Session 6 Flashcards
(26 cards)
Explain about attachment
[*] Attachment theory developed by John Bowlby (1969, 1973) to understand the relationship between infants and their primary care-givers. Theory was influenced by Harlow’s work (50s and 60s)
[*] Attachment as a biologically based system that functions to maintain proximity to the infant’s care-giver (relationship about security, comfort and safety not just food)
[*] Infants are predisposed to exhibit:
- Proximity seeking behaviours
- Contact maintaining behaviours
[*] The infant forms first ‘mental model’ of relationship based on interactions with their primary care giver.
[*] Secure attachment – worthy of love and care, others will be available to them in times of need
- Influences brain development
- Better social competence, peer relations, self-reliance, physical and emotional health
[*] ‘Critical period’ for first attachment during first year and problems may result if separated during first 4 years. Particularly mental health problems such as depression, suicide tendencies and personality disorders
What are the stages of social development in infancy (Schaffer 1977)?
- Newborns show preference for human faces to inanimate objects. First ‘social smile’ (sign of interaction with care givers) at about 6 weeks.
- At approximately 3 months, babies can distinguish strangers from non strangers. Showing preference for non-strangers (e.g. smiling) but will still allow any caring individual to handle them without becoming unduly upset.
- At approximately 7 to 8 months, specific attachments are formed. Child will miss key people and show signs of distress in their absence. Wary of strangers picking them up, touching them even with key people present.
What are the different attachment styles?
Secure
- Child gets upset when mother leaves but calms down quickly when she returns and explores the environment when she is there. Mother is quick to respond to physical and emotional needs of the child Helps the child to cope with their stress.
Insecure
- Avoidant: Child explores the environment and does not respond when mother leaves or returns. Mother does not respond when child is upset. Tries to stop child crying and encourages independence and exploration.
- Ambivalent: Child gets upset when mother leaves but can be comforted by a stranger. When the mother returns the child will act ambivalently and resist contact or appear angry. Mother is inconsistent – varies between responding quickly and appropriately on some occasions and no responding on other occasions. Child is therefore preoccupied with whether mother is available before they can use her as a secure base.
- Disorganised: Child can be secure, ambivalent, or avoidant but also shows some difficulty coping when the mother returns with behaviour such as rocking themselves. Mother’s behaviour can be negative, withdrawn, inappropriate, roles not clearly defined, sometimes child maltreatment.
What is secure attachment predicted by?
- Carer sensitive to child’s signals (Crying, smiling, discomfort, cooing)
- Rapid, appropriate response emitted consistently
- Interactive synchrony with carer
- Carer accepts role of parent/carer
- Carer has higher self-esteem
What happens when the attachment figure is absent?
[*] When attachment figure is absent (seen in children separated from carers for a long time)
Behavioural changes:
- Separation anxiety
- Increased aggression
- Clinging behaviour
- Bed wetting
- Detachment
Physical impact:
- Work on primates: depression, slower movement, less play, less sleep (including 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)
What are the criticisms of the attachment theory?
- Too simplistic
- Overly focussed on mothers, fathers marginalised
- Multiple attachment figures may be formed (theory only considered primary caregiver initially)
- Quality of substitute care not considered
Despite these criticisms, there is agreement that separation of children from carers is distressing for both, and can have negative short and long term psychological and physical consequences.
