This chapter will focus on the impact on children of traumatic events other than child abuse or neglect, which are covered in Chapter 9.3.3. According to the DSM-IV-TR definition of post-traumatic stress disorder (PTSD), traumatic events involve exposure to actual or threatened death or injury, or a threat to physical integrity. The child's response generally involves an intense reaction of fear, horror, or helplessness which may be exhibited through disorganized or agitated behaviour. Terr suggested separating traumatic events into type I traumas which are single sudden events and type II traumas which are long-standing or repeated events. If the traumatic event includes bereavement, the reactions may be complicated and readers should consult Chapter 9.3.7 to address the bereavement aspects of the event. Following a traumatic event, children may react in a variety of ways (see Chapters 4.6.1 and 4.6.2 for the adult perspective on reactions to stressful and traumatic events). Many show some of the symptoms of post-traumatic stress disorder—re-experiencing the event (e.g. through nightmares, flashbacks, intrusive thoughts, re-enactment, or repetitive play of the event), avoidance and numbing (e.g. avoidance of conversations, thoughts, people, places, and activities associated with the traumatic event, inability to remember a part of the event, withdrawal from previously enjoyed activities, feeling different from others, restriction of emotions, sense of foreshortened future), and physiological arousal (e.g. sleep disturbance, irritability, concentration problems, being excessively alert to further danger, and being more jumpy). In young children the nightmares may become general nightmares rather than trauma-specific. Other reactions to trauma in children are: ♦ becoming tearful and upset or depressed ♦ becoming clingy to carers or having separation anxiety ♦ becoming quiet and withdrawn ♦ becoming aggressive ♦ feeling guilty ♦ acquiring low self-esteem ♦ deliberately self-harming ♦ acquiring eating problems ♦ feeling as if they knew it was going to happen ♦ developing sleep disturbances such as night-terrors or sleepwalking ♦ dissociating or appearing ‘spaced out’ ♦ losing previously acquired developmental abilities or regression ♦ developing physical symptoms such as stomach aches and headaches ♦ acquiring difficulties remembering new information ♦ developing attachment problems ♦ acquiring new fears ♦ developing problems with alcohol or drugs. Such problems may individually or in combination cause substantial difficulties at school and at home. The reactions of some children will diminish over time; however, for some they will persist, causing distress or impairment, warranting diagnosis, and/or intervention. Research predicting which children will be more likely to be distressed following a traumatic event suffers from a number of methodological flaws. However, factors which are often identified as constituting a risk for developing PTSD across a number of studies include: level of exposure, perceived level of threat and peri-traumatic fear, previous psychological problems, family difficulties, co-morbid diagnoses, subsequent life events, and lack of social support.
The uniqueness of the DSM definition of post-traumatic stress disorder: implications for research
