13.2 Developmental Theories

Developmental theories explain stages of human development and associated actions, beliefs, and abilities as children mature. This section will provide an overview of key developmental theories and discuss how nurses can use this information as they work with children at various stages of development.

Freud’s Theory of Psychosexual Development

Sigmund Freud is considered to be one of the fathers of modern psychology. His methods of listening to clients to understand their thinking and providing psychoanalysis continue to influence the field of modern psychology. See Figure 13.1^[1] for an image of Sigmund Freud.

Freud’s theory of psychosexual development helps explain why children’s early experiences can shape their personality and behaviors in adulthood. In this theory, the word “sexual” refers to general feelings of pleasure. Freud’s theory of psychosexual development suggests that there are three parts of the self called the id, ego, and superego that develop in early childhood^[2],[3],[4]:

• Id: The id is the individual’s biological, instinctual, unconscious drive that is involved in seeking pleasure and gratification. A newborn’s behavior is pure id and is driven by innate instincts and reflexes. For example, a newborn cries when hungry and has a sucking reflex to help achieve gratification of eating, but the sucking reflex also soothes them and provides pleasure. As the child matures, the ego differentiates from the id.
• Ego: The ego develops through interaction with others. In contradiction to the id, which operates based on pleasure and immediate gratification, the ego seeks satisfaction via practical strategies. The ego’s goal is to satisfy the id’s demands in a safe and socially acceptable way and has the ability to delay gratification. For example, toddlers may want a cookie that was just served to a playmate, but instead of snatching it away from the playmate, they learn to wait their turn to be served. According to Freudian theory, dysfunctional family dynamics can lead to an individual developing a weak and fragile ego, limiting its ability to contain the desires of the id.
• Superego: The superego develops in children at around three to five years of age and incorporates the morals and values of society. The superego is the voice of one’s conscience that distinguishes between right and wrong and creates feelings of guilt. It also establishes an ideal self and represents career aspirations, how to treat other people, and how to behave as a member of society. For example, children may feel the urge to steal a desired candy bar from a store, but they suppress this urge because they know that stealing is wrong. The ideal self and conscience are shaped largely during childhood by the values and parenting styles of parents and caregivers.

Freud stressed that the first five years of life are crucial to the formation of adult personality. The id’s drive for gratification and pleasure must be controlled by the ego and superego according to society expectations. This control is achieved as an individual matures through five stages of development. Freud organized maturation into five stages, which concentrate on different areas of the body called erogenous zones. Freud’s theory suggests that the ways parents or other caregivers interact with children as they progress through these stages can have a long-lasting impact on their personality and emotional state. To mature into a well-functioning adult, a child must progress sequentially through each of these stages^[5],[6]:

• Oral (Age 0-1 year): An infant obtains its first pleasurable feelings by eating or sucking. The earliest attachment of an infant is to a person who provides gratification to their oral needs by feeding them.
• Anal (1-3 years old): Toilet training is an important milestone during this period. Conflict and frustration can occur when adults impose restrictions on when and where the child can defecate. The child may be reprimanded and feel inadequate if they fail to perform appropriately according to their parents’ or caretakers’ expectations for toilet training.
• Genitalia (3-6 years old): During this stage, a child begins to experience pleasure associated with their genitalia. They become increasingly aware of their bodies and their understanding of anatomical sex differences begins to form. This period includes identification, where children start adopting the characteristics of their same-sex parent.
• Latency (6 years old to puberty): The child focuses on relationships formed with peers in school, sports, and other hobbies. Sexual drives are dormant during this stage, and no further psychosexual development occurs.
• Sexual Feelings (Puberty to adulthood): During this stage, sexual drives emerge as the child’s sexual reproduction system matures. During this stage, adolescents start to begin to explore their sexuality and form intimate relationships.

Some components of Freud’s theory of psychosexual development are now considered controversial in modern psychology. However, many theorists have based their work on Freud’s theory in terms of personality, child development, and psychoanalysis.

