Ped201 s1t1 Prelim Growth and Development

Pediatrics 1
Growth and Development

Eric Olivares, MD | 11 September 2018 | Topic 1
of gene expression, without change
I. Overview and Assessment of Variability in DNA sequencing. These
• Pediatricians require knowledge of normal growth, epigenetic changes, such as DNA
development and behavior in order to effectively monitor methylation and histone acetylation,
children’s progress, identify delays or abnormalities in are a result of environmental insults.
development, obtain needed services and counsel
parents and caretakers. C. Neuronal Plasticity
• Growth- an indicator of overall well-being, status of o Critical to learning and remembering,
chronic disease and interpersonal and psychologic
which permits the central nervous
stress.
system to reorganize neuronal
networks in response to
A. Biopsychosocial model and Ecobiodevelopmental
Framework: Models of Development environmental stimulation, both
§ Biopsychosocial model positive and negative.
o Higher-level systems are o An overproduction of neuronal
precursors eventually leads to about
simultaneously considered with the
lower-level systems that make up the 100 billion neurons in the adult brain.
person and person’s environment. o Each neuron develops on average
15,000 synapses by 3 years of age.
o A patient’s symptoms are examined
and explained in the context of the o Synapses in frequently used pathway
patient’s existence are preserved, whereas less-used
number of synapses and
B. Ecobiodevelopmental Framework reorganization of neuronal circuits
also play important roles in brain
plasticity.
o The plasticity of the brain continues
into adolescence, with further
development of the prefrontal
cortex, which is important in
decision-making, future planning,
and emotional control; neurogenesis
persist in adulthood in certain areas
of the brain, including the
subventricular zone of the lateral
ventricles and in portions of the
hippocampus.
§ Children with different talents and
temperaments (already a combination of
genetics and environment) further elicit
different stimuli from their (differing)
environments.
1. Biologic Influences
o This framework emphasizes how to • Include genetics, in utero exposure to teratogens, the
ecology of childhood (social and long-term negative effects of low birth weight (neo-natal
physical environments) interacts with morbidities plus increased rates of obesity, coronary
biologic processes to determine heart disease, stroke, hypertension and type 2
outcomes and life trajectories. diabetes), postnatal illnesses, exposure to hazardous
o Early influences, particularly those substances and maturation.
producing toxic levels of stress, affect • Any chronic illness can affect growth and development,
the individual through modification either directly or through changes in nutrition,
parenting, or peer interactions.
Transcribed by: Page 1 of 22

PED201 LECTURE TITLE T1
MATURATIONAL CHANGES: • Attachment refers to a biologically

§ Decrements in growth rate and sleep determined tendency of a young child to seek
requirements around 2 years of age often proximity to the parent during times of stress
and also to the relationship that allows
generate concern about poor appetite and
securely attached children to use their parents
refusal to nap.
to reestablish a sense of well-being after a
§ Although it is possible to accelerate many stressful experience.
developmental milestones (toilet training a 12 • Insecure attachment may be predictive of later
months old or teaching a 3 years old to read), behavioral and learning problems.
the long-term benefits of such precocious • In early infancy, such contingent
accomplishments are questionable. responsiveness to signs of overarousal or
underarousal helps maintain infants in a state
§ Physical changes in size, body proportions and
of quiet alertness and fosters autonomic self-
strength, maturation brings about hormonal regulation.
changes. • Contingent responses (reinforcement
§ Sexual differentiation, both somatic and depending on the behavior of the other) to
neurologic, begins in utero. nonverbal gestures create the groundwork for
§ Both stress and reproductive hormones affect the shared attention and reciprocity that are
brain development as well as behavior critical for later language and social
development.
throughout development.
• Children learn best when new challenges are
just slightly harder than what they have already
TEMPERAMENT
mastered, a degree of difficulty dubbed the
“zone of proximal development”.
• The stable, early-appearing individual variations in
• Psychologic forces, such as attention problems
behavioral dimensions, including emotionality (crying, or mood disorders, will have profound effects
laughing, sulking), activity level, attention, sociability on many aspects of an older child’s life
and persistence.
Social Factors: Family Systems and Ecologic Model
THE CLASSIC THEORY PROPOSES 9 DIMENSIONS OF • Contemporary models of child development recognize
TEMPERAMENT the critical importance of influences outside of the
These characteristics lead to 3 common constellations: mother-child dyad.
• The easy child, highly adaptable child, who has regular biologic • Fathers play critical roles, both in their direct
relationships with their children and in supporting
cycles
mothers.
• The difficult child, who withdraws from new stimuli and is easily • Families function as systems, with internal and external
frustrated boundaries, subsystems, roles and rules for interaction.
• The slow to warm up child, who needs extra time to • In families with rigidity of defined parental subsystems,
adapt to new circumstances. children may be denied any decision-making,
• Temperament has long been described as biologic or “inherited”. exacerbating rebelliousness.
• Monzygotic twins are rated by their parents as temperamentally • In families with poorly defined parent-child boundaries,
children may be required to take on responsibilities
similar more often than are dizygotic twins.
beyond their years, or may be recruited to play a
• Estimated of heritability suggest that genetic differences account spousal role.
for approximately 20-60% of the variability of temperament • Family systems theory recognizes that individuals within
within a population. systems adopt implicit roles:
• Maternal prenatal stress and anxiety is associated with child o Troublemaker
temperament, possibly through stress hormones, o Negotiator
o Quiet
• Polymorphisms of specific genes moderate the influence of
o Birth order may have profound effects on
maternal stress on infant temperament (specifically irritability) personality development, through its
illustrating the interplay between genes and environment. influences on family roles and patterns of
• Longitudinal twin studies of adult personality indicate that interaction.
changes in personality over time largely result from non-shared o Families are dynamic.
environmental influences, whereas stability of temperament o The birth of a new child, attainment of
appears to result from genetic factors. developmental milestones such as
independent walking, the onset of nighttime
fears and the death of a grandparent are all
Psychologic Influences: Attachment and Contingency
changes that require renegotiation of roles
• Infants in hospitals and orphanages, devoid of within the family and have the potential for
opportunities for attachment, have severe healthy adaptation or dysfunction.
developmental deficits. o Bronfenbrenner’s ecologic model
Transcribed by: Idgee, Carl, Hana, Argie, Vence Edited by: Sarah Bee Page 2 of 22
ü Depicts these relationships as concentric DEVELOPMENTAL DOMAINS AND THEORIES OF

circles, with the parent-child dyad at the EMOTION AND COGNITION
center (with associated risks and
protective factors) and the larger society • Child development can also be tracked by the child’s
at the periphery. developmental progress in particular domains, such as
gross motor, fine motor, social, emotional, language
UNIFYING CONCEPTS: THE TRANSACTIONAL MODEL, and cognition.
RISK AND RESILIENCE • Developmental lines in gross motor domain:
v Transactional model o Rolling
o Proposes that a child’s status at any point in time is a o Creeping
function of the interaction between biologic and social o Independent walking
influences. o Several psychoanalytic theories are based on
o The influences are bidirectional: Biologic factors, such stages as qualitatively different epochs in the
as temperament and health status, both affect the child- development of emotion and cognition.
rearing environment and are affected by it.
o Children with biologic risk factors may do well
developmentally if the childrearing environment is
PSYCHOANALYTIC THEORIES
supportive.
o Premature infants with electroencephalographic • Freudian Theory
evidence of neurologic immaturity may be at increased o Is the idea of body-centered (or broadly,
risk for cognitive delay. This risk may only be realized “sexual”) drives; the emotional health of both
when the quality of parent-child interaction is poor. the child and the adult depends on adequate
o When parent-child interactions are optimal,
resolution of these conflicts.
prematurity carries a reduced risk of developmental
• Erickson recast Freud’s stages in terms of emerging
disability.
personality:
o The child’s sense of basic trust develops
through the successful negotiation of infantile
needs.
o It is predictable that a toddler will be
preoccupied with establishing a sense of
autonomy, whereas a late adolescent may be
more focused on establishing meaningful
relationships and an occupational identity.
COGNITIVE THEORIES
• A central tenet of Piaget’s work is that cognition changes
in quality, not just quantity.
o During the sensorimotor stage, an infant’s
thinking is tied to immediate sensations and a
Children at Risk: child’s ability to manipulate objects.
§ Children growing up in Poverty o The concept of ‘in’ is embodied in a child’s act
o Under nutrition
of putting a block into a cup.
o Lack of stimulation in the home
o With the arrival of language, the nature of
o Decreased access to interventional education and
therapeutics experiences thinking changes dramatically; symbols
o Withdrawal or acting out increasingly take the place of objects and
o Further discourage positive stimulation from those actions.
around them o Piaget described how children actively
§ Children of adolescent mothers construct knowledge for themselves through
o When early intervention programs provide timely,
the linked processes of assimilation (taking in
intensive, comprehensive and prolonged services, at-
risk children show marked and sustained upswings in new experiences according to exiting
their developmental trajectory. schemata) and accommodation (creating new
o The personal histories of children who overcome patterns of understanding to adapt to new
poverty often include at least 1 trusted adult (parent, information).
grandparent, teacher) with whom the child has a o Children’s understanding of cause and effect
special, supportive, close relationship.
may be considerably more advanced in the
context of sibling relationships than in the
manipulation and perception of inanimate o It is difficult to tell just how babies interpret the
objects. stimulus by simply recording whether they
o In many children, logical thinking appears well look at a stimulus.
before puberty, the age of postulation by
Piaget. PHYSICAL KNOWLEDGE DEVELOPMENT
• Piaget’s work is of special importance to pediatricians • From the time infants are very young they understand
for 3 reasons: some of the basic properties of physical objects.
1. Piaget’s observations provide insight into o In the first few months of life, they know that
many puzzling behaviors of infancy, such objects are 3-dimensional and extended in
as the common exacerbation of sleep space, that they can’t pass through other
problems at 9 and 18 months of age objects, and that they continue to exist when
2. Piaget’s observations often lend they move behind a screen. They also have a
themselves to quick replication in the basic concept of numbers, at least up to 3.
office, with little special equipment o Infants also have a surprisingly early
3. Open-ended questioning, based on understanding of relationships that cross
Piaget’s work, can provide insights into sensory modalities.
children’s understanding of illness and o They recognize parallelisms between lip
hospitalization. movements and vocal sounds, between the
feel of a pacifier and the way it looks, or
II. COGNITIVE DEVELOPMENT: DOMAINS AND between the visual image of a bouncing ball
THEORIES and the sound it makes.
Methodologies o Babies also have surprisingly early and
• Psychoanalysts sophisticated understanding of statistics and
o asked adults to remember their childhood probability.
• Behaviorists § Before they are 1 year old, they
o Extrapolated from experiments on animals expect that a ball taken at random
• Jean Piaget the founder of the field of cognitive from a box of 80 red and 20 white
development relied on observing the spontaneous balls is more likely to be red than
behavior of babies, or on clinical interviews in which he white.
asked children to say what they thought about mind o Infants can also recognize statistical patterns in
and body or life and death. both visual and auditory sequences.
o One group of methods involves seeing what o In their second year, babies have a basic
babies prefer to look at (visual preferences), or understanding of spatial relationships like
listen to, or even smell. gravity and containment.
o Other methods use the fact that babies pay § They can also categorize objects,
more attention to things that are unexpected recognizing that animals go together
that to those that are more predictable or and are different from artifacts.
familiar. o Preschoolers continue to learn about the
o Babies are habituated to a stimulus; they look physical world, but they also begin to learn
or listen until their attention wanders, and about the biologic world.
when they see a variant of that stimulus they § Preschoolers also have a first
focus attention to the new stimulus if it is understanding of basic biologic ideas
different. like inheritance, growth and illness;
• Violation-of-Expectation studies they are not animists as Piaget
o Experimenters present babies with events that though.
are surprising from an adult point of view § Preschoolers also have a much more
o sophisticated understanding of
o Example: causal relationships than we
§ One object apparently moving previously though.
through another, and see whether § Preschoolers also, against
babies look longer at those events conventional wisdom, can
than at similar unsurprising events. understand the difference between
• Looking-time technique the physical and the mental, reality
o Has a drawback and fantasy from a very young age.
§ Preschoolers may be intensely caregivers and then

emotionally affected by the products reunited
of fantasy, from imaginary friends to • Security- babies are
monsters in the closet. distressed at separation but
o Three and Four year olds are essentialists. are quickly comforted when
§ They assume that categories of the caregiver returns
animals or plants, such as birds or • Avoidant- babies seem to
daisies, will have the same insides repress their distress; they
and the same essence even if they are ignore the caregiver both
perceptually diverse. when she leaves and returns
o By 5 years of age, preschoolers have a more • Anxious- babies are very
unified concept of something like a life force. distressed and take a long
§ They believe that the presence of this time to comfort
st
force makes living things grow and o 1 year babies develop an even rich
thrive, and its absence leads to illness understanding of others.
and death. § One year olds don’t just imitate
§ They also start to understand the actions; they reproduce the results of
relationship between our beliefs and those actions.
the world around us. § One year old child are able to walk
nd
o Older children understand the mechanics of o 2 year old children also start to understand
simple physical systems. that their own perception, attention and
emotion may be shared by others.
SOCIAL KNOWLEDGE DEVELOPMENT § At this age they start to engage in
• Some of the most impressive kinds of early knowledge joint attention behaviors;
and learning involve children’s understanding of other • they will follow the gaze or
people. point of another person and
they will point to objects
Theory-of-mind themselves.
• Abilities are particularly important for social interaction § They also start to understand that
and appear to specifically impaired in children with closing your eyes or wearing a
autism. blindfold may make it more difficult
• From the time they are born, infants treat people as to see.
special. o Social referencing:
st
o 1 month: infants prefer to look at human faces § Babies will react appropriately to the
and listen to human voices, and rapidly prefer emotional expression of another
to look the face, voice and even smell of their person that is directed at an object; if
caregivers. 1 year olds see someone react to an
o Newborn infants also imitate facial ambiguous object with fear they will
expressions. To do this they must link what avoid the object themselves.
they see on the face of another person and o From 2-6 years of age, children discover
how it feels to be them inside. further fundamental facts about how their own
th
o 7 month old babies appreciate that human minds and the minds of others work.
actions are directed towards particular goals. o Between 3 and 5 years of age, children also
§ Seven month olds look longer when start to develop capacities for what
the hand goes to the teddy bear psychologists call executive control, which
instead if the ball. is the ability to control your own actions,
th
o 8 month old babies can imitate in an even thoughts and feelings.
more sophisticated way. o These capacities seem to be specifically
§ Also they start to show an related to Theory-of-mind abilities.
understanding of love.
• Attachment-babies behave THEORIES OF COGNITIVE DEVELOPMENT
differently when they are • On class approach, often called Nativism
separated from their
o Suggest that much of this abstract structure is • By preschool, what is

in place innately; babies are born knowing sometimes called implicit or
about crucial aspects of the world. intuitive pedagogy plays an
o Although babies are far from being blank increasingly important role
slates, there also seem to be significant in children’s learning.
changes in their understanding of the world. • Preschoolers tend to give
• The alternative approach, Empiricism grownup testimony that
o Suggest that all of children’s knowledge is benefit of the doubt, but
simply the result of a process of associating or they can also distinguish
combining particular sensory experiences, or between reliable and
detecting the statistics of the environment. unreliable teachers.
o Although children are able to associate • However, Preschoolers
particular experiences and to detect statistics, sensitivity to implicit
those abilities don’t seem to be sufficient to teaching can be a double-
explain their remarkable growth of knowledge. edge sword. Some studies
• Piaget originally articulated constructivism an show that children less
alternative to both nativism and empiricism. likely to engage in wide-
o The theory theory is the more current ranging exploration when
version of constructivism. adults provide them with
§ The idea is that children develop answers.
their knowledge of the world by • Preschoolers left to their
constructing every day or intuitive own resources are often
theories, much like scientific able to solve complex
theories. problems.
§ Unlike empiricism, proposes that • In addition because play is
even babies may be born with innate such an important
theory of the world, but unlike component of a preschool-
nativism, it proposes that those age child’s learning process,
theories may be radically the learning environment
transformed as children learn so may need to be less
much from the evidence they structured, more child-
encounter. focused, and with less
• Nativism, Empiricism and constructivism emphasis on traditional
o All focus on the process of learning from academic instruction.
evidence.
o Two other approaches describe other factors
that contribute to cognitive development. THE EMOTIONAL COMPONENT
§ Information-processing: • Malaguzzi believed that the concept of well-being leads
• Approaches stress the to educational approach.
development of genera • Creating an educational environment that recognizes
abilities to process and the child’s social-emotional well-being mean creating a
organize information, such place where every child is valued and respected as an
as memory or attention. individual and as an equal member of a group.
§ Sociocultural approach: • Malaguzzi believed that every moment should be
• Emphasizes the contribution enjoyable and satisfactory.
that expert adults can make
to children’s knowledge.
• There is growing evidence
that from very early in
infancy babes are THE ETHICAL COMPONENT
specifically and powerfully The following points characterize the Reggio Emilia ethical code:
tuned to information that • Education is not just a technique but is a shared process
comes to them from their for revealing values
caregivers.
• The school is a place that transmits and constructs

culture through experiences. The reciprocal relations
between transmission and construction gives schools
and teachers a responsibility and an active role in
THE IMAGE OF A CHILD
sustaining and generating a culture that is based on the
past yet looking ahead to the future • Loris Malaguzzi said “Each has inside ourselves an image
• The school, should focus not only on knowledge but of the child that directs you as you begin to relate a
child.
also on concepts, ideas and values
• The educator influences the future, and as such needs • Impact of the image to the awareness of the teachers, as
to generate the connections between the individual and only the awareness would enable the teacher to follow
the world. the desired image of children; one that sees and
accepts the child as an active competent partner,
• Children are born with myriad ways to construct and
plentiful with potential and capabilities.
process knowledge.
• Usually the strength and the talents of children are
underestimated and schools tend to suppress the
THE AESTHETIC COMPONENT child’s potential by creating an environment of
• Education must focus on the aesthetics because the transmission, instead of exploration.
child knows how to value beauty and is able to interact • The concept of a “blank slate” first mentioned by the
with all the expressive languages. philosopher John Locke, is presented here as a
• Malaguzzi’s innovative idea for approaching and characterizing traditional point of view in education that
embracing the expressive-aesthetic aspects to early does not believe in the child’s abilities and leaves no
childhood education was the atelier room for the child’s feelings, thoughts, imagination, and
o The atelier is a statement about the creativity.
importance of imagination, creativity, o It also reflects that the child is waiting for the
expression and aesthetics in the learning and school and society to “ write” on, nourish, and
knowledge construction processes. fill his or her slate.
PEDAGOGIC THINKING: CORE CONCEPTS AROUND 3 THE IMAGE OF THE EDUCATOR

MAJOR AREAS The role of the teacher in the above image encompasses the
following aspects:
• To define and create the context within which all
learning/ teaching processes would occur. The context
enables the landscape of learning to emerge and
develop
• To think and plan using symbols and concepts
• To interpret the child concepts and symbols with the
group
• To elaborate on the experiences and the interpretations
done with the children
• To review with the children a second round of
One of the cornerstones of this approach is the concept of experiences built on the previous day
images. • To add improvisations according to the previous
• All of the perceptions and interpretations are organized learning processes.
into clusters that serve as our inner compass and
navigate our way in the personal and social-cultural life There are reciprocal relationships between the image of the child
that we share with others. and the image of the teacher and each is complementary and
• When it comes to education, the images play a crucial bound to the other.
and determinative role as is reflected in the following
quote from Carla Rinaldi: “Everyone (you, us, each,
THE IMAGE OF THE CONTEXTUAL COMMUNITY
parent..) has his or her own image of the child and
consequently, we have our own educational theories • The concept at the core of the educational communal
that we develop based on personal, social, cultural and life is the idea of the other that is the essence of the
political experience and that we construct or acquire as Reggio Emilia pedagogic approach.
part of our society and culture.
• The “other” might be the child, the family or a • By 10 weeks, the face is recognizably human. The
colleague- in a sense, any person who is interacting with midgut return to abdomen from the umbilical cord,
the educational system. rotating counterclockwise to bring the stomach, small
• All members together, through the relations that are intestine and large intestine into their normal positions.
constructed among all, are part of creating a sense of • By 12 weeks, the gender of the external genitals become
belonging for the system and for its members. clearly distinguishable. Lung development proceeds,
• The feeling of belonging serves as a foundation for the with the budding of bronchi, bronchioles, and
community life. successively smaller dividions.
• When people who are part of the system feel they are • By 20-24 weeks, primitive alveoli have formed and
seen, heard and known, a culture of participation can surfactant production has begun; before that time, the
be developed. absence of alveoli renders the lungs useless as organs of
• The idea of crossing the boundaries of the subjectivity gas exchange.
rd
to arrive at the intersubjective landscape emerges from • During the 3 trimester, weight triples and length
a very important declaration that the school send to the doubles as body stores of protein, fat, iron, and calcium
community. increase.
• Concepts like welcoming, plurality, dialog and
intercultural dynamics are explored and new meanings NEUROLOGIC DEVELOPMWNT
rd
are attributed to them, as a realization that every • During the 3 week, a neural plate appears on the
word/concept or value could have different meanings. ectodermal surface of the trilaminar embryo.
• Neuroectodermal cells differentiate into neurons,
III. ASSESSMENT OF FETAL GROWTH AND astrocytes, oligodendrocytes, and ependymal cells,
DEVELOPMENT whereas microglial cells are derived from mesoderm.
th
SOMATIC DEVELOPMENT • By the 5 week, the 3 main subdivisions of forebrain,
midbrain and hindbrain are evident.
Embryonic Period • The dorsal and ventral horns of the spinal cord have
• By 6 days post conception age, the embryo consists of a begun to form, along with peripheral motor and sensory
spherical mass of cells with a central cavity (the nerves. Myelinization begins at midgestation and
blastocyst) continues for years.
• By 2 wks, implantation is complete and the • By the end of the embryonic period (8 weeks), the gross
uteroplacental circulation has begun; the embryo has 2 structure of the nervous system has been established.
distinct layers, endoderm and ectoderm, and the • On a cellular level, neurons migrate outward to form
amnion has begun to form. the 6 cortical layers.
rd • Migration is complete by the 6 months, but
• By 3wk, the 3 primary germ layer (mesoderm) has
appeared, along with a primitive neural tube and blood differentiation continues.
vessels. Paired tubes have begun to pump.
• During week 4-8, lateral folding of the embryologic BEHAVIORAL DEVELOPMENT
plate, followed by growth at the cranial and caudal ends • No behavioral evidence of neural function is detectable
rd
and the budding of arms and legs, produces a human- until the 3 months.
like shape. Precursors of skeletal muscles and vertebrae • Reflexive responses to tactile stimulation develop in a
(somites) appear, along with the brachial arches that will craniocaudal sequence. By week 13-14, breathing and
form the mandible, maxilla, palate, external ear and swallowing motion appear.
other head and neck structures. • The grasp reflex appears at 17 weeks and is well
• Lens placodes appear, marking the site of future eyes; developed by 27 weeks.
brain grows rapidly. • Eye opening occurs around 26-28 week. By
• By the end of wk 8, as the embryonic period closes, the midgestation, the full range of neonatal movements can
rudiments of all major organ systems have developed; be observed.
rd
the crown-rump length is 3 cm. • During the 3 trimester, fetuses respond to external
stimuli with heart rate elevation and body movements.
Fetal Period • As with infants in the postnatal period, reactivity to
th
• From the 9 week on (fetal period), somatic changes auditory (vibroacoustic) and visual (bright light) stimuli
consist of rapid body growth as well as differentiation of vary, depending on their behavioral state, which can be
tissues, organs and organ systems depicts changes in characterized as quiet sleep, active sleep or awake.
body proportion. • Fetal behavior is affected by maternal medications and
diet, increasing after ingestion of caffeine.
• Behavior may be entrained to the mother’s diural

rhythms: asleep during the day active at night.
• Fetal movement increases in response to a sudden
auditory tone, but decreases after several repetitions.
PSYCHOLOGIC CHANGES IN PARENTS

• Many psychologic changes occur during pregnancy. An
unplanned pregnancy may be met with anger, denial or
depression.
• Ambivalent feelings are the norm, whether or not the
pregnancy was planned.
• Elation at the thought of producing a baby and the wish
to be the perfect parent compete with fears of
inadequacy and of the lifestyle changes that mothering
will impose.
IV. THE NEWBORN 2. Peripartum and Postpartum Influences

– Regardless of gestational age, the new born (neonatal) – The continuous presence during labor of a woman trained
period begins at birth and includes the first month of life. to offer friendly support and encouragement (a doula)
– Marked physiologic transitions occur in all organ systems results in shorter labor, fewer obstetric complications
– Infants thrive physically and psychologically including (including cesarean section), and reduced postpartum
parent’s roll as well. hospital stays. Early skin-to-skin contact between mothers
and infants immediately after birth may correlate with an
A. Parental Role in Mother- Infant Attachment increased rate and longer duration of breastfeeding.
– Parenting a newborn infant requires dedication because a – Postpartum depression may occur in the 1st wk or up to 6
newborn’s needs are urgent, continuous, and often unclear. mo after delivery and can adversely affect neonatal growth
Parents must attend to an infant’s signals and respond and development. Screening methods are available for use
empathically. Many factors influence parents’ ability to during neonatal and infant visits to the pediatric provider.
assume this role. Referral for care will greatly accelerate recovery.
1. Prenatal Factors
– Pregnancy is a period of psychological preparation for the B. Parental Role in Mother- Infant Attachment
profound demands of parenting. – The in utero environment contributes greatly but not
– For adolescent mothers, the demand that they relinquish completely to the future growth and development of
their own developmental agenda, such as an active social the fetus. These abnormal growth patterns not only
life, may be especially burdensome. predispose infants to an increased requirement for
– Bonding may be adversely affected by several risk factors medical intervention, but also may affect their ability to
during pregnancy and in the postpartum period that respond behaviorally to their parents.
undermine the mother– child relationship and may
threaten the infant’s cognitive and emotional development. 1. Physical examination
– Social support during pregnancy, particularly support from – Examination of the newborn should include an evaluation
the father and close family members, is also important. of growth and an observation of behavior. The average term
newborn weighs approximately 3.4 kg (7.5 lb); boys are
slightly heavier than girls. Average weight does vary by
ethnicity and socioeconomic status. The average length and
head circumference are about 50 cm (20 in) and 35 cm (14
in).
2. Interactional Abilities
– Neonates are nearsighted, having a fixed focal length of 8-12
inches, approximately the distance from the breast to the
mother’s face, as well as an inborn visual preference for
faces. The initial period of social interaction, usually lasting
about 40 minutes, is followed by a period of somnolence.
3. Modulation of Arousal A. 0-2 Months

– Adaptation to extrauterine life requires rapid and profound – In the full-term infant, myelination is present by the time of
physiologic changes, including aeration of the lungs, birth in the dorsal brainstem, cerebellar peduncles, and
rerouting of the circulation, and activation of the intestinal posterior limb of the internal capsule. The cerebellar white
tract. matter acquires myelin by 1 mo of age and is well
– Underaroused infants are not able to feed and interact; myelinated by 3 mo of age.
overaroused infants show signs of autonomic instability, – A newborn’s weight may initially decrease 10% below
including flushing or mottling, perioral pallor, hiccupping, birthweight in the 1st wk as a result of excretion of excess
vomiting, uncontrolled limb movements, and inconsolable extravascular fluid and limited nutritional intake. Nutrition
crying. improves as colostrum is replaced by higher-fat breast milk.
– Infants regain or exceed birthweight by 2 wk of age and
should grow at approximately 30 g (1 oz)/per day during the
1st mo.
– This is the period of fastest postnatal growth.
– Infants can differentiate among patterns, colors, and
consonants. They can recognize facial expressions (smiles)
4. Behavioral States as similar, even when they appear on different faces.
– Six states have been described: – Rhythmic patterns in native language
• Quiet
• Sleep – Crying occurs in response to stimuli that may be obvious (a
• Active Sleep soiled diaper), but are often obscure.
• Drowsy – Infants who are consistently picked up and held in
• Alert response to distress cry less at 1 yr and show less-aggressive
• Fussy behavior at 2 yr.
• Crying
– Alert state, infants visually fixate on objects or faces and
follow them horizontally and (within a month) vertically. A. 2-6 Months
– Active sleep, an infant may show progressively less – Crying occurs in response to stimuli that may be obvious (a
reaction to a repeated heel stick (habituation). soiled diaper), but are often obscure.
– Drowsy state, the same stimulus may push a child into – At about age 2 mo, the emergence of voluntary (social)
fussing or crying. smiles and increasing eye contact mark a change in the
parent–child relationship, heightening the parents’ sense of
C. Implication for Pediatrician being loved reciprocally.
– Pediatric visit allows pediatricians to assess potential – During the next months, an infant’s range of motor and
threats. social control and cognitive engagement increases
– Baby friendly hospitalhave shown great increase dramatically.
breastfeeding rates. – Mutual regulation takes the form of complex social
– Assess parent-infant interaction interchanges, resulting in strong mutual attachment and
– Teach about individual competencies in taking care of an enjoyment. Routines are established.
infant – Parents are less fatigued.
– rate of growth slows to approximately 20 g/day
– Increasing control of truncal flexion makes intentional
V. The First Year rolling possible.
– At 4 mo of age, infants are described as “hatching” socially,
– Neural plasticity, the ability of the brain to be shaped by
becoming interested in a wider world.
experience, both positive and negative, is at its peak.
– 1st stage of personality development
– Total brain volume doubles in the 1st yr of life and increases
– When face-to-face, the infant and a trusted adult can match
by an additional 15% over the 2nd yr. Total brain volume at
affective expressions (smiling or surprise) approximately
age 1 mo is approximately 36% of adult volume but by age 1
30% of the time
yr is approximately 72% (83% by 2 yr). The acquisition of
– Infants who do not show this reciprocal language and
seemingly “simple” skills, such as swallowing, reflect a series
movements are at risk for autism spectrum disorders
of intricate and highly coordinated processes involving
– Giving vaccines and drawing blood while the child is seated
multiple levels of neural control
on the parent’s lap.
– Myelination of the cortex begins at 7-8 mo gestation and
continues into adolescence and young adulthood. It
proceeds in a posterior to anterior fashion, allowing
progressive maturation of sensory, motor, and finally A. 6-12 Months
associative pathways. – With achievement of the sitting position, increased
mobility, and newskills to explore the world around them
– New tensions around the themes of attachment and
separation.
– Growth slows more by the 1st birthday, birth weight has – Height and weight increase at a steady rate during this year,
tripled, length has increased by 50%, and head with a gain of 5 in and 5 lb.
circumference has increased by 10 cm. – Head growth slows slightly. Eighty-five percent of adult
– These explorations are aided by the emergence of a head circumference is achieved by age 2 yr, with just an
thumb–finger grasp (8-9 mo) and a neat pincer grasp by 12 additional 5 cm gain over the next few years
mo. – Object permanence is firmly established
– Voluntary release emerges at 9 mo. – Cause and effect are better understood, and toddlers
– Some walk by 1 yr. demonstrate flexibility in problem solving
– Tooth eruption occurs, usually starting with the mandibular – Symbolic transformations in play are no longer tied to the
central incisors toddler’s own body, so that a doll can be “fed” from an
– 6 mo old infant has discovered his hands and will soon empty plate.
learn to manipulate objects – preceding half-year often gives way to increased clinginess
– A major milestone is the achievement by 9 mo of object around 18 mo. This stage, described as “rapprochement,”
permanence (constancy), the understanding that may be a reaction to growing awareness of the possibility of
objects continue to exist, even when not seen. separation.
– Infants look back and forth between an approaching – Separation anxiety will be manifest at bedtime special
stranger and a parent, and may cling or cry anxiously, blanket or stuffed toy as a transitional object, which
demonstrating stranger anxiety. functions as a symbol of the absent parent.
– child’s use of “no” is a way of declaring independence.
– Labeling of objects coincides with the advent of symbolic
– Tantrums make their first appearance as the drives for thought. child’s vocabulary balloons from 10-15 words at 18
autonomy and mastery come in conflict with parental mo to between 50 and 100 at 2 yr.
controls and the infants’ still-limited abilities. – toddlers understand 2-step commands, such as “Give
– 7 mo of age are adept at nonverbal communication me the ball and then get your shoes.”
– 9 mo of age, infants become aware that emotions can be – increasing mobility, physical limits on their explorations
shared between people become less effective
– Between 8 and 10 mo of age, babbling takes on a new
complexity, with multisyllabic sounds (“ba-da-ma”)
– Introduction of a transitional object may allow the
infant to self-comfort in the parents’ absence.
VI. The Second Year

– The toddler’s newly found ability to walk allows separation
and independence
– However the toddler continues to need secure attachment
to the parents
– At approximately 18 mo of age, the emergence of symbolic
thought and language causes a reorganization of behavior,
with implications across many developmental domains.
A. 12-18 Months
– Increase in head circumference 2 cm over the year
– Toddlers have relatively short legs and long torsos, with
exaggerated lumbar lordosis and protruding abdomens.
– Infants initially toddle with a wide-based gait, with the
knees bent and the arms flexed at the elbow
– Make-believe (symbolic) play centers on the child’s own
body (pretending to drink from an empty cup)
– Toddlers are described as “intoxicated” or “giddy” with their
new ability and with the power to control the distance
between themselves and their parents
– Infants speak their first words around 12 mo of age
– Toddlers also enjoy polysyllabic jargoning
A. 18-24 Months
– Improvements in balance and agility and the emergence of
running and stair climbing
• Decrease in cortical thickness

• Changes in cortical volume
• Changes in gray and white matter tissue properties
• Increase in brain metabolic demands
-SCAFFOLDING
• Greater number of brain regions are required to
complete a task among younger children compared to
older ones.
B. Physical Development
nd
-End of 2 year of life:
• Somatic and brain growth slows with corresponding
decrease in nutritional requirements and appetite
• “Picky” eating habits
• Increase of approx. 2kg (4-5 lb) in weight and 7-8 cm (2-
3c inches) in height
-4x the birth weight by 2.5 years
-at 3 yrs of age, all 20 primary teeth have erupted
rd
-has a mature gait and runs steadily before end of 3 year
-4 year old (Average) is 40 lb in weight and 40 inches tall
- Head grows an additional 5-6 cm between 3-18 yrs old.
-Children with early increase in BMI are at increased risk for Adult
obesity
-has Genu Valgum ( knock-knees) and mild pes planus (flat foot)
-Physical energy peaks, declined need for sleep 11-13 hrs/day,
child eventually dropping the nap [SANA ALL!!! ;( ]
-Visual acuity 20/30 by age 3; 20/20 at age 4
-there is wide variation in ability
• throwing, catching and kicking balls; riding on bicycles;
climbing on playground structures, dancing and other
complex pattern behaviors
-toe walking is unlikely
-social environment plays a part on their cognitive and emotional
development
-parents or teachers who encourages physical activity=energetic
and coordinated child
-adults who value quiet play=child with lower energy
-HANDEDNESS (individual preference for use of hand) is
rd
established by 3 year
-Bowel and bladder control:
• (+)readiness for toileting.
• Girls tend to train faster than boys.
• Bed-wetting is normal up to age 4 year in girls and 5 year
in boys
• Refusal to defecate in the toilet or potty is common,
may lead to constipation and parental frustration.
Implications for parents and paediatricians

- Normal decrease in appetite at this age may cause parental
VII. The Preschool Years concern about nutrition.
• Growth charts should reassure parents that child’s
intake is adequate
A. Structural Development of the brain
• Complete multivitamin can be used to assure adequate
- The preschool brain experiences dramatic changes in its vitamin and mineral intake.
anatomical and physiologic characteristics, characterized by • Predictable eating schedule should be provided, with 3
growth and expansion: meals and 2 snacks per day, allowing the child to
• Increase in cortical area choose how much to eat
• Counselling about safety precautions • Common difficulties:

§ Risk for injury is increased at this age. § Pauses and repetitions of initial sounds made
worse by stress or excitement.
th
C. Language, Cognition and Play § resolve in 80% of children by 8 year.
• Children with this condition should be referred for
1.Language evaluation if it is severe, persistent or associated with
anxiety, or if parental concern is elicited.
-Language development occurs most rapidly between 2 and 5
• Treatment
years of age. § Parental guidance to reduce pressure
• Vocabulary increases from 50-100 words to more than associated with speaking
2000.
• Sentence advances from telegraphic phrases (baby cry) 3.Cognition
to structured sentences. -Piaget’s Pre Operational (Pre-logical) Stage
• Number of words in a sentence=Child’s age • characterized by magical thinking, egocentrism and
• 21-24 months thinking dominated by perception, not abstraction.
§ Use of possessives (ex: “My Ball”), progressives
• Magical thinking
(-ing construction, as in “I playing”), questions § confusing coincidence with causality, animism
and negatives. and unrealistic beliefs about the power of
• 4 yrs wishes.
§ Count to 4 and use the past tense • Egocentrism
• 5 yrs § child’s inability to take another’s point of view,
§ use of future tense does not connote selfishness.
§ Do not use figurative speech, takes words
• Imitation
literally (ex: light as a feather) § goes beyond the mere repetition of observed
movements
2. Speech vs. Language
§ Ex. A child who watches an adult
unsuccessfully unscrew a lid will imitate the
-Speech is the production of intelligible sounds action but with the failed outcome
-Language refers to underlying mental act and includes both • Self-identification of Sex by age 3
expressive and receptive functions.
4.Play
-Receptive language (understanding) varies less in its rate of
acquisition than does expressive language, making it of greater -involves learning, physical activity, socialization with peers and
prognostic importance. practicing adult roles.
-Key determinants: -increases in complexity and imagination
• Amount and variety of speech directed towards • from simple imitation (2or 3 yrs)
children • more extended scenarios (3 or 4 yrs)
• Frequency of asking questions and encouragement of • creation of scenarios that have only been imagined (4 or
verbalizations 5 yrs).
• Economic status -Cooperative Play at age 3, and later on, a more structured
§ children raised in poverty has a lower role-play activity (as in playing house)
performance than those in economically -becomes increasingly governed by rule
advantaged families. • asking and taking (2 yrs)
-Language delays may be the first indication of an intellectual • according to desires of players (4 qnd 5 yrs)
disability, autism or is being maltreated. • beginning of the recognition of rules as relatively
-Language allows children to express feelings without acting immutable (5 yrs)
them out; Higher rate of tantrums are shown in language delayed -Electronic forms of play may be beneficial if it is interactive and
children educational.
-Preschool language development determines later success in -allows resolution of conflicts and anxieties and may serve as
school. creative outlets.
-Picture books are important for development of verbal language
5.Implications for parents and Paediatricians:
-Constantly reading to them improves vocabulary and receptive
language
-Parents can support emotional development by using words
-Dialogic Reading
that describe how the child is feeling
• ideal for child learning.
• done by repeatedly focusing the child on a particular • “You sound angry right now.”
picture, asking questions and feedback from the child. • urge the child to use words to express, rather than
-Period of Rapid Language Acquisition acting it out.
-Regular time for reading with their children
• when developmental dysfluency and stuttering
most likely to emerge. • promote language development
-Parental Guidance in watching quality television programs -Sense of control over his/her body and the surroundings is
• limit it to 2 hrs/day important for a pre-schooler.
-Children should be given simple and concrete explanation -Prepare the patient of what will happen will provide
regarding illness and treatment procedures. reassurance.
-Parents should: -Don’t ask permission if you won’t take no as an answer.
• acknowledge the fear -Only give options approved by the parents
• offer reassurance -encourage independence on self-care activities to avoid
• give a sense of security and control over the situation
conflicts.
-A brief introduction about private parts is important before any
D. Emotional and Moral Development genital examination
-Use of corporal punishment for disciplining the children is not
-Emotional challenges include: an effective behavioural control.
• accepting limits while maintaining a sense of direction
• As spanking is done habitually, children get used to it
• reining in aggressive and sexual impulse and parents need to spank even harder to get the
• interacting with a widening circle of adults. desired response, which might cause serious injury.
-Learning of acceptable behaviors and how much power they • In the later years, they are the ones demonstrating
have over important adults by testing limits . aggressive behaviors.
• Excessively tight limits undermine a child’s sense of -DISCIPLINE
initiative • process that allows the child to internalize controls on
• overly loose ones can provoke anxiety in a child feeling behaviour.
no one is in control. • It is characterized by consistent limit setting, clear
• Control communication of rules and frequent approval
§ central issue due to their lack of control in • should be Immediate, Specific to the behaviour and
many aspects of their lives( where to go or how time-limited.
long they will stay) • Time-Out, 1 min/ year of age , is found to be very
-Temper tantrums effective
• pre-schoolers tend to loose internal control
§ which may be caused by fear, overtiredness, VIII. The Middle Childhood
inconsistent expectations or physical
– Middle childhood (6-11 yrs of age) increasingly separate
discomfort
st from parents and seek acceptance from teachers, other
• normally appears toward the end of 1 year of life
adults and peers (Peer pressure)
• peaks bet 2 and 4 years of age
– They are now judged according to their ability to
• More than 15 mins or regularly occurring more than
produce socially valuable outputs
3x/day means an underlying medical, emotional or
• Ex. Getting good grades
social problems.
-Complicated feelings toward their parents starts to develop
which leads to fear of abandonment. A.Physical Development
-Play and language foster the development of emotional control
-Growth occurs discontinuously
by allowing them to express emotions
• 3-6 irregularly timed spurts each year
-Curiosity about genitals and adult sexual organs are normal,
• varies among individuals
even masturbation. -Average growth
• Excessive masturbation, mimicry of adult seductive • 3-3.5 kg(6.6-7.7 lbs)
behaviour and the like-suggest of sexual abuse or • 6-7cm (2.4-2.8 inches) per year
inappropriate exposure. -Head grows only 2cm in circumference the entire period,
• Parents should begin teaching them about private body reflecting a slowing of brain growth.
parts before school age -Myelinization
-At age 2 • continues in adolescence
• child’s sense of right and wrong • peak gray matter at 12-14 yrs.
§ desire to earn approval from parents and avoid -Body habitus more erect, long legs compared with the torso
negative consequences. -Growth of midface and lower face occurs gradually
• Empathic responses to other’s distress -Teeth:
-Fairness is important at this age, regardless of circumstances • Loss of deciduous teeth, beginning around 6 yr of age
• Ex. A 4 yr old child will acknowledge taking turns but • Replacement of adult teeth, 4/year
will complain if he/she didn’t got enough time • By 9 years, children will have 8 permanent incisors and
4 permanent molars.
Implications for parents and Paediatricians: • Premolars erupt by 11-12 years of age
-Lymphoid tissue hypertrophy, Gives rise to impressive tonsils
and adenoids.
-Muscular strength, coordination and strength and ability to do • Causes for school age concepts, academic and behavior
complex task increases progressively problems:
-Physical fitness declined among school-age children due to • deficits in perception
sedentary habits • Specific learning disabilities
-Body image perception develop early during this period. • Global cognitive delay(mental retardation)
• as young as 5-6 yrs, many already express dissatisfaction • primary attention deficit
with their body image • attention deficit secondary to family dysfunction,
• Some are reported to use ill-advised regimens for diet depression, anxiety or chronic illness
purposes, by age 8-9 yrs. -Identify child's strengths
-Interests in gender differences and sexual behavior increases -discipline strategies
progressively until puberty • involve negotiating and a clear understanding of
• due to increased gonadotropin release. consequences.
-Masturbation is common.
B. Social and Emotional Development
Implications for parents and Paediatricians:
-At this period, energy is directed toward creativity and
productivity
-Fears of being abnormal leading to avoidance of situations in -3 spheres where changes occur:
which physical differences might be revealed. • Home still remains the most influential.
• Ex.. Gym class or medical examinations § Parents should make demands for effort in
-Counselling on establishing healthy eating habits and limited school and extra-curricular activities, celebrate
screen time should be given to all families successes and offer unconditional acceptance
-Pre-pubertal children should avoid in engaging to high stress, when failures occur.
high impact sports § Siblings play a critical role as competitors, loyal
• skeletal immaturity increases the risk of injury. supporters and role models.
• Beginning of School increases importance of teacher
B.Cognitive Development and peer relationship.
-Concrete logical operations § Social groups contribute to a child's growing
• apply rules based on observable phenomena, factor in social development and competence.
multiple dimensions and point of view, and interpret § Popularity , being the central ingredient of
their perceptions using physical laws. self-esteem, maybe won through possessions,
• Interactional relational model personal attractiveness, accomplishments and
§ focuses on the child, the environment and the actual social skills.
interactions therein. § Attributions conferred by peers may become
§ recognizes the importance of early incorporated into a child's self-image and
experiences for later development. affect the child's personality and even their
§ Rather than delaying school entry, High quality school performance.
early education programs maybe the key to • Neighbourhood
ultimate school success. § Real dangers tax school-age child's common
-School makes increasing cognitive demands on the child. The sense and resourcefulness.
volume of work increases along with the complexity. § Media exposure to adult materialism,
sexuality, substance and violence may frighten
Implications for parents and Paediatricians: and make the child feel powerless in the larger
-The role of the paediatrician world.
• promote health through immunizations, adequate
nutrition, appropriate recreation and screening for
physical, developmental and cognitive disorders. C. Moral Development
Notes:
-American Academy of Pediatrics recommends the 5R's of early -by the age of 6,
education: • Conscience is starting to develop
• They believe that rules are established and enforced by
R-eading as a daily family activity
R-hyming, Playing, and cuddling together an authority figure (parent or teacher) and decision-
R-outines and regular times for meals, play and sleep making is guided by self-interest.
R-eward through praise for successes • Need of others are not strongly considered in decision
R-eciprocal nurturing relationships making.
• Social behaviors socially undesirable are considered
wrong
-Concrete operations allow children to understand simple -By age 10-11 yr,
explanations for illnesses and necessary treatments, although • combination of peer pressure, desire to please authority
they may revert to pre-logical thinking under stress. figures and understanding of reciprocity shapes their
-Find the problem areas: behavior.
Implications for parents and Paediatricians: § Females: appearance of breast buds(thelarche)

