typically involve hyperarousal, such as restlessness, sleep disturbance, irritability, heightened startle reactions and avoidance. Children over three often tend to withdraw and refuse to speak directly about traumatic experiences. The ability for verbal expression increases during development. A marked increase occurs around the concrete operational stage (8-9 years old), when children develop the ability to provide a reliable chronology of events. During this stage, concrete operations and temporal and spatial capacities develop.126 These new skills are still fragile, and it is not usually until the beginning of the formal operational stage (12 years old) that children are consistently able to construct a coherent narrative. Adolescence is a turbulent developmental period. The effects of torture can vary widely. Torture experiences may cause profound personality changes in adolescents resulting in antisocial behaviour.127 Alternatively, the effects of torture on adolescents may be similar to those seen in younger children. 5. Children and torture 310. Torture can impact a child directly or indirectly. The impact can be due to the child’s having been tortured or detained, the torture of parents or close family members or witnessing torture and violence. When individuals in a child’s environment are tortured, the torture will inevitably have an impact on the child, albeit indirect, because torture affects the entire family and community of torture victims. A complete discussion of the psychological impact of torture on children and complete guidelines for conducting an evaluation of a child who has been tortured is beyond the scope of this manual. Nevertheless, several important points can be summarized. 311. First, when evaluating a child who is suspected of having undergone or witnessed torture, the clinician must make sure that the child receives support from caring individuals and that he or she feels secure during the evaluation. This may require a parent or trusted care provider to be present during the evaluation. Second, the clinician must keep in mind that children do not often express their thoughts and emotions regarding trauma verbally, but rather behaviourally.123 The degree to which children are able to verbalize thought and affect depends on the child’s age, developmental level and other factors, such as family dynamics, personality characteristics and cultural norms. (b) Clinical considerations 314. Symptoms of PTSD may appear in children. The symptoms can be similar to those observed in adults, but the clinician must rely more heavily on observations of the child’s behaviour than on verbal expression.128, 129, 130, 131 For example, the child may demonstrate symptoms of re-experiencing as manifested by monotonous, repetitive play representing aspects of the traumatic event, visual memories of the events in and out of play, repeated questions or declarations about the traumatic event and nightmares. The child may develop bedwetting, loss of control of bowel movements, social withdrawal, restricted affect, attitude changes towards self and others and feelings that there is no future. He or she may experience hyperarousal and have night terrors, problems going to bed, sleep disturbance, heightened startle response, irritability and significant disturbances in attention and concentration. Fears and aggressive behaviour that were non-existent before the traumatic event may appear as aggressiveness towards peers, adults or animals, fear of the dark, fear of going to the toilet alone and phobias. The child may demonstrate sexual behaviour that is inappropriate for his or her age and somatic reactions. Anxiety symptoms, such as exaggerated fear of strangers, separation anxiety, panic, agitation, temper tantrums and uncontrolled crying may appear. The child may also develop eating problems. 312. If a child has been physically or sexually assaulted, it is important, if at all possible, for the child to be seen by an expert in child abuse. Genital examination of children, likely to be experienced as traumatic, should be performed by clinicians experienced in interpreting the findings. Sometimes it is appropriate to videotape the examination so that other experts can give opinions on the physical findings without the child having to be examined again. It may be inappropriate to perform a full genital or anal examination without a general anaesthetic. Furthermore, the examiner should be aware that the examination itself may be reminiscent of the assault and it is possible that the child may make a spontaneous outcry or psychologically decompensate during the examination. (a) Developmental considerations 313. A child’s reactions to torture depend on age, developmental stage and cognitive skills. The younger the child, the more his or her experience and understanding of the traumatic event will be influenced by the immediate reactions and attitudes of caregivers following the event.124 For children under the age of three who have experienced or witnessed torture, the protective and reassuring role of their caregivers is crucial.125 The reactions of very young children to traumatic experiences (c) Role of the family 315. The family plays an important dynamic role in persisting symptomatology among children. In order to preserve cohesion in the family, dysfunctional behaviours 126 J. Piaget, La naissance de l’intelligence chez l’enfant (Neuchâtel, Delachaux et Niestlé, 1977). 127 See footnote 125. 128 L. C. Terr, “Childhood traumas: an outline and overview”, American Journal of Psychiatry, vol. 148 (1991), pp. 10-20. 129 National Center for Infants, Toddlers and Families, Zero to Three (1994). 130 F. Sironi, “On torture un enfant, ou les avatars de l’ethnocentrisme psychologique”, Enfances, No. 4 (1995), pp. 205-215. 131 L. Bailly, Les catastrophes et leurs conséquences psychotraumatiques chez l’enfant (Paris, ESF, 1996). 123 C. Schlar, “Evaluation and documentation of psychological evidence of torture”, unpublished paper, 1999. 124 S. von Overbeck Ottino, “Familles victimes de violences collectives et en exil : quelle urgence, quel modèle de soins ? Le point de vue d’une pédopsychiatre”, Revue française de psychiatrie et de psychologie médicale, vol. 14 (1998), pp. 35-39. 125 V. Grappe, “La guerre en ex-Yougoslavie: un regard sur les enfants réfugiés”, Psychiatrie humanitaire en ex-Yougoslavie et en Arménie. Face au traumatisme, M. R. Moro and S. Lebovici, eds. (Paris, Presses universitaires de France, 1995). 57