Editorial, J Trauma Stress Disor Treat Vol: 7 Issue: 4

Litigation and Compensation Seeking In Children with PTSD: The Parent-Child Relationship Context

Maayan Shorer^* and Alan Apter

Department of Psychological Medicine, Schneider Children's Medical Center of Israel, Petach Tikvah, Israel

*Corresponding Author : Maayan Shorer
Psychological Medicine, Schneider Children's Medical Center of Israel, 14th Kaplan St., Petach Tikvah, Israel
Tel: +972523402547
E-mail: maayans@clalit.org.il

Received: October 20, 2018 Accepted: November 8, 2018 Published: November 15, 2018

Citation: Shorer M, Apter A (2018) Litigation and Compensation Seeking In Children with PTSD: The Parent-Child Relationship Context. J Trauma Stress Disor Treat 7:3. doi: 10.4172/2324-8947.1000e109

Abstract

Keywords: Adolescents; Anxiety; Bullying; Priming

Editorial

Victims of traumatic events are often involved in litigation processes and pursuit for financial compensation [1-3]. These conditions were identified as associated with elevated distress and symptom overreporting among patients diagnosed with PTSD [1-8]. Although there is a dispute on the interpretation of the evidence, it seems that litigation and compensation seeking may have the undesired effect of impeding recovery [9].

Sayer reviewed some empirically supported explanations for this effect: First, trauma survivors who file claims were found to be more psychiatrically impaired than those who do not [10]. This group difference in symptom reporting may reflect real differences in trauma related symptoms and impairments. Second, individuals who are involved in litigation may exaggerate trauma related symptoms so as to establish a basis for their claims or to maximize compensation. A third possible explanation is that the claim process itself may act as a stressor that triggers genuine symptom increases.

Indeed, symptom exaggeration is often discussed in the context of PTSD. Some psychological models were offered to account for the motivation underlying symptom exaggeration. Rogers suggested that an individual might feign symptoms due to unconscious intrapsychic needs (dependence needs, adapting the sick role, etc.), based on antisocial motives (i.e. deception for external benefits), or as a mean to adapt and to cope with challenging circumstances [11,12].

Although the effect of litigation and compensation seeking is well recognized and studied among adults with diagnosis of PTSD, much less attention has been dedicated to these phenomena in pediatric population [13]. In fact, empirical data is available almost exclusively on adults, leaving the data regarding youth limited. We believe that the impact of litigation and compensation seeking on children with PTSD deserves its own separate examination, for several reasons.

The first and most important reason is that children, by their nature, are dependent on their parents. Thus, the impact of litigation on children must be considered in the context of the parent-child relationship. On the practical level, the legal claim is usually managed by the parents on behalf of their child. The child may be only partially (if at all) aware of the claim, may have incomplete understanding of its implications, and may be less exposed to the stress involved in its management. On the other hand, children’s emotional state following a traumatic experience is profoundly influenced by their parent’s emotional distress [14]. Thus, it might be speculated that the parent’s emotional reaction to the litigation process will mediate, to some extent, their children’s PTSD symptom level. Unfortunately, to our best knowledge, no empirical studies have examined these associations to date.

The children’s motivations and malingering behaviors may also be associated with their parent’s underlying motivations. According to Libow, children may exaggerate symptoms for diverse, internal and external, reasons, such as: elevated attention from adults, permission to avoid challenging developmental tasks, and even a sense of self competence from the act of lying itself [13]. In addition, Libow states that children may exaggerate symptoms as a result of social learning and imitation of their parent’s behaviors. In other cases, children may malinger as a result of a direct or indirect (latent) pressure imposed by their parents. This phenomenon has been termed in the literature ‘malingering by proxy’ [15]. In these cases, it might be argued that while the parent’s main motivation is gaining external compensation, the children’s major motivation is pleasing their parent’s overt and latent wishes.

Continuing this line of thinking, it is interesting to examine not only whether children are influenced by their parent’s emotional reaction to the litigation process and by their parent’s motivations, but also which characteristics of the parent-child relationship makes the child more vulnerable to this influence. For example, would ‘malingering by proxy’ be more evident in children as their parent’s parenting style is more controlling/authoritarian [16]. Darling, Cumsille and Martines found that Adolescents who perceived their parents to be high in monitoring were more likely to endorse parental legitimacy and obligation to obey over time [17]. Insecure attachment might also be associated with greater vulnerability to ‘malingering by proxy’, as the insecure child may make greater attempts to please his parents and ensure their love. Studies on adult populations have demonstrated that people with insecure attachment are more likely to be obedient than people with secure attachment [18,19]. This might be especially true following a traumatic event that activates the attachment system [20]. In this sense, children’s malingering via PTSD symptoms can be seen as an adaptive behavior.

Another issue is the impact of litigation and compensation seeking on treatment outcomes in children with PTSD. A common clinical convention states that compensation-seeking patients will fail to benefit from PTSD treatment because of the need to demonstrate illness. However, the few studies examining compensation and treatment outcome in adults suggest that compensation seeking does not impair PTSD treatment outcome in most contexts [10,21,22]. Unfortunately, there is no empirical evidence regarding children. In our pediatric PTSD clinic the vast majority of patients are involved in a legal claim during treatment. Although we have encountered some cases of blatant ‘malingering by proxy’ (e.g. a father who in the waiting room, instructed his son to lie to his therapist), in most cases our impression was that children’s treatment compliance was not harmed by the legal process. Regardless, we make an effort to identify conflicting motivations (i.e. motivation for healing vs. motivation to remain “ill” and consequent secondary gains) and to raise the child’s and parent’s awareness of this conflict. Our clinical experience has taught us that many parents experienced this discussion as judgmental and reacted defensively, hence the therapist’s empathy and nonjudgmental attitude is required. A sensitive but direct discussion with parents on the motivational conflict makes it more conscious and helps parents to become aware of the potential negative effect of the legal process. This enables them to discuss with their child the wish to gain compensation, or justice, without putting pressure on him to adopt the sick roll. We found that a solid therapeutic alliance between the therapist, the child and the parents may serve as a strong ‘antidote’ against the motivation to preserve illness. However, this is not always easy to achieve. We have noticed that therapist’s reaction to the information that a family is involved in a legal claim (even if there is no evidence for malingering) is at many times negative. Suspicion and mistrust are not rare. Therefore, in our experience, it is essential to discuss and process these issues in therapist’s consultations and staff ongoing training.

In summary, we feel that there is a lacuna in understanding the impact of legal claims and compensation seeking on children with PTSD. We claim that this phenomenon should be investigated distinctively. Children’s fundamental reliance on their parents in managing the claim, and the significant influence of parent’s motivations and emotional reaction to the legal process on the child’s distress explain some of this process. Moreover, it is as yet unknown how children with PTSD experience the legal process, their moral judgments regarding malingering and the impact of litigation and compensation seeking on PTSD treatment outcomes in children.

References

1. Blanchard EB, Hickling EJ, Taylor AE, Buckley TC, Loos WR, et al. (1998) Effects of litigation settlements on posttraumatic stress symptoms in motor vehicle accident victims. J Trauma Stress 1: 337-354.
2. Bryant RA, Harvey AG (2003) The influence of litigation on maintenance of posttraumatic stress disorder. J Nerv Ment Des 191: 191-193.
3. Bryant B, Mayou R, Lloid-Bostock S (1997) Compensation claims following road accidents: A six-year follow-up study. Med Sci Law 37: 326-336.
4. Frueh BC, Elhai JD, Gold PB, Monnier J, Magruder KM, et al. (2003) Disability compensation seeking among veterans evaluated for posttraumatic stress disorder. Psych Services 54: 84-91.
5. Hall RC (2007) Detection of malingered PTSD: an overview of clinical, psychometric, and physiological assessment: where do we stand. J Forensic Sci 52: 717-725.
6. Solomon Z, Neria Y, Ohry A, Waysman M, Ginzburg K (1994) PTSD among Israeli former prisoners of war and soldiers with combat stress reaction: a longitudinal study. Am J Psychiatry 151: 554-559.
7. Taylor S, Frueh CB, Asmundson GJ (2007) Detection and management of malingering in people presenting for treatment of posttraumatic stress disorder: Methods, obstacles, and recommendations. J Anxiety Disord 21: 22-41.
8. Franklin CL, Repasklin SA, Thompson KE, Shelton SA, Uddo M (2003) Assessment of response style in combat veterans seeking compensation for posttraumatic stress disorder. J Trauma Stress 16: 251-255.
9. Mendelson G (1995) ‘Compensation neurosis’ revisited: outcome studies of the effects of litigation. J Psychosom Res 39: 695-706.
10. Sayer NA (2007) Compensation and PTSD: Consequences for symptoms and treatment. PTSD Research Quarterly 18: 1-8.
11. Rogers R (1990) Development of a new classificatory model of malingering. Bulletin of the American Academy of Psychiatry and Law 18: 323-333.
12. Rogers R, Newmann CS (2003) Conceptual issues and explanatory models of malingering. Oxford University Press, USA, 71-84.
13. Libow JA (2003) Illness falsification in children: pathways to prevention? In: PW Halligan. Oxford University Press, USA. 147-156.
14. Laor N, Wolmer L, Cohen DJ (2001) Mothers' functioning and children's symptoms 5 years after a SCUD missile attack. Am J Psychiatry 158: 1020-1026.
15. Slick DJ, Sherman EMS, Iverson GL (1999) Diagnostic criteria for malingered neurocognitive dysfunction: Proposed standards for clinical practice and research. Clin Neuropsychol 13: 545-561.
16. Baumrind D (1966) Effects of authoritative parental control on child behavior. Child Development 37: 887-907.
17. Darling N, Cumsille P, Martínez ML (2007) Adolescents' as active agents in the socialization process: Legitimacy of parental authority and obligation to obey as predictors of obedience. J Adolesc Health 30: 297-311.
18. Gudjonsson GH, Sigurdsson JF, Lydsdottir LB, Olafsdottir H (2008) The relationship between adult romantic attachment and compliance. Personality and Individual Differences 45: 276-280.
19. Impett EA, Peplau LA (2002) Why some women consent to unwanted sex with a dating partner: Insights from attachment theory. Psychol Women Q 26: 360-370.
20. Cassidy J (1994) Emotion regulation: Influences of attachment relationships. Monographs of the Society for Research in Child Development 59: 228-249.
21. Deviva JC, Bloem WD (2003) Symptom exaggeration and compensation seeking among combat veterans with posttraumatic stress disorder. J Trauma Stress 16: 503-507.
22. Taylor S, Fedoroff IC, Koch WJ, Thordarson DS, Fecteau G, et al. (2001) Posttraumatic stress disorder arising after road traffic collisions: Patterns of response to cognitive-behavior therapy. J Consult Clin Psychol 69: 541-551.