Why is Post Traumatic Stress Disorder Often Missed in Children and Adolescents?
Post-Traumatic Stress Disorder (PTSD) involves exposure to a traumatic event, and the development numerous subsequent symptoms which fall into the categories of re-experiencing, avoidance, and hyperarousal. The re-experiencing presents as intense psychological distress on reminders of the trauma, physical symptoms such as sweating, raised heart rate, or tummy aches, repetitive play, bad dreams and/or nightmares, and flashbacks. Bad dreams are often not reported, especially as they are often not remembered, and the child may just appear grumpy and underslept. The flashbacks can often impair concentration, and may simply present as being in trouble for reduced academic performance.
The next group of symptoms are avoidance symptoms. In my clinical experience, these are extremely common after a trauma, and lead to avoidance of all thoughts, discussions, people and places creating reminders of the bad memory. Entire families, for example, who have been through an accident, or traumatic loss, will never mention the incident, in case anyone becomes upset. The longer it goes on, the more chronic the PTSD can become.
Hyperarousal typically leads to poor sleep, anger outbursts, and poor concentration. The young person may seem permanently ‘jumpy’, or ‘on edge’. Children may just be seen as ‘naughty’, or behaviourally disturbed.
Sometimes, children with PTSD end up with secondary depression, because they are so tired, socially withdrawn, and with deteriorating schoolwork due to poor concentration.
So how can PTSD be accurately assessed? The Child Revised Impact of Events Scale (Children and War Foundation) is an easy short symptom checklist which gives an indication of the level of PTSD symptomatology. This was developed from the original Impact of Events Scale for Adults devised by Horowitz in 1979. A more detailed structured Interview typically used for research into childhood PTSD is the Children’s PTSD Inventory developed by Philip Saigh (2004). This gives an accurate picture as to the presence or absence of a diagnosis of PTSD (DSM IV Criteria), and also clarifies whether the PTSD is acute, chronic or of delayed onset.
Unfortunately, as PTSD is so often missed, once it is recognised, it is often chronic. However, the good news is that it is never too late to attempt treatment, even years after the original traumatic event.