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head sags on ventral suspension Supine: Generally flexed and a little stiff Visual: May fixate face on light in line of vision; dolls eye movement (oculocephalic reflex) of eyes on turning of the body Reflex: Moro response active; stepping and placing reflexes; grasp reflex active Social: Visual preference for human face AT 1 MO Prone: Legs more extended; holds chin up; turns head; head lifted momentarily to plane of body on ventral suspension Supine: Tonic neck posture predominates; supple and relaxed; head lags when pulled to sitting position Visual: Watches person; follows moving object Social: Body movements in cadence with voice of other in social contact; beginning to smile AT 2 MO Prone: Raises head slightly farther; head sustained in plane of body on ventral suspension Supine: Tonic neck posture predominates; head lags when pulled to sitting position Visual: Follows moving object 180 degrees Social: Smiles on social contact; listens to voice and coos AT 3 MO Prone: Lifts head and chest with arms extended; head above plane of body on ventral suspension Supine: Tonic neck posture predominates; reaches toward and misses objects; waves at toy Sitting: Head lag partially compensated when pulled to sitting position; early head control with bobbing motion; back rounded Reflex: Typical Moro response has not persisted; makes defensive movements or selective withdrawal reactions Social: Sustained social contact; listens to music; says aah, ngah AT 4 MO Prone: Lifts head and chest, with head in approximately vertical axis; legs extended Supine: Symmetric posture predominates, hands in midline; reaches and grasps objects and brings them to mouth Sitting: No head lag when pulled to sitting position; head steady, tipped forward; enjoys sitting with full truncal support Standing: When held erect, pushes with feet Adaptive: Sees raisin, but makes no move to reach for it Social: Laughs out loud; may show displeasure if social contact is broken; excited at sight of food AT 7 MO Prone: Rolls over; pivots; crawls or creep crawls (Knobloch) Supine: Lifts head; rolls over; squirms Sitting: Sits briefly, with support of pelvis; leans forward on hands; back rounded Standing: May support most of weight; bounces actively Adaptive: Reaches out for and grasps large object; transfers objects from hand to hand; grasp uses radial palm; rakes at raisin Language: Forms polysyllabic vowel sounds Social: Prefers mother; babbles; enjoys mirror; responds to changes in emotional content of social contact AT 10 MO Sitting: Sits up alone and indefinitely without support, with back straight Standing: Pulls to standing position; cruises or walks holding on to furniture Motor: Creeps or crawls Adaptive: Grasps objects with thumb and forefinger; pokes at things with forefinger; picks up pellet with assisted pincer movement; uncovers hidden toy; attempts to retrieve dropped object; releases object grasped by other person Language: Repetitive consonant sounds (mama, dada) Social: Responds to sound of name; plays peek a boo or pat a cake; waves bye bye AT 1 YR Motor: Walks with one hand held; rises independently, takes several steps (Knobloch) Adaptive: Picks up raisin with
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unassisted pincer movement of forefinger and thumb; releases object to other person on request or gesture Language: Says a few words besides mama, dada Social: Plays simple ball game; makes postural adjustment to dressing Data are derived from those of Gesell (as revised by Knobloch), Shirley, Provence, Wolf, Bailey, and others. Data from Knobloch H, Stevens F, Malone AF. Manual of Developmental Diagnosis. Hagerstown, MD: Harper Row;1980. gaze across at things rather than merely looking up at them, opening up a new visual range. They can begin taking food from a spoon. At the same time, maturation of the visual system allows greater depth perception. In this period, infants achieve stable state regulation and regular sleep wake cycles. Total sleep requirements are approximately 14 16 hours per 24 hours, with about 9 10 hours concentrated at night and 2 naps per day. Approximately 70 of infants sleep for a 6 8 hour stretch by age 6 months (see Fig. 23.2). By 4 6 months, the sleep electroencephalogram shows a mature pattern, with demarcation of rapid eye movement and three stages of nonrapid eye movement sleep. The sleep cycle remains shorter than in adults (50 60 minutes vs approximately 90 minutes). As a result, infants arouse to light sleep or wake frequently during the night, setting the stage for behavioral sleep problems (see Chapter 31). Cognitive Development The overall effect of these developments is a qualitative change. At 4 months of age, infants are described as hatching socially, becoming interested in a wider world. During feeding, infants no longer focus exclusively on the mother, but become distracted. In the mothers arms, the infant may literally turn around, preferring to face outward. Downloaded for mohamed ahmed (dr.mms2020gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright 2024. Elsevier Inc. All rights reserved. Chapter 23 u The First Year 155 Infants at this age also explore their own bodies, staring intently at their hands; vocalizing; blowing bubbles; and touching their ears, cheeks, and genitals. These explorations represent an early stage in the understanding of cause and effect as infants learn that voluntary muscle movements generate predictable tactile and visual sensations. Learn ing and memory involving the hippocampus can be demonstrated at 3 months. These activities have a role in the emergence of a sense of self, separate from the parents. This is the first stage of personality development. Infants come to associate certain sensations through fre quent repetition. The proprioceptive feeling of holding up the hand and wiggling the fingers always accompanies the sight of the fingers mov ing. Such self sensations are consistently linked and reproducible at will. In contrast, sensations that are associated with other occur with less regularity and in varying combinations. The sound, smell, and feel of the parent sometimes appear promptly in response to crying, but sometimes do not. The satisfaction that the mother or another loving adult provides continues the process of attachment.
