Understanding child development and its associated constructs sets the care of children apart from the care of adults.¹ There is consensus on the need to provide developmentally appropriate health care to children and adolescents, especially in the context of disability and chronic illness.² When provided with an appropriate venue children across developmental ages can develop mastery in skills necessary to adapt and cope with illness, hospitalization, and treatment. They begin to understand many aspects of illness and treatment. Over time they are adept participants in care and treatment planning, able to communicate their needs as active partners in physician-patient-parent communication triads.³

DEVELOPMENTAL STREAMS AND MILESTONES

Human development is a highly dynamic process that involves an interaction between the genetic and neurologic makeup of a child with the environment in which he or she lives.⁴ Children are typically monitored in health supervision visits across dimensions or streams of development including physical, social and emotional, language, and cognitive growth.¹ Milestones are the myriad of developmental achievements that occur in typical patterns over predictable sequences in time.⁴ Knowledge of these sequences aids the inpatient medicine physician in being able to explain diagnosis, care, and treatment to patients and families, aid parents in helping their children adapt to hospitalization, and promote health and well-being in a developmentally appropriate manner. Table 9-1 outlines the specific milestones for various developmental streams, with special attention paid to when the absence of a skill becomes a red flag for problems.

Physical Development

Beginning with neonatal reflexes, the development of both gross and fine motor skills is a process of extreme variability, both in the rate of maturation and in the way that skills are achieved.⁴ Despite the variation, there are constants in motor development that are largely universal. For example, reflexive movement always precedes voluntary movement, proximal control always precedes distal control, and pronation always precedes supination.⁵ In addition, children develop the ability for a particular action before they learn to inhibit it; if they begin to run, it may take a few falls before they learn how to stop.

Social and Emotional Development

The development of adequate social and emotional skills is one of the most complex and critical tasks of childhood. Social development is interdependent on other streams of development as well as influenced by environment. Attachments formed in infancy are critical for emotional, social, and behavioral self-regulation and the formation of social relationships with others.^4,6 In the medical setting, coping with hospitalization, separation, and overall adjustment to disease and illness, as well as family adaptation and adherence to regimens are correlated to the social and emotional abilities of a chronically ill child.³

Language Development

Language is part of a broader set of communication skills that involve a combination of speech content and character (e.g. intonation), nonverbal gestures, attention, and comprehension skills. These skills are thought to be the building blocks for socialization, memory formation, achievement, and learning. In medicine, patient-provider communication involves understanding the level at which your patient can communicate effectively to you, and is vital to quality patient care.⁷ Eliciting symptoms from children, explaining illness, procedures, and regimens adequately necessitates a developmentally sensitive approach, which requires a fundamental understanding of the basic developmental milestones of expressive and receptive communication.

Cognitive Development

Cognitive development is a known determinant of child understanding of illness and pain.^8-10 Historically, research has explored how cognition shapes a child’s attitudes, beliefs, and behavior, as well as overall adjustment to disease, injury, and illness.^8-10 According to Piaget’s theory, children progress through stages of development, each with tasks necessary for cognitive progression to the next stage. Piagetian stages have persisted as the foundation for how children formulate ideas about their own health and illness (Table 9-2). Although type of information presented and prior experience can enhance understanding, it has been shown that cognitive developmental status predicts childhood understanding of disease and medical procedures better than age or other variables do.^6,8-10