Delores Seel and Marieta Northup for helping with recruiting; Connie. Bamberger, Kathryn Engelbrecht, Janice Simmons, Karin Ritter, Vicki. Ungart, Linda ...
Journal of Consulting and Clinic 2000, Vol. 68, No. 2, 322-330
Copyright 2000 by the American Psychological Association, Inc. 0022-006X;00/$5.00 DOI 10.10377/0022-006X.68.2.322
The Presence of Security Blankets or Mothers (or Both) Affects Distress During Pediatric Examinations Gabriel J. Ybarra and Richard H. Passman
Carl S. L. Eisenberg
University of Wisconsin—Milwaukee
Milwaukee Medical Clinic and Medical College of Wisconsin
Because of parental interference, some pediatricians prefer examining children without parents nearby. Can inanimate, noninterfering attachment agents placate children during medical evaluations? Accompanied through random assignment by their mother, blanket, mother plus blanket, or no supportive agent, 64 blanket-attached or blanket-nonattached 3-year-olds underwent 4 routine medical procedures. Behavioral and physiological measures showed that mothers and blankets (for children attached to them) equally mitigated distress compared with no supportive agents. However, simultaneously presenting 2 attachment agents did not produce additive soothing effects. For comforting blanket-attached children during moderately upsetting medical procedures, blankets can function as appropriate maternal substitutes. Distress evidenced by children with no attachment agent demonstrates the undesirability of conducting medical examinations without supportive agents.
Although generally not as upsetting as physically invasive medical procedures involving inoculations or surgery, routine pediatric examinations can be challenging for both physicians and their patients when the children are unparticipative or become distressed. Young children appear to express greater behavioral disturbance from typical medical or dental examinations than do older children or adults (Jacobsen et al., 1990; Koplik, Lamping, & Reznikoff, 1992; Shaw & Routh, 1982). To circumvent potential
Because of the complex interaction among the characteristics and behaviors of mothers and children within any medical situation (Lumley, Melamed, & Abeles, 1993), research on the influence of maternal presence on children's distress during medical visits has produced conflicting results. Several investigations have found uncooperativeness and agitation to increase when parents are nearby (e.g., Gonzalez et al., 1989; Jay & Elliott, 1984). The mothers' presence, for instance, can initiate calls for help or
difficulties, pediatricians often request thai mothers accompany their young child into the examination room to provide a source of attachment and security.
protection (Gross, Stem, Levin, Dale, & Wojnilower, 1983; Shaw & Routh, 1982). Moreover, mothers may occasionally become disruptive influences themselves by modeling anxiety, acting overprotectively, or preparing the child overzealously for a separation from them (Adams & Passman, 1981, 1983; Jay & Elliott, 1984; Lumley et al., 1993). Vernon, Foley, and Schulman (1967), how-
Gabriel J. Ybarra, Department of Psychology, University of Wiscon-
ever, observed lowered distress during anesthesia when parents were near. O'Laughlin and Ridley-Johnson (1995) argued that it
sin—Milwaukee; Richard H. Passman, Department of Psychology and Early Childhood Research Center, University of Wisconsin—Milwaukee;
was the level of the mothers' involvement, not their presence, that affected distress: Children whose mother passively witnessed im-
Carl S. L. Eisenberg, Department of Pediatrics, Milwaukee Medical Clinic, Milwaukee, Wisconsin, and Department of Pediatrics, Medical College of
munization procedures were less upset than were those whose
Wisconsin. This research is based in part on a thesis submitted by Gabriel J. Ybarra
mother was freely interactive or was absent. O'Laughlin and Ridley-Johnson suggested that a noninteracting mother's presence
to the Department of Psychology, University of Wisconsin—Milwaukee, in partial fulfillment of the requirements for the Master of Science degree under the supervision of Richard H. Passman.
was sufficient to provide reassurance without eliciting protest or attempts for assistance. Providing information prior to stressful health care procedures
Portions of this study were presented at the 105th Annual Convention of the American Psychological Association, Chicago, Illinois, August 1997.
can also be beneficial (Bush, Melamed, Sheras, & Greenbaum, 1986; Melamed & Siegel, 1975; Siegel & Peterson, 1981)—but not always (Jacobsen et al., 1990; Peterson & Toler, 1986). Using coping techniques, such as cognitive—behavioral therapy (Jay,
We are grateful to Cedor Aranou, Kathleen Burchby, Thomas Chatton, John Goet/,, and Kevin Scammel for providing access to their patients; Delores Seel and Marieta Northup for helping with recruiting; Connie Bamberger, Kathryn Engelbrecht, Janice Simmons, Karin Ritter, Vicki Ungart, Linda Wegner, Michelle Weis, and Becky Weyker for their assistance as nurses in conducting the examinations; Tanya DeBoth, Keith Suhr,
Elliott, Katz, & Siegel, 1987), modeling (Bloum et al., 1992; Faust, Olson, & Rodriguez, 1991), or priming of young children's perceived control of a future medical situation (Cortez & Bugental,
Nicole Demming, and Kristi Balge for their help in collecting data; and Raymond Fleming and Robyn Ridley for their review of a earlier version
1995), has largely been successful. These prophylactics, however, do not rule out problems from mothers' overprotectiveness or transmitting their own anxiety (Jay & Elliott, 1984; Lumley et al., 1993; O'Laughlin & Ridley-Johnson, 1995); besides, they are
of this article. Correspondence concerning the article should be addressed to Richard H. Passman, Department of Psychology, University of Wisconsin—Milwaukee, 212 Garland Hall, P.O. Box 413, Milwaukee, Wisconsin 53201.
322
THE PRESENCE OF SECURITY BLANKETS OR MOTHERS
time-consuming and expensive because of the training required for the children, parents, or medical staff. Furthermore, all of these procedures may be carried too far: Research involving brief nonmedical separations from mothers has shown that too much preparation has deleterious effects on children's subsequent adaptation, regardless of whether it is the mothers (Adams & Passman, 1981, 1983) or strangers (Donate-Bartfield & Passman, in press) who overdo the attention. In light of the many difficulties associated with using mothers as sources of comfort during potentially agitating medical examinations, could inanimate attachment objects be used as noninterfering, nonprovocative substitutes'.' Ainsworth (1979) posited that attachment behaviors may be redirected from the mother toward a nonhuman object when the mother is unavailable. Indeed, at the beginning of their 3rd year, 58% of children in the United States demonstrate attachments to soft, nonsocial security objects like blankets (Passman & Halonen, 1979). When such attachments exist, their presence can forestall distress, facilitate positive interactions with unfamiliar people, promote learning, and enable children to maintain distance from their mother (Kameshima, 1990; Passman, 1977, 1987, 1998; Passman & Weisberg, 1975; Tabin, 1992). According to various theoretical interpretations (see Ainsworth, 1979; Bowlby, 1969; Gewirtz, 1972; Passman, 1987, 1998; Passman & Adams, 1982; Passman & Weisberg, 1975; and Rajecki, Lamb, & Obmascher, 1978, for more thorough discussions), attachments to soft, inanimate objects may originate through their proximity and associations with the mother. Positive activities such as feeding, diaper changing, and rocking may thus become associated with the blanket. Not only does the blanket eventually come to stand for the mother, but its own positive characteristics, like softness and warmth, also enhance its desirability. These attachments may be further maintained through the reduction of anxiety or unpleasant arousal in the object's presence, and the object may come to be used as a buffer against overstimulation. The blanket, moreover, appears to be a more salient, valued, and proficient attachment agent than are other inanimate objects: Blanket-attached children more often select their blanket over other choices, and blankets more effectively forestall arousal and emotional upset than do such objects as favorite hard toys (Passman & Adams, 1982; Passman & Weisberg, 1975). Under moderately arousing circumstances, security blankets' adaptive functions are comparable with those of mothers, although blankets' advantageous effects are more easily vitiated in stressful conditions (Passman, 1976, 1987, 1998; Passman & Lautmann, 1982; Passman & Weisberg, 1975). The two types of attachment agents are thus not equals; if obliged to select between them, children overwhelmingly choose their mothers over security blankets (Passman & Adams, 1982). No research, however, has yet examined the combinative effects of these two different kinds of attachment agents for facilitating adaptive behaviors. Because mothers and security blankets are individually comforting, allowing children simultaneous access to both may have a combinative effect and be even more salubrious. Unlike 1st-, 2nd-, and 4th-year medical examinations, which typically include the administration of immunizations, standard 3rd-year pediatric evaluations generally involve little more than the measurement of weight, height, blood pressure, and heart rate in addition to the physician's brief examination of the child. All are noninvasive procedures in which discomfort should be consider-
323
ably lower than during venipuncture (e.g., injections) or surgeries usually examined by other researchers of child distress (e.g., Blount et al., 1992; Gonzalez et al., 1989; Lumley et al., 1993; Melamed & Siegel, 1975; O'Laughlin & Ridley-Johnson, 1995). Furthermore, at 3 years of age, children's blanket attachments are at their height (by a 6:1 ratio over hard toys), with 60% of American children being blanket attached (Passman & Halonen, 1979). Because attachment objects, being inanimate and noninterfering, may be able to provide soothing support by their mere presence, without the necessity for training of coping skills (Blount et al., 1992; Cortez & Bugental, 1995; Jay et al., 1987), security blankets may serve as an efficient means for helping a majority of 3-year-olds cope with commonly experienced aversive situations like medical or dental examinations. The purpose of the present study was to determine whether nonparental attachment objects like blankets could reduce discomfort as effectively as noninteractive mothers within a routine pediatric physical examination. If so, would two attachment agents be better than one? Method Participants Participants were 64 children (mean age = 37.0 months, range = 35-45 months) brought to two suburban, private clinics by their mother for a routine pediatric examination that measured
the 3-year-old's height,
weight, blood pressure, and heart rate. Children and mothers were recruited through their physicians, and, to preserve their confidentiality initially, first contact was made by the clinic's receptionists. During the course of the study, all the mothers of children who were scheduled for their 3-year medical examination at the clinics were tapped for possible participation. Of the 98 mothers contacted by the physicians' receptionists, 74 (76%) agreed to participate. To facilitate the later assignment of children to experimental conditions, mothers gave a tentative, preliminary rating of their child's intensity of attachment to security blankets (Passman, 1976, 1977; Passman & Adams, 1982; Passman & Lautmann, 1982; Passman & Weisberg, 1975). Mothers were instructed not to mention the research to their child and, on the morning of their medical appointment, unobtrusively to place in a brown paper bag their child's blanket (one to which their child was attached or used for sleeping). All the children were in good mental and physical health as predetermined by their physicians. To avoid selecting individuals with prior aversive or atypical experiences associated with medical settings, children who had undergone major medical or dental procedures within the past year were to have been deleted from the study; however, none of the potential participants had such a history. Overall, 10 of the 74 participants were excluded: 3 because their mother did not follow instructions, 2 because of nurses' errors, and 5 because additional family members (such as a sibling) intruded on the experimental procedures and distracted the child. Of the remaining 64 children who participated in the study, 56 were White (88%), 4 were African American (6%), 1 was Hispanic (2%), and 1 was Asian (2%); 33 were female (52%); and 58 were from two-parent households (91%), 3 lived with divorced or not-remarried parents (5%), 2 lived with single, never-married mothers (3%), and 1 lived with divorced and remarried parents (2%). The mothers' mean age was 33.8 years, with 16% having a high school education or less, 33% having some college education, and 52% graduating from college.
