CHAPTER 12

During the first 18 months of life, the social and emotional areas of the brain grow and develop more rapidly than the language and cognitive areas.1 These right brain nonverbal systems build from social-, relational-, and attachment-based experiences and create the emotional regulation and stress regulatory systems of the body that may last a lifetime. Therefore, the quality of the child’s early social and emotional experiences may have lasting implications. The young child who is raised in a nurturing, predictable, and safe environment is likely to be more resilient when faced with stressful experiences later in life. Conversely, the young child who is faced with stressful, chaotic, or traumatic early experiences may suffer lifelong consequences.

As children grow and develop through early childhood, middle childhood, and adolescence, the quality of their interactions with caregivers, extended family, peers, teachers and coaches, and other community members has an ongoing impact on their social and emotional development. The monitoring of social and emotional development and family relationship patterns from infancy through adolescence is a vital component of health supervision.

America’s Promise Alliance has identified 5 key resources or “promises” that correlate with success in youth and adulthood.² Children who grow up in homes with caring adults, in safe places where they have opportunities for constructive use of time, with a healthy start and healthy development, with effective education for marketable skills and lifelong learning, and with opportunities to make a difference through helping others have a much greater chance of experiencing success.² Teens who receive 4 of these 5 promises are nearly two-thirds more likely than those who have only 0 or 1 promise to be generous, respectful, and empathetic, and to resolve conflicts calmly. Younger children with 4 or more promises are twice as likely as their peers to be socially competent than their peers with 0 or 1 promise. Unfortunately, research performed by America’s Promise Alliance indicates that more than two-thirds of children from 6 to 17 years of age are not receiving sufficient resources to place them on a path for success.

Felitti3 and Shonkoff and Garner¹⁴ have documented that adverse childhood experiences, especially inadequacies in early parental care, are associated with higher rates of both acute and chronic psychosocial disorders in adulthood. Most long-term sequelae seem to depend on a series of short-term links, some related to continued elevated risks of environmental adversity, others related to psychological vulnerabilities and resiliencies and problems in intimate social relationships. Primary pediatric health care professionals are well positioned to work with families to promote social competence at individual, practice, and community levels and potentially reduce the risk for long-term concerns in social and emotional health.

Social and Emotional Milestones

Social and emotional development progresses through predictable stages in healthy children. Monitoring the milestones of social and emotional development is an important component of health supervision from infancy to young adulthood. Multiple observations will provide opportunities to identify variation from the expected path of development early, facilitating early identification and treatment. Failure to achieve expected milestones at any age should trigger further investigation and consideration of referral.

During the infant and toddler period, the major tasks of social and emotional development are to experience and regulate emotions, develop secure relationships, and begin to explore and learn. Even in the first few months of life, the infant’s temperamental characteristics will emerge. Chess and Thomas5 have described 3 functional constellations of temperament. The “easy” group includes 40% of children. These children demonstrate regularity, positive approach responses to new situations, high adaptability to change, and a mild-to-moderate, predominantly positive mood. About 10% of children have a “difficult” temperament. These children have irregularity in biological functions, negative withdrawal responses to new situations, poor or slow adaptation to change, and intense, often negative moods. The “slow to warm up” temperament is seen in 15% of children. This group combines mild, negative responses to new situations with slow adaptability after repeated exposure. With additional opportunities with new experiences, these children will eventually show quiet and positive interest. Not all children fit into 1 of these 3 groups. Others will have a mix of temperamental characteristics. It is vital that the child’s temperament be considered when assessing social and emotional development and parent-child interaction. The most important factor may be the “goodness of fit” between the child’s temperament and the temperaments of his caregivers.

Information on the stages of social and emotional development outlined below is adapted from Bright Futures.⁶

The newborn is most responsive during short periods in a quiet, alert state. She recognizes the unique smell of her mother, can hear and prefers her parents’ voices, responds favorably to gentle touch while withdrawing from unpleasant touches, and can imitate simple facial expressions from a distance of 7 to 8 inches.

Throughout the first 2 months, the infant becomes increasingly capable of consoling and comforting himself while becoming increasingly alert, smiling responsively, and responding to calming actions when upset. By 4 months, he smiles spontaneously, initiates, sustains, and reciprocates during social interactions, and shows an even greater capacity to comfort himself. He has discovered that he can control the movements of his hands and may use them to console and comfort.

By 6 months, she recognizes and responds specifically to familiar faces and is beginning to notice strangers. She has sustained interactions and jointly attends to actions and objects of interest with her parents and regular caregivers. At 9 months, she is apprehensive of strangers and actively seeks out her parents for play, comfort, and assistance. By 12 months, she has a strong attachment with her parents and significant caregivers and shows distress on separation from her parents. The 12-month-old plays interactive games like peek-a-boo and pat-a-cake and uses gestures to wave bye-bye and to indicate interests and needs. She will hand a toy or book to her parent when she wants to play or hear a story.

By 15 months, he is very interested in imitating whatever he sees. He may start to help with simple household tasks and will listen actively to stories. His interactions with his parent or caregiver should be robust, complex, continuous, and goal-directed. By 18 months, his temperament will be more and more evident in his approach to participating in new or familiar group settings. Temper tantrums frequently emerge. He may be interactive or withdrawn, friendly or aggressive. He will show increasing willingness to separate and explore on his own, testing boundaries and limits but will want his parent in close proximity for periodic, reassuring check-ins or encouragement. He is spontaneous with affection and laughs in response to others.

The Association of Maternal and Child Health Programs and the National Network of State Adolescent Health Coordinators have identified critical developmental tasks that indicate healthy progression through adolescence from 10 to 24 years of age.7 In the context of caring, supportive relationships with family, other adults, and peers, a child will have increasing opportunities to engage in positive activities in his community that will promote a sense of self-confidence, hopefulness, and well-being. As the 11- to 14-year-old approaches adolescence, there is a greater drive for independence and a growing commitment to the peer group. Concurrently, the young adolescent develops a capacity for abstract and symbolic thinking that enables deeper and more creative cognitive analysis along with the tendency to challenge his own thinking and that of the adult authority figures in his life. As a result, he may engage in risky behavior to impress his peers. He will respond well to authoritative parenting that is firm, accepting, and democratic. Social networks will form, break down, and then form again. He will usually cope well with these stressful experiences and should be encouraged and supported while making more and more independent decisions. As the adolescent approaches young adulthood, school and work and its activities are the central focus of his life. It becomes increasingly important to monitor for emotional problems and risk-taking behaviors.

By understanding the expected path of social and emotional development from infancy through adolescence, the primary pediatric health care professional will be well positioned to anticipate areas for timely guidance and to identify variations in development that warrant intervention (Table 12.1).

The fourth edition of Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents outlines the components of health supervision and places special emphasis on promoting child development, mental/behavioral health, and life-long health for families and communities, along with resources for key themes to be addressed in the well-child visits.⁶ Bright Futures recommends that each preventive health visit include establishing a context for the visit, setting priorities for the visit, a review of the interval history, observation of parent-child interaction, surveillance of development, a physical examination, screening, immunizations, other practice-based interventions, inquiry into relevant social contexts and family transitions or stressors, including screening for maternal depression, and offering anticipatory guidance. The American Academy of Pediatrics (AAP) has published recommendations for developmental surveillance and screening of young children.⁸ The components of surveillance include eliciting and attending to the parents’ concerns, identifying risks and protective factors, maintaining a developmental history, making accurate observations of the child, and documenting the process and findings. These components can be reviewed in the context of the Bright Futures framework. All of these elements can contribute significantly to the understanding of a child’s social and emotional development and assist in identifying opportunities to build on strengths within the child, family, and community, as well as identifying concerns that may require additional support and intervention.

Context

Squires et al recommend considering the following variables: setting/time, development, health, and family/cultural considerations.9 First, where and when a behavior occurs may lead to different interpretations of the behavior. A child who is hitting or biting his younger sibling may have that behavior accidentally rewarded when it draws attention from his mother. However, the same behavior may quickly disappear in a child care setting where the child is redirected and given descriptive praise for gentle touching and has models for appropriate play with peers. Timing makes a difference as well. A child who experiences a major traumatic event early in life may experience lasting effects, while the same experience for an adolescent with strong coping skills may lead to only a temporary setback.

Second, it is vital that demands and expectations placed on the child be matched to the child’s overall level of development, including cognition, language, academic, and motor skills. Children with isolated or global delays in development may develop secondary behavioral or emotional symptoms due to frustration or a tendency to avoid tasks that may be too difficult for them. There may be wide variation in achieving various milestones. Opportunities for serial observations allow the primary pediatric health care professional to establish whether the child is progressing as expected over time. However, the health care professional should not dismiss problems based on the assumption that they are simply due to normal variation.

Third, health variables may also affect children’s social and emotional functioning. The child with obstructive sleep apnea may be irritable and inattentive at school. A child with atopic dermatitis may be so uncomfortable with pruritus that she may be noncompliant. Children with special health care needs may develop a pattern of learned helplessness because of their chronic illness and its accompanying challenges.

