Normal early relationships

In the first 2 months of a baby’s life, infants are not fussy about who responds to their needs. From 3 to 6 months they become more selective, demanding comfort from one or two caregivers. By 6–8 months they are particular about who responds to their needs or holds them, especially when distressed, and show tearful separation anxiety if their main caregiver, usually the mother, is not there. If tired, fearful, unhappy or in pain, they will cling to her and be comforted by her presence as an attachment figure. At this time, the child learns to crawl, and so is able to leave a primary caregiver and possibly encounter danger. The development of attachment behaviour allows the infant to keep track of their parent’s whereabouts and resist separation. This close attachment relationship derives from social interaction and the mother’s sensitive responsiveness to the baby’s needs, not from any blood tie. It need not be with the biological mother, although it usually is. Its importance lies in it being:

This underscores the importance of having a young child’s parent ‘rooming in’ if admitted to hospital. Otherwise the child would be doubly distressed both by the absence of their attachment figure as well as by the threat of strange surroundings or procedures and by the stress of pain or illness.

If a young child is placed in strange, impersonal surroundings and separated from the mother for more than several hours, a triphasic acute separation reaction may set in (Fig. 23.1):

Recreating the original closeness can take weeks and is accompanied by a phase of irritability, misbehaviour and clinging. This can sometimes be seen when children who have been admitted to hospital as an emergency return home.

Children who have never had the opportunity for a close, secure attachment relationship in their early years are at risk of growing up as self-centred individuals who seek the affection and attention of others but have difficulty with close personal relationships and with learning to conform with social rules of conduct.

The selective clinging of early attachment behaviour diminishes over time so that in the second year of life children extend their emotional attachments to other family members and carers. By school age, they can tolerate separations from their parents for several hours. Children vary in their ability to do this depending on their temperament and social circumstances. For example, a child who is constitutionally apprehensive, who has an exceptionally anxious mother, or who has parents who threaten abandonment is likely to continue to cling to his/her mother for protection and comfort. A series of frightening events will tend to perpetuate clinging, which may persist well into middle childhood (age 5–12 years). This interferes with children’s capacity to learn how to cope with anxiety on their own (Fig. 23.2).

With entry into school, the importance of teachers and other children in shaping psychosocial development increases and their influence must be taken into account in understanding any schoolchild’s development.

Temperament

Children differ from each other in personality from birth, just as they do in physical appearance. This individuality in behavioural style or temperament is partly genetically determined. It is not fixed but changes slowly in the light of experience. It affects how other people deal with them.

A child born with a difficult temperament is prone to:

Such a pattern is a vulnerability factor for future emotional and behavioural problems. It may be hard for parents to maintain an affectionate relationship with a child who has a difficult temperament. Their self-confidence falters as they feel guilty that they have failed as parents. Such parents need support to maintain a positive, loving relationship with their child who will, if this can be done, soften and become easier to handle over a period of months. If parents lapse into irritable intolerance themselves, this is likely to maintain the child’s grouchy and unsatisfied manner and may lead eventually to low self-esteem or the development of behavioural problems.

Self-esteem

Children develop views and make attributions about themselves. Most children experience praise and success in enough areas of their lives to develop a sense of inner self-confidence and self-worth. Those who do not are at increased risk of developing emotional and behavioural disorders which in turn may breed further shame and failure. A child who does not consider him/herself worthwhile and valued by others will play safe and not attempt new activities or explore new situations because of a fear of failure. This restricts the development of coping skills and knowledge of the world generally. It may also be a vulnerability factor for depression and anxiety disorders. Children who lack a belief in their own worth may adopt extraordinary and problematic behaviours in order to attract the attention and acclaim of others. For instance, one child took to openly eating dog faeces because it attracted a crowd of amazed children around her. Repeated failure, academically or socially, will undermine self-esteem, as will some disorders themselves (dyspraxia, enuresis and faecal soiling in particular). An important source of low self-esteem, however, is the child’s parents, either because of their own low self-esteem or because of abuse (emotional, sexual or physical) and neglect.

Cognitive style

As children grow older, their thinking style evolves from one that is concrete to one that is able to cope with abstract thought. Below the age of about 5 years, thought is fundamentally egocentric, with the child being at the centre of his world (Box 23.2). During middle childhood, the dominant mode of thought is practical and orderly but tied to immediate circumstances and specific experiences rather than hypothetical possibilities or metaphors. Not until the mid-teens does the adult style of abstract thought begin to appear.

Coping with chronic or serious illness or adversities in childhood

Children can respond to adversity, including illness, in a number of ways:

• Cognitive response – can lie anywhere along the spectrum of over-acceptance to denial, with fluctuation over time. In over-acceptance, the child may allow the illness to overtake their life resulting in more impairment than is expected for level of symptoms, and high levels of anxiety about the slightest symptom. With denial, symptoms and warning signs may be ignored and treatment poorly adhered to.

• Emotional response – to diagnosis of illness and at times of relapse, may have similarities to a bereavement reaction or reaction to loss, with shock, denial, anger, followed by acceptance and adjustment (Fig. 23.3). Such responses to a serious illness are normal as long as the child proceeds through the phases.

• Behavioural response – young children tend to regress when stressed and behave younger than they actually are. A toddler may become overactive or clingy and display sleep and feeding difficulties. Regressive responses in older children predominantly manifest as problems with toileting, academic performance and peer relationships.

• Somatic response – can include expression of worry and distress through bodily symptoms such as recurrent abdominal pain.

Children suffering from chronic or serious illness are more vulnerable to mental health problems. This is related to:

This is a common problem in the toddler years. The child will not go to sleep unless the parent is present. Most instances are normal expressions of separation anxiety, but there may be other obvious reasons for it which can be explored in taking a history (Box 23.6), supplemented if necessary by the parents keeping a prospective sleep diary. Many cases will respond to simple advice:

If that advice does not resolve the problem, a more active intervention may be required. This involves parents imposing a graded pattern of lengthening periods between tucking their child up in bed and coming back after a few minutes to visit, but leaving the room before the child falls asleep, even if they are protesting. The object is to provide the opportunity for the child to learn how to fall sleep alone, a skill not yet developed. More refractory cases may require specialist referral.

Disobedience, defiance and tantrums

Normal toddlers often go through a phase of refusing to comply with parents’ demands, sometimes angrily (‘the terrible 2s’). This is an understandable reaction to the discovery that the world is not organised around them. They also become confused and angered by the fact that the parent who provides them with comfort when they are distressed is also the person who is making them do things they do not wish to do. This seems exceptionally unfair to them. That is one reason why children play their parents up but may be fine with others. All this can exhaust and demoralise parents, not least because many people offer advice or criticism (everyone thinks themselves an expert in the area of children’s development and behaviour). The points listed in Box 23.7 can be made.