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3 Adjustment disorderdiffers from PTSD and acute stress disorder in that it
involves a less severe shock and the response triggered by this shock is
greater than would be expected for most people. It involves a very wide
range of possible symptoms that are not marked enough to meet criteria
of any specific disorder, and these symptoms may continue for up to six
months after the upsetting event has ceased. Bereavement, which is not
allowed to be coded as an adjustment disorder in DSM-IV, is discussed
separately.
Assessment
Until the 1970s some textbooks of child and adolescent psychiatry stated
that children showed few reactions to acute stress. This view was based, in
part, on an approach to assessment that only gathered information from
adult informants without asking children about their own experiences. It
has since become clear that it is vital to carry out a careful appraisal of
stressed children’s emotions, cognitions and behaviour. It is often possible
to get useful accounts from children as young as 3 years of age. Thus even
with young children, it is important not to rely exclusively on interviewing
parents and getting teacher reports.
It is now recognised that a comprehensive assessment needs to consider
specific circumscribed fears and not just general fearfulness; to enquire
about intrusive thoughts and images; and to ask about avoidance. Children
will often reveal these when asked sympathetically, and may say they
hadn’t previously told their parents about these symptoms because they
hadn’t wanted to upset them. It is also important to consider any effect on
psychosocial functioning as seen in friendships and schoolwork.
General screening measure of child and adolescent symptoms, such as
the SDQ or CBCL, will pick up indications of serious problems in most chil-
dren and adolescents with PTSD – but a significant minority will be missed.
This is particularly a problem if the screening measure is only administered
to adult informants – preoccupied and numbed children may seem partic-
ularly well behaved to teachers or parents. When filled in by the stressed
children or adolescents themselves, general screening measures will usu-
ally pick up associated anxiety, misery and impact – but they cannot
detect PTSD-specific symptoms because they do not ask about them. When
assessing victims of severe traumas, routine screening measures clearly
need to be supplemented by specific enquiries about PTSD symptoms. It
is sometimes helpful to use a structured measure such as the Impact of
Events Scale.
Post-traumatic stress disorder (PTSD)
PTSD was first recognised as a disorder by the American Psychiatric Asso-
ciation in 1980 in DSM-III. This was the result of accumulating experience
with Vietnam War veterans who presented with the characteristic triad of: