4.1 Life events of normal children
Although every child follows his or her own individual developmental trajectory, most children achieve developmental milestones at predictable ages (see Chapter 2.2). These anticipated milestones provide an important yardstick against which to assess the individual child’s development. A departure from these expected developmental milestones, usually presenting as a developmental delay or behavioural problem, should prompt concerns that development is not proceeding normally.
• Organic causes of infant crying are uncommon but should be suspected if there is associated atopic disease (such as eczema), poor weight gain, frequent (more than three times per day) vomiting or blood/mucus in the infant’s bowel actions.
• In toddlers, low-priority misbehaviours (e.g. tantrums, whining) are best managed by ignoring or distraction.
• High-priority misbehaviours (e.g. hitting, kicking) are best managed by asking the child to stop and, if they do not, by putting them in ‘time out’.
• A child with unexplained school-based behaviour or learning problems usually needs a multidisciplinary assessment, including vision and hearing testing and, where possible, cognitive testing by an educational psychologist.
• Up to one in five adolescents will experience significant physical or emotional problems. Screening questionnaires that encompass home, school, recreational drug use, sexuality and suicide/depression issues can help to detect these problems.
The development of infants and young children is determined by their genetic potential as expressed by their interaction with the environment. In the early years it is the parents, most often the mother, who shape the infant’s environment. Research in recent years has served to re-emphasize the importance of the caretaking environment on the developing brain, which in turn impacts on functioning later in life.
A key requirement for optimal child development is secure attachment to a nurturing and responsive caregiver, with consistent affection and caring. A child’s and subsequently an adult’s emotional health are significantly influenced by these early relationships. Early development in the context of secure early relationships lays the foundations for future developmental competence.
The child’s behaviour and development are always the result of a complex series of transactions between the child and the environment. Assessment of the child’s environmental context therefore, is a critical part of behavioural and developmental assessment.
Risk and resilience
There are well-documented risk factors that make the child vulnerable to a less than optimal outcome. Similarly, there are protective factors that increase the resilience of the child and increase the likelihood of a good outcome. Some of the risk and protective factors are:
• Child factors (e.g. prematurity or chronic illness versus good language or social skills)
• Family factors (e.g. parental mental illness versus stable income or family cohesion)
• Community factors (e.g. inadequate housing versus participation in community activities)
• Broader environmental influences (e.g. drought versus universally available health care).
Parent and family relationships are some of the most important protective factors in promoting optimal development. Recent research suggests the initial ‘map’ for brain development provided by genes is shaped and sculpted by the caretaking environment. The development of neural connections in early childhood is determined largely by environmental inputs.
Risk and protective factors tend to be cumulative, so that combinations of risk or protective factors are more powerful than individual factors.
Developmental stages
In the course of the child’s development there are certain important transition stages. Each stage is associated with predictable developmental events and behaviours, stresses and challenges. The negotiation of each of these transitions is an important milestone that allows the child and the family to proceed to the next level of development. Stresses and challenges that are commonly encountered during these transitions but not managed appropriately may result in negative influences on the child’s developmental trajectory.
Important developmental stages are considered below. Risk factors and professional interventions that may be of assistance are outlined.
Pregnancy and birth
The goal is to produce a healthy, full-term infant, together with a healthy mother who can cope with the inevitable stresses and change in lifestyle that comes with a newborn baby.
Risk factors include maternal factors such as physical and mental illness, substance abuse, smoking, inadequate folate intake, low maternal age, single parenthood and poverty. Infant risk factors include genetic defects, birth trauma and prematurity.
Professional intervention. Regular antenatal care enables early detection and intervention for maternal and fetal complications. During labour the presence of a supportive partner or friend has been shown to decrease time in labour and reduce complications. Early mother–baby contact facilitates breastfeeding and sets the stage for a positive mother–infant relationship. While in hospital it is important to establish links with postnatal services such as maternal and child nurses, general practitioners and home visiting services.
Early infancy (0–6 months)
This is often a challenging time for the family. Parents and family aim to establish a routine incorporating the needs and demands of the new infant. Parents bring to this transaction their own beliefs and experiences, with varying levels of confidence and competence, and skills at handling stress, uncertainty and fatigue. Parents begin to understand their baby’s visual, motor and verbal cues, and respond appropriately. This is the beginning of a reciprocal relationship or ‘dance’ that shapes the baby’s brain development. If things do not go smoothly, and the mother perceives the infant as difficult and demanding, the long-term mother–child relationship can be compromised, setting the stage for possible future parenting and behaviour difficulties.
Establishing appropriate feeding patterns, preferably breastfeeding as this has many advantages, is another crucial task. Another important task is the introduction of solids, with many mothers beginning to think about weaning between 4 and 6 months of age.
Risk factors include maternal factors such as an unwanted child, prenatal complications, problems with bonding and attachment, maternal depression, social isolation, few or no identified supports, and a stressful family situation. Infant risk factors include difficult temperament, excessive crying and irritability, sleep problems and difficulty feeding.
Professional intervention. Providing support to parents is essential. Assisting parents with realistic expectations and understanding of their baby’s developmental needs and linking them up with a network of family and professional supports are crucial interventions. Medication and frequent formula changes are usually inappropriate for sleeping and crying problems. Rather, parents need reassurance that their infant is healthy and does not have any underlying medical condition. They should aim to settle their infant with a consistent approach that enables the infant to fall asleep on his or her own rather than being held, rocked or fed to sleep. Some families find a routine of feeding the baby followed by a short play and then sleep helps. Mothers experiencing problems with breastfeeding should be managed by an experienced community nurse or lactation consultant. Sometimes there are early clues as to serious dysfunction, such as maternal depression or major difficulties in the mother–child relationship, so that more intensive intervention may be required. All parents need to learn how to manage the following inevitable issues:
• Crying. All infants cry. This is now understood to be a normal part of development. However, some infants are difficult to console and their crying causes major stress for parents. About 10% of infants cry for more than 3 hours per day, 3 or more days per week for 3 or more weeks. These infants are often labelled ‘colicky’. Underlying medical causes for crying are uncommon (< 5%) and include cow’s milk protein allergy, lactose intolerance and possibly gastro-oesophageal reflux disease. Most crying abates by age 3–4 months, and crying persisting after this raises the possibility of organic illness or concerns in the mother–baby relationship.
• Feeding. Most mothers want to breastfeed their infant but not all mothers find breastfeeding easy. Problems with incorrect attachment to the breast are common and may lead to difficult and painful breastfeeding and early weaning.
• Sleeping issues. Most infants establish a sleep pattern after 3 months of age, although they may not begin to sleep through the night until 6 months. Common parental complaints include difficulties settling their infant and frequent night waking.
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