Therefore, PTSD should be diagnosed only when the child experiences impairment or distress associated with the following symptoms in the aftermath of the traumatic experience:
- Intrusions, including recurrent, involuntary, distressing memories or dreams related to the traumatic event, flashbacks in which the individual feels or acts like the traumatic event is reoccurring, intense or prolonged emotional distress in response to reminders of the traumatic event, or strong physiological reactions to reminders of the traumatic event.
- Avoidance of reminders of the traumatic event, including avoiding distressing thoughts, feelings, or memories related to the traumatic event, or avoidance of external situations (e.g., people; places) that are associated with the traumatic event.
- Negative changes in thoughts or moods following the traumatic event, including at least two of the following:
- Amnesia for important parts of the traumatic event (not explained by use of substances or head injury sustained during the trauma)
- Exaggerated and persistent negative views of oneself, others, or the world (e.g., “I can’t trust anyone,” “I’m damaged,” “the world is a dangerous and scary place”)
- Persistent and distorted blaming of oneself or others for the trauma
- Persistent negative emotional state (e.g., persistent fear, shame, or anger)
- Significant loss of interest or reduced participation in significant activities
- Feeling detached from other people
- Persistent inability to experience positive emotions (e.g., happiness, satisfaction, or love)
- Changes in autonomic arousal or reactivity following the traumatic event, including at least two of the following:
- Irritability or angry outbursts
- Reckless, impulsive, or self-destructive behavior
- Exaggerated startle response
- Impaired concentration
- Sleep disturbances (e.g., difficulty falling asleep; disrupted sleep)
Developmental psychopathology research indicates that young children may express symptoms of PTSD somewhat differently than do older children. Therefore, the criteria for PTSD in children 6 years of age or younger are slightly modified, as follows:
- Directly experiencing or witnessing actual or threatened death, serious injury, or sexual violence. Note that media exposure does not qualify as “witnessing” these events.
- Intrusions, as evidenced by recurrent, intrusive distressing memories of the traumatic event (repetitive play where the trauma is reenacted), recurrent distressing dreams related to traumatic themes, dissociative flashbacks, intense or prolonged emotional distress or physiological reactions in response to being reminded of the trauma.
- Avoidance of people, places, or things that remind the child of the trauma, or negative changes in cognitions, including an increased frequency of negative emotional states, loss of interest or lack of participation in play or other significant activities, socially withdrawn behavior, and persistent reduction in the expression of positive emotions.
- Alterations in arousal, including irritable or angry outbursts or extreme temper tantrums, hypervigilance, exaggerated startle response, impaired concentration, or sleep disturbance (e.g., difficulty falling asleep or restless or disturbed sleep).
Many of these symptoms are normal responses to traumatic events, and will remit over time. Therefore, PTSD is diagnosed only when the symptoms last one month or longer and lead to clinically significant distress or impairment. Symptoms do not need to occur immediately following the trauma for a PTSD diagnosis to be warranted. Some individuals experience a delayed onset of PTSD, in which symptoms do not begin until weeks, months, or longer following the trauma. The specifier “with delayed onset” is applied when symptoms do not reach full diagnostic criteria until 6 months after the trauma.
PTSD may also be specified as occurring “with dissociative symptoms.” Dissociative symptoms can include depersonalization, in which the person feels detached from him or herself or as though he or she is “out of body” in some way, or derealization, in which the person experiences his or her surroundings as dreamlike or unreal in some way.