126 Chapter 13
friends or family have been killed or injured, it is common for surviving
children and adolescents to experience ‘survivor guilt’ because they lived
while others died, because of what they did to survive, or because they did
not do enough to aid others.
The degree of exposure to the trauma influences the extent of
symptoms, with those directly experiencing pain or coming very close to
death tending to be the worst affected. There is typically marked fear and
avoidance of objects or events directly connected to the trauma, and lesser
fear and avoidance of tangentially related stimuli. For example, children
who have been on a sinking ship are subsequently likely to have marked
fears related to boats, and may also have lesser fears relating to travel by
train or plane; they are no more likely than other children to fear objects
or events unrelated to the disaster. While general anxiety and depression
tends to wane over time, specific fears and avoidance can be remarkably
persistent. The symptoms are often accompanied by ongoing physiological
effects. For example, five years after an Armenian earthquake, those with
symptoms of intrusive re-experiencing of the trauma still had elevated
resting cortisol levels.
Moderating variables
Both in childhood and adulthood, apparently similar traumas can have
extremely different effects on different individuals. In part, this may reflect
differences in temperament, personality or genetic liability to specific
disorders. Some cognitive attributes, such as good problem-solving skills,
may also be relevant. It also seems likely from the literature on resilience
that affected children and adolescents will be better able to buffer stress
if they have a good relationship with at least one parent, a cohesive and
harmonious family and support from a wider social network of peers and
teachers. Conversely, family dysfunction, peer problems and severe social
disadvantage are all likely to impair resilience. These factors are more fully
discussed in Chapter 34.
Epidemiology
Community studies of older adolescents have reported that around 6–10%
have experienced PTSDat some point in their lives(lifetime prevalence).
The British survey described in Box 3.1 (Chapter 3) showed thatat the
time of the survey, roughly 0.4% of 11–15-year-olds met criteria for PTSD
(point prevalence), with girls being affected twice as often as boys. A
point prevalence will obviously be lower than a lifetime prevalence – but
the difference between 0.4% and 10% is so great that other factors are
probably also relevant, for example, variation in the sensitivity of different
assessment tools.
Physiological changes
In the short term, stress leads to activation of the sympathetic nervous
system (SNS) resulting in higher heart rate, arousal and alertness – the
well-known ‘flight or fight’ response. There is also immediate activation of