What is the diagnosis for a 6-7 year old girl with a history of paternal death, interpersonal conflicts, and witnessed physical aggression, presenting with symptoms of grief and trauma exposure?

Diagnosis: Adjustment Disorder with Mixed Anxiety and Depressed Mood

This 6-7 year old girl meets criteria for Adjustment Disorder with Mixed Anxiety and Depressed Mood, characterized by an identifiable stressor (paternal death, witnessed physical aggression, interpersonal conflicts) that precipitated emotional symptoms within 3 months, including sadness, disappointment, and guilt. 1

Why This Diagnosis Rather Than PTSD

The clinical presentation does not meet full criteria for Posttraumatic Stress Disorder (PTSD) based on the American Academy of Pediatrics DSM-5 criteria, which requires symptoms persisting for more than 1 month across four specific domains 2:

• Intrusion symptoms: No evidence of repeated distressing memories, nightmares, flashbacks, or repetitive play involving trauma themes 1
• Avoidance: No documented avoidance of distressing memories, thoughts, feelings, activities, or places 2
• Negative alterations in cognitions and mood: While grief is present, there is no evidence of memory problems about the traumatic event, persistent negative beliefs, social withdrawal, or markedly diminished interest in activities 2
• Increased arousal and reactivity: No documented irritable outbursts, hypervigilance, exaggerated startle response, concentration problems, or sleep disturbance 2

Trauma Exposure Qualifies as Diagnostic Criterion

The child's exposure meets trauma criteria through multiple pathways 2, 3:

• Witnessing traumatic events involving a caretaker (physical aggression) constitutes direct trauma exposure 2
• Learning that a traumatic event occurred involving a close family member (paternal death) qualifies as trauma exposure even without direct witnessing 2
• Abandonment through parental death represents exposure to actual or threatened separation from caregivers 3

Complex Trauma Context

This child has experienced complex childhood trauma, defined by the American Academy of Pediatrics as exposure to multiple interpersonal traumatic events including maltreatment and household dysfunction, which disrupts attachment with caregivers and sense of self 1. The combination of paternal death, witnessed violence, and interpersonal conflicts represents cumulative adverse childhood experiences 2.

Favorable Prognostic Indicators

Several factors suggest a more favorable trajectory 1:

• Symptoms have not progressed to full PTSD despite significant trauma exposure 1
• Maintained functioning in multiple domains (academic, social, self-care) is a favorable prognostic indicator 1
• Environmental responsiveness: If symptoms improve with environmental changes (e.g., moving to new home, removal from conflict), this suggests strong capacity for recovery 1

Critical Diagnostic Pitfalls to Avoid

Do not overlook this diagnosis simply because the child appears to be functioning. The American Academy of Pediatrics reports that two-thirds of children with trauma symptoms do not seek care despite availability of services, often due to cost and perceived stigma 3. Additionally, 87% of children surveyed after traumatic events reported at least one ongoing symptom that persisted 6 months after the event 2.

Consider that functional complaints may be early manifestations of trauma. Sleep difficulty, changes in appetite, toileting concerns, and challenges with school functioning may be early presentations of ongoing trauma 2. The American Academy of Pediatrics emphasizes that symptoms of trauma overlap with symptoms of other common pediatric conditions, and failure to consider trauma may lead to incorrect or incomplete diagnosis 2.

Screen for safety concerns. 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.

Differential Diagnosis Considerations

The provider should consider trauma as a possible etiology because 2:

1. The experience of adversity is extremely common
2. Symptoms of trauma overlap with other common pediatric conditions
3. Failure to do so might lead to incorrect or incomplete diagnosis and treatment

Attention-deficit/hyperactivity disorder and adjustment disorder diagnostic criteria overlap with functional symptoms of trauma, making it essential to include trauma in the differential diagnosis when these signs are noted 2.

Why Not Reactive Attachment Disorder or Disinhibited Social Engagement Disorder

While the DSM-5 recognizes two abandonment-specific disorders in young children—Reactive Attachment Disorder (characterized by emotionally withdrawn behavior toward caregivers) and Disinhibited Social Engagement Disorder (manifested by overly familiar behavior with strangers)—there is no evidence presented that this child exhibits these specific attachment-related behaviors 3.

Importance of Dual Reporting

Both the child and caregivers should be included in trauma screening procedures. Research demonstrates that children report significantly more exposure to accidents or illness, community violence, and sexual abuse than their caregivers, with only fair to moderate agreement rates 4. Children generally have higher post-traumatic stress symptoms and functional impairment scores when child exposure to potentially traumatizing events is reported by both the caregiver and the child 4.