Litigating a case involving a minor, especially one below 11 years of age, typically raises questions about what a child’s behaviour and adjustment was prior to an index event. Lawyers and parents alike are also cognizant of the potential stress of “putting the child through” a stressful psychological or psychiatric interview and examination. In this article, two psychologists address these two issues in the light of their own medico-legal experience.
Children of all ages are involved in road traffic accidents. Fortunately, most of these accidents are not severe and most children recover from the psychological effects of road traffic accidents within the first three months.
Parents of very young, pre-school children express a high level of anxiety, and seek advice from their GP when their children are involved in accidents. It is on this age group, the 0 – 5 years, that this article will concentrate.
In order to differentiate between accident and non-accident factor the following needs to be addressed:-
• Common presenting problems of the pre school child
• Typical problems in this age group following road traffic accidents
• How to conduct an assessment with the pre school child
• When and what treatment is indicated
COMMON PROBLEMS IN THE PRE SCHOOL YEARS
Emotional problems during pre school years tend to manifest behaviourally. The most common problems are those of eating, sleeping, wetting, soiling, conduct and separation. More infrequently emotional problems are somatised (tummy aches, sickness).
Delays in development, such as in language, and learning difficulties often become apparent between toddlerhood and school age. These often impact upon the behaviour of children as these children become frustrated at their limitations in comparison to their peers.
The problem most commonly seen by Specialist Child and Adolescent Mental Health (CAMHS) workers are “behaviour problems”. That is, children are presented to services because their parents or carers have difficulties in terms of managing their behaviour. The typical presentation is one of tantrums, defiance, and aggression. These make up approximately 40% of CAMHS referrals, (Hoare at al 1996).
PROBLEMS FOLLOWING ROAD TRAFFIC ACCIDENTS
In comparison to the literature on the effects of road traffic accidents in adults, relatively little is known about the psychological effects of road traffic accidents on children. Bryant et all (2004) assessed children who had been in road traffic accidents and who attended an A&E department. According to this study twenty five percent of the children suffered Post Traumatic Stress Disorder at three months. Post traumatic consequences for mothers were also common.
In our clinical experience, however, preschool children rarely express the “intense horror or fear/ disorganised or agitated behaviour” that must be present to fulfil the DSM IV diagnostic criteria for PTSD. In addition, the majority of accidents involving young children would not meet the gateway criteria which states “the person experienced, witnessed or was confronted with an event or events that involved actual or threatened death or serious injury or thereat to physical integrity of self or others”.
Clinically speaking then other anxiety disorders, specifically Separation Anxiety Disorder and Travel Anxiety are more often seen in this younger age group of children.
Separation anxiety is characterised by “clingy” behaviour, worries about separating from parents, and a reluctance to attend nursery or preschool. This is usually accompanied by a reluctance to spend time with other members of the family away from parents. Nightmares are a common symptom of separation anxiety, and also of PTSD. Children under eight frequently report sleep disturbance following road traffic accidents. Dreams may, but do not have to be, thematically related to the accident in order to fulfil the DSM IV criteria for PTSD in childhood.
Travel anxiety is characterised by “an extreme fear and resistance to car travel”. Children can experience situationally-specific panic attacks, and / or more often tantrums. They can actively resist or avoid car travel. There is the potential to diagnose a Specific Phobia in respect of these symptoms.
Children require an efficient and timely response to road traffic accidents so that their functioning remains at optimum level. Symptoms should be assessed as soon as possible following the accident and when treatment is indicated it should be initiated quickly to prevent further psychological cost to the child.
Depending on the age of the child, interviewing the very young child about the accident may be fruitless. However, having the child in the room for at least part of the interview, is useful in terms of generating data about the child’s presentation and their reaction to discussions about the accident.
Part way through the interview it is useful to separate the child from the parent so a more detailed history can be obtained from the parent . This exercise also allows behavioural observation of how the child fairs when separated from their primary attachment figure.
Activities such as crayons or appropriate toys are useful to have in the room, in order to engage the child, and allow time if the child is present during the interview to speak to the parents. Discussion with parents should generate information on a number of areas such as:
• previous emotional and behavioural problems (e.g pre existing problems)
• developmental history of the child, personal history and background
• description of the index accident
• history of emotional and / or behavioural problems since the accident. (It is useful to break such symptoms down into immediately following the accident (first four to eight weeks) and current symptoms.)
Parental reaction to road traffic accidents is crucial. Parents can feel guilty because they were driving the car at the time of the accident. A common reaction is to allow for this, by relaxing rules or avoiding situations that the child might find difficult. This in turn can lead to an exacerbation of anxiety, pushing of boundaries, and, an increase in difficulties in terms of conduct.
Parental reaction is also influenced by parental mood state. If the parent themselves has psychological difficulties, then they are unlikely to be able to provide the child with appropriate reassurance, guidance and boundaries that will enable him to put the accident in the past. Anxious parents are likely to “model” anxious behaviour and they may well model avoidant coping. The most common manifestation of this is for the parent to avoid driving or car travel.
Behavioural testing is a useful adjunct to the clinical interview. Asking how the child arrived at interview can offer further information about travel anxiety. Asking how they feel before they leave is also relevant. Observation of the family leaving the session and getting into the car is helpful in formulating an opinion.
INDICATIONS FOR TREATMENT.
Treatment is indicated when:
1. Emotional and behavioural problems have been ongoing for a period of three months or more, and are clinically significant. A clinical diagnosis is a good indicator of the need for psychological intervention.
2. When parental strategies are maladaptive or inconsistent, and are serving to maintain the child’s problems.
3. When problems are causing significant functional disturbance. For example, when travel anxiety is impacting upon a child’s ability to get to nursery or to visit the wider family.
Psychological distresses following a road accident is a common childhood experience. Assessing its severity and also within the wider family and school context is crucial, not only its impact on the child but also the most effective ‘way forward’ for the family to reinforce and maintain a natural improvement, with or without treatment.
Byrant, B, Mayou, R, Wiggs, L, Ehles, A, Stores, G, (2004) Psychological Medicine 34:2 , 335-346.
Hoare, P, Norton, B, Chisholm, D, Parry-Jones, W, (1996) An audit of 7000 Successive Child and Adolescent Psychiatry Referrals in Scotland, Clinical Child Psychology and Psychiatry, 1 , 229-249
Koch H.C.H. & Kevan T. (005) Psychological Injury XPL Press, St. Albans.