Describe the implications of separation for the hospitalised child
Bowly (1969) described the behaviour of children in residential nurseries and hospital separated from their mothers (pattern of behaviour had 3 phases):
- Protest (distressed, look for mother, may cling to substitute, can last hours or even days)
- Despair (signs of helplessness – they’ve realized crying doesn’t work, withdrawn, cry only intermittently)
- Detachment (more interested in surroundings, may smile and be sociable but when carer returns, they are remote and apthetic)
Second two phases often mistaken for recovery
- Most (apparent) distress for children aged between 6 months and 3 years
- Lack ability to keep image of carer in mind
- Limited language (e.g. ‘tomorrow’)
- Lack ability to understand abstract concepts
- 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
[*] Other 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
Give examples of good practice in the organisation of hospital care for children
[*] Allow parental/carer access (as much as possible)
[*] Allow attachment objects
[*] Reassure that child not being punished or abandoned (recognition of importance of explaining to child why they are in hospital)
[*] Environment more like home
[*] Stimulating toys and activities
[*] High quality substitute care, specialist nurses
[*] Continuity of staff (so children can start to develop relationships)
[*] Despite this good practice, hospitalisation of children can still be a highly distressing time, and result in separation from the sick child’s siblings (separation from other loved ones)
Describe the features of Piaget’s four stages of childhood cognitive development
[*] Jean Piaget: child’s mind develops through 4 different stages, with distinct differences in thought processes
[*] Sensorimotor (0-2years)
- Babies experience world through senses
- Develop motor co-ordination
- No abstract concepts
- Develop body schema – awareness of where they ‘end’ and the world starts
- Develop understanding of permanence around 8 months – understand continuing existence of objects even when they are out of sight
[*] Preoperational (2-7 years)
- Language development, symbolic thought, able to imagine things
- Egocentricism (difficulty seeing things from other’s point of view, believe everyone experiences the world they do)
- Lack of concept of conservation
- Classification by a single feature (e.g. all red objects; order by size) – cannot classify by multiple feautures e.g. colour AND size
- Don’t understand about reversibility – don’t understand what can be undone or can’t be undone
[*] Concrete operational (7-12 years)
- Think logically but concrete rather than abstract
- Achieve conservation of number, mass and weight
- Classification by multiple features
- Able to see things from others’ perspectives
[*] Formal operational (12+ years)
- Abstract logic
- Hypothetic-deductive reasoning
What are the criticisms of Piaget’s theory?
- Tends to focus on what child cannot do, not what they can achieve
- IF child is deemed too young to appreciate a given concept, no point in trying to inform them. But partial information can be damaging, the child will try and make sense of the situation anyway.
- Risk of underestimating/overestimating an individual
Describe Vygotsky’s theory of social development
- Cognitive development requires social interaction
- Child as ‘apprentice’, learns through shared problem solving (e.g. parents sitting down and playing with them)
- With able instruction and support from older peers/parents, child can achieve some increase in understanding (x + 1)
- Focus on ‘zone of proximal development’ (the +1 bit)
Discuss the implications of theory about childhood cognitive development for communicating with children about illness and treatment
- Don’t assume ‘average’ ability, need to assess each child’s level of understanding and their zone of proximal development, and tailor communication (e.g. puppets, videos, picture books, play specialists etc)
- Young children lack theory of mind, may think others know they feel
- Difficult to articulate feelings
- Danger of using metaphors e.g. lungs inflate like balloons. With young children, being concrete is very important (children may not be able to think abstract or hypothetically)
- Difficulty thinking about the future (consent and adherence)
Give examples of good practice in communicating well with children
[*] Diabetes:
- Child sufferers of diabetes can learn the difficult task of injecting themselves with a scheme that lets them try it out on teddy first (concrete way of learning rather than abstract)
- Juvenile Diabetes Research Foundation provides 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
[*] Teddy Bear Hospital: Leicester Yr 3 students take role-play to local schools – aims to reduce fear and anxiety of hospitals
Describe adolescence
[*] Adolescence is a biopsychosocial phenomenon that involves physical, cognitive and social changes. The major psychological challenges include adjusting to a changing body size and shape; coming to terms with sexuality; adjusting to new ways of thinking; and striving for emotional maturity and economic independence.
[*] There are observed changes in mood. Boys tend to express more anger and irritability; girls tend to express more anger and depression. These alterations could be due to hormonal changes or responses to new life events and developmental changes
Describe how the timing of puberty can have different effects on boys and girls
- Because puberty onset is earlier for girls than boys, girls who mature early are the very first of their peers to mature. Early maturing girls tend to dislike the experience. They tend to be less sociable, engage in more risk behaviours, have a lower educational attainment, lower self-esteem and poorer body image.
- Boys tend to like maturing early because they are the first of their male peers to gain height and musculature. Early maturing boys tend to be more popular and likely to be leaders, good-natured and may have a cognitive advantage early on. However they may also tend to be more cautious, bound by rules and routines. Late maturing boys tend to be more dependent, insecure, aggressive and more likely to rebel against their parents.
Give some views for the explanation of how the relationship with adults changes during adolescence
- One explanation proposes that these occur because adolescents individuate from their parents, becoming more emotionally and behaviourally independent.
- An alternative view suggests changes in parent-child relationships can lead to psychological independence with continued connectedness.
- Studies of how adolescents spend their time show that although older adolescents spend diminishing amounts of time in family interactions, the time they spend one-to-one with parents does not change and the quality of such interactions often improves. The decline in time spent with family members appears to be due to pulls away from external factors such as friends and work rather than pushes away from bad interactions with parents.
