Normal Child and Adolescent Development

Normal Child and Adolescent Development
Sophia Hrycko MD, FRCPC Psychiatrist Department of Psychiatry, University of Ottawa January 21, 2015 Ja

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Why study normal development?
Need to know what is normal to be able to diagnose pathology. How to “use” these slides: Some topics are discussed to help you understand key concepts (Work of Ainsworth, Thomas and Chess, etc.) you don’t need to “memorize this”! I will tell you which slides are “key”. (slides with * = supplemental information) The objectives DON’T include pathology/disorders. I may mention some disorders to help you understand why and how , in the practice of medicine, understanding child development is important.

Objectives Describe the normal development of children from infancy to adolescence (5273) Explain the major theories of development including the work of Sigmund Freud, Erik Erikson and Jean Piaget (5274) Describe the theory of attachment described by Bowlby (5277 )

Game plan Present normal development chronologically i.e. infancy, pre-school, latency/school age, and adolescence Will discuss in infancy the concepts of major developmental theories which will be reviewed for specific stage of development Will have short video after each stage of development and 2 video at the end on attachment, emotions

Child Development “normative” child Development is a dynamic process
Nature (genes) interacts with nurture (environment) continually Complex process (impact of risk/protective factors)

Developmental Phases (Erickson)
Infancy Birth to 24 months, Basic Trust: I trust my parents and others Pre-school 2 to 5 (6) years, Autonomy: I like to explore, but sometimes I get afraid when I can’t see my mom or dad. School-age/latency 6 years-12 years, Industry: I like to show my friends what I can do. Adolescence 12 years to 19 (24) years, Identity: I know who I am, and I’m not exactly like my parents.

Infancy (0 – 2y) Prenatal Variables Perinatal Variables
Physical abilities Cognitive abilities Temperament Emotions (Erikson: Basic Trust vs Mistrust, Autonomy vs Shame and Doubt)

Infancy 0 – 2y Motor skills 4 wks: tonic neck reflex
16 wks: rolls to prone, hands engage in midline 28 wks: sits unsupported 40 wks: pulls to stand, cruises 52 wks: picks up objects, walks several steps 15 mo: walks alone Adaptive skills 4 wks: responds to sounds, follow moving object to midline 16 wks: looks at object in hand 28 wks: one hand reach and grasp of toy, transfer toy 52 wks: releases toy, imitates scribble

Infancy Language skills
8 wks: vocalized in response to social stimulation; 16 wks: laughs and squeals, “talks to people”; 40 wks: “mama, “dada”, responds to “no-no”; 15 mo: words, knows body part Social skills 4 wks: regards face; 8 wks: follows moving person, smiles responsively; 16 wks: initiates social smiles; 40 wks: initiates “peek-a-boo”; 52 wks: points for wants

Attachment (Bowlby) Attachment is primary drive for survival (evolutionary advantage). It is an emotional relationship (connection) with mutual affection, desire to maintain proximity. Specific to the person. Sensitive period in the first 3 years Attachment behaviors promote proximity to caregiver (crying, following, smiling, clinging).

Bowlby’s theory of Attachment*
Pre-attachment: 0 to 12 weeks Attachment making: 12 weeks – 6 mo. With appropriate care giving, infants are able to prefer one particular person and begin attachment making phase Clear cut attachment: 6 mo – 2 y. Has learned trust, people can be counted on to be there Reciprocal relationship: 2 y on. Reciprocity: people take turns interacting. Effectance: their behavior produces some kind of result in the parenting person. Partnership, internal working models

Mary Ainsworth* Expanded on Bowlby’s observations.
Confirmed that attachment serves the purpose to decrease anxiety. : for 9 months, observed 28 children aged 1 to 24 mo. Secure attachment N = 16 Child cries little, happy to be with mother, can explore environment in mother’s presence Insecure attachment N = 7 Cry often, even in mother’s arms, little exploration of environment Avoidant attachment N = 5 Not yet attached, respond the same to mother and other adults

M. Ainsworth Strange Situation*
For child 12 mo with mother observed in the lab. Note the reaction of the child over 8 episodes of 3 min. involving separation and reunion between mother and child, introduction of a stranger. B. Secure attachment 65% (best) A. Insecure avoidant 21% C. Insecure ambivalent 14% (“cranky”) D. Insecure-Disorganized (5% but 80% of abused children) Main & Solomon 1990

Temperament Development*
Definition: “an individual’s character, disposition, and tendencies as revealed in his reactions.” Collins Dict. Affective tone, responsivity, motivation, “personality” Chess and Thomas conceptualized temperament as representing the HOW, or style of behavior, as contrasted to the WHY, or motivations and goals of behavior, and the WHAT, or perceptions abilities, and talents of the individual.

