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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
University
of
Wisconsin—Milwaukee
Carl
S. L.
Eisenberg
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? Accom-
panied
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 substi-
tutes.
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
med-
ical procedures
involving
inoculations
or
surgery,
routine
pediatric
examinations
can be
challenging
for
both physicians
and
their
patients
when
the
children
are
unparticipative
or
become dis-
tressed. Young children appear
to
express greater behavioral dis-
turbance
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
difficulties,
pediatricians
often
request
thai
mothers accompany
their
young
child into
the
examination room
to
provide
a
source
of
attachment
and
security.
Gabriel
J.
Ybarra, Department
of
Psychology, University
of
Wiscon-
sin—Milwaukee;
Richard
H.
Passman, Department
of
Psychology
and
Early Childhood Research
Center,
University
of
Wisconsin—Milwaukee;
Carl
S. L.
Eisenberg, Department
of
Pediatrics,
Milwaukee Medical Clinic,
Milwaukee, Wisconsin,
and
Department
of
Pediatrics, Medical
College
of
Wisconsin.
This research
is
based
in
part
on a
thesis submitted
by
Gabriel
J.
Ybarra
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.
Portions
of
this
study were presented
at the
105th
Annual Convention
of
the
American Psychological Association,
Chicago,
Illinois, August 1997.
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 assis-
tance
as
nurses
in
conducting
the
examinations; Tanya DeBoth, Keith Suhr,
Nicole
Demming,
and
Kristi
Balge
for
their
help
in
collecting data;
and
Raymond Fleming
and
Robyn Ridley
for
their review
of a
earlier
version
of
this
article.
Correspondence concerning
the
article
should
be
addressed
to
Richard
H.
Passman, Department
of
Psychology, University
of
Wisconsin—Mil-
waukee,
212
Garland Hall, P.O.
Box
413, Milwaukee, Wisconsin
53201.
Because
of the
complex interaction among
the
characteristics
and
behaviors
of
mothers
and
children
within
any
medical situa-
tion
(Lumley,
Melamed,
&
Abeles, 1993), research
on the
influ-
ence
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
protection
(Gross, Stem, Levin, Dale,
&
Wojnilower, 1983;
Shaw
&
Routh, 1982). Moreover, mothers
may
occasionally become
disruptive
influences
themselves
by
modeling anxiety, acting over-
protectively,
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-
ever, observed lowered distress during anesthesia when parents
were
near.
O'Laughlin
and
Ridley-Johnson (1995) argued that
it
was
the
level
of the
mothers' involvement,
not
their presence, that
affected
distress: Children whose
mother
passively
witnessed
im-
munization
procedures were less upset than were those whose
mother
was
freely
interactive
or was
absent.
O'Laughlin
and
Ridley-Johnson
suggested that
a
noninteracting
mother's presence
was
sufficient
to
provide reassurance
without
eliciting
protest
or
attempts
for
assistance.
Providing
information
prior
to
stressful
health
care procedures
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,
Elliott, Katz,
&
Siegel, 1987), modeling
(Bloum
et
al.,
1992; Faust,
Olson,
&
Rodriguez, 1991),
or
priming
of
young
children's
per-
ceived
control
of a
future
medical situation
(Cortez
&
Bugental,
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
322
THE
PRESENCE
OF
SECURITY
BLANKETS
OR
MOTHERS
323
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 non-
medical separations
from
mothers
has
shown
that
too
much
prep-
aration
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 agi-
tating
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,
inani-
mate
objects
may
originate through their
proximity
and
associa-
tions
with
the
mother. Positive activities such
as
feeding, diaper
changing,
and
rocking
may
thus
become associated with
the
blan-
ket.
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 blan-
kets
(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, allow-
ing
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