Stress Disorders 129or threatened death or severe injury. The reaction has to include intense
fear, helplessness or horror. In addition to the type of re-experiencing,
avoidance, and arousal symptoms seen in PTSD, dissociative symptoms are
present, such as emotional numbness, reduced awareness of surroundings
(‘being in a daze’), derealisation, depersonalisation, denial or amnesia.
There are few studies of Acute Stress Reactions in childhood. The symp-
toms tend to be seen as likely precursors of PTSD and handled accordingly.
Adjustment disorder
This term is used to denote a wide range of symptoms that do not meet
full criteria for any other disorder, but that appear to be excessive in
relation to how upsetting the event was. Impairment is an important
criterion in making the diagnosis. Although symptoms characteristic of
most common disorders can occur, the commonest presentations are with
depression alone, or with a mixture of anxiety and depression; children
and adolescents who suffer adverse life events are about five times more
likely to suffer from these disorders. Excessive reactions to acute stress are
far commoner when the individual is already experiencing several ongoing
adversities – they are ‘the straw that broke the camel’s back’. Underlying
mechanisms are more fully discussed in Chapter 34.
Treatment should help the individual understand and cope with the
stress. In addition, it is often important to attempt to reduce the ongoing
adversities, for example, by pointing parents towards couple therapy to
reduce their discord, contacting teachers to tackle bullying, and encourag-
ing moving out of a dangerous area. Promoting protective factors can help
considerably, for example, by encouraging a child to join a sports team or
a dance class so that skills, self- confidence and positive peer relations can
be fostered.
Bereavement
Three main stages of grief in children were described by writers such as
Anna Freud and John Bowlby; empirical observations have broadly con-
firmed these. First, there is an initial crisis response with shock, denial and
disbelief, emotional numbness and feelings of detachment; thoughts and
behaviour are mainly directed towards the lost one. Emotional disorgan-
isation follows, with sadness and crying, anger and resentment, feelings
of despair, disappointment, hopelessness and worthlessness, poor sleep
and appetite, and sometimes guilt or self-blame. Adjustment to the loss is
eventually evident in reduced anxiety, increased enjoyment of life, greater
engagement in everyday activities and the formation of new attachments.
These stages merge into each other and may co-exist. The rate of progress
from one stage to another is very variable, and transitions are not irre-
versible – the child may temporarily go back a stage when stressed again.