A DISCUSSION OF SEPARATION ANXIETY FOLLOWING A ROAD TRAFFIC ACCIDENT

Children involved in road traffic accidents (RTAs) are prone to developing psychological or psychiatric disorders. Stallard (1998) found that a third of children involved in RTAs developed post traumatic stress disorder. However, the literature on children remains relatively sparse and the main research in this area focuses on Post Traumatic Stress Disorder, as opposed to other types of anxiety or depressive disorder. In this article we concentrate on the issue of separation anxiety following an RTA.

WHAT IS SEPARATION ANXIETY DISORDER?
The diagnostic criteria for Separation Anxiety Disorder is as follows: Developmentally inappropriate and excessive anxiety concerning separation from home or from those to whom the individual is attached, as evidenced by three (or more) of the following:   – recurrent excessive distress when separation from home or major attachment figures occurs or is anticipated. – persistent and excessive worry about losing, or about possible harm befalling, major attachment figures. – persistent and excessive worry that an untoward event will lead to separation from a major attachment figure (e.g. getting lost or being kidnapped). – persistent reluctance or refusal to go to school or elsewhere because of fear of separation. – persistently and excessively fearful or reluctant to be alone or without major attachment figures at home or without significant adults in other settings. – persistent reluctance or refusal to go to sleep without being near a major attachment figure or to sleep away from home.  – repeated nightmares involving the theme of separation.  – repeated complaints of physical symptoms (such as headaches, stomach aches, nausea, or vomiting) when separation from major attachment figures occurs or is anticipated. – The duration of the disturbance is at least 4 weeks.  – The onset is before age 18 years.  – The disturbance causes clinically significant distress or impairment in social, academic (occupational), or other important areas of functioning. – The disturbance does not occur exclusively during the course of a Pervasive Developmental Disorder, Panic Disorder With Diagnostic and Statistical Manual of Mental Disorders, fourth Edition. Copyright 1994 American Psychiatric Association) At medico-legal interviews with parents and children following an RTA, it is commonly reported that children have become anxious about separating from their parents.

This behaviour is regarded as problematic by parents. Typical comments made by parents at interviews include: “She wouldn’t leave my side”, “She was like my little shadow; I couldn’t even go to the toilet without her following” and “She crept into my bed at night.” When considering a diagnosis of Separation Anxiety Disorder, we must not only look to the diagnostic criteria, but we must also look at a number of other relevant factors, such as: What was the parental reaction to the accident? What is the child’s temperament; What were the child’s previous reactions to separation, such as starting nursery or school? How has the child reacted to other stressful life events and were there any such stressors in the 12 months prior to the accident. What is “normal” separation anxiety? Consideration can be given to each of these factors in turn. Parental reaction to accidents can often be one of shock and increased need to protect their child. Children of anxious parents are more likely to be anxious themselves and if they see their parents reacting in an obviously fearful way, then they may well follow suit. Anxious parents may encourage their children to remain in closer proximity to them following a stressful event such as an accident, and this behaviour can become reinforcing for a child.

With regard to a child’s temperament, children who are born with “a difficult temperament” are more likely to demonstrate separation anxiety. These children are generally more irritable and difficult to soothe as babies, frequently described as “colicky”. These children will show fear more readily in new situations and are generally shyer and more passive. These children tend to have more difficulty establishing a regular schedule and find transitions difficult. This should therefore be enquired about at interview. Children’s previous reactions to separations can provide a good indicator of pre-accident symptoms. It is essential in any clinical interview that previous separations are enquired about in detail and points in normal child development, that are often key in terms of separation anxiety issues, need to be explored. Finally, a history of negative life events, such as deaths or other previous traumas need to be elicited at interview. Where it appears that there were no difficulties in terms of separation from the parents prior to the accident, then a diagnosis for Separation Anxiety Disorder may be warranted.

WHAT IS “NORMAL” SEPARATION ANXIETY?
The possibility of the behaviour being normal separation anxiety in young children should also be a consideration in making this diagnosis. A reluctance to be separated from one’s care giver in infancy is a normal, healthy response. This would indicate the development of a secure attachment. Such attachment behaviour is generally seen from eight months onwards, peaking between twelve and twenty four months. Some degree of separation anxiety in the pre-school period can be also indicative that a child has developed a healthy attachment. Children often cry and protest when left with a care giver or at a nursery, however, this distress usually remits soon after the parent leaves. Extended episodes of distress might indicate problems. Behaviour indicative of separation anxiety includes crying, clinginess and proximity-seeking. Young children cry when a parent leaves because they do not understand that the parent will come back. Separation anxiety generally reduces between the age of two and three years, meaning that children are able to withstand longer periods of separation by the time they start school. They are, by then, able to “mentally represent” the parent in their mind. Factors that may also contribute to separation anxiety are tiredness, changes in the household routine, or changes in care giver. Consequently, RTAs, particularly those that occur in the pre-school period may well exacerbate fears about separation and need to be managed effectively by the parent.

HOW SEPARATION ANXIETY CAN BE MANAGED BY PARENTS FOLLOWING AN RTA
“Tips” to effectively manage separation fears following an RTA include: – Offer the child additional reassurance. Ensure routines are not disturbed (do not alter the bedtime routine). – Try to encourage the use of a comforter. Use parental photographs in the child’s bedroom. – Use a fictional character that the child identifies with, and talk about their bravery. – Prepare for any separations. Always say goodbye. Do not come back several times. – Do not display your own anxiety.

WHEN IS THERAPY INDICATED?
Therapy will be indicated when difficulties continue for over a month or more. Therapy is indicated when difficulties reach the threshold of the diagnostic criteria, or where there is a high functional impact upon the child and the family, although the diagnosis is sub-clinical. For example, if a child shows distress when separated from parents and reports a high level of physical symptoms.

TREATMENT
There are three main possibilities for treatment. The first would involve a cognitive behavioural approach. This would usually involve a psycho-educational component, meetings with parents, and possibly the child. It would attempt to improve the parent-child relationship, improve self esteem and confidence and reduce avoidance behaviours. A family therapy approach might also be a possibility. This would involve the child, their parents, and usually grandparents and siblings. The difficulty would be seen as something that the whole family has to focus on and the problem would not be seen within the child but rather within the system. The impact of the separation anxiety on all members of the family would be considered. Finally, play therapy might be an option. This would involve one-to-one work with the child.

REFERENCES
Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) – 4th ed. (1994) Published by the American Psychiatric Association.
Koch H.C.H (1999] ‘I cant sleep mummy – I keep thinking about the accident’.
The psychological effects of personal injury to children. Stallard P,  Velleman R, and  Baldwin S (1998) Prospective study of post-traumatic stress disorder in children involved in road traffic accidents, BMJ 317:1619-1623