Core Childhood Needs (Part 2)

Whilst Part 1 of this post looked at the protective factors which might help keep a person well, Part 2 considers childhood risk factors, which may increase the likelihood of an individual developing mental health problems; be it in childhood or later in their lives.

Adverse Childhood Experiences

"Adverse childhood experiences" are those which may cause high levels of distress, disruption, or harm to a young person.  These may include:

- Physical, psychological, or sexual abuse.
- Physical or emotional neglect.
- Criminal behaviour in the household.
- Substance abuse.
- Parental domestic violence.
- Parental mental illness.
- Parental incarceration.
- Parental conflict, separation, or divorce.

Whilst many children may experience one of these at some point in their childhood, the effects appear to be cumulative, with worse outcomes for those who experience several of the above.  For example, one study found that the risk of suicide attempts, alcoholism, drug abuse, and depression in adults who had experienced four or more categories of adverse childhood experience were increased 4 to 12-fold. 

Similarly, an accumulation of less 'dramatic' risk factors in a child's life can have a severe impact on their development and well-being.

Let's look at some examples.


Isaiah

Isaiah's early life was happy and fairly uneventful.  He lived with his mum, dad, and older sister, Sasha.  They didn't have a lot of money, but they got by, and his parents spent a lot of time with their children, reading, playing games, and taking them to the park, the cinema, and museums.

But that all changed when Isaiah's mum got arrested and sent to prison.

Since then, his dad has been feeling very depressed and has struggled to motivate himself to even get out of bed.  Though he loves his children, he is caught up in what has happened and can't seem to find the energy to spend time with them.


Isaiah has not had anyone to read with him or help him do his homework.  No-one is doing jigsaws with him or ensuring he knows how to tie his laces.  Each day, Isaiah notices he is a little further behind his peers.  He's starting to feel very bad about himself as he suspects he must be stupid if he can't do what everyone else can.  And with no-one for him to tell about these feelings or anything else that is happening in his life, Isaiah's language and ability to express his needs are also being affected.  This emotional neglect is teaching Isaiah that him and his needs are not very important to anyone else.

With Mum in prison and Dad spending a lot of time in bed, Isaiah's sister Sasha has started to spend more and more time away from home.  She has made friends with a group of older teenagers and is staying out late drinking in the park with them sometimes.  Since no-one is reinforcing the rules at home, Sasha is no longer doing her homework, and her behaviour at school has become increasingly challenging.

In the absence of his parents, Isaiah looks to Sasha to be a role-model, and is learning from her what is acceptable and what is not.  Over time, Isaiah too might seek a sense of belonging and acceptance in a peer group, and is thus at higher risk of joining a gang.   His sense of himself as unimportant, and of others as being unavailable might increase his risk of developing mental health problems, and using unhealthy coping mechanisms such as substances or self-harm to manage these.  In this way, one major event in Isaiah's childhood may have a domino effect with long-term consequences for his future.

David

David is the son of a doctor and a lawyer.  His parents are both very successful, and very busy.  Their jobs are demanding and they work long hours.  The stress they experience often rolls over into their home life, and they frequently argue.  

With so much going on, David's parents need him to behave well.  Their parenting style is authoritarian and demands unquestioning obedience, whilst offering little warmth. As a result of following such regimented rules and regulations, David is timid and unsure of his own mind.  With little freedom to express himself or experiment, he rarely takes initiative, and feels anxious when he is expected to do things independently at school or with friends.

David's anxiety is also triggered by his parents' arguments. He fears being abandoned by one of his parents, or being forced to choose between them.  Sometimes David worries that he is responsible for his parents' arguments.

Although David has a lovely home and all the books he could ever need, his parents' stress and demands may place him at higher risk of developing mental health problems; particularly anxiety or eating disorders.


Jessie

Jessie's home life is very different from David's, though her mum is also very stressed.  Jessie is one of five children, and her mother Kerry is a single parent.  The absence of a second parent in the home means less 1:1 time with a parent for each child, with associated consequences for their adjustment, self-esteem, and conduct.

Overwhelmed by the competing demands of her children, Kerry struggles to set firm rules.  It isn't really clear to Jessie what is expected of her at any one time and since the rules are inconsistently reinforced she often refuses to do as she is told.

Jessie and Kerry frequently butt heads and argue for extended periods of time.  Eventually, Kerry gives in for the sake of some peace and quiet, and Jessie gets what she wanted.  Over time, Jessie has learned that the best way to get what she wants is through opposition and aggression.  If this pattern is not broken, Jessie's conduct problems may extend outside of the home, and she may find herself in trouble at school or even with the law.  Communicating her needs in such a hostile way might also make it difficult for Jessie to form and maintain healthy relationships, leaving her isolated.  


Ahmed

Whilst Jessie has very little 1:1 time with her mother, Ahmed has lots!  Complications at birth left Ahmed very unwell for a short period at the beginning of his life, and his mother has never forgotten her terror at the prospect of losing him.

Aisha is a doting mother who showers Ahmed with love.  Her parenting style is permissive, and whilst it is very warm, it is lacking in discipline.  As a result, Ahmed is used to getting what he wants, when he wants it, and lacks impulse control.  

Aisha is over-involved in Ahmed's life, and he rarely does anything independently.  Though he is a happy child who enjoys spending time with his family, being away from them for even short periods of time can be quite distressing for him, and he experiences acute separation anxiety, complaining of stomach aches and headaches.  His mother's constant fussing may also teach Ahmed he is vulnerable to harm and illness, and cause him to worry excessively about his own safety.

As Ahmed grows older he may be at increased risk of anxiety disorders, including health anxiety.  


Elaheh

Elaheh's family are refugees who only recently arrived in the UK.  Her parents witnessed atrocities in their home country, and her father has post-traumatic stress disorder (PTSD) which can make him respond in scary, unpredictable ways at times.

None of Elaheh's family speak English fluently, and as such, they are quite isolated.  With no social support in the UK they have no-one to ask for help when things are difficult. Elaheh's limited English is also tricky for her at school where she struggles to follow the lessons and is shy with her peers, with whom she would like to make friends.  Sometimes she feels quite lonely.

Whilst both of Elaheh's parents would like to work, neither have a job as yet.  As such, they are living in a very rundown area with high levels of social disadvantage and crime.  The violence in the local area is particularly scary for Elaheh who remembers dangerous things happening before she came to the UK.

The family's financial situation means Elaheh has no internet access at home, and very few books.  Whilst her mother is happy to take her to the library, Elaheh's opportunities to learn at home are limited as compared to her peers.

Sometimes Elaheh witnesses strangers being racist to her parents, and her parents being scared.  If this persists, she might begin to believe they are less acceptable than other people, or that other people are largely hostile and to be feared.  

Elaheh's early experience of atrocity and fear, her father's mental health problems, and a move to a new country where her family are isolated and socially disadvantaged may place her at increased risk of mental health problems.


Paul

As a small child, Paul was the victim of physical and psychological abuse.  He was removed from the family home and placed in residential care.  

Though the people who work at the care home are nice enough, there are a lot of staff members and they all work shifts. Sometimes, Paul starts to form a good relationship with a staff member or another child only for them to leave soon after.  He therefore struggles to form a secure attachment to anyone, and may present as aloof in interpersonal relationships.  

As a child who has been abused, Paul is at higher risk of developing depression, anxiety, eating disorder, or a personality disorder later in life.  His experience of others as dangerous may lead him to respond with either excessive fear or aggression, or to avoid difficult memories using substances.

Paul is likely to need specialist help to process what has happened to him and to help him develop healthy beliefs about the world, and ways of coping with it.


Summary

Whilst we cannot be sure what causes mental illness, there is significant evidence to suggest life experiences and environment play a part, with those who have had multiple adverse experiences at highest risk.  For those who experience difficult times but do not develop mental illness, there are likely a number of protective factors in play.


Next time we will begin to look at mental illness.

The Bear xXx

Core Childhood Needs (Part 1)

Much like a plant needs water, air, sun, and nutrients in order to grow, a child has core needs which must be met in order for them to thrive.  

These core needs include:

• Safety
• (Age appropriate) Autonomy and self-expression
• Food and shelter
• Empathy and attachment
• Parent-child communication and play
• Clear rules and limits
• Parents who can manage their own frustrations

Nobody is perfect, and these needs are unlikely to be met 100% of the time; however the less they are met, the worse the consequences.  For example, a child whose parents are very busy one week and unable to spend time playing with them may be hurt and upset by this, but if their parents make time for them the following week no lasting damage should result.  However, for a child whose parents never spend any time communicating with them, the effects may be more severe and long-lasting.

A child whose parents never play with or talk to them is unlikely to have sufficient opportunities to learn.  They may find it difficult to understand other minds, to develop language, and to reach the appropriate academic level.  Over time, the child may become acutely aware of their difficulties, with consequences for their self-esteem.  They may struggle at school, find it difficult to express their needs, and have problems making friends.

Children are very dependent on their families for both physical and emotional safety.  Parenting therefore involves teaching children to recognise danger, and minimising potential hazards in their environment.  It is inevitable that children will hurt themselves at some point in their lives (e.g. scrapes and bruises), especially as they explore the world and learn what they can and cannot do.  Parents cannot reasonably watch their children 24-hours-per-day and accidents (including broken bones or cuts needing stitches) may happen.  They may also be hurt emotionally, for example, by an untrustworthy 'friend'.  However, "good enough" parenting seeks to ensure damage is kept to a minimum and a child who has been hurt is protected from further harm.

Although a lack of food and shelter are certainly associated with physical consequences for a child, they may also result in emotional problems.  Being homeless can be an extremely stressful experience for all involved, and stressed, anxious parents may not have the resources to sensitively parent their children.  They may be socially isolated and thus unable to draw on the support of a social network, and may struggle to keep their child safe, warm, and fed.  This experience of adversity may have a lasting impact on a child's development. 

Feeling loved, understood, and validated is key to a child establishing a sense of their value and self-worth, and children with insecure attachment types, or those whose parents do not empathise with them are at greater risk of emotional difficulties.

Accepting a child and empathising with their feelings and experiences does not mean letting them do as they please, however!  Children need clear rules and limits in order to safely explore their environment, and to learn to conduct themselves in a way which is socially acceptable, and which will enable them to function as part of society as they grow up.  Although they may rebel against them, children come to understand that parents set rules because they care about them and the person they will become.

Effective rules and limits are consistent, clear, and developmentally appropriate.  A child who does not understand the rules may become anxious, frustrated, or distressed when they are punished for doing what they thought was expected of them.

Sometimes, if a family is very close, or has very strict rules, there may be limited opportunities for a child to develop a sense of who they are, and confidence in doing things independently.  In order to thrive, they must have the chance to try things for themselves, and to pursue their own interests.  In very close families where children spend all of their time with their parents and siblings, separation anxiety may arise, whereby a child becomes distressed when away from the family, preferring not to socialise with others, and experiencing physical symptoms such as stomach aches when even a temporary separation is anticipated.

Parenting is not an easy job, and when combined with other stressors, parents may struggle.  It is crucial, however, that they manage their own frustrations so as to protect their children from the impact of this.  A parent who does not effectively manage their frustration may be neglectful, emotionally or psychologically abusive, or even physically abusive towards their child, all with lasting consequences for the relationship and the child's well-being.  It is therefore vital that struggling parents seek help, be it from friends and family, their GP, or the appropriate health service.

If core childhood needs are consistently unmet, a child is at increased risk of mental health problems, both now, and later in life.

PROTECTIVE FACTORS

As afore mentioned, nobody is perfect, and children's needs will not always be met perfectly, 100% of the time.  How this impacts a child, and the likelihood of them developing a mental illness when one or more of their needs are not met over a longer period may depend on the balance of protective and risk factors in their lives.

Let's look at an example of a child with lots of protective factors which will minimise the chances of her developing a mental illness.

This is Olivia.  

Olivia has a lot of personal, protective factors. These are things specific to her, rather than her environment.  Olivia appears to be a naturally optimistic child with an easy temperament, and a tendency to recognise her own achievements.  There's no real history of mental illness in her immediate family, and the pregnancy and her birth went well with no complications.  Olivia has never been seriously ill or suffered any severe injuries.  She has learned healthy coping mechanisms (for example, seeking help when distressed) as a result of her secure attachment/s.

Olivia is lucky enough to have two parents who have a loving, harmonious relationship,  Their parenting style is authoritative (warm and child-centred, with a moderate level of control) and allows Olivia to develop a sense of age-appropriate autonomy, which improves her self-confidence.  Her parents both communicate clearly with her, and she understands what is expected of her.

One of Olivia's mums was securely attached as a child.  Her other mother was not, but has worked through her issues and resolved them so she too is able to provide a secure attachment figure to Olivia.  Both parents have healthy coping mechanisms and good self-esteem, and have accurate expectations of Olivia, based on her development and personality.

Olivia's parents are not afraid to seek help and advice from other agencies to ensure Olivia's needs are met.  They engage positively with her teachers and any doctors she comes into contact with, and are committed to helping her in any way they can.

Olivia's little brother, Jasper, is now in day care, just like Olivia was before she started pre-school.  The day care is of a high quality with a low infant to staff ratio, which ensures the staff are able to be responsive to the children's needs.  It is safe, spacious, and well-equipped to meet the needs of little ones.  When Olivia was in day care she had a secure attachment to staff there.

When Olivia later went to pre-school she learned to start to take some responsibility for herself, for example by putting her coat on her peg, or by helping to tidy up after herself.  This helped her develop confidence and age-appropriate independence.

Now Olivia is in primary school.  Her school takes an authoritative approach, expecting high standards but offering a lot of emotional support to the children.  There are clear rules and expectations, and plenty of role models  for good behaviour.  Olivia gets lots of feedback about her work, and is rewarded for her effort and achievements.

Because Olivia has a good relationship with her parents, has learned healthy coping strategies, and knows how to behave appropriately, she has been able to make friends at school.  Olivia feels a sense of belonging and like she is valued by her friends, which boosts her self-esteem.

Olivia's experiences at home and in the wider world are teaching her that she is a valuable individual who people like to spend time with.  She is confident that someone will help if she needs it, and that she is safe and loved.  These messages have boosted her self-esteem, confidence, and independence and reduce (though by no means eliminate) the risk of Olivia developing mental health problems in later life.

In Part 2, we will think about the risk factors which increase the chances of developing mental health problems in childhood or later life.

The Bear xXx

Attachment: The impact of early relationships.

Attachment (Bowlby, 1969) is an instinctive tendency to seek safety in the company of a specific other when feeling anxious or vulnerable.  This is most evident in babies, who are especially in need of the care and protection of a parent or caregiver in order to survive, but is a major component of human experience, and continues to play a part in how we relate to others throughout our lives.

With limited communication skills at birth, babies express their needs through their behaviour and facial expressions.  The infant's needs are both practical (safety, warmth, nourishment, etc) and emotional, and the absence of one or other type of care can have a long-term detrimental impact on their development.  

Over time, the child learns what to expect of their caregiver and their environment, and begins to form an "internal working model"; a sort of blueprint for how things might go, e.g whether they should anticipate frequent threat and/or danger, and how the caregiver might respond should such circumstances arise.  The general pattern of responses from the caregiver also helps the child to develop a sense of themselves and their value, e.g. are they worth the caregiver's time, and are their needs important?