Temperamental Attributes*

Temperamental Constellations*
Easy Temperament 40% Biological regularity, approach tendencies to the new, quick adaptability to change, a predominantly positive mood of mild or moderate intensity Difficult Temperament 10% Biological irregularity, withdrawal tendencies to the new, slow adaptability to change, frequent negative emotional expressions of high intensity Slow to warm up temperament 15% Withdrawal tendencies to the new, slow adaptability to change, frequent negative emotional reaction of low intensity, “shy” Other 35%

Goodness of Fit The compatibility of traits between children and their parents = Goodness of fit Good fit: results in parents behaving with more sensitivity and positive interactions with their children Therapy: work to improve fit

Developmental Theories
Psychoanalytical: Sigmund Freud Cognitive development: Jean Piaget Social development: Erik Erikson

Psychoanalytical (Freud)
Psychoanalytical (the sexual aim of young infant is to obtain pleasure and relief from discomfort by the most immediate means possible. The infant draws pleasure from visual, tactile, kinesthetic and auditory stimuli). (conscious and unconscious emotions and defense mechanisms can contribute to the development of negative emotional/cognitive states) Stages: Oral phase (birth – 18 mo) (Infancy) Anal phase (12 – 18 mo – 3 y) (Toddlerhood) Phallic-Oedipal phase (3 – 5 y) (Pre-school) Latency phase (5 – 6 – 11 y) (School-age) Adolescent Genital Phase (11 – 12 y on)

Oral Stage: mouth, most sensitive and greatest source of pleasure. Mouthing, sucking and biting. Anal Stage:. Control, Action, controllable pleasure. Phallic-Oedipal Phase: Child is aware of anatomical differences between sexes, experience of intense sexual and aggressive urges toward both parents. Understanding of the relationship between parents, a wish to remain the center of their lives, while realizing the gender/sexual roles of the same sex-parent. Oedipus complex: the child’s desire for intimacy with the opposite sex parent. Resolution: identify with same-sex parent while retaining affection of opposite-sex parent. Consolidation of gender identity formation.

Latency Stage: relative quiescence of libidinal drives. Sexual drives are channeled into socially appropriate activities (school, sports). Development of ego, superego. Adolescent Genital Stage: Final stage of psychosexual development, separation from family, identity formation and psychological capacity for true intimacy

Cognitive Development (Piaget)*
A child needs to find ways to understand, to remember, to solve problems, and to organize their environment. “making and using knowledge”: includes attention, information processing, thinking, intuition, memory, etc. Constructivism, stage-based theory The child is a scientist trying to develop mature scientific thought processes Explains cognitive maturation by use of a biological model that focuses upon schemes (i.e. organized ways for children’s developing brains to make sense of their experiences or internalized frame of reference) No focus on social and emotional development

Cognitive Development (Piaget)*
To structure such schemes, children use 2 complementary processes: Assimilation: integration of external element (take new experience into existing schema) Accommodation: modify existing schema to adapt to new experience Equilibrium (balance) = creation of new knowledge Cognitive growth occurs in structural stages Cognitive maturity is defined by a child’s increasingly refined ability to conceptualize space, both internally and externally.

Piaget’s 4 Periods of Cognitive Development

Sensorimotor stage (birth – 2 y)
Infant use body senses and activity to explore their environment. Reflexive, presymbolic: - imitation, smiles, playful - looks for objects partially hidden (interactions with the external world) - peek-a-boo, finds hidden objects (complex intentional behavior) explores properties and drops objects

Sensorymotor (1 – 2y) 18 mo – 2 y: mental representation, make believe play, memory of objects Object permanence: i.e. the ability to remember an object once it is out of sight (12 – 18 mo) (can manipulate images, words internally)

