Stress and anxiety in children

Many children will cope very positively following an accident and will show no signs of emotional distress or psychological difficulties. However, a proportion will struggle from an emotional point of view, and a small number are likely to develop significant psychological difficulties. (For more information, see Psychological Injuries by HCH Koch and T Kevan, 2005.) Children's adjustment is dependent upon a number of different factors, including family reaction.

Children who are involved in road traffic accidents are often travelling with their parents at the time. As a consequence of the accident, parents often have their own adjustment difficulties (anxiety and guilt), and although in general they do their best to shield their children from this, children are normally aware of parents' own anxieties (eg in relation to travel). In this way, a parent's post-event anxiety is likely to impact directly on a child's post-accident adjustment, leading to longer emotional recovery times and increased subjective distress.

It is difficult for parents to support children with anxiety difficulties effectively. Most parents will alternate between pushing their children to face their fears sometimes (when they are not ready to do so) and supporting their children in avoiding their feared situations. Both of these strategies may have the undesired effect of increasing or maintaining a child's anxiety. (For more information, see the paper 'Parenting and young anxious children' by BJ Laskey, ACAMH conference, 2011.) In addition, parents will often relax normal rules, routines and boundaries following a difficult or traumatic event, and this may serve to undermine a child's sense of security and predictability.

In addition, it has been shown that following a trauma children often lose recently acquired development competencies (eg continence or sleep patterns), which may cause parents a high level of anxiety.

Medico-legal questions

1. What, if any, psychological injuries resulted from the child's accident?

2. Are there physical injuries attributable to this accident?

3. Did any of these symptoms pre-exist the accident and, if so, were they exacerbated by the accident?

4. How long did these injuries last?

5. What intervention or treatment is needed?

Common psychological effects

Following the experience of a road traffic accident, a child or their parent will often report one or more of the following symptoms:

• intrusive thoughts,

• re-enactment of accident themes in play/conversation,

• sleep disturbance,

• mood changes,

• general anxiety,

• behavioural difficulties at home or at school,

• clinging behaviour, and

• travel anxiety.

The level of symptomatology will depend on several accident-related factors:

a) The child's understanding of the accident as traumatic and life-threatening to him/herself or other occupants of the car (especially his/her parents);

b) The child's physical injuries, including the level of visible injury or scarring;

c) The child's experience and adjustment to post-accident events (eg travelling in an ambulance, being separated from their parents, staying in hospital); and

d) The parents' own emotional adjustment to the accident and their consequent reactions to their child's difficulties.

The most common psychological disorders found following a road accident are:

• Anxiety disorders (including separation anxiety, travel anxiety/phobia, acute stress disorder, post-traumatic stress disorder); and

• Adjustment disorders (mood and sleep disturbance, bedwetting, nightmares, general or separation anxiety).

Most children are very resistant emotionally. However, approximately 10 to 15 per cent will experience and show a persistent level of symptoms. A small number of these cases will be severe enough for symptoms to be classified as a psychological or psychiatric disorder, both in terms of the subjective distress felt and the level of disruption in the child's everyday life.

Classification of childhood problems

A careful history-taking will establish whether any of the symptoms that are reported following the index accident in fact predated the accident. It is well documented that a wide variety of symptoms and behaviours occur during a child's natural and normal development.

It is therefore essential when making a reliable and valid assessment of a child's accident-related problems to establish any pre-existing problems, and to determine the child's general physical and psychological health in terms of temperament, self-esteem and general wellbeing.

Structuring the interview

It is essential to 'look after' the young person during the five distinct phases of the interview process: the pre-interview induction, 'first five minutes', discussion with the child, discussion with the parent, and 'closing' of the interview.

Having made a clear assessment of which of the child's psychological difficulties are attributable to the accident (and/or attributable to other factors), the interviewer discusses practical 'treatment' options with the parent. These may involve one or more of the following:

1) Reinforcing the parent's current behavioural management strategies and providing additional practical advice. A follow-up assessment in six months is suggested at times to reassure the parent that further support is available if required;

2) Signposting self-help material for parents that may aid them in supporting their child with particular presenting issues/behaviours; and

3) Suggesting a brief programme of behavioural management via a short number of therapy session with a clinical psychologist experienced in working with children and families.

Children's behavioural difficulties in this context are often time-limited, and positive expectations concerning prognosis need to be encouraged. Advice, whether this is given by the interviewer or via a GP, health visitor or specialist clinical psychologist, is typically brief, focused and highly practical.

Parent-child context

In some ways, the assessment is partly of the child as an individual and partly of the child-parent(s) interaction and relationship as this is of relevance in terms of:

a) The reaction to the trauma;

b) Maintenance of this reaction and subsequent symptoms; and

c) Any underlying predisposition towards emotional problems.

The child's reaction to a trauma will be mediated by a parent's own emotional adjustment.

A parent with their own apparent psychological difficulties post-accident will be likely to experience difficulties in attuning to and providing for their child's emotional needs, due to feeling overwhelmed by their own. Other family features, such as parental relationship conflict, social difficulties or family debt, will also reduce the level of parental availability to a child following a road traffic accident.

A child's natural travel nervousness will be reinforced, or even exacerbated, by either or both parents themselves being anxious travellers. This is particularly true in families where avoidance of travel becomes the norm. Once a pattern of behavioural or emotional disturbance has been established in a child, parents will draw on pre-existing resources for child management to help modify this pattern, ie consistency of directions, firmness, positive expectation and hopefulness, all of which contribute to overcoming a child's difficulties and distress. A traumatic incident such as a road traffic accident tests a family's coping strategies, and can highlight dysfunctional coping strategies which have been dormant or previously concealed. Some of these patterns will be evident in the interview itself (eg parents' overprotectiveness).

To treat or not to treat?

We have already mentioned that the provision of behavioural management advice and/or treatment is on the agenda in a child assessment. That being said, most trauma-related problems are time-limited. Specific behavioural interventions can accelerate a natural recovery.

Common areas of intervention include:

1) Sleep disturbance, eg modification of parental response to 'bed hopping' or bedwetting;

2) Separation anxiety, eg helping child and parent have confidence when apart;

3) Travel anxiety, eg reinforcing practice, distraction techniques, ensuring parental confidence; and

4) Self-confidence, eg increasing parental reinforcement of child's efforts, raising frequency of child's self-worth thoughts.

The interviewer and similar professional colleagues are not the only people who can provide such advice, although the approach used by clinical psychologists is not only effective but typically efficient in terms of time and effort. Other professionals, such as GPs, health visitors and counsellors, also provide 'common sense' advice in these areas, drawing on both their clinical experience and their own child-rearing experience. It is important for both the family and the medical-legal system that the intervention, if needed, is timely, easy to access, and both effective and efficient.

Regaining confidence

Supporting children who are anxious following a traumatic incident is a complex and often confusing task for parents. The following strategies will provide a solid foundation upon which parents can build a child's confidence, depending on the child's specific needs:

1. Maintaining normal everyday rules, routines and boundaries (bedtimes, house rules, school attendance, etc) will help children to feel secure and contained;

2. Parents will be helped by accessing basic information about a child's likely response to a frightening or traumatic accident. This will reduce the risk of parents worrying unduly about their child's post-accident adjustment;

3. Supporting children's motivation to undertake anxiety-provoking tasks by using praise and rewards is likely to increase the speed with which they regain pre-accident confidence. Praise and rewards should be proportionate to the tasks undertaken;

4. Involving a child in developing a hierarchy of feared situations and a reward system will increase the likelihood of their compliance and success in rebuilding confidence;

5. Following a road traffic accident (or other accident), an anxious parent may not be the best person to support a child. The child is likely to benefit from the support of other confident adults with exposure tasks;

6. A small number of families will require outside support (therapy) to enable them to rebuild a child's confidence following an accident.

Medical-legal issues

Six issues are worthy of mention for the lawyer considering the need for a psychological assessment of a child who has recently been involved in an accident:

1) A psychological assessment should be thorough and comprehensive, using a structured approach which results in a 'multi-axial' summary, explicitly citing:

• A diagnosis (if present) using a system of classification of mental disorders (such as DSM-IV or ICD-10 categories);

• Predisposing or pre-existing psychological or social factors;

• Attribution of symptoms to index accident; and

• Prognosis and need for treatment.

2) This assessment should be carried out in a manner which reassures the child and parent(s) and effectively manages any distress inherent in the process of revisiting accident-related experiences. The process, from the initial correspondence to the interview procedure and final briefing of family members, should be seen by the family as helpful and non-intrusive.

3) Instructions, whether they originate from the claimant's or defendant's solicitor or are joint instructions, should be clearly explained to the parents by both the instructing solicitor and the instructed psychologist to allay any fears of the interview process itself being unnerving for the child (or parent).

4) The process from instruction of expert to receipt of report should be short and typically of the order of six to eight weeks. This is not only to meet demanding legal timescales but also to keep family anxieties to a minimum and to provide advice, if and where appropriate, as soon as possible.

5) In child cases, malingering, total invention of symptoms and disability for obvious gain is uncommon. Inconsistency of data is typically related to parental anxiety and lack of interviewer clarity. Magnification is common and, again, typically attributable to parental anxiety, and can be modified sensitively but rapidly by careful questioning and data collection.

6) Causation and attribution in child assessment must be on the basis of the available evidence, whether clinical or medical record-based. The experienced clinician will be aware of, and at times make explicit, the 'range of possible opinions' before stating the final (or provisional) opinion which 'best fits' the available facts.

Children, like adults, experience the stress and trauma of being through an event such as a road traffic accident. As a result, the assessment of such stress should be reliable, thorough and multi-method. In undertaking assessment of children, the clinician should make the process as non-threatening as possible for both child and parent, and should provide them with reassurance and, where appropriate, practical advice on new and continuing coping strategies. Finally, the overall assessment should address the medical-legal issues of reliability, truthfulness, causation and attribution in ways which stand up to scrutiny and debate, are independent, and assist the court in its final decision.

Dr Hugh Koch and Dr Ben Laskey are chartered clinical psychologists at Hugh Koch Associates

www.hughkochassociates.co.uk