20 Values and Beliefs
Standards of Practice
• Anticipate patients will have spiritual or religious concerns.
• Develop a self-awareness of one’s own spiritual and religious history and perspective.
• Become broadly familiar with the religious worldview of the patient groups for whom they care.
• Work with individual families and children to learn their specific values and beliefs.
• Develop strategic interviewing skills.
• Develop a resource list and network of local consultants.
Much of the focus on spiritual needs of children and families has been related to critical care or end-of-life decisions, and addressing spiritual beliefs may be particularly important for families facing life-threatening illnesses that seem unfair or that have no reasonable explanation. However, these discussions should be part of well-child visits as well as care of children who are acutely or chronically ill. Spirituality is essential to all human life and is a critical part of every child’s healthy development.
Normal Patterns of Behavior
Definitions and Relationship to Behavior
Values have been defined as perceptions held about the worth or importance of a certain thing, person, or idea. Beliefs are attitudes representing whether one holds something to be true. Values and beliefs influence actions, both consciously and unconsciously. They are guides that individuals use as they make decisions. Values and beliefs are learned phenomena, and recognition and acceptance of shared values and beliefs are fundamental to the integrity of the individual, the family, and the social group (see Chapter 3). Although perceptions, attitudes, values, and beliefs are transmitted from one generation to another, they remain open to change and are responsive to social contexts and situations. Values clarification is the process by which one examines behavior in light of values and changing circumstances and asks why a certain action is taken or whether that action is consistent with the values one claims to have. Change in values, beliefs, and behavior can result from the process of values clarification. Faith, according to Fowler and Dell, is the basis for developing beliefs, values, and meaning. Faith “(1) gives coherence and direction to persons’ lives; (2) links them in shared trusts and loyalties with others; (3) grounds their personal stances and communal loyalties in a sense of relatedness to a larger frame of reference; and (4) enables them to face and deal with the challenges of human life and death, relying on that which has the quality of ultimacy in their lives” (Fowler and Dell, 2004, p 17). In this broad conceptualization, faith encompasses a wide range of religious and spiritual expression.
Spirituality has been defined as an awareness of and commitment to a sacred, unifying force that gives meaning to life; the recognition of a nonmaterial higher power that encompasses all of life’s affairs and is mediated through the individual’s relationships to others, to the community, and to the environment (McLeod and Wright, 2008). Although integral to religion, spirituality and religion should not be confused. Religion is the organized expression of values and beliefs through religious activities, rituals, and behaviors. Characteristics of spirituality are listed in Box 20-1.
Development of Moral Integrity or Conscience
Moral and spiritual values are grounded in cultural, social, and family dynamics, and are a part of the human condition (see Chapter 3 for a discussion of the cultural dynamics that shape children’s growth; Chapter 16 presents stages and factors influencing the development of healthy self-perception in children). Moral integrity involves demonstrating an understanding of right and wrong (moral cognition); engaging in reflection on ethical issues of justice and fairness (moral judgment); expressing a sense of responsibility to oneself, others, and the environment (moral sensitivity and emotions); and taking action based on one’s moral values (moral character). Moral virtues include things such as honesty, openness, fairness, self-control, constancy, unity, and dedication. Empathy, a fundamental moral emotion, is the ability to understand the perspective or condition of another and to experience a visceral or emotional reaction to that condition.
The development of moral integrity is an evolutionary process, influenced to a degree by prenatal and genetic factors and continuing into adulthood. It is difficult to say at just what age or stage, with what degree of complexity, and as a result of which variables children will demonstrate moral integrity. Kohlberg (1969) claims that mature moral reasoning does not appear until postconventional stages 5 and 6 (middle to late childhood and adolescence). Fontaine and colleagues (2009) found that the ability to assess the moral value of behaviors and make moral decisions (the Response Evaluation and Decision [RED] process) was rudimentary before middle childhood. Gibbs and associates (1992) argue that mature moral reasoning can appear as early as stages 3 and 4 (early school-age children), as children develop friendships, learn to care about others, and understand rights and responsibilities as essential to societal functioning. Other research suggests that preschool-age children “attempt to construct moral self-consistency,” making efforts to present themselves as “good” in their stories (Gutzwiller-Helfenfinger et al, 2010); that “children’s early conscience, a system that comprises self-regulated conduct and moral emotions…begins to emerge in the toddler years” (Kochanska et al, 2010a, p 1320); and that even very young children demonstrate a moral awareness, though it is primarily experiential rather than reflective (Johansson, 2001). Ongoing research continues to identify specific characteristics, dynamics, and determinants of the process of developing moral integrity.
• Developmental theories: Research on the ways children gain moral integrity has primarily been based in developmental theory. Kohlberg’s notion that moral development proceeds sequentially through phases related to intellectual development and social interactions is probably the most well known of these theories (Kohlberg, 1969), although other developmental perspectives have been offered. Freud, for example, asserted that children develop a conscience through identification with a significant caregiver mediated by the processes of guilt and shame. Piaget claimed that children’s moral development parallels their intellectual development and ability to reason. And social learning theory (e.g., Vygotsky) states that positive role modeling and active social engagement with others teaches moral behavior. These theories are discussed more fully in Chapter 4.
• Attachment, temperament, and reciprocity: Kochanska and colleagues have conducted extensive research on how toddlers and preschool children develop a moral identity, a sense of their “moral self” that guides their future conduct. Secure attachment to the primary caregiver early in life is a critical determinant; this attachment supports an “eager, willing stance” toward the parent, and facilitates internalization of parental rules and standards as well as a sense of empathy with others (Kochanska et al, 2010b). In fact, secure attachment may override genetic effects as children develop the ability to self-regulate (Kochanska et al, 2009). Temperament can affect the child-parent interaction and the development of conscience in two ways: first, the natural temperament of the child may lend itself to internalization of parental values. Children with a naturally fearful temperament tend to more quickly internalize their parents’ message and, as a result, require gentle parenting with “subtle discipline” for healthy development. Second, temperament may be difficult or conflictive between parent and child and require more directive socialization strategies. Children who demonstrate a “fearless” temperament appear to function best when there is a “mutually positive, responsive, binding, and cooperative orientation between parent and child” (i.e., reciprocity) (Kochanska and Aksan, 2006). When the parent is responsive to the child, the child’s cooperation is enhanced; children actively engaged in a supportive, reciprocal relationship with their parent more likely want to do what the parent suggests (Kochanska et al, 2004, 2010a).
• Gender: Some theorists contend that gender plays a significant role in the way children interpret situations and make choices based on moral judgment (Gilligan, 1990), and there is evidence that girls are likely to be more empathic and more highly skilled in emotional judgments than boys (Fumagalli et al, 2010; Malti and Buchmann, 2010). The relationship among genetics, neurobiology, and environment (including socialization) as determinants of this gender difference remains to be explained.
• Neurobiology: Recent research explores the role of neural development on moral behavior (Shirtcliff et al, 2009). Empathy, it appears, is grounded in the brain. Three primary areas of brain circuitry process emotions, memory, and the cognitive functions that integrate behavioral responses: