284 Chapter 34
Hospital admission
Since pain and illness activate a child’s drive to stay close to an attachment
figure, being admitted alone to hospital is a particularly stressful sort of
separation experience. Over the course of several days or weeks, children
admitted to hospital, who do not see their parents, go through sequential
phases of protest, despair and detachment. These reactions to separation
are observed most clearly when children are aged between 6 months and
4 years of age, and have been captured poignantly on the films made by
James and Joyce Robertson. Though a single separation due to a hospital
admission is not associated with an increased risk of subsequent psychiatric
disorder, multiple admissions are associated with higher rates of later
problems, mainly disruptive behaviour and delinquency. This increased
risk is far more marked in discordant families, suggesting that many of
the harmful long-term consequences of multiple hospital admissions may
be mediated by an adverse impact on subsequent family relationships.
Though separations are painful for the child, most families are able to
buffer the child’s distress during and after hospital admissions and thereby
minimise the long-term consequences.
Studies carried out at a time when children’s wards generally dis-
couraged parental contact showed that the harmful effects of hospital
admissions could be reduced by increased parental contact. Fortunately,
as awareness of children’s attachment needs has grown, hospital policies
have shifted markedly so that parents are now usually encouraged to stay
with their child for as long as they can, or even to ‘room in’ with them. For
somewhat different reasons, the parents of premature babies on intensive
care units are also encouraged to have frequent contact and interact with
their children. Though the babies are too young to be specifically attached,
increased contact promotes more sensitive and responsive parenting sub-
sequently. Hopefully, by strengthening the parent’s bond to the child, this
will help counteract the raised risk of child abuse after premature birth.
Bereavement
The death of a parent is typically followed by a period of considerable
distress that gradually diminishes over months. Distress may show itself
through emotional symptoms, disruptive behaviour, or a mixture of the
two. The severe depressive withdrawal seen in some adults is less marked
in children. A year later, overt distress is generally much less evident,
although other manifestations, such as lack of interest in school, may
persist. There is certainly not a strong link with depression in subsequent
adult life; whether there is a weak link remains controversial. Where
there are adverse effects on psychosocial outcome in adult life, these are
less associated with the bereavement itself, but arise more from indirect
consequences such as becoming poorer, the surviving parent becoming
depressed, or negative experiences with a step-parent. Traumatic death
witnessed by the child, such as their mother dying during an attack by a
partner, or during war, is associated with considerably higher morbidity.