Effects of a Stressful Event in Early Childhood on Social Development: Interplay of Attachment, Self-Esteem, Temperament, and Emotional Reactions
Simon Fraser University
EDUC 322-C 100 The Social Lives Of School Children
Case Study: E.J. Age: 3 years 4 months Hospitalization and Diagnosis of Epilepsy
E.J. was a normally developing 3 year old achieving all appropriate developmental milestones. On July 20 2015, E.J.’s mother noticed that she was falling down frequently despite there being no obstacles in her way. This progressed rapidly to falling over while sitting and being unable to stand. Later that evening, E.J.’s parents took her to their local Children’s Hospital to be assessed by the doctors there.
A week long hospital stay ensued. E.J. underwent eight blood tests, including three failed attempts to insert the needle after multiple tries. She underwent an EEG test, which required her to be sleep deprived, have electrodes glued to her head, a strobe light flashed in her eyes, and hyperventilation. E.J. also had an MRI test and a spinal fluid tap, both of which required general anaesthetic. Upon coming out of the anaesthetic after the spinal tap procedure, E.J. experienced post-operative delirium. Disoriented, unable to recognize her parents, she screamed for hours and hit herself repeatedly. E.J.’s symptoms worsened until she could not walk or sit unsupported. Worry increased for the doctors and E.J.’s parents. After several days of testing, an EEG test revealed that E.J. was having seizures. A diagnosis of atypical Rolandic epilepsy was made. Anti-seizure medications were prescribed and E.J. was released from the hospital when the medication began to take effect and control the seizures.
E.J.’s reaction to this stressful event will be assessed by examining four key elements of social development: attachment, self-esteem, temperament, and emotional reactions. Specifically, how these factors affect and influence each other and how the negative effects of this major stressor can be mitigated by sensitive caregiving.
Attachment is the most influential factor in this scenario, the lynch-pin that directly affects all the others. Attachment is commonly defined as a positive connection between a child and a special caregiver (Kostelnik, Soderman, Whiren, Rupiper, & Gregory, 2012). The benefits of secure attachment are beyond the scope of this discussion, but suffice to say it has been well documented that secure attachment results in lower cortisol production and higher production of opioids and oxytocin in a child’s brain, (Sunderland, 2016) which helps mitigate the effects of cortisol producing (stressful) situations. E.J. has a strong attachment to both of her parents. They are conscientious about giving E.J. physical affection, speaking warmly to her, and spending time reading, playing, and talking together every day. After her hospitalization, E.J. sought out both parents for more holding, rocking, and reading together. Her parents allowed this increase in attachment behaviors, and they decreased to their previous levels before hospitalization within about six weeks of discharge
Attachment builds self esteem
The consistent, responsive care of attachment leads a child to believe that they are worthy of attention and love (Kostelnik et al., 2012). Knowing that one is valued by others, one’s “worth”, is an important dimension of self-esteem (Kostelnik et al., 2012). Self-esteem encompasses three dimensions – worth, competence, and power over one’s situation (Kostelnik et al., 2012). After the stress of hospitalization, E.J,’s self-esteem was diminished, possibly as a result of having no power over her situation. She was forced to participate in painful, frightening procedures against her will. The medical professionals assured E.J.’s parents that her vigorous protests were an indicator of healthy self-esteem – valuing oneself and asserting one’s wishes – and advised them to offer affection and reassurance (attachment behaviors) to rebuild it.
E.J. cried more than was usual for her after her return home. She asked repeatedly why the doctors and nurses did not stop hurting her even when she asked them to. E.J. expressed confusion and doubt about her abilities to defend herself. She needed to hear repeated explanations of what happened to her at the hospital. Her parents complied and made sure they offered physical affection during these conversations to rebuild E.J.’s self-esteem. These behaviors diminished about four weeks after discharge and E.J. began asserting herself again.
Attachment mitigates temperament
E.J.’s temperament appears to be mostly ‘slow to warm up’ (Kostelnik et al., 2012). She prefers to observe a new situation before engaging. E.J.’s parents have found that she engages in new situations more quickly when one of her preferred caregivers offers warmth and affection while she observes. By using attachment behaviors in new situations, E.J.’s ‘slow to warm up’ temperament is mitigated. Temperament is a genetically based inborn set of characteristics (Kostelnik et al., 2012) so there was no noticeable change in E.J.’s temperament after the stress of hospitalization. However, due to her natural tendency to be slow and cautious in new situations, the onslaught of brand new events that were frightening and painful, taking place in a noisy environment with bright lights at a fast pace, probably caused more stress and higher cortisol levels than what a child with an easy temperament would have experienced.
Attachment regulates emotional reactions
A child who is experiencing an emotionally intense reaction to stress can cope more effectively when a trusted adult helps them to acknowledge their feelings and teaches them coping strategies (Kostelnik et al., 2012). Strategies include encouraging the child to take three deep breaths and talking to themselves i.e. “I can do it” (Kostelnik et al., 2012). Adding warmth and physical affection to these conversation will further strengthen the bond of attachment. High quality, secure attachment can mitigate strong emotional reactions in children when they are reassured and calmed by preferred caregivers.
E.J. appeared to be emotionally fragile after discharge. She cried over minor incidents that did not bother her before hospitalization. She had periods of quiet withdrawal when she said nothing and retreated to her room. E.J.’s parents increased their responsiveness. They had repeated conversations about coping strategies while holding her. Over a period of several weeks, E.J. learned to use coping strategies such as talking to herself and identifying her feelings with words. Her negative emotions diminished slowly and had disappeared by about eight weeks after returning home from the hospital.
Although attachment plays the dominant role in connecting and influencing other factors of social development, there are several other connections between these factors observed in E.J.’s case.
Self-Esteem influences emotional reactions
If a child has a healthy self-esteem, believing that they are worthy, competent, and have control over their lives (Kostelnik et al., 2012) it is likely that they would be willing to express their feelings and use words to describe them. A child with poor self-esteem would be unlikely to volunteer information about their feelings, and might be reluctant to even express them, possibly believing that they are “not that good” or “not good at many things” (Kostelnik et al., 2012). This
was observed in E.J.’s case. In the early days after hospital discharge when her self-esteem was low, E.J. would not talk about her feelings or express them. She would withdraw into silence and retreat to a hiding place. As time passed and her parents stepped up their attachment behaviors, she was able to express her emotions, tell them how she was feeling, and use the coping strategies they taught her.
Temperament affects emotional reactions
Considering that a key component of temperament is emotional regulation (Kostelnik et al. 2012), it is reasonable to expect that a child’s temperament could affect their emotional reactions to stress. As a child with a slow to warm up temperament, E.J. reacts strongly to new situations. This manifested after she came home from the hospital in her new medical fears – taking her anti-seizure medication, doctor’s follow-up appointments and ambulance sirens. Her parents are aware of her temperament, and realized that this could result in a more intense emotional reaction than a child with an easy temperament (Kostelnik et al., 2012). They adjusted their responses accordingly and offered many repetitions of reassurance and comfort.
Serious illness and hospitalization is one of the most severe stressors of a young child’s life (Rennick, Dougherty, Chambers, Stremler, Childerhose, Stack…Hutchinson, 2014). Persistent psychological and behavioral difficulties affect approximately 25% of children following discharge (Rennick et al., 2014). Issues such as decreases in self-esteem and emotional well-being, increases in fearfulness and anxiety, sleep disturbances and increased medical fears are common after hospitalization (Rennick et al., 2014). E.J. displayed all of these common post-discharge symptoms. An effort by her parents to promote attachment ameliorated these symptoms. All were greatly diminished by eight weeks after discharge.
Increasing the attachment bond had an interesting ripple effect across other elements of social development as it interacted with self-esteem, temperament, and emotional reactions. Attachment positively influenced self-esteem, emotional reactions to stress, and mitigated temperament. In addition, self-esteem and temperament affected emotional reactions.
Two years after the trauma of her hospitalization and diagnosis, E.J. is a well-adjusted 5 year old doing well in preschool and entering a mainstream kindergarten class in the fall.
Kostelnik, M., Soderman A., Whiren A., Rupiper M., & Gregory, K. (2012). Guiding children’s social development & learning: Theory and skills. Stamford, United States: Cengage Learning
Rennick, J., Dougherty G., Chambers, C., Stremler, R., Childerhose, J., Stack, D.,… Hutchinson, J. (2014). Children’s psychological and behavioral responses following pediatric intensive care unit hospitalization. Bio Medical Central Pediatrics, 14, 276. doi:10.1186/1471-2431-14-276
Sunderland, M. (2016) The science of parenting. New York, United States: DK Publishing.