By K. M. Asano

S E R I E S C O N S U L T A N T Anne S. Walters, Ph.D. Emma Pendleton Bradley Hospital Warren Alpert Medical School of Brown University

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Foreword: Dr. Anne S. Walters, Ph.D.. ......................................... 6 Chapter 1: Introduction to Trauma and Stressor Related Disorders....................................... 11 Chapter 2: Post-Traumatic Stress Disorder. ............................... 27 Chapter 3: Adjustment Disorders.............................................. 43 Chapter 4: Acute Stress Disorder. ............................................. 57 Chapter 5: Attachment Disorders. ............................................ 69 Chapter 6: Treatments for Trauma and Stressor Related Disorders....................................... 83 Chapter Notes. ..................................................................... 100 Series Glossary of Key Terms. ................................................ 102 Further Reading. .................................................................. 104 Internet Resources................................................................ 105 Organizations to Contact....................................................... 106 Index................................................................................... 108 Author’s Biography / Credits................................................. 112 KEY ICONS TO LOOK FOR: Words to Understand: These words with their easy-to-understand definitions will increase the reader’s understanding of the text while building vocabulary skills. Sidebars: This boxed material within the main text allows readers to build knowledge, gain insights, explore possibilities, and broaden their perspectives by weaving together additional information to provide realistic and holistic perspectives. Educational videos: Readers can view videos by scanning our QR codes, providing them with additional educational content to supplement the text. Examples include news coverage, moments in history, speeches, iconic sports moments, and much more! Text-Dependent Questions: These questions send the reader back to the text for more careful attention to the evidence presented there. Research Projects: Readers are pointed toward areas of further inquiry connected to each chapter. Suggestions are provided for projects that encourage deeper research and analysis. Series Glossary of Key Terms: This back-of-the-book glossary contains terminology used throughout this series. Words found here increase the reader’s ability to read and comprehend higher-level books and articles in this field.


Dr. Anne S. Walters, Ph.D.

Almost one in seven children and adolescents in the United States has a diagnosable mental illness, according to the National Institute of Mental Health (NIMH), the leading federal agency for research on mental disorders. That’s more than the number of children and adolescents suffering from cancer, AIDS, and diabetes combined. NIMH

research has found that almost 50 percent of these young people will experience an episode of mental illness before the age of eighteen. The rate of mental illness is even higher among young adults between the ages of eighteen and twenty-five. This is not a uniquely American problem, however. The World Health Organization (WHO) reports that mental disorders are the leading cause of disability among young people in all regions of the world.


The most common behavioral health diagnoses in children include attention deficit hyperactivity disorder (ADHD), behavior problems, anxiety, and depression. Some of these conditions commonly occur together. For example, about three in four children (73.8 percent) between the ages of three and seventeen who have been diagnosed with depression also suffer from anxiety, and almost one in two (47.2 percent) exhibit behavioral problems, according to the Centers for Disease Control and Prevention. What do these numbers mean? To start, it means that mental illness is very common. Most of you reading this will have at least one friend or family member who either is currently struggling or has struggled in the past with a psychiatric illness. That number may even include you and may mean that you have symptoms of both anxiety and depression. In addition, mental illness is becoming more common. Suicide rates have increased in children and adolescents over the past ten years, and this is a major concern at present for professionals in the behavioral health field. No one is sure what has caused these increases, though some speculate it is related to “cultural trends.” A combination of factors such as social media and technology advances or the opioid crisis may all play contributing roles. Other professionals have wondered about how violence in our schools


might impact youth mental health, and still others have pointed to the potential effects of decreased sleep on these illnesses. Despite there being more widespread information about the prevalence of mental health issues for children and adolescents, only slightly more than half of these children receive treatment. What gets in the way? One of the barriers to seeking treatment is the fear that others will find out. Children, adolescents, and even parents fear the stigma of being identified as having a mental illness. Despite progress in the diagnosis and treatment of these illnesses, the stigma that surrounds mental illness is still very profound, even today. Parents fear that their children will experience shame. As long as this stigma exists, it affects the likelihood that children or their families will seek help. Other barriers include doctor and hospital wait lists, concern about medical expense, a shortage of available mental health providers, and lack of knowledge about treatment options. Some of the movements toward reducing stigma have been helpful in this regard. Notable examples are actress Glenn Close and her foundation aimed at reducing the stigma for those with bipolar disorder, or Olympic athlete Michael Phelps speaking out about his own depression. The good news in all of this is that in recent years, evidence-based treatment has become available. The term “evidence based” refers to treatment that has been tested via research and


proven to be effective for various types of mental illness. For example, we know that a form of treatment called “Coping Cat,” utilizes a cognitive behavioral form of treatment that is effective for childhood anxiety, and that effectiveness is improved with the use of certain medications as well. Cognitive behavioral therapy (CBT) targets the way that we negatively interpret or perceive situations, and teaches us to “restructure” those thoughts, leading to different feelings and experiences. We know CBT is helpful because researchers have performed studies comparing patients who get this form of treatment with patients that receive other forms of treatment. Our readers will learn more about all these topics in the volumes ahead. We hope that having more information will help you to combat the stigma that surrounds mental illness, and therefore reduce the length of time it takes a child and family to seek treatment. Our hope is that this series will spark conversation and provide important information for children, parents, and school personnel about the various diagnoses that are most common in childhood and adolescence. With this series, we hope you will understand much more about mental illnesses, what is involved, and what to do to help those who might be suffering like family, friends, or even you.



constructive: something that is beneficial, helpful, insightful, or encouraging irrational: something that is illogical or unfounded, nevertheless very strongly believed multifaceted: complex, multi-layered, very involved and complicated in nature stereotype: a false or misguided label applied to an entire group based on one individual


1 chapter

Introduction to Trauma and Stressor Related Disorders Stress is something all of us have experienced. Stress is simply a part of life and is something many of us do not give much thought to. At its most basic level, stress is the body’s reaction to outside stimuli; as such, it requires an adjustment or response from the mind or the body. The body responds to these changes in stimuli and reacts with physical, mental, and emotional symptoms. A person can experience stress from several sources: environmental (noise or temperature), physical (hunger), or mental (sadness, self-criticism). “The word stress is used in different ways. It can refer to the challenges of everyday life, which do not always cause us problems. But the word is also used for the feeling inside us if we cannot respond to the challenge. The medical term for this is anxiety.” 1 Because stress can come frommany sources, it can take on many forms, so understanding stress can be a challenging undertaking. People have very different ideas with respect to the definition of stress. Probably the most common definition is physical, mental, or emotional strain or tension. Another popular definition of stress is a condition or feeling experienced when a person perceives


that demands exceed the personal resources the individual can mobilize… Stress is ubiquitous and follows us everywhere. Since there is simply no avoiding it, the task for mental health professionals has become to further our understanding to improve management in our patients and in ourselves. 2 Stress in and of itself does not carry any type of diagnosis of a mental disorder, but it is closely linked to mental health in a number of key ways. Stress also can be an indicator that another condition may be at play. Pay Attention to Stress Even though stress is common and is somewhat of a natural part of life that we all experience, it is important to learn all we can about stress and its impact on our lives. Events that occur naturally can be hazardous and harmful, like hurricanes, arsenic, and snake venom. Likewise, stress can be harmful to us in certain situations. Stress is not something to ignore. Instead, we need to learn how stress affects us and adapt to it. Stress is something we cannot escape. In fact, turning a blind eye to stress could prove dangerous. “Stress can cause mental health problems and make existing problems worse. For example, when a person struggles to manage feelings of stress, he or she might develop a mental health problem like anxiety or depression. Mental health problems can cause stress. You might find coping with the day-to-day symptoms of your mental health problem, managing medication, and scheduling healthcare appointments or treatments become extra sources of stress. This can start to feel like a vicious circle, and it might be hard to see where stress ends and your mental health problem begins.” 3 This is the basic cycle that stress can lead to. Ignoring the causes and impacts of stress only make the symptoms worse. The only way to deal with stress in a healthy and constructive way is to face it,


Behavioral Disorders: Trauma and Stressor Related Disorders

For people with stressor related disorders, things such as managing their stress medication can itself be an added stressor.


Introduction to Trauma and Stressor Related Disorders

Stress can affect how people think, feel, and react, which can have a significant impact on their lives.


Behavioral Disorders: Trauma and Stressor Related Disorders

learn about it, adapt to it, and fight it. Stress can affect anyone and the number of people suffering from excessive stress, related health conditions, and mental disorders continues to grow year after year. Children are susceptible to developing stress-related disorders such as separation anxiety, and social anxiety. “On any given day, three to five percent of children and adolescents in the United States have some type of anxiety disorder. Without treatment, this kind of disorder can interfere with the ability to carry out everyday tasks, succeed in school, or make and keep friends. Or it may simply cause great distress that saps much of their enjoyment from life.” 4 As staggering as these figures are, even more people are believed to suffer from stress-related disorders such as generalized anxiety disorder, social anxiety, separation anxiety, and adjustment and mental disorders connected to stress. The Problem With Treating Stress-Related Disorders “A person can only take so much stress before he or she begins to feel uncomfortable. The mind and body become agitated: there is a vague sense of fear for the future; it becomes impossible to get a problem out of your head; you find it difficult to relax, especially at night. Sometimes, stress can even make you slow down and become depressed, rather than agitated.” 5 These changes in how a person thinks and feels and reacts can have a huge impact on his or her life. When stress cannot be experienced, processed, and realized, it can build and fester and affect people in a negative way. When this occurs for long enough, it can result in the development of a stress-related mental disorder. These disorders can affect how individuals think and feel about themselves and those around them, the world they live in, and any manner of behavior, thought, feeling, or idea that they face in day-to


Introduction to Trauma and Stressor Related Disorders

Mental health professionals advocate for breaking the stigma surrounding mental health disorders, which are caused by a combination of biological and environmental factors, not by the relative mental strength or weakness of the afflicted person.


Behavioral Disorders: Trauma and Stressor Related Disorders

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