Social and Emotional Development


Social and Emotional Development

John C. Duby, MD, FAAP, CPE


Healthy social and emotional development sets the foundation for promoting all other domains of children’s development. After all, children learn to think, reason, communicate, run, jump, climb, care for themselves, and play in the course of social interactions with caregivers and peers. Children’s development progresses in the context of the dynamic transactions between their biological and genetic tendencies and their life experiences. Life experiences are rooted in social and emotional relationships. Children who grow up in supportive, predictable, and nurturing environments are better prepared for a healthy, productive, adulthood and healthy, lifelong relationships.

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.


Key Points

Social and emotional development progresses through predictable stages.

Consider the developmental and environmental context when assessing any social-emotional concerns.

Clearly identify and address the family’s concerns.

Perform surveillance using open-ended trigger questions.

Attend to your observations of parent-child interaction and the child’s interaction with you.

Use standardized screening tools that match the level of risk in the population you serve.

Explore options for offering evidence-based interventions in the medical home.

Use evidence-based strategies for behavior management as part of your anticipatory guidance.

Promote community-based linkages and resources to support families to promote resilience and to address social-emotional concerns.

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 2-year-old is becoming increasingly independent. She refers to herself as “I” or “me.” She may have a special attachment to a book, a toy, or a blanket to help her make the transition to independence more smoothly. She will show an eagerness to share, show, and engage with the parent, to the parent’s delight. She plays alongside other children and is showing more pretend play. At 2.5 years, imaginative play is clearly evident, and she shows evidence of symbolic play, making an object into something new or different. Her play now includes other children. As she struggles with her newly found independence, she may be fearful of unexpected changes in daily life.

By 3 years of age, he will show much more elaborate imaginative play with themes and story lines. He enjoys interactive play and is delighted to show his parents his capacity for independence with feeding, dressing, and toileting. The 4-year-old is working to establish a comfortable place in an expanding world. Depending on his temperament and the history of his relationship patterns, he may be predominantly cooperative, friendly, and responsive or withdrawn, aggressive, or defiant. Extremes of behavior may be seen at times of stress. He is also able to see himself as an individual yet equally enjoys demonstrating his relational capacity as a communicator and entertainer. He knows his gender and age and can describe his interests and what he does well. He has favorite toys and favorite stories. He spends more time in fantasy play.

The 5- to 6-year-old is successful at listening, attending, and following simple rules and directions. However, she is also likely to test those rules. She is becoming comfortable with spending more time with a peer group. As she approaches 7 to 8 years of age, she more fully understands rules, relationships, and mores. She will consistently show cooperation and attention and is capable of taking on family responsibilities and chores. As her moral development progresses, her coping skills emerge. Her beliefs may be tested by her peers, as she turns more to them and other adults for new ideas and activities. She may have a best friend and will usually identify most with children of the same gender that have similar interests and abilities. By 9 to 10 years, her peer group takes on greater importance. Her growing need for independence from her family will often be a valuable incentive for her to make contributions at home in order to earn privileges with her friends. She will demonstrate increasingly responsible and independent decision-making. At times, she may disparage and dismiss the knowledge of adults. Her feelings of self-confidence can be bolstered by descriptive praise, affection, and quality time in a nurturing relationship with her family.

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.

Table 12.1. Social-Emotional Milestones6,7




Is most responsive in a quiet, alert state.

Recognizes the unique smell of her mother.

Prefers her parents’ voices.

Responds favorably to gentle touch and withdraws from unpleasant touches. Imitates simple facial expressions from a distance of 7-8 inches.

2 months

Consoles and comforts self.

Is increasingly alert.

Smiles responsively.

Responds to calming actions when upset.

4 months

Smiles spontaneously.

Initiates social interactions.

Shows greater capacity to comfort self.

Controls the movements of his hands and may use them to console and comfort.

6 months

Recognizes familiar faces and is beginning to notice strangers. Sustains interactions.

Jointly attends to actions and objects of interest to her caregivers.

9 months

Has clear apprehension with strangers.

Seeks out her parents for play, comfort, and assistance. Plays interactive games like peek-a-boo and pat-a-cake. Waves bye-bye.

Looks preferentially when name is called.

12 months

Uses protoimperative pointing; uses gestures to indicate needs.

Hands a toy or book to her parent when she wants to play or hear a story.

15 months

Uses protodeclarative pointing to indicate interests. Imitates whatever he sees.

Helps with simple household tasks.

Listens actively to stories.

18 months

Temperament will be more and more evident in new or group settings.

Is willing to separate and explore on his own but will want his parent close by. Is spontaneous with affection.

Laughs in response to others.

2 years

Is more independent.

Refers to herself as “I” or “me.•

May have a special object to assist with transition to independence. Plays alongside other children.

Shows more pretend play.

2.5 years

Shows imaginative play.

Shows symbolic play, making an object into something new or different. Play includes other children.

May be fearful of unexpected changes in daily life.

3 years

Shows much more elaborate imaginative play with themes and story lines. Enjoys interactive play.

Is independent with feeding, dressing, and toileting.

4 years

Extremes of behavior may be seen at times of stress. Sees himself as an individual.

Knows gender and age.

Describes interests and strengths.

Has favorite toys and favorite stories.

Spends more time in fantasy play.

5-6 years

Listens, attends, and follows simple rules and directions. Tests rules.

Spends more time with a peer group.

7-8 years

More fully understands rules, relationships, and mores.

Shows cooperation and attention.

Takes on family responsibilities and chores.

May have a best friend.

Identifies most with children of the same gender with similar interests and abilities.

9-10 years

Peer group takes on greater importance.

Demonstrates increasingly responsible and independent decision-making.

11-14 years

Has a greater drive for independence and a growing commitment to the peer group. May engage in risky behavior to impress her peers.

Forms and breaks down social networks.

Copes well with stressful experiences.

Makes more and more independent decisions.

15-24 years

School, extracurricular activities, and work become central focus.

Forms caring, supportive relationships with family, other adults, and peers. Participates in the community.

Demonstrates resilience with everyday life stressors.

Increases independence in decision-making.

Shows self-confidence and hopefulness.


When assessing a child’s social and emotional development, it is important to consider a number of contexts. At any health care encounter, it is vital to consider the child’s age, developmental level, and psychosocial, socioeconomic, and cultural circumstances in order to accurately interpret any concerns regarding social and emotional development.

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 poverty13,14 may show changes in their social and emotional functioning in an attempt to cope with these challenges.


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.

Healthy children are better prepared to explore and learn. Parents who actively protect and promote their children’s health, including maintaining the recommended immunization schedule, help to secure the foundation for healthy social and emotional development. In addition, observation of the child’s behavior during the immunization process can provide additional insight into her coping skills and into the parent-child interaction. The administration of immunizations may provide an opportunity for the health care professional to model and teach coping and relaxation skills.

Physical Examination

Oct 22, 2019 | Posted by in PEDIATRICS | Comments Off on Social and Emotional Development
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