is accompanied by avoidance of stimuli that remind the person of the trauma and by autonomic hyperarousal (Table 17-5). Type, severity, duration, and proximity of the traumatic event are the most likely predictors of PTSD. Presentation often depends on the age group of the child. In preverbal children, there are changes in behavior: regressed clingy behavior, increased aggression, unwillingness to explore the environment, alterations in feeding, sleeping behaviors, and difficulty soothing child. Preschool children may display rapidly changing emotional states like anger, sadness, and excitement and play may have compulsive reenactments linked to the traumatic event. Later symptomatology is more typical of adult PTSD, except that flashbacks are more daydream quality than the sudden intrusive events seen in adults, and complaint of restriction of effect and numbing are less frequent.
Dissociative states lasting a few seconds to many hours, in which the person relives the traumatic event, are referred to as flashbacks. Reexperiencing trauma in children may be nonspecific to the trauma (e.g., dreams of monsters). In adolescents anticipation of unwanted visual imagery increases the risk of irritable mood, anger, and voluntary sleep deprivation. When faced with reminders of the original trauma, physical signs of anxiety or increased arousal occur, including difficulty falling or staying asleep, hypervigilance, exaggerated startle response, irritability, angry outbursts, and difficulty concentrating.
Typically an acute stress disorder is present immediately after the trauma. The risk of chronic PTSD increases when symptoms are unresolved by 6 weeks and there are higher premorbid levels of anxiety or depression. PTSD usually begins
A. The person has been exposed to a traumatic event in which both of the following were present: 1.
The person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury or a threat to the physical integrity of self or others.
2.
The person’s response involved intense fear, helplessness, or horror. Note: In children, this may be expressed instead by disorganized or agitated behavior.
B. The traumatic event is persistently reexperienced in one or more of the following ways: 1.
Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. Note: In young children, repetitive play may occur in which themes or aspects of the trauma are expressed.
2.
Recurrent distressing dreams of the event. Note: In children, there may be frightening dreams without recognizable content.
3.
Acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including flashbacks that occur on awakening or when intoxicated). Note: In young children, trauma-specific re-enactment may occur.
4.
Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.
5.
Physiologic reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.
C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three or more of the following: 1.
Efforts to avoid thoughts, feelings, or conversations associated with the trauma 2.
Efforts to avoid activities, places, or people that arouse recollections of the trauma 3.
Inability to recall an important aspect of the trauma 4.
5.
Feeling of detachment or estrangement from others 6.
Restricted range of affect (e.g., unable to have loving feelings) 7.
Sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span)
D. Persistent symptoms of increased arousal (not present before the trauma), as indicated by two or more of the following: 1.
2.