between ages 8-12 yr.
-Children is in need of unconditional support and realistic • Discharges
demands as they journey into the world. Exerting excessive § Males: Sperm may be found in the urine By
pressure on them to achieve success and not meeting it in the SMR
end may cause conflicts § Females: Physiologic leukorrhea (clear vaginal
-Home should be a secure base for refueling emotional energies discharge) maybe present prior to menarche
and not otherwise. § Menses begins 2.5 years after onset of puberty
-Bullying between SMR 3-4.
• indicates a need for evaluation o (Average age 12.5; normal range 9-15
• associated with mood disorders, family problems and yr)
school adjustment problems. C. Somatic Growth
• Parents should ensure exposure to hazards is reduced -Peak height velocity
-Pediatrician visits are infrequent so once they do, he/she must • Males
be able to assess children's function in all the 3 spheres: home, § 9-10cm/yr at a later SMR stage(3-4) and
School and the neighborhood. continue their linear growth for approx 2-3 yrs
-Television and internet exposure should be limited to 2hrs/day, after females have stopped growing
monitor what they watch. • Females
-Some useful tools in assessing a child's functioning: § 8-9cm/yr at SMR 2-3,approx 6 months before
• Draw-a-person (for ages 3-10 to draw a complete menarche
person) -Body Mass
• Kinetic family drawing (beginning at 5yr, to draw a • Males
picture of the family member doing something) § Increase in lean body mass (strength spurt)
• Females
§ development of higher proportion of body fat
IX. The Adolescent -Bone growth precedes increase in bone mineralization and
bone density
- undergo not only dramatic changes in physical appearance, but
• there is increased risk of fracture
also hormonally-driven physiologic changes and ongoing
neurologic development in the setting of social structures.
-3 phases: D. Cardiovascular changes
1. Early 10-13 yrs
2. Middle 14-17 -Increased heart size
3. Late 18-21 -Higher BP
A.Physical Development -increase in blood volume and haematocrit (particularly males)
-Increased lung vital capacity—-> greater aerobic capacity
-Puberty
• biologic transition from childhood to adulthood
E. Other changes
• Changes include:
§ appearance of the secondary sexual
-stimulation of sebaceous and apocrine glands
characteristics
§ Increase in height • may result to acne and body odor
§ change in body composition -Change in voice quality preceded by vocal instability(voice
§ Development of reproductive capacity cracking), in males
-As early as 6 yrs, • due to enlargement of larynx, pharynx and lungs
• Androgen , chiefly Dehydroepiandrosterone -Myopia due to the elongation of the optic globe
-Dental changes
sulfate (DHEAS ), may be produced
• maturation of Gonadotropin Releasing • Jaw growth
hormone(GRH). • loss of final deciduous teeth
§ stimulates the Pituitary gland to secrete LH and • eruption of the permanent cuspids, premolars and
FSH which increases gonadal androgens and molars
estrogens. -sleep pattern
-High concentration of the hormone Leptin • physiological changes
• associated with increased body fat and earliest onset of • increase in sleep requirement
puberty
F. Neurologic, Cognitive and moral development
B. Sexual Development
– Tanner Stages , or Sexual Maturity Rating (SMR) -adolescents develop and refine their ability to use formal
• First visible sign of puberty and hallmark of SMR 2: operational thought processes
§ Males: testicular enlargement, which begins as -Middle and late adolescents have now the ability to consider
early as 9.5 yr options and its long term consequences
-Enhanced capacity for verbal expression
-Neuromaturation continues into the 3rd decade. It is -Adolescents may take religious or political views, influential and
characterized by: appealing.
• decrease in gray matter(selective pruning of rarely used
synaptic connections) H. Psychosocial Development
• increase in white matter(increasing myelinization,
subsequent facilitation of integrated brain activity) -subjected to environmental and cultural influences
• increase in the efficiency of communication and
connectivity between diff brain regions. 1. Identity Formation
• Starts with the posterior cortex, progresses anteriorly
-moving away from nurturing protection of the family
-The immaturity of the pre frontal cortex which is
-increased affiliation with peer group
responsible for executive functions and early maturation of the
-defines himself/herself as an INDIVIDUAL.
amygdala and other limbic structures , involved in the
-Hallmark: Separation from parents
experience of fear and emotion, explains why they are more
-Early adolescence
likely to make poor decisions in highly emotionally charged
• independence from parents
situations in comparison with mature adults.
• may seek out alternative adult role models
-Middle Adolescence
-2 types of cognitive process:
• peak of Parental-child conflict
• Hot cognition
• Intermittence in seeking and rejecting parental advice
§ associated with strong affective experience
• accordingly, the adolescents need to conceive of the
• Cold cognition
parents as "wrong" to ameliorate the pain of separation.
§ less emotional state
-Late adolescence
-Early adolescence is characterized by:
• More adult-adult type of relationship with parents
• Egocentricity
• considers parental advice again upon entering
§ Believing that they are the center of everyone's
Adulthood
attention
§ Can be stressful, they may feel that others are 2. Increasing importance of peer group
constantly judging or evaluating them.
• a greater need for privacy
-Early adolescence
-Middle adolescence • same sex peer, both in individual friends or larger
• Recognizes the needs and feelings of other people groups
• enhanced creativity and intellectual abilities • group cohesion and sense of belonging becomes
• Risk takers important
§ feel the sense of immunity to the -Middle Adolescence
consequences of risky behaviors • increased importance of peers
-Late adolescence • may include both gender, both from organized
activities or friendships.
• more future-oriented • Gang membership is another form of peer acceptance.
• able to delay gratification -Late adolescence
• thinks more independently • Less vulnerability to peer group influence
• considers other's view and compromises • establishes their own stable identity
• Has a stronger sense of self
3. Sexual Awareness and Interest
• more stable interests
• (+) stress may cause them to go back to the cognitive
process and coping strategies at their younger age -Early adolescence
• Increased, may manifest as sexual talk and gossip,
G. Moral Development focused on sexual anatomy.
• Masturbation and other sexual exploration, sometimes
with same sex peers are common.
-Pre adolescence
• Romantic relationships lack emotional depth
• follow rules in order to please authority figures, avoids
-Middle Adolescence
punishments
• Sexual curiosity experimentation and activity become
-Early Adolescence
more common.
• stronger sense of right and wrong
• Sexual attraction over emotional intimacy
-Middle and Late Adolescence
-Late adolescence
• driven by desire to be seen as a good person
• relationships increasingly involve love and commitment
• based on perceived place in society and obligation to
and demonstrates greater stability
care for others.
• Late adolescents may develop a rational conscience 4. Body Image
and an independent system of values(usually goes with
parental values)
-Early and middle Adolescence
• distorted or poor body image
• eating disorders may arise they should be addressed by the parents and health care
• Early adolescent undergo rapid physical changes
§ Importance of reassuring them that what
they're going through is normal
• Middle adolescent experiences slow changes
§ Concern: whether they're attractive or not
-Late adolescent is characterized by:
• A shifting balance toward introspection, with less
emphasis on external characteristics.
5. Timing of Pubertal Change
-Males perceive progression of pubertal change as positive but

