Continuing Education Activity

Child development is the stages a child goes through from birth until he or she becomes an adult. Children are first newborns, and they acquire the skills that allow them to adapt and function during their growth. Child development should be carefully monitored to ensure its full development. This activity reviews the stages of child development, developmental screening, and its utility by the interprofessional team.

Objectives:

• Describe the development of the newborn, later infancy, and adolescent periods.

• Identify the types of attachment during infancy.

• Assess the importance of developmental screening.

• Identify the reflexes that can be used to access development.

Introduction

Child development is a complex process that begins in the womb and continues until adulthood. It is influenced by biology and the environment and can be shaped positively or negatively. A person's mental health depends significantly on their development as a child. Following a child’s development is crucial to ensure it is adequate. This is done mainly by parents and primary doctors through parental observations, routine visits, and screening tools. Once a gap or delay is identified, the correct services should be arranged to optimize a child's well-being and, thus, the well-being of the future adult.

Function

Newborn Period and Primitive Reflexes

The newborn period is significant in development. The adequate development of a newborn is assessed mainly by a complete physical exam. The neurologic exam is vital for this assessment. Specifically, primitive reflexes reveal adequate central nervous system (CNS) development. They appear and disappear at specific times of development. These include the rooting, sucking, stepping, palmar and plantar grasp, Babinski, Landau, glabella, Asymmetric Tonic Neck, and Parachute Reflex.

Rooting/Sucking Reflex

The rooting reflex involves touching the infant’s mouth or cheek and the head-turning response toward the stimulus. The sucking reflex is a sucking motion by placing a finger (or the nipple) inside the infant’s mouth; it can assess the trigeminal and hypoglossal cranial nerves. Both reflexes are present at birth and disappear by 4 months. Their absence may indicate prematurity or CNS depression.

Moro Reflex

The Moro Reflex can be present as early as 25 weeks. It is elicited with a loud noise, allowing the head to fall into the examiner’s hand or suddenly release their hands. The physiologic response is abduction and extension of the limbs. The normal reflex response is symmetrical. Asymmetry suggests injury to the brachial plexus, clavicular or humeral fracture, or hemiplegia. This reflex generally disappears by 4 months of age.

Stepping Reflex

The stepping reflex is found in the first 6 weeks. It is elicited by holding the baby upright while both feet touch a surface. The normal response is that the baby raises the feet as if walking. It disappears by 2 months of age.

Palmar Grasp and Plantar Grasp

The palmar grasp reflex is found at 28 weeks gestation. The examiner prompts it when placing a finger into the infant’s palm. The normal response is the flexion of the fingers, forming a fist around the finger. Absent grasp response may indicate nerve injury. It disappears by 6 months of age.  The plantar grasp is similar to the palmar grasp, in which the examiner places a finger on the plantar aspect of the foot. The normal response is curling inward of the toes. It disappears by 15 months of age.

Babinski Reflex

The Babinski Reflex is prompted by stroking the lateral plantar surface from the heel to the toes and then towards the big toe. To this stimulus, there is the fanning of the big toe. This response is normal in the infant up to 2 years of age. In adults, a positive Babinski sign suggests an upper motor neuron disease.[1]

Landau Reflex

The Landau Reflex appears in the first 3 months. It is elicited by holding the baby in a supine position in mid-air. The response is an extension of the legs and head as if looking up. It disappears by 24 months.

Glabella Sign

It is elicited by tapping the glabella with the response of the bilateral blinking of the eyes.

Asymmetric Tonic Neck Reflex

Also called the fencing reflex, the asymmetric tonic neck reflex is elicited when the infant is supine by turning the head to one side. The normal response is the extension of the arm to the opposite side. When it disappears, the infant can roll over.

Parachute Reflex

The parachute reflex appears around 8 months of life and never disappears. It is elicited by positioning the infant prone in mid-air, head first. The infant's response is to extend the arms and spread the fingers to protect the head. Asymmetry may suggest extremity weakness, spasticity, or even complex neurological deficits.

Later Infancy, School Age and Pre-Adolescence

The child continues to grow and develop past the newborn period. The primary developmental domains are gross motor, fine motor, language, cognition, and social-emotional behavior. A baby only learns to hold his head, grasp, crawl, sit, stand, and walk in the first year.[2] They also begin to smile, and language is developed by cooing and babbling. As they grow, they show interest in others and their surroundings and learn to follow simple commands. Once they reach 12 months, they can point to the desired object and understand the meaning of no. Development from one to two years includes learning more words, combining them, scribbling, running, and playing with another infant.[3]

From 3 to 6 years, children can learn to copy figures on a piece of paper and later draw a person, use a scissor, point to colors, and do daily activities like brushing their teeth or using the bathroom. They begin to learn to read and write and can have friends. They are also able to answer “why” questions.[3] Children can do more complex sports or play an instrument in the later part of childhood, including six to twelve years. Reading becomes a learning activity.[3]

Adolescence

The years of adolescence are ones of fast and significant changes. It is the time when the child becomes mature emotionally, biologically, and socially. The development consists of finding an identity and becoming autonomous. Adolescence has three main phases: early, from 10-13 years; middle, from 14 to 17 years; and late, from 18-21 years. Early adolescence starts with puberty and is characterized by egocentricity, emotional liability, and concrete thinking. Socially, interest changes from family relationships towards friends, especially of the same sex. Middle adolescence is the time for abstract thinking. Social development includes friends of the opposite sex, and romantic relationships may also start. They spend more time alone or with friends instead of family in an attempt to search for their own identity and autonomy. Most of the pubertal physical changes have already occurred, and at this time, they start feeling more comfortable with their body. This is also the time when sexual relationships start. 

Last but not least comes late adolescence. For most, it is the time when they reach their maximum independence. Emotionally, identity is well-formed, interests are more stable, and there is interest in future decisions. Abstract thinking is firmly established. Socially, they are not so influenced by others anymore, the family becomes more important, and closer relationships with them can be formed. More serious and stable romantic relationships can be established.[4]

Issues of Concern

Attachment in Infancy

All normally developing infants develop attachment relationships with their caregivers. Infant-parent attachment is vital for the social and emotional outcome of a child’s development. The type of attachment between a child and the parent is associated with emotional and behavioral problems or lack thereof.[5] Children develop attachment relationships unrelated to the type of caregiver they have, even those who are neglectful. The definition of attachment is the aspect of the relationship that makes a child feel protected and safe. It develops at around 6 months of life. At this age, infants can predict the reaction of their caregiver and modify their response to this reaction.

There are four types of attachments, divided into organized and disorganized and further classified into secure or insecure. The type of attachment a child has is the result of the caregiver's response when a child is searching for attachment. A child searches for attachment when feeling threatened, scared, or insecure. Organized types are those where the child knows what to do with the caregiver. For example, a child might know he/she can approach or avoid the person who cares for him/her. Secure attachments have a very low risk of developing adjustment problems in the future.

The first type is an organized and secure attachment. These infants have prompt, loving responses to the stressors of the infant. The infant knows how the caregiver will respond, making it organized and secure.[5] Next is the organized yet insecure and avoidant attachment type. These infants have caregivers who dismissively react to their stressors. It is considered organized because the child knows to avoid the caregiver because of the rejection they will receive. The third is the organized, insecure, and resistant attachment. These caregivers react inconsistently and intend that the infant attend to the caregiver’s stressors. It is organized because the infant learns to consistently get their caregiver’s attention despite their changing and unexpected response. The last of the attachment types is the disorganized and insecure type. This is the one most commonly used by infants in high-risk situations. These children are exposed to unusual parental caregiver behaviors, meaning frightened, sexualized, or atypical. These behaviors occur with or without a stressor in the child.[6]

Evidence has demonstrated that when an infant has an organized and secure attachment type of relationship, it is protective from social and emotional maladjustments in later infancy and adolescence. Specifically, the disorganized attachment is strongly predictive of severe maladjustments and psychological issues. They are more sensitive to stress, have issues with controlling emotions, and tend to present with aggressive behaviors—about 80% of children who have been victims of abuse display a disorganized attachment. During childhood, they can present with oppositional defiant disorder, destructive classroom behaviors, low performance in mathematics, and low self-esteem. Adolescents may present with more psychiatric diseases, impaired operational skills, and poor self-control.

School Readiness

School readiness is defined as the optimal relationship between the readiness of the child, the readiness of the school, and the family’s interactions that support the child will ensure a child's success in school. These three aspects can be discussed individually. When it comes to the child, this means adequate physical, social, and emotional development. These include good health and growth, communication (listening and speaking), and behavioral control. In regards to school, there should be an easy transition between school and home, and parents must be able to interact with the school. Teachers must be committed to providing instruction to children and be willing to change their approach if the initial one does not result well. As for the family, this aspect begins as early as prenatal care, and having a primary physician for the child, nutrition must be optimal, and parents must be willing to take time to help their children.

There are five needs of children that determine school readiness.

• Proper nutrition, clothing, shelter, education, and preventive physical and mental health services 
• Nurturing relationships with their caretakers 
• Opportunities to develop skills and talents to help in the community 
• Protection from self-abuse and violence exposure 
• Caretakers allow children to heal physically and mentally, developing a reliance on them.

A child’s experience with early development, in whatever setting they are in (home, daycare, or preschool), influences their education. If children have a routine and are supported emotionally, they can learn better and be more resilient as they grow.[7] If a child is exposed early on to an engaging and supportive environment, it is more likely that they will be mentally healthy later in life.

