4 Developmental Management in Pediatric Primary Care
Modern approaches to managing children’s well-being differ dramatically from those that prevailed at the turn of the last century, when health supervision often consisted of a brief examination to detect communicable or contagious diseases. In the twenty-first century significant social, economic, and demographic changes continue to influence the American family and affect children’s health. Children’s health supervision uses a broader approach than that necessary for disease detection. Pediatric primary care providers have a responsibility to monitor children’s overall physical, cognitive, and psychosocial development, and to provide anticipatory guidance to families as children grow. This requires a strong background in child development, knowledge of strategies that help parents understand and adjust to their child’s development, and an ability to establish effective relationships with children and their parents.
The Classification of Child and Adolescent Mental Health Diagnoses in Primary Care: Diagnostic and Statistical Manual for Primary Care (DSM-PC), Child and Adolescent Version (Wolraich et al, 1996) presents a comprehensive description of the physical and psychosocial developmental concerns of childhood and adolescence. An estimated 17% of American children have developmental or behavioral disorders (Bhasin et al, 2006). Thus, the pediatric primary care provider must have a sound knowledge of developmental and behavioral norms and variations (Dixon and Stein, 2006).
Pediatric providers offer parents support and suggest diverse approaches to childrearing. They help parents understand the challenges that new accomplishments create and how to best handle these challenges. Providers who develop a close relationship with parents and their children share in the parents’ pride as their child grows.
Not all health care providers satisfy the parents’ needs for guidance, however. A national survey of early childhood health (Blumberg et al, 2004) gathered data on parents’ perceptions of the anticipatory guidance received from their child’s primary health care provider. Parent reports indicated there were unmet needs, particularly for discussion related to discipline strategies and toilet training (expressed by 36% of parents with children 4 to 9 months old and 56% of parents with children 10 to 35 months old). Other areas in which parents wanted more information included reading, vocabulary development, social development, childcare, and burn prevention (Olson et al, 2004). To meet the needs of parents and children, it is imperative for primary care providers to have a sound foundation regarding all aspects of evaluating, assessing, and managing child development.
This chapter presents an introduction to principles of development, developmental theories, methods of developmental assessment, and identification and management of developmental problems. Chapters 5 through 8 review developmental theories, describe normal patterns of development, identify “red flags” related to development, and recommend anticipatory guidance for families of infants, toddlers and preschoolers, school-age children, and adolescents.
Developmental Principles
Development is a lifelong, dynamic process. Achievement of milestones in one phase sets the stage for the next phase. Development is also a dynamic and reciprocal process that occurs between the child’s internal and external environments. Key principles provide a context to understand concepts of development. Exactly how these principles manifest in a particular child depends on the child’s genetic background, personality, and intrauterine and extrauterine environmental factors.
Principle 1. Growth and development are orderly and sequential. Although children differ in rates and timing of developmental changes, they generally follow certain predictable stages or phases. Specific examples include the rapid growth during the first year of life, progress toward independence throughout childhood, and the development of secondary sex characteristics during adolescence.
Principle 2. The pace of growth and development is specific for each child. Developmental changes vary considerably for each child. Some children demonstrate early skill in motor coordination, others in language acquisition. These changes represent the uniqueness of each child.
Principle 3. Development occurs in a cephalocaudal and proximodistal direction. An example of this principle is seen as infants develop increasing motor coordination, gaining head control before sitting and walking. Similarly, developmental progress is seen in controlled movements that occur first near the midline of the body, such as rolling over. Eventually distal coordination of the hands, such as mastery of the pincer grasp, occurs.
Principle 4. Growth and development become increasingly integrated. Behavior that is taken for granted, such as self-feeding, occurs as a result of numerous small changes and skills acquired by the child. Simple skills and behaviors are integrated into more complex behaviors as the child grows and develops.
Principle 5. Developmental abilities increasingly organize and differentiate. As a result of increasing maturation and experience, children’s behaviors and responses to internal and external cues become more regulated, organized, and differentiated. The infant’s crying and body movements in response to hunger cues are different from the toddler’s walking to the refrigerator in response to the same cues.
Principle 6. The child’s internal and external environments affect growth and development. Opportunities for play, societal norms, cultural values, family traditions, and family beliefs all influence the development of children. Similarly, children influence their environment to achieve desired experiences and opportunities.
Principle 7. Certain periods are critical during growth and development. Critical periods are points of time when developmental advances occur and are particularly susceptible to alterations due to internal and external influences. The development of congenital anomalies when the fetus is exposed to certain viruses during fetal growth is one example.
Principle 8. Growth and development are dynamic processes influenced by many factors. Development is a continual process, often without smooth transitions. Phases of development are marked by periods of change, growth, and stability plateaus. Developmental predictors must incorporate the individual nature of development and the numerous individual factors that influence developmental outcomes (Cech and Martin, 2002).
Developmental Theories
Developmental theories include an array of ideas about how children progress from infancy through adolescence and provide many perspectives on children’s growth and development. Health care providers need to stay abreast of changing ideas regarding child development and appreciate new developmental theories relating to children. Developmental theories are based on various cultures, personalities, environmental issues, philosophical beliefs, and investigative methods. Thus, when using a developmental perspective in practice, the provider should understand how the theory was developed and how it may relate to a particular family and child. Developmental theories provide guidelines for understanding the unfolding of the child’s behavior, personality, and physical abilities. It is usually necessary to combine several theories to understand the child as a whole person.
Criticism of the work of early child development theorists stated that they lacked an evidence base, failed to consider the child in different cultural and socioeconomic settings, and had a linear focus that missed the subtleties of the interaction of “nature” and “nurture.” More research is being conducted to validate and test developmental theories, incorporate new concepts, and gain a better understanding of children’s learning mechanisms, especially children who have special needs.
Ethology: Animal Studies
The study of animal behavior, looking at the concepts of bonding, altruism, social intelligence, and dominant and submissive behavior led to theoretic assumptions that frame the study of child development. Bowlby (1969) first generalized theories developed about animal behavior to bonding for humans, articulating the concept of attachment theory. Ainsworth and colleagues (1971) examined the elements of early attachment and separation in child development and personality. This was followed by Klaus and Kennel’s work (1976), which emphasized the importance of early mother-infant contact. Their work later became the basis for changes in hospital rooming-in care.
Maturational Theories: Developmental Milestones
Early theories about human behavior set the stage for studies of child development. Rousseau’s descriptions in 1762 of the natural, innately good growth of the child, if not misled by a “corrupt social environment,” provided the foundation for maturational theories. Gesell (1940) is credited with the term maturation in reference to the orderly, sequential developmental changes that occur over time. He described cycles of behavior that correspond to certain chronologic ages. His work resulted in the chronologic growth and development norms for motor, affective, linguistic, and social domains that are now used to assess developmental progress.
Lewin (1936) identified growth principles and the currently acknowledged stages of infancy, early childhood, and adolescence. He provided an understanding of the play and decision-making phases through which children progress.
Havighurst’s work (1953), a summation of ideas from many theorists, popularized the concept of developmental tasks as “successful achievement which leads to happiness and to success with later tasks, while failure leads to unhappiness in the individual, disapproval by society, and difficulty with later tasks.”
Cognitive-Structural Theories: Language and Thought
Cognitive-structural theories examine the ways in which children think, reason, and use language. They are based on assumptions about central nervous system maturation and children’s interactions with their environment. Individual differences are ascribed to genetic endowment and environmental influences.
Jean Piaget’s observations, many of which were of his own children, provide an understanding of children’s cognitive development and their perception and interaction with the world around them. Piaget (1969) described how children actively use their life experiences, incorporating them into their own mental and physical being over time. He emphasized how children modify themselves depending on their environmental experiences and their stage-related competency level. Piaget described four stages of cognitive development (Table 4-1).
Sensorimotor Stage (Birth to 2 Years)
At this stage children learn about the world through their actions and sensory and motor movements. Key concepts during this period include object permanence, spatial relationships, causality, use of instruments, and combination of objects. The child’s framework for learning is the self, and there is little cognitive connection to objects outside the self.
Preoperational Stage (2 to 7 Years)
Children next attempt to make sense of the world and reality. However, this is based on an egocentric perspective and is accomplished through certain mental operations that are linked to concrete objects. Children at this stage are not able to understand cause and effect. Therefore, their reasoning is often flawed. Children begin to use semiotic functioning, or the use of one thing to represent another. Intuitive reasoning emerges toward the end of this stage, but reasoning continues to be connected to the concrete reality of the here and now.
Concrete Operational Stage (7 to 12 Years)
Children use symbols to represent concrete objects (here and now) and perform mental operations in their head. This requires cognitive skills to organize experiences and classify increasingly complex information. Most schoolwork requires functioning at this level with flexibility of thought, declining egocentrism, logical reasoning, and greater social cognition.
Formal Operational Stage (13 Years through Adulthood)
At this stage, children begin to think abstractly and imagine different solutions to problems and different outcomes. Adolescents begin to develop increased awareness of degrees of illness and personal control of one’s health. Renewed egocentrism may be noted early in this stage as a result of a lack of differentiation between what others are thinking and one’s own thoughts. This egocentric thinking eventually gives way to an appreciation of the differences in judgment between the adolescent and other individuals, societies, and cultures. It becomes the basis of an adolescent’s ability to think about politics, law, and society in terms of abstract principles and benefits rather than focusing only on the punitive aspects of societal laws.
Piaget’s work was expanded by theorists such as Flavell (1977) and Siegler and colleagues (1973), who looked at specific intellectual capabilities via the information processing model. This model included concepts of attention, perception, memory, and making inferences and provided an initial understanding of how mental activity leads progressively to more sophisticated ways of handling information.
Kohlberg (1969) focused on theories of moral development and socialization, emphasizing the process by which children learn the expectations and norms of their society and culture (see Table 4-1). Kohlberg’s work primarily involved male participants. Gilligan (1982) suggested that female thoughts and actions involve significantly different objectives and goals, specifically that girls tend to think more in terms of caring and relationships, basing their moral judgments on complexities they perceive in human interactions.
The Role of Social Interaction in Cognitive Development
Vygotsky’s theory of child learning states that as children interact with others, they develop as individuals within cultural contexts. They simultaneously develop memory, problem-solving skills, attention, and concept formation (1978). Core to Vygotsky’s theory is the “zone of proximal development,” which is the difference between what a child can do on his or her own and what he or she can do with help from others.
Vygotsky believes that children learn by watching adults and other children and that children learn best when their parents and caregivers provide them with opportunities in the child’s zone of proximal development. This theory holds that cognitive development occurs in a social, historical, and cultural context, and that adults guide children to learn. Development depends on the use of language, play, and extensive social interaction. One of Vygotsky’s examples is the process of the child learning to point his or her finger. Initially, the infant points his or her finger without meaning; however, as people, and especially caregivers, respond to the finger pointing, the infant learns there is meaning to the movement. What starts as a muscle movement becomes a means of interpersonal connection between two people (Vygotsky, 1978). This theory further holds that play and learning should be constructed to take into consideration the child’s needs, inclination, and incentives. This theory supports the benefit of adult social learning opportunities via group interaction and observation.
Psychoanalytic Theories
Personality and Emotions
Psychodynamic theorists study factors that influence the emotional and psychological behavior of individuals. Personality includes the characteristics of temperament and motivation, in addition to concepts related to self-esteem and self-concept. Sigmund Freud (1938) was one of the most influential theorists in this area. Freud sought to find links between the conscious mind and the body through the unconscious mind (see Table 4-1). Some of his most significant contributions were his descriptions of the interactions of id, ego, and superego (Thomas, 1985).
Erikson (1964) expanded Freud’s theories, describing the stages of the individual throughout the life span (see Table 4-1). Each stage presents problems that the individual seeks to master. Erikson believed that if problems were not resolved, they would be revisited again at future stages.
Mahler and colleagues (1975) analyzed the development of an infant’s evolving independence through study of the mother-infant dyad. Three phases of development were proposed: autism, symbiosis, and separation-individuation. They posited that these phases account for the gradually increasing awareness of the infant’s sense of self and others. In the autistic phase (3 to 5 weeks old), the infant has no concept of self but is working, physiologically, to achieve homeostasis in the extrauterine world. The second phase, symbiosis, refers to a period of undifferentiation or fusion with the mother in which infant and mother form a dual unity. Separation-individuation (from about 4 to 5 months old onward) is characterized by a steady increase in awareness of the separateness of the self and the other.
Infant attachment within the context of separation and connectedness has been explored by Stern (1985), Emde and Buchsbaum (1990), and Rogoff (1990). They propose that the quality and consistency of infant-caregiver relationships help the infant develop an affective, or emotional, sense of self. The early beginnings of the sense of self are based on three biologic principles: self-regulation, social fittedness, and affective monitoring (Emde, 1988). Infants with attachment security and a sense of connectedness are more likely to explore and be autonomous; they also have what is called an internal working model to guide them in later attachments.
The concept of intersubjectivity, or mutual understanding of meaning and mutual engagement in social interactions, underlies attachment theory. Observing that even very young infants demonstrate an ability to interact beyond an instinctive or reflexive manner with a sympathetic individual, Trevarthen and Aitken conducted an extensive review of the literature on the topic of infant intersubjectivity (2001). They concluded that the infant’s capacity for self-regulation may be based in the operation of an intrinsic motive formation (IMF) developed in the parietotemporal region of the prenatal brain. Studies of the brain and infant behavior suggest that this IMF guides the newborn’s ability to integrate sensory-motor coordination, orient to preferred stimuli (e.g., mother’s voice), sustain mutual attention with an affectionate other, and anticipate what to expect in the environment. Successful development of the infant’s “purposive consciousness” and the ability to cooperate with and learn from another depends on the neurologic functioning and the presence of a supportive environment. The parent guides the infant to connect with others and experience mutuality. Social interactions and infant engagement with their parents and objects in their world are major developmental influences.
These theories help the provider assist parents to understand why, for example, 9-month-old infants (who now understand object permanence) will look over the side of the highchair for food or a toy that has fallen to the floor and smile and laugh when they spot it because they knew it would be there. These same infants may call a parent to their room in the middle of the night; they now have “person permanence.” They can picture their parent in their mind and, perhaps experiencing normal separation anxiety, they want the parent to come to them. The provider can use the concepts of attachment theory and intersubjectivity to explain that this behavior is that of a normal developing infant trying to have his or her needs met. The behavior reflects an infant who is attached and who uses the parent as a secure base from which to explore the world. It is not a problem, nor is the child being “bad.”
Behavioral Theories: Human
Actions and Interactions
Behaviorism, the study of the general laws of human behavior, focuses on the present and ways that the environment influences human behavior. Skinner’s view of child development examined learning that was controlled through classic operant conditioning (1953). Behavior modification therapy is largely based on Skinner’s work. Bandura’s social learning theory looked at imitation and modeling as a means of learning, emphasizing the social variables involved (Mott, 1990; Thomas, 1985). Bijou and Baer (1965) responded to critics of behaviorism’s view of the child as a passive object, arguing that children’s responses to environmental stimuli are dependent on their genetic structure and personal history (Thomas, 1985).
Humanistic Theories
Innermost Self
Maslow (1971), Buhler and Allen (1972), and Mahrer (1978) are among the most well-known humanistic theorists, examining development throughout the life span. Maslow’s hierarchy of needs included physiologic, safety, belongingness and love, esteem, and self-actualization needs. He differentiated deficiency needs from growth or self-actualization needs. Rather than proposing stages through which children or adults mature, the humanists believe that individuals and those around them are responsible for any movement they make from one plateau of needs to another; intrinsic forces do not move them along.
Ecologic Theories
The key concepts of human ecology theory (Bronfenbrenner, 1979) emphasize the interdependence between environmental settings (roles, interpersonal relations, and activities) and the developing child. Development is described as the growing capacity to discover, sustain, or alter the self or the environment. Children are viewed as dynamic entities who are increasingly able to restructure the settings in which they live. Environments are seen as influencing children, leading to mutual accommodation and reciprocity. Children’s perceptions of the environment influence their behavior and development more than the objective reality does.
Children are influenced by the home and family, child care settings, schools, entertainment and recreational activities, their parents’ work, and broad economic opportunities in society. Recognition is given to ecologic transitions or changes in an individual’s role or setting, such as the birth of a sibling or changes in family structure. Routine and ritual within the family system can be powerful mediators of children’s development (Fiese, 2002; Kubicek, 2002). The parent-child interaction also may be inhibited or enhanced by the parents’ relationships. When parents experience positive mutual feelings, the parent-child relationship is strengthened. Alternatively, when parents experience mutual antagonism or interference, the parent-child relationship may be impaired (Kelly and Barnard, 2000). These theories are especially useful to better understand the impact of domestic violence on a child’s development and future.
Temperament
The work of Chess and Thomas (1995) explains the role that temperament plays in children’s behavior. They identified characteristics or qualities of temperament and introduced the concept of “goodness of fit” to describe the degree to which the child’s environment and parents’ characteristics, including the parents’ temperament, are congruous with the child’s natural temperamental characteristics. Understanding the child’s unique temperament prepares the health care provider to help parents and other caregivers to better understand the child’s behavior, especially when the behavioral reactions are confusing or problematic for the parents. The provider can discuss with parents their view of their child’s temperament, how it “fits” with the parents’ temperament or that of other family members, and what parent-child strategies can be used if conflicts emerge between the child’s temperament and the caregivers’ personal style. The intent is to alleviate guilt and frustration and to assist parents to develop skills that enhance positive behaviors rather than exaggerate difficult temperamental characteristics. Being able to support both the parent and child’s needs can prevent significant problems later on. Table 4-2 further defines characteristics of temperamental differences.
TABLE 4-2 Characteristics of Temperament
| Temperament Characteristic | Description |
|---|---|
| Activity | What is the child’s activity level? Is the child moving all the time he or she is awake, some of the time, or rarely? |
| Rhythmicity | How predictable is the child’s sleep-wake pattern, feeding schedule, and elimination pattern? |
| Approach or withdrawal | What is the child’s response when presented with something new such as a new toy, a new experience, or a new person? Does he or she immediately approach or turn away? |
| Adaptability | How quickly does the child get used to new things? Quickly or not at all? |
| Threshold of response | How much stimulation does the child require for calming? A quiet voice and touch or more intense, loud voice or firm grasp? |
| Intensity of reaction | Are the child’s responses (crying or laughing) very subtle or extremely intense? |
| Quality of mood | Is the child’s mood usually outgoing, happy, joyful, pleasant or unfriendly, withdrawn, or quiet? |
| Distractibility | How easily is the child distracted by outside disturbances such as a phone ringing, TV, siblings? |
| Attention span and persistence |
Self-Regulation
Self-regulation involves a transition from mutual regulation between mother and newborn and emphasizes the importance of both “nature and nurture” in a child’s development (Shonkoff and Phillips, 2000; Trevarthen and Aitken, 2001). Examples of self-regulation are early infant sleep patterns and the ability to self-soothe, the toddler’s ability to manage emerging emotions, the preschooler’s ability to transition from home to school, the school-age child’s ability to focus attention on important tasks, and the adolescent’s sense of confidence and competence. Learning self-regulation is influenced by differences in temperament, genetics, child abilities, and characteristics of the child’s environment (Kochanska et al, 2001). The ways in which the social environment interacts with the individuality of the child and the types of interventions that will contribute to successful self-regulation continue to be explored. One important variable influencing the child’s development appears to be a need for a predictable and consistent environment and a caring, emotionally available caregiver (Bronson, 2000).
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