What is the likely diagnosis for a 13-year-old female patient with a history of emotional distress, neglect, and maltreatment, presenting with symptoms of anxiety, sadness, and guilt following a traumatic family conflict?

DSM-5 Diagnosis for Medicolegal Evaluation

This 13-year-old female meets diagnostic criteria for Adjustment Disorder with Mixed Anxiety and Depressed Mood (309.28), with the index traumatic event (knife threat and family conflict) serving as the identifiable stressor, and her symptoms of sadness, guilt, and sleep disturbance representing a clinically significant emotional response that has not progressed to full PTSD criteria. 1

Primary Diagnostic Formulation

Adjustment Disorder with Mixed Anxiety and Depressed Mood

• The patient experienced an identifiable stressor (witnessing knife threat, verbal assault, and family conflict) on the index date that precipitated emotional symptoms within 3 months 1
• Current symptoms include sadness, disappointment, guilt, and initial insomnia (difficulty falling asleep until 12-1 AM), which represent emotional distress in response to the stressor 1
• Critically, she does NOT meet full criteria for PTSD, as she explicitly denies the core symptom clusters: no nightmares, no flashbacks, no panic symptoms, no avoidance behaviors, and no hyperarousal symptoms 1
• Her functioning remains largely intact with adequate school performance, appropriate peer socialization, maintained appetite, and continuous sleep once initiated 1

Supporting Diagnostic Considerations

Complex Childhood Trauma (Background Context)

• The patient has documented exposure to multiple interpersonal traumatic events including emotional abuse ("dun ka na sa [RELATIVE] mo"), physical maltreatment (hit with slipper), verbal abuse (cursing, blaming), and educational neglect during the period living with her [RELATIVE] 1, 2
• The American Academy of Pediatrics defines complex childhood trauma as exposure to multiple interpersonal traumatic events including maltreatment and household dysfunction, which disrupts attachment with caregivers and sense of self 1, 3
• Her history includes parental separation at an unspecified date, followed by a period of living with her [RELATIVE] characterized by neglect and maltreatment, meeting criteria for Adverse Childhood Experiences (ACEs) 1, 2

Why NOT PTSD

• PTSD requires four symptom clusters persisting >1 month: (1) intrusion symptoms (distressing memories, nightmares, flashbacks), (2) avoidance, (3) negative alterations in cognitions/mood, and (4) hyperarousal (irritability, exaggerated startle, hypervigilance, sleep disturbance, concentration problems) 1
• This patient explicitly denies intrusion symptoms (no nightmares, no flashbacks, no panic symptoms) and avoidance behaviors 1
• Her sleep disturbance is limited to initial insomnia without the broader hyperarousal constellation 1
• The [RELATIVE]'s observation of occasional quiet or staring moments does not constitute dissociative symptoms or significant functional impairment 1

Why NOT Acute Stress Disorder

• Acute Stress Disorder requires symptoms occurring 3 days to 1 month after trauma exposure with similar symptom clusters to PTSD 1
• The timeline is appropriate (incident occurred recently), but again, she lacks the required intrusion, dissociative, and avoidance symptoms 1

Additional Diagnostic Considerations for Comprehensive Evaluation

V-Code: Child Psychological Abuse (Confirmed)

• Document history of emotional abuse by [RELATIVE] including verbal assault ("dun ka na sa [RELATIVE] mo"), blame for minor issues, and statements designed to induce guilt 1, 4
• Emotional abuse is defined as a pattern of harmful caregiver-child interactions that impair development across functional domains, requiring no physical contact 4

V-Code: Child Physical Abuse (Confirmed)

• Document history of physical maltreatment (hit with slipper) by [RELATIVE], though patient retrospectively interprets earlier discipline as normative 1

V-Code: Child Neglect (Confirmed)

• Document educational neglect during period with [RELATIVE], characterized by "neglect of schooling, declining academic performance, frequent absences" 1

V-Code: Witness to Domestic Violence

• Document witnessing knife threat and verbal assault during index incident 1
• The American Academy of Pediatrics identifies witnessing violence as an expanded ACE that increases risk for long-term psychiatric sequelae 1, 2

Protective Factors and Current Functioning

Significant Resilience Indicators

• Marked improvement in all domains since moving to live with [RELATIVE]: improved mood, academic performance, sleep quality, and overall functioning 1
• Demonstrates agency and problem-solving capacity (independently contacted [RELATIVE] at age 13 to request change in living arrangement) 1
• Maintains appropriate peer relationships and adequate school performance (Grade 9, afternoon classes) 1
• Preserved appetite and ability to maintain weekend contact with siblings 1

Critical Clinical Pitfalls for Medicolegal Documentation

Avoid Over-Pathologizing

• The American Academy of Pediatrics warns that two-thirds of children with trauma symptoms do not seek care due to cost and perceived stigma, but this patient's current symptoms are relatively mild and time-limited 2
• Her functional capacity remains largely intact, which argues against more severe diagnoses 1

Document Cumulative Trauma Burden

• Cumulative childhood trauma exposure is associated with higher rates of adult psychiatric disorders (OR 1.2-1.3) and poor functional outcomes even after adjusting for confounders 5
• The American Academy of Pediatrics reports that preventing childhood trauma could reduce adult depression incidence by 44.1% and heavy drinking by 23.9% 2
• For medicolegal purposes, document the TOTAL burden of ACEs: parental separation, emotional abuse, physical abuse, educational neglect, and witnessed violence 1, 2

Subjective vs. Objective Maltreatment

• Research demonstrates that subjective experience of childhood maltreatment (how the child perceives and remembers it) is more predictive of long-term emotional disorder course than objective documentation alone (IRR 1.49-2.30 for depression/anxiety) 6
• This patient's subjective distress about the [RELATIVE]'s statement "pinapalaki yung gulo" and feelings of guilt are clinically significant regardless of objective severity 6

Screening and Safety Assessment Requirements

Mandatory Screening per Guidelines

• The Women's Preventive Services Initiative recommends screening for anxiety in adolescent girls aged 13 years or older, as anxiety disorders have 40% lifetime prevalence in women with median onset at age 11 1
• The American Academy of Child and Adolescent Psychiatry requires assessment of safety risks including suicidal thoughts, self-harm, risk-taking behaviors, and impulsivity at evaluation and throughout treatment 1
• This patient explicitly denies suicidal ideation, self-harm thoughts, or intent 1

Trauma-Informed Approach

• The American Academy of Pediatrics emphasizes that trauma-informed care requires understanding the biological effects of adversity without suggesting childhood adversity is destiny, using a compassionate approach that does not suggest blame 1
• Assessment should explore whether abuse or neglect requires reporting to state child welfare authority 1

Prognostic Considerations

Favorable Prognostic Indicators

• Rapid symptom improvement with environmental change (moving to [RELATIVE]'s home) suggests strong environmental responsiveness 1
• Maintained functioning in multiple domains (academic, social, self-care) 1
• Absence of comorbid substance use, which frequently co-occurs with anxiety disorders 1

Risk Factors Requiring Monitoring

• Family conflict is prospectively associated with development of anxiety symptoms, depressive symptoms, conduct problems, and peer problems through elevated emotional insecurity about the family system 7
• Her expressed worry about "possible future conflicts related to custody and family arrangements" represents ongoing stress exposure 7
• Unresolved predisaster psychopathology may resurface with future stressors even when unrelated to current events 2

Treatment Planning Implications

Indicated Interventions

• The American Academy of Child and Adolescent Psychiatry recommends that treatment planning derive from diagnoses and clinical formulation, prioritized according to acuity, severity, distress, and impairment 1
• For Adjustment Disorder, supportive psychotherapy and brief problem-focused interventions are first-line 1
• Cognitive-behavioral therapy (CBT) is indicated if symptoms persist or worsen, particularly given her history of emotional maltreatment (though childhood maltreatment does not affect CBT response rates for anxiety) 8

Monitoring Requirements

• Follow-up assessment to ensure symptoms resolve within 6 months of stressor (per Adjustment Disorder criteria) 1
• Screen for emergence of full PTSD criteria if intrusion or avoidance symptoms develop 1
• Monitor for stress generation effect, as past stress predicts future stress, particularly in interpersonal domains 1