Traumat event the first criterion for the diagnosis of PTSD is that the child has

experienced a traumatic event which DSM IV TR defines as an event involving actual or

threatened death, serious injury, or a threat to the self or others. Further, the individual’s reaction
to that event is one of intense fear, helplessness or horror or, in children, agitation or
disorganizedbbehavior. (see table 8.8) this is one respect in which PTSD differs from all other
anxiety disorders it lacks the element of irrationality. If a boy is terrified of riding the school bus
when nothing out of the ordinary has happened, we are puzzled however if a boy is terrified of
riding a school bus after beingin one that has skidded off the road and turned over we might say
“ of course”.

However, in order for an event to be traumatic it must be perceived as such (pynoos,

steinberg, wraith,1995). In other words, the child’s appraisal of the event is important to
determining whether it results in PTSD. A boy who views a car accident as a thrilling adventure
with which to regale friends, for example, is not likely to be traumatized no matter how real the
actual threat of harm. By the same token, the child whose cognitions about an event involve
negative appraisals, such as shame helplessness, and self blame, is likely to experience a more
severe posttraumatic reaction.

Traumatic events can be of two types (terr,1991). Type I traumas involve sudden,
anticipated single events “short, sharp,shocks” such as car accidents, natural disaster, house fires,
or school shootings type II traumas, in contrast, involve long standing repeated exposure to
horrific events, such as those experienced by children who are victims of chronic child abuse.
We will focus here on type I traumas and in chapter 14 we will return to the study of type II
PTSD in the context of child maltreatment.

Traumatic event the first criterion for the diagnosis of PTSD that the child has experienced a
traumatic event which DSM IV TR defines as an event involving actual or threatened death,
serious injury or a threat to the self or others

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 senseof reliving
the experience, illusions, hallucinations, and dissociative flashback episodes,
including those that occur on awakening or when intoxicated. Note : in young
children, trauma specific reenactment may occur
4. Intense psychological distress at exposure to internal or external cues that symbolize
or resemble an aspect of the traumatic event
5. Psychological 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 o 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. Markedly diminished interest or participation in significant activities
5. Feeling of detachment or astrangement from others
6. Restricted range of affect (e.g., unable to have loving feelings)
7. Sense of a foreshertened 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. Difficulty falling or staying asleep
2. Irritability or outbursts of anger
3. Difficulty concentrating
4. Hypervigilance
5. Exaggerated startle response

E. Duration of the disturbance (symptoms in criteria B,C and D) is more than 1 month.

Specify if :

Acute (duration of symptoms less than 3 months)

Chronic (duration of symptoms is 3 months or more)
Delayed onset (onset of symptoms is a least 6 months after the stressor)

Symptom clusters three clusters of symtoms define the disorde : reexperiencing, avoidance, and
humbing (APA,2000).
First, children who develop PTSD following a traumatic experience exhibit persistent
reexperiencing of the event, characterized by intrusive, distressing recollections of the incident.
Reexperiencing may occur at unexpected moments throughout the day, but often occurs when
the child is exposed to traumatic reminders. For example, while in a restaurant 3 weeks after
undergoing a series of extremely painful treatments for a burn on her chest, a 5 year old girl
erupted in tears upon spying the white latex gloves on the hands of a food service worker
replenishing a salad bar, because the gloves reminded her of those that the doctor had worn
during the medical procedure. Sometimes the traumatic reminders are so subtle that their
connection to the distressing event is hard to discern. Sounds, colors, and the quality of the light
at a certain time of day all might act as triggers for emotions of distress that, to the child and
others, seemingly come out of nowhere. Reexperiencing also might take the form of dreams
about the traumatic event or, in children, nightmares with nonevent related content such as
getting lost or being attacked by monsters. Particularly in younger children, reexperiencing takes
the form of posttraumatic play in which aspects of the event are reacted. Although “playing it
out” can be therapeutic for children, posttraumatic play is differentiated by the fact that it is
repetitive, compulsive, and anxiety arousing rather than relieving. For example, a 5 year old girl
who was attacked and bitten by a monkey at the zoo repeatedly played out this theme with her
dolls, although the play did nothing to help her master her fright.
The second cluster of symtoms involves persistent avoidance of stimuli associated with
the truma or numbing of general responsiveness. Children with PTSD may actively avoid
thoughts or activities and people that arouse recollections of the trauma. For example the girl
who had been burned covered her ears anytime her mother attempted to talk to her about the scar
on her chest and insisted when mention was made of it by curious peers, “ I don’t know what
you’re talking about”. Avoidance may also take the form of numbing, which is evidenced by a
markedly diminished interest in activities that previously were pleasurable. The child with PTSD
may no longer show enjoyment of play.
The third cluster of symptoms is characterized by increased arousal. Heightened
emotional arousal in children may take such forms as sleep disturbance, irritability, difficulty
concentrating, heightened physiological reactivity and hypervigilance. The hypervigilance child
is overly sensitive to the environment, scanning constantly for signs of danger and reacting
intensely to unexpected stimuli. A classic sign of posttraumatic arousal is the exaggerated startle
response for example the child who jumps out of her skin and begins to tremble when a door
slams suddenly down the hallway.