Finally, the patterns of interactions and communication within family relationships in the context of family values and culture have a significant role in determining children’s social and emotional responses. Some cultures allow their emotions to flow freely and openly, while others expect children to hold their emotions inside. Various cultures have different expectations regarding when children should sleep on their own, be weaned, master toileting, and dress themselves.¹⁰ Children who grow up in families affected by parental mental illness,¹¹ marital discord and domestic violence,¹² high levels of stress,⁴ or poverty^13,14 may show changes in their social and emotional functioning in an attempt to cope with these challenges.

Priorities

The needs, concerns and resources of the family should be given first priority during each visit. Because as many as 25% of children have social or behavioral problems,15 it is likely that concerns about social and emotional development will be raised during many preventive health visits. It may be necessary to give up one’s professional priorities for the visit in order to address the family’s and child’s concerns. The American Academy of Pediatrics recommends routine screening for behavioral and emotional problems.¹⁶ In addition, Bright Futures recommends that maternal and family functioning be a priority for all health supervision visits,⁶ including screening for maternal depression in early infancy.¹⁷ A focus on social and emotional functioning and parent-child interactive patterns should be emphasized during early infancy, between 18 and 30 months, and at the transitions to kindergarten, middle school, and high school. These times coincide with anticipated challenges to social and emotional competence.

Social-Emotional Surveillance and Interval History

When social and emotional development is identified as a priority for the visit, several open-ended questions can set the stage for a productive, targeted discussion. Asking parents to share emerging abilities, behavior and personality can be a good starting point. Following this by asking whether there are any concerns about the child’s development, behavior, or learning can be very productive. Parents’ concerns about their child’s development, behavior, and learning are substantiated at least 70% of the time.^18,19

Additional trigger questions to assess social and emotional functioning include²⁰

■How are things going for you as a parent?

■What changes have you seen in your child’s development or behavior since the last visit?

■What does your child do really well? With you? At school? In the community?

■What kind of child is she? Tell me about your child’s personality or temperament.

■What are your child’s favorite play or recreational activities?

■What do you enjoy doing together?

■Have there been any significant changes or stressful events in the family since the last visit?

■Has anything bad, sad, or scary happened to you or your family since our last visit?

■What do you find most difficult about caring for your child now?

■How do you and your child solve problems?

The Classification of Child and Adolescent Mental Diagnoses in Primary Care: Diagnostic and Statistical Manual for Primary Care (DSM-PC)²¹ provides a framework for assessing protective factors and environmental challenges. When faced with a child or family who appears at risk, this framework can provide a structured approach to identify opportunities to further support social competence and for remediation.

Once children reach the age of 3 or 4 years and through adolescence, these questions can be adapted and asked directly of the child. The primary pediatric health care professional may be reassured by the response or may feel a need to probe further.

Children have a full set of emotions by 3 years of age.22 By 5 years of age, most children are skilled at describing their feelings. It is appropriate to ask school-aged children to describe examples of what leads them to feel various emotions.

■What makes you happy? Sad? Mad?

■What makes you afraid?

■What do you worry about? Do you have any worries about your body or about your health?

■Are there things you are afraid might happen to you or to people you care about?

■Have you ever thought about hurting yourself or running away? If so, have you made a plan? If you ever do think of hurting yourself, is there an adult you can talk to about your feelings?

■Do you have a best friend? What do you like to do with your friends? Are you being bullied?

■What would you like to change about yourself? What would you like to change about school? What would you like to change about your family?

■If you had 3 wishes, what would they be?

All of these questions can assist the primary pediatric health care professional in determining whether further history, evaluation, or referral may be indicated.

As children approach middle childhood and adolescence, it is often important to interview the child alone. This provides an opportunity to discuss risk-taking behaviors or to identify any perceived risk within the family system.

Observation of Parent-Child Interaction

Beginning in the newborn period, and on through adolescence, observation of parent-child interaction can offer insight into family relationships, parenting style, and the child’s social and emotional well-being. Often much can be learned by observing what is happening when the health care professional opens the examination room door. Is the infant held in the mother’s lap in a loving embrace with good eye contact and nice vocalizations? Or is the child tearing apart the office and climbing on the cupboards while the father is intent on reading a magazine? Neither of these observations should lead to a diagnostic conclusion, but one might offer the opportunity to provide descriptive praise, while the other might serve as an opportunity for incidental teaching. Yet, it is within the family relational and behavioral patterns that one sees, firsthand, the strengths and vulnerabilities of social-emotional developmental competency.

It is also important to attend to the quality of the interaction between the child and the health care professional. Are the child’s responses developmentally appropriate? Does the child make good eye contact? Is the toddler showing joint attention skills and protoimperative and protodeclarative pointing? Is the child’s mood and affect appropriate or flat or withdrawn? Is the child anxious about what is going to happen next? Is the parent or the child flushed or visibly nervous? These observations may add to the assessment of the child’s social and emotional functioning.

Stay updated, free articles. Join our Telegram channel

Join