Sudden occurrence of cranio-cerebral traumatism (CCT) in one of the family parents brings imbalance in the functioning of the family and requires adaptive strategies for this new situation from all the family members. We analyze in this article the coping strategies used by children in the event of such a traumatic occurrence, their dynamics during the research period (6 months) and their value for psychological counseling orientation. Frequency analysis off ers us information about preferred coping strategies by age and gender, while their dynamics off er us important cues about the vulnerabilities and the resources of children that should be taken into account during the psychological intervention.
Generally speaking, medical services are highly specialised, and when one person appeals to such a service as a patient, the medical staff concentrate their eff orts on treating that particular sick person. Only family medicine addresses the person and sees them as part of a system, but even here the intervention is individualised and it does not take into consideration the needs of the family as a whole. Th us, when severe illness situations occur in a family, they have unseen eff ects on the others. Th ese eff ects are not catered for and may manifest themselves only later in time, when they produce negative consequences and other specialised medical services will have to be appealed to.
IMPORTANCE AND NOVELTY
Th e interest in children from families where one of the parents became ill appeared in the specialized publications during the last decades of the past century.
Most of the studies were on parents with cancer. Th e group studies focusing on the risk factors that trigger psychosocial problems used a range of intervening variables. Th e unfavourable prognosis and the illness duration were associated with higher level of stress at kids (Compas et al., 1994; Welch et al., 1996).
Other studies found that the illness, with its objective characteristics, cannot predict the child’s distress. Th ere is another stronger predictor for it: the child’s subjective perception about the severity ofthe illness (Howes, Hoke, Winterbottom, & Delafi eld, 1994; Compas, Worsham, Ey & Howell, 1996).
Various studies showed that the relation between the gender of the child and the gender of the parent can predict the level of child’s distress. If the parent has the same gender as the child, the child exhibits more symptoms (Howes et al., 1994, Compas et al.,1996, Visser et al., 2005). Th erefore, what I consider to be of paramount importance according to the COSIP study results is that attention has to be oriented towards the whole familial system to which the ill person belongs, especially towards its children.
During 2002 – 2005, the international research Project COSIP “Children of Somatically Ill Parents” was implemented in Romania, a multi-centre research project, coordinated by the University of Hamburg, meant to assess the state of health as well as to prevent the psychic disorders of children with parents with chronic somatic aff ections. Eight European university centres were part of this project, among which the Medicine and Pharmaceutical University of Bucharest (UMF Bucureşti), with Mr. Acad. Prof. Dr. Milea Ştefan as coordinator.
Th e study focused on the state of children from families where a parent suddenly becomes ill. Th e study proposes a new approach in the medical assistance of this category, by off ering a medical service which is still inexistent: the counselling of the family found in such a situation.
Its importance is given by the following facts: it addresses, for the fi rst time in our country, a category of children at risk, those from families where a parent suddenly becomes somatically ill; it gathered a signifi cant volume of fi eld data, using various psychological questionnaires and interviews, some of them used in Romania for the fi rst time; the results obtained are valuable for the guidance of the subsequent intervention.
Th is article analyses data obtained from the target group by means of questionnaires. Usually, when a crisis situation appears in family, the adults direct all their eff orts towards the person affected with illness and towards maintaining the family on a reasonable level of functionality. Th e children are supplied with basic needs (food, safety), without anyone aiming their attention at the emotional impact that the traumatic event has upon them. Many adults imagine the children can cope by themselves or that “they are children and cannot realize what happens”.
However, studies made on families where parents suff ered severe or chronic illnesses showed that these situations have a signifi cant impact upon the emotional life of the child. Th erefore, it is important that the supporting parent and the children should be directed towards crisis counselling services. It is a psycho- prophylactic service that reduces the infl uence of present traumatogenic factors in the future thus increasing the children’s quality of life.
Th e objectives aimed at are:
- To identify the used coping strategies, the frequency of their usage and the particularities of this usage according to age and gender.
- Tothrow light upon the dynamics of these strategies, between the initial and the fi nal moments of research.
- To guide the objectives of therapeutic or psycho- prophylactic intervention, according to the data obtained.
This last objective is a preventive one, addressing those who could fall into the afore-mentioned risk category in the future. It addresses those children who, if ignored just after the psycho-traumatic event happened in their family, may later develop psychic or psycho-somatic disorders of clinical or sub-clinical magnitude.
Combined with other supporting or triggering factors, these children may later become clients of various types of medical services, according to the disorders they can develop.
Alternatively, they may exhibit a lower quality of life or a modifi ed course of psycho-emotional development. The psycho-prophylactic secondary intervention aims to off er specialized services in order to reduce the risk of illness and in order to increase the life quality of the population in future.
- The first questions one formulates when they wish to off er such a service are: What are the psychological needs of this person?
- How do I fi nd what these needs are?
Some of these needs, the ones that the person is able to articulate, can be discovered through interviews.
But, if we want to go deeper with our psychological intervention, we need to get into those depths that the person cannot communicate directly.
We hypothesize diff erences between the coping strategies used immediately after fi nding out about the parent’s illness and the coping strategies used after a 6 month monitoring. We hypothesize diff erences between the coping strategies used by younger children (7 – 12 years old) and older children (13 – 17 years old), at the initial moment (T0).
We hypothesize diff erences between the coping strategies used by the boys and by the girls.
Th e research lot consists of 58 families, 58 children with ages between 6 and 17 years. Th e research methods used within the study were the interview and the observation. Th e research instruments used were the semi-standardized and the standardized questionnaires.
Identifying the coping strategies gives us clues about the emotional vulnerable areas of the child that he avoids using various strategies (e.g. distraction, self-criticism, social withdrawal), as well as about the areas where the child has psychic resources in order to cope with the situation, to learn new social roles, to adapt (e.g. emotional regulation, problem solving, cognitive restructuring).
Child and family counselling is based on data obtained from applying these questionnaires. Th e psychotherapeutic intervention has to take into consideration how the individuals answer to the psychotraumatic situation. Both before, as well as during the intervention, one has to assess the preferred answers of children to trauma, namely, their coping strategies.
Th e questionnaires applied to both the supporting (healthy) parents and to the children were: BADOC, BDI, CBCL, YSR, Kid-Cope, F-COPES, FAD. One of the questionnaires applied was KidCope, which measures what coping strategies a child uses when in a diffi cult life situation and how effi cient the child perceives these strategies to be.
What did we seek by applying the statistical analysis?
We wanted to see if these coping strategies diff er according to age, gender and the moment of interview (initially, i.e. a few days after the parent’s illness was revealed, and after six months, respectively).
Th e study was performed upon a sample of 58 cases, of which 23 mothers with illness and 35 fathers with illness. Concerning the gender distribution of the children, the sample contained 28 girls and 30 boys. Th e corresponding KidCope version of the questionnaire was administered to the 58 children, according to their age group. Th e Kidcope questionnaire has two age variants, one for the children between 7 and 12 years old and one for those between 13 and 17 years old. Th e questionnaire contains 10 coping strategies, grouped in 2 categories, a positive approach and a negative, avoidance approach.
Th e 10 coping strategies are (A. Spirito):
- Social Withdrawal
- Cognitive Restructuring
- Blaming Others
- Problem Solving
- Emotional Regulation
- Wishful Th inking
- Social Support
Initially, a few days after fi nding out about the parent’s illness, the younger children, aged 7 to 12, use the following coping strategies:
- High incidence: Emotional Regulation (100%), Wishful Th inking (100%), Resignation (92%) and Problem Solving (83%)
- Medium incidence: Social Support (75%), Cognitive Restructuring (75%), Distraction (67%) (increasing fromT0 to T2), Social Withdrawal (58%) (decreases fromT0 to T2), Blaming Others (42%) (decreasing fromT0 to T2).
- Low incidence: Self-Criticism (17%)
Older children aged 13 to 17, use the following hierarchy of coping strategies:
- High incidence: Emotional Regulation (97%), Wishful Th inking (94%), Distraction (94%), Resignation (91%), Social Support (88%)
- Medium incidence: Cognitive Restructuring (76%), Problem Solving (71%), Social Withdrawal (53%), Blaming Others (53%)
- Low incidence: Self-Criticism (24%)
We observe that there are coping strategies used with similar frequencies by both the younger and the older children (emotional regulation, wishful thinking, resignation), as well as strategies used diff erently by the two age categories. Th e older children, 13 to 17 years old, use “the distraction” more frequently, i.e. they stay less in contact with their feelings and turn their attention towards fi nding ways of reducing their psychic discomfort, blaming others and seeking social support. Younger children are less capable than the older ones to use “distraction” as strategy of reducing the psychic tensions they feel. Instead, they use the “wishful thinking” strategy more often than the older children (up to 100%). Th e younger children think more often about “problem solving” than the older children, who go to others in order to ask for help.
What we also noticed are the high rates of using these various coping strategies. 7 out of 10 strategies have an incidence rate higher that 70%. And the only strategy that appears with a low rate, “self-criticism”, has to do with the type of event lived by the subjects, since we speak of sudden accidents for which the children have no contribution or responsibility.
Th e boys’ rates of coping strategies are the following:
- High incidence: Emotional Regulation (95%), Wishful Th inking (89%), Resignation (89%), Distraction (84%), Social Support (79%).
- Medium incidence: Cognitive Restructuring (68%), Problem Solving (63%), Social Withdrawal (53%), Blaming Others (53%).
- Low incidence: Self-Criticism (16%)
Th e girls’ rates of coping strategies are the following:
- High incidence: Emotional Regulation (100%) Wishful Th inking (100%), Resignation (93%), Distraction (89%), Social Support (89%), Cognitive Restructuring (81%), Problem Solving (81%).
- Medium incidence: Social Withdrawal (56%), Blaming Others (48%)
- Low incidence: Self-Criticism (26%)
We identify the following main diff erence between genders: the boys show lower rates than the girls in all coping strategies. We also observe that two of these adaptive value. Th erefore we can say that the girls have more resources to cope with the situation, while the boys show higher levels of vulnerability. Th e boys use the “resignation” and the “distraction” strategies as often as the girls. However, both of them are passive strategies. Compared with the girls, who are also able to trigger the positive adaptive coping strategies, the boys activate these positive strategies less often.
EVOLUTION IN TIME: T0 – T2
Younger Children, 7 to 12 year olds
Th e coping strategies rates observed in younger children aged 7 to 12, at the initial moment T0 are: Emotional Regulation (100%), Wishful Th inking (100%), Problem Solving (83%), Resignation (92%), Distraction (67%), Social Support (75%), Cognitive Restructuring (75%), Social Withdrawal (58%), Blaming Others (42%), and Self-Criticism (17%). Th e coping strategies rates observed in younger children, 7 to 12, after six months, at the T2 moment, are: Emotional Regulation (100%), Wishful Th inking (100%), Problem Solving (92%), Resignation (83%), Distraction (75%), Social Support (67%), Cognitive Restructuring (58%), Social Withdrawal (42%), Blaming Others (33%), and Self-Criticism (0%). If we compare the initial moment T0 and the moment six months after it, T2, among the younger children, 7 to 12 year olds, we observe the following increases in the coping strategies:
- Problem Solving
At the same time, the following decrease:
- Social Support,
- Cognitive Restructuring,
- Social Withdrawal,
Blaming Others, while two of the remaining coping strategies:
- Emotional Regulation
- Wishful Th inking, remained at the same maximal levels.
We may observe that the variations between the T0 and the T2 moments are not too big, keeping within an interval of maximum 15 percentage points. When taking into account the initial high rates, we can conclude that the coping strategies are still being often used six months after the traumatic incidents.
Older Children, 13 to 17 year old
Th e coping strategies rates observed in older children, 13 to 17, at the initial moment T0, are: Resignation (91%), Social Support (88%), Cognitive Regulation (97%), Distraction (94%), Wishful Th inking (94%), Cognitive Restructuring (76%), Problem Solving (71%), Social Withdrawal (53%), Blaming Others (53%), and Self-Criticism (24%).
Th e coping strategies rates observed in older children, 13 to 17, after six months, at the T2 moment, are: Resignation (97%), Social Support (94%), Emotional Regulation (91%), Distraction (88%), Wishful Th inking (98%), Cognitive Restructuring (82%), strategies, “emotional regulation” and “wishful thinking”, were used by all the girls in the sample. Th e least used strategy was “self-criticism”. Th e girls showed higher rates than the boys, because of the above-mentioned reasons. Bigger diff erences (more than 10 percentage points) were found for the following strategies:
girls seek social support more often than the boys; they also have a better established tendency to restructure the situation cognitively and to seek to solve the problems. Th ese are all positive stra-tegies, with a higher Problem Solving (76%), Social Withdrawal (62%), Blaming Others (53%), and Self-Criticism (18%). We identify the following evolutions in 13 to 17 year old children, between the momentsT0 and T2:
Increased rate of incidence:
- Social Withdrawal
- Cognitive Restructuring
- Problem Solving
Decreased rate of incidence:
- Emotional Regulation
- Wishful Th inking
As in the case of younger children, the percental diff erences are not very big. We can therefore conclude that, in the case of older children, the coping strategies used at theT0 moment are still being often used six months after the traumatic incidents, at the T2 moment.
What happened with the boys, younger as well as older ones, between theT0 and the T2 moments? Th e answer is: not too much. Th e coping strategies mainly remained at constant levels of incidence. We did not record big diff erences between the two moments, as in the case of the evolution of the age groups. Bigger diff erences were observed in boys only when split according to age groups. Th e only evolutions that can be assessed are in the case of the Social Withdrawal strategy (increased incidence) and of the Self-Criticism (decreased incidence).
What happened with the girls, irrespective of their age group, between theT0 and the T2 moments? We can observe increased levels of incidence for:
- Problem Solving and decreased levels for
- Emotional Regulation
- Social Withdrawal.
Th e highest diff erence is found in the case of the “Problem Solving” coping strategy. Th is one is used in much higher rates at the T2 moment: increase from 63% to 79%. Also, “Resignation” installed with all the girls within the sample (up from 89%). Th ey do not need to get “Distracted”, as much as at the T0 moment (decreasing from 84% to 74%).
THE ADAPTIVE VALUE OF THESE COPING STRATEGIES
At the respective moment, the various coping strategies used have a clear adaptive value for the person in question.
By them, the child fi nds a way of reducing the emotional tension produced by the traumatic situation.
However, if we address adaptation in the larger context, taking into account the social values, the norms according to which we assess if certain behaviour has adaptive value or not, we can conclude that the coping strategies do not present long-term adaptive value. For instance, using the “wishful thinking” strategy (and, according to data obtained from our sample, its incidence is very high) it helps the child momentarily to pull out from the real situation that is a burden too diffi cult to carry and to let his or her thoughts wander off to scenarios where reality is the way the child wishes it to be.
However, if used in excess, this strategy would make the child lose contact with the harsh reality he or she has to cope with. Th erefore, this strategy has to be followed by another one, oriented towards confronting the objective requirements of the situation and thus towards adapting to the situation.
- When, in a family, a parent becomes suddenly ill, the child resorts to a mix of various coping strategies, both positive as well as negative. It this case, the child goes through various phases, from moments when s/he seeks to express emotionally towards other persons and looks for solutions to problems, to moments when s/he abandons herself or himself to imaginations and builds desirable scenarios that help to momentarily distance herself or himself from the distressing event.
- We presented the above-mentioned general data in order to get an idea about what we would expect in a new situation. We underline again the need for receiving and assessing any new situation with an open mind, oriented towards what happens particularly in this kind of situation. From such a perspective we should start understanding the way the child relates and interacts with the signifi cant others: those close in the family, the neighbours, friends, colleagues and other adults. Th e coping strategy activated at a particular moment can off er us the key to understand the present reactions and behaviours, as well as their various orientations in future.
- Although after this study we have statistically meaningful data that off er us an encompassing image of the population studied, information concerning trends and particularities according to age or gender, in the case of intervention targeted upon a particular case we however need particular data that refl ects the concrete situation of that moment. Th at is because the psychological process of intervention has to be oriented starting from that particular reality and not from general statistical data previously obtained or from our presuppositions, our own projections transferred to that particular case. Th e argument is that each new case represents a specifi c reality, with personalized needs of intervention.
- Those that come fi rst in contact with the ill persons and with their families should explain and accentuate the following ideas:
- The need to contact specialised services.
- That is a consequence of the results of the study, where the rejection levels were very high, 64% of the total of initial contacts. Such a rate guides the eff ort towards informing the families about the role of such a specialised service.
- The event has an impact in the emotional life of the child as well.
- This impact whose intensity we do not know yet can have medium or long range consequences.
- The personal reactivity is very diverse. Th e above-mentioned medium or long term consequences can be identifi ed only after a specialised evaluation and after monitoring the evolution of the child over a longer period.
- Brown, L. K., Spirito, A., Reynolds, L.A.& Hemstreet, A. (1992). Adolescent coping behaviour when confronted with a friend with AIDS. Journal of Adolescence, 15, 467-477.
- McCubbin Hi., Joy CB, Cauble şi alţii. Family stress and coping: a decade review. Journal of Family 42: 855-871, 1980
- Milea, S. Profi laxia primară a tulburărilor psihice la copil şi adolescent, vol. I-II, 2006-2009.
- Ratjen, Eva-M. B., Client-centered therapy: an European perspective , Sage Publications, Londra, 2001
- Riedesser, P., Fisher, G. Tratat de psihotraumatologie, Editura Trei, Bucureşti, 2005
- Spirito, A., L.J., Gil, K., &Tyc, V. (1995), Coping with everyday and disease-related stressors by chronically ill children and adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 34, 283-290.
- Spirito, A., Stark, L.J., & Williams, C. (1988). Development of a brief checklist to assess coping in pediatric patients. Journal of Pediatric Psychology, 13, 555-574.
- Shapiro, J. Family reactions and coping strategies in response to the physically ill or handicaped child: A review. Soc Sci Med 17(14):913, 1983.
- Spirito, A., Francis, G., Overholser, J., & Frank, N. Coping, depression and adolescent suicide attempts. Journal of Clinical Child Psychology, 1996, 25, 147-155.
- Wegmann, J.A.: Instruments that measure coping. Oncological Nurses Forum 11 (4): 119-120, 1984.