Continuing Education Activity

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

Objectives:

• Describe the development of the newborn period, later infancy, and the adolescent period.
• Identify the types of attachment during infancy.
• Explain the importance of developmental screening.
• Summarize 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 it can be shaped by these, either positively or negatively. The mental health of a person depends greatly on the development they had as a child. It is crucial to follow a child’s development to ensure that 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 in order to optimize the well-being of a child, 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 key for this assessment. Specifically, primitive reflexes reveal adequate Central Nervous System development. They appear and disappear in 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 consists of touching the infant’s mouth or cheek and the response of head-turning toward the stimulus. The sucking reflex is a sucking motion with 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

This 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 releasing 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

This reflex is found in the first six weeks. It is elicited by holding the baby upright while both feed 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. It is prompted when the examiner places 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 to the plantar aspect of the foot. The normal response is curling inward of the toes. It disappears by 15 months.

Babinski Reflex

It 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

It 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 fencing reflex, this 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

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

Later Infancy, School Age and Pre-Adolescence

The child continues to grow and develop past the newborn period. The main developmental domains are gross motor, fine motor, language, cognition, and social-emotional behavior. Only in the first year, a baby learns to hold his head, grasp, crawl, sit, stand, and walk.[2] They also begin to smile, language is developed with first cooing and then babbling. As they continue to grow, they start to show interest in others and their surroundings and learn to follow simple commands. Once they reach 12 months old, 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 play with another infant.[3]

From 3 to 6 years, infants can learn to copy figures in a piece of paper and later draw a person, use a scissor, point to colors, and do some daily living 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] In the later part of infancy, including six to twelve years, children can do more complex sports or play an instrument. Reading becomes a learning activity.[3]

Adolescence

The years of adolescence are ones of fast and big changes. It is the time when the child becomes mature, emotionally, biologically, and socially. The development consists of finding an identity and becoming autonomous. There are three main phases in adolescence: 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 the family in an attempt to search for their own identity and autonomy. Most of the pubertal physical changes have already occurred, and it is at this time that 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 where 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 key for the social and emotional outcome of a child’s development. The type of attachment that exists 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 feels 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, and they are divided into organized and disorganized and are further classified into secure or insecure. The type of attachment a child has is the result of the response of the caregiver when a child is searching for attachment. A child searches for attachment when he or she feels threatened, scared, or insecure. Organized types are those where the child knows what to do with the caregiver. Examples of this are that a child might know that he can approach or avoid the person who cares for him/her. Secure attachments are those that have a very low risk of developing adjustment problems in the future.

The first type is 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 are the caregivers who react inconsistently and intend that the infant attends to the caregiver’s own 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 adolescent years. Specifically, the disorganized attachment is strongly predictive of serious 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 conditions like oppositional defiant disorder, bad classroom behaviors, low performance in mathematics, and low self-esteem. Adolescents may present with more psychiatric diseases and impaired operational skills as well as poor self-control.

School Readiness

 School readiness is defined as the optimal relationship between the readiness of the child, the readiness of school, and the family’s interactions that support the child that will ensure the success of a child 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 and being able to communicate (listening and speaking)and have behavioral control. In regards to school, there should be an easy transition between school and home, and parents must be able to have an interaction with the school. Teachers must be committed to provide instruction to children and be willing to change their approach if the initial one is not resulting 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 need to 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 
• Have the opportunity to develop skills and talents to help in the community 
• Protection from abuse to themselves and protection from violence exposure 
• Caretakers that allows children to heal physically and mentally, as this develops a reliance on them.

All of 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 environment that is engaging and supportive, it is more likely that they are mentally healthy later in life.

Temperament

Temperament in children encompasses the different reactions and ability of a child to self-regulate. These can be formed within the first year of life, and they include physiologic and emotional reactions. It is inherited, and it is also stable. However, it is influenced by environmental and social interactions. Temperament also has a great impact on child development, both socially and emotionally. It is believed that it plays a role in social interactions, cognition, and adjustment.

A difficult 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 frustration or anger that is disproportionate to the situation. Some of the behaviors that children demonstrate during temper tantrums are hitting, screaming, waiving the extremities, falling to the floor, headbanging, throwing of kicking things, holding their breath. A child has temper tantrums mostly. 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 important to know that temper tantrums are a normal part of child development. It is a transition while they are learning to control emotions and become more independent. The age they appear the most are 2-3 years of age. If 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 time of duration and age may indicate that it is not a normal part of a child’s development. If a tantrum lasts more than 15 minutes, if the child is more than 5 years of age, if the child injures him/herself, destroys something, or injures another person, if there is another behavior accompanying the tantrum (for example enuresis) or if the behavior between tantrums does not return to baseline.

The best treatment for temper tantrums is to prevent them. Identifying triggers. Having daily routines is a way of avoiding inconsistencies and the child knows what to expect from their caretaker. Children should be taught early about feelings. This way when they are ready to communicate, they know how to express these in words.  Once a temper tantrum starts, the caretaker should stay calm, offer a “time-out”, ignore the behavior but make sure that 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 there’s 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 health 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 normally 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, when these standardized tests are integrated as part of developmental surveillance and interpreted in a much wider context, the diagnostic capability expands. Developmental surveillance is a longitudinal process that consists of repeated reviews of the patient and family. It aims to early detect and intervene in risk factors of developmental delays, such as eliciting parental concerns, offering them guidance depending on their needs, and making skilled periodical 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 estimates of development.[10]

Children should be referred for formal assessment when there are any of the following red flags: suspicion of autism, developmental regression, prematurity specially <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 major parental concerns that persist even if there's a normal observation of the patient.

Enhancing Healthcare Team Outcomes

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

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

It is a societal responsibility to raise physically and mentally healthy children to have successful adults. To improve this, there should be strong ties between the entities that take part in a child's life.