Stress Disorders 125intrusive thoughts of the trauma; emotional numbing and avoidance of
reminders of the trauma; and physiological hyperarousal.
It was subsequently recognised that PTSD also occurred in children and
adolescents in a broadly similar form, though modified criteria are needed
with very young children, for example, repetitive, intrusive thoughts
about the trauma may be more evident from young children’s drawings
and play than from anything they say. As well as occurring after experi-
encing or witnessing disasters and gross violence, PTSD can also occur after
sexual or physical abuse, life-threatening illnesses, medical procedures and
road traffic accidents. Children and adolescents also commonly witness
serious domestic violence; it has been estimated, for example, that they
witness 10–20% of murders (the majority of murders arise out of domestic
disputes). Those in hospital with serious injuries or illnesses are also at
higher risk, as are refugees from war-torn countries. Within these various
groups, a substantial minority or even a majority develop PTSD. In many
cases, the PTSD goes unrecognised and untreated. The first step is to recog-
nise the PTSD. The second step is to formulate a broad management plan
the not only treats the PTSD symptoms but also takes adequate account of
broader difficulties in the child and family’s life – a plan in which education
and social services may play larger roles than health services.
Diagnostic criteria for PTSD
The criteria differ slightly between DSM-IV and ICD-10, but both stipulate
that in the aftermath of an event that would have distressed almost
anyone, the person (there are no specific child or adolescent criteria)
experiences for at least a month symptoms in each of the following three
groups:
1 The traumatic event is persistently re-experienced, leading, for example,
to intrusive images, traumatic dreams, repetitive re-enactment in play,
or distress at reminders.
2 There is either continued avoidance of stimuli associated with the
trauma or numbing of responsiveness, as indicated by: avoidance of
thoughts, feelings, locations, situations; feelings of being alone or de-
tached, reduced interests and restricted emotional range; poor memory
for important aspects of the trauma; and loss of confidence in the future,
for example, leading some affected individuals to feel that they should
live one day at a time and not plan ahead.
3 There are new symptoms of increased arousal. These can include:
sleep disturbance; irritability; poor concentration; memory problems
in learning new material and in recalling previously learned facts and
skills; hypervigilance and alertness to any perceived danger; and an
exaggerated startle response.
Clinical manifestations
In addition to the symptoms covered by the PTSD criteria themselves,
separation difficulties are frequent and children may want to sleep with
their parents. Panic attacks occur not infrequently. Increased irritability
can lead to angry outbursts against family and friends. In disasters where