Temperament

Temperament in children encompasses a child's different reactions and ability to self-regulate. These can be formed within the first year of life, including physiologic and emotional reactions. It is inherited, and it is also stable. However, it is influenced by environmental and social interactions. Temperament also significantly impacts child development, both socially and emotionally. It is believed to play a role in social interactions, cognition, and adjustment.

A problematic temperament includes a baby that is difficult to soothe, a child that reacts highly to a stimulus, or a very fussy child.[8] A child with a difficult temperament is likely to be an adolescent with a difficult temperament. This type of temperament is a risk factor for having psychological pathologies in the future.

Temper Tantrums

Temper tantrums are very common in children. A temper tantrum is an intense period of demonstrating disproportionate frustration or anger to the situation. Children demonstrate behaviors during temper tantrums: hitting, screaming, waiving the extremities, falling to the floor, headbanging, throwing or kicking things, and holding their breath. After all, they cannot communicate because they cannot cope with a situation, but it can also be because they are looking for attention. The child might be hungry, sick, or frustrated and make a temper tantrum to communicate this.

It is essential to know that temper tantrums are a normal part of child development. It is a transition while they learn to control emotions and become more independent. The age they appear the most are 2-3 years of age. If a temper tantrum persists beyond this age, it may indicate that the child still has not learned coping mechanisms. Once a child can communicate and express their feelings, temper tantrums subside.[9]

Temper tantrums can be abnormal, however. The duration and age may indicate that it is not a normal part of a child’s development. Examples include a tantrum lasting more than 15 minutes, a child is more than 5 years of age, a child injuring him/herself, destroying something, or injuring another person, another behavior accompanying the tantrum (for example, enuresis), or a behavior between tantrums does not return to baseline.

The best treatment for temper tantrums is to prevent them and identify triggers. Daily routines avoid inconsistencies, and the child knows what to expect from their caretaker. Children should be taught early about feelings. This way, they can express these in words when they are ready to communicate.  Once a temper tantrum starts, the caretaker should stay calm, offer a “time-out,” ignore the behavior, and ensure the child is not in danger. It is correct to leave the room and wait for the tantrum to stop.[9]

Clinical Significance

Normal child development is predictable, with observable milestones according to age. Individuals vary, so a delay in a particular milestone may not mean a delay, but the risk rises when there’s a delay in achieving several milestones.

The factors that impact the child’s development can be biological, like chronic illness, abnormal hearing or vision test, prematurity, and low birth weight; or environmental risk factors, whether they’re from the community (poor or lack of access to services, poor housing) or the immediate family (poverty [has the highest association to mild/intermediate developmental delay], social isolation, parental mental illness or low education).  

Parental concern is the most reliable method of early detection and should never be ignored by the healthcare professional. However, a lack of concern from the parents doesn’t mean that the development is normal; also, recall of milestones could be biased toward normality and is more accurate when the delay is significant. 

Having a milestone checklist is also a reliable method of early detection; however, relying on this method alone could likely lead to overidentification of delay in children due to them usually having a singular delay at a particular point in time but eventually catching up to the norm. A physician who solely bases their assessment on a clinical judgment is not using a reliable method of identifying developmental problems.[10]

Another method of early detection of developmental issues with low specificity is the developmental screening tests, such as the Denver Developmental Screening Test (DDST) and other more recent ones. These tests should not be considered diagnostic.[10] However, the diagnostic capability expands when these standardized tests are integrated as part of developmental surveillance and interpreted in a much broader context. Developmental surveillance is a longitudinal process consisting of repeated patient and family reviews. It aims to detect and intervene early in developmental delay risk factors, such as eliciting parental concerns, offering them guidance depending on their needs, and making skilled periodic observations of the children's milestones during every GP encounter.

Involving the parents with questionnaires, such as the Parents' Evaluation of Developmental Status (PEDS), helps improve the accuracy of clinical development estimates.[10]

Children should be referred for formal assessment when there are any of the following red flags: suspicion of autism, developmental regression, prematurity, especially <28 weeks of gestation or born with <1500g,  conditions associated with a high risk of developmental delays such as an abnormal neurological examination, chromosomal, hearing and/or vision abnormalities, and lastly those patients with failed screening tests, major risk factors, and significant parental concerns that persist even if there's a routine observation of the patient.

Enhancing Healthcare Team Outcomes

Child development is universal. The surveillance and management of it are intricate and challenging. 

Behavioral and developmental issues in children are common and can present in diverse ways. Managing these conditions requires interprofessional coordination and communication between the parent or the caregiver, the primary care physician, and the school system. Monitoring a child's well-being is a collaborative effort of each well-care visit, as well as the parents, who are the most reliable and first-hand witnesses. Once a child enters school, the teachers are also responsible for identifying issues. 

It is a societal responsibility to raise physically and mentally healthy children to be successful adults. There should be strong ties between the entities participating in a child's life to improve this.