Paediatrics: Post-traumatic stress disorder

Post-traumatic stress disorder

Prevalence

No unitary prevalence—all traumatic events vary in threat exposure and individual responses vary by developmental stage, past experiences, and competencies. Prevalence varies from 100% of children taken hostage to 10% after natural disasters. Girls may report more PTSD symptoms.

Diagnostic criteria

A range of psychopathology may be experienced following an emotionally traumatic event, dependent on pre-existing vulnerabilities, event expo-sure, and related loss and grief. PTSD occurs as a response to an excep-tionally threatening or catastrophic event. This leads to:

·  Re-experiencing phenomena: e.g. nightmares, flashbacks, and intrusive memories.

·  Persistent avoidance of reminders of the trauma.

·  Inability to recall, either partially or completely, some important aspects of the period of exposure to the stressor, or;

·  Persistent symptoms of increased psychological sensitivity and arousal: e.g. difficulty falling or staying asleep, irritability or outbursts of anger, difficulty concentrating, hyper-vigilance, exaggerated startle response.

Emotional numbing and detachment is also often reported.

Age-specific symptoms

Younger children often present as regressed with altered sleep and feeding routines; exhibiting clingy, anxious, or aggressive behaviour; or engaging in post-traumatic play. Young children cannot report emotional numbing or detachment; parents report these symptoms as a ‘personality change’.

Differential diagnosis

Other anxiety disorders including event-related phobias, GAD, OCD, or, if of lesser severity, an adjustment disorder. Comorbidity with depression is common. If trauma is repetitive expect disruptive behaviours in boys and early evidence of personality dysfunction in teenagers.

Treatment

If severe, treatment can be complex and take time. Interventions include cognitive strategies such as identifying and modifying dysfunctional schema, behavioural strategies including prolonged re-exposure, skills acquisition such as relaxation techniques, supportive therapy, and family interven-tions to monitor for secondary impairment and altered family function-ing. Eye movement desensitization and reprocessing (EMDR) has a role. Psychopharmacology may provide some symptomatic relief.

Prognosis

Many children seem to be resilient to traumatic events, but long-term problems including symptom chronicity, generalization of fears, and generalized impairment have been reported—especially if parents have been unable to help the child manage their trauma. A history of chronic, repetitive trauma, such as sexual abuse, is overrepresented in other men-tal health presentations including drug and alcohol abuse, bulimia.