Religious faith doesn't come up regularly in examining room conversation. Yet patients--and parents--beliefs can sometimes affect medical care.
Religious faith doesn't come up regularly in examining room conversation. Yet patients' and parents' beliefs can appreciably influence their attitudes about health and illnessand sometimes affect medical care.
As pediatricians, we do not generally ask patients and parents about religious observance or connection to a faith tradition. Yet religious belief can greatly influence the way a child (or parent) approaches health and illness. This article focuses on the stages of faith development in children and adolescents and on their relevance to health and disease. The descriptions of the stages are based on the work of James Fowler, who, in turn, based his hypotheses on the work of Erik Erikson and Jean Piaget. Fowler's stages are applicable to Western (usually Christian) faith traditions.
To begin with, a few definitions are in order. For the purposes of this discussion, "God" refers to the divine, that which human beings deem the ultimate. For Christians, Jews, and Muslims, the three most common faith traditions in the United States, God is a being who created, and can enter into relationship with, each human being. In other faith traditions, "God" may be thought of as the "Ultimate," "Prime Mover," or "First Principle"in other words, not a being. "Faith" is the belief in something larger than oneself, even though that something cannot be apprehended with the senses or the scientific method. "Hope" is the confidence that certain things will happen and is grounded in faith. "Love" is the unselfish regard for another, placing that person's needs or desires above one's own.
"Religion" refers to the formal, structured way in which people of similar beliefs approach or gather together to worship God as they understand God. "Spiritual" refers to each person's relationship to God as that person understands God and to the relationship with all persons and, indeed, all creation that results from the primary relationship to God. One's relationship to the divine can be marked by belief, skepticism, or denial, any of which can be expected to affect one's overall relationship with the world.
Fowler, who holds doctoral degrees in psychology and ministry, explored stages of faith across the human lifespan, just as Erikson explored psychological stages throughout life. In Stages of Faith, published in the mid-1970s, Fowler synthesized Erikson's cognitive theories and Piaget's theories about how children learn to describe the development of faith from infancy through advanced age.1 He hypothesized the following stages of faith development from infancy through adolescence:
02 years: Universal faith (based on Erikson's trust vs. mistrust). In their helplessness, infants and young children must depend on older children or adults to do everything for them. Erikson noted that if young children are treated in a trustworthy fashion, they will learn to trust; if their needs are not met, if they are ridiculed or abused, they will lack trust.
Similarly, Fowler believes that young children whose needs are met in a reliable way develop faith in those around them. Extending this to the divine, he proposes that children learn about God through the words and, more important, the actions of those closest to them. Both words and actions play a major role in the young child's nascent ideas about God. If trustworthy people speak about God with reverence, even young children associate the word/sound "God" with something special. More important, if adults and older children act as if this God is special, young children assimilate certain behaviors associated with the divine (folding hands in prayer, bowing one's head). On the other hand, young children who see that trustworthy adults lack a high regard for God (using the name of God in anger when swearing, for example) will likely imitate such behavior and develop a careless attitude toward God.
Children who perceive a high opinion of God in adults who are not trustworthy may be confused as to what this God is all about or how much on the side of young children God might be. This is especially true for a child who is abused by a significant adult who tells the child that God is on the abuser's side or that God doesn't like children.
Preschool years: Intuitive- projective faith (based, in part, on Piaget's preoperational stage of learning). Piaget noted that preschoolers have a vivid imagination; for them, anything is possible. Their ideas about the world are not "logical" in the adult sense of logic. The way that they see a situation is not necessarily wrong, but it may be vastly different from the way older children and adults see it. Young children also may have hunches or intuitions about people, places, things, or situations that are (sometimes uncannily) accurate, even though they were not formally taught such insights.
Because of their limited repertoire of life experiences, preschoolers often project onto novel people, things, or situations their understanding of previously encountered people, things, or events that they perceive as similar. Such projections can be positive, negative, or neutral. (A preschooler who has never seen a fox, for example, spies one in the yard and says, "It's a red dog!" because of the shape of its ears, tail, and body, and its size. This is a neutral projection.)
Fowler, using Piaget's observations, notes that young children have age-specific insights and intuitions about events, people, things, and even God. Moreover, they often project to help them make sense of their worldand God as well. Young children project onto God the attributes of their own parents (or other significant adults). If a child's mother is furious when he fails to eat his vegetables, for example, he may believe that God is equally furious, even if the mother did not say so. If a parent does say that God is furious over a child's deed or failure to do something, the effect is even more pronounced. (An extreme example is the abusive adult who tells a child that the abuse is the child's faultthat is, that the child has done something to deserve itand that if the abuse is discovered, God will be angry at the child and will punish the child rather than the abuser.) If, on the other hand, a parent or other trusted adult repeatedly emphasizes that God continues to forgive and love people no matter what they do, the child will believe that God loves and forgives him.
Early-mid elementary school years: Mythic-literal faith (based on Piaget's concrete operations and Erikson's industry vs. inferiority). Piaget noted that children in the early years of elementary school must learn many concrete taskshow to count, manipulate numbers, spell, print, write, and so onif they are to succeed in society. Early elementary school reinforces and capitalizes on their concrete thinking by constantly drilling them in various skills, noting when they are wrong in their attempts and when they are right.
Erikson observed that no matter how hard some children try and how industrious they are, however, they will never be the best. If they can excel in some areas of their life, lack of ability in another area is usually not devastating. If, despite their best attempts, they never excel at anything, they will feel inadequate or inferior. Their failure to excel strikes them as "unfair" because they are keeping their end of the bargainthey are working or studying hard. And fairness is a highly important concept to early elementary-school-age children.
In terms of faith development, children of this age love mythsstories of beings larger than life who deal with basic human concerns. The most beloved myths are those in which a good being (person or animal) triumphs over evil. Because children of this age are very concrete in their thinking, they want to hear the story exactly as it was told (or written)no variations! Hence, elementary-school-age children love stories from their faith tradition's sacred scripture, and the more astounding the story, the better. For these children, the stories are not only possible but plausible. Their faith is as certain as their grasp of the alphabet. Unless they are exposed to questioning or doubting adults or older siblings, children do not question or doubt at this age. That comes later.
In terms of their relationship to God, they expect God to be fair to them. For example, if they are good (or if they pray), they expect good things to happen, just as they would expect friends to treat them well if they treat the friends well. God is a friend, and a very powerful one at that. Small wonder that children feel cheated by God when they try hard (or pray hard) and don't get what they most want. This is especially true if they are ill and pray to get better (but don't), or if they pray to have friends but are still alone.
Preteen and early adolescence: Synthetic-conventional faith (based on Piaget's formal operations stage and Erikson's identity vs. role diffusion). As children approach adolescence, they begin to acquire the ability to think abstractly, to think about things that they have never experienced, and to put themselves in others' places. Piaget called this development formal operations. Children this age are also beginning the process of separating themselves from their parents and building an identity that goes beyond being someone's son or daughter. To do this, they try on different roles to see how these roles suit themthe Eriksonian stage of identity vs. role diffusion.
In terms of faith, young people of this age are in transition between the earlier stage of certainty and one that encompasses greater ambiguity. The "conventional" part of this stage is the aspect of these young people that is still attracted to the concrete, certain element of their faith, whereas the "synthetic" aspect acknowledges that different people believe different things. For example, a young teen encounters someone whose beliefs about God are very different from hers and yet is a truly good person. Or, a preteen sees that someone who shares the same religious denomination as his parents lives out that faith tradition in a very different way. These young people begin to "synthesize" many ideas based on what they see or experience, and in the process many questions arisewhose faith tradition is "right"?, for example, and how do we know for sure? These are questions with which adults also struggle.
Mid-late adolescence: Individuative-reflective faith (also based on Piaget's formal operations and Erikson's identity vs. role diffusion). As they develop beyond the synthetic-conventional stage of faith, adolescents begin to wonder what they themselves believe nownot what their families believe, not what they have believed in the past. Although family and friends can support them in their search, it is an individual task that requires much reflection.
Typically, this is the stage during which young people stop attending services in their own faith tradition or begin to attend others' services. Although some say that they are atheists or agnostics, most are neither (surveys of adolescents indicate that the majority are believers). But they do have questions as they ponder the world that they will inherit. They wonder what kind of God permits suffering on such a large scale, especially of innocent people. They also wonder why there is so much evil in the world. They must completely examine all the tenets of their faith that they hold dear so that they can come to a new understanding of their beliefs and a new sense of meaning. The process is neither brief nor painless. For some young people, this stage does not occur until adulthood; for others, it begins in adolescence and lasts years, or even decades.
Stages of faith development can greatly influence the way a child (or parent) approaches health issues. At the most basic level, one's stage of faith can shape fundamental questions about why one is healthy or ill. For example: "Am I healthy because God loves me and wants me to be healthy (intuitive-projective); because I do the things God wants me to do (mythic-literal); because I do what good people do (synthetic-conventional); or because I am sincere and will only say or do that which I truly believe in, all the while questioning what doesn't seem right (individuative- reflective)?" Or, "Am I ill because God wants me to be sick or doesn't love me (intuitive-projective); because I didn't do what God wanted me to do (mythic-literal); because I don't do what other people do (synthetic-conventional); or because I ask too many questions or have too many doubts (individuative-reflective)?"
Health and illness can also affect stages of faith development. Seriously ill children may move through the developmental stages more rapidly than they would have otherwise, for example. After all, a serious injury or a terminal illness raises many hard questions, even for the mythic-literal child: "Why does God let me (or my mommy, daddy, sister, brother) be sick?" "Is God mad at me?" "Did I do something really bad?" "Why doesn't God answer my prayers?" Illness or trauma often precipitates a reevaluation of what one believes, for children as well as adults, and this can be very painfulalthough, in the long run, it also can be liberating. On the other hand, serious illness may lead to a regression of faith stage, as when a person in the individuative-reflective stage moves backward toward the mythic-literal stage, which offers the comfort of certainty and sure answers to one's questions.
Children and parents who think concretely interpret the world concretely: If A, then B, in other words. Not only children but also many adults believe that if they live properly, following certain rules, God should reward them in this life or spare them from the troubles that other people face. They may be devastated when the worst happens in spite of their compliance. Children and parents who approach life with questions, on the other hand, bring even more questions to their examination of events.
Put another way, children whose parents believe that bad things happen to good people for reasons that are not always clear tend to adopt that same attitude, and they will not view illness or tragedy as necessarily related to their actions. Children whose parents believe that bad things happen for specific reasons, which are always obvious upon careful reflection, are much more likely to attribute misfortune to particular causes, whether or not such causes are plausible.
As an example of the latter case, an 8-year-old girl who had been warned repeatedly by her mother not to run into the street to retrieve her ball ran into the street one day and was struck by a car. She said being hit by the car was punishment for disobeying her mother: "I was supposed to listen to my mom, and I didn't, so I got hit." No amount of discussion could change her assessment of the reason that she had been struck. And because her leg was broken as a result of the episode, she concluded that she had really done wrong: "I know someone who got hit by a car and didn't even get cut or anything. So, what I did must have been worse." In other words, because of her disobedience, she obviously merited greater "punishment" than the child who was not as seriously injured.
One's understanding of and relationship with God can influence the therapeutic relationship with the clinician. Parents and children who believe that God wants all people to be healthy are much more likely to adhere to recommended regimens than those who believe that God doesn't want health for some people. In a striking example of the latter case, the mother of a patient refused to take needed antiretroviral medications for her HIV infection because, in her words, "This illness is my punishment for the kind of life I led. To take medicine and try to get better would be like trying to put one over on God. To get out of what I deserve. Oh no, I can't do that." If one's primary image of God is a judge and punisher, small wonder that a very literal-minded person would resist trying to get out of her punishment (richly deserved, in her mind), even if the punishment is a potentially fatal illness.
Although most parents would not necessarily impose their belief about their "need" for punishment on their children, parents' beliefs do influence their children's beliefs. If, for example, a parent believes that God has created certain people, such as doctors and nurses, to help others in a special way, the child is more likely to view health professionals with respect and follow their recommendations.
A root issue in health and illness is each person's notion of his or her self-worth and how that self-worth is defined. If my worth is defined primarily by what I do instead of what I am, I will be driven to accomplish more and more, and I will be devastated when I fail to meet my own expectations. If my worth is defined primarily by who I am, my accomplishments may bring me joy, but my failure to accomplish a goal will not necessarily devastate me. In some families, children believe, rightly or wrongly, that their parents value them only if they make the honor roll, a sports team, or win an award. Such children are driven to win approval by their actions. Although everyone wants to be loved and accepted for who he or she is, many children receive (and, as adults, give their own children) a very different message.
In spiritual terms, children and adolescents whose self-worth is related to the idea that they are loved by God (regardless of their religious affiliation) are more likely to value themselves physically, emotionally, and spiritually. They are more likely to attend worship and to become involved in faith-related activities. And, the greater their involvement, the less likely they are to do things which run against the grain of their belief system. A number of investigators have noted that a young person's investment in a faith traditionalong with such factors as high self-esteem, good relations with parents, academic interests, and healthy peer relationspredicts a lower incidence of behaviors such as early sexual activity, drug and alcohol abuse, and illegal activities.216 A tie to a faith tradition might also provide a buffer in times of challenge, stress, sadness, or confusion, reducing the likelihood that such circumstances might push a child or adolescent into one or more dysfunctional behaviors.
No organized studies have been done of children raised in homes that do not adhere to a particular faith tradition. Anecdotal evidence suggests that some children and adolescents adopt their parents' beliefs with ease whereas others, paradoxically, may develop an almost fanatical adherence to beliefs diametrically opposed to those of their parents, becoming "super-religious" and very judgmental of their parents or other authority figures. Whenever youth soundly reject parental values in this way, they run the risk of going too far in the opposite direction. Of course, this is also true when youth reject the religious values of parents, expecially if the youth believe that those values have been forced upon them. In Eriksonian terms, as these youths attempt to forge their own identities, they try on many roles, not all of which are good for them.
Pediatricians need to be aware that religious services or spiritual practices play a role in the lives of many families. This is especially true in times of trouble, illness, or grieving. This role may be positive or it may be negativeas when parents feel that their faith tradition has let them down in times of greatest need.
Certain questions can help the health professional get a better sense of a family's investment in its faith tradition: How involved is the patient in the practice of his faith? How involved are the parents? Is religion a help or hindrance in coping with life in general? How so? Do parents view their faith congregation (if they have one) as a support in time of need? This is good information to have before injury or illness occurs; it gives the physician a better handle on what part faith plays in the patient's and family's coping mechanisms and the social support that a family's religious affiliation may confer, as well as problems that may arise. In the words of Barnes and colleagues, "Allow families and children to be your teachers about the specifics [of their beliefs]."17 We have much to give our patients, of course, but they and their families also have much to give us.
Under no circumstances should a health professional proselytize patients or parents or enter into debate about points of belief. Beliefsof the health professional, the patient, and the familyare a given. It is possible to provide good medical care without being in total agreement with the patient's belief system. Only when a belief interferes with medical treatment is discussionbut not debatea must. Certain belief systems may forbid some interventions. Unless the situation is emergent and allows little time for discussion, the physician's first task is to get a better understanding of the patient's and family's perspective. When no middle ground can be reached regarding therapy, a mediator, such as a trusted friend of the family or the family's religious leader, may be needed. In extreme cases, if there is serious concern that the patient's life is in jeopardy, a hospital ethics committee or the judicial system may need to be involved.
Even when religious belief does not interfere with treatment, it is helpful to know how a child or parent views illness and the attempt to treat it. Although it is not the physician's place to enter into theological debate, understanding the patient's or parent's perspective can be useful.
Such information can be especially valuable if a child confronts the physician with a question such as "Doctor, why does God make people sick?" Such a question can be handled in several ways. The doctor can turn it around and ask the child what she thinks, without offering a personal opinion. Or the physician can ask the child the question and then give a personal perspective. The doctor can also ask the child how her parents or spiritual leader (pastor, rabbi, imam, etc.) might answer the question and whether she agrees with the answeror suggest that she ask those persons the question if she has not already done so. Under no circumstances should one ignore the question, ridicule it, or tell the child that her point of view is wrong.
Many pediatric health professionals may not be comfortable discussing spiritual or religious matters with patients or their parents, and they should not feel that they must. Nevertheless, it is prudent to cultivate resource persons from among the various religious traditions represented in one's practice to assist when religious or spiritual topics arise, especially when a child is seriously ill or injured or has died. These consultantswho might include, for example, hospital chaplains and community religious leaderscan provide printed information or answer questions about a family's faith tradition.
Last, it is the wise pediatric health professional who is aware of his or her own religious history and spiritual orientation and how the death of a patient or the diagnosis of a preventable, terminal, or catastrophic condition may affect his or her personal beliefs.
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Four-year-old Samantha is very upset. Her father moved out of the house, and Samantha's mother told Samantha and her brother that their father couldn't put up with their noisy fights and went to live with a lady who didn't have any children. Samantha thinks God also must be fed up with her and her brother and is punishing them by taking their father away. She wonders if God will ever love her again. She is scared because she fights with her brother more than ever now that their father is gone, and she wonders if God will take her mother away, too.
Eight-year-old Terry is shy and obese. She cries all the time because no one wants to play with her. The other kids call her "fat crybaby." Although Terry considers God her best friend, she longs for a friend "with skin." Her father told her to ask God for a friend, which she has doneto no avail. She has been especially well-behaved at home to prove to God that she deserves a friend, but still no special friend has appeared. She wonders why God doesn't answer her prayers and reward her good behavior.
Cherise doesn't want to go to church anymore. Although she attended faithfully throughout elementary school, she has decided that going to church is "babyish" now that she's in middle school. Some of her new middle school friends don't go to church at all, and they are all nice people. Cherise wants to tell them that she doesn't go to church either. She has been arguing every week with her parents, who are faithful church attenders.
Josh is 18 years old. He is a paraplegic as a result of a motor vehicle accident in which his best friend was killed. "I don't believe in God," he says. "Where was God on the night of my accident? Nowhere to be found! All that praying and churchgoing I did as a kidfor what? People who say there is a God are stupid or immature. If there's a God, how come none of us have seen him? And don't give me that line about 'we see God in each other' because it's bull. There are a lot of folks who say they believe in God, but they're the biggest hypocrites around! And then there are a lot of people, like my friends, who don't believe in God, but they're the ones who are really good."
Patricia Fosarelli. Children and the development of faith: Implications for pediatric practice. Contemporary Pediatrics 2003;1:85.