Erik Erikson’s Psychosocial Theory

Erik Erikson (1902-1994) expanded on Freud’s theory to develop his theory of psychosocial development. See Figure 13.2^[7] for an image of Erik Erison. The word psychosocial comprises the terms psychological (how we think and feel) and social (how we interact with others). Erikson suggested that a combination of a child’s relationships and society’s expectations motivates their behavior as they develop psychosocially. Erikson believed we make conscious choices in life, and these choices focus on meeting certain social and cultural needs. Humans are motivated, for instance, by the need to feel that the world is a trustworthy place, that we are capable individuals, that we can make a contribution to society, and that we have lived a meaningful life.^[8]

Erikson divided the life span into eight stages, ranging from birth to late adulthood. In each stage, individuals have a major psychosocial task to accomplish or a crisis to overcome. Erikson believed that our personality continues to evolve throughout our life span as we face these tasks and crises. The eight stages of Erikson’s theory of psychosocial development include the following^[9]:

• Trust vs. mistrust (Birth to 1 year of age): Infants must have their basic needs met in a consistent way to feel that the world is a trustworthy place.
• Autonomy vs. shame and doubt (1-2 years of age): Toddlers become mobile and begin to explore their environment. When allowed to do so, they learn basic independence.
• Initiative vs. guilt (3-5 years of age): Preschoolers like to initiate social activities, emphasize doing things “all by myself,” and assert control over their world through play.
• Industry vs. inferiority (6-11 years of age): School-aged children focus on accomplishments and begin making comparisons between themselves and their classmates.
• Identity vs. role confusion (Adolescence): Teenagers try to gain a sense of their identity as they experiment with various roles, beliefs, and ideas.
• Intimacy vs. isolation (Young adulthood): Adults in their 20s and 30s form intimate relationships and long-term commitments.
• Generativity vs. stagnation (Middle adulthood): Adults in their 40s through early 60s focus on being productive at work and at home and are motivated by wanting to feel that they have made a contribution to society.
• Integrity vs. Despair (Late adulthood): Older adults look back on their lives and want to feel they lived a life of integrity according to their personal beliefs.

The first five stages of Erikson’s psychosocial theory are related to children and adolescents and are further discussed in Table 13.2a, along with suggested nursing actions to support children in each stage.

Table 13.2a. Erik Erikson’s Psychosocial Theory Stages of Development and Associated Nursing Actions^[10],[11]

One criticism of Erikson’s theory of psychosocial is that it focuses on the social expectations that are found in certain cultures, but not necessarily found in all cultures. For example, the idea that adolescence is a time of searching for identity might translate well in the middle-class culture of the United States, but it may not be applicable in cultures where independent decision-making is not valued.^[12]

Behaviorism

Developmental theories by Freud and Erikson explained childhood development in terms of what is happening in their minds. Behaviorism theories suggest that learning occurs due to external stimuli.

According to Ivan Pavlov, individuals learn conditioned responses to stimuli, also referred to as classical conditioning. For example, in his research, dogs received food when a bell rang, and this, ultimately, resulted in them salivating at just the sound of the bell. Salivation was a natural response to food, and a conditioned response occurred to the ringing bell. In a similar manner, the smell of freshly baked cookies can trigger feelings of happiness and comfort in humans due to the association of this smell with happy memories at home.^[14]

John B. Watson believed most of our fears and other emotional responses are classically conditioned. He proved this in his research with children and white rats. He first showed an 18-month-old child several objects that included a white rat. At first, the child moved curiously toward each of the objects without fear. However, Watson then paired the sound of a loud, unpleasant noise with the appearance of a white rat, thus stimulating feelings of fear in the child. The child learned from this experience that a white rat was associated with fear, and from then on cried whenever the white rat was shown even without the accompanying noise. Watson suggested that punishment can be used as classical conditioning to elicit desired behavioral responses from children.^[15]

Negative reinforcement refers to removing an undesirable stimulus from the environment to encourage a specific behavior. For example, the loud and unpleasant sound of an alarm clock reinforces the behavior of getting up and turning it off to stop the unpleasant noise.

Punishment refers to using an unpleasant or painful stimulus to discourage a specific behavior, such as the use of spanking with children.

Positive reinforcement refers to using anything an individual is interested in and motivated to obtain to reward desired behavior.

Punishment is less effective than positive reinforcement for several reasons^[16]:

• It doesn’t clearly indicate the desired behavior to the child.
• The child may only behave in the desired way when the parent is present to threaten and/or execute punishment.
• The desired behavior may go unnoticed.

B. F. Skinner suggested that positive reinforcement is more effective than punishment in encouraging desired behavior. For example, parents can offer a reward, such as a movie, after a child cleans their room. The positive reinforcement increases the likelihood of the behavior being repeated in the future.^[17]

Albert Bandura’s social learning theory is a type of behaviorism but suggests that individuals learn by observing and imitating others. Children often learn behaviors by imitating others. For example, a kindergartner may observe their peers on the first day of school and try to mimic their actions to fit in. In a similar way, as adolescents form their identity, they heavily depend on their peers’ behaviors as role models.

Bandura also suggested that people are mutually influenced by their environment. Parents not only influence their child’s behavior through the use of positive reinforcement, but children can also influence their parents. For example, because of the evolving family environment and the mutual influence that parents and children have on each other, a parent may have very different expectations for their first-born child compared to their youngest child. In this way, our environment creates us, and we create our environment.^[18]

See Table 13.2b for application of behaviorism theories to childhood development and associated nursing actions to support a child.

Table 13.2b. Behaviorism and Related Nursing Actions

Jean Piaget’s Theory of Cognitive Development

Jean Piaget was an influential cognitive theorist who was one of the first to recognize that children’s ways of thinking differ from that of adults. He believed that a child’s intellectual skills change over time through maturation, and they interpret the world differently as they mature.^[19] See Figure 13.3^[20] for an image of Jean Piaget.

Piaget divided cognitive development into four stages, including sensorimotor, pre-operational, concrete operational, and formal operational. Each stage is described in Table 13.2c, along with associated nursing actions.

Table 13.2c. Application of Piaget’s Theory of Cognitive Development^[21]

Piaget’s theory has been criticized for underestimating the role that culture and experiences play in a child’s cognitive development. For example, children from different countries and cultures demonstrate considerable variation in what they are able and expected to do at various ages. Culture also shapes how individuals interpret and interact with their environment.^[22]

Kohlberg’s Moral Development

Lawrence Kohlberg built on Piaget’s work in terms of how moral reasoning changes as children develop into adults. Kohlberg’s theory of moral development suggests that individuals develop morals in three major levels called preconventional, conventional, and postconventional morality that are further divided into six stages.^[23],[24] Each stage is described in Table 13.2d.

Table 13.2d. Kohlberg’s Moral Development Stages

One of the classic moral dilemmas that Kohlberg used in his research was a scenario where a wife became very ill and needed medication to survive. However, the pharmacist marked up the price of the medication so high that the sick woman’s husband could not afford it. The husband asked the pharmacist to sell the medication at a reduced price, but he refused. The husband broke into the lab and stole the medication to help save his wife’s life.^[25] Based on the six stages of moral development, individuals may interpret the right or wrongness of this action in the following ways:

• Stage 1: The husband’s action is viewed as wrong only if he will get punished for it.
• Stage 2: The husband’s action is right if it serves his wife’s best interests in getting well.
• Stage 3: The husband’s action is viewed as wrong if his community views it as wrong or viewed as right if his community views it as right.
• Stage 4: The husband’s action is viewed as wrong because rules must be followed to prevent the chaos of breaking and entering businesses.
• Stage 5: The rule of not breaking into a business and stealing something is interpreted to determine if it serves the right purpose in this situation. The husband’s action may be viewed as right if it serves the purpose of saving his wife’s life.
• Stage 6: The entire situation of a person not being able to afford life-saving medication may be interpreted as unjust and the man’s action of robbing the pharmacy to obtain the life-saving medication may be viewed as a right action to compassionately save the wife’s life.