Age Sigmund Freud Jean Piaget Erik Erickson Infancy 0-2y Oral stage (mouth: frustration/gratification) Anal stage (1-3y): toilet training Sensory motor stage: reflexes, uses senses to interact with environment, motor activities Object permanence Onset language Basic Trust: weaning, separation from parent, need to trust and feel loved by caregivers Autonomy vs Shame/Doubt (1-3y): toilet training, independence, need to be supported by parent, need to be able to try things without fear of being punished/judged if fails

Video 2 weeks, primitive reflexes (#6)
Primitive reflexes shown in this clip: toe grasp, clonus, tone, incurvation, crawling, walking, weight-bearing. Note head control. – Some reflexes extinguish with development (only returning in pathological states), others persist. Video boy 11.5 mo and girl 10.5 mo (#7) Social communication, aggression, frustration, competition, negotiation, conflict resolution btwn infants Video Ainsworth strange situation (#10)

Social Development – Attachment Theory*
4 phases in the social maturation process: Period of attachment, child develop a sense of self Period of self-understanding: allows children to analyze their own make up Period of perspective taking: child apply self-knowledge to adults and peers Period of true friendship and peer orientation

Social Development Erik Erikson
Basic Trust vs Mistrust (0 – 1 y) Autonomy vs Shame/Doubt (1 – 3 y) Initiative vs Guilt (3 – 5 y) Industry vs Inferiority (6 – 11 y) Identity vs Role Confusion (11 – 20 y) Intimacy vs Isolation (21 – 40 y) Generativity vs Stagnation (40 – 65 y) Integrity vs Despair (65+)

Pre-school (2 – 5 y) Tasks: Role of Environment:
Autonomous identity: separate individuals who can be autonomous despite wish to be dependent at times on parents/others Gender identity: I am a boy/girl. Role of Environment: Protect child in his assertive explorations from experiencing too many episodes of over/under-stimulation. Teach child to gratify his needs/wishes within the family/social environment while respecting limits/rules of parents. Provide emphatically attuned encouragements support/admiration for growing autonomy while teaching that autonomy has limits/restrictions.

Preschool Physical development: Cognitive development:
Can walk, run, control of sphincters (21/2 for day urination, night: 4 y, bowel: 4 y) Sleep: 12 h (naps) Cognitive development: Sense of themselves as separate Can appreciate right, wrong, good, bad, valued/not valued. Can infer the emotional state of another person, they usually project their own feelings onto others and they identify with the projected feelings. Use verbal language to identify actions. Ability to understand concepts expressed in verbal language: can store explicit memories (information encoded in verbal form)

Preschool Cognitive Development: Ability to form fantasies
Ability to form beliefs: a conception that establishes the relationship between 2 or more inanimate objects, aspects of nature’s law or people. The sun makes the earth warm, the earth moves. Ability to form categories. Ability to use primary (magical, absence of logical connections) and secondary process (reality based, logical) thinking. Cannot understand conservation (pie cut in 4 and 8 pieces not equal, want the one cut in 8)

Preschool Play: primary means by which children teach themselves Pretend games, imaginary friend common Function of play: Act out playful fantasy, a pleasurable life experience using toys, other adults, children as symbols for the real experience, acquiring new knowledge in the process. To practice delaying the behavioral or verbal expression of skills and feelings that are causing developmental conflicts with parents. To unconsciously attempt to reconstruct a pathogenic belief, especially one resulting from a traumatic experience

Preschool Child has an autonomous and valued identity
Child has a gender identity as male or female Child speaks in sentences, thinking is egocentric, empathy is not present Preoperational phase: begins to think symbolically Emotional and Social Development: Erikson: autonomy vs shame/doubt; initiative vs guilt Freud: anal stage of development; phallic/Oedipal stage Gender identity

Piaget Preoperational Phase (2 – 7 y)
Children become intuitive, anticipating experiences with consequences. Think symbolically but illogically Concepts*: Egocentric, unable to perceive self from others in their environment. Animistic “I’m afraid of the moon” Lack of hierarchy “where do these blocks go” Centration “I want it now, not after dinner” Irreversibility: “I don’t know how to go back to that room” Transductive reasoning “We have to go this way because that’s the way Daddy goes”

Preschool Theory of mind or mentalisation: Child has an awareness that others have internal states and mental representations. (decentering, perspective taking: children become aware that 2 children looking at the same display from different side of a table will see two different view of the display. Later they can incorporate thoughts and feelings of others as different from their own).