Characteristics
Prevalence though the incidence of PTSD in children who undergo traumatic events is
estimated to be high ranging from 12 percent (march et al 1997) to 60 percent (pynoos & nader,
1987) many children with symtoms of PTSD are never identified and never receive treatment,
despite the distress the experience. An estimated, 6 percent of children 18 years (pfefferbaum,
1997). The data in regard to gender differences are contradictory. A number of studies with large
samples have found girls exposed to trauma to be more symtomatic than boys, but other studies
have found the opposite (pfefferbaum 1997).
Ethnic and cultural factors data on ethnic differences are very sparse but indicate that,
among those reffered to clinics, african american children are more likely to have a history of
PTSD when compared to european american children (last& perrin1993).
 Studies of refugee populations, who commonly suffer the stresses of political violence,
displacement and immigration, suggest the importance of cultural factors in symtom expression.
Cambodian refugee children for example while suffering from PTSD and comorbid anxiety and
depression do not show the increase in conduct disorders or substance abuse seen in european
american samples. They are respectful of authority, have a positive view of school and function
at a high level (pfefferbaum 1997).
Comorbidity and differential diagnosis comorbid conditions are common, with PTSD
significantly increasing the risk of depression, anxiety and disruptive behavior disorders (amaya-
jackson&march,1995). PTSD can be differentiated from other anxiety disorders by virtue of the
fact that there is a specific precipitating event, a unique symptom constellation, including such
symtoms as reexperiencing, and a definitive timeline. Developmental considerations the kinds of
symtoms children msnifest after being exposed to traumatic events vary with age (kerig et al
2000). Young children may regress to a previous level of functioning, such as losing bowel and
bladder control collapsing into tears at small frustrations, sucking their thumbs, and developing
fears and eating problems. Separation anxiety is apt to reappear. Avoidance and numbing may
lead children to be come inattentive, “spaced out” quiet and withdrawn.
While children rarely exhibit total amnesia for traumatic events, preschoolers are
particularly vulnerable to cognitive distortions that exacerbate their distress. For example one
young boy was distressed by the memory of the SWAT team members who came to rescue him
and this classmates during a sniper attack, because he misperceived these bouted weapon
carrying men as a second wave of assailants. Young children may also confuse the ordering of
events. The reversal of couse and effect can result in omen formation the mistaken belief that
they could have predicted and therefore prevented the catastrophe.
For school aged children fears and anxieties are the predominant symtoms. These
children also more often complain of headaches and visual and hearing problems fight with or
withdraw from peers and have sleep disturbances such as night mares and bed wetting. Younger
children reexperience through behavior such as by engaging in elaborate reenactments of the
traumatic event, while older children might reexperience in thoughts. For example they may
have repetitive fantasies of being rescued or avenging themselves against the perpetrator (terr,
1988).
 Preadolescents and adolescents, like school age children may develop various physical
complaints, become withdrawn, suffer from loss of appetite and sleep and become withdrawn,
suffer from loss of appetite and sleep and become disruptive or fail at school. Numbing may
result in a feeling of estrangement from others leading to withdrawal, truancy, and even
aggression.
Although listed as criteria for both children and adults some symtoms of PTSD are
particulararly evident in children. For example children and adolescents may exhibit a sense of
futurelessnes, or foreshortened future, in that they do not expect to grow up marry or achieve
happiness in adulthood (saigh, 1992).