Setting and Medical Personnel Medical examinations were conducted in standard pediatric examination rooms located at one of two large suburban clinics that provided a variety of health care services. Of the nine pediatricians who practiced there, six
324
YBARRA, PASSMAN, AND EISENBERG
supplied their routinely scheduled patients for the research. The eight
behavioral expressions greater than subtle expressions. To provide a total
nurses affiliated with the participating pediatricians conducted the medical procedures.
distress score for each of the four procedures, we summed scores within each of the eight distress categories, divided by the number of 15-s intervals that each phase required, and multiplied by the intensity weights,
Procedure Each mother and child who agreed to participate arrived at the clinic 15 rain before the scheduled appointment with the child's blanket hidden in a bag. Experimental procedures were explained, and the mother provided demographic information. She next formally rated the intensity of her child's attachment to a blanket on a 10-point scale ranging from 1 (no attachment) to 10 (extremely strong attachment; Passman, 1976, 1977; Passman & Adams, 1982; Passman & Lautmann, 1982; Passman & Weisberg, 1975). Children receiving blanket-attachment ratings above the median (3.50) for the sample were classified as blanket attached (median rating = 6.50), whereas those below the median were considered blanket nonattached (median rating = 1.00). The makeup of these classifications corresponds closely to those in the previous studies. Following these categorizations, the 32 blanket-attached and 32 blanketnonattached children were randomly and equally assigned to one of four experimental conditions: mother present, blanket present, mother plus blanket present, or no supportive agent present during their examination. Thus, there were eight groups, each containing 8 children. In every condition, the mother entered the pediatric examination room with her child, a female nurse, and a male observer (who positioned himself unobtrusively during the examination). If the mother was to be present, she was instructed to observe the examination in a noninteractive manner. If the blanket was to be present, the mother handed it to her child as they entered the examination room and stated, "Here is your blanket, [name]"; otherwise, it was kept out of view in the bag. If the child was to be accompanied only by the blanket, the mother informed her child that she was leaving but would be right back. She then exited and waited outside the room until the medical examination was completed. If both the mother and the blanket were to be present, she gave the blanket to her child; stated, "Here is your blanket, [name]"; and remained for the examination. If no supportive agent was to be available, the mother left, the blanket stayed hidden in the bag, and the child remained alone with the nurse and observer. Each nurse was masked with regard to the purposes of the study. The experimental procedure did not alter the manner in which the nurse conducted her medical examinations. She executed all of the procedures in the sequence in which they are routinely administered at die clinics: She measured weight, height, blood pressure, and heart rate. If any child cried continuously for 2 min, the physical examination was temporarily halted, the child was placated, and the experiment was discontinued (n = 1).
Measures To assess children's responses to the medical situation, we analyzed both behavioral and physiological measures. Behavioral and physiological re-
as specified by Jay and Elliott: information seeking (1.5), cry (1.5), scream (4.0), physical restraint (4.0), verbal resistance (2.S), seeks emotional support (2.0), verbal pain (2.5), and flail (4.0). According to the instrument's standard use, the resulting weights were then summed across the OSBD's eight categories. In the present study, the mean of the total OSBD scores from the four procedures was used to provide an omnibus measure of behavioral distress. The OSBD's interrater reliabilities within invasive medical situations have ranged from .72 to .99, with interrater agreement over the presence of the distress-related behaviors ranging from .80 to .91 (Elliott, Jay, & Woody, 1987; Jay, Ozolins, & Elliott, 1983). In terms of validity, OSBD scores are moderately associated with children's Trait Anxiety scores (r = .62), self-ratings of experienced pain (r = .62), nurses' overall ratings of distress (r = .69), and parents' overall ratings of children's distress (r = .38; Elliott et al., 1987; Jay et al., 1983). In addition, the OSBD is significantly related to heart rate (r = .32) and systolic blood pressure (SBP; r = .38; Elliott et al., 1987). In previous research, children aged 2 to 12 years undergoing painful medical procedures were found to obtain OSBD scores varying from 2.08 to 4.33 (Jay, Elliott, Woody, & Siegel, 1991; Jay et al., 1983). As a direct estimate of the child's overall distress, both the nurse and the male observer used a 10-point scale ranging from 1 (no distress) to 10 (very distressed) to rate the child's discomfort. (Intermediate examples of 3, 5, and 7 scores would be mild expressions of fear or arousal, protest directed toward the mother, and initial emotional resistance toward the nurse followed by compliance, respectively.) The single rating began with the child's entry into the examination room and ended at the completion of the fourth medical procedure. The observer's and attending nurse's independent ratings of overall distress were highly related (r = .96). As a second reliability assessment of the observers' ratings, 13 randomly selected participants (20%) had an additional observer present during the examination who separately recorded overall ratings of distress (r = .94) and OSBD scores (r = .91). The child's heart rate, assessed by the nurse as part of the pediatric examination, was used as one physiological index of distress. Likewise, the child's SBP, also obtained as part of the examination, was recorded as another physiological measure of distress. Under ordinary conditions of awake rest, 3- to 6-year-olds typically display heart rates ranging from 95 to 129 bpm (beats per minute; e.g., El-Sheikh, Cummings, & Goetsch, 1989; Raine, Venables, & Mednick, 1997), with SBP varying from 82 to 98 mm (e.g., Taras & Sallis, 1992). Because of constraints within the medical procedures, no reliability checks for the nurses' judgments of the physiological measures of heart rate and SBP were possible.