For succinctness, I will refer to the primary caregiver as "mum" from now on; however for many children this might be their father, another relative, or perhaps a foster-parent.  Who the person is is less important than what they do.  Simply meeting the child's physical needs will not necessarily invite an attachment, something effectively demonstrated by Harlow's monkeys.  In Harlow's (rather distressing) study, newborn rhesus monkeys were separated from their mothers and placed in a cage with two 'surrogate mothers', one of which was made of wire, and held food, and one of which offered no food, but was covered in terry cloth, and thus offered tactile comfort.  Harlow found that all of the monkeys preferred the cloth 'mother', and would stray from her only to access food.  If a frightening object was placed in the cage, the babies would flee to the safety of the cloth mother, and cling.  He thus concluded that attachment was about more about comfort than the provision of food.

Attachment in human infants

As an infant's sense of self-worth and safety is contingent on the attachment relationship, the quality of this attachment (Ainsworth, 1971, 1978) is paramount.  

Secure attachment

Here we have Luke and his mum Clare.  Luke is securely attached to Clare, because she is attuned to his needs, and interprets his cues accurately enough.  Since Clare is not psychic she will not know Luke's mind all of the time, and might misunderstand what he wants and needs occasionally!  This is okay, because for the most part she is at least close with her interpretations, and her responses are therefore appropriate.  Luke communicates a need and he feels confident that Clare will meet it.

Because Luke believes help will be available as and when he might need it, he feels able to explore his environment and learn about the world.  From time to time he looks back to check Clare is there, and might bring things to her or draw her attention to something he is looking at to see what she thinks of it.  This kind of social referencing helps Luke learn what he should make of things and what is safe or unsafe.  If at any time he becomes uncertain or scared, he can run back to Clare who will comfort and protect him.  In Luke's internal working model, the world is relatively safe, and people are helpful, responsive, and available.

Avoidant attachment

Kelsey's mum, Sarah, is not sensitive to her needs in the way Clare is to Luke's.  Sometimes Kelsey cries for a very long time before Sarah responds, or she finds that Sarah is overwhelmed by her needs and gets upset or angry herself.

Kelsey doesn't feel very confident that Sarah will be there when she is feeling distressed, or that she will help her feel better if she is.  She tries to be independent of her mum when exploring her environment, and doesn't seek her when she is scared or upset.  Kelsey's internal working model tells her help is often unavailable when she needs it, and her mum may even walk away at times.  She has therefore developed an avoidant attachment style. 


Resistant attachment

Mieko can be quite inconsistent in meeting Hiroto's needs. Though she tries her best she can struggle with depression and is sometimes emotionally or even physically absent when Hiroto needs her.  At other times she tries desperately to make things up to him and can be intrusive in a way which is frightening or confusing for him.

Because Mieko's behaviour is inconsistent, Hiroto is not sure what to expect from her.  At times he can cling and appear very dependent, but he might also reject her efforts when they interact.  Hiroto has been unable to form a sense of security in his relationship with his mother, so it is difficult for her to soothe him when he is distressed.  His attachment type can be described as resistant.

Disorganised attachment

Hope has a problem.  Her mother, Tracey, is terrifying. Sometimes, without any real warning, Tracey completely loses her temper and shouts and screams at Hope.

Hope's instinct (like that of any child) is to seek safety.  But the person who is supposed to protect her is the source of her fear.  There is no real solution available to her.  Sometimes Hope instinctively starts towards her mother for help, but then freezes as she remembers this isn't safe.  At other times she dissociates to remove herself psychologically from a situation she cannot physically escape.  Because Hope has no single effective way of relating to Tracey, her attachment style is disorganised.


Through our relationships with our parents we learn what to expect from our environments and from other people.  A child who learns the world is largely safe and that help is readily available when it is not is far more likely to feel confident in exploring it, and thus to access more opportunities to learn and develop than a child who has found the world to be a dangerous, frightening place in which they are very much alone.  In this way, early attachments begin to establish patterns in the way individuals think, feel, and behave, which may persist across their lifespan in the absence of corrective or reparative experiences.

The Bear xXx

Why does maternal mental health matter?

It is widely accepted that mental health is a product of both biology and environment, and the ways in which the two interact. However, some may be surprised by how early in life this begins to be the case.   Recently,  studies have suggested that our experiences in-utero can begin to shape us neurologically in a way that can have lasting consequences (Talge, Neal, & Glover, 2007).

For the sake of simplicity, let's imagine a mother and baby.

This is Sandra.  Sandra would describe herself as usually being "a bit of a worrier", and is having a stressful time at the moment.  As a result, she is feeling quite anxious and depressed.  She is not alone.  Up to 13% of women experience depressive episodes during pregnancy or within their baby's first year (Swinson, 2005).

Sandra's current mental health is associated with a biochemical imbalance.  Her norepinephrine and cortisol (stress) levels are high, and her dopamine (reward and pleasure) levels are low.  She is feeling sick with anxiety and eating less than usual.

Inside Sandra is her unborn child, Billy.  Billy is exposed to his mother's hormonal imbalance, and his behaviour becomes dysregulated.  His levels of activity, sleep pattern, and movements are not typical of a foetus at this stage of development.  His heart rate is also different, and he responds less to vibratory stimuli.  As a baby of a depressed mother, Billy is at risk of being born prematurely with a low birth weight, with consequences for his later development (Gold & Marcus, 2008).

At birth, Billy's sleep pattern is not predictable or settled.  He is less responsive to the facial expressions of others, and his own facial expressions tend to be sad or angry.

Sandra is still feeling depressed, and varies between being withdrawn (emotionally, and physically), and being overly intrusive (fussing, or interfering with Billy in a way that makes them both feel irritable).  Billy is not sleeping well and Sandra is frustrated and exhausted.  Whenever she looks at Billy he looks miserable, and he seems more comfortable with her when she is sad than when she is happy  (Field, 1998).  

If things continue like this for Sandra and Billy, Sandra may feel more and more defeated and less able to parent Billy, who in turn will feel and show more distress. Intervention is needed.

One recent study found that something as simple as music and massage therapy for both mum and baby can reduce levels of cortisol and norepinephrine in both, leaving mum more receptive to being coached to engage with her baby in a more positive way, with a resultant improvement in their relationship.

New mothers suffering with mental health problems may also need the support of their partner, friends, family, or a healthcare professional, and may even consider taking medication to reduce their symptoms.  Existing mental health problems can be exacerbated by pregnancy and the transition to parenthood, and first episodes can also occur.  The evidence suggests the impact of maternal mental illness on an infant is buffered by the input of a stable caregiver, for example, the child's father.

Sandra and Billy try music and massage, and Sandra confides in a friend and her healthcare visitor about how she feels.  She is supported to try relating to Billy in a different way, and to enjoy her time with him more.  Her partner ensures she has time for herself, during which she naps or pursues a hobby.  Both Billy and Sandra feel less stressed, his sleep settles into a more organised pattern, and he steadily gains weight. Both parties are happier and more connected.  The intervention came at the right time for Sandra and Billy.

But what happens when the relationship between infant and caregiver continues to be difficult?  This is where attachment styles comes into play.

The Bear xXx

We all have mental health.

Mental health is something we all have, just like physical health.  It is something we need to work to maintain, and something which fluctuates in response to what is going on inside our bodies and in our environments.  Much as we can become physically ill, we can become mentally ill, and whilst the episode may resolve with rest and appropriate nurture, we might also need treatment to get well.  

As with physical health, there are some conditions we cannot "cure" and which we simply learn to manage to ensure the best possible quality of life.  Likewise, other episodes of mental illness can be successfully treated and may never recur.

Our education system teaches us little if anything about mental health unless we choose to study specific subjects later in our academic lives.  As such, the general public is historically poorly informed about this subject, and misunderstanding and stigma abound.

When faced with mental illness, we should bear in mind that mental health is part of the human experience, and mental illness is therefore very common, affecting 1 in 4 people each year.

This blog seeks to share some basic information about mental health and psychology in a bite-sized doodle format.  I hope you find it either interesting or helpful.

The Bear xXx