Post Traumatic Stress Disorder: Cognitive Therapy with Children and Young People

By Patrick Smith; Sean Perrin et al. | Go to book overview

9
Co-morbidity

Introduction

Leo Kanner, the doyen of American child psychiatry and the person who first recognised infantile autism, once gave a lecture entitled ‘But the children do not read the textbooks’. By this he meant that no matter how well we define childhood disorders through research studies and careful clinical practice, the next child we see in the clinic will not fit any diagnosis precisely. This is only too true of PTSD in children.

Classificatory systems such as DSM and ICD are very helpful as shorthand ways of ensuring more accurate communication between professionals and roughly pointing the way to appropriate interventions, but the clinician needs to go well beyond this in making sense of the individual presentation of each patient. Only careful observation and interviews with the child and the family can help to pinpoint how best to help the child. The different classification systems have their own rules. DSM presents a series of algorithms that can result in the same presenting reactions or symptoms being used to decide that the child has met criteria for a number of different diagnoses – what is currently termed ‘co-morbidity’. At the same time, if a child is deemed to have met criteria for PTSD, then the clinician is not supposed to diagnose, for example, a simple phobia. Under ICD rules, the clinician has to match the presenting symptoms to a complex exemplar and has to try to give only one main diagnosis. In both cases, children may have additional distressing symptoms that may not fit the diagnostic picture but that do need treatment.

In one large follow-up study of adolescents caught up in the sinking of the cruise ship Jupiter (Bolton et al. 2000), 41 per cent of survivors had developed an anxiety disorder (excluding PTSD), one-third had developed major depression, nearly a quarter had developed a specific phobia, 7 per cent had developed separation anxiety and 6 per cent had developed substance misuse. Altogether, 57 per cent had developed at least one major

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