Transcript 'A Stitch in Time': Identifying and Treating Early Parent

Is
A Little Learning
Such
A
Dangerous Thing?
Sharing A Vision Conference
Springfield, IL
1 October 2003
The University of Chicago
Bennett L. Leventhal, M.D.
Irving B. Harris Professor of Child and Adolescent Psychiatry
Professor of Psychiatry and Pediatrics
Director, Child and Adolescent Psychiatry
Director, The Sonia Shankman Orthogenic School
Laboratory of Developmental Neurosciences
Is
A Little Learning
Such
A
Dangerous Thing?
A little of what is being learned?
A little who is learning?
What is the basic goal of early
learning?
To enhance developmental
outcomes
Nature and Nurture

Interdependent concepts (examples)
 Nonhuman
primate studies
 Effects of abuse on human infants
– effect of nurture on nature
 Effects
of autistic disorder on maternalinfant interaction
– effect of nature on nurture

Additive or Synergistic when genetic
parents raise child
Basic Premise
All considerations
of all events in childhood
(or in adulthood, for that matter),
be they
physiologic, psychological or experiential
must take place
in a
developmental context
Why Consider Development?
What is Development?
Longitudinal?
Cross-Sectional?
Development is a Process
Individual and groups of
characteristics and variables
acting individually and together.
Phases/Stages
– Characterized by most prominent signs of rapid
development within a given developmental line
during a given time
– Length of phase determined more by completion of a
related set of changes within a developmental line
than by number of months or years
– Should not be generally assumed that developmental
tasks which are not most prominent are not
developing or being used
Critical period
– Development of a function takes place during a
restricted time period relative to gestation
– If appropriate stimulation is not present at that time,
development will be affected
– Example - Hubel and Wiesel - monocular deprivation
of kittens during critical period of visual system
development (environmental input and NMDA
receptor dependent)
Sensitive period
 Times
during which loss of appropriate
environmental stimulation may have adverse
consequences, but which may be overridden by
stimulation outside of a narrow window
 Example
- abused or neglected children, who
develop relatively normally after rehabilitation
of parents' substance abuse, or after placement
in a nurturing, structured adoptive home
Normality (necessary concept)




There is no normal race, gender, or sexual
preference
Normality must be defined in the context of each
person's personal and cultural context
For example, in Physical Diagnosis you won't be
diagnosing your male patients as avaginal
Concept around which one should constantly refine
one's clinical judgment as a physician
Examples of normal as average
not being healthy
Although most children in Israel or the
Palestinian territories may have
experienced violence, it does not make it a
healthy experience
Is Successful Development
NATURAL?
or
LEARNED?
What is Successful Development?
The optimal use of individual and
environmental factors to reach the
highest possible level of adaptive
functioning
Individual Characteristics


Genetics
Appearance






Size
Attractive/Dysmorphic
Intelligence
Social Skills
Personality
Temperament
Developmental Lines
Development - Longitudinal

Developmental Lines

Physical/Gross & Fine Motor
 Cognitive
 Language
 Psychosexual
 Interpersonal/psychosocial
 Affective
 Moral
 Spiritual
Longitudinal Models










Social
Freud
Mahler – Separation-Individuation
Erikson - Psychosocial
Piaget - Cognitive
Language
Motor
Kohut – Object Relations
Kohlberg – Moral
Others
Social Stages of Development








0-12 months - Infancy
12 –36 months - Toddler
36 – 60 months - Preschool
7 – 12 years - School Age
12 – 18 years - Adolescence
18 – ?25 years Young Adulthood
25 – ?65 years - Adulthood
65 years + - Older Adulthood
Language
6 months – Coos, smiles, reaches
 12 months - First words
 18 months - Increasing words
 24 months – 2-3 word sentences
 36 months - 3 word phrases
 8 years - Knows person, place, time

Gross Motor
Roll over at 4 mo.
 4 months – roll over
 6 months - Sit unassisted
 12-15 months - Walk unassisted
 30 months - run
 36 months - Stairs one step/foot, Ride tricycle

6-7 years - Ride bicycle
Fine Motor
4 weeks – hands fisted
 6 months - Grasps cube
 18 months - Tower of 3 cubes
 3 years - Draws circle
 4 years - Draws square

Development - Cross-sectional
 Observation
of human development at a
given time
 Domains are interdependent
 Quality of integration of domains is
important
 The "whole" child or adult is subject of
study
 Pro and con: See forest well, but trees not
as clear
Cross-Sectional Development
Prenatal Development
Almost all neurons “born” before 11
weeks gestation
 Almost all cell migration complete by 16
weeks gestation
 Drug exposures, most commonly
alcohol and nicotine lead to later
behavioral problems (dose-related)

