12:00pm! BHIPP Webinars are a series of interactive, web-based learning sessions that are a virtual space for pediatric primary care, emergency medicine, and behavioral health providers to connect, learn and share about strategies, practices and resources to promote mental health and resilience among children and families as well as providers. Free CME and CEU credit is available for participation.

Click here to register!

New BHIPP ECHO: Enhanced Behavioral Health Training for PMHNPs

Register for the new BHIPP PMHNP ECHO series! The next session will be held on February 4th from 11:00am-12:00pm. Join our multidisciplinary team of child behavioral health experts every month between November 2024 and April 2025 for virtual case-based learning and didactic presentations. This series is designed for Maryland Psychiatric-Mental Health Nurse Practitioners (PMHNPs) who want to deepen their knowledge of child and adolescent mental health. Free CEU credit is available for participation.

View Flyer
Click here to register!

Sign up for an upcoming BHIPP Webinar!

Register for an upcoming BHIPP Webinar on February 6th at 12:00pm! BHIPP Webinars are a series of interactive, web-based learning sessions that are a virtual space for pediatric primary care, emergency medicine, and behavioral health providers to connect, learn and share about strategies, practices and resources to promote mental health and resilience among children and families as well as providers. Free CME and CEU credit is available for participation.

Click here to register!

Join the BHIPP ECHO Beyond the Basics Series!

Register for the BHIPP ECHO Beyond the Basics series! The next session will be held on February 13th from 12:00-1:00pm. Join our multidisciplinary team of child behavioral health experts on the second Thursday of every month between October 2024 and May 2025 for virtual case-based learning and didactic presentations. This series is great for providers who have already participated in BHIPP ECHO, or who feel like they are experienced in treating behavioral health in their practice and are looking to explore advanced topics. Free CME and CEU credit is available for participation.

View Flyer
Click here to register!

Join the BHIPP ECHO Core Foundations Series Learning Collaborative!

Register for the BHIPP ECHO Core Foundations series! The next session will be held on February 27th from 12:00-1:00pm. Join our multidisciplinary team of child behavioral health experts every month between October 2024 and May 2025 for virtual case-based learning and didactic presentations. This series is great for providers who want to improve their knowledge of child mental health and develop foundational skills. Free CME and CEU credit is available for participation.

View Flyer
Click here to register!
BHIPP Bulletin Archive
Visit our website
Facebook  X  Linkedin  Youtube  

BHIPP is supported by funding from the Maryland Department of Health, Behavioral Health Administration and operates as a collaboration between the University of Maryland School of Medicine, the Johns Hopkins University School of Medicine, and Salisbury University.


BHIPP and this newsletter are also supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award totaling $1,379,327 with approximately 20% financed by non-governmental sources. The contents of this newsletter are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS or the U.S. Government. For more information, visit www.hrsa.gov.


Copyright © 2021 Maryland Behavioral Health Integration in Pediatric Primary Care (BHIPP), All rights reserved.