Session 3

The development of self-esteem

The development of self-esteem depends on parental attitudes, opinions and
behaviour, combined with children’s experience of mastery of the environment. Over
the years children’s feelings about their worth and capabilities become increasingly
internalised and are less dependent upon the immediate responses of those around
them. Self-esteem comes from being loved and wanted, as well as having a sense of
belonging. Thus, self-esteem develops from a reference to other groups, such as
family and friends. From early childhood onwards children are trying to find their
place in groups, through friends, clubs and religious affiliations. As toddlers learn to
walk, explore their environment, play, talk and engage in all kinds of social
interactions they look to their parents and other adults for their reactions. This is all
part of the development of self-esteem. In healthy families parents’ reactions are
affirming and supportive, even when limits have to be set on children’s behavior.
Parents also need to set realistic expectations for their children. Self-esteem
therefore initially develops as a result of interpersonal relationships within the
family, which gradually give precedence to school influences and those within the
larger society
For children of school age, however, self-esteem continues to be affected mainly by the
significant people in their lives, usually parents, teachers and peers.The development of
self-esteem takes place throughout childhood, adolescence and adulthood. It is
considered to begin in infancy with the development of basic trust and from relationships
with empathic others as well as children’s emerging capacity to accomplish tasks
successfully. If a child is to flourish emotionally and socially parents have to be very
attentive to the noises and expressions of babies. It is this sensitivity from familiar
figures that gives children the sense of security required for social and emotional
competence.
A secure attachment is the basis for the capacity to be curious, to learn and to be
sympathetic to the concerns of others. In the first year, the development of the sense of
oneself as separate from the surroundings is the first step in the development of self-
concept and is one of the most important achievements of this period. In the second year
of life the infant’s ability for self-recognition is usually acquired, with the first categories
being age and sex.
The realisation of object permanence and intentional behaviour. enables the
infant to explore and investigate the environment with considerably more
confidence. School-age children extend their self-definition to include their likes
and dislikes and comparisons with other children. In middle childhood children’s
social circles widen so that their self-esteem comes to be influenced by a wider
range of people. The influence of the attitudes and opinions of others depends
upon how highly such people are valued by children. Important too are children’s
successes and failures. Children with disabilities may compare themselves
unfavourably with others so it may be more difficult for them to maintain a sense
of mastery over their environment, which is an important ingredient of self-
esteem. By adolescence the self-image has become part of the personality
structure, and, though it is still subject to modification, this becomes harder as the
years go by. During adolescence there is an extended period of re-evaluation of
one’s self.
The importance of self-esteem
Those who do not value themselves treat themselves and others badly, although
this is usually an unconscious thing. Low self-esteem is often a major factor in
abuse, depression, crime, loneliness, low achievement, mental illness and
unhappiness. People with high self-esteem are usually more creative, happy and
productive. If we accept ourselves unconditionally we can accept praise or
criticism of our actions without it affecting our sense of self-worth. This means
that we can be more realistic about our achievements and our weaknesses
because we are not dependent on the judgement of others. Self-esteem is
therefore an important aspect of learning. If we trust ourselves we can risk
being wrong and make mistakes. Both mental health and learning have
foundations in self-esteem so creating an environment that fosters high self-
esteem can be beneficial for both. Teachers can have a powerful influence on
the self-esteem of young people.
Children with high self-esteem do better academically, see themselves as
in control of their own destiny, have more friends and get along better
with their parents. These These children also tend to come from families
where independent achievements are valued and praised and in which
there is a warm and affectionate relationship with parents who set clearly
defined and enforced boundaries for behaviour. The impact of families on
children’s development and behaviour is therefore crucial and is
considered next.
 The influence of the family on children’s development and
behaviour
Most of children’s development occurs within the family unit. The fact that
children are dependent on others means that their relationships with family
members have a critical role to play in their development and the context of their
family is of major significance in this. Relationships with family members involve
aspects of dependency, caring and trust which are critical in children’s
development. So in order to understand children’s development fully it is
important to gain a thorough understanding of how families function.
Current models suggest thatchildren’s development results from a continual
interplay between a changing individual and a changing family and social
environment. Families are considered both to affect and be affected by their
individual members (Bell, 1968).
This suggests that the behaviour of family members is a function of the family
system of which they are a part. A change in the family system will inevitably
lead to a change in the behaviour of each of the family members. Likewise, a
change in an individual’s behaviour will cause the family system to change.
Also, the functioning of the family system is considered to comprise more
than just a summation of the contributions of its individual members.
Interactions between family members and the organisational structure of
families also play a part in family dynamics (Coopersmith, 1984; Berger,
1984).
Intervention at the level of the family system is therefore likely to
have more impact than intervention aimed at one of its members.
Some writers go even further and claim that treatment of individuals,
without taking their families into account, may result in an increase in
problems experienced by the family as a whole (Chilman et al.,
1988).
Therefore, knowledge of how families function is essential in the understanding of children’s mental health
problems. A useful model for understanding family functioning is provided by the Family Systems Conceptual
Framework developed by Turnbull and Turnbull (1986). This framework focuses on four aspects or components
of family dynamics: family interactions, family resources, family functions, and the family life cycle.These are
discussed briefly below.
Family interactions
This component refers to the relationships that occur within and
between the various subsystems of family members, that is
between husband and wife, parent and child and between the
children. It also refers to extra-familial interactions, such as
those between children and grandparents or those between a
father and his work mates. Interactions within and between all
these sub-systems will have an impact on children’s
development and behaviour. Other aspects of family interaction
that are crucial to children’s development are cohesion,
adaptability and communication. The two extremes of cohesion
are enmeshment and disengagement.
Enmeshed families have weak boundaries between subsystems and therefore
tend to be overprotective of children, whereas disengaged families have rigid
sub-system boundaries and exhibit a lack of care for each other and a neglect
of children. A healthy family functions somewhere between these two
extremes such that children feel cared for but are encouraged to be as
independent as possible. Adaptability refers to the family’s ability to change
in response to events. The more inflexible family members are the more
difficulties the family will face in adapting to living with a child with mental
health problems. Healthy families are also considered to have open
expression of opinions and feelings as opposed to the poor communication
and hidden agendas of unhealthy families.
Family resources
This component refers to the various elements of the family, including characteristics of the
mental health problem, such as type and severity; characteristics of the family, such as size,
cultural background and socio-economic status; and personal characteristics, such as health,
ideologies and coping styles. The impact of these factors on children’s development and the
overall family system is discussed in relation to the microsystem level of the ecological
model .

Family functions

This component refers to the different types of needs for which the family provides, such as
economic needs, physical care, recuperation, socialization, affection, self-definition,
educational and vocational needs. All families differ regarding the priorities they attach to
the various functions and with respect to which family members are assigned to perform
specific roles within the family. However, caring for a child with mental health problems is
likely to affect these family functions in certain ways. For example, the family’s earning
capacity may be reduced because one parent may be unable to work full time owing to the
extra demands placed on the family. Also, the family’s self-definition, or the way members
view themselves and their family, is likely to be changed when a child with a mental health
problem is part of the family.
Family life cycle
This component represents the sequence of developmental changes that affect
families as they progress through various stages. The family has to change and
adapt as children develop. Families are liable to get into difficulties when
faced with transition from one phase of development to the next. The
challenges facing families nowadays are considerable and one of these is
adapting to rearing children as they go through the different stages in their
development, which were described earlier. Parents within families, at the
same time, traverse their own individual life cycles which are considered to
consist of early adulthood, mid-life transition, middle adulthood, late adult
transition and late adulthood (Levinson, 1978). Each family member is
therefore engaged with developmental tasks associated with each of their
children’s development and their own individual life cycle stage. In addition,
families also go through various developmental or life cycle stages (Carter
and McGoldrick, 1980).
Consideration of the family’s developmental stage is essential when considering
children’s mental health problems since many of the difficulties that arise
can be related to problems in family development as well as individual
children’s development. A summary of the developmental stages which
families pass through, and the associated developmental tasks, is
presented in Table 2.1. The first two stages of the family life cycle are
ones in which the adults must address various developmental tasks
necessary to prepare them for successful parenting. The next three stages
involve the birth of children, their upbringing and their launch into
independent adulthood. The final two stages are ones in which parents
readjust to family life with children having left the family home. At each
stage different developmental tasks need to be addressed.
1) Premarital: a) Appropriate choice of marital partner b)
Becoming independent from parents
courtship period

(a) Developing sexual compatibility

2) Early marriage
(b) Balancing autonomy with
no children interdependence

(a) Developing nurturing family

3) Child-bearing years
patterns.
from birth of first child to school entry (b) Adapting to financial reduction.

4 ) Children in school (a) Encouraging independence in children

first child from 6 to 18 years of age

(b) Broadening family interests

5 )Reduction in family size: a) Support leaving of the children

first to last child leaving home (b) Adapt to family functioning with fewer

Children.
(a) Develop enjoyment of marital
6) Dyadic last child leaves home to
relationship.
parental retirement
(b) Develop new relationships across
independent: generations.

7) Advanced age: (a) Adapt to retirement of spouse

Consideration of the family life cycle, family interactions, functions and
resources makes it clear why it is important to see children within the context of
their families and to bear in mind what is happening within the family. Many
things may happen that interrupt normal family functioning, such as separation
or divorce, bereavement and remarriage. All these will have an impact on
children’s behaviour and development. Although at one time most mental health
problems were perceived to be a function of parenting, it is now known that this
differs in extent between different problems and is therefore discussed in the
individual chapters for specific disorders.
 The influence of the social context on children’s development
and behaviour
Relationships with people outside the family, such as peers and teachers,
also help to shape children’s behaviour. Children both shape and are
shaped by their environment and their psychological make-up is almost
always a reflection of these interactions. Children’s development and
behaviour cannot be understood independently of the social context in
which it occurs. The social environment influences the behaviour of
children and families and this occurs at several levels. Children’s
behaviour is strongly influenced by the wider social environment in which
they are living, including the extended family, the education system, the
services available and community attitudes. This is illustrated by the
ecological.
The microsystem
The family of a child with a mental health problem or EBD is considered to
constitute a microsystem with the child, parents and siblings reciprocally
influencing each other. How well this nuclear family functions therefore
depends on variables associated with each of its members. First, features of
the child’s problem itself, such as the type, severity and when it was
diagnosed, will have an influence. Uncertainties about the diagnosis, which
often occur with problems such as autism, can be more difficult for families
to come to terms with than in clear-cut cases. Second, factors associated
with children with EBD and their siblings will have an influence on family
functioning. Whether the child is the first born, last born, a middle child, an
only child or a twin, for example, will have an impact on the family.
Third, factors associated with parents themselves, such as their ages,
personalities, financial status, employment status, educational levels and the
state of their health, and their relationship will have a major influence on
family functioning. A healthy marital relationship, for example, will exert a
positive influence on the family whereas an unhappy marriage is likely to
lead to tension and conflict throughout the family microsystem.

The mesosystem
The family microsystem is influenced by the mesosystem in which it is
embedded. The mesosystem comprises the range of settings in which the
family actively participates, such as the extended family and the community
in which the family lives. The extended family has a key role in determining
how well parents cope with having a child with a mental health problem. If
the child’s grandparents, for example, are understanding and supportive they
can have a significant positive influence on family functioning, whereas, if
they are in conflict with the child’s parents, or have little contact with them,
the family misses out on an important source of support.
Neighbours, work mates, friends and other parents can also have a positive
or negative influence on family functioning. When neighbours are friendly
and allow the child into their homes to play with their own children, for
example, parents can feel pleased that their family is accepted. In contrast,
work mates who talk of their own children’s achievements while being too
embarrassed to talk about a child with mental health problems turn a
possible source of support into one of tension and unhappiness.
Typically, some of the parents’ friends will find it difficult to adjust to them having achild with EBD and will tend to stay
away. The contacts which parents have with professionals,such as social workers, teachers and doctors, can also help to
promote healthy family functioning if they are sensitive, understanding, knowledgeable and supportive. When parents find
such contacts unhelpful or even off-putting this increases stress and leads to reduced feelings of well-being within the
family.
The exosystem
The mesosystem is itself influenced by the ecosystem that consists of social
settings that indirectly affect the family, such as the mass media, the education
system and voluntary agencies. The way children with mental health problems
are portrayed in the newspapers or on television, for example, will have an
impact on the family. When unsympathetic attitudes are perpetuated by the
media this does not help families who have such children to integrate into the
community. Second, the quality and types of health, education and social
welfare services available to parents will have a critical influence on the way
that families cope with their child’s special needs. Families of children with
EBD typically need intensive levels of help in these areas. Third, the
availability of support groups which have been established to help the parents
of children with mental health problems can be a significant factor in
determining how well these families cope
The macrosystem
Finally, there is the macrosystem which refers to the attitudes, beliefs, values and
ideologies inherent in the social institutions of a particular society, which all have an
impact on the way the family of a child with a mental health problem will function.
First of all, the particular culture in which the family is living will have major effects
on the family. If the culture is one which emphasises humanitarian values then there is
much more likely to be positive attitudes towards children with special needs than in
cultures that emphasise materialism. Also, the specific area in which the family lives
will have an impact on many different aspects of family life. For example, it may be
easier to cope with a child with EBD in a rural rather than an urban community. The
beliefs of the particular ethnic or religious group to which the family belongs will also
exert an influence on the way the family reacts to the child’s special needs. In addition,
different people hold different beliefs about unacceptable behaviour and if the child’s
behavior does not fit with the social context, others may consider that behavior as
deviant from normal. Part of the treatment process in some cases may therefore include
normalisation of the behaviour in the eyes of significant others.
The overall economic situation in the society in which the family lives will
affect many aspects of how the family copes with having a child with special
needs and political and economic policies will also be influential. The legal
system too has a role to play in interpreting the law in individual cases of
children with EBD and such rulings are often used to provide guidance for
services, thereby affecting large numbers of similar families.
In conclusion, how children with mental health problems function is influenced
not only by interactions within the microsystem, but also by interactions with
other levels of the entire social system. These all need to be taken into account
by teachers when they are working with these children and their families.
Abnormal behavior:-
Difficulties arise when considering what is abnormal behaviour in childhood.
What adults might perceive as a problem may not be regarded so by children and
what parents regard as abnormal might not be seen as such by professionals, and
vice versa. In addition, failure to develop may be either a temporary problem or
an indication of more serious long-term difficulties. Further, what might be
considered abnormal behaviour may be exhibited, at least to some extent, by
normal children. It is important that children’s stages of development, their
ability to adapt to their surroundings and their methods of coping with
difficulties are taken into account. Three primary considerations need to be taken
into account when identifying abnormal behaviour and mental health disorders.
These are:
• evidence of psychological dysfunction or disability.
• evidence of severe distress or impairment.
• evidence of increased risk of further suffering or harm.
Diagnosis of abnormal behavior:-
In this chapter various explanations of the normal sequence of and conditions for
children’s development have been presented. Implicit in much of the discussion is the
assumption that deviation from the normal sequence of events leads to abnormal devel-
opment, which results in children having mental health problems. However, the point
was made in Chapter 1 that children’s behaviour needs to be seen as spanning a
continuum from naughtiness that is within the normal range of behaviour, through
emotional or behavioural difficulties, to mental health problems and disorders.
The difficulty then is agreeing criteria for deciding whether behaviour is within the
normal range or whether it really is abnormal and therefore warrants attention. There is
no one agreed system for child and adolescent mental health disorders, but the most
widely used guide for making such decisions is what is commonly referred to as DSM-
IV. This is the fourth edition of the Diagnostic and Statistical Manual of Mental
Disorders (AmericanPsychiatric Association, 1994). Within DSM-IV, disorders are
grouped together with their own criteria and children who exhibit a sufficient number
of symptoms receive the diagnosis. Another system, the ICD-10, the tenth edition of
the International Classification of Diseases (World Health Organization, 1992), is used
more widely in Europe and takes a similar approach.
The classification of mental disorder often seems to have negative
connotations, whatever terms are used, but having a classification system
creates order and allows broad treatment approaches to be considered for
similar cases, as well as providing an agreed system that can be used by
different professionals. Being able to classify the problem helps draw on
existing research to understand the child and his or her family and to select
effective treatment approaches. It should be recognised, however, that
many childhood disorders do not fit neatly into categories and there is
often an overlap of symptoms between one disorder and another, despite
the fact that, over the last few decades, criteria have become more and
more refined.
DSM-IV uses what is called multi-axial assessment because rather than put
a problem into a single category, it summarises information in five areas or
axes in order to provide a more complete picture. These are outlined
below.
Axis I: clinical disorders
These include problems such as schizophrenia, school phobia, mood
disorders, anxiety disorders, adjustment disorders and identity disorders.

Axis II: personality disorders and cognitive impairment

These include factors which are not the main concern but which may make
the problem worse, such as paranoid thoughts or limited intellectual
ability.

Axis III: general medical conditions

These include conditions that may influence behaviour, such as a heart
condition or a high level of stress.
Axis IV: psychosocial and environmental problems
These include factors that can add to stress and thereby make problems worse,
such as bereavement and marriage breakdown

Axis V: global functioning

This focuses on how children are functioning in their day-to-day lives. It
considers
Psychological, social and vocational domains. It involves an overall rating on a
scale from one to a hundred of how an individual is functioning, with one
representing persistent danger of serious harm to self or others and a hundred
representing superior functioning in a wide range of activities.
For diagnosis, the number and severity of symptoms are vital, as is also
the requirement for symptoms to lead to significant impairment in a
variety of aspects of the child’s life. To some extent, however, the cut-
off point is arbitrary and if it is too high there may be some children
who need help that do not receive it, whilst if it is too low those that
might to the wise be considered normal will be diagnosed with the
disorder.
DSM-IV has been criticised for taking the view that mental disorder is
inherent within the individual and for not taking into account the contextual
factors involved. Such a view can lead to children and families abdicating
responsibility for behaviour and to limited treatment interventions. More
recently, mental health professionals have taken the view that contextual
factors are important and this is reflected in their treatment methods. Despite
diagnosis, each individual has a unique personality, background and factors
that pertain to their particular situation that need to be taken into account
when considering treatment approaches. They will have their own strengths,
weaknesses and coping strategies and it is important therefore not to rely
solely on diagnosis. The giving of a diagnosis in itself has both positive and
negative aspects. On the one hand, the negative effects of labelling at this
early stage may not be helpful.
Once labelled, children may be
perceived and responded to differently by their parents, their peer group,
teachers and others. The majority of mental health professionals are aware of
these issues and guard against unnecessary and negative labelling, as well as
encouraging other professionals to do the same. On the other hand, diagnosis
makes it easier for the family to cope as the problem becomes more
understandable and acceptable and indirectly this is then likely to have a
positive effect on the child. Improved access to services and a more positive
attitude from others are additional benefits. The benefits of diagnosis
therefore have to be weighed against the negative consequences.