Prenatal Development



Nutrition important during prenatal
development
Full-term or near-full term developmental
failure is mostly due to hypoxia and related to
CNS bleeding when birth excessively
premature
However, outcomes progressively improving
with advances in neonatal care
Post-natal Development

When does it really begin?
 At
delivery?
 In utero, near delivery?
Post-natal Development

Physiological homeostasis is main goal

Key first step is feeding, which requires
adequate muscle tone for sucking
Post-natal Development

First 2 months social life largely bilateral

Parental functioning is important
 Goodness
of fit
 Support systems

Time after birth is a sensitive period for
developing attachment between
caregivers and the infant
Post-natal Development

Bonding vs Attachment

Bonding

Lorenz
 like imprinting
 a critical period

Attachment



Bilateral
Complex behavioral interaction
Begins at birth
2-4 months




2 month social smile is very overdue for firsttime parents up all night with frequently crying
infants
Parents begin to more reliably read subtle
cues and patterns of child (e.g.
communication of hunger vs. needing a diaper
change
4 months - rolling over increases the risk for
falls
Interest in objects in environment


Color
movement
4-6 Months

Rolling over at 4 months to sitting up
unassisted at 6 months

Child develops more three dimensional
view of their world but mobility limited

By 6 months, children are relatively
social without much fear of strangers
6-9 Months

Emergence of normative separation anxiety
and stranger wariness

Children become more mobile although not
usually walking




Creeping
Crawling
Pulling up and standing
For most children sleep and eating schedules
are relatively organized
9-12 Months

Exciting time with development of single
words starting with ‘dada’ (then ‘mama’) and
with many other single words by 12 months

Development of walking from assisted to
unassisted typically by 12 months

Increasing need for child-proofing (although
this should occur prenatally)
12-18 Months

Generally a time in which child is “in love with
the world” enjoying new mobility and its
freedom

Object permanence by 12 months

Joint attention by 12 months (will follow a
point by a parent to attend to something other
than the parent and child, just because of
interest to the parent)
18-36 Month-olds

18-36 months - anal period
(psychosexual), autonomy vs. shame
and doubt (psychosocial), separationindividuation

reorganization of nervous system
(pruning in primary sensory cortex)
18-36 Months
“Terrible two’s”
 Parental response important
 Child struggles to be soothed by parent
without feeling smothered
 Voracious appetite for learning and
trying new things
 Language

 2-3
word phrases ->short sentences
18-36 Months

Ambivalent struggle over autonomy,
because child still needs parent
 Parent
has to set limits where necessary
(esp. safety issues)
 Parent has to help child find a way out of
unsolvable conflicts (provide child with
easy-to-understand choices)
 Parent has to be secure enough not to
have to try to win the power struggles
36-48 Months



Emergence of focus on more complex
relationships and enjoyment of developing
skills without focusing on autonomy
Begin to directly play with other children but
play is often parallel
Language plays a role in play



Can speak in full thoughts – sentences
Many, but not all children enter nursery school
Independence associated with bowel control –
end of traditional anal period
Four year-olds





Has mastered toileting, although accidents not
uncommon, especially through the night
Rapid increase in social interest and
competence
Nursery school (common, but not compulsory)
Conflicts over autonomy are not most
prominent conflict, but persist as a concern
Fundamentals of spoken language mastered
– can tell a story and share feelings – but still
concrete
Four year-olds

Conflicts over autonomy are not most
prominent conflict, but persist as a
concern
Four year-olds
Identify self by gender
 Gender roles become stereotypic

 Internal
forces
– child feels how they behave is who they are
– insecurity leads to conformity
 External
forces
Four year-old
Learning basic rules of right and wrong
 Mastery of aggressive impulses often
more difficult for boys than girls

?
due to less well developed social
competence in boys (can’t separate out
nature from nurture here) vs. preference for
aggressive behavior
Four year-old

Triadic relationships are emergent
domain
 (present
before, but diadic relationships
often dominate scene earlier)
Competition more prominent
 Often competition with same sex parent
and less conflictual relationships with
opposite sex parent

Five year-old
Kindergarten
 Pre-academic skills

 early
reading
 writing currently enhanced by “inventive
spelling” - idea is to encourage expression
without constraint of spelling rules and
details for which child not ready
 early reading, mostly by sight identification
Five-year old - Academic
 early
math skills - especially geometric and
functional
 Counting and alphabet usually solid
 Early adding, but subtraction not typical
Five year-old

social skills further developing –
 most
children can contain their violence in
classroom at this point
 disorders of activity and violence such as
ADHD and conduct disorder often first
diagnosed
Five year-old


Continence typical, even at bedtime
Failure to establish continence first diagnosed

Enuresis - daytime or more commonly nocturnal
wetting
– usually spontaneously remits by adolescence

Encopresis - daytime or nighttime defecation
– if regular symptomatic of constipation or emotional
conflicts, particularly re: autonomy
Age (years)
0-0.5
0.5-1
1-1.5
1.5-3
3-6
6-12
12-18
Psychosexual
Freud
Infancy
Oral (diadic)
"
"
Toddler
"
"
Anal (diadic)
Preschool
Oedipal/Elektral
School Age
Latency
Adolescence
Adolescence
Young Adulthood Adulthood
Adulthood
"
Older Adulthood
"
Age (years)
0-0.5
0.5-1
1-1.5
1.5-3
3-6
6-12
12-18
Social
Infancy
"
Toddler
"
Preschool
School Age
Adolescence
Young Adulthood
Adulthood
Older Adulthood
Psychosocial
Erikson
Separation-Individuation (S-I)
Mahler
Cognitive
Piaget
Trust v Mistrust
"
"
Autonomy v Shame & doubt
Initiative v Guilt
Industry v Inferiority
Identity v Identity diffusion
Intimacy v Isolation
Generativity v Self-absorption
Integrity v Disgust,Despair
Autistic (0-1mo.), symbiotic phases
S-I phase: hatching
S-I phase: practicing
S-I: rapprochement, object constancy
Sensori-motor (S-M)
S-M
S-M: Object permanence 12 mo.
Emergence of symbolic thought
Pre-operational thought
Operational thought
Formal operations
Gross Motor
Fine Motor
Language
Social smile (2 mo) Roll over at 4 mo.
Stranger anxiety Sit unassisted at 6 months
Walk unassisted 12-15 months
"No!"
Stairs one step/foot at 3
Age of play
Ride tricycle at 3
Peers increasing Ride bicycle at 6-7
Sep.-Indiv. Part 2
Notes:
Diadic: relationships focused on child and caregiver
Triadic: relationships focused on child, caregiver, and another person
Object permanence - can find an object hidden under 2 blankets
Object constancy - can retain a positive, sustaining image of primary caregiver
Hands fisted at 4 weeks
Grasps cube at 6 months
Tower of 3 cubes by 18 months
Draws circle at 3
Draws square at 4
Coos
First words
Increasing words
2 word sentences by 2 years
3 word phrases by 3 years
Knows person, place, time by 8 years
Interactional Models
Interactional Models - Example

Rutter's study (England) of effects of
coeducational schooling on girls with
early puberty
 adverse
effect of coeducation only for low
socioeconomic status (SES) girls
(increased risk for delinquency (conduct
disorder)
Interactional Model - Example

Low birthweight (prematurity) and SES
 1500
- 2500 g range, low birthweight leads
to decreased cognitive capacity only in low
SES group
 below 1500 g SES less important than
birthweight for cognitive outcome
 < 1500 g maternal risk behavior for
prematurity at higher rates in low SES
groups
Mediators
and
Modifiers
Socioeconomic Status (SES)
A generalizable risk factor
Not to be equated with African-American, AsianAmerican, Appalachian, Liverpoolian
Each society differs in generalizable effects of race,
gender, sexual preference on SES
There are NO generalizable effects of race, part of
world, part of country, gender, sexual preference on
any of the developmental lines listed above or on risk
for psychopathology which are independent of SES
effects
Strengths
Resilience
Strengths/Resilience

Too often we overlook strengths when
considering health or overlook context
when considering extent of stressors

Many children grow up healthy even
under traumatic experiences

Chronic trauma usually more
problematic than acute trauma, largely
due to the absence of care correlated
with chronic trauma
Is Impairment an indicator of:
Developmental Failure?
Inadequate Strengths or Resilience?
Can We Create Strength?
What Fosters Resilience?
Principles of Mental Health
in Early Childhood
Centrality of early parent-child
relationship
 Development as transactional process
 Intergenerational influences
 Development in context
 Multiple pathways
 Adaptation

Socioemotional Milestones in
Young Children
Social reciprocity
( 3-6 mos.)
 Attachment
( 6-12 mos.)
 Exploration/mastery (12-18 mos.)
 Individuation
(18-30 mos.)
 Self-control
(30-54 mos.)
 Cooperative play
(30-54 mos.)
 Empathy
(30-54 mos.)

Infant Characteristics
State regulation
 Soothability
 Predictability
 Temperament
 Robustness
 Interest in Exploration
 Social Responsiveness

Infant Risk Factors
Difficult temperament
 Low birthweight
 Prenatal exposure to substances
 Gender
 Developmental delay
 Physical health problems

Parenting
Parenting
Biological
 Social
 Child-rearing

Parenting

Preparation
 Biology
 Maturity
 Modeling
 Formal
Education
Parenting

Planning
 Unplanned
 Planned

Partnerships
 Alone
 Mother-father
 Other
models
Parenting Risk Factors
Young age at first birth
 History of maltreatment/deprivation
 Maternal depression
 domestic violence/marital discord
 multiple, closely spaced births
 social isolation
 poverty

Parenting

Goodness of Fit:
 Individual
characteristics of each parent
 Parent-to-parent
 Parents to child
 Parents to extended family
 Child to extended family
 Parents to community
 Child to Community
Dyadic Processes
Reciprocity
 Emotional engagement
 Synchrony
 Goodness of fit
 attachment

Parent-Child Contributions to
Relationship Processes
PARENT:
 Emotional
availability
 Sensitivity
 Predictability
 Flexibility
 Psychological
resources
CHILD:
 Social
responsiveness
 Readability
 Regularity
 Adaptability
 Developmental
functioning
Responsive Parenting
Read cues accurately
 Interpret appropriately
 Respond contingently
 Awareness/responsiveness to child’s
changing developmental needs
 Attunement to child’s emotional state
 Packaging stimulation

Responsive Parenting with
Toddlers and Preschoolers
Emotional availability
 Autonomy support
 Joint negotiation
 Consistent limit-setting
 Flexibility
 Labelling of emotions
 Fostering verbal problem-solving

Discipline
Authoritarian
vs
Authoritative
How Young Children Learn To
Control Their Behavior
Developmental advances
 Structure and routine
 Parental guidance and modeling
 Experience of manageable challenge
and mastery
 Experience of social problem-solving
and negotiation of conflict

Child Risk Factors for
Developing Behavior Problems
Genetic
 Prenatal substance exposure
 cognitive and language delays
 Temperament: reactive, low adaptability,
social wariness, fussy/irritable

Family Contributors to Young
Children’s Behavior Problems
Exposure to violence
 Low parental supervision/monitoring
 Inconsistent, ineffective discipline
 Unresponsive Parenting
 Absence of proactive adult input in
learning to manage feelings, tolerate
frustration and persist

Supporting Healthy Emotional
Development in Young Children







Providing safe, secure, consistent
environments
Fostering exploration and curiousity
Building trusting relationships
Nurturing families
Helping children know “their place”
Engendering hope
Fostering development of adaptive skills
Interventions for Young Children
Behavioral
 Psychotherapeutic
 Psychopharmacologic

AND

Educational
A few lessons before closing:
Provide an appropriate structure
Activity should be qualitatively and
qualitatively appropriate
Provide rules
Not too many
Make them simple and reasonable
Somethings are hard to teach
They still must be taught so that
the child at least has an accurate
understanding of the facts
Talk is cheap
But, it is better than not talking at
all – and conversing is even better
Be developmentally sensitive
Too much too soon can be as
problematic as too little too late
Might is not always right
But, it is still important to
understand differences in adult
and child roles and how that
impacts learning
Personal resources do make a
difference
Despite our wishes to the contrary
– we all have limits
We all get angry and frustrated, at
least once in a while
Managing frustration is at least as
important as managing stress
Experience does make a
difference
Not all experiences are good but
there are usually ways to make
them have some positive value
Fostering successful development
is never easy
The absence of frustration and
failure means that you either:
Did not try hard enough
Or
You are a liar
Don’t ever under estimate the
power of modeling
Both Positive and Negative
Timing isn’t everything
But, time well spent is pretty
important
Honesty is best policy
Always tell the truth but being
brutally frank is not necessary
Good behavior in the absence of
complete comprehension can be
good
And, it may even be adaptive
What you see is not always what
you get
Blind reliance on or exposure to
the media can be dangerous
Biology is not necessarily destiny
Some biological factors can be
modified by experience
The competent, consistent and
developmentally appropriate
control of the child is never
wrong!
And, contrary to popular opinion, it
neither limits development nor
inhibits creativity
Dreaming is good
It is better to have a dream
dashed then to have never
dreamed at all
Is
A Little Learning
Such
A
Dangerous Thing?
I hoped you learned a little
I hope that
You did not feel endangered
AND
You are not dangerous