Post-traumatic stress disorder and trauma responses — branching viva

Stem

The examiner opens with a child seen shortly after a frightening event, then escalates through the timeline, risk factors, first-line treatment, a debriefing request, a pharmacotherapy question, and a safeguarding twist. [1] [11]

Branch 1 — The continuum

Examiner: A child is seen two weeks after a crash with moderate symptoms but improving. Diagnosis? [11]

Strong answer: This is still within the recovery window — an expected acute stress reaction with good prognostic signs (improving, functioning). I would not label PTSD yet. I offer psychoeducation, protect sleep and routine, and watchful-wait with a clear safety-net, stepping to TF-CBT only if symptoms persist beyond one month with impairment. [11]

Examiner: And if the same symptoms are present at six weeks with school decline? [11]

Strong answer: Now the time threshold (more than one month) and the functional impairment are met, so this is PTSD, and first-line is trauma-focused CBT. [1] [11]

Branch 2 — Risk and assessment

Examiner: Which children are most likely to persist? [8]

Strong answer: The Trickey meta-analysis points to perceived life threat, peri-traumatic fear or dissociation, lack of social support, prior psychopathology, and female sex in adolescence. Most exposed children recover; persistence is the exception my assessment exists to find. [7] [8]

Examiner: How do you take the history without harming? [12]

Strong answer: Trauma-informed: safety and rapport first, child-led pace, choice, and I never force disclosure. I map symptoms to the four clusters, use an age-appropriate screen such as the UCLA PTSD Reaction Index or CPSS, gather multi-informant data, and assess risk and caregiver capacity. [12]

Branch 3 — Treatment

Examiner: First-line definitive treatment? [1]

Strong answer: Trauma-focused CBT, roughly eight to sixteen sessions, with psychoeducation, parenting, gradual exposure and a trauma narrative, cognitive restructuring, affect regulation and in-vivo mastery, and caregiver involvement integral to the paediatric model. The Cohen RCT is the foundational evidence. [1] [12]

Examiner: Parent asks for a counsellor to debrief him now to prevent PTSD. [10]

Strong answer: I would not recommend single-session debriefing; the evidence shows no benefit and possible harm. Psychological first aid plus watchful waiting is the correct early approach. [10]

Branch 4 — Pharmacotherapy and special groups

Examiner: Should you start an SSRI? [12]

Strong answer: Not first-line. SSRIs are adjunctive in adolescents with persistent symptoms or comorbid depression under specialist care; they are not appropriate as stand-alone treatment for prepubertal PTSD. [12]

Examiner: What about a four-year-old? [2]

Strong answer: Developmentally-adapted TF-CBT — Scheeringa demonstrated efficacy for three-to-six year-olds, and stepped care is non-inferior in young children, which matters where specialist capacity is thin. [2]

Branch 5 — Safeguarding conversion

Examiner: The child discloses ongoing abuse at home. [9]

Strong answer: I stop routine trauma work. Immediate safety and child-protection/mandatory reporting are the priority; exposure-based therapy must not run in an unsafe environment. I make a same-day safety plan, coordinate with child protection, school and the GP, and close the loop with a named owner and follow-up. [11] [13]

Examiner scoring cues

• Uses time, impairment and the four clusters to separate reaction, ASD and PTSD. [11]
• Names the recognised risk factors and the recovery baseline. [7] [8]
• TF-CBT first-line; rejects debriefing and first-line SSRI in prepubertal children. [1] [10]
• Converts immediately for safety and safeguarding and closes the loop. [11] [13]