Both DSM-IV-TR and the ICD-10 diagnostic classification of PTSD are appropriate for use with adults and although children from 8 years old do display similar symptoms to adults⁽²⁾ there are some developmental differences particularly in younger children.⁽³⁾ Alternative diagnostic criteria for pre-school children have therefore been developed, which draw on reports by carers and include more behavioural symptoms such as loss of developmental skills, and development of new fears or anxiety.⁽⁴⁾

Careful assessment is required to make an accurate differential diagnosis. According to DSM-IV-TR, PTSD can only be diagnosed 1 month after the event, prior to that a diagnosis of acute stress disorder (ASD) may be appropriate. Whereas ICD-10 PTSD can be diagnosed within the first month, and the acute stress reaction is reserved to describe a disturbance that resolves rapidly. If the event is not of sufficient severity to meet the criteria for PTSD and the reaction does not last more than 6 months after the stressor has ceased, then a diagnosis of adjustment disorder may be appropriate. Recovery may take longer for children if their parents continue to suffer from symptoms of PTSD which may constitute a chronic source of stress which may in turn prolong the symptoms of the child. Further information on these diagnoses from an adult perspective can be found in Chapters 4.6.1,4.6.2,4.6.3,4.6.4,4.6.5.

Other diagnosable disorders may result from traumatic events, and may be present singularly or co-morbidly with PTSD; 60 per cent of children with PTSD have a co-morbid mental health diagnosis.⁽⁵⁾ According to Fletcher’s meta-analysis, common co-morbid diagnoses are: anxiety disorders, depression, alcohol and drug abuse in adolescents, and attention deficit hyperactivity disorder (ADHD).⁽²⁾

As with other psychiatric disorders, the best assessment can be made by integrating information from a number of sources such as an interview of the parent/carer alone, an interview of the family together, information from school, and information from psychological measures (see below). Careful consideration should be given to which members of the family will be involved in any interviews so as to avoid exposing previously unaffected children to the traumatic details of the event. Sometimes children try to ‘protect’ their carers from distress by under-reporting their symptoms of trauma, it is therefore also essential to interview the child on their own where possible.⁽⁶⁾

In order to assess what elements of the child’s current functioning and distress may be a result of the traumatic event, and those that may pre-date it, it is important to gain as full a picture as possible of their developmental history and their pre-morbid functioning. Reports from teachers and other professionals may be particularly useful in this respect.

On assessment, some account of the traumatic event is necessary so that the clinician can gain an understanding of what exactly was experienced. Furthermore, it is helpful to give the sense that the clinician can bear to hear a story which the child and family may have been avoiding to tell for some time. However, this must be balanced against the child’s understandable avoidance of the memory. There is little point gaining a full account of the event during the assessment, if the child becomes so distressed that they do not return for treatment. Pynoos and Eth offer a structure for conducting such an initial assessment which begins with a projective drawing and storytelling. It then proceeds to discussion of the actual event and its impact, followed by closure.⁽⁷⁾ If the assessment has included talking about the traumatic event the child and family may become very distressed, and it may be necessary to invest some time in winding down the session, so that the family does not leave overly distressed. This will increase the likelihood of them engaging in the treatment process, which is likely to involve thinking through the event—something which they often do not intuitively want to do.