The impact of skin disease on the motherchild relationship

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For a very young child or baby who is dependent on his or her mother for all his or her care, there is likely to be a reciprocal relationship between the mother and child in terms of both the child's physical and psychological state. For example, if a baby is distressed or fretful because of physical discomfort, this may result in an increased need for care from his or her mother, and this increased demand on the mother's caring resources may make her feel more stressed and she may respond less positively towards her baby. The complex interrelationships between the mother's physical and psychological state, and the babies' physical and psychological state need to be recognised although it has been hard to separate out these different influences in research.

There are several ways in which the mother-child relationship may be affected by a child with a skin condition. For conditions that are present at birth but were not necessarily expected (e.g. birthmarks or epidermolysis bullosa), the physical appearance of the child's skin can be very distressing. The mother's immediate reaction may well be of shock and she is likely to need some time and possibly support to adjust to this. There is considerable variation between mothers on how they respond to a skin condition, depending on factors related to the appearance of the baby, and the mother's own beliefs and attitudes towards physical appearance (Walters, 1997). Whilst for some mothers, a skin condition can undoubtedly make it harder for her to bond with her child, for mothers who bond well it can lead to an increased feeling of protectiveness towards the child arising out of the need to protect a more 'vulnerable' child. In the long term it is important for the mother to be able to find an appropriate balance between caring for her child and allowing the child to develop his or her own resources for dealing with difficult situations arising from a skin condition.

In addition, physical contact between a mother and her baby are very important for the developing relationship. If the baby or child has a skin condition which is painful or uncomfortable this may have an impact on the quality of physical contact between the mother and child (Koblenzer, 1990). In some cases, if the treatment requires a lot of skin contact, for example, applying moisturisers or other topical medication, or if the child requires a lot of physical contact to soothe them and reduce their discomfort, this can result in additional physical contact between mother and child, although the quality of this contact may still be affected if the child is uncomfortable and finds the treatment procedures unpleasant. Bick (1986), described the psychoanalytic treatment of a child with eczema and emphasised the importance of the mother's ability to 'contain' the child's discomfort and drew a parallel between this and the mother's role in managing a young infant's behaviour.

There are few empirical studies which assess the relationship between a mother and child with a skin condition but Solomon and Gagnon (1987) carried out an observational study which compared the relationship between mothers and healthy children with mothers of children with eczema. They found that mothers of children with eczema touched, soothed and stroked their babies as much as mothers of healthy children and that, contrary to their expectations, the babies were not more distressed or difficult to soothe than the babies in the control group. However, they did find that the mothers and babies with eczema had fewer episodes of positive interactions, which would be worth examining in a future study.

Gil et al. (1988) also carried out an observational study and showed an important relationship between scratching behaviour and parental response to scratching. In particular, this study indicated that scratching actually increased during periods when parents asked the children not to scratch, and decreased during times when the child was actively involved in tasks or when parents attended to other appropriate behaviour by the child.

It has often been assumed in the past that difficulties accepting a child with a skin condition may result in a disruption to the attachment of the child to his or her parent. Attachment is the normal process through which a young child forms a close relationship with their caregiver and which is thought to provide the basis for the development of subsequent relationships (Bowlby, 1980). This initial relationship provides the child with a secure base and enables the child to explore the world safely and confidently, and therefore increase independence. If the child feels upset or threatened, this important relationship acts as a secure base to which the child can return and be comforted. In order for the child to develop a secure attachment to the primary caregiver, the mother needs to be able to be sensitive to the child's needs and responsive to them.

There is also very little evidence from empirical studies about the effect on the child's attachment to his or her mother as a result of a skin condition. Daud et al. (1993) tested the hypothesis that young children with eczema are more insecurely attached to their mothers than healthy children using the strange situation procedure (Ainsworth et al., 1978). Contrary to expectation, they found no differences in the security of the child's attachment to his or her mother between the children with eczema and their control group of healthy children. However, these mothers did report difficulties in their relationship with their child in terms of parenting and reported finding it hard to discipline their child effectively and on parent report questionnaires they did identify higher rates of behavioural problems amongst their children compared to healthy children.

The balance of evidence suggests that the presence of a skin condition does not always result in difficulties in the mother-child relationship, but that for some mothers and children difficulties may develop. These mothers will need sympathetic understanding of their difficulties with their baby and it is important that any difficulties are not seen as the mother's 'fault' and she does not feel blamed for these difficulties. Too often the mother is seen as 'rejecting' her child or dismissed as unable to bond with her child, whereas she may need help and understanding to overcome her own fears and anxieties about her child's appearance. Developing the mother's confidence in handling her baby and managing any treatment is very important, as is enabling her to manage other people's reactions confidently. Encouraging direct physical contact can help; for example, by using simple massage techniques (Schachner et al., 1998). Mothers often find it very helpful to talk to others with the same condition, especially if the condition is very rare and is likely not to be well understood by most people (Clarke, 1999).

In addition, any physical treatment plan needs to be clearly demonstrated and time spent with the mother discussing her concerns. Nurse-led clinics have been shown to be very effective in terms of improving the mother's understanding of the child's condition and her use of prescribed treatment (Cork et al., 2003) and this in turn can lead to improved management of the condition and reduced severity of the condition. Several studies have indicated high levels of dissatisfaction about the conventional medical treatment offered to children with skin problems, and this leads to low levels of adherence to prescribed treatments and expensive use of alternative or complementary treatments (Ernst, 2000). Skin care routines are complex and can be time consuming, and it is essential to ensure that enough guidance is given at the time treatment is prescribed if it is to be used effectively.

There is good evidence that caring for a child with a skin condition, such as eczema, places additional demands on mothers and that the common problems of young children (such as sleeping, eating and behaviour problems) can be more difficult to manage with a young child with eczema (Elliott & Luker, 1997; Pauli-Pott et al., 1999). The additional demands of the physical skin care routine can result in high levels of parental stress and have a marked impact on the quality of life for the family (Lawson et al., 1998; Warschburger et al., 2004). Parents of young children with eczema report that they find parenting their child more difficult as a result of the eczema and may need additional help with strategies for managing sleep difficulties or common behavioural problems (Titman, 2003).

It is very important for the child that his or her mother is able to overcome high levels of anxiety and is able to manage the child's skin condition confidently. It is also important for the mother to feel she is able to love and fully accept her child despite any appearance difficulty. If the child's mother is able to become resolved about the child's condition, she is more likely to enable her child to develop a positive attitude towards his or her own skin, and develop a good sense of self-esteem. She will also be in the best position to deal with any anxieties or difficulties her child has in a constructive way.

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