Results
sponses may sometimes bear little correlation (Lumley et al., 1993), and affect regulation theory suggests that young children in particular may be
To deterrnine whether the eight groups of participants differed on
prone to expressing differential behavioral and physiological distress
any of the demographic variables, we compared them with regard to
(Saarni, 1984). A multimodal approach to assessment can therefore help address the reactions of children who appear physiologically but not behaviorally distressed, and vice versa. The Observational Scale of Behavioral Distress (OSBD; Jay & Elliott, 1984), a behavioral measure of children's discomfort, was used to rate participants' distress. While the nurse measured weight, height, blood pressure, and heart rate, a rating was made by an independent observer every 15 s (range = one to four ratings for each of the four medical procedures, depending on their duration). Eight behavioral distress variables were observed with the OSBD: information seeking, cry, scream, physical restraint, verbal resistance, seeks emotional support, verbal pain, and flail (Jay & Elliott, 1984). The OSBD was modified to weigh obvious
children's age, children's birth order, children's gender, mothers' age, fathers' age, marital status, mothers' education, fathers' education, family income, and children's perceived fearrulness of the medical setting. Separate 4 (agent present) X 2 (blanket-attachment level) analyses of variance computed on the continuous variables of children's age, mothers' age, fathers' age, and children's perceived fearrulness of the medical setting revealed no significant group differences (ps > .10). Chi-square analyses of the categorical variables of children's gender, children's birth order, marital status, mothers' education, fathers' education, and family income also showed no significant group differences (ps > .10), except for mothers' educa-
325
THE PRESENCE OF SECURITY BLANKETS OR MOTHERS tion for blanket-attached children, )f(9, N = 32) = 17.13, p < .05, and, marginally, for blanket-nonattached children, )f(9, N = 32) = 16.07, p< .10. We conducted a 4 (agent present: mother, blanket, mother plus blanket, no support) X 2 (blanket-attachment level: attached, nonattached) multivariate analysis of variance (MANOVA) on data from the two physiological measures (heart rate and SBP), the observer's 10-point overall ratings of distress, and the mean OSBD scores. The Agent Present X Blanket-Attachment Level inter-
action,
provided
the
clearest
illustration
of the
significant
MANOVA interaction and is used in Figure 1 to exemplify and display graphically the complex patterns of results. The observer's overall ratings of distress, depicted in Figure. 2, serve to illustrate how the mother-plus-blanket manipulation produced a second, somewhat distinct, set of results. For children accompanied by their blanket, attachment to it was a significant factor: Children attached to a blanket scored lower on the overall ratings of distress than did those not attached to it (M = 1.50
action was significant, Hotelling-Lawley T = 0.54, F(12, 155) = 2.34, p < .01, as was the main effect for agent present,
vs. 5.00; see Tables 1 and 2) and had lower OSBD scores (M = 0.10
Hotelling-Lawley T = 1.16, F(12, 155) = 5.01, p < .001. Uni-
(M = 96.0 vs. 109.5 bpm; see Figure 1). Moreover, for children
vs. 0.91), SBP levels (M = 89.8 vs. 97.3 mm), and heart rates
variate analyses revealed significant Agent Present X Blanket-
attached to their blanket, the blanket soothed distress more than did
Attachment
F(3,
having no agent present. Blanket-attached children with their blanket
Level
interactions
for
the
overall
rating,
56) = 2.99, p < .05, and SBP, F(3, 56) = 2.89, p < .05, with heart
were judged less distressed overall than were blanket-attached chil-
rate being marginally significant, F(3, 56) = 2.59, p < .10. The
dren with no agent available (M = 1.50 vs. 4.50) and had lower
univariate analyses also yielded significant main effects for agent
OSBD scores (M = 0.10 vs. 1.18), SBP levels (M = 89.8 vs. 94.5
present on each of the dependent variables: overall rating, F(3,
mm), and heart rates (M - 96.0 vs. 109.5 bpm).
56) = 3.14, p < .05; OSBD score, F(3,56) = 6.83, p < .01; heart rate, F(3,56) = 5.37,p < .01; and SBP, F(3, 56) = 6.83,p < .01.
by their blanket did not react any differently from blanket-attached
We used post hoc comparisons to examine patterns of results within the interactions. According to the observer's overall ratings of distress, children with just their mother were judged to be significantly less distressed (M = 2.00 on the 10-point scale) than were children
On all of the measures, blanket-attached children accompanied children with their mother present (ps > .10), with the sole exception of children with their mother having marginally lower SBP than did blanket-attached children with their blanket. On the other hand, blanket-nonattached children with their blanket always
with no supportive agent present (M — 4.50; see Tables 1 and 2). The other behavioral measure, the OSBD, yielded a like effect: Children with their mother displayed less distress (M = 0.15 on the 5.5-point
reacted more negatively than did blanket-nonattached children
scale) than did those with no supportive agent (M = 1.31). The two
blanket-nonattached children with no agent present on any measure, except for marginally higher SPB. Blanket-attached and
physiological measures revealed similar patterns: Children with their mother present had lower SBP (M = S3.1 mm) and lower heart rates (M = 96.9 bpm) than did their peers with no agent present (Ms = 93.1 mm and 108.0 bpm, respectively). Except for one condition, mother plus blanket, the experimental manipulations resulted in similar patterns of behavior across the four measures. Heart rate, although yielding a marginally significant univariate Agent Present X Blanket-Attachment Level inter-
with their mother available (see Table 2 and Figure 1). Indeed, the blanket-nonattached children with their blanket did not differ from
blanket-nonattached children did not differ on any of the measures when each group was accompanied by their mother or by no supportive agent. Post hoc comparisons for children simultaneously provided with two different attachment agents (their mother plus their blanket) yielded some unexpected results. Being attached or not attached to the blanket did not matter when the child had both the mother and
Table 1 Behavioral and Physiological Means and Standard Deviations for Blanket-Attached and Blanket-Nonattached Children Accompanied by One of Four Agents Behavioral Agent present and blanket-attachment level Mother Blanket attached Blanket nonattached Mother plus blanket Blanket attached Blanket nonattached Blanket Blanket attached Blanket nonattached No agent Blanket attached Blanket nonattached
OSBD total
Physiological
Overall rating
Heart rate"
M
SBP
SD
M
M
SD
M
SD
0.107 0.182
0.104 0.244
1.38 2.63
0.52 2.33
98.25 95.50
8.10 8.40
83.38 84.00
6.95 7.01
0.459 0.283
0.624 0.240
3.50 2.25
3.46 1.49
96.50 93.50
13.39 13.91
92.79 86.98
8.00 11.70
0.098 0.910
0.094 0.289
1.50 5.00
0.76 2.00
96.00 109.49
10.93 5.21
89.81 97.30
5.29 5.75
1.176 1.441
1.361 1.540
4.50 4.50
2.83 3.38
109.51 106.50
7.69 10.92
94.50 91.75
5.33 6.27
Note. OSBD = Observational Scale of Behavioral Distress; SBP = systolic blood pressure. a Beats per minute.
SD
326
YBARRA, PASSMAN, AND EISENBERG
Table 2 Summary of Comparisons Between Mother, Blanket, Mother Plus Blanket, and No Agent for Blanket-Attached and Blanket-Nonattached Children Overall rating
Heart rate3
SBP
OSBD total
Comparison Mother vs. no agent for all children Blanket for attached vs. nonattached Blanket vs. no agent for attached Blanket vs. mother for attached Blanket vs. mother for nonattached Blanket vs. no agent for nonattached Mother for attached vs. nonattached No agent for attached vs. nonattached Mother plus blanket for attached vs. nonattached Mother plus blanket vs. mother for attached Mother plus blanket vs. blanket for attached Mother plus blanket vs. no agent for attached Mother plus blanket vs. mother for nonattached Mother plus blanket vs. blanket for nonattached Mother plus blanket vs. no agent for nonattached
df
2.89**
30
3.28**
30
4.56**
30
3.62**
30
4.63***
14
7.57***
14
2.72*
14
3.16**
14
2.90*
14
2.41*
14
2.33*
14
2.86*
14
2.07t
14
4.13**
14
1.83t
14
ns 2.19*
ns 14
5.45***
14
ns 4.01**
14
ns
ns
ns
«s
ns
ns
ns
ns
ns
ns
ns
ns
ns
ns
ns
1 .891
22
2.92*
22
ns
ns
ns
ns
ns
ns
ns
ns
ns
2.98*
22 ns
1.99*
22 ns
ns
2.95*
ns ns
2.47*
22 ns
22
2,00t
ns
22 ns
Note. OSBD = Observational Scale of Behavioral Distress: SBP = systolic blood pressure. a Beats per minute. t p < .10 (marginally significant). * p < . 0 5 . * * / > < . 0 1 . ***p < .001.
blanket available: Although their distress was consistently greater on all four measures (see Table 1). blanket-attached children with their mother plus blanket did not differ significantly from blanketnonattached children with both agents present (see Table 2). Blanket-attached children accompanied by their mother plus blanket had higher SBP levels (Af = 92.8 mm) than did children with only their mother (M = 83.7 mm) and tended toward higher OSBD scores (M = 0.46 vs. 0.15), but their overall ratings of distress and heart rates did not differ. That is, adding the blanket to the mother did not serve to reduce arousal beyond levels attained by the mother alone. Rather, SBP and (marginally) OSBD indices increased. Blanket-attached children with only their blanket did not differ on any measure from their counterparts provided both agents. Therefore, having both agents had no discernible effects over the blanket alone for blanket-attached children. Compared with all of the children who had no agent present (M = 108.0 bpm), blanket-attached children with their mother plus blanket had lower heart rates (M = 96.0 bpm) but did not differ on the other three measures. Thus, having only the mother or only the attached blanket consistently produced less distress than having no agent available, except for SBP (see Table 2 and Figure 2). However, the mother-plus-blanket combination was no better than having no agent available, except for heart rate (see Figure 1).
Blanket-nonattached children with their mother plus blanket did not differ significantly from children with only their mother available on any of the measures. The addition of the blanket to the mother had neither positive nor negative influences on blanketnonattached children's adjustment. Blanket-nonattached children with both mother and blanket did not differ from those with no agent (see Table 2 and Figure 1). Nevertheless, on all of the measures, blanket-nonattached children consistently evidenced less distress with both agents than with only their blanket. In general, then, providing children with two different attachment agents rarely decreased but sometimes increased their distress relative to giving them only the blanket or only the mother (see Figure 2). Discussion Although they did not meet clinical levels, each of the measures indicated that the pediatric examinations were both behaviorally and physiologically arousing when no external sources of comfort were available during the 3-year-olds' medical evaluations (e.g., Jacobsen et al., 1990; Shaw & Routh, 1982). Nevertheless, even with nonclinical levels of arousal, the benefits of allowing blanketattached children access to their blanket were substantial (e.g.,
THE PRESENCE OF SECURITY BLANKETS OR MOTHERS
327
-6-Mother (M) -O-Mother plus Blanket (M+B) -*-Blanket (B) -•-No Agent (N)
110.
105
a 100 0)
95
Attached
Nonattached
Blanket Attachment Level Figure 1.
Effects of the agent present and blanket-attachment level on the children's mean heart rate.
OSBD scores of 1.18 with no agent vs. 0.10 with the blanket, 109.5
highly involved (O'Laughlin & Ridley-Johnson, 1995), the mere presence of a minimally interactive mother helped mitigate dis-
vs. 96.0, and SBP levels of 94.5 vs. 89.8). Previous investigations
tress. On every measure, children undergoing the four routine
of attachments to caregivers and objects have shown that children
medical procedures displayed less or equal distress with their
may be soothed by the presence of such supportive agents in a
overall distress ratings of 4.50 vs. 1.50, heart rates of
1990; Melamed & Siegel, 1975; Passman & Lautmann, 1982;
mother nearby than with (a) no agent, (b) the blanket, or (c) both their mother and the blanket present. The inanimate blanket, being less interfering than a noninteracting mother could possibly be,
Passman & Weisberg, 1975). Although mothers have sometimes
functioned equivalently according to all of the behavioral and
been seen as effective calming influences during medical proce-
physiological measures—but only when the children were at-
dures (e.g., O'Laughlin & Ridley-Johnson, 1995; Vernon et al.,
tached to it. With their blanket, they evidenced lower distress than
1967), the present study is the first to demonstrate similar advan-
did blanket-nonattached children given their blanket. Moreover, they fared better than did others with no supportive agent present.
variety of novel and stimulating situations (e.g., Kameshima,
tageous effects of blankets. Furthermore, never before has the supportive nature of security blankets been shown using physiological measures.
Indeed, for the 3-year-olds attached to their blanket, the blanket was as effective as the mother was (except in reducing SBP). Thus,
As seen in previous research showing children to be less upset
blanket-attached children with their blanket were able to transcend
when their mother watched noninterveningly rather than being
the mild stress of the medical procedures, as well as that of their
328
YBARRA, PASSMAN, AND EISENBERG
-Mother
(M)
-Mother plus Blanket -Blanket -No Agent
Attached
(M+B)
(B) (N)
Nonattached
Blanket Attachment Level Figure 2.
Effects of the agent present and blanket-attachment level on the children's mean overall distress.
mother's absence, by using the blanket as a source of support. In
salubrious effects appear to be more predictable than the moth-
contrast, blanket-nonattached children with their blanket reacted no differently from the 3-year-olds with no agent present. To them,
er's—at least at 3 years of age when blanket attachments are most prevalent.
the blanket was functionally meaningless (Passman & Adams,
Because exposure to the mother effectively quelled distress and
1982; Passman & Weisberg, 1975). The distress evidenced by these two groups of children demonstrates the undesirability of
the security blanket was nearly equally as helpful, it might be
conducting even routine medical examinations without some supportive agent nearby.
beneficial. However, in no case was the pairing of the mother plus
Regardless of their profession, practitioners examining a young client often must decide whether to allow a parent to accompany the child (e.g., Marcum, Turner, & Courts, 1995). The parent's presence may soothe and enhance cooperation (O'Laughlin & Ridley-Johnson, 1995; Vernon et al., 1967), but it may also be
expected that the simultaneous access to both would be even more blanket more soothing than was just the mother or security blanket alone; indeed, sometimes the combination was less effective than was their singular influence. With both the mother and blanket present, blanket-attached children's distress was greater relative to having only the mother (i.e., higher SBP levels and marginally
disruptive for a variety of reasons, including parental anxiety and overpreparation (Adams & Passman 1981, 1983; Donate-Bartfield
higher OSBD scores, although heart rate and overall distress did not differ). They also evidenced no less distress than did children with no agent (except for heart rate), whereas those with either
& Passman, in press; Gonzalez et al., 1989; Gross et al., 1983; Jay et al., 1983; Passman & Lautmann, 1982). The security blanket,
their blanket or their mother evidenced significantly less distress according to three of the four measures. Furthermore, blanket-
however, being silent and inanimate, cannot interfere, and its
attached children no longer adapted better than did their blanket-
THE PRESENCE OF SECURITY BLANKETS OR MOTHERS
nonattached peers. The strategy of giving blanket-attached children two different attachment agents thus sometimes backfired. On the other hand, the additional presence of the meaningless blanket for the blanket-nonattached children neither enhanced nor diminished the soothing effects of mother's presence. Systematic replications of the present study are necessary to help understand why the two attachment agents did not provide the predicted combinative effect. Perhaps the conjunction of the mother plus blanket was an instance of overdoing the preparation. Like the negative effects of strangers' extended interactions (Donate-Bartfield & Passman, in press) or mothers' overly lengthy assurances to children regarding upcoming separations from their mother (Adams & Passman, 1981, 1983), excessive information about venipuncture (Jacobsen et al., 1990), and too-active assistance during medical procedures (O'Laughlin & Ridley-Johnson, 1995), the availability of two distinct agents may have constituted overpreparation. Adding a second attachment figure (a double dose of attachment) may have created an unusual atmosphere that sometimes eroded the agents' individual qualities. More may not
329
Adams, R. E., & Passman, R. H. (1983). Explaining to young children about an upcoming separation from their mother: When do I tell them? Journal of Applied Developmental Psychology, 4, 35-42. Ainsworth, M. D. S. (1979). Infant-mother attachment. American Psychologist, 34, 932-937. Blount, R. L., Bachanas, P. J., Powers, S. W., Cotter, M. C, Franklin, A., Chaplin, W., Mayfield, J., Henderson, M., & Blount, S. (1992). Training children to cope and parents to coach them during routine immunizations: Effects on child, parent, and staff behaviors. Behavior Therapy, 23, 689-705. Bowlby, J. (1969). Attachment and loss: Vol. 1. Attachment, New York: Basic Books. Bush, J. P., Melamed, B. G., Sheras, P. L., & Greenbaum, P. E. (1986). Mother-child patterns of coping with anticipatory medical stress. Health Psychology. 5, 137-157. Cortez. V. L., & Bugental, D. B. (1995). Priming of perceived control in young children as a buffer against fear-inducing events. Child Development, 66, 687-696. Donate-Bartfield, E., & Passman, R. H. (in press). Establishing rapport with preschool-age children: Implications for practitioners. Children's Health Care.
always be better. Clinical applications for the present results may extend beyond pediatric evaluations. Because some parents are either unwilling or
Elliott, C. H., Jay, S. M., & Woody, P. (1987). An observation scale for
unable to remain noninteractive during their child's medical (or other) procedures, practitioners cannot rely on parents' consis-
El-Sheikh, M., Cummings, E. M., & Goetsch, V. L. (1989). Coping with
tently assuaging their child's distress. For example, because of
in preschoolers. Developmental Psychology, 25, 490-498. Faust, J., Olson, R., & Rodriguez, H. (1991). Same-day surgery prepara-
dentists' concerns with parental interference, many prohibit parents from the dental operatory (Marcum et al., 1995). Similar considerations exist for psychologists and psychometricians (Passman & Lautmann, 1982). If in doubt regarding parental demeanor, practitioners can consider substituting an inanimate attachment object (for the 60% of children who have one; Passman & Halonen, 1979), which was generally found to be as effective as the mother was in mitigating distress. Unlike other techniques involving cognitive-behavior therapy (Jay et al., 1987) or modeling (Blount et al., 1992; Faust et al., 1991), preparing a child by merely providing a blanket necessitates no additional training or time for staff personnel. As preventative medicine, early and consistent associations of the blanket's soothing qualities with the practitioner may additionally help in obviating medical, dental, or psychologist phobia. Applications of the present findings, like the findings themselves, undoubtedly have limitations. The participants were a suburban, Midwestern, largely White sample of 3-year-olds from two-parent, middle-class households who had no prior adverse medical experiences. Caution must be used in generalizing the results to other populations. Security blankets, moreover, may not be the panaceas they appear to be in this study because they can lose potency under conditions of high arousal (Passman, 1976, 1987, 1998; Passman & Lautmann, 1982; Passman & Weisberg, 1975). The 3rd-year pediatric evaluation examined in the present study was deliberately chosen because it was expected to be nonthreatening. Therefore, the potentially beneficial effects of supplying inanimate attachment objects during invasive medical or dental interventions must still be examined in future research.
References Adams, R. E., & Passman, R. H. (1981). The effects of preparing twoyear-olds for brief separations from their mothers. Child Developmen!. 52, 1068-1070.
measuring children's distress during medical procedures. Journal of Pediatric Psychology, 12, 543-551. adults' angry behavior: Behavioral, physiological, and verbal responses
tion: Reduction of pediatric patient arousal and distress through participant modeling. Journal of Consulting and Clinical Psychology, 59, 475-478. Gewirtz, J. L. (1972). Attachment, dependence, and a distinction in terms of stimulus control. In J. L. Gewirtz (Ed.), Attachment and dependency (pp. 139-177). Washington, DC: Winston. Gonzalez, J. C., Routh, D. K., Saab, P. G., Armstrong, F. D., Shifman, L., Guerra, E., & Fawcert, N. (1989). Effects of parent presence on children's reactions to injections: Behavioral, psychological, and subjective aspects, journal of Pediatric Psychology, 14, 449-462. Gross, A. M., Stern, R. M., Levin, R. B., Dale, J., & Wojnilower, D. A. (1983). The effect of mother-child separation on the behavior of children experiencing a diagnostic medical procedure. Journal of Consulting and Clinical Psychology, 51, 783-785. Jacobsen, P. B., Manne, S. L., Gorfmkle, K., Schorr, O., Rapkin. B., & Redd, W. H. (1990). Analysis of child and parent behavior during painful medical procedures. Health Psychology, 9, 559-576. Jay, S. M., & Elliott, C. H. (1984). Behavioral observation scales for measuring children's distress: The effects of increased methodological rigor. Journal of Consulting and Clinical Psychology, 52, 1106-1107. Jay, S. M., Elliott, C. H., Katz. E., & Siegel, S. E. (1987). Cognitivebehavioral and pharmacologic interventions for children's distress during painful medical procedures. Journal of Consulting and Clinical Psychology, 55, 860-865. Jay, S. M., Elliott, C. H., Woody, P. D., & Siegel, S. (1991). An investigation of cognitive-behavioral therapy combined with oral valium for children undergoing painful medical procedures. Health Psychology, 10, 317-322. Jay, S. M., Ozolins, M., & Elliott, C. H. (1983). Assessment of children's distress during painful medical procedures. Health Psychology, 2, 133147. Kameshima, S. (1990). Transitional object use, mother-infant interaction and temperament. Dissertation Abstracts International, 51, 1014B. Koplik, E. K., Lamping, D. L., & Reznikoff, M. (1992). The relationship of mother-child coping styles and mothers' presence on children's response to dental stress. The Journal of Psychology, 126, 79-92.
330
YBARRA, PASSMAN, AND EISENBERG
Lutnley, M. A., Melamed, B. G., & Abeles, L. A. (1993). Predicting children's presurgical anxiety and subsequent behavior changes. Journal ofPediatric Psychology, 18, 481-497. Marcum, B. K., Turner, C., & Courts, F. J. (1995). Pediatric dentists' attitudes regarding parental presence during dental procedures. Pediatric Dentistry, 17, 432-436.
promoting play and exploration by young children in a novel environment: The effects of social and non-social attachment objects. Developmental Psychology, 11, 170-177. Peterson, L., & Toler, S. M. (1986). An information seeking disposition in child surgery patients. Health Psychology, 5, 343-358. Raine, A., Venables, P. H., & Mednick, S. A. (1997). Low resting heart rate
Melamed, B. G., & Siegel, L. (1975). Reduction of anxiety in children
at age 3 years predisposes to aggression at age 11 years: Evidence from
facing hospitalization and surgery by use of filmed modeling. Journal of
Mauritius Child Health Project. Journal of American Academy of Child
Consulting and Clinical Psychology, 43, 511-521. O'Laughlin, E., & Ridley-Johnson, R. (1995). Maternal presence during children's routine immunizations: The effect of mother as observer in reducing child distress. Children's Health Care, 24, 175-191. Passman, R. H. (1976). Arousal reducing properties of attachment objects: Testing the functional limits of the security blanket relative to the mother. Developmental Psychology, 12, 468-469. Passman, R. H. (1977). Providing attachment objects to facilitate learning and reduce distress: Effects of mothers and security blankets. Developmental Psychology, 13, 25-28. Passman, R. H. (1987). Attachments to inanimate objects: Are children who have security blankets insecure? Journal of Consulting and Clinical Psychology, 55, 825-830. Passman, R. H. (1998). Security objects. In J. Kagan (Ed.), The Gale encyclopedia of childhood and adolescence (pp. 553—555). Detroit, MI: Gale Research. Passman, R. H., & Adams, R. E. (1982). Preferences for mothers and security blankets and their effectiveness as reinforcers for young children's behavior. Journal of Child Psychology and Psychiatry, 23, 223-
and Adolescent Psychiatry, 36, 1457-1464. Rajecki, D. W., Lamb, M. E., & Obmascher, P. (1978). Toward a general theory of infantile attachment: A comparative review of aspects of the social bond. The Behavioral and Brain Sciences, 3, 417-464. Saarni, C. (1984). An observational study of children's attempts to monitor their expressive behavior. Child Development. 55, 1504-1513. Shaw, E. G., & Routh. D. K. (1982). Effect of mothers' presence on children's reaction to aversive procedures. Journal ofPedialrk Psychology, 7, 33-42. Siegel, L. J., & Peterson, L. (1981). Maintenance effects of coping skills and sensory information on young children's response to repeated dental procedures. Behavior Therapy, 12. 530-535. Tabin, J. K. (1992). Transitional objects as objectifiers of the self in toddlers and adolescents. Bulletin of the Menninger Foundation, 56, 209-220. Taras, H. L., & Sallis, J. F. (1992). Blood pressure reactivity in young children: Comparing three stressors. Developmental and Behavioral Pediatrics, 13, 41-45.
236. Passman, R. H., & Halonen, J. S. (1979). A developmental survey of young
Vemon, D. T. A., Foley, J. M., & Schulman, J. L. (1967). Effect of
children's attachments to inanimate objects. Journal of Genetic Psychol-
to two potentially stressful experiences. Journal of Personality and Social Psychology, 5, 162-174.
ogy, 134, 165-178.
mother-child separation and birth-order on young children's responses
Passman, R. H., & Lautmann, L. A. (1982). Fathers', mothers', and security blankets' effects on the responsiveness of young children during projective testing. Journal of Consulting and Clinical Psychology, 50, 310-312. Passman, R. H., & Weisberg, P. (1975). Mothers and blankets as agents for
Received August 3, 1998 Revision received June 7, 1999 Accepted June 15, 1999