DEVELOPMENTAL COURSE
The meager prospective data suggest that the developmental course depends on the
chronicity of trauma. Children tend to outgrow their reactions to single occurence stressors, but
(not surprisingly) continue to be disturbed by exposure to repeated, multiple stressors.

RISK, VULNERABILITIES AND PROTECTIVE FACTORS

Characteristics of the child as well as the nature of the traumatic event help to determine whether
PTSD will develop and whether it will take a prolonged course (kerig et al., 2000). Risk is
increased when traumas are intens and repeated and involve human aggression particularly when
violence is perpetrated toward the child or a person to whom the child looks for security, such as
a perent. The events with the most impact also willbe those experienced directly by the child.
Although vicarious traumatization does occur, the child most likely to be distressed is the one
who actually witnessed a family member being shot, for example, rather than the child who
merely heard about it. On the other hand, the risk is reduced when the event is an acute one with
a specific end point so that, once life has returned to normal, the child will have the opportunity
to outgrow is effects. Factors that increase a child’s vulnerability to trauma include previous
traumatization, a difficult temperament, affect regulation skills, internal locus of control, a
history of learning how to cope with and master stresful events as well as a supportive family
environment (pynoos et al., 1995).
INTERVENTION

Crisis intervention strategies are described by nader and pynos (1991), who offer
“psychological first aid” to children exposed to disaster or community violence. By taking the
treatment directly on the school, the clinicians are able to reach children early in the process and
act quickly in order to prevent psychopathological reactions from forming, the central goals of
treatment are to normalize PTSD reactions, minimize confusion and fearcontagion, end to engad
in theraputic reexposure. For example, following a sniper attack in withs a clesmate was shot,
children were ancouraged to draw a picture and tell a story about their experience of the event.
The drawings had the moust therapeutik benefit when children were able to depict healing or
repair of the damage that had beendone.

Amaya – Jackson and colleagues (2002) empiricalli testede a cognitif tive behavioral
group intervention for children and adoles cents exposed to single- incident stressors, such as
hurricanes, car accidents, or bunsot wunds. The sessions begin with psychoeducation regarding
PTSD in order to normalized the symtoms that sometimes make children feel that day are “going
crazy”. Children are then invited to tell the story of their trauma to the other group members and
to begin constructing a narrative of their recovery in the form of a storybook entitled “ my scary
story with a good ending”. In subsequent sessions, children are taught anxiety management
strategies and cognitive skills for “ standing up to the bully “ of PTSD. As children talk about
their there trauma, they are helped to identify degrees of fear on their “stress thermometer”. The
therapist then guides the development of graduated exposure tasks to help children face trauma
related stimuli that they are avoiding. Exposure to mildly stressful reminders is paired with
relaxation strategies until the child can tolerate than comfortably. Parents often play key roles in
helping children carry out exposure tasks, and adolescentes are event encouraged to involve
close friends in their practices. The investigators reported that the intervention provided children
significant relief. After treatment, 57% of the children no longger met criteria for PTSD and 86%
did not meet criteria at a follow up evaluation 6 months later. There was a 40% reducation in
PTSD symtoms immediately after treatment.
Developmental pathways to anxiety disorders

Until recently it was erroneously believed that child hood anxiety need not be taken
seriously because the symtoms were unstable an liable to before grown. As we had seen in our
discusion of each or the DSM IV TR categories of anciety, data using disverse methods and
population show that on the countrary, having an anxiety disorder increases the risk for future
anxiety disorder or related distury bances (Kovacs & Devlin, 1998). Moreover, anxiety disorder
in childhood can be the beginning of a longtime pattern of disturbance.