negatively for females.
-Early maturing females
• decrease in self esteem
• engage in more disruptive behavior
• more conflict with their parents than on-time or late
maturing ones.
-Early maturing males
• possess greater self confidence
• social and academic success
• late-maturing males are at risk for more internalizing
behaviors and diminished self esteem
•
Implication for Providers and parents
- reassure adolescents that some of the challenges are normal
developmental milestones and should be anticipated and
accepted.
-Early maturing females and late-maturing males should be
supported for they are at risk for psychosocial challenges
-Promotion of positive coping strategies to all youths
-Physical examination should be performed in private (with
parents outside the room to allow discussion of confidential
issues)
-Remind parents that adolescents are typically more
independent and an increase in parent-child conflict, doesn't
necessarily mean parent's inputs and perspectives are not valued.
-Parents should be encouraged to avoid categorically dismissing
their child's negative behavior. Instead, use this opportunity to
model critical thinking about its impact.
-Authoritative parenting
• strongly associated with a positive psychosocial
development.
• It is characterized by clear and appropriate setting of
negotiated limits, in the context of a caring and mutually
respectful Parent-child relationship
-Parental connectedness and close supervision/monitoring of
youth activity and peer group
• protective against early onset of sexual activity and
involvement in risk taking behaviors
• can foster positive youth development
-Encourage adolescents to anticipate the possibility of highly
affectively charged situations and by making a plan while they're
under conditions of cool cognition, it may change the way they
deal with it when the time comes.
• Ex: Unprotected sex if a romantic couple gets carried
away in a sexual situation
-When the adolescent's behaviors cause significant dysfunction
in the domains of home life, academics or peer relationships,
provider.
-Referral to a mental health provider, if the need arises, is also
considered.
X. ASSESSMENT OF GROWTH
• Essential to eradicate malnutrition
o Malnutrition has devastating effects
particularly on brain growth and development
o Poor growth may persist
• To improve a child’s health
o aberrant growth may be the first sign of an
underlying biophysiologic or psychosocial
problem.
• Most crucial during the first 3 years because growth is
most rapid and energy needs is the greatest.
GROWTH CHART
• Most powerful tool in growth assessment Figure. Sample growth chart (length/height for age boys)
• Will allow comparison of a specific child Specialized charts
a. With children of his age (norm) • very-low birthweight and prematurity
b. With his own pattern of development • Down
• The percentile curve indicates the percentage of • Turner
children at a given age on the x-axis whose measured • Klinefelter syndromes
value falls below the corresponding value on the y-axis • cerebral palsy
th
• Median or 50 percentile is also called the standard • achondroplasia.
value
• WHO CGS <5 y/o Premature Infants
• CDC/NCHS 5-19 y/o • Corrections for Gestational Age
Normal Variation 1. Weight up to 24 months of age

1. Familial – height 2. Stature up to 40 months of age
2. Posture – vertebral curves 3. HC up to 18 months of age
3. Race – Caucasians taller than Asians
4. Ethnic culture – physique
5. Sex – males heavier than female WEIGHT
6. Twins – smaller babies • < 2 y/o or cannot stand (Tared weighing or infant scale)
7. Understimulation – constitutional delay • Simple and reproducible parameter
• Ideally done without clothing or minimal clothing
Growth Charts for Clinical Use (1985 FNRI-FPS Anthropometric
(diapers)
Charts)
• >2 y/o : weighing alone (They can stand on their own)
• Weight and age (0-36 months and 2-19 yrs for boys and
• < 6 months old
girls) o Weight in Grams = Age in Months x 600 + Birth
• Height and age (0-36 months and 2-19 yrs for boys and
weight
girls) • 6-12 months
• Weight-for-length/ height and age (0-36 months and 2-
o Weight in Grams = Age in months x 500 + Birth
10 yrs for boys and girls) weight
• Head circumference and age (0-36 months for boys and
girls)
• Normally, a child is expected to remain in the same Changes in Weight at Different Ages
percentile grp from age to age • At 4-5 months 2x Birthweight
• Weight and height may differ in percentile positions but • At 1 year 3x Birthweight
should maintain the same general relationship. • At 2 years 4x Birthweight
• At 3 years 5x Birthweight
LENGTH/HEIGHT
• <3 y/o use recumbent length Screening for children’s
• Head part is fixed • language,
• Infantometer • motor
• 3 y/o and above are able to stand à use standing height • cognitive/academic
• Without footwear • self-help
• Eye level • social–emotional status
• Use a cardboard or anything flat to mark
• Make sure legs are standing straight XII. Loss, Separation and Bereavement
All children will experience involuntary separations, whether from
HEAD CIRCUMFERENCE/ OCCIPITAL FRONTAL illness, death, or other causes, from loved ones at some time in their lives.
CIRCUMFERENCE Relatively brief separations of children from their parents, such as
• At birth head circumference is 35 cm vacations, usually produce minor transient effects, but more enduring
• Should be monitored routinely during the first 3 years of and frequent separation may cause sequelae. The potential impact of
life each event must be considered in light of the age and stage of
• Especially in the first 2 years development of the child, the particular relationship with the absent
• Assessment of brain growth person, and the nature of the situation.
• Sometimes equal with the chest circumference (in the A. Separation and Loss
early years of life) Causes of Separations may be from: Temporary or Permanent
• Measured over the most prominent part of the occiput Ø Temporary Separation
and just above the supraorbital ridges 1. Vacations
2. Parental job restrictions
3. Natural disasters
BODY MASS INDEX (BMI)
4. Parental or sibling illness requiring hospitalization.
• >2y/o
• A valid predictor of adiposity Ø Permanent Separation
• Indirect measure of body fat 1. Divorce,
• Best clinical standard for defining obesity 2. Placement in foster care or adoption
• BMI = wt (kg)/Ht (m2) 3. Death.
OTHER INDICES OF GROWTH o Children Response to Separation and Loss

• Body proportions
The initial reaction of young children to separation of any duration may
• Skeletal maturation
involve crying, either of a tantrum-like, protesting type, or of a quieter,
• Dental development sadder type.
XI. DEVELOPMENTAL- BEHAVIORAL SCREENING AND

In General children’s behavior may appear:
SURVEILLANCE
1. Subdued,
2. Withdrawn
3. Fussy, or moody,
4. Resistance to authority.
In Specific problems may include:
1. Poor appetite,
2. Behavior issues such as acting against caregiver requests
3. Reluctance to go to bed
4. Sleep problems
5. Regressive behavior ( e.g requesting a bottle or bed-wetting)
School-age children reaction to separation may include:

1. Impaired cognitive functioning
2. Poor performance in school.
3. May repeatedly ask for the absent parent and question when
the absent parent will return.
4. Look or search for the absent parent;
5. Other children may not refer to the parental absence at all.
Response to reunion may be consisting of:
1. Surprise or alarm an unprepared parent.
2. A parent who joyfully returns to the family may be met by wary
or cautious children.
3. After a brief interchange of affection, children may seem
indifferent to the parent’s return. This response may indicate
anger at being left and wariness that the event will
happen again, or the child may feel, as a result of magical
thinking, as if the child caused the parent’s departure.
4. If the mother who frequently says “Stop it, or you’ll give me a
headache” is hospitalized, the child may feel at fault and During School-age
guilty. 1. Children may respond with evident depression, indifferent,
angry.
As a result of these feelings, children may seem to be more closely 2. Deny or avoid the issue, behaviourally or verbally.
attached to the other present parent than to the absent one, or 3. Guilt
even to the grandparent or babysitter who cared for them during 4. Adopt a “sick” role as a strategy for reuniting their parents.
their parent’s absence. Some children, particularly younger ones,
During Adolescents:
may become more clinging and dependent than they were before
the separation, while continuing any regressive behavior that
1. Show intense anger.
occurred during the separation. Such behavior may engage the 2.
th
5 Year after the breakup - intense unhappiness and
returned parent more closely and help to re-establish the bond that dissatisfaction with their lives and their reconfigured families,
the child felt was broken. Such reactions are usually transient and another 1 3 show clear evidence of a satisfactory adjustment,
within 1-2 wks., children will have recovered their usual behavior whereas the remaining 1 3 demonstrate a mixed picture, with
and equilibrium. good achievement in some areas and faltering achievement in
others.
th
3. 10 Year - approximately 45% do well, but 40% may have
Recurrent separations may tend to make children more wary and
academic, social, and/or emotional problems. As adults, some
guarded about re-establishing the relationship with the repeatedly are reluctant to form intimate relationships, fearful of repeating
absent parent, and these traits may affect other personal their parents’ experience.
relationships.
Good adjustment of children after a divorce is related to ongoing
involvement with 2 psychologically healthy parents who minimize
A dv ice t o Pare nt s :
conflict, and to the siblings and other relatives who provide a positive
Do not try to ameliorate a child’s behavior by threatening to leave.
support system.
A dv ice to Pa rents:
ü Divorcing parents should be encouraged to avoid adversarial
II. Divorce processes and to use a trained mediator to resolve disputes if
More sustained experiences of loss, such as divorce or placement in needed.
ü Parents should be informed that different children may have
foster care, can give rise to the same kinds of reactions noted earlier, different reactions
but they are more intense and possibly more lasting. Currently in the ü The continued presence of both parents in the child’s life, with
United States, approximately 40% of marriages end in divorce. minimal interparental conflict, is most beneficial to the child.
Divorce has been found to be associated with negative parent

functioning such as: III. Move/Family Relocation
1. Parental depression and feelings of incompetence,
For children, the move is essentially involuntary and out of their
2. Inconsistent discipline
3. Decreased communication control.
4. Decreased affection. Changes in family structure that can cause stress to the child:
5. Loss of contact with the noncustodial parent (Usually the 1. Divorce
father) 2. Death
3. Move or Relocation
Greater childhood distress is associated with greater parental 4. Parental sadness surrounding the move may transmit
distress. unhappiness to the children.
5. Loss of their old friends
Two of the most important factors that contribute to morbidity of the 6. The comfort of a familiar bedroom and house, and their
children in a divorce include: ties to school and community.
1. Parental psychopathology In the evaluation of migrant children and families, it is important to
2. Disrupted parenting before the separation. ask about the circumstances of the migration, including legal status,
violence or threat of violence, conflict of loyalties, and moral, ethical,
Problem following the divorce: and religious differences. Transient periods of regressive behavior
st
1 Year - Period when problems are most apparent
nd
may be noted in preschool children after moving, and these should
2 Year - Problems tend to dissipate
th be understood and accepted.
5 Year – Depression may be present
th
10 Year – Educational or Occupational decline may occur
A dv ice t o Pare nt s :
The degree of interparental conflict may be the most important factor ü Parents should assist the entry of their children into the new
associated with child morbidity. A continued relationship with the community, and whenever possible, exchanges of letters and
noncustodial parent, as long as there is minimal interparental conflict, visits with old friends should be encouraged.
was a factor associated with more positive outcomes. ü Parents should prepare children well in advance of any move
and allow them to express any unhappy feelings or misgivings.
Children Response following the divorce:
or those presumed
IV. PARENTAL/SIBLING DEATH responsible for the death.
At 12-14 years 1. Children begin to use
Parents should prepare children well in advance of any move and symbolic thinking, reason
allow them to express any unhappy feelings or misgivings. abstractly, and analyze
hypothetical, or “what if,”
scenarios systematically.
V. GRIEF AND BEREAVEMENT 2. Teenagers are often
Grief is a personal, emotional state of bereavement or an anticipated ambivalent about
response to loss, such as a death. dependence and
independence and may
Children need to know that their parents love them and will continue to withdraw emotionally from
protect them. Children need opportunities to talk about their relative’s surviving family members,
death and associated memories. A surviving sibling may feel guilty
only to mourn in isolation.
simply because he or she survived, especially if the death was the
3. Adolescents begin to
result of an accident that involved both children. Siblings’ grief,
especially when compounded by feelings of guilt, may be manifested by understand complex
regressive behavior or anger. physiologic systems in
relationship to death
4. Depression, resentment,
A dv ice to Pa rents:
mood swings, rage, and risk-
ü Parents should be informed of this possibility and encouraged taking behaviors can emerge
to discuss the possibility with their children
as the adolescent seeks
answers to questions of
values, safety, evil, and
fairness.
VI. DEVELOPMENTAL PERSPECTIVE
VII. Treatment
Age Remarks
Suggesting interventions outside the natural support network of family
Children younger than 3 1. Little or no understanding of
and friends can often prove useful to grieving families. Bereavement
years the concept of death.
counselling should be readily offered if needed or requested by the
2. Young children may respond
family. Interventions that enhance or promote attachments and security,
in reaction to observing
as well as give the family a means of expressing and understanding death,
distress in others, such as a
help to reduce the likelihood of future or prolonged disturbance,
parent or sibling who is crying,
especially in children. Collaboration between pediatric and mental
withdrawn, or angry.
health professionals can help determine the timing and appropriateness
of services.
Preschool children 1. Preoperational cognitive
stage REFERENCES
2. The primary care provider has
1. Kliegman, R.M Nelson Textbook of Pediatrics. 20
th
ed,
a very important role in updated. Philadelphia: Saunders-Elsevier, 2016.
helping families understand
the child’s struggle to
comprehend death.
3. Children conceptualize events
in the context of their own
experiential reality, and
therefore consider death in
terms of sleep, separation, and
injury.
Younger school-age children 1. Think concretely, recognize
that death is irreversible, but
believe it will not happen to
them or affect them, and
begin to understand biologic
processes of the human body
Children of 9 years 1. Older do understand that
death is irreversible and that it
may involve them or their
families.
2. Tend to experience more
anxiety, overt symptoms of
depression, and somatic
complaints than do younger
children.
3. Often left with anger focused
on the loved one, those who
could not save the deceased,

Ped201 s1t1 Prelim Growth and Development

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Ped201 s1t1 Prelim Growth and Development

Uploaded by

Copyright:

Available Formats

Pediatrics 1

Growth and Development

Transcribed by: Page 1 of 22

MATURATIONAL CHANGES: • Attachment refers to a biologically

ü Depicts these relationships as concentric DEVELOPMENTAL DOMAINS AND THEORIES OF

§ Preschoolers may be intensely caregivers and then

o Suggest that much of this abstract structure is • By preschool, what is

• The school is a place that transmits and constructs

PEDAGOGIC THINKING: CORE CONCEPTS AROUND 3 THE IMAGE OF THE EDUCATOR

• Behavior may be entrained to the mother’s diural

PSYCHOLOGIC CHANGES IN PARENTS

IV. THE NEWBORN 2. Peripartum and Postpartum Influences

3. Modulation of Arousal A. 0-2 Months

VI. The Second Year

• Decrease in cortical thickness

Implications for parents and paediatricians

• Counselling about safety precautions • Common difficulties:

Implications for parents and Paediatricians: § Females: appearance of breast buds(thelarche)

5. Timing of Pubertal Change

-Males perceive progression of pubertal change as positive but

Normal Variation 1. Weight up to 24 months of age

OTHER INDICES OF GROWTH o Children Response to Separation and Loss

XI. DEVELOPMENTAL- BEHAVIORAL SCREENING AND

School-age children reaction to separation may include:

Divorce has been found to be associated with negative parent

You might also like