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Pedia

Normal Development
Dr. Isaguirre

able to retain what is learned and to recall and apply it


when required
Personal: ability to perform activities of daily living such as feeding,
dressing, and bathing

Part 1
-

Goals of pediatric care


Maximize each childs potentials
Understand normal G&D and behavior
o Monitor childrens progress
o Identify delays or abnormalities in development
o To counsel parents
Development
Process of unfolding, expanding, becoming fuller, more complex
and complete
Includes growth, increase in understanding, acquisition of new
skills, more sophisticated responses and behavior
Mechanisms of development
Well-formed and functioning nervous system
Environment provides appropriate and adequate nutrition at all
stages
Opportunities to lean and act
Challenges and rewards
Unique set of genes
Basic laws of development
Development goes through defined stages and phases which are
constant and identical for all normal children
Development infers change
Development is seen as an increase in function and ability
Development involves maturation. Myelination essential for the
maturation of motor development phase
Development and maturity take time
Motor development takes a cephalocaudal route which begins
before birth
Development proceeds from the general to the specific
Development has a compound interest effect
Domains of development
Gross motor: ability to control large groups of muscles to sit, stand,
walk, run and transfer from one position to another while
maintaining proper balance, stance and gait
Fine motor: ability to use hands deftly to manipulate objects in
order to eat, dress, write, and play
Language:
o Ability to comprehend and produce verbal and nonverbal
symbols to communicate needs, opinions, feelings,
requests and demands; ability to initiate and maintain
conversation in an articulate, fluent and intelligible speech
Cognitive
o Ability to learn and understand, to solve problems, through
intuition, perception, verbal and nonverbal reasoning, to be

Social:
o ability to interact, to form and maintain relationships with
parents, peers, teachers, siblings, and people at large
o ability to initiate joint attention, to cooperate with others
and to be aware and responsive to feelings of others
Milestones of development
Functional skill acquired at a certain age
Serve as criteria in assessing developmental expectations
Acquired in stages
Gross motor:
Have little association with intelligence
head to foot route
Early stabilization of the head facilitates survival and enable
awareness
Fine motor:
Proximal to distal
Refers to upper extremities and hand manipulation & eye-hand
coordination
Infants and children: blocks, puzzles
Older children: visuomotor or drawing tasks
Earliest visuomotor abilities fairly productive of later cognitive
abilities
Language
Expressive and receptive aspects
Includes prelinguistic vocalizations like crying, babbling, cooing
Social-adaptive skills (personal-social skills)
Depend on environmental factors such as social expectations, level
of parenting skills, education and training
Parents role
Inadequate o incorrect child rearing information
Cross cultural differences variable self-help skills
Cognitive skills
Cognitive development refers to the growth and construction of
processes for thinking
o Remembering
o Problem solving
o Decision making
Maintain areas which develop and can be associated in infancy
o Information processing
o Language (communication)
o Memory
The neonate
Neonatal period (1st 4 weeks)
o Posture

Prone

Visual

Reflex

Social

Supine

Lies in flexed position


Turns head from side-to-side
Head lags on ventral suspension
Generally flexed and a little stiff

May fixate face on light in line of vision


dolls eye movement of eyes on turning of the
body
Moro response active
Stepping and placing reflex
Active grasp reflex

Visual preference for human face


NB visit
o Vision: regards object in line of vision and follows short
distances
o Hearing: immobilizes to nearby sound and social approach
o Motor: flexed posture
3 to 4 months old visit
Head control
o In prone, holds head erect and raises body on hands
o Has spontaneous social smile
o Laughs and squeals, babbles and coos
6 months old visit
Sits with slight support
Turns towards sounds and voices
Reaches for objects and mouths them
May lunge forward or start crawling
sitting up world, play games, babbles, turns to source of sound,
recognizes name
Still if there is any suspicion of hearing loss, testing should be done
as early as possible
9 months old visit
Language
o Responds to own name
o Understands a few words like no no
o Babbles, imitates socialization
Gross motor : Sits, crawls, creeps
Fine motor
o Shakes, bangs and throws objects
o Points with finger
12 months old visit
Pulls to stand, cruises, takes a few steps alone
Plays social games
Has precise pincer grasp
Points with index finger
-

Waves bye
Feeds self
Walking is the crowning achievement of this motor years
15-18 months old visit
Has a vocabulary of 3-6 words
Can point to one or more body parts
Understands simple commands
Walks well, stoops, climb stairs
Indicates wants by pointing
2 years old visit
Walks up and down stairs
Begin to run
Scribbles spontaneously
Points to objects or pictures when named
Says several single words
Uses phrases
Follow simple commands
Begins make believe play
2 years old visit
*ready for preschool
Knows full name, age, sex
Names and recognizes common objects
Uses sentences
Speaks clearly
Climbs well
Jumps with both feet
Walks up and down stairs
Holds pencil, makes strokes
Builds a tower of > 6 blocks
Completes 3-pc puzzle
3 years old visit
Jumps in place, kicks a ball, balance on one fot
Rides a tricycle
Knows own name, age, sex
Copies a circle and cross
Has self care skills
Shows early imaginative behavior
Does sentence of 3-4 words, short paragraph
Shows early imaginative behavior
Gross motor milestones
Walking
11 mos
Tricycle
3 yrs
Bicycle
6 yrs
Fine motor milestones
Unfists
3 mos
Midline play
4 mos
Reaches and grasps
5 mos
Transfers
5 mos
Holds bottle
6 mos
Performs pincer grasp 10-12 mos
Copy circle
3 yrs

Draw cross
Square
Triangle
Diamond
Cylinder
Cube

3 yrs
4 yrs
5 yrs
6 yrs
9 yrs
10 yrs

Effective language
Coo
1.5 mos
Babbles
6.5 mos
Receptive language
Understands no
9 mos
4-5 years old visit
Growth patterns:
o Weight: 2 kg/yr
o Height: 6-8 cm/yr
Neurodevelopmental patterns
o Coordination and balance of an adult
o Coordination and use of hands almost fully developed;
mature dynamic tripod grip
Language development
o Pronounce most sounds except f, v, s, z
o Not fully master sh, l, zh
o 1,500 word vocabulary
Cognitive development
o Understand essentials of counting, alphabet, at least 4
colors
5-6 years old visit
Gross motor
o Hopping, skipping, rhythmic dancing
Fine motor
o Hold pencil maturely; drawing, painting, figures have limbs
and face
Language
o Asks meanings of abstract words, count to 20 or more,
distinguish parts of the day, name coins and colors
6-10 years old (school age)
Physical development
o Height: 2-3 inches/yr
o Weight: 5-7 lbs/yr
Motor development smoother, more coordinated
Fine motor
o Hands become steadier
o Paste, tie shoes, fasten clothes
Language
o Mastered basic grammar and syntax
o Figures of speech, clauses
8-10 years old
Letter size become smaller

Selective attention increase ability to focus attention in class and


complete task effectively
What are red flag signs?
Noteworthy clinical signs that can help identify children at risk
These clinical indicators are tracked through routing developmental
surveillance procedures
Limit ages are often used for quick developmental checks
Developmental delay
Refers to a significant lag in one or more areas of development
Also describe a global delay across all areas of development
Limit ages for various child abilities
AGE
Ability if absent or doubtful merits a referral
1
Some indication of attention
2
Attention to objects
3
Head held erect
4
Hands not fisted, show interest in people
5
Reaches for objects
6
Visual fixation and following established. Turns to sound
7
Holds objects in hands
9
Gives attention to gestures
12
Gives attention to words
15
Releases held object
18
Walks alone, no casting, mouthing or drooling.
Can point to body parts
Has joint attention
21
Kicks when standing
Single words with meaning
27
Puts 2-3 words into a phrase
3 yrs
Can stand on one leg. Talk in sentences
4
Use fully intelligible speech
Developmental surveillance and developmental screening
Childhood Development Services
Developmental surveillance, screening and assessment
Developmentally based health promotions and educations
Developmentally based intervention
Care coordination
Levels of Early Childhood Developmental Detection
Developmental surveillance or monitoring
o eliciting and attending to parental concerns
o obtaining a relevant developmental history
o making accurate and informative observations of children
o sharing opinions and concerns with other relevant
professionals
Developmental screening
o Refers to a brief assessment procedure designed to identify
children who should receive more intensive diagnoses or
assessments
o Use of parent reports

Developmental assessment or evaluation


o Refers to more in-depth evaluation of children and may
lead to a definitive diagnosis, plan or remediation or further
observation
When to do developmental screening?
When developmental surveillance demonstrates risks
When the child is 9 months, 18 months, 24 (or 30) months and
once a year thereafter
Anytime when parents express concerns
Who needs surveillance?
Typically developing children
Components of effective surveillance
Eliciting and attending to the parents concerns
o Do you have andy concerns about your childs
development? Behavior? Learning?
Maintaining a developmental history
o What changes have you seen in your childs development
since our last visit?
o Check all domains of development
Making accurate and informed observations of the child
Identifying the presence of risk and protective factors
o Risks: environmental, genetic, biological and demographic
factors
o Protective: loving, supportive family, opportunities
Documenting the process and findings
Standards for screening tests
Standardized on a national scale/sample
Proof of reliability
Evidence of validity
Accuracy
o Sensitivity is 70-80%
o Specificity is 70-80%
Screening tools
Two major categories
o Developmental

Parents Evaluation of Developmental Status


(PEDS)

PEDS-Developmental Milestones (PEDS-DM)

Ages and Stages Questionnaire


o Behavioral

Pediatric Symptom Checklist

Modified Checklist for Autism in Toddlers (M-CHAT)

Connors Rating Scale


Two methods of administration
o Parental report
o Provider observation
Developmental Tools
Denver Developmental Screening Test II (0-6 years old)
Gessel Developmental Screening Test
Screening Behavior Inventory
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Part 2
Intellectual development
Intelligence
Types
o Formal intelligence

Academic learning
o Contentional intelligence

Common sense

Difficult to measure
Mental operations
o Recognition
o Attention span
o Retention and recall
o Inductive and deductive reasoning
o Abstraction and generalization
o Organization
IQ tests
o Inaccurate before 5 years of age (*behavior and
developmental skills are inconsistent)
o IQ =
mental age
x 100
Chronologic age
o IQ scores

90-109
normal or average

116-119
above average

50-55 to 70
mild mental retardation
(intermittent support)

35-40 to 50-55 moderate (limited support)

20-25 to 35-40 severe (extensive support)

Below 20-25
profound (pervasive support)
o Bayley Scales of Infant Development 0-36 months
o Weschler Intelligence Test for Children R (> 6 yo)
o Stanford Binet Test (> 6 yo)
o Cattell Test (2-30 months)
o Minnesota Preschool Test (18 mos 6 yrs)
7 domains of intelligence
o Linguistic
o Musical
o Logical-mathematical
o Spatial
o Bodily kinesthetic
o Intrapersonal
o Interpersonal
o Affinity with nature
Factors affecting intelligence
o Genetics
o Health, physical development

Sex? boys excel on physical science and math; girls


superior in humanities
o Emotional factors presence of maturation, ability for
frustration tolerance
An introduction to behavior
Behavior like development evolves in stages and age specific
phases
Behavior is the content and style of actions of a child in his/her
relationships
Multiple factors are responsible for a childs behavior
Development is a reflection of maturation
Acquiring behavior
A childs behavior is the outcome of interaction
o Between himself
o Between his parents
o Between his environment
Child factors
Temperament How
Intellectual potential How well
Learning style
Interactive style
Resilience How far
Temperament
Easy
o Rhythmic, adaptable, good mood
o 40%
Slow to warm up
o Inhibited, withdrawn, poorly adaptable, inactive
o 15%
Difficult
o Active, intense, poorly adaptable, distractible and quick to
react
o 10%
Parent factors
Coping style
Personality
Intelligence
Education
*children of depressed mothers show greater risk of developing
socio-economic behavior problems
*positive-association between parental schooling levels and
childrens achievement and behavior
Child development principles
Psychoanalytic concepts Sigmund Freud
Psychosocial concepts Eric Erikson
Cognitive Jean Piaget
Moral Ethical Kohlberg
Psychoanalytic theories
Sigmund Freud
Core: body-centered drives
o

Drives
o Shifts with maturation
o Stages
Oral stage
o Autistic phase

0-3 mos

Passivity
o Symbiotic phase

3-18 mos

Dependency

Aggression, biting

Weaning: cultural challenge

Projection: defense mechanism


Anal stage
o 12-36 mos
o Diminishing dependency
o terrible twos
o Temper tantrums
o Identification and regression: defense mechanism
o Toilet training: cultural challenge
Phallic stage
o 3-4 years up to 5-7 years
o Ambivalence
o Curiosity
o Believes in magic
o Masturbation
o Castration anxiety and penis envy: *cultural challenge
o Oedipus complex
Latency stage
o 5-7 years to 8-12 years
o School-age child
o Identification with parent of same sex
o Obsessiveness
o Club or gang formation
Adolescence
o 10-12 years to 16-18 years
o Heterosexual interests
o Inconsistencies in behavior
o Intense interest
Psychosocial theories
Paralles Freudian stages
Centers more on social interactions and less on sexual matters
Dependent on social relations
Stage 1: 0-1 yr
o Corresponds to oral stage
o Trust vs mistrust
o Focus on parent-infant interaction
Stage 2: 1-3 yrs
o Major issue is autonomy
-

o no stage
o Strives individuality
Stage 3: 3-6 yrs
o Preschool period
o Shows initiative, or ability to work
o Win mother away from father
Stage 4: 6-12 yrs
o Industry vs inferiority
o Children industriously learn skills
o Fear of failure
o *warrior stage
Stage 5: puberty
o who am I? stage
o Adolescents strive to develop an identity
o Conscious with physical appearance
Stage 6, 7, 8
o Encompasses adulthood
o Development continues through life
o Capable of mature unselfish relations
Cognition theory
Deal with processes of learning
Perception, memory, recognition, abstraction, and generalization
Sensorimotor period: 0-2 yrs
o Six stages

Neonatal reflexes (0-1 mon)

Specific responses

New response patterns (1-4 mos)

As a result of chance combination of


primitive reflexes

Response patterns intentionally formed (4-8 mos)


Anticipatory

Direct effort (1- 1 )

Internal experimentation (1 - 2 yo)


Preoperational thought period: 2-7 yrs
o Egocentricity expressed in relating everything to himself
o 2 stages

Preconceptual stage

Perceptual intuitive stage


Concrete operational period: 7-11 yrs
o More logical thinking
o Intellectual development proceeds rapidly
o Conceptual operations are characteristic
Formal operational period: 11 yrs to adulthood
o Logical thinking and ability to reason
Moral Ethical theory
Theory of Moral development
6 stages: early childhood adulthood
Preschoolers
o Earliest sense of right and wrong is egocentric

o Motivated by external controls


School age
o Perceive equality, fairness; reciprocity
o Understanding of interpersonal interactions
o More perspective way of thinking
Theory distinguishes between morality and social conventions
Moral thinking
o Considers interpersonal interactions, justice, human
welfare
Social conventions
o Agreed on standards of behavior particular to a social or
cultural group
Children guided by basic precepts of moral behavior
Also be dictated upon by local standards
The First Year
0-2 mos
o Dependent on environment to meet his needs
o Crying occurs in response to an obvious stimuli (wet
diaper), or obscure
o Crying peaks at 6 weeks 3 hrs/day

Less 1 hr by 3 mos
o Infants consistently picked up

Cry less at 1 yr

Less aggressive behavior 2 yrs


o Consistent availability of a trusted adult condition for
secure attachment
o Basic trust vs mistrust depends on reciprocal maternal
bonding
o Emotional significance of any experience of the child would
be dependent on the childs temperament and the parent
response
2-6 mos
o Primary emotions: anger, joy, interest, fear and disgust
o Appear in appropriate contexts, distinct facial expressions
o Face to face adult and child match expressions 30% of
the time
o Reveals infants ability to share emotion
o Games (facial imitation, singing, hand games) social
development
o Infants of depressed parents show sadness and lack of
energy
6-12 mos
o Stranger anxiety object permanence
o Separations become more difficult
o New demand for autonomy feeding issues
o Emerging independence of infant and parent control of
feeding 2 spoon method
o Tantrums
12-18 mos
-

o
o
o

18-24
o
o
o
o
o
o
o
o

Walking first steps: irritable


Toddlers intoxicated or giddy
Eriksons autonomy and separation

Accomplishments secure

Overly controlled toddlers doubt, shame, anger,


insecurity
mos
Increased clinginess
Rapprochement reaction to growing awareness of
separation
Separation anxiety at bedtime
Special blanket or stuffed toy transitional object (absent
parent)
no stage declaring independence
Self-conscious awareness look at mirror, reach for their
face
Language impulse control, reasoning and connection
Formation of conscience touching of objects, weakness or
strength in refusal

Preschool
Accepting limits learn acceptable behaviors, tests limits
Interacts with a wider group of adults and peers
Tantrums peak at 2-4 years of age
Curious with genitals
Oedipal stage
Strongly attached to the parent of the opposite sex
4 yo turn-taking behavior
Modesty appears 4-6 yo
Acceptance of parental responsibility
Middle childhood (6-11 yrs)
latency
Energy directed to creativity and productivity
Same sex social groups
Popularity self esteem: important; by winning classmates through
possession; based on their accomplishments and social skills
Adolescents
VARIABLE
EARLY
MIDDLE
LATE
ADOLESCEN
ADOLESCENCE
ADOLESCENCE
CE
Age (yr)
1013
1416
1720 and
beyond
Sexual
12
35
5
maturity
rating[*]
Somatic
Secondary sex Height growth peaks
Physically mature
characteristics
Beginning of
Body shape and
Slower growth
rapid growth
composition change
Awkward
Acne and odor
appearance

Cognitive and
moral

Concrete
operations
Unable to
perceive longterm outcome
of current
decisionmaking
Conventional
morality

Selfconcept/identi
ty formation

Family

Peers

Sexual

Preoccupied
with changing
body
Selfconsciousness
about
appearance
and
attractiveness
Fantasy and
presentoriented

Menarche/spermarch
e
Emergence of
abstract thought
(formal operations)
May perceive future
implications, but
may not apply in
decision-making

Able to think
things through
independently
Questioning mores
Concern with
attractiveness

More stable body


image

Increasing
introspection

Attractiveness
may still be of
concern

Stereotypical
adolescent

Emancipation
complete

Increased
need for
privacy

Conflicts over control


and independence

Increased bid
for
independence
Seeks samesex peer
affiliation to
counter
instability

Struggle for
acceptance of
greater autonomy
Intense peer group
involvement

Increased
interest in
sexual
anatomy

Future-oriented
with sense of
perspective
Idealism;absolutis
m

Preoccupation with
peer culture
Peers provide
behavioral example
Testing ability to
attract partner

Firmer identity
Emotional and
physical
separation from
family
Increased
autonomy
Peer group and
values recede in
importance
Intimacy/possible
commitment
takes precedence
Consolidation of
sexual identity

Relationship
to society

Anxieties and
questions
about genital
changes, size
Limited dating
and intimacy

Initiation of
relationships and
sexual activity

Middle school
adjustment

Gauging skills and


opportunities

Questions of sexual
orientation

Focus on intimacy
and formation of
stable
relationships
Planning for
future and
commitment
Career decisions
(e.g., college,
work)

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