How Kids Understand Health and Illness: Some Reflections from and for the Theory of Social Representations

Health and illness viewed by children and adolescents: empirical facts and comments. The purpose of the article is twofold: 1) to argue about the relevance and the advantages of the social representational perspective applied to the field of health and illness in case of children and adolescents; 2) to discuss the potential and fertility of cultural-historical psychology for further development of the theory of SRs, in particular — on genesis of SRs of health and illness.

The numerous terms (e.g.: understanding, perception, internal picture, vision, point of view, concept, lay thinking, ideas, image and representation) were used to indicate how children and adolescents interpret health and illness notions [7; 20; 30; 31; 36].

One of the main reasons for this research interest is that childhood and adolescence are the periods when habits and attitudes towards health and healthy life style, illness, risk and risky behaviour are formed [7; 20; 30; 31; 36]. Therefore, educational programs need to take into account how children and adolescents see this reality.

Following the ideas of Piaget on cognitive development the researchers assumed that the children’s concept of health and illness went through some systematic and predictable stages, starting from global and phenomenological vision and moving to a more «sophisticated» one [6].

Children shift from global and nonspecific explanation of illness towards a more specific and sophisticated concept, they articulate different aspects of illness (psychological, affective and social). They also associate illness with infection or germs, however they are unable to explain the mechanism clearly. They can determine whether they are healthy or not by using internal characteristics. The comprehension of contagious illness corresponds to the concrete and formal operation stages. As children become more mature in terms of cognitive development they perceive illness as a more controllable state, they do not use moralistic explanation of illness.

In case of health the transition from the preopera- tional stage to the formal operation stage is characterised by the following changes: 1) from health seen as feeling good and doing desired activity towards health seen as performing desired activity; 2) health became the integration of learned facts [30]; 3) health was defined as not being sick in the course of reversibility development.

Contradictory results were obtained from the analysis of impact of hospitalization and illness experience on illness conceptualization. Probably the initial theoretical model is not able to integrate the illness/ health experience into conceptualization of illness or health.

According to L.Schmidnt and H.Frohling children are active theory builders, but their thinking is not determined only by development stages [36]. We can add that children are active theory builders in interaction, or in co-activity with adults to whom they address their famous questions «Why?» when observing the world. The horizontal shifts in groups of children and adolescents were revealed while asking about different categories of illnesses (cold, measles, heart infarction, cancer, AIDS) [36]. The development turned to be not linear as opposed to what had been claimed in other studies [36].

Among other limitations of this research line is the fact that health and illness are considered in a social vacuum, as if they were not part of everyday life, as if children and adolescents did not have their own experience of it, as if health and illness were observed by children and adolescents from the outside. It has been widely discussed in the literature that health and illness are the social entities, omnipresent in our everyday life [3; 16; 39].

Another point of criticism is that a human body was neglected in these studies. Analysing representations of health and illness researchers should not overlook the fact that a human body is a phenomenon interrelated with health and illness. According to V.V.Nikolaeva and G.A.Arina corporeality is a cultural-historical and developing entity [32]; it follows the same development pathway as any higher mental functions and eventually acquires the same symbolic and cultural character [29; 32]. This understanding of corporeality as a cultural-historical and developing entity has some very important consequences for the analysis of representations of health and illness, namely, the differences in the understanding of body in relation to health and illness become obvious in case of children, adolescents and adults. During the socialization a human body becomes a place where the social norms function. This process implies transformation of natural bodily functions into socially determined actions [29]. The studies discussed above overlooked this important point. An attempt to articulate the ideas of corporeality as a cultural-historical and developing entity with the dynamics of representations of health and illness proposed by K.O.Kazanskaya and B.G.Meshcheryakov in a longitudinal study realised on primary school-age children [20]. The authors suppose that the fact that children go to school is a crisis in terms of psychosomatic development. A schoolchild has to control bodily states, take care of his/her health etc. The comparison of representations of health and illness in schoolchildren of the 1^st grade and of the same schoolchildren two years later showed [20]: 1) The 1^st grade schoolchildren used more complex definitions of illness in comparison to those of health. The 3^rd grade schoolchildren did not differ on this variable. 2) The 1^st grade schoolchildren used several characteristics to define health and illness. 3) There was a shift (in schoolchildren from the 1^st to the 3^rd grade) from semiotic (symptoms and phenomena) to nosological (etiological and causal) explications of illness. This shift was explained as a matter of cognitive tools on reflection of own experience of illness.

This study is a rare attempt to analyse the dynamic of understanding of health and illness that articulates the idea of corporeality socialization. With no account of the sample size (10 girls and 4 boys), this study has serious limitation caused by absence of the notion of structure of the representations of health and illness which complicates the comparison [20]. The study also ignores the fact that health and illness are complex entities that articulate biological, psychological and socio-cultural dimensions. The polymorphic nature makes health and illness a perfect object for the analysis in the field of the theory of SRs.

Theory of SRs: some insights into the study of health and illness in children and adolescents. The theory of SRs, proposed by S.Moscovici in 1961, has become a particularly heuristic and productive tradition in the field of social psychology [1; 9; 11; 12; 14; 15; 16; 17; 18; 21; 22; 23; 24; 26; 28; 34; 39]. The cartography of scientific publications demonstrates the spread of the theory round the world [21].

In one of several definitions done by S. Moscovici the SRs are: «systems of values, ideas and practices with a twofold function...»: first, to establish an order which will enable individuals to orient themselves in their material and social world and to master it; and secondly to enable communication to take place among members of a community by providing them with a code for social exchange and a code for naming and classifying unambiguously the various aspects of their world and their individual and group history» [24, p. xiii]. The SRs are socially produced and shared, they are organised and possess certain social utility. It evokes an important point, the existence of a SR implies the existence of a group that shares it, that communicates about the object of the SR. Particular interest to this point is explained by the reflection on the genesis of SRs in groups of children, we will come back to this point later.

The SRs are the form of common sense knowledge worked out by people in everyday communications in order to give meaning to different objects, phenomena, events, etc. that are new, strange, unknown, threatening. The SRs transform the strangeness of such objects, phenomena, etc., by putting them into the existing frame. Other functions of SRs are: the function of regulation of social behaviour and practice, the function of social identity construction and support, and the function of justification of social relations [1; 15; 23; 34; 39].

The four different theoretical approaches towards the analysis of the SRs can be distinguished: sociogenet- ic, structural, sociodynamical and dialogical [23]. These approaches are not opposed to one another, Moscovici highlighted about sociodynamical and structural approaches «from many points of view, there is a profound analogy between these two hypotheses, which touch on the problems of how representations change and of their generativity respectively, to the extent that change and generativity concern the same fundamental phenomenon, that is to say, the question of the formation and evolution of SRs in the course of history» [28, p. 160]. The four approaches are complimentary to one another and they are originated from the complimentary definitions of the SRs proposed by Moscovici himself [23].

The first approach was introduced and developed by S. Moscovici [26]. Its main interest was to study the genesis and the development of SRs. The new event or object, unknown or strange, leads to the formation of a SR. The SRs are the form of common sense knowledge worked out by people in everyday communications in order to give meaning to different objects, phenomena, events, etc. that are new, strange, unknown, threatening. As Moscovici underlines it, «...the purpose of all representations is to make something unfamiliar, or unfamiliarity itself, familiar. What I mean is that consensual universes are places where everybody wants to feel at home, secure from any risk.» [28, p. 37].

Being inspired by G.Holton’s thematic analysis of science S. Moscovici has proposed that «folk knowledge is grafted on canonic themata that motivate or compel people in their cognitive search» [25, p. 3]. Themata («source-ideas» or «image concepts») orient the cognitive functioning, it generates SR. The concept of the- mata demonstrates the articulation of language, communication and SRs [23], it highlights the importance of cultural and historical entities for SRs. Even though the concept of themata has not got a clear operationalization yet [23], it definitely has a promising potential for further development of the theory of SRs [22] .

The second approach was put forward by J.-C.Abric and C. Flament [1; 23; 34; 39]. SR consists of two parts: the central core and peripheral elements. The central core has three functions: meaning, organization, and stabilization [39]. Changes of the central core elements inflict two types of consequences: they lead to a modification of the meaning, they can provoke a social disconnection as a result of lack of consensus [39]. The central core relates to norms, values and history of a group that shares the SR. The central core provides the group homogeneity. The peripheral elements realise three functions: concretization, adaptation, and defence; they refer to individual experience. The notion of the structure enables us to study the dynamic of SRs, to compare the SRs in different groups.

The third approach was proposed by W.Doise [9; 23; 34]. Following the idea of anchoring formulated by S. Moscovici, Doise explains how social structure influences on formation of SR [9; 23; 34], in other words, how «a metasystem of social regulations intervening in the system of cognitive functioning» [34, р. 85]. SRs are seen «as organizing principles of symbolic relationships between individuals and groups» [34, p. 97].

The fourth approach formulated by I. Markova [22; 23] refers to the theory of SRs as a theory of social knowledge. Being passionate about the ideas of M. Bakhtin concerning the dialogical communication she puts in the focus of analysis the notion of dialogicality, explained as «a fundamental capacity of the human mind to conceive, create and communicate about social realities in terms of the Ego-Alter» [22, p. 93]. This capacity is a result of phylogenesis and of the socio-cultural history of humans. Developing the idea of dialogicality Markova emphasizes the importance of dialogical communication in relation to intersubjectivity formation. The dynamic unit of the theory of social knowledge is Ego-Alter-Object triad. A «fundamental conceptual tool in the development of the theory of social knowledge» as Markova puts it [22, p. 57] is thinking in antimonies. This tool seems to be very promising in relation to the notion of themata.

Even from this brief glance at the main ideas of the theoretical approaches to the SRs it becomes obvious that this is a very productive and fertile tool to analyse social phenomena.

The notion of SR applied to the field of health and illness provides the vision of health and illness that a person builds up with an idea of structure and functions that correspond to this construction. SRs play a role of filter for the preventive information [3]. Paradoxically, it is not the knowledge on health or illness, but the SRs that guide the corresponding action or inaction, justify the social relations.

Health and illness are among the main topics of the social representational analysis [3; 7; 13; 14; 16; 17; 26; 39]. However, it applies to adults to a great extent; and we know only a little about children’s understanding of health and illness.

The bibliographic analysis realised on the PsycINFO database (keywords «SRs», «development», «child» or «adolescent») revealed that 34% of studies on SRs were carried out in groups of children and/or adolescents in the field of health and illness (e.g.: nutrition, pregnancy, HIV/AIDS, smoking) [2].

Childhood and adolescence are important periods when social knowledge about the world being developed [12]. This particular period is an interesting moment for the analysis of genesis and transformation of the SRs. Children are born in the world of SRs shared by adults or by siblings. By being born children become a part of a group that shares certain image of the world, particular representations and during the socialization process children appropriate the social knowledge by interiori- sation process [11; 12]. Here we come to the point about the relation group-SR discussed before in this article. It is certainly true that SR implies a group that works up and shares it, but in case of the SRs in children the question about the group where the representations are built up and shared becomes important. Children are involved into communications on health and illness with parents or other family members, children learn from parents to take care of their health and to protect themselves from danger. Children interiorised the representations of their parents [31]. In case of adolescents the communications on health and illness are shared with peers, as far as the leading activity according to D.B. Elconin is interpersonal communication.

SRs of health and illness are being transformed during the whole lifespan of an individual, so the analysis of these changes would «explore the way a society is conceived and experienced simultaneously by different groups and generations» [28, p. 76].

Cultural-historical psychology: a perspective for further development of the theory of SRs. In this part of the article we will present some ideas coming from the cultural-historical psychology and will discuss their fertility for the theory of SRs, especially in terms of genesis of SRs. The question of genesis and transformation of the SRs is somehow a zone of proximal development of the theory of SRs as far as very few studies focused on this question [12; 24]. The ideas of Vygotsky have not been reflected in the collective monograph on SRs published recently [21]. In order to relaunch the discussion and the theoretical reflections on the question of genesis of SRs we need to make a brief account of the classical theory of Vygotsky as suggested by Duveen, as well as to provide insight into further development of Vygotsky’s ideas by his collaborators or scholars of his scientific school.

In the chapter «Social psychology and developmental psychology: extending the conversation» published in 1990 in the book «Social representations and the development of knowledge» Serge Moscovici said about the interiorisa- tion process proposed by Vygotsky: «I am not sure about his (Vygotsky’s) notion of an evolutionary metamorphosis from the social to the individual, namely, that what is experienced initially at the inter-psychological level is later found at the intra-psychological level. As the saying goes, it is too good to be true, but a surprise is possible» [27, p. 178—179]. S.Moscovici doubts that the interpsychologi- cal becomes intrapsychological without any mediation.

The surprise mentioned by Moscovici probably will not appear in here, but some explications will be presented. It goes in line with the idea of Duveen that «a constructive engagement with the classical theories of Piaget and Vygotsky may also contribute to the further elaboration of the theory of social representations» [11, p. 6]

Putting aside the discussion of the claim that «the English translations of Vygotsky’s texts leave much to be desired» as N.N. Veresov underlines it [40, p. 25], we shall review some ideas of Vygotsky’s theory [41] that are pertinent for the theory of SRs in general and specifically to the field of health and illness in children.

The two types of interiorisation could be illustrated by the inner speech development process. The first transformation from communication into egocentric speech corresponds to the interiorisation from social to individual (from communicative function the speech shifts to the function of regulation and planning), the second — from egocentric to inner speech — corresponds to the in- teriorisation from external to internal (the speech is not used for communication any longer, it becomes predicative, not clear to other people) [38].

A child is born into a social situation and his development as a social being can be approximated by the following schema: «collective activity, signs and symbols, individual activity, individual consciousness» [35, p. 6].

Summing up the fundamental points of the cultural- historical theory of Vygotsky and his scientific school, V.V. Rubtsov proposes to state the main points [35]:

1)   qualitative change of the social situation is the ground for a human’s mental development.

2)   learning and upbringing are the main points of human’s mental development.

3)   initial form of activity is realised by an individual in its social or collective plane.

4)   new psychological formations are results of the in- teriorisation of the initial form of human activity.

5)  signs and symbols play a significant role in the process of interiorisation.

6)          unity of emotions and intelligence.

These points are the dimensions of further development of cultural-historical psychology, some of them concerning the mental development and interiorisation process are the key points for the theory of SRs (especially applied to the problem of genesis of SRs of health and illness).

Finally, the idea of interiorisation proposed by P.Ya. Galperin in the theory of planned stage-by-stage formation of mental actions could be another way to explain the genesis of SRs of health and illness in children and adolescents as researchers proposed in case of the corporeality development [31].

SRs of health and illness with children: a roadmap for future researches. Two main interdependent stakes (theoretical and methodological) should be taken into account for the development of researches concerning the SRs of health and illness in children. A major epistemological issue is associated with the articulation between an epistemic subject (as defined by Piaget), and the SR approach which does not envisage that knowledge structures are regulated by some pre-established end-points. Another important question is how a change occurs. From this point of view, at least two perspectives can be drawn.

The first, the microgenesis process (interpersonal communications and practices) is based on transmission via familial socialization. It seems necessary to study the interrelations between self-other-objects [18] through identity building, social relationships, and child’s understanding of the world (society) in which he/she grows up. The study of the social inclusion of children as social agents seems necessary for understanding the genesis and dynamic of SRs. These situations of learning can be considered in terms of «guardianship interactions» [5; 42], interactions in which the adult accompanies the child in ‘problem solving’ that he or she does not yet know how to solve on his or her own. With regard to health and disease, this perspective is particularly important.

The second, it seems essential to develop studies that simultaneously take into account the issues of cognitive and moral development of the child and those related to access to, dissemination and development of social knowledge. In other words, to articulate developmental psychology and societal social psychology. Finally, a substantial gap is linked to the presupposition of an articulation between a SR and a group, that is a central point of the SR theory. SR is supposed to be the SR of a particular group. However, the question of children’ identification with particular social groups has been given little or no consideration. Furthermore, if we take into account the socio-cognitive development of children and the articulation between group membership and SR, we are confronted with an epistemological limit that needs to be explored, for example, by studying more specifically the possible levels of identification in children.

Concerning the methodological stake, one of the most important challenges is how we can gain access to the development of SRs. Studying the genesis and development of SR implies being interested in the diachronic aspect of thought [2]. In order to carry out a survey designed to examine the diachronic aspect of thought, the researcher can use longitudinal and transverse approaches. Longitudinal studies could be further developed in the field of the SR study in order to better understand the process of ontogenesis (how children gain access to the SR of their community in a ‘thinking society’)

Furthermore, tools and methods used in research on children need specific improvements in lines with their cognitive skills. Indeed, it seems relevant to develop specific procedures for helping participants to contextualize their meanings in order to ensure their proper understanding by researchers. For example, by using some supports or methods (contextualization sentences, interview, pictures, drawing, scenario, vignette) in such a way as to encourage the explanation of representations that can be developed or transmitted in a non-verbal way. Similarly, when considering the classification of ideas and representational elements, children should be accompanied in sorting procedures to encourage both thematic and taxonomic categorization [4].

Frequently used in researches on the psychology of development [8], observation is rarely used for studying SR despite its particular interest to study social practices related to health and illness [17]. Indeed, health (as well as illness) is embedded in the daily practice-routines and in specific contexts of communication (home, school, care settings etc.). The obvious status of certain social practices and daily routines sometimes makes it difficult to access of their socio-cognitive elaboration and rationalization. Furthermore, the increase of new technologies opens up many possibilities in research on children and adolescents, it could be interesting to use these technologies (personal computer, smartphone, pad) as a tool to collect and analyse SRs (using serious games for example).

Conclusion. Our starting point was, on the one hand — to provide some reflections from the point of view of the theory of SRs in relation to health and illness viewed by children and adolescents, on the other hand, to provide some reflections for the theory of SRs, for its further development (by researching the question of the SRs genesis). What has been done? The studies based on Piagetian stages of cognitive development have been analysed and the limitations of this approach revealed. It has been argued that the theory of SRs took into consideration the polymorphic nature of health and illness, it was a relevant framework to analyse how children and adolescents understand health and illness. Finally, we have reviewed some of Vygotsky’s ideas that would be pertinent for further development of the theory of SRs, especially in the field of health and illness in children.

What should be done? The perspective outlined by S. Moscovici: to «explore the way a society is conceived and experienced simultaneously by different groups and generations» [28, p.76] is still open, but some obstacles have been removed.

Funding

This article is a part of the research project supported by RGNF (16-26-08001 a) and FMSH.