Why are adolescents often dissatisfied with their doctors?
[*] Research indicates that many adolescents are dissatisfied with their interactions with doctors. Some of this dissatisfaction stems from concerns about privacy and confidentiality; some arises from embarrassment arising from talking about sensitive issues such as body image, sexual behaviour or illegal behaviours such as alcohol or drug use. It is therefore important to be sensitive to these concerns and to remind patients that information exchanged in consultations will be private and confidential. It is also important to encourage adolescents to develop their capacity to discuss their health concerns during medical consultations.
[*] Older adolescents may feel uncomfortable or dissatisfied with three-way communications involving themselves, their doctor and their parents. This may be more likely if they feel that they are being spoken about rather than spoken to.
Describe risky behaviour in adolescents
[*] Piaget’s theory argued that formal operational thought develops during adolescence. In this stage adolescents become able to understand abstract principles and use propositional logic. Thinking also becomes multi-dimension: a range of possible situations can be imagined:
- Although the development of metacognition (the capacity to think about thinking) and introspection (the capacity to think about emotions) should facilitate a better understanding of others, much of adolescents’ thinking is directed toward themselves. Thus, adolescents may become self-absorbed and egocentric. However, this is different from the egocentrism characteristic of the pre-operational stage: pre-operational children cannot help their ego-centrism whereas adolescents can. The combination of metacognition, introspection and egocentrism can lead to feelings of there being an imaginary audience observing our actions. Adolescents tend to have a heightened sense of self-consciousness and may feel that their behaviour and appearance are the focus of everyone else’s concern and attention. They believe that all their experiences are novel and unique e.g. ‘Nobody has ever felt love this strong’. This personal fable may be dangerous when it is applied to health risk behaviour.
- Many health risks are gendered and adolescents may engage in risky behaviours as part of the development of their gender identities. Thus, many male adolescents seek to test or display their masculinity by engaging in risky or unhealthy behaviours. Similarly, women’s desire to conform to or resist traditional feminine roles influences whether they engage in risky or unhealthy behaviours.
Tips for communicating with children and parents
[*] Children and parents
- Social referencing
- Initial contact with parents/carers (quickly find out what parents’ concerns are, listen actively and attentively, => parents relax because they understand you’re taking their concerns seriously => child relaxes because parents are relaxed)
- Rapidly instil confidence
- Draw child in
[*] Parents
- Different levels of understanding
- Differences between parents (e.g. mother may be principal care figure sometimes)
Describe communication with babies and infants
- Motor
- Sensory (e.g. touch)
- Non-verbal cues (including touch, smiling)
Describe communication with children
- Language level easiest guide to understanding (be careful when English is the second language)
- Non-verbal cues are important
- 7 year olds can name/draw heart and brain
- 10 years can do simple concepts like digestion
Descrieb communication with special needs
- Assess level of understanding by watching the way they play to assess their disability
- Assess level/skill of communication
- Visual cues
- Pragmatic to explain to patients who in turn (may) explain to the child (if they understand)
- Alternate communication (Makaton)
[*] Sensory impairment
- Visual impairment
- Hearing impairment
- Dual sensory impairment
- Don’t make assumptions
Describe communication with adolescents
- Increasing independence (Gillick Competence)
- Increasing risk taking (compliance, health education)
- Increasing self awareness
- Increasing conflict with parents
- Decreasing communication
- See with or without carers?
List of Do’s
- Smile (or look saddened) as appropriate. Maintain good eye contact. Being calm shows you are in control
- Acknowledge and greet the child. Talking to parents or carers first gives the child time and space to relax
- Observe, wait, listen (OWL). Careful observation and attentive listening can provide valuable information and improve cooperation
- Give simple and clear information. Take time to state your expectations.
- Act out. Imitating with a doll what you want the child to do can be helpful
- Giving them choice empowers children: “Do you want me to examine you on Mummy’s lap or on the bed?”
- Play. Adapt yourself to the situation. Children engage better while having fun.
- Distraction. Talk about their interests, their school, their likes and dislikes, etc while you examine. Make use of play therapists, nurses, parents or carers, etc to play and distract
- Children like to hear positive things about themselves. By giving enthusiastic praise, you hit the emotional jackpot.
- Acknowledge the child’s feelings. Appreciate his or her struggle with a word, for example, “Mmm”, “I see”, etc. Congratulate him or her on their effort.
- Have some quick fixes up your sleeve, give rewards like stickers or superstar certificates, play with a special toy etc
