Illness through the eyes of the child: the development of children's understanding of the causes of illness

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Abstract

In this study 158 children, 80 children with diabetes mellitus and 78 healthy classmates, were interviewed about their concept of different types of illness (a cold, diabetes, infection, the most and least serious disease) and illness-related concepts (pain, becoming ill and going to the doctor or hospital). Special attention was given to the relationship between development of thinking and the variables anxiety, locus of control and family- and school functioning. The results show that the ideas of the children about the causes of illness follow a sequence of developmental stages, described as ‘Through the Eyes of the Child’ (TEC) model. Perception seems to be the child's central auto regulative system of cognitive development. The findings suggest that thinking about illness develops relatively independently of other influences. The practical relevance of knowing how children's thinking about illness develops is elaborated in terms of their implications for health education. Immature thoughts of children about illness can be detected and accepted and not dismissed as irrational. With the help of this model, health education of the child can be facilitated.

Introduction

Understanding how children view the processes of causation, prevention and treatment of illness is needed to help health professionals and educators in their work with children. However, most literature describes the emotional reactions of children to hospital admission, focusing on the possibilities to support the child or to prevent emotional problems from emerging [1], [2], [3], [4], [5]. Only a few investigators have attempted to get a better insight into the child's cognitive perspective of illness [3], [6], [7], [8], [9], [10], [11], [12], [13], [14], [15], [16], [17], [18]. What information does a child need to understand its’ illness? How detailed can a doctor be when describing the processes taking place inside the body? What cannot be explained to a child of a certain age?

Most of the contributions in this field are based on the work of Piaget [6], [19] and Werner [7]. Piaget's outline of cognitive development provides a valuable theoretical perspective to conceptualise the child's ability to view illness in a logical way. Werner maintains that perception is the child's central auto regulative system of cognitive action. He asserts that the development of perceptual activity goes through an orderly sequence of stages (global, analytic, synthetic). Bibace and Walsh [10], [20], [21] used the fundaments of Piaget's and Werners work in their theory about the development of children's thoughts about illness. Their work in combination with the theory of perception of Werner [7], [22], [23] formed the starting point of this study.

Piaget suggested [24] that stress (of the burden of illness) might act as an intrusion factor, leading to lower levels of cognitive performance. So it is possible that other variables are also linked to the maturing cognitive development of the child and therefore these influences must also be considered in the development of a child's thoughts about disease. In acknowledging this, the literature presents differing views on the influence of the family on children's thoughts [25], [26]. The mother's role is not clearly interpretable. A child with an over-concerned mother, does not necessarily develop similar or opposite ideas to the mother [8]. The mother's ideas about disease are not a good indicator of the ideas the child will have. However, as the child gets older, the literature suggests that explanations of illness will look more and more like those of the mother [25], [26]. In other words: children's thinking about disease approaches more the adult way of thinking. The literature therefore implies that children learn about illness in relation to their cognitive and social development [27]. Children learn more from what parents do and from how they react than from the verbalisations of the parents. A higher education level of the parents stimulates the development of the child's understanding about illness [28]. The influence of environment is also found in the children's thinking about illness. Children from the higher social class are less dependent and passive in their notion/view of the causes of illness [29]. In one study, children who perceived greater personal control over their health demonstrated a more sophisticated conceptual understanding of disease than did children with a more external orientation. The healthy children scored significantly higher on the illness concepts questions and expressed significantly more internal health locus of control beliefs than did their peers with a chronic physical illness [30]. Therefore, in our study we compared the development of causal thinking about illness in children with a chronic illness with their healthy classmates. We also evaluated the role of possible ‘stress’ factors, these included anxiety, locus of control and family- and school functioning to see what influence they have on the development of causal thinking about illness.

Section snippets

Sampling

The sample consisted of 80 children with diabetes mellitus and 78 healthy classmates (matched on age, sex, intellectual development, area of residence) ranging in age from 6 to 12 years old. Paediatricians from nine (children's) hospitals in the Western part of the Netherlands randomly made the selection of children with diabetes mellitus. All children studied, were functioning at grade level in regular classrooms (Table 1).

The average age of the children with diabetes was 8 years and 9 months

Results

Quantitative analysis shows that the factor structure of the Illness Interview was in line with the preconceived dimensions that explained 67% of the variance. The internal consistency of the interview was satisfactory (Cronbach's alpha 0.80). Overall, only one significant difference is seen in the mean Illness Interview scores of children with diabetes mellitus or healthy classmates. The children with diabetes mellitus showed a significantly better Illness Interview Sum score (Student t-test; p

Discussion and conclusion

The results were consistent with previous studies in that the development of illness concepts in both groups was congruent with Piaget's theory of cognitive development and Bibace and Walsh illness phases [10], [20], [21]. As has been demonstrated in other studies [12], [36], [37], [38] the relationship between children's thinking about illness and other variables (anxiety, locus of control and family- and school functioning) were without statistical significance.

A new finding was that the

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