R Psychosocial Issues in the Health Care of Children and Young people. A case study discussing the application and analysis of theories applicable to the psychological care of and child and their family.
A case study discussing the application and analysis of theories applicable to the psychological care of and child and their family. I’m going to discuss a case study of a child named Jake. The name has been changed to comply with NMC confidentiality (Nursing and Midwifery Council 2012).
Jake is four, and has been admitted to hospital due to a head injury. He also suffers from Asthma. The story behind this accident is vague and this family had previously contact with social services for child protection issues and the suspicion of abuse.
This essay will consider the psychological effects this abuse may have on Jake; it will not discuss the actual reporting of the abuse. Jake is at an age where he requires psychological support and interaction to enable his development; Piaget demonstrated this though his Theory of Cognitive Development.Piaget believed that children go through a multiple number of stages of development and move from one stage to another once they achieve specific developmental milestones (Oakley 2004). This is backed up by Ericson’s stages of psychosocial development. He believed each stage of development has a specific conflict that the child has to overcome before moving to the next stage. If a child is unable to successfully overcome a particular conflict, the child will remain stuck at that stage until they are able to resolve that issue (Shaffer 2005).
It is thought that in order to move through these stages children need stimulation, encouragement and love from those around them. This will allow them build their trust, confidence and sense of security overall helping them successfully develop psychologically, in the form of social skills, cognitive and emotional development. In this case Jake may not have had the opportunity for this development due to possible neglect and abuse. He is less likely to be encouraged and may be anxious and insecure with a lack of trust in all adults.
This means he may not thrive and will be ‘stuck’ at Piaget and Ericson’s development stages (Wadsworth 2004). There are many psychological theories and explanations that can be applied to this case with Jake, due to these disruptive and uneasy first few years of his life. Jake is very likely to have experienced a lot of stress. Stress can be defined as physical, mental, or emotional factor that affect the functioning of the body (Weller 2009). It becomes a problem when stress reactions are so severe that the child is unable to handle them effectively, which could apply to Jake.
This stress experienced from abuse starts as a daily hassle, but can lead to more long term chronic stress (Thomas 2007). Jake is currently experiencing both types of stress, firstly due to the chronic stress of abuse and secondly the additional stress of coming into hospital. Being only four he is not old enough to manage stress or understand what he’s going though, therefore it’s likely to have a huge effect on him and his development as he can’t manage it effectively. At this age, this stress response allows the child to gain control in the short term yet not manage the long term stress.He is likely to express extreme behaviors in order to cope including, withdrawal, denial and impulsive acting out. These are defense mechanisms, which are ineffective in the long term, and lead to a more extreme way to cope, this could be shown by, panic, depression, self-harm and refusal to play with his peers (Kostelnik 1998). This is the type of coping mechanism a boy of Jake’s age is likely to express. Stress is said to be divided into three different ‘types’.
Positive stress, this is experienced in everyday life and is essential for development such as meeting new people or going to a new school.Tolerable stress causes more distress but is short lived, such as the death of a loved one. The third is toxic stress; this is what Jake is experiencing as a result of the abuse he is experiencing.
If toxic stress is sustained over a long period of time the stress response system gets activated for the equivalent amount of time. This can lead to permanent changes in the development of the brain. Toxic stress is caused by abuse or neglect. (Shonkoff 2000). Biological Psychologists have also found a correlation between toxic stress and bodily development (National Scientific Council on the Developing Child 2004).
Examples of this include impairment of the brain circuits, which can result in a smaller brain size, as well as the hormones released due to toxic stress damaging parts of the brain responsible for memory and learning. In Jake’s case, this type of stress he is experiencing could influence his learning and development as he goes into adulthood, however, this is a correlation; cause and effect cannot be established (Middlebrooks 2008). Stress can have a large influence on the health of the child. A stressed child will firstly show outward signs of stress, these will include being upset, crying, whilst having little trust in adults.Stress is also likely to have an influence upon development including children’s physical, psychological, emotional well-being as well as their ability to concentrate and learn (Thomas 2007). Jake’s behavior shows that he is experiencing anxiety; so he is therefore expressing symptoms such as nausea, racing heart rate and muscle pain. It is known that the long term effects of anxiety can also influence his immune system, this is due to the levels of stress hormones released (Glaser 2008). His body is constantly in the ‘fight or flight’ mode, which is due to the level of stress hormone corticosteroids and adrenaline being released.
This focuses the body’s attention away from systems, including the immune system, making him more susceptible to illness (Selye 1997). The physical abuse and limited nurturance that Jake is experiencing could also be linked to chronic impairment; this could explain why Jake has asthma. A study carried out by Coogan found childhood abuse causes stress that leads to “physiological consequences. ” The stress of living in an abusive situation takes a toll on the body, specifically on the immune system and on airway development; this is evident in Jake’s case (Coogan 2006).This stress is likely to also influence Jake’s social development, which is an important development stage for a boy of Jakes age. If Jake has been neglected, his parents may have not helped him develop social skills and taught him how to interact with others, this will influence his speech development.
When he starts school, this will have a big impact on his ability to interact with peers and teachers. It will also influence his ability to have friendships and learn to play with others as he is unable to interact with them.Jake is likely to get frustrated which could lead to signs of aggression as this is what he thinks is the ‘correct’ way to act towards others due to this early experience of abuse (Haskett 1999). Jakes role model will be his primary care givers of who are also likely to be his abusers.
Even in this situation Jake will want to ‘be like’ these role models, unfortunately they are not showing him the correct way to behave. Their behaviors will be expressed by Jake too, which will lead to serious social problems.He will also be confused when he is told his behavior is not correct, as he doesn’t known any different, this can be frustrating for him and could lead to him becoming violent and in the long term effect his education (Smith 2004). As a result of Jakes poor development, he is likely to under-achieve in school and subsequently to have a low income as an adult. As a consequence of this he is also likely to have children at a very early age, and provide poor health care, nutrition and stimulation to his children, therefore contributing to poverty and further poor development.Research has also found that he is likely to demonstrate this abusive behavior onto his own children (World Health Organization 2009).
The long-term effects of stress have been widely researched by psychologists. However, it is difficult to determine whether childhood stress was the route cause. The Nature/Nurture debate by Darwin is relevant to the impact of childhood experiences.
Darwin questions whether the stress experienced during childhood lead to consequences in adulthood (Nurture) or if genetic makeup and traits have an impact (Nature) (Paris 2005).The long-term effects of stress were researched by the Centers for Disease Control and Prevention. They looked into the link between childhood stressors and adult health. They conducted a study on adverse childhood experiences (ACE), including abuse and neglect. They interviewed 170,000 participants and around one third stated they experienced an ACE during their childhood. The ACE Study uses the ACE Score; this calculated the total number of ACE respondents reported.
The ACE Score is used to assess the total amount of stress during childhood as the number of ACE increase, the risk of health problems increases.Health problems include alcohol abuse, cardiac problems, depression and teenage pregnancy (Middlebrooks 2008). Children react to stress and learn to cope in many ways, including: defense mechanisms, such as denial, regression, withdrawal and impulsive acting-out. These stress responses can allow the child to temporarily gain a sense of control or balance. However, these defense mechanisms are generally not productive in the long-term and can lead to more serious stress responses, including, panic, self-harm and refusal to play with their peers (Kostelnik 1998).Therefore, support from the parents is necessary for children to learn how to respond to stress in a physically and emotionally healthy manner. Another appropriate theory in relation on Jake is attachment theory.
This is referred to as the innate strong emotional bond between an infant and primary care giver (PCG), which is present in the long-term. Attachment is an important process, as children’s physical, emotional, and psychological development depends on attachments formed with the PCG. While the supply of food, clothing, and shelter is important, it is not enough to promote development.Loving care and attention are also needed if children are to grow into adults capable of forming healthy relationships with others. Attachment is the basis for a child’s understanding of themselves, the world and the people in it. This theory was developed by John Bowlby in 1969. This bond starts to form from birth and is usually with the child’s mother or father (Walker 2002). In the case of Jake, he is less likely to have formed this type of attachment with his parents.
Children who have been abused have usually also experienced neglect and rejection.They have not formed the emotional bond due to not receiving positive care and attention from them, as they are punished or hurt by the people they spend most of their time with. Chronic experiences like this result in fear and insecurity, which then undermine the child’s ability to form attachment, as well as the child linking the attachment figure to pain and injury (Prior 2006). The attachment bond has several key elements.
Attachment is turning to PCG to protect us and to manage our feelings, fears, anxieties, and distress as well as being a ‘safe base’. The loss or threat of loss of the person evokes distress.This first bond is thought by psychologists to form a working framework for future relationships. A successful relationship with the PCG during infancy will affect future relationships, whereas a poor relationship with the PCG during infancy is linked to emotional and behavioral problems later in life (Perry 2010). Mary Ainsworth looked into Bowlbys Attachment theory in more depth; she divided attachment up into different types and studied the effect this had on their psychological health and relationship formation, as well as how children responded to their PCG.The study involved observing children between the ages of 12 to 18 months responding to a situation in which they were briefly left alone and then reunited with their mother (Ainsworth, 1978). Ainsworth concluded that there were three major styles of attachment: secure attachment, ambivalent-insecure attachment, and avoidant-insecure attachment. These early attachment styles have an influence upon behaviors in later life (Colin 2000).
In the case with Jake, he is likely to be in the category of insecure-avoidant attachment to his PCG.In the strange situation an insecure-avoidant child will fail to develop any feelings of security from the attachment figure. Accordingly they exhibit difficulty moving away from the attachment figure to explore surroundings.
When distressed they are difficult to soothe and are not comforted by the PCG. This is due to the extreme lack of trust in the PCG as well as not getting responsive, nurturing, consistent care in the early weeks and months of their lives They don’t know how to receive this reassuring care in a distressing situation, which is how Jake is likely to respond in this situation (Crittenden 2001).However this study was in an artificial environment so has low ecological validity, as well as it only showing the attachment towards one PCG, whom may not be the main attachment figure, the unusual environment may influence the child’s behavior also. For Jake multiple problems are likely to arise due to this disordered attachment in early life.
Some issues are obvious such as development delays, such as language development, social behaviors and cognitive development, this is due to the early bond between child and PCG is not present which is a vital for development.Emotional functioning is usually also disordered in abused children, they maybe ‘too loving’ and hug virtual strangers, this is likely to be ‘safety seeking’ behavior to try to avoid further abuse (McPherson 2002). Children also mirror adult behavior. In this case of abused children, such as Jake, the children learn that this behavior is the ‘correct’ way to interact with others, causing problems in current and future social encounters.
Another major problem with these children is aggression; this is thought to be due to lack of empathy and poor impulse control.Children like Jake do not understand others have feelings and the impact their actions may have on others. They are also likely to hurt animals, smaller children and siblings due to wanting the hurtful control their PCG has over them (Kail 2006).
Based on current evidence, it is important that when children like Jake come into the healthcare setting they receive the appropriate care both physically and emotionally to make sure they are safe and their experience of coming into hospital causes as little distress as possible. Empathy and consideration should be expressed by the nurses looking after him.They need to meet his needs yet be careful ad he is likely to be hostile and have a lack of trust in any adults. He is also going to be unable to verbalize his feelings as well as adults can, due to not having their words to describe his fears and worries. Nurses need to take this into account and use different ways to allow Jake to discuss his worries, for example though play. Jake is also unable to take positive action towards managing stress when it arises, nurses should strive to relive this stress wherever possible and offer initiatives such as counseling to the children like Jake to help reduce this stress.Whilst Jake is in hospital it is important to reassure him he isn’t being punished for being ill. He may think that he has done something wrong, which is why he has been taken from his home and adults may be hurting him by the forms of injections and medication.
This needs to be explained to Jake, so he gains trust in the medical staff, this can be done by making his time in hospital enjoyable and getting him involved. A new initiative has also been realized which teaches healthcare staff how to recognize children who come in suffering from abuse or neglect.This will help them build up a better picture of what is happening in the child’s life so they can alert social services if they think something might be wrong (Poulter 2012). In conclusion Jake’s situation has raised many psychological concerns about how his development is being influenced by his abusive relationship with his parents. This stress he is experiencing and the complicated attachment he has to his parents could also lead onto other psychological problems such as depression, social problems and maybe even become a risk to his health as well as extensive development problems.Nurses should work as part of a multi-disciplinary team with social services and Jakes parents to help protect Jake and his future. Ainsworth (1978). Patterns of Attachment: A Psychological Study of the Strange Solution.
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