Portal de Periódicos da CAPES

Preschool Development Part 2:Psychosocial/Behavioral Development

1997; American Academy of Pediatrics; Volume: 18; Issue: 10 Linguagem: Inglês

10.1542/pir.18.10.327

1529-7233

Raymond A. Sturner, Barbara J. Howard,

Infant Development and Preterm Care

During the preschool years, children are rapidly developing patterns of behavior and psychosocial skills that can be long-lasting. Clinicians have important opportunities to monitor and help shape optimal development when seeing preschool children for their health supervision visits. This is the second of a two-part article discussing the development of the preschool child from the point of view of the clinician who is conducting a visit using Bright Futures:Guidelines for Health Supervision of Infants, Children, and Adolescents. Both articles are organized by the“trigger questions” suggested for visits at ages 2, 3, 4, and 5 years of age. The trigger questions regarding psychosocial and behavioral aspects of the child’s development are reviewed here; the first article(Pediatrics in Review September 1997) focused on the “more traditional” developmental areas of communication and motor development.Any dichotomy between behavior and development is murky because behavioral issues often are uncovered when reviewing areas traditionally called development, and behavior can be interpreted only in light of the child’s level of developmental functioning. Research indicates that emotions and cognition are interconnected in a complex mechanism that makes any separation based on causal sequence or distinct domains rather arbitrary.Clinicians generally approach the psychosocial and behavioral milestones quite differently from the more traditional developmental milestones, which tend to be discussed matter-of-factly, perhaps with some shared celebration of the child’s accomplishments. This general approach can be of value in behavioral areas as well. Clinicians can focus on some of the developmental underpinnings of emerging behavioral issues that will help parents remain objective and positive about their child and avoid misinterpretations leading to unnecessary upset and problems. A familiar example would be celebrating the baby’s crying upon separation from the parents as an achievement in memory capacity because it signals that“out of sight is no longer out of mind.” This is often edifying to mothers who may interpret separation distress with guilty feelings because of their own return to work.In the second year, new problems will arise related to sibling jealousy and possessiveness based on the child’s emerging self-identity, an essential prerequisite for any personal ambition. In that light, the clinician might attempt to reframe some trying behaviors more positively by asking if the child is beginning to get a sense of himself or herself by being possessive of things and jealous of the parent. A pediatric focus on emerging underlying developmental structures even may help reduce the emotional charge to a preschooler’s first attempts at lying and other deception. Parents can learn that the child’s ability to block a natural emotional expression is a normal survival skill that emerges during the third year and will require moral instruction and modeling from trusted individuals to learn its appropriate use. Unlike the more traditional areas of development,addressing behavior not only documents whether the underlying developmental milestone has been attained, but how it is manifested based on the child’s temperament. How does the child’s new awareness of the world play out, given his or her general tendency for approach or withdrawal in social situations or ability to tolerate the frustration of delayed gratification, and how does the parent modulate these tendencies? The necessary history taking clearly is more complex than for most areas of the more traditional developmental milestones.Traditional developmental milestones may be measured quantitatively, such as by standard intelligence quotient (IQ) or language tests, but assessment of behavioral milestones requires greater reliance on subjective judgments. However,some more objective assessments recently have been developed, even for problems presenting in primary care. The Diagnostic and Statistical Manual of Mental Disorders has revolutionized psychiatric diagnostic classification by use of standard criteria based on research and consensus of expert opinion. A new Classification of Child and Adolescent Mental Diagnoses in Primary Care: Diagnostic and Statistical Manual for Primary Care(DSM-PC) addresses the need to develop similar clear definitions for behavioral issues that do not yet represent psychiatric disorders but are appropriate for review as part of child health supervision. The DSM-PCidentifies clusters of parent complaints and provides age-related criteria for judging whether the concern is within the expected range of “developmental variation”or has reached a “problem” level or even the severity or quality requiring diagnosis of a psychiatric“disorder.” This classification scheme will be illustrated for some of the areas of behavioral development elicited by the trigger questions along with their code numbers.Data gathering, anticipatory guidance, and problem-solving related to child development suggested here may seem unrealistic or impossible within the brief time frame generally committed for these visits. It is neither feasible nor desirable to attempt to address all of the potential trigger question areas of development during a single health supervision visit. Instead, we advocate limiting discussion to one or two issues that are determined by identifying an individualized child/family’s hypothesized trajectory of development.The clinician should consider the balance of risk and protective factors in the child’s developmental course as well as both temperamental tendencies and parental style in selecting the most important issue to address. This may be a strength to promote or a challenge to favorable developmental progress and happiness to moderate. For example, the parents of a preschool child who has demonstrated a pattern of timidity and persistent social withdrawal outside the home may feel that the child is vulnerable and, therefore, tend to be overly protective. These parents may need encouragement to provide the child with experiences with peers and other mild challenges to help desensitize or “immunize” him or her to moderate this reaction tendency. Another child who has a similar temperamental pattern may have parents who are pushing him or her into numerous activities and seem intolerant of resistance and insensitive to the child’s increasing upset. These parents could be encouraged to be patient with a temperamental pattern that may require time to warm up in social situations and gentle encouragement to take on more.The priority given to such individually focused discussion means that some potential routine anticipatory guidance topics may need to be foreshortened or omitted. Routine information may be conveyed by someone other than the clinician, by handouts, by a parent group, or via media such as videotapes. The individualized approach proposed here requires much higher degrees of clinical skill and judgment as well as knowledge of child development and of the particular child and family than are required to recite a standard minilecture at each age/visit. This approach is in contrast to the perspective that the quality of child health supervision should be judged by the number of different anticipatory guidance topics covered. The information provided here should enable the clinician to be a more knowledgeable discussant in the conversation that follows typical clinical probes such as those suggested by the Bright Futures Guidelines.Trigger Question: “How does ____ act around family members?”Bright Futures offers additional related trigger questions, including: “How does she/he react to strangers?”; “How is child care(preschool, kindergarten) going?”(as related to separation); “How do you deal with tantrums?”;“What do you and your partner enjoy most about ____?”; and“What seems to be most difficult?”Evidence during the visit: Any tantrums and how parent manages them. Reaction to fears related to the visit and how parents manage. Ability of the child to pay attention to instructions and interview questions during the visit. Ability to attend during vision and hearing testing. How do siblings get along with each other during the visit? Are they supportive of fears? Do they tease about the shots or other matters? How does the parent handle these interactions? Is there fighting in the room? How does the parent handle that? Does the parent openly compare or shame children during the visit? How does the child relate to you and office staff? Does the parent express pride about the child verbally or nonverbally? Does the parent express frustration or negativity about the child verbally or nonverbally during the visit?“Behavior around others” is comprised of the quality of relationships, social skills and emotional development, temperament, family discipline, biologically determined behavioral predispositions, and contextual stresses and supports. Controlling emotional states, including delaying gratification, and tolerating frustration, separations, and fears without breaking down emotionally,are lifelong tasks that should be mastered during the preschool period. Displays of uninhibited anger and frustration increase during the second year and then decrease in the third. The intrusiveness and painful procedures of the health supervision visit taxes these skills and may provide an unrepresentative picture of the child’s typical coping abilities, although future research may reveal that specific patterns of response have clinical significance.Bright Futures’ suggested categories of response: Anxious about separation or not; dependent or self-reliant. Tolerating separation from the parents is necessary to the growing autonomy of the child that is characteristic of this period. After the initial developmental task of forming attachments to their primary caregivers over the first 2 years,children now must hold the security of those relationships in their minds to function when separated to go or stay with other adults. The average 3-year-old child can separate easily from parents and go to known adults. However, there is great variability before this age, related primarily to individual temperament. Some children cope by adopting a transitional object or “lovey,” usually a soft, malleable object that can acquire the odor of the mother, to carry in times of stress or separation,which serves as a symbolic reminder of the parent. The use of such an object is associated with greater,not lesser independent activity.Children who have insecure patterns of attachment or painful separation experiences, whether due to losses of primary caregivers or dysfunctional parent-child relationships, are more likely to react abnormally to separation. They may be excessively clinging and fearful or they may be socially promiscuous, showing affection indiscriminately. Many potential coping styles tend to persist once established,even if they do not serve the child well. Often parents express concern about a behavior that actually is a coping mechanism for the child, such as social shyness or a tendency to be aggressive when fearful. Discovering the meaning of the behavior for the child is essential to determining whether intervention is needed and what is appropriate and likely to be effective.Bright Futures’ suggested categories of response: Responsive or withdrawn; outgoing or slow to warm up; wary/resistant. Beyond the most common factor of temperament, children develop their emotional tone in several ways. The pattern of secure attachment to primary caregivers in infancy has some predictive power for “joy in mastery,”“sociability” (and IQ) in the preschooler. Children younger than age 6 are especially responsive to the environment in terms of their emotional states. Even infants in the first 3 months of life respond to parental emotional tone with matched tone,which persists after the parent changes his or her expressed mood. Parental problems with child management and especially in conjunction with marital discord may strongly affect the child’s longer term mood and adjustment and are very common (with divorce rates at 45% in the United States).Fantasy life becomes very rich during the preschool years. At first, it is indistinguishable from reality,resulting in a tendency for fears. By the age of 4, children frequently have frightening dreams that they can state are “not real,” although this does not necessarily reassure them. Excessive fears or nightmares can be related to excessive life stresses on any developmental process; real dangers such as from abuse, dangerous surroundings, or sibling or peer bullies; or from the media. Temperamentally timid children may blame fears for their behavior. Aggressive children sometimes have excessive fears because they realize that they deserve retribution. Conversely, some children act aggressively to avoid that which they fear by attacking others before they are attacked. Some children differ physiologically in their reactivity,having a distinct tendency to experience shyness or fear in new situations. Kagan has shown how levels of adrenocortical hormone by-products and heart rate reactivity distinguish these children at a young age and how these tendencies persist. Because children continue to rely on verbal or nonverbal signals from their primary caregivers to shape their own emotional reactions to new situations, the parents’ styles of handling situations should be considered when adaptability or fears are a problem.Temper tantrums are so common as to be characteristic of 2-year-olds,but they should be infrequent by age 5, although there is another peak at 6 years, perhaps in response to the greater stresses of formal academic schooling. Temper tantrums can be exacerbated by: reinforcement by the parents; modeling in the family;exposure to violence, including physical punishment; temperamental low threshold, high reactivity, or lack of adaptability; fatigue; hunger;and lack of routines. Breath-holding spells may follow a tantrum. They occur in 5% of children younger than 8 years of age, are associated with a family history in 23%, and are related to other behavior problems in 18%. Eighty percent of these spells cease by age 5 and 90%by age 6. They are worsened by parental overconcern and attempts to intervene or to avoid tantrums through giving in. Children who have had a temperamental pattern of easy arousability, as well as those who have developmental weaknesses in expressive language or fine motor skills, often have more tantrums than expected for their age because of their repeated frustrations. Children who are outmatched by their playmates, even if their skills are normal, may react with tantrums.Bright Futures’ suggested category of response: Compliant or defiant. Additional trigger questions: “Do both parents and all caregivers agree on disciplinary style and setting limits?”(2 years); “Are you able to set clear and specific limits for ____?” (3 and older);“What do you and your partner do when you disagree or argue about discipline?”; “How do you deal with ____’s greater independence (3 and older)”; and “What do you do when ____ has ideas that are different from yours?”.Evidence during the visit: How does the parent set limits on exploration of the room, their possessions,their bodies, and excessive silliness or talking? Observations of the parents’ limit-setting on siblings. Do parents interfere with each other’s management in the room? Do parents hit the child in the waiting room or office? Does the parent allow the child to answer for himself or herself? How is the child able to ask and answer questions, separate for the examination, go to the bathroom alone, and go through vision and hearing testing?Almost all preschool children are noncompliant, at least some of the time—on the average, they comply with adult requests about 50% of the time. This struggle for autonomy can be viewed as a positive milestone of development, with passivity representing a potential symptom of depression or intimidation. It is the parents’ job to provide the structure that will influence the child to comply with our culture’s standards for behavior. Research indicates that parents who are authoritative and firm but also warm, encouraging,and rational are more likely to have children who are self-reliant and self-controlled. Parents need to establish a system of discipline at least by the preschool years that includes three essential components:positive reinforcement for desired behaviors; consequences for undesired behaviors; and, most importantly, interactions that promote the parent-child relationship. Noncompliance as part of conduct disturbances is more common in families whose parenting practices include lax, harsh, inconsistent rules;unclear, complex, or emotionally charged instructions; lack of warmth;or poor monitoring of the child.One major concern of parents of preschoolers that affects both the relationship and the child’s compliance is his or her activity level. Sturner found that 25.3% of parents of 4-year-olds included “overactive”in a checklist of adjectives about their child. However, poor control of attention is a greater detriment to academic success than high activity level. Multiple factors affect the attentional system, including health(eg, lead levels, anemia, past neurologic insult), current presence of medications, emotional problems such as anxiety or depression,environmental stresses, ability to see and hear adequately, hunger and fatigue,and temperament. There are different patterns of attention difficulties,including capturing attention,sustaining attention, and moving attention from one subject to the next,which currently are not well delineated clinically. Attention deficit disorder with (DSM 314.01) or without hyperactivity (DSM 314.00)is one of the most common mental health diagnoses of preschool children. Two to seven percent of pre-schoolers are affected, and it may be comorbid with oppositional defiant disorder (DSM 313.81). A high activity level also can represent vigor, which should be admired and harnessed productively later. This is a point of view that clinicians can encourage and model, especially for parents who are beginning to develop a negative perception of the child.Although temperamental factors predispose children to oppositional and aggressive reactions, some oppositional behavior problems may be prevented through optimizing behavioral management by parents. It is often unclear what proportion of the problem can be attributed to child factors and how much is due to parental management difficulties or other environmental factors. When behavior management intervention includes discussion of the importance of constitutional factors, parents often feel less blame and are more open to suggestions and examination of extenuating environmental factors.Because oppositionality and aggression peak during the preschool years, clinicians may discount concerns as representing typical behavior and predict that the child will outgrow it. However, aggression during the preschool period correlates (r = 0.68) with later serious behavior and conduct disorders.In addition, even if these problems were to subside naturally, the family anguish and pain should be considered. Evaluation should include a review of the amount of distress the behavior is causing, the extent to which it interferes with normal everyday functioning of the child(such as elicited by the trigger questions related to independent functioning), and whether the child is usually happy.Clinicians should respond to any parental concern about oppositionality or aggression, but they also should be able to differentiate situations that are beyond the expected variation for preschoolers for which reassurance would be inappropriate. The DSM-PC differentiates aggressive/oppositional “variation” from“problems” and from psychiatric“disorders.” The developmental“variation” category (DSM-PC V65.4) is used for situations in which there is only mild negative impact, no one is hurt by the oppositionality, and parents do not change their plans significantly,even though the child may procrastinate, use bad language, and argue.In contrast, an oppositional “problem”(DSM-PC 71.02) includes tantrums when asked to do chores or purposely messing up the house,accompanied by a negative attitude that persists for many days. These children may run away from their parents on several occasions. When a hostile, defiant attitude persists for 6 months, it meets criteria for oppositional defiant “disorder.” An“aggressive developmental variation” is the term and code used to describe typical preschool grabbing of toys, hitting or kicking siblings several times per week but with minimal negative impact, and regular negative response to parental reprimand. A preschooler’s aggression is said to reach the “problem”level when the negative impact of the behaviors causes people to change their routines, property begins to be damaged seriously,and the aggression is frequent. Symptoms rarely reach the level of a conduct disorder (DSM-PC 312.81)before 5 or 6 years of age, but the launching of such a trajectory can be seen. A review of anticipatory guidance and pediatric counseling for issues of compliance and aggression is beyond the scope of this article(see Howard in Suggested Reading),but specific advice regarding a well-defined and labeled “special time,”reinforcers such as marks on the hand, and well-structured bedtime and time-out routines often is required in addition to an understanding of contributing child and parent background factors.Problems with siblings are a common concern of both children and their parents. Sixty-five percent of children report fights with their siblings that only decrease “some” after third grade and reduce “more significantly” after one of the children passes 15 years of age. Many factors are associated with greater sibling rivalry, including opposite gender,difficult temperament, insecure pattern of attachment, family discord,corporal punishment, and, most importantly, perception of differential treatment. The entrance of a new baby into the family is likely during the preschool years. How a child interacts with the new arrival in the first 3 weeks predicts interactions into the second year. More than 90%of children “regress” when a new baby is born, exhibiting behavioral changes of increased naughtiness,thumb sucking, and altered patterns of feeding, sleeping, or toileting that are considered by some to be signs of “imitation” of the newborn. These same types of responses occur under stress of any kind to the young child. The stress in this case entails separation and loss or threatened loss of the parents’ love and attention as well as actual worries in older children over danger to the mother. Parents have been noted to become stricter in their discipline during and after pregnancy as well.On the other hand, children, like adults, experience excitement, love of the infant, and enhanced self-esteem through their relationships with a new sibling. Preparation for the sibling through sibling classes,avoidance of forced interactions and descriptions of the mother’s pain during labor and delivery, a strong pre-existing relationship between the older child and the father, good support for the mother postpartum,individual time continued with each parent, and intense empathetic talk about the new baby’s feelings and point of view have been shown to be helpful. Logical but unresearched practices to assist adjustment to a new sibling include having visitors greet the older child first, providing presents for the older child, giving the child some role in caring for the infant, and allowing an attempt(albeit with an attitude of mild surprise) when the older child requests a breastfeeding.Interaction between siblings can be improved through prompt limiting of aggression toward the sibling,acknowledgment of the child’s positive and negative feelings,reinforcement through praise, and teaching such strategies as distraction,trading, taking turns, and teaching. Siblings can be encouraged to cooperate by having the parents show that they value cooperation by talking about it and commenting on its presence or absence, having the parents distract the children from irritated interactions, setting tasks with joint goals, promoting noncompetitive games, and working continually for individualized treatment.When siblings fight in spite of all effort to guide positive relationships, it is important to know that parents’ interventions tend to increase fighting several fold. Instead, a“graded” approach is better. Minor skirmishes are ignored if possible. More intense disputes can be handled by having the parent enter the scene, describe what is seen(especially the feelings and dynamics present), hear both sides briefly,then leave, stating confidence in the children’s good intentions and ability to resolve it. More serious disputes should be handled similarly except that the children or the object of dispute should be removed. Physical battles require further actions,such as time-out for both children for the length of time appropriate for the younger child. Attempts to determine fault are generally unproductive, but chronic bullying or sibling abuse must be avoided. Positive sibling relationships often result in lifelong loyalty, friendship, and support.Trigger question: “How does ____ act around other children(Table 1)?Evidence during the visit: Is there any aggression by the child during the visit (eg, when restrained for the examination or procedures,when undressing)? Is there any physical punishment of the child by the parent during the examination or in the waiting room? How does the child interact with other children in the waiting room?Bright Futures’ suggested categories of response: Friendly/affectionate or hostile/aggressive;interactive or withdrawn/resistant. One of the most obvious tasks of developmental progress for the preschool child is learning to interact happily with peers. At the age of 2 years,most play still is parallel, although children frequently look at peers and copy some of their actions. By the age of 3, children should have mastered aggression and should be able to initiate associative play with a peer, have joint goals in their play together, and take turns, although children generally can play effectively only with groups of children in the same numbers as their years of age. Thus, by age 4, children usually can play with three others fairly well. Fantasy or pretend play gains prominence at about age 3. Children can play out longer stories as they mature, with each child taking a specific role. By age 5,the child has many social skills expected of adults, such as responding to the good fortune of others spontaneously with positive verbal messages, apologizing for unintentional mistakes, and relating to a group of friends.Pretend friends are very common in children up to the age of 4. These fantasy figures often fill the role of scapegoat for misbehavior,demonstrating that the child recognizes correct behavior but cannot always do the right thing. Alternatively, the pretend friend can be an “alter ego”or ideal self, such as an outgoing companion for a naturally shy child,who can help children through difficult or anxiety-provoking experiences. In general, children who invent imaginary friends are well-adjusted and believed to be creative, reflective, and cooperative. However, when fantasy friends dominate the child’s play, his or her opportunities for interaction and social abilities should be evaluated.Mastery of aggressive impulses should improve after 2½ years of age. Prior to that time, most children will try aggression for“instrumental” reasons to obtain a desired toy. Hostile aggression (intended to hurt the other) is more common in boys,especially those who have poor impulse control, who are punished physically, who view violence, or who are suffering from a difficult separation experience. These aggressive drives, although quite variable from one individual to the next,usually are converted progressively into language and symbolic violent play. Children create gun play even without apparent models and use it to express aggression safely as well as to fantasize powerful roles that help them deal with their fears about their very real vulnerability.Fathers play an important role in teaching young children to modulate their aggression, partly through horseplay on which the father sets limits. Boys raised without a father figure tend to have more difficulty mastering their aggression. Thwarting of any major developmental need can result in hyperaggressivity. Lack of adequate expressive language or fine motor skills; lack of appropriate parental limits (either through excessive strictness or little control); and modeling or exposure to violence through television, the neighborhood, or within the home also promote aggression. The DSM-PC categories of aggression as a“developmental variation” or“problem” in the aggressive/oppositional series described previously with regard to family members also represents the appropriate descriptors and codes for difficulties with peers.Trigger question: “Does ____ show an ability to understand the feelings of others?” Bright Futuresoffers additional related trigger questions: “Tell me about ____’s typical play.”; “Is ____ interested in other children?”; “Does ____ have playmates?”Evidence during the visit: Any observed interactions in the waiting room, hallway, or with siblings in the room; discussion about friends;drawing of children. Does the parent offer privacy from siblings for the examination? Does the child demonstrate modesty during the examination?Social development during the preschool years should include acquisition of the human characteristics of shame, guilt, empathy,self-awareness, and class