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Emotional Development and Communication Babies interact with increasing sophistication and range. They have an innate ability for facial expressions that, over time, become the func tional expressions of emotion (anger, joy, interest, fear, disgust, and surprise). Infants can discriminate and imitate facial expressions, when paired with vocalizations, of adults as well as other infants. Initiating games (singing, hand games) increases social development. Such face to face behavior reveals the infants ability to share emotional states, the first step in the development of communication. Infants of depressed parents show a different pattern, spending less time in coordinated movement with their parents and making fewer efforts to reengage. Rather than anger, they show sadness and a loss of energy when the parents continue to be unavailable. Implications for Parents and Pediatricians Motor and sensory maturation makes infants at 3 6 months exciting and interactive. Some parents experience their 4 month old childs outward turning as a rejection, secretly fearing that their infants no longer love them. For most parents, this is a happy period and they may excitedly report that they can hold conversations with their infants, taking turns vocalizing and listening. Pediatricians share in the enjoyment, as the baby coos, makes eye contact, and moves rhythmically. Infants who do not show this reciprocal language and movements are at risk for autism spectrum disorder or other developmental disabilities (see Chapters 56 and 58). If this visit does not feel joyful and relaxed, causes such as social Table 23.3 Time of Radiographic Appearance of Centers of Ossification in Infancy and Childhood MALES: AGE AT APPEARANCE BONES AND EPIPHYSEAL CENTERS FEMALES: AGE AT APPEARANCE HUMERUS, HEAD 3 wk 3 wk CARPAL BONES 2 mo 2 mo Capitate 2 mo 2 mo 3 mo 2 mo Hamate 2 mo 2 mo 30 mo 16 mo Triangular 21 mo 14 mo 42 mo 19 mo Lunate 34 mo 13 mo 67 mo 19 mo Trapezium 47 mo 14 mo 69 mo 15 mo Trapezoid 49 mo 12 mo 66 mo 15 mo Scaphoid 51 mo 12 mo No standards available Pisiform No standards available METACARPAL BONES 18 mo 5 mo II 12 mo 3 mo 20 mo 5 mo III 13 mo 3 mo 23 mo 6 mo IV 15 mo 4 mo 26 mo 7 mo V 16 mo 5 mo 32 mo 9 mo I 18 mo 5 mo FINGERS (EPIPHYSES) 16 mo 4 mo Proximal phalanx, 3rd finger 10 mo 3 mo 16 mo 4 mo Proximal phalanx, 2nd finger 11 mo 3 mo 17 mo 5 mo Proximal phalanx, 4th finger 11 mo 3 mo 19 mo 7 mo Distal phalanx, 1st finger 12 mo 4 mo 21 mo 5 mo Proximal phalanx, 5th finger 14 mo 4 mo 24 mo 6 mo Middle phalanx, 3rd finger 15 mo 5 mo 24 mo 6 mo Middle phalanx, 4th finger 15 mo 5 mo 26 mo 6 mo Middle phalanx, 2nd finger 16 mo 5 mo 28 mo 6 mo Distal phalanx, 3rd
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finger 18 mo 4 mo 28 mo 6 mo Distal phalanx, 4th finger 18 mo 5 mo 32 mo 7 mo Proximal phalanx, 1st finger 20 mo 5 mo 37 mo 9 mo Distal phalanx, 5th finger 23 mo 6 mo 37 mo 8 mo Distal phalanx, 2nd finger 23 mo 6 mo 39 mo 10 mo Middle phalanx, 5th finger 22 mo 7 mo 152 mo 18 mo Sesamoid (adductor pollicis) 121 mo 13 mo HIP AND KNEE Usually present at birth Femur, distal Usually present at birth Usually present at birth Tibia, proximal Usually present at birth 4 mo 2 mo Femur, head 4 mo 2 mo 46 mo 11 mo Patella 29 mo 7 mo FOOT AND ANKLE To nearest month. Except for the capitate and hamate bones, the variability of carpal centers is too great to make them very useful clinically. Standards for the foot are available, but normal variation is wide, including some familial variants, so this area is of little clinical use. Values represent mean standard deviation, when applicable. The norms present a composite of published data from the Fels Research Institute, Yellow Springs, OH (Pyle SI, Sontag L. AJR Am J Roentgenol. 1943, 49:102), and unpublished data from the Brush Foundation, Case Western Reserve University, Cleveland, OH, and the Harvard School of Public Health, Boston, MA. Compiled by Lieb, Buehl, and Pyle. Hours of sleep Age Total hours of sleep 1 wk 1 mo 3 mo 16.5 15.5 15 14.25 14 13.75 13.5 13 12 11.50 11 10.75 10.50 10.25 10 9.75 9.50 9.25 9.25 9 8.75 8.50 8.25 8.25 6 mo 9 mo 12 mo 18 mo 2 yr 3 yr 4 yr 5 yr 6 yr 7 yr 8 yr 9 yr 10 yr 11 yr 12 yr 13 yr 14 yr 15 yr 16 yr 17 yr 18 yr 2 4 6 8 10 12 14 16 2 4 6 8 Nighttime sleep Daytime sleep Divided into typical number of naps per day. Length of naps may be quite variable. Fig. 23.2 Typical sleep requirements in children. (From Ferber R. Solve Your Childs Sleep Problems, New York: Simon Schuster; 1985.) Downloaded for mohamed ahmed (dr.mms2020gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright 2024. Elsevier Inc. All rights reserved. 156 Part II u Growth, Development, and Behavior stress, family dysfunction, parental mental illness, or problems in the infantparent relationship should be considered. Parents can be reas sured that responding to an infants emotional needs cannot spoil the infant. Giving vaccines and drawing blood while the child is seated on the parents lap or nursing at the breast increases pain tolerance. AGE 6 12 MONTHS With achievement of the sitting position, increased mobility, and new skills to explore the world around them, 6 12 month old infants show advances in cognitive understanding and communication, and new tensions arise in regard to attachment and separation. Infants develop
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will and intentions, characteristics that most parents welcome but still find challenging to manage. Physical Development Growth slows more (see Table 27.1 and Figs. 24.1 and 24.2). By the first birthday, birthweight has tripled, length has increased by 50, and head circumference has increased by 10 cm (4 in). The ability to sit unsupported (6 7 months) and to pivot while sitting (around 9 10 months) provides increasing opportunities to manipulate several objects at a time and to experiment with novel combinations of objects. These explorations are aided by the emergence of a thumb finger grasp (8 9 months) and a neat pincer grasp by 12 months. Voluntary release emerges at 9 months. Many infants begin crawling and pulling to stand around 8 months, followed by cruising. Some walk by 1 year. Motor achievements correlate with increasing myelinization and cerebellar growth. These gross motor skills expand infants exploratory range and create new physical dangers, as well as opportunities for learning. Tooth eruption occurs, usually starting with the mandibular central incisors. Tooth development (see Table 353.1) reflects skeletal matura tion and bone age, although there is wide individual variation. Cognitive Development The 6 month old infant has discovered his hands and will soon learn to manipulate objects. At first, everything is mouthed. In time, novel objects are picked up, inspected, passed from hand to hand, banged, dropped, and then mouthed. Each action represents a nonverbal idea about what things are for (in Piagetian terms, a schema; see Chapter 19). The com plexity of an infants play, how many different schemata are brought to bear, is a useful index of cognitive development at this age. The pleasure, persistence, and energy with which infants tackle these challenges sug gest the existence of an intrinsic drive or mastery motivation. Mastery behavior occurs when infants feel secure; those with less secure attach ments show limited experimentation and less competence. A major milestone is the achievement by 9 months of object perma nence (constancy), the understanding that objects continue to exist, even when not seen. At 4 7 months of age, infants look down for a yarn ball that has been dropped but quickly give up if it is not seen. With object constancy, older infants persist in searching. They will find objects hidden under a cloth or behind the examiners back. Peek a boo brings unlimited pleasure as the child magically brings back the other player. Events seem to occur as a result of the childs own activities. Emotional Development The advent of object permanence corresponds with qualitative changes in social and communicative development. Infants look back and forth between an approaching stranger and a parent and may cling or cry anxiously, demonstrating stranger anxiety. Separations often become more difficult. Infants who have been sleeping through the night for months begin to awaken regularly and cry, as though remembering that the parents are nearby or in the next room (see Chapter 31). A new demand for autonomy also emerges. Poor weight gain at this age
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often reflects a struggle between an infants emerging inde pendence and parents control of the feeding situation. Use of the two spoon method of feeding (one for the child and one for the parent), finger foods, and a high chair with tray table can avert potential prob lems. Tantrums make their first appearance as the drives for autonomy and mastery come in conflict with parental controls and the infants still limited abilities. Communication Infants at 7 months of age are adept at nonverbal communication, expressing a range of emotions and responding to vocal tone and facial expressions. At about 9 months of age infants become aware that emotions can be shared between people; they show parents toys as a way of sharing their happy feelings. Between 8 and 10 months of age, babbling takes on a new complexity, with multisyllabic sounds (ba da ma) called canonical babbling. Babies can discriminate between languages. Infants in bilingual homes learn the characteris tics and rules that govern two different languages. Social interaction (attentive adults taking turns vocalizing with the infant) profoundly influences the acquisition and production of new sounds. The first true word (i.e., a sound used consistently to refer to a specific object or person) appears in concert with an infants discovery of object permanence. Picture books now provide an ideal context for ver bal language acquisition. With a familiar book as a shared focus of attention, a parent and child engage in repeated cycles of pointing and labeling, with elaboration and feedback by the parent. Often infants learn a gesture to communicate before the can say the word (e.g., waving bye bye before saying bye bye), and there is limited evidence that the addition of sign language may support infant development while enhancing parentinfant communication. Implications for Parents and Pediatricians With the developmental reorganization that occurs around 9 months of age, previously resolved issues of feeding and sleeping reemerge. Pedia tricians can prepare parents at the 6 month visit so that these problems can be understood as the result of developmental progress and not regression. Parents should be encouraged to plan ahead for necessary, and inevitable, separations (e.g., babysitter, daycare). Routine prepara tions may make these separations easier. Dual parent employment has not been consistently found to be harmful or beneficial for long term cognitive or social emotional outcomes. Introduction of a transitional object may allow the infant to self comfort in the parents absence. The object cannot have any potential for asphyxiation or strangulation. Infants wariness of strangers often makes the 9 month examination dif ficult, particularly if the infant is temperamentally prone to react negatively to unfamiliar situations. Initially, the pediatrician should avoid direct eye contact with the child. Time spent talking with the parent and introducing the child to a small, washable toy will be rewarded with more coopera tion. The examination can be continued on the parents lap when feasible. Encourage parents to read, play, and communicate with their infant. Visit Elsevier eBooks at eBooks.Health.Elsevier.com for Bibliography.
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23.1 Infant Crying and Colic Mutiat T. Onigbanjo and Susan Feigelman Crying or fussiness is present in all babies but reaches medical atten tion in about 20 of infants younger than 2 months. Although usually a transient and normal infant behavior, crying is often associated with parental concern and distress. On average, babies cry 2 hours per day, peaking at 6 weeks of age. Premature infants will have peak crying at 6 weeks corrected age (Fig. 23.3). Small for gestational age and prema ture babies may be at higher risk. The peak period of infant crying usu ally occurs in the evenings and early part of the night. Excessive crying or fussiness persisting longer than 3 5 months may be associated with behavioral problems in an older child (anxiety, aggression, hyperactiv ity), decreased duration of breastfeeding, or postnatal depression, but it is uncertain which is the cause or effect. Most infants with crying fussiness do not have gastroesophageal reflux, lactose intolerance, con stipation, or cows milk protein allergy. Acute onset uncontrollable crying could be caused by a medical condition. Potentially overlooked conditions to consider include cor neal abrasion, tourniquet effect of a hair wrapped around a digit or Downloaded for mohamed ahmed (dr.mms2020gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright 2024. Elsevier Inc. All rights reserved. Chapter 23 u The First Year 157 penis, occult fracture, urinary tract infection, acute abdomen including inguinal hernia, or anomalous coronary artery. Breastfeeding mothers should be asked about medications, drugs, and diet. Gastrointestinal distress can result from a maternal diet high in cruciferous vegetables. Most of the time, the etiology of a serious problem can be discovered with a careful history and physical examination. Crying is a normal part of neurobehavioral development. Infants have various signals for their needs and for getting attention from a caregiver. These behaviors progressively increase in intensity in many infants, from changes in breathing and color, to postural and movement changes, and then to calm vocalizations. These precry cues, if not attended to, will eventually lead to active crying. Some infants may go directly to crying, perhaps based on temperament; these infants may be less easily consol able, more intense, or more responsive to sensory stimuli. Management of cryingfussiness should include teaching caregivers about precry cues and responding to the signal for feeding in a calm, relaxed manner. If sen sory overstimulation is a factor, creating a nondistracting, calm environ ment may help, as well as swaddling. When lack of sensory stimulation is present, parentinfant skin to skin contact and carrying the infant may be beneficial. In all situations, reassurance that this is both normal and transient, with only 5 of infants persisting beyond 3 months of age, helps the family cope. Teaching families about expectations for normal crying behavior can reduce emergency department visits. The emotional significance of any experience depends on both the individual childs temperament and the parents responses (see
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Table 19.1); differing feeding schedules produce differing reactions. Hunger generates increasing tension; as the urgency peaks, the infant cries, the parent offers the breast or bottle, and the tension dissipates. Infants fed on demand consistently experience this link among their distress, the arrival of the parent, and relief from hunger. Most infants fed on a fixed schedule quickly adapt their hunger cycle to the schedule. Those who cannot adapt, because they are temperamentally prone to irregu lar biologic rhythms, experience periods of unrelieved hunger as well as unwanted feedings when they already feel full. Similarly, infants who are fed at the parents convenience, with neither attention to the infants hunger cues nor a fixed schedule, may not consistently experi ence feeding as the pleasurable reduction of tension. Infants with early dysregulation often show increased irritability and physiologic insta bility (spitting, diarrhea, poor weight gain) as well as later behavioral problems. Infants with excess crying after 4 6 months may have neu robehavioral dysregulation and may be at higher risk of other behavior problems (sleep, behavior, feeding). Colic is characterized by the rule of 3. It occurs in a healthy, thriving infant beginning in the second or third week of life with crying that lasts at least 3 hours per day, occurs at least 3 days per week, lasts for more than 3 weeks, and resolves by 3 or 4 months of age. It is equally common in breast fed and bottle fed infants, although prevalence is variable (up to 20). There is no racial, socioeconomic status, or gender risk for colic. Colic is a diagnosis of exclusion following a careful history and physical exami nation. Few cases will be found to have an organic etiology. Although all babies have crying episodes, colicky babies cry excessively and are difficult to settle. The fussiness is not associated with hunger or any other form of discomfort. Colicky babies may be more reactive to the same stimulus and may cry louder than other babies. Although crying periods are a nor mal developmental phenomenon, babies with colic can cause parents to become anxious, distraught, frustrated, and sleep deprived. Mothers are at higher risk for postpartum depression if they report inconsolable crying episodes lasting more than 20 minutes. Depression may lead to cessation of breastfeeding. The risk of abuse increases as frustrated parents may use aggressive means in an attempt to quiet the child, resulting in the shaken baby syndrome. There is no specific treatment for colic, but practitioners should pro vide advice and reassurance to parents. Parents must be counseled about the problem, the importance of implementing a series of calm, systematic steps to soothe the infant, and having a plan for stress relief, such as time out for parents and substitute caregivers. Parents can be advised that colic is self limited with no adverse effects on the child. Public health programs, such as the Period of PURPLE Crying (http:purplecrying.info) and Take 5 Safety Plan for Crying, are invaluable tools for parents. These pro grams
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inform parents that all babies go through periods of crying, deflect ing parental guilt and self recrimination. Most importantly, parents are reminded that it is better to allow the baby to cry than engage in shaking that leads to head trauma. Although babies with colic will have inconsol able periods when there is no relief, parents can try some simple steps. Predictable daily schedules may help, ensuring the baby has adequate sleep. Parents should provide appropriate stimulation throughout the day when baby is in an alertawake period. The sleep environment should be free of stimulation. Swaddling, rocking, white noise, and movement (e.g., stroller, car ride) help some babies settle. Infants who are carried by a par ent show different physiologic changes than when held in a sitting posi tion, although there is no evidence that continuous carrying is effective in colic management. A study in a hunter gatherer society showed that chil dren who are continuously carried by their mothers display similar crying periods as those in Western societies. Some studies have found differences in fecal microflora (dysbio sis) between babies with excess crying and controls. Results include fewer bifidobacteria and lactobacilli and more coliform bacteria such as Escherichia coli. None has been conclusive, however, and each study was found to have limitations such as lack of precise inclusion criteria, lack of blinded observers, and variability in outcome measurements. If the child appears to have gastrointestinal symptoms, breastfeeding mothers may try elimination of milk, beans, and cruciferous vegetables from their diets. In allergic families, mothers may try a stricter elimina tion of food allergens (milk, egg, wheat, nuts, soy, and fish), although nutritional status should be monitored. For formula fed infants, changing from milk based to soy based or other lactose free formulas had no effect in most studies. A protein hydrolysate formula may moderately improve symptoms. The cause of colic in not known, and no medical intervention has been consistently effective. Colic has been described as a functional gastro intestinal disorder and has been associated with maternal migraines, as well as later development of migraine in the child. Simethicone has not been shown to be better than placebo. Anticholinergic medications should not be used in infants younger than 6 months. Early studies of probiotics look promising, but evidence is insufficient to recommend their routine use. Among various complementary therapies, certain herbal teas, sugar solutions, Gripe water (containing herbal supple ments), chamomile and fennel extract may have benefit, but the evidence is weak. Baby massage may be helpful, but chiropractic manipulation should not be performed in young children. Acupuncture was effective in one trial and singing while in utero may produce babies who cry less. Visit Elsevier eBooks at eBooks.Health.Elsevier.com for Bibliography. Recording week M in u te s d ay d is tr es s w1 180 160 140 120 100 80 60 40 20 0 w2 w3 w4 w5 w6 w7 w8 w9 w10 w11 w12 Fig. 23.3 Crying amounts and patterns from three North American studies illustrating
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similarities in crying pattern. (From Barr RG, Trent RB, Cross J. Age related incidence curve of hospitalized shaken baby syndrome cases: convergent evidence for crying as a trigger to shaking. Child Abuse Negl. 2006;30:716.) Downloaded for mohamed ahmed (dr.mms2020gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright 2024. Elsevier Inc. All rights reserved. 158 Part II u Growth, Development, and Behavior The second year of life is a time of rapid growth and development, par ticularly in the realms of social emotional and cognitive skills as well as motor development. The toddlers newly found ability to walk allows separation and independence; however, the toddler continues to need secure attachment to the parents. At approximately 18 months of age, the emergence of symbolic thought and language causes a reorganization of behavior, with implications across many developmental domains. AGE 12 18 MONTHS Physical Development Although overall rate of growth continues to decline, the toddler continues to experience considerable brain growth and myelination in the second year of life, resulting in an increase in head circumference of 2 cm over the year (Figs. 24.1 and 24.2). Toddlers have relatively short legs and long torsos, with exaggerated lumbar lordosis and protruding abdomens. Most children begin to walk independently at about 12 15 months of age. Early walking is not associated with advanced development in other domains. Infants initially toddle with a wide based gait, with the knees bent and the arms flexed at the elbow; the entire torso rotates with each stride; the toes may point in or out, and the feet strike the floor flat. The appearance is that of genu varum (bowleg). Subsequent refinement leads to greater steadiness and energy efficiency. After several months of prac tice, the center of gravity shifts back and the torso stabilizes, while the knees extend and the arms swing at the sides for balance. The feet are held in better alignment, and the child is able to stop, pivot, and stoop without toppling over (see Chapters 713 and 714). Cognitive Development Exploration of the environment increases in parallel with improved dexterity (reaching, grasping, releasing) and mobility. Learning follows the precepts of Piagets sensorimotor stage (see Chapter 19). Toddlers manipulate objects in novel ways to create interesting effects, such as stacking blocks or filling and dumping buckets. Playthings are also more likely to be used for their intended purposes (combs for hair, cups for drinking). Imitation of parents and older siblings or other children is an important mode of learning. Make believe play (symbolic play) centers on the childs own body, such as pretending to drink from an empty cup (Table 24.1; see also Table 23.1). Emotional Development Infants who are approaching the developmental milestone of taking their first steps may be irritable. Once they start walking, their predominant mood changes markedly. Toddlers are often elated with their new ability and with the power to control the distance between themselves and their
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parents. Exploring toddlers will orbit around their trusted adults, moving away and then returning for a reassuring touch before moving away again. A child with secure attachment will use the trusted adult as a secure base from which to explore independently. Proud of their accomplishments, the child illustrates Eriksons stage of autonomy and separation (see Chapter 19). The toddler who is overly controlled and discouraged from active exploration may feel doubt, shame, anger, and insecurity. All chil dren will experience tantrums, reflecting their inability to delay gratifica tion, suppress or displace anger, or verbally communicate their emotional states. Children may form secure attachments with parents as well as other trusted adults, thereby reinforcing the value of quality childcare if parents are employed out of the home. Linguistic Development Receptive language precedes expressive language. By the time infants speak their first words around 12 months of age, they already respond appropriately to several simple statements, such as no, bye bye, and give me. By 15 months, the average child points to major body parts and uses four to six words spontaneously and correctly. Toddlers also enjoy polysyllabic jargoning (see Tables 23.1 and 24.1) and do not seem upset that no one understands. Most communication of wants and ideas continues to be nonverbal (e.g., by pointing, facial expressions). Implications for Parents and Pediatricians Parents who cannot recall any other milestone tend to remember when their child began to walk, perhaps because of the symbolic significance of walking as an act of independence and because of the new demands that the ambulating toddler places on the parent. All toddlers should be encouraged to explore their environment; however, a childs ability to wan der out of sight also increases the risks of injury and the need for supervi sion, making recommendations regarding childproofing an integral focus of physician visits. Parents must understand the importance of exploration. Rather than limiting movement, parents should place toddlers in safe environments or substitute one activity for another. In the office setting, many toddlers are comfortable exploring the examination room, but cling to the par ents under the stress of the examination. Children who become more, not less, distressed in their parents arms or who avoid their parents at times of stress may be insecurely attached. Young children who, when distressed, turn to strangers rather than parents for comfort are particu larly worrisome. Children raised in environments with extreme andor chronic levels of stress (toxic stress) have increased vulnerability to dis ease that continues into adulthood (see Chapter 1). These effects can be mediated by fostering elements of resiliency including introduction of a supportive or encouraging trusted adult. The conflicts between inde pendence and security manifest in issues of discipline, temper tantrums, toilet training, and changing feeding behaviors. Parents should be coun seled on these matters within the framework of normal development. Parents may express concern about poor food intake as growth slows. The growth chart should provide reassurance. Many children still take two daytime naps, although the duration
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steadily decreases and may start to condense to one longer nap (see Fig. 23.2). AGE 1824 MONTHS Physical Development Motor development during this period is reflected in improvements in balance and agility and the emergence of running and stair climbing. Height and weight increase at a steady rate during this year, with a gain of 5 in and 5 lb. By 24 months, children are about half their ultimate adult height. Head growth slows slightly, with 85 of adult head cir cumference achieved by age 2 years, leaving only an additional 5 cm (2 in) gain over the next few years (see Fig. 24.1 and Table 27.1). Cognitive Development At approximately 18 mo of age, several cognitive changes coalesce, mark ing the conclusion of the sensorimotor period. These can be observed during self initiated play. Object permanence, which was first demon strated around 9 months of age (see Chapter 23), is now firmly estab lished; toddlers anticipate where an object will end up, even though the object was not visible while it was being moved. Cause and effect are bet ter understood, and toddlers demonstrate flexibility in problem solving (e.g., using a stick to obtain a toy that is out of reach, figuring out how to wind a mechanical toy). Symbolic transformations in play are no longer tied to the toddlers own body; thus a doll can be fed from an empty plate. As with the reorganization that occurs at 9 months (see Chapter 23), the cognitive changes at 18 months correlate with important changes in the emotional and linguistic domains (see Table 24.1). Emotional Development The relative independence of the preceding half year often gives way to increased clinginess at about 18 months. This stage, described as rap prochement, may be a reaction to growing awareness of the possibility of separation. Many parents report that they cannot go anywhere without having a small child attached to them. Separation anxiety will manifest at bedtime. Many children use a special blanket or stuffed toy as a transi tional object, which functions as a symbol of the absent parent. The tran sitional object remains important until the transition to symbolic thought Chapter 24 The Second Year Rebecca G. Carter and Susan Feigelman Downloaded for mohamed ahmed (dr.mms2020gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright 2024. Elsevier Inc. All rights reserved. Chapter 24 u The Second Year 159 A Fig. 24.1 World Health Organization growth charts. A, Weight for length and head circumference for age for boys, birth to 24 months. B, Weight for length and head circumference for age for girls, birth to 24 months. (Courtesy World Health Organization: WHO Child Growth Standards, 2021.) Downloaded for mohamed ahmed (dr.mms2020gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright 2024. Elsevier Inc. All rights reserved. 160 Part II u Growth, Development, and Behavior
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B Fig. 24.1, contd Downloaded for mohamed ahmed (dr.mms2020gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright 2024. Elsevier Inc. All rights reserved. Chapter 24 u The Second Year 161 A Fig. 24.2 World Health Organization growth charts. A, Length for age and weight for age for boys, birth to 24 months. B, Length for age and weight for age for girls, birth to 24 months. (Courtesy World Health Organization: WHO Child Growth Standards, 2021.) Downloaded for mohamed ahmed (dr.mms2020gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright 2024. Elsevier Inc. All rights reserved. 162 Part II u Growth, Development, and Behavior Birth to 24 months: Girls Lengthforage and Weightforage percentiles Published by the Centers for Disease Control and Prevention, November 1, 2009 SOURCE: WHO Child Growth Standards (http:www.who.intchildgrowthen) 98 95 90 75 50 25 10 5 2 98 95 90 75 50 25 10 5 2 B Fig. 24.2, contd Downloaded for mohamed ahmed (dr.mms2020gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright 2024. Elsevier Inc. All rights reserved. Chapter 24 u The Second Year 163 has been completed and the symbolic presence of the parent fully internal ized. Despite the attachment to the parent, the childs use of no is a way of declaring independence. Individual differences in temperament, in both the child and the parents, play a critical role in determining the balance of conflict vs cooperation in the parentchild relationship. As effective lan guage emerges, conflicts often become less frequent. Self conscious awareness and internalized standards of behavior first appear at this age. Toddlers looking in a mirror will, for the first time, reach for their own face rather than the mirror image if they notice something unusual on their nose. They begin to recognize when toys are broken and may hand them to their parents to fix. Language becomes a means of impulse control, early reasoning, and connection between ideas. When tempted to touch a forbidden object, they may tell themselves no, no. This is the very beginning of the formation of a conscience. The fact that they often go on to touch the object anyway demonstrates the relative weakness of internalized inhibitions at this stage. Linguistic Development Perhaps the most dramatic developments in this period are linguistic. Labeling of objects coincides with the advent of symbolic thought. After the realization occurs that words can stand for objects or ideas, a childs vocabulary grows from 10 15 words at 18 months to between 50 and 100 at 2 years. After acquiring a vocabulary of about 50 words, toddlers begin to combine them to make simple sentences, marking the beginning of grammar. At this stage, toddlers understand two step commands, such as Give me the ball and then get your shoes.
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Language also gives the tod dler a sense of control over the surroundings, as in night night or bye bye. The emergence of verbal language marks the end of the sensorimotor period. As toddlers learn to use symbols to express ideas and solve prob lems, the need for cognition based on direct sensation and motor manipu lation wanes. Implications for Parents and Pediatricians With childrens increasing mobility, physical limits on their explorations become less effective; words become increasingly important for behavior control as well as cognition. Children with delayed language acquisition often have greater behavior problems and frustrations due to problems with communication. Language development is facilitated when parents and caregivers use clear, simple sentences; ask questions; pause to allow time to process and generate verbal responses and respond to childrens incomplete sentences and gestural communication with the appropriate words. Television and distracted screen time viewing, as well as television as background noise, decreases parentchild verbal interactions, whereas looking at picture books and engaging the child in two way conversa tions stimulates language development. In the world of constant access to tablets, phones, and screens, parents and children have more distractions from direct language engagement. Even educational programing needs to be limited on screens to reinforce face to face contact with caregivers dur ing language acquisition; solo media use should be avoided in this age. As an introduction to this topic, the provider can ask What are your childs favorite activities? and What activities do you like to do with your child? Performing most of the physical examination in the parents lap may help allay fears of separation and stranger anxiety. Avoid direct eye contact initially and introduce all tools used during the exam such as the otoscope for the patient to explore before use. Save the more invasive portions of the exam to the end (i.e., ears, throat, etc.). Pediatricians can help parents understand the resurgence of prob lems with separation and the appearance of a transitional object as developmental phenomenon. Methods of discipline should be dis cussed; effective alternatives to corporal punishment will usually be appreciated (see Chapter 20 and Tables 20.3 and 20.4). Helping par ents to understand and adapt to their childrens different tempera mental styles can constitute an important intervention (see Table 19.1). Developing daily routines is helpful to all children at this age. Rigidity in those routines reflects a need for mastery over a changing environment. Parents should also institute systems to help prepare their child during times of transition from one activity or setting to another to help foster a sense of trust and communication. Visit Elsevier eBooks at eBooks.Health.Elsevier.com for Bibliography. Table 24.1 Emerging Patterns of Behavior from 1 5 Years of Age 15 MO Motor: Walks alone; crawls up stairs Adaptive: Makes tower of 3 cubes; makes a line with crayon; inserts raisin in bottle Language: Jargon; follows simple commands; may name a familiar object (e.g., ball); responds to hisher name Social: Indicates some desires or needs by pointing; hugs parents
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18 MO Motor: Runs stiffly; sits on small chair; walks up stairs with 1 hand held; explores drawers and wastebaskets Adaptive: Makes tower of 4 cubes; imitates scribbling; imitates vertical stroke; dumps raisin from bottle Language: 10 words (average); names pictures; identifies 1 or more parts of body Social: Feeds self; seeks help when in trouble; may complain when wet or soiled; kisses parent with pucker 24 MO Motor: Runs well, walks up and down stairs, 1 step at a time; opens doors; climbs on furniture; jumps Adaptive: Makes tower of 7 cubes (6 at 21 mo); scribbles in circular pattern; imitates horizontal stroke; folds paper once imitatively Language: Puts 3 words together (subject, verb, object) Social: Handles spoon well; often tells about immediate experiences; helps to undress; listens to stories when shown pictures 30 MO Motor: Goes up stairs alternating feet Adaptive: Makes tower of 9 cubes; makes vertical and horizontal strokes, but generally will not join them to make cross; imitates circular stroke, forming closed figure Language: Refers to self by pronoun I; knows full name Social: Helps put things away; pretends in play 36 MO Motor: Rides tricycle; stands momentarily on 1 foot Adaptive: Makes tower of 10 cubes; imitates construction of bridge of 3 cubes; copies circle; imitates cross Language: Knows age and gender; counts 3 objects correctly; repeats 3 numbers or a sentence of 6 syllables; most of speech intelligible to strangers Social: Plays simple games (in parallel with other children); helps in dressing (unbuttons clothing and puts on shoes); washes hands 48 MO Motor: Hops on 1 foot; throws ball overhand; uses scissors to cut out pictures; climbs well Adaptive: Copies bridge from model; imitates construction of gate of 5 cubes; copies cross and square; draws man with 2 4 parts besides head; identifies longer of 2 lines Language: Counts 4 pennies accurately; tells story Social: Plays with several children, with beginning of social interaction and role playing; goes to toilet alone 60 MO Motor: Skips Adaptive: Draws triangle from copy; names heavier of 2 weights Language: Names 4 colors; repeats sentence of 10 syllables; counts 10 pennies correctly Social: Dresses and undresses; asks questions about meaning of words; engages in domestic role playing Data derived from those of Gesell (as revised by Knobloch), Shirley, Provence, Wolf, Bailey, and others. After 6 yr, the Wechsler Intelligence Scales for Children (WISC IV) and other scales offer the most precise estimates of cognitive development. To have their greatest value, they should be administered only by an experienced and qualified person. Downloaded for mohamed ahmed (dr.mms2020gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright 2024. Elsevier Inc. All rights reserved. 164 Part II u Growth, Development, and Behavior The emergence of language and exposure of children to an expand ing social sphere represent the critical milestones for children age 2 5 years. As toddlers, children learn to walk away and come back
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to the secure adult. As preschoolers, they explore emotional separation, alter nating between stubborn opposition and cheerful compliance, between bold exploration and clinging dependence. Increasing time spent in classrooms and playgrounds strengthens a childs ability to adapt to new rules and relationships. Emboldened by their growing array of new skills and accomplishments, preschool children also are increas ingly cognizant of the constraints imposed on them by the adult world and their own limited abilities. STRUCTURAL DEVELOPMENT OF THE BRAIN The preschool brain experiences dramatic changes in its anatomic and physiologic characteristics, with increases in cortical area, decreases in cortical thickness, and changing cortical volume. These changes are not uniform across the brain and vary by region. Gray and white matter tis sue properties change dramatically, including diffusion properties in the major cerebral fiber tracts. Dramatic increases occur in brain metabolic demands. In general, more brain regions are required in younger than in older children to complete the same cognitive task. This duplica tion has been interpreted as a form of scaffolding, which is discarded with increasing age. The preschool brain is characterized by growth and expansion of synapses that will be followed in later years by pruning. PHYSICAL DEVELOPMENT Somatic and brain growth slows by the end of the second year of life, with corresponding decreases in nutritional requirements and appetite, and the emergence of picky eating habits (see Table 27.1). Increases of approximately 2 kg (4 5 lb) in weight and 7 8 cm (2 3 in) in height per year are expected. Birthweight quadruples by 2.5 years of age. An average 4 year old weighs 40 lb and is 40 in tall. The head will grow only an additional 5 6 cm between ages 3 and 18 years. Current growth charts, with growth parameters, can be found on the U.S. Centers for Disease Control and Prevention website (http:www.cdc.govgrowt hcharts) and in Chapter 27. Children with early adiposity rebound (increase in body mass index) are at increased risk for adult obesity. The preschooler has genu valgum (knock knees) and mild pes pla nus (flatfoot). The torso slims as the legs lengthen. Growth of sexual organs is commensurate with somatic growth. Physical energy peaks, and the need for sleep declines to 11 13 hours per 24 hours, with the child eventually dropping the nap (see Fig. 23.2). Visual acuity reaches 2030 by age 4 years and 2020 by school age. All 20 primary teeth have erupted by 3 years of age (see Chapter 353). Most children walk with a mature gait and run steadily before the end of their third year (see Table 24.1). Beyond this basic level, there is wide variation in ability as the range of motor activities expands to include throwing, catching, and kicking balls; riding on bicycles; climbing on playground structures; dancing; and other complex pat tern behaviors. Stylistic features of gross motor activity, such as tempo, intensity, and cautiousness, also vary significantly. Although toddlers may walk with different styles, toe walking should not persist. The
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effects of such individual differences on cognitive and emotional development depend in part on the demands of the social environment and alignment with their caregivers temperaments. Energetic, coordi nated children may thrive emotionally with parents or teachers who encourage physical activity; lower energy, more cerebral children may thrive with adults who value quiet play. Handedness is usually established by the third year. Frustration may result from inability to properly teach skills based on childs hand preference. Variations in fine motor development reflect both indi vidual proclivities and different opportunities for learning. Children who are restricted from drawing with crayons, for example, develop a mature pencil grasp later. Bowel and bladder control emerge during this period, with readi ness for toileting having large individual and cultural variation. Females tend to potty train faster and earlier than males. Bed wetting is common up to age 5 years (see Chapter 580). Many children master toileting with ease, particularly once they are able to verbalize their bodily needs. For others, toilet training can involve a protracted power struggle. Refusal to defecate in the toilet or potty is relatively common, associated with constipation, and can lead to parental frustration. Defusing the issue with a temporary cessation of training (and a return to diapers) often allows toilet mastery to proceed. Parents should focus on positive reinforcement and avoid negative reactions during the toi let training process. Implications for Parents and Pediatricians The normal decrease in appetite at this age may cause parental concern about nutrition; growth charts should reassure parents that the childs intake is adequate. Children normally modulate their food intake to match their somatic needs according to feelings of hunger and sati ety. Daily intake fluctuates, at times widely, but intake over a week is relatively stable. Parents should provide a predictable eating schedule, with three meals and two snacks per day, allowing the child to choose how much to eat. This will avoid power struggles and allows the child to respond to satiety cues. However, it is important to obtain thorough diet histories for children at this age to advise parents about healthy choices and encourage physical activity to decrease long term obesity risks and improve learning and cognitive development. Highly active children face increased risks of injury, and parents should be counseled about safety precautions. Parental concerns about possible hyperactivity may reflect inappropriate expectations, heightened fears, or true overactivity. Children who engage in ongoing impulsive activity with no apparent regard for personal safety or those harming others on a regular basis should be evaluated further. Assessment of motor skills must take into account a childs expo sure history. Before diagnosing a motor delay based on screening tools, pediatricians should explore any limitations to a childs exposure and encourage parents to seek opportunities to work on these skills. Chil dren should be followed closely at this age; referral to therapies should be pursued when true delays are identified given the proven benefits of early intervention. LANGUAGE, COGNITION, AND PLAY These three domains all
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involve symbolic function, a mode of dealing with the world that emerges during the preschool period. Language Our understanding of the acquisition of language is evolving. Preschool children command significant computational skills and understanding of statistical patterns that allow them to learn about both language and causation. The 2 and 3 year old child employs frequency distributions to identify phonetic units distinguishing words in his or her native lan guage from other languages. Language development occurs most rapidly between 2 and 5 years of age. Vocabulary increases from 50 100 words to more than 2,000. Sentence structure advances from telegraphic phrases (baby cry) to sentences incorporating all the major grammatical components (see Chapter 53). As a rule of thumb, between ages 2 and 5 years, the number of words the child puts in a typical sentence should, at a minimum, equal the childs age (2 by age 2 years, 3 by age 3 years, and so on). By 21 24 months, most children are using possessives (my ball), progressives (the ing construction, as in I playing), ques tions, and negatives. By age 4 years, most children can count to 4 and use the past tense; by age 5 years, they can use the future tense. Young children do not use figurative speech; they will comprehend only the literal meaning of words. Referring to an object as light as a feather may produce a quizzical look on a child. Chapter 25 The Preschool Years Rebecca G. Carter and Susan Feigelman Downloaded for mohamed ahmed (dr.mms2020gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright 2024. Elsevier Inc. All rights reserved. Chapter 25 u The Preschool Years 165 It is important to distinguish between speech (the production of intelligible sounds) and language, which refers to the underlying men tal act. Language includes both expressive and receptive functions. Receptive language (understanding) varies less in its rate of acquisi tion than does expressive language; therefore it has greater prognostic importance (see Chapters 28 and 53). Language acquisition depends critically on environmental input. Key determinants include the amount and variety of speech directed toward children and the frequency with which adults ask questions and encourage verbalization. Children raised in poverty typically per form lower on measures of language development than children from economically advantaged families, who tend to be exposed to many more words in the preschool period. Interventions aimed at increasing access to books in the home can temper these differences and improve language and pre reading skills in the preschool child. Although experience influences the rate of language development, many linguists believe that the basic mechanism for language learn ing is hard wired in the brain. Children do not simply imitate adult speech; they abstract the complex rules of grammar from the ambient language, generating implicit hypotheses. Evidence for the existence of such implicit rules comes from analysis of grammatical errors, such as the overgeneralized use of s to
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signify the plural and ed to signify the past (We seed lots of mouses.). Language is linked to both cognitive and emotional development. Language delays may be the first indication of an intellectual disability, autism spectrum disorder, or child neglect or maltreatment. Language plays a critical part in the regulation of behavior through internal ized private speech in which a child repeats adult prohibitions, first audibly and then mentally. Language also allows children to express feelings, such as anger or frustration, without acting them out; conse quently, language delayed children may show higher rates of tantrums and other externalizing behaviors. Preschool language development lays the foundation for later suc cess in school. Approximately 35 of U.S. children may enter school lacking the language skills that are the prerequisites for acquiring lit eracy. Children from socially and economically disadvantaged back grounds have an increased risk of school problems, making early detection, along with referral and enrichment in programs such as Head Start, highly crucial for later development. Although children typically learn to read and write in elementary school, critical founda tions for literacy are established during the preschool years. Through repeated early exposure to written words, children learn about the uses of writing (telling stories or sending messages) and about its form (left to right, top to bottom). Early errors in writing, like errors in speak ing, reveal that literacy acquisition is an active process involving the generation and revision of hypotheses. Bilingual children may initially appear to lag behind their monolingual peers in acquiring language. They learn the differing rules governing both languages, and generally have the same number of total words between the languages. Bilingual children do not follow the same course of language development as monolingual children, but rather create a different system of language cues. Several cognitive advantages have been repeatedly demonstrated among bilingual compared to monolingual children. Picture books have a special role in familiarizing young children with the printed word and in the development of verbal language. Childrens vocabulary and receptive language improve when their parents or caregivers consistently read to them. Reading aloud with a young child is an interactive process in which a parent repeatedly focuses the childs attention on a particular picture, asks questions, and then gives the child feedback (dialogic reading). The elements of shared attention, active participation, immediate feedback, repetition, and graduated difficulty make such routines ideal for language learn ing. Programs in which physicians provide books to preschool children have shown improvement in language skills among the children (e.g., Reach Out and Read). The period of rapid language acquisition is also when developmental dysfluency and stuttering are most likely to emerge (see Chapter 53.1); these can be traced to activation of the cortical motor, sensory, and cerebellar areas. Common difficulties include pauses and repetitions of initial sounds. Stress or excitement exacerbates these difficulties, which generally resolve on their own. Although 5 of preschool children will stutter, it will resolve in 80 of those children by age 8 years. Chil
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dren with stuttering should be referred for evaluation if it is severe, persistent, or associated with anxiety, or if parental concern is elicited. Treatment includes guidance to parents to reduce pressures associated with speaking. Cognition The preschool period corresponds to Piagets preoperational (pre logical) stage, characterized by magical thinking, egocentrism, and thinking that is dominated by perception, not abstraction (see Table 19.2). Magical thinking includes confusing coincidence with causal ity, animism (attributing motivations to inanimate objects and events), and unrealistic beliefs about the power of wishes. A child might believe that people cause it to rain by carrying umbrellas, that the sun goes down because it is tired, or that feeling resentment toward a sibling can actually make that sibling sick. Egocentrism refers to a childs inabil ity to take anothers point of view and does not connote selfishness. A child might try to comfort an adult who is upset by bringing the adult a favorite stuffed animal. After 2 years of age, the child develops a concept of herself or himself as an individual and senses the need to feel whole. Piaget demonstrated the dominance of perception over logic. In one experiment, water is poured back and forth between a tall, thin vase and a low, wide dish, and children are asked which container has more water. Typically, preschool age children choose the one that looks larger (usually the tall vase), even when the examiner points out that no water has been added or taken away. Such misunderstandings reflect young childrens developing hypotheses about the nature of the world, as well as their difficulty in attending simultaneously to multiple aspects of a situation. Preschool children also are able to understand causal relationships; this adds to our understanding of the ability of preschool children to engage in abstract thinking (see Chapter 19). Imitation, central to the learning experience of preschool children, is a complex act because of differences in the size of the operators (the adult and the child), different levels of dexterity, and even different out comes. A child who watches an adult unsuccessfully attempt a simple act (unscrew a lid) will imitate the action, but often with the intended outcome and not the demonstrated (failed) outcome. Thus imitation goes beyond the mere repetition of observed movements. By age 3 years, children have self identified their sex and are actively seeking understanding of the meaning of gender identification. There is a developmental progression from rigidity (males and female have strict gender roles) in the early preschool years to a more flexible real istic understanding (males and females can have a variety of interests that are not gender specific). Parents can facilitate this flexibility by eliminating gender based expectations and expanding play options. Play Play involves learning, physical activity, socialization with peers, and practicing adult roles. Play increases in complexity and imagination, from simple imitation of common experiences, