Keywords
Development, Neonatal reflexes, Sports physical, Autonomy, Adolescence, Behavior
Newborn Period
Observation of any asymmetric movement or altered muscle tone and function may indicate a significant central nervous system abnormality or a nerve palsy resulting from the delivery and requires further evaluation. Primitive neonatal reflexes are unique in the newborn period and can further elucidate or eliminate concerns over asymmetric function. The most important reflexes to assess during the newborn period are as follows:
The Moro reflex is elicited by allowing the infant’s head to gently move back suddenly (from a few inches off of the mattress onto the examiner’s hand), resulting in a startle, then abduction and upward movement of the arms followed by adduction and flexion. The legs respond with flexion.
The rooting reflex is elicited by touching the corner of the infant’s mouth, resulting in lowering of the lower lip on the same side with tongue movement toward the stimulus. The face also turns toward the stimulus.
The sucking reflex occurs with almost any object placed in the newborn’s mouth. The infant responds with vigorous sucking. The sucking reflex is replaced later by voluntary sucking.
The asymmetric tonic neck reflex is elicited by placing the infant supine and turning the head to the side. This placement results in ipsilateral extension of the arm and the leg into a “fencing” position. The contralateral side flexes as well.
A delay in the expected disappearance of the reflexes may also warrant an evaluation of the central nervous system.
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, last, distal musculature. As the infant progresses through these stages, the parents may notice orthopedic deformities (see Chapters 202 and 203 ). The infant also may have deformities that are related to intrauterine positioning. Physical examination should indicate whether the deformity is fixed or can be moved passively into the proper position. When a joint held in an abnormal fashion can be moved passively into the proper position, there is 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 early health maintenance visits; interventions after age 2 decrease the chance of preserving binocular vision or normal visual acuity (see Chapter 179 ).
School Age/Preadolescent
Older school-age children who begin to participate in competitive sports should have a comprehensive sports history and physical examination, including a careful evaluation of the cardiovascular system. The American Academy of Pediatrics 4th edition sports preparticipation form is excellent for documenting cardiovascular and other risks. The patient and parent should complete the history form and be interviewed to assess cardiovascular risk. Any history of heart disease or a murmur must be referred for evaluation by a pediatric cardiologist. A child with a history of dyspnea or chest pain on exertion, irregular heart rate (i.e., skipped beats, palpitations), or syncope should also be referred to a pediatric cardiologist. 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 the evaluation before participation in sports.
Adolescence
Adolescents need annual comprehensive health assessments to ensure progression through puberty without major problems (see Chapters 67 and 68 ). Sexual maturity is an important issue in adolescents, and all adolescents should be assessed to monitor progression through sexual maturity rating stages (see Chapter 67 ). Other issues in physical development include scoliosis, obesity, and common orthopedic growth issues (e.g., Osgood Schlatter; see Chapters 29 and 203 ). Most scoliosis is mild and requires only observation for resolution. Obesity may first manifest during childhood and is a growing public health for many adolescents.
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 is 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 as easy to assess. Easily measured developmental milestones are well established through age 6 years only. Other types of assessment (e.g., intelligence tests, school performance, and personality profiles) that expand the developmental milestone approach are available for older children.
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.
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 in the first 4 months, 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 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. Ages 2-3 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 a balance of the child’s emerging independence.
Early Childhood Education
There is a growing body of evidence that notes that children who are in high quality early learning environments are more prepared to succeed in school. Every dollar invested in early childhood education may save taxpayers up to 13 dollars in future costs. These children commit fewer crimes and are better prepared to enter the workforce after school. Early Head Start (less than 3 years), Head Start (3-4 years), and prekindergarten programs (4-5 years) all demonstrate better educational attainment, although the earlier the start, the better the results.
School Readiness
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 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 chronological age and gender. Children tend to do better in kindergarten if their fifth birthday is at least 4-6 months before the beginning of school. Girls usually are ready earlier than boys. If the child is in less than the average developmental range, he or she should not be forced into early kindergarten. 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.
