CHAPTER 7 Normal Development
PHYSICAL ASSESSMENT
Parallel to the changes in the developing brain (cognition, language, behavior) are changes in the physical development of the body.
NEWBORN PERIOD
Primitive neonatal reflexes are unique in the newborn period. Any asymmetry, increase, or decrease in tone elicited by passive movement may indicate a significant central nervous system abnormality and requires further evaluation. Similarly, a delay in the expected disappearance of the reflexes may warrant an evaluation of the central nervous system. The most important reflexes to assess during the newborn period are as follows:
See Sections 11 and 26 for additional information on the newborn period.
LATER INFANCY
With the development of gross motor skills, the infant is first able to control his or her posture, then proximal musculature, and lastly distal musculature. As the infant progresses through these developmental stages, the parents may notice orthopedic deformities (see Chapters 201 and 202). The infant also may have deformities that are related to intrauterine positioning. Physical examination should indicate whether the deformity is fixed or is able to be moved passively into the proper position. When the infant positions a joint in an abnormal fashion, but the examiner is able to move the extremity passively into the proper position, this deformity has a high likelihood of resolving with the progression of gross motor development. Fixed deformities warrant immediate pediatric orthopedic consultation (see Section 26).
Evaluation of vision and ocular movements is important to prevent the serious outcome of strabismus. The cover test and light reflex should be performed at every health maintenance visit (see Chapter 179).
LATE SCHOOL-AGE PERIOD/EARLY ADOLESCENCE
Older school-age children, who begin to participate in competitive sports, should have a comprehensive sports history and physical examination, including evaluation of the cardiovascular system. The American Academy of Pediatrics sports preparticipation form is excellent for documenting cardiovascular and other risks. Before the examination, the patient and parent should be interviewed to assess cardiovascular risk. Any history of heart disease or a murmur must be referred for evaluation by a pediatric cardiologist. Similarly, a child with a history of dyspnea or chest pain on exertion, irregular heart rate (skipped beats, palpitations), or syncope should be referred to a pediatric cardiologist for further evaluation. A family history of a primary (immediate family) or secondary (immediate family’s immediate family) atherosclerotic disease (myocardial infarction or cerebrovascular disease) before 50 years of age or sudden unexplained death at any age also requires additional assessment.
Children interested in contact sports should be assessed for special vulnerabilities. Similarly, vision should be assessed as a crucial part of a comprehensive history and physical examination before participation in sports.
ADOLESCENCE
Adolescents need a comprehensive health assessment to ensure that they progress through puberty without major problems (see Chapters 67 and 68). Other issues in physical development include scoliosis, obesity, and trauma (see Chapters 29 and 202). Most scoliosis is mild and requires only observation for progression. Obesity may first become manifest during childhood and is an issue for many adolescents. Orthopedic problems may arise from trauma to developing joints and bones (see Chapter 198).
Sexual maturity is another important issue in adolescents. All adolescents should be assessed to determine the sexual maturity rating (see Chapter 67). Monitoring the progression through sexual maturity rating stages provides an ongoing evaluation of puberty.
DEVELOPMENTAL MILESTONES
The use of milestones to assess development focuses on discrete behaviors that the clinician can observe or accept as present by parental report. This approach is based on comparing the patient’s behavior with that of many normal children whose behaviors evolve in a uniform sequence within specific age ranges (see Chapter 8). The development of the neuromuscular system, similar to that of other organ systems, is determined first by genetic endowment and then molded by environmental influences.
Although a sequence of specific, easily measured behaviors can adequately represent some areas of development (gross motor, fine motor, and language), other areas, particularly social and emotional development, are not adequately assessed. Easily measured developmental milestones are well established only through 6 years of age. Other types of assessment (intelligence tests, achievement tests, school performance, personality profiles, and neurodevelopmental assessments) that expand the developmental milestone approach beyond the 6 years of age are available for older children. These tests generally require time and expertise in administration and interpretation that are not available in the primary care setting.
PSYCHOSOCIAL ASSESSMENT
Bonding and Attachment in Infancy
The terms bonding and attachment describe the affective relationships between parents and infants. Bonding occurs shortly after birth and reflects the feelings of the parents toward the newborn (unidirectional). Attachment involves reciprocal feelings between parent and infant and develops gradually over the first year. Effective bonding in the postpartum period may enhance the development of attachment.
Attachment of infants outside of the newborn period is crucial for optimal development. Infants who receive extra attention, such as parents responding immediately to any crying or fussiness, show less crying and fussiness at the end of the first year. Stranger anxiety develops between 9 and 18 months of age, when infants normally become insecure about separation from the primary caregiver. The infant’s new motor skills and attraction to novelty may lead to headlong plunges into new adventures that result in fright or pain followed by frantic efforts to find and cling to the primary caregiver. The result is dramatic swings from stubborn independence to clinging dependence that can be frustrating and confusing to parents. With a secure attachment, this period of ambivalence may be shorter and less tumultuous.
Developing Autonomy in Early Childhood
Toddlers build on attachment and begin developing autonomy that allows separation from parents. In times of stress, toddlers often cling to their parents, but in their usual activities they may be actively separated (frequently saying “No!” to their parents). Ages 2 to 3 years are a time of major accomplishments in fine motor skills, social skills, cognitive skills, and language skills. The dependency of infancy yields to developing independence, and the “I can do it myself” age. Limit setting is essential to balance the child’s emerging independence.
School Readiness
When a toddler has achieved autonomy and independence, school readiness should be assessed. Readiness for preschool depends on the development of autonomy and the ability of the parent and the child to separate for hours at a time. Preschool experiences help 3- to 4-year-old children develop socialization skills; improve language; increase skill building in areas such as colors, numbers, and letters; and increase problem solving (puzzles).
Readiness for school (kindergarten) requires emotional maturity, peer group and individual social skills, cognitive abilities, and fine and gross motor skills (Table 7-1). Other issues include chronologic age and gender. Although not a perfect association, children do better in kindergarten if their fifth birthday is at least 4 to 6 months before the beginning of school. In addition, girls usually are ready earlier than boys. Knowledge of the prior developmental status also helps. If the child is in less than the average developmental range, he or she should not be forced into early school. Holding a child back for reasons of developmental delay, in the false hope that the child will catch up, can also lead to difficulties. The child should enroll on schedule, and educational planning should be initiated to address any deficiencies. Pushing a child into an environment for which he or she is not prepared can contribute to school refusal, poor school achievement, and behavioral problems.
TABLE 7-1 Evaluating School Readiness
PHYSICIAN OBSERVATIONS (BEHAVIORS OBSERVED IN THE OFFICE)
PARENT OBSERVATIONS (QUESTIONS ANSWERED BY HISTORY)
Physicians should be able to identify children at risk for school difficulties, such as those who have developmental delays or physical disabilities. These children may require specialized school services. Federal law mandates these services for children who qualify; services may include speech-language therapy, occupational therapy, or physical therapy (see Chapter 10).
Adolescence
Although the Society for Adolescent Medicine defines adolescence as 10 to 25 years of age, adolescence is characterized better by developmental stages (early, middle, and late adolescence) that all teens must negotiate to develop into healthy, functional adults. Different behavioral and developmental issues characterize each stage. The age at which each issue becomes manifest and the importance of these issues vary widely among individuals, as do the rates of cognitive, psychosexual, psychosocial, and physical development.
During early adolescence, attention is focused on the present and on the peer group. Concerns are primarily related to the body’s physical changes and normality. Strivings for independence are ambivalent. These young adolescents are difficult to interview because they often respond with short, clipped conversation and may have little insight. They are just becoming accustomed to abstract thinking.
Middle adolescence can be a difficult time for adolescents and the adults who have contact with them. Cognitive processes are more sophisticated. Through abstract thinking, middle adolescents can experiment with ideas, consider things as they might be, develop insight, and reflect on their own feelings and the feelings of others. As they mature cognitively and psychosocially, these adolescents focus on issues of identity not limited solely to the physical aspects of their body. They explore their parents’ and the culture’s values, and they may do this by expressing the contrary side of the dominant value. Many middle adolescents explore these values only in their minds; others do so by challenging their parents’ authority. Many engage in high-risk behaviors, including unprotected sexual intercourse, substance abuse, or dangerous driving. The strivings of middle adolescents for independence, limit testing, and need for autonomy are often distressing to their families, teachers, or other authority figures. These adolescents are at higher risk for morbidity and mortality from accidents, homicide, or suicide.
Late adolescence usually is marked by formal operational thinking, including thoughts about the future (educational, vocational, and sexual). Late adolescents are usually more committed to their sexual partners than are middle adolescents. Unresolved separation anxiety from previous developmental stages may emerge at this time as the young person begins to move physically away from the family of origin to college or vocational school, a job, or military service.
MODIFYING PSYCHOSOCIAL BEHAVIORS
Child behavior is determined by heredity and by the environment. Behavioral theory postulates that behavior is primarily a product of external environmental determinants and that manipulation of the environmental antecedents and consequences of behavior can be used to modify maladaptive behavior and to increase desirable behavior (operant conditioning). The four major methods of operant conditioning are positive reinforcement, negative reinforcement, extinction, and punishment. Many common behavioral problems of children can be ameliorated by these methods.
Positive reinforcement increases the frequency of a behavior by following the behavior with a favorable event. Praising a child for his or her excellent school performance and rewarding an adolescent with a later curfew hour are examples. Negative reinforcement increases the frequency of a behavior by following the behavior with the removal, cessation, or avoidance of an unpleasant event. Conversely, sometimes, this reinforcement may occur unintentionally, increasing the frequency of an undesirable behavior. A toddler may purposely try to stick a pencil in a light socket to obtain attention, be it positive or negative. Extinction occurs when there is a decrease in the frequency of a previously reinforced behavior because the reinforcement is withheld. Extinction is the principle behind the common advice to ignore such behavior as crying at bedtime or temper tantrums, which parents may unwittingly reinforce through attention and comforting. Punishment decreases the frequency of a behavior through unpleasant consequences. Positive reinforcement has been proved to be more effective than punishment. Punishment is more effective when combined with positive reinforcement. A toddler who draws on the wall with a crayon may be punished, but he or she learns much quicker when positive reinforcement is given for proper use of the crayon, on paper, not the wall. Interrupting and modifying behaviors are discussed in detail in Section 3.
TEMPERAMENT
Significant individual differences exist within the normal development of temperament (behavioral style). Temperament must be appreciated because, if an expected pattern of behavior is too narrowly defined, normal behavior may be inappropriately labeled as abnormal or pathologic. There are three common constellations of temperamental characteristics:
The remaining children have more mixed temperaments. The individual temperament of a child has important implications for parenting and for the advice a pediatrician may give in anticipatory guidance or behavioral problem counseling.
Although temperament may be, to some degree, hardwired (nature) in each child, the environment (nurture) in which the child grows has a strong effect on the child’s adjustment. Social and cultural factors can have marked effects on the child through differences in parenting style, educational approaches, and behavioral expectations.