Age 0-2 Months
The infant is dependent on the environment to meet his or her needs. The consistent availability of a trusted adult to meet the infant’s urgent needs creates the conditions for secure attachment. Basic trust vs mistrust, the first of Erikson’s psychosocial stages, depends on attachment and reciprocal maternal bonding. Crying occurs in response to stimuli that may be obvious (a soiled diaper), but are often obscure. Infants who are consistently picked up and held in response to distress cry less at 1 yr and show less aggressive behavior at 2 yr. Cross-cultural studies show that in societies in which infants are carried close to the mother, babies cry less than in societies in which babies are only periodically carried. Crying normally peaks at about 6 wk of age, when healthy infants cry up to 3 hr/day, then decreases to 1 hr or less by 3 mo.
The emotional significance of any experience depends on both the individual child’s temperament and the parent’s responses. Consider the impact of different feeding schedules. Hunger generates increasing tension; as the urgency peaks, the infant cries, the parent offers the bottle or breast, and the tension dissipates. Infants fed “on demand” consistently experience this link between their distress, the arrival of the parent, and relief from hunger. Most infants fed on fixed schedule quickly adapt their hunger cycle to the schedule. Those who cannot because they are temperamentally prone to irregular biologic rhythms experience periods of unrelieved hunger as well as unwanted feedings when they already feel full. Similarly, infants fed at the parents’ convenience, with neither attention to the infant’s hunger cues nor a fixed schedule, may not consistently experience feeding as the pleasurable reduction of tension. These infants often show increased irritability and physiologic instability (spitting, diarrhea, poor weight gain) as well as later behavioral problems.
IMPLICATIONS FOR PARENTS
Success or failure in establishing feeding and sleep cycles determines parents’ feelings of efficacy. When things go well, the parents’ anxiety and ambivalence, as well as the exhaustion of the early weeks, decrease. Infant issues (colic) or familial conflict will prevent this from occurring. With physical recovery from delivery and endocrinoligic normalization, the mild postpartum depression that affects many mothers passes. If the mother continues to feel sad, overwhelmed, and anxious, the possibility of moderate to severe postpartum depression,, found in 10% of postpartum women, need to be considered. Major depression that arises during pregnancy or in the postpartum period threatens the mother-child relationship and is a risk factor for later cognitive and behavioral problems.
Age 2-6 Months
Babies interact with increasing sophistication and range. The primary emotions of anger, joy interest, fear disgust, and surprise appear in appropriate contexts as distinct facial expressions. When face-to-face, the infant and a trusted adult match affective expressions (smiling or surprise) about 30% of the time. Initiating “games” (facial imitation, singing, hand games) increases social development. Such face-to-face behavior reveals the infant’s ability to share emotional states, the first step in the development of communication. Infants of depressed parents show a different pattern, spending less time in coordinated movement with their parents and making fewer efforts to re-engage. Rather than anger, they show sadness and a loss of energy when the parents continue to be unavailable.
IMPLICATIONS FOR PARENTS
Motor and sensory maturation makes infants at 3-6 mo exciting and interactive. Some parents experience their 4 mo old child’s outward turning as a rejection, secretly fearing that their infant s no longer love them. For most parents, however, this is a happy period. Most parents excitedly report that they can hold “conversation” with their infants, taking turns vocalizing and listening. Parents can be reassured that responding to an infant’s emotional needs cannot “spoil” him or her. Giving vaccines and drawing blood while the child is seated on the parent’s lap increases pain tolerance.
Age 6-12 Months
The advent of object permanence corresponds with qualitative change in social and communicative development. Infants look back and forth between an approaching stranger and a parent, and may cling or cry anxiously, demonstrating “stranger anxiety.” Separations often become more difficult. Infants who have been sleeping through the night for months begin to awaken regularly and cry, as though remembering that the parents are in the next room.
A new demand for autonomy also emerges. Poor weight gain at this age often reflects a struggle between an infant’s emerging independence and parent’s control of the feeding situation. Use of the 2-spoon method of feeding (1 for the child and 1 for the parent), finger foods, and a high chair with a tray table can avert potential problems. Tantrums make their first appearance as the drives for autonomy and mastery come in conflict with parental controls and the infants’ still-limited abilities.
With the developmental reorganization that occur around 9 mo of age, previously resolved issues of feeding and sleeping re-emerge. Parents should be encouraged to plan ahead for necessary, and inevitable, separation (e.g., baby sitter, daycare). Routine preparations may make these separations easier. Introduction of “transitional object” may allow the infant to self-comfort in the parents’ absence.
Time spent talking with the parent and introducing the child to a small, washable toy will be rewarded with more cooperation. The examination can be continued on the parent’s lap when feasible.
Age 12-18 Months
Infants who are approaching the developmental milestone of taking their first steps may be irritable. Once they start walking, their predominant mood changes markedly. Toddlers are described as “intoxicated” or “giddy” with their new ability and with the power to control the distance between themselves and their parents. Exploring toddlers orbit around their parents, moving away and then returning for reassuring touch before moving away again. A securely attached child will use the parent as a secure base from which to explore independently. Proud of her or his accomplishments, the child illustrates Erikson’s stage of autonomy and separation. The toddler who is overly controlled and discouraged from active exploration will feel doubt, shame, anger, and insecurity. All children will experience tantrums reflecting their inability to delay gratification, suppress or displace anger, or verbally communicate their emotional stage. The quality of the maternal-child relationship may moderate negative effects of child care arrangements when parents work.
IMPLICATIONS FOR PARENTS
Parents may express concern about poor intake as growth slows. The growth chart should provide reassurance. Parents who cannot recall any other milestone tend to remember when their child began to walk, perhaps because of the symbolic significance of walking as an act of independence. All toddlers should be encouraged to explore their environments; a child’s ability to wander out of sight also increases the risks of injury and the need for supervision. In the office setting, many toddlers are comfortable exploring the examination room, but cling to the parents under the stress of the examination. Performing most of the physical examination in the parent’s lap may help allay fears of separation. Infants who become more, not less, distressed in their parents’ arms or who avoid their parents at time of stress may be insecurely attached. Young children who, when distressed, turn to strangers rather than parents for comfort are particularly worrisome. The conflicts between independence and security manifest in issues of discipline, temper tantrums, toilet training, and changing feeding behaviors. Parents should be counseled on these matters within the framework of normal development.
Age 18-24 Months
In many children, the relative independence of the receding period gives way to increased clinginess around 18 mo. This stage, described as “rapprochement,” may be a reaction to growing awareness of the possibility of separation. Many parents report that they cannot go anywhere without having a small child attached to them. Separation anxiety will be manifest at bedtime. Many children use a special blanket or stuffed toy as a transitional object, which function as a symbol of the absent parent. The transitional object remains important until the transition to symbolic thought has been completed and the symbolic presence of the parent has been fully internalized. Despite the attachment to the parent, the child’s use of “no” is a way of declaring independence. Individual differences in temperament, in both the child and the parents play a critical role in determining the balance of conflict vs cooperation in the parent-child relationship. As effective language emerges, conflicts become less frequent.
Self-conscious awareness and internalized standards of behavior first appear at this age. Toddlers looking in a mirror will, for the first time, reach for their own face rather than the mirror image if they notice something unusual on their nose. They begin to recognize when toys are broken and may hand them to their parents to fix. When tempted to touch a forbidden object, they may tell themselves “no’ no.” Language becomes a means of impulse control, early reasoning, and connection between ideas,. This is the very beginning of the formation of a conscience. The fact that they often go on to touch the object anyway demonstrates the relative weakness of internalized inhibitions at this stage.
IMPLICATIONS FOR PARENTS
With children’s increasing mobility, physical limits on their explorations become less effective; words become increasingly important for behavior control as well as cognition. Children with delayed language acquisition often have greater behavior problems and frustrations due to problems with communication. Language development is facilitated when parents and caregivers use clear, simple sentences; ask questions; and respond to children’s incomplete sentences and gestural communication with the appropriate words. Regular periods of looking at picture books together continue to provide an ideal context for language development.
In the office setting, certain procedures may lessen the child’s stranger anxiety. Avoid direct eye contact initially. Perform as much of the examination as feasible with the child on the parent’s lap. Parents should understand the resurgence of problems with separation and the appearance of the treasured blanket or teddy bear as a developmental phenomenon. Parents must understand the importance of exploration. Rather than limiting movement, parents should place toddlers in safe environments or substitute 1 activity for another. Methods of discipline, including corporal punishment, should be discussed; effective stand and adapt to their children’s different temperamental styles can constitute an important intervention (see Table 6-1). Developing daily routines is helpful to all children at this age. Rigidity in those routines reflects a need for mastery over a changing environment.
Age 2-5 Yrs.
Emotional challenges facing preschool children include accepting limits while maintaining a sense of self-direction, reining in aggressive and sexual impulses, and interacting with a widening circle of \adults and peers. At 2 yr of age, behavioral limits are predominantly external; by 5 yr of age, these controls need to be internalized if a child is to function in typical classroom. Success in achieving this goal relies on prior emotional development, particularly the ability to use internalized images of trusted adults to provide secure environment in times of stress. The love a child feels for important adults is the main incentive for the development of self-control. Children learn what behaviors are acceptable and how much power they wield vis-a vis important adults by testing limits. Testing increases when it elicits attention, even though that attention is often negative, and when limits are inconsistent. Testing often arouses parental anger or inappropriate solicitude as a child struggles to separate, and it gives rise to a corresponding parental challenge: letting go. Excessively tight limits can undermine a child’s sense of initiative, whereas overly loose limits can provoke anxiety in a child who feels that no one is in control.
Control is central issue. Young children cannot control many aspects of their lives, including where they go, how long they stay, and what they take home form the store. They are also prone to lose internal control, that is, to have temper tantrums. Fear, over-tiredness, inconsistent expectations, or physical discomfort can also evoke tantrums. Tantrums normally appear toward the end of the 1st yr of life and peak in prevalence between 2 and 4 yr of age. Tantrums lasting more than 15 min of regularly occurring more than 3 times/day may reflect underlying medical, emotional, or social problems.
Preschool children normally experience complicated feelings toward their parents that can include strong attachment and possessiveness toward the parent of the opposite sex, jealousy and resentment of the other patent, and fear that these negative feeling might lead to abandonment. These emotions, most of which are beyond a child’s ability to comprehend or verbalize, often find expression in highly liable moods. The resolution of this crisis (a process extending over years) involves a child’s in spoken decision to identify with the parents rather than compete with them. Play and language foster the development of emotional controls by allowing children to express emotions and role-play.
Curiosity about genitals and adult sexual organs is normal, as is masturbation. Excessive masturbation interfering with normal activity, acting out sexual intercourse, extreme modesty, or mimicry of adult seductive behavior all suggests the possibility of sexual abuse or inappropriate exposure. Modesty appears gradually between 4 and 6 yr of age, with side wide variations among cultures and families. Parents should begin to teach children about “private” areas before school entry.
Moral thinking is constrained by a child’s cognitive level and language abilities, but develops as the child continues her or his identity with the parents. Beginning before the 2nd birthday, the child’s sense of right and wrong stems from the desire to earn approval from the parents and avoid negative consequences. The child’s impulses are tempered by external forces; she or he has not yet internalized societal rules or a sense of justice and fairness. Over time, as the child internalizes parental admonitions, words are substituted for aggressive behaviors. Finally, the child accepts personal responsibility. Actions will be viewed by damage caused, not by intent. Empathic responses to others’ distress arise during the 2nd yr of life, but the ability to consider another child’s point of view remains limited throughout this period. In keeping with a child’s inability to focus on more than 1 aspect of a situation at a time, fairness is taken to mean equal treatment, regardless of circumstance. A 4 yr old will acknowledge the importance of taking turns, but will complain if he didn’t get enough time. Rules tend to be absolute, with guilt assigned for bad outcomes, regardless of intentions.
IMPLICATIONS FOR PARENTS
The importance of the preschooler’s sense of control over his or her body and surroundings has implications for practice. Preparing the patient by letting the child know how the visit will proceed is reassuring. Tell the child what will happen, but don’t ask permission unless you are willing to deal with a “no” answer.
The visit of the 4 or 5 yr old should be entertaining, due to the child’s ability to communicate as well as his or her natural curiosity. Guidance emphasizing appropriate expectations for behavioral and emotional development and acknowledging normal parental feelings of anger, guilt, and confusion should be part of all visits at this time. Parents should be queried about daily routines and their expectations of child behavior. Providing children with choices (all options being acceptable to the parent) and encouraging independence in self-care activities (feeding, dressing, bathing) will reduce conflicts.
Corporal punishment is inappropriate in the modern context in which most families live. Parents usually claim that they do not like spanking, and many acknowledge that it is not very effective. As children habituate to repeated spanking, parents have to spank ever harder to get the desired response, increasing the risk of serous injury. Sufficiently harsh punishment may inhibit undesired behaviors, but at great psychologic cost. Children mimic the corporal punishment that they receive, and it is common for preschool children to strike their parents or other children. Whereas spanking is the use of force, externally applied, to produce behavior change, discipline is a method that allows the to internalize controls on behavior. Alternative discipline strategies should be offered, such as the “countdown,” consistent approval. Discipline should be immediate, specific to the behavior, and time-limited. Time-out for approximately 1min/yr of age is very effective.
Age 6-11 yrs
In this period, previously referred to as “latency,” energy is directed toward creativity and productivity. The central Ericksonian psychosocial issue, the crisis between industry and inferiority, guides social and emotional development. Changes occur in three spheres: the home, the school, and the neighborhood. Of these, the home and family remain the most influential. Increasing independence is marked by the 1st sleepover at a friend’s house and the 1st time at overnight camp. Parents should make demands for effort in school and extracurricular activities, celebrate successes, and chores, associated with an allowance, provide an opportunity for children to contribute to family functioning and learn the value of money. These responsibilities may be a testing ground for psychologic separation, leading to conflict. Siblings have critical roles as competitors, loyal supporters, and role models.
The beginning of school coincides with a child’s further separation from the family and the increasing importance of teacher and peer relationships. Social groups tend to be same-sex, with frequent changing of membership, contributing to a child’s growing social development and competence. Popularity, a central ingredient of self-esteem, may be won through possessions (having the latest electronic gadgets or the right clothes) as well as through personal attractiveness, accomplishment, and actual social skills.
Some children conform readily to the peer norms and enjoy easy social success. Those who adopt individualistic styles or have visible differences may be teased. Such children may be painfully aware that they are different, or they may be puzzled by their lack of popularity. Children with deficits in social skills may go to extreme lengths to win deficits in social skills may go to extreme lengths to win acceptance, only to meet with repeated failure. Attributions conferred by peers, such as funny, stupid, bad, or scary, may become incorporated into a child’s self-image and affect the child’s personality. Parents may have their greatest effect indirectly, through actions that change the peer group (moving to new community or insisting on involvement in structured after-school activities).
In the neighborhood, real dangers, such as busy streets, bullies, and strangers, tax school-aged children’s common sense and resourcefulness. Interactions with peers without close adult supervision call on increasing conflict resolution or pugilistic skills. Media exposure to adult materialism, sexuality, and violence may be frightening, reinforcing children’s feeling of powerlessness in the larger world. Compensatory fantasies of being powerful may fuel the fascination with heroes and superheroes. A balance between fantasy and an appropriate ability to negotiate real-world challenges indicates healthy emotional development.
By the age of 5 or 6 yr, the child has developed a conscience, meaning that he or she has internalized the rules of the society. She or he can distinguish right from wrong but may take context and motivation into account. Children will adopt family and community values, seeking approval of peers, parents, and other adult role models. Social conventions are important, even though the reason behind some rules may not be understood. Initially, children have a rigid sense of morality, relying on clear rules for themselves and others. By age 10 yr, most children understand fairness as reciprocity (treat others as you wish to be treated).
IMPLICATIONS FOR PARENTS
Children need unconditional support as well as realistic demands as they venture into a world that is often frightening. A daily query from parents over the dinner table or at bedtime about the good and bad things that happened during the child’s day may uncover problems early. Parents may have difficulty allowing the child independence or may exert excessive pressure on their children to achieve academic or competitive success. Children who struggle to meet such expectations may have behavior problems or psychosomatic complaints.
Many children face stressors that exceed the normal challenges of separation and success in school and the neighborhood. Divorce affects nearly 50% of children. Domestic violence, parental substance abuse, and other mental health problems may also impair a child’s ability to use home as a secure base for refueling emotional energies. In many neighborhoods, random violence makes the normal development of independence extremely dangerous. Older children may join gangs as means of self-protection and a way to appropriate power and belong to a cohesive group. Children who bully others, or are victims of bullying, should be evaluated, since this behavior is associated with mood disorders, family problems and school adjustment problems. Parents should reduce exposure to hazards where possible. Due to the risk of unintentional firearm injuries of playmates whether a gun is kept in their home and, if so, how it is secured. The high prevalence of adjustment disorders among school-aged children attests to the effects of such overwhelming stressors on development.
Maladaptive behaviors, both internalizing and externalizing, occur when stress in nay of these environments overwhelms the child’s coping responses. Due to continuous exposure and the strong influence of media (programming and advertisements) on children’s beliefs and attitudes, parents must be alert to exposures form the television and Internet. An average American youth spends 4-6 hr/day with a variety of media, and over ½ of these children have a television in their from their children’s rooms, limit viewing to 2 hr/day, and monitor what programs children watch. The Draw-a-Person (for ages 3-10 yr, with instructions to “draw a complete person”) and Kinetic Family Drawing (beginning at age5, with instructions to “draw a picture of everyone in your family doing something”) are useful office tools to assess a child’s functioning.