PTSD is an emotional and behavioural syndrome following a traumatic event in the family or outside it. In the family setting, it is the result of traumas such as physical or sexual abuse, or the loss of a parent. Outside the family, it is connected with traffic accidents, natural disasters, war or terror. In childhood PTSD, the person's subjective experience of the event is at least as important as any objective characteristics of the trauma .
As opposed to what was thought in the past, there is evidence now that children are more likely to develop PTSD than adolescents and adults [35,36]. This tends to be more true of girls than boys, although this finding is still questionable [37,38]. Accordingly, this is a diagnosis that requires attention and should be ruled out in every case of a "difficult" child who is referred for evaluation.
The DSM-IV category of PTSD mainly concerns adults. Scheeringa et al.  developed a set of alternative criteria, in which re-experiencing is expressed by reiterative games, recollection of the event, nightmares, flashbacks and distress at discovering elements that recall the event. Numbing is expressed by limited play activities and social introversion, limited affect and loss of developmental skills that had already appeared. Arousal is expressed as nightmares, insomnia, waking up frequently, loss of concentration, hypervigilance and exaggerated startle response. In addition, there is a unique subgroup of symptoms, including new aggressiveness, renewed appearance of separation anxiety, fear of going to the bathroom alone, fear of the dark or any apparently baseless suddenly appearing fear.
There are no studies to date estimating prevalence of PTSD in children. Yule's survey  presents a number of reports from recent years, according to which the incidence rate in children who underwent a traffic accident is around 20%, while it is about 10-12% in children who were hospitalized as a result of ''common childhood mishaps''. Children who develop PTSD as a result of injury may be the same children who suffer from ADHD or ODD, since children from these populations tend to be more involved in accidents and various injuries.
PTSD in children includes three groups of symptoms: recurrent experience of the trauma, avoidance traits (such as emotional withdrawal, refusal to deal with the trauma, etc.) and arousal symptoms (such as insomnia, irritability, concentration difficulties and heightened startle response) . The third group of symptoms is the one that makes these children ''difficult''.
In the initial stage, the child generally reacts to the trauma with separation anxiety, and in more severe cases with regression (e.g. bedwetting at night). Regression can at times be to very early stages of childhood. A 10-year-old child who arrived at our clinic about 6 years ago, whose classmates introduced a pencil into his sexual organ, regressed to a developmental stage of 2 years old for a period of a year and only regained speech 4 years after the trauma. Difficulties with falling asleep and waking up in the middle of the night appear. A lower stimulus threshold is present, as well as expressions of unexpected aggression. The most important element in the diagnosis is the change that takes place in the child's behaviour. This change, when compared with previous behaviour, must bring the clinician to suspect a traumatic event.
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