Phallic stage: Oedipal complex
Sigmund Freud Jean Piaget Erik Erickson Preschool 2 – 6y Phallic stage: Oedipal complex Preoperational phase: Think symbolically, egocentric, magical thinking Initiative vs guilt: imitate adults, do things independently, has goals

Video age 3y 8mo (# 18) Pretends to be a pink elephant animal (special blanket), fantasy vs reality, transitional object Video age 2 1/2y (#106) Ability to role play, and relive daily events by creating small reenactments. – Some gender role rehearsing is involved (she is pretending to be Mommy, not Daddy). – Use of 2nd person pronouns. Video age 4y 2mo (#132) Piaget: conservation of length; knows categories but lacks flexibility to shift concepts. Pre-operational thought

School-age (6 – 12 y) Language and cognitive development
Can express complex ideas Logic is very important Piaget: concrete operations: conceptual skills develop and thinking become organized and logical. Improved gross motor development: sports, arts

School-age Emotional and social behavior
Freud: latency period. Superego development Moral development starts Identification with other adults Idealize same parent Peer interactions are more important Empathy starts Erikson: Industry versus Inferiority

Piaget: Concrete Operational Stage
Ability to think logically, in an organized fashion Concepts*: Hierarchical classifications: arranges cars by types Reversibility: can play games backward and forward Conservation: lose 2 dimes can look for same Decentration: worry about small details, obsessive Spatial operations: likes models for directions

Latency, ego and superego development
Age Sigmund Freud Jean Piaget Erik Erickson Latency/school age 6-12y Latency, ego and superego development Concrete operational phase: ongoing learning and consolidation of knowledge: thinks logically. Concepts; classification (hierarchy), reversibility, conservation, decentration Industry vs inferiority. Task: going to school, doing things and creation to discover interests talents, learn their strengths,. Competence

Video age 6y 8 mo (# 23) “don’t hope for things : they will come true, and vice-versa”. God (or her conscience) punishes her for disobeying her father, by causing a flat tire. Magical thinking, egocentricity, religion, moral development, development of conscience Trying to make sense of the world, searching for cause and effect.

Video 11 y (#32) Time management will be a crucial life skill, affecting his future success in academics, his career, and his ability to juggle work and home life. This is a good time to learn how to prioritize, plan, and not leave things to the last minute. –Rather than not allowing Brian to go to the pick-up game, Mom lets Brian make his own decisions, then encourages him to learn from his experience and change future choices accordingly. –Effort is highly dependent on the degree to which one is inspired by the task at hand (soccer versus clarinet, for example). Mom never had to remind Brian to get ready to go to his soccer games, or push him to practice his athletic skills.

Adolescence (12 – 19y) Profound biological, social and psychological changes Biological: rapid acceleration of skeletal growth; physical sexual development Psychological: acceleration of cognitive development; consolidation of personality formation; thinking becomes abstract, conceptual, future oriented Social: preparation for role of young adult; development of morals (conformity to shared standards, rights and duties) Variable: age of onset, length, rate of growth etc. Rite of passage Adolescent turmoil is NOT common, NOT normal About 20% of adolescents will have a diagnosable mental disorder: Adjustment disorder, anxiety disorder, depressive disorder.

Piaget: Formal Operational (11 +)
Concepts: Hypothetic-deductive reasoning Imaginary audience, everyone is looking at them Personal fable: inflated opinion of themselves Propositional thinking, logic Capacity to think abstractly (can think about thoughts)

Adolescence Development of identity, sense of self (self-concept, self- image) is more negative and less stable early than later adolescence Social Development: expansion of relationships beyond the family: peer group; shift from parents to peers as providers of companionship, intimacy; need peer approval and advice; development of empathy Risk taking: 40% of all teenage death due to MVA survey: 40% of HS students used THC, 85% alcohol (32% binge drinking), 3% cigarettes

Adolescence Pressures: to succeed academically
to make vocational choices early Autonomy from family Accept growing/changing body

Genital stage: ability to have intimate relationships
Sigmund Freud Jean Piaget Erik Erickson Adolescence 12 – 24y Genital stage: ability to have intimate relationships Formal operational phase. Concept: hypothetic-deductive reasoning, logic, capacity to think abstractly, Identity vs role confusion. Task: social identity, need to define and clarify personal and professional interests. Importance of appearance, role models, belonging to a group Strength: Fidelity

Video age 13.5 (#8) Cheated on an exam. Morality, parental expectation, observation of peers behavior (tolerating it)

Question 1 Theories of development formulated by Freud, Erikson, and Piaget share which of the following characteristics? A. They postulate a genetically determined capacity for the development of patterns or systems of behavior by the child. B. They propose that the overall behavior patterns that emerge are qualitatively similar to one another. C. They are all structural theories of development that imply that reorganizations within the child is unnecessary. D. They postulate that the child reacts in particular ways to environmental stimuli. E. None of the above.

Question 2 By age 5 years, a child will have attained all of the following motor developmental milestones except: A. Can stand on one foot. B. Can dance and jump. C. Manifests firmly established legs, eye and ear dominance. D. Can copy a square. E. Can build a tower of 10 cubes.

Question 2 By age 5 years, a child will have attained all of the following motor developmental milestones except: A. Can stand on one foot. B. Can dance and jump. C. Manifests firmly established legs, eye and ear dominance. (starts age 2-3, well developed age 5) D. Can copy a square. E. Can build a tower of 10 cubes. Dominance: foot: 7y, eye 8y, ear 9y

Question 3 Piaget conceptualized 4 major stages of cognitive development. Which of the following states the correct sequence in which these stages normally occur, from birth to adolescence? A. Preoperational, sensorimotor, concrete operational, formal operational. B. Concrete operational, sensorimotor, preoperational, formal operational. C. Sensorimotor, concrete operational, formal porational, preoperational. D. Formal operational, concrete operational, sensorimotor, preoperational. E. Sensorimotor, preoperational, concrete operational, formal operational.

Question 4 Best description of motor behavior in a 1 y old child:
A. Sits steadily on the floor B. Pulls self to standing C. Walks with one hand held D. Runs E. Rides a tricycle

Question 5 Erickson’s basic trust vs mistrust stage corresponds to Freud’s ……. Stage: A. Oral B. Anal C. Phallic D. Latency

Question 6 Development task Age Social smile Reach for/grasp toy
Stand out without support Rides a tricycle Say 2-3 words Pick up a small object with thumb/index

Question 6 Development task Age Social smile 2 mo (4-8 wks)
Reach for/grasp toy mo Stand out without support mo Rides a tricycle y Say 2-3 words y Pick up a small object with thumb/index 10 mo

Question 7 Preschoolers struggle to deal with separation because:
Their repertoire of coping abilities is still developing They have increased cognitive abilities They are able to reassure themselves easily They have never experienced a successful separation They are emotionally stable

Question 8 True or False: most preschool children do not recognize that their imaginary friends are not really visible. True False

Question 9 True or False: infant assessments are not only a measure of the child’s functional or developmental status, but also a measure of the child’s environment. True False

Question 10 Infant are able to respond differently to their fathers and mothers by what age? 8 months 6 months 4 months 2 months

Question 11 In Psychoanalytic theory, the anal phase of psychosexual development is characterized by A. The child’s focus on autorerotic activities. B. The child’s experience of intense sexual and aggressive urges toward both parents. C. The child’s development of concepts of inevitability regarding birth, death, and sex differences. D. The child’s experience of feelings of separateness and worth. E. the child’s sequential development of play.

Question 12 True statements about enuresis include
A. The majority of enuretic children wet intentionally B. There is a correlation between enuresis and psychological disturbance that increases with age C. Children with enuresis are more likely to have developmental delays than other children D. There is no evidence for a genetic component to enuresis E. Children living in socially disadvantaged environments do not have an increased incidence of enuresis

Question 13 A two year old child will most likely be able to:
A. Build a tower of 2 or 3 cubes B. Draw a circle C. Run D. Copy a square E. Copy a triangle

References Essentials of Lewis’s Child and Adolescent Psychiatry Volkmar & Martin, 2011 Normal Development in the First ten years of Life, Geri Fox (DVD) Normal Development in Middle childhood and Adolescence, Geri Fox (DVD) Video: A simple gift: Comforting your baby (10 min) and Helping Young children cope with Emotions (17 min ) Infant Mental Health Promotion project, The Hospital for Sick Children, 1998

References* html (Development of the Young Brain For more than twenty years, National Institute of Mental Health neuroscientist Dr. Jay Giedd has studied the development of the adolescent brain. Decades of imaging work have led to remarkable insight and a more than a few surprises.) Many other videos on brain development, including adolescents.

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