Health Psychology and Human

DiversityChild development
DR.SURA SAHIB
FAKHERELDEIN
M.B.CH.B F.I.C.M.S
SPECIALIST PSYCHIATRIST
CHILD DEVELOPMENT

OBJECTIVES TO ENABLE YOU TO:

CONSIDER THE IMPLICATIONS OF
ATTACHMENT THEORY FOR THE
HOSPITALISED CHILD
OUTLINE PIAGET’S THEORY AND HOW IT HAS
BEEN USED TO EXPLAIN CHILDREN’S
UNDERSTANDING OF HEALTH AND ILLNESS
CONSIDER SOME OF THE CRITICISMS OF
PIAGET’S THEORY, AND IT’S ALTERNATIVES
ATTACHMENT THEORY

Attachment theory developed by John Bowlby

(1969,1973) to understand the relationship
between infants and their primary care-givers
Move from Freudian approaches towards the new
cognitive approach to psychology, also draws on
evolutionary theory (influence of Harlow’s work)
Attachment as a biologically based system that
functions to maintain proximity to the infant’s
care-giver.
Infants predisposed to exhibit
Proximity seeking behaviours
Contact maintaining behaviours
HARLOW’S WORK WITH PRIMATES

Given a choice, infant

monkeys preferred
surrogate mothers covered
with soft terry cloth with no
food to less ‘comforting’
mothers that gave food.
Attachment is not just
about ‘cupboard love’.
 ATTACHMENT THEORY

THE INFANT FORMS FIRST ‘MENTAL MODEL’ OF

RELATIONSHIP BASED ON INTERACTIONS WITH
THEIR PRIMARY CARE GIVER
CHILDHOOD ATTACHMENT MODELS MAY
CONTINUE TO INFLUENCE ADULT
RELATIONSHIPS
‘CRITICAL PERIOD’ FOR FIRST ATTACHMENT
DURING FIRST YEAR, AND PROBLEMS RESULT IF
SEPARATED DURING FIRST 4 YEARS?
INSECURE ATTACHMENT IN INFANCY MAY RESULT
SHORT TERM AND LONG TERM PROBLEMS
STAGES OF SOCIAL DEVELOPMENT IN
INFANCY (SCHAFFER, 1977)

Newborns show preference for human faces to

inanimate objects. First ‘social smile’ at about 6 wks
Approx 3m. Distinguish strangers from non-
strangers. Show preference for non-strangers (eg
smiling) will allow any caring adult to handle them
without becoming unduly upset
7_8 MONTHS SPECIFIC ATTACHEMENTS
FORMED .CHILD WILL MISS KEY PEOPLE AND SHOW
SIGNS OF DISTRESSS IN THEIR ABSENCE .
WARY OF STRANGERS PICKING THEM UP , TOUCHING
THEM ,EVEN WITH KEY PEOPLE PRESENT
EFFECTS OF SEPARATION

Bowlby (1969) described the behaviour of

children in residential nurseries and hospital
separated from their mothers. He found a
predictable pattern of behaviour following 3
phases:
Protest (distressed, look for mother, may cling to
substitute, can last hours or even days)
Despair (signs of helplessness, withdrawn, cry only
intermittently)
Detachment (more interested in surroundings, may smile
and be sociable, but when career returns they are
remote and apathetic)
Second two phases often mistaken for recovery
MOST (OVERT) DISTRESS FOR CHILDREN
AGED 6M – 3YRS
LACK ABILITY TO KEEP IMAGE OF CARER IN
MIND
LIMITED LANGUAGE (E.G. ‘TOMORROW’)
LACK ABILITY TO UNDERSTAND ABSTRACT
CONCEPTS? (SEE PIAGET LATER)
OFTEN FEEL ABANDONED, AND MAY
ATTRIBUTE IT TO THEIR OWN FAILING (E.G
SHE’S GONE BECAUSE I WAS NAUGHTY’),
AND SEE BEING LEFT AS ‘PUNISHMENT’.
WHEN ATTACHMENT FIGURE IS ABSENT

IN LONG-TERM ABSENCE
1. SEPARATION ANXIETY

2. INCREASED AGGRESSION

3. CLINGING BEHAVIOUR

4. BED WETTING

5. DETACHMENT

FIRST 3/4 YEARS OF LIFE APPEAR TO BE

CRITICAL (OR SENSITIVE) PERIOD FOR
FORMING ATTACHMENTS
ATTACHMENT STYLES
SECURE
INSECURE
RESISTANT
AVOIDANT
DISORGANISED
STRANGE SITUATION TEST (AINSWORTH, 1973)
A METHOD FOR IDENTIFYING ATTACHMENT STYLE
CONTROLLED ENVIRONMENT AND EVENTS
INFANT OBSERVED IN 8 X 3MIN EPISODES
CHILD OBSERVED REGARDING:
WILLINGNESS TO EXPLORE AND INTERACT WITH TOYS
REACTION TO CAREGIVER’S DEPARTURE
REACTION TO ‘STRANGER’
REACTION TO RETURN OF CARE GIVER
STRANGE SITUATION TEST: CHILD OBSERVED
REGARDING
WILLINGNESS TO EXPLORE AND INTERACT WITH
TOYS (SAFE BASE)
REACTION TO CAREGIVER’S DEPARTURE
REACTION TO ‘STRANGER’
REACTION TO RETURN OF CARE GIVER
LIMITATIONS OF STRANGE SITUATION
TEST
STRANGE SITUATION ONLY HAS MOMENTARY
SEPARATIONS, SO RESULTS ONLY RELEVANT TO
SHORT TERM STRESSORS?
AFTER PROLONGED SEPARATION MOST CHILDREN
REJECT MOTHER (AT LEAST INITIALLY), SO ALL
WOULD BE ‘INSECURE’
NOT ECOLOGICALLY SOUND?
INFANTS MAY FORM MULTIPLE ATTACHMENTS, THIS
ONLY LOOKED AT BEHAVIOUR WITH MAIN CARER.
CHILDREN DO NOT TEND TO CLING TO OTHER
ATTACHMENT FIGURES (FIELD ET AL, 1984)
LIMITED TO INFANT ATTACHMENT BEHAVIOUR
 SECURE ATTACHMENT PREDICTED BY

1. CARER SENSITIVE TO CHILD’S SIGNALS

(CRYING, SMILING, DISCOMFORT, COOING)
2. RAPID, APPROPRIATE RESPONSE EMITTED
CONSISTENTLY
3. INTERACTIVE SYNCHRONY WITH CARER
4. CARER ACCEPTS ROLE OF PARENT/CARER
5. CARER HAS HIGHER SELF-ESTEEM
COSTS OF SEPARATION
Affectionless psychopathy?
Work with primates – depression, slower
movement, less play, less sleep ( less REM sleep),
changes in heart rate and body temperature
(Reite et al 1978)
Similar changes in preschool children hospitalised
for chemotherapy (Hollenbeck et al 1980)
Separation from peers also distressing, and have
similar effects (Field 1984)
Lack of reinforcement from mother contributes to
helplessness? (Coe & Levine, 1983)
See: Field, T. (1996) Attachment and separation in young
children. Annual Review of Psychology, 47: 541-61.
(Available on-line)
Other possible implications for health
outcomes

Adherence to treatment may be adversely

affected, and this in turn may impede
recovery
Patients experience of pain may be worse if
anxiety levels high
Patients may suffer from adverse effects of
stress on health
CRITICISMS OF ATTACHMENT THEORY
TOO SIMPLISTIC
OVERLY FOCUSED ON MOTHERS, FATHERS
MARGINALISED
MULTIPLE ATTACHMENT FIGURES MAY BE
FORMED, THIS WAS NOT EXPLORED INITIALLY
QUALITY OF SUBSTITUTE CARE NOT CONSIDERED

DESPITE CRITICISMS OF ATTACHMENT THEORY:

AGREEMENT THAT SEPARATION OF CHILDREN
FROM CARERS DISTRESSING FOR BOTH, AND
CAN HAVE NEGATIVE PSYCHOLOGICAL AND
PHYSICAL CONSEQUENCES
PRACTICE IN BOWLBY’S DAY
PRACTICE IN THE 1950’S AND 60’S WAS TO RESTRICT
PARENT’S ACCESS TO HOSPITALISED CHILDREN
WARDS WERE ‘STERILE’ AND CLINICAL
PARENTS’ LEAVING WAS A CAUSE OF DISTRESS SO
FREQUENCY OF VISITS LIMITED
DISAPPEARANCE OF OVERT DISTRESS IN CHILDREN
WAS SEEN AS A POSITIVE
MAY MASK UNDERLYING DISTRESS AND BE A THREAT
TO ATTACHMENTS, CAUSE DAMAGE TO
RELATIONSHIPS
RESISTANCE TO ACCEPT CHANGES TO PARENTS’
ACCESS
 IMPROVEMENTS TO PRACTICE TODAY
1. ALLOW PARENTAL/CARER ACCESS
2. ALLOW ATTACHMENT OBJECTS
3. REASSURE THAT CHILD NOT BEING PUNISHED OR
ABANDONED
4. ENVIRONMENT MORE LIKE HOME
5. STIMULATING TOYS AND ACTIVITIES
6. HIGH QUALITY SUBSTITUTE CARE, SPECIALIST NURSES
7. CONTINUITY OF STAFF

DESPITE THIS GOOD PRACTICE, HOSPITALISATION OF

CHILDREN CAN STILL BE A HIGHLY DISTRESSING TIME,
AND RESULT SEPARATION FROM THE SICK CHILD’S
SIBLINGS
CHILDHOOD COGNITIVE DEVELOPMENT

JEAN PIAGET
GENETIC EPISTEMOLOGIST
WORK WITH INTELLIGENCE TESTS
USE OF CLINICAL INTERVIEW
QUALITATIVE DIFFERENCES IN THOUGHT
PROCESSES AT DIFFERENT AGES.
Intelligence grows through interaction of child
with the environment
Child ‘operates’ on the environment and sees the
effect (little scientist)
Thinking is mental operation
New skills represented as schemata
Knowledge assimilated or accommodated
REDUCING EGOCENTRICITY

COGNITIVE DEVELOPMENT REDUCES

EGOCENTRICITY
BODY SCHEMA - LEARNING WHERE YOU END
AND THE WORLD STARTS!
OBJECT PERMANENCE – CONTINUING
EXISTENCE OF OBJECTS EVEN WHEN THEY
ARE OUT OF SIGHT
ABILITY TO DECENTRE – E.G. SWISS
MOUNTAIN TEST
PIAGET’S STAGES OF COGNITIVE
DEVELOPMENT

SENSORI-MOTOR (0-2 YRS)

ORGANISE SENSORY INFORMATION
DEVELOP MOTOR CO-ORDINATION
DEVELOP BODY SCHEMA
DEVELOP OBJECT CONSTANCY
PRE-OPERATIONAL (2-7 YRS)
EGOCENTRIC SPEECH
CENTRATION
REVERSIBILITY
CONSERVATION
OVER-GENERALISATION
CONCRETE OPERATIONAL STAGE (7-12
YRS)
DIFFICULTY WITH ABSTRACT THOUGHT
LIKE COLLECTING INFO ON FAVOURITE
TOPIC
FORMAL OPERATIONAL (12YRS+)
ABSTRACT LOGIC
DEVELOP HYPOTHESES
CRITICISM OF PIAGETIAN APPROACH
(RUSHFORTH 1999*)

TENDS TO FOCUS ON WHAT CHILD CAN NOT

DO, NOT WHAT THEY CAN ACHIEVE
IF CHILD DEEMED TOO YOUNG TO
APPRECIATE A GIVEN CONCEPT, NO POINT IN
TRYING TO INFORM THEM
PARTIAL INFORMATION CAN BE DAMAGING,
THE CHILD WILL TRY AND MAKE SENSE OF
THE SITUATION ANYWA
ALTERNATIVE APPROACHES

Carey 1985 – child an adult shares common

journey from novice to expert?
More knowledge, build schemata, increase
understanding
However, cannot deny that child’s ability does
have some limits!
Vygotsky – Child as an ‘apprentice’, compromise
between Piagetian view and Carey
With ‘able instruction’, child can achieve some
increase in understanding.
Focus on ‘zone of proximal development’
ABLE INSTRUCTION – BEST DONE ONE-TO-ONE
DON’T ASSUME ‘AVERAGE’ ABILITY, NEED TO ASSESS
EACH CHILD’S ‘X’ LEVEL AND THEIR ZONE OF
PROXIMAL DEVELOPMENT
PREPARING CHILD FOR ADMISSION AND PROCEDURES
USE OF DIFFERENT MEDIA FOR COMMUNICATION (E.G.
PUPPETS, VIDEOS, PICTURE BOOKS, PLAY SPECIALISTS
ETC.)
CHECK UNDERSTANDING (E.G. DEMON, BUGS, IRON)
TAKE CARE WITH METAPHORS, (E.G. LUNGS INFLATE
LIKE BALLOONS…)
HELP CHILD EXPRESS FEELINGS, (E.G. PAIN CHARTS
WITH SMILEY FACE – SAD FACE RANGE)
 SUMMARY

ATTACHMENT THEORY REINFORCES NEED FOR

ACCESS OF FAMILY TO HOSPITALISED CHILDREN,
AND OF CHILDREN TO HOSPITALISED FAMILY
MEMBERS.
SEPARATION FROM ATTACHMENT FIGURES CAN
CAUSE PSYCHOLOGICAL AND PHYSICAL
DISTRESS, DAMAGE RELATIONSHIPS, AND
INFLUENCE MAY PERSIST INTO ADULTHOOD
IF ACCESS TO CARERS HAS TO BE RESTRICTED,
GOOD QUALITY HOSPITAL CARE CAN HELP
HOMELY, STIMULATING ENVIRONMENT, FAMILIAR TOYS
PLAY SPECIALISTS
CONTINUITY OF CONTACTS
PIAGETIAN APPROACH IDENTIFIES LIMITATIONS OF
CHILDREN DEPENDENT ON THEIR STAGE COGNITIVE
DEVELOPMENT
RUSHFORTH ARGUES FOR VYGOTSKY’S ADAPTATION,
WITH FOCUS ON ‘ZONE OF PROXIMAL DEVELOPMENT’
TO HELP EACH CHILD REACH THEIR BEST POTENTIAL
REQUIRES ASSESSMENT OF EACH INDIVIDUAL CHILD’S
ABILITY AND PROVISION OF ‘ABLE INSTRUCTION’ (SO
MORE COSTLY)
MULTI-DISCIPLINARY TEAM AND USE OF DIFFERENT
MEDIA CAN AID COMMUNICATION
SCOPE FOR MISUNDERSTANDING IS GREAT – NEED TO
CHECK!
 EXAMPLES OF GOOD PRACTICE
CHILD SUFFERERS OF DIABETES CAN LEARN THE DIFFICULT
TASK OF INJECTING THEMSELVES WITH A SCHEME THAT LETS
THEM TRY IT OUT ON TEDDY FIRST. THE JUVENILE DIABETES
RESEARCH FOUNDATION (JDRF) LAUNCHED A SCHEME IN
MARCH 2002 TO PROVIDE TEDDY BEARS TO CHILDREN JUST
DIAGNOSED WITH DIABETES.
COMPLETE WITH THEIR OWN INSULIN INJECTING KIT THE
BEARS WEAR ABSORBENT PADS SO THAT CHILDREN CAN
PRACTICE ON THEM IN AS REAL A WAY AS POSSIBLE.
DIABETES AMONG CHILDREN IS ON THE INCREASE, ACROSS
EUROPE IT IS RISING AT A RATE OF 3-4% PER ANNUM IN THE
UNDER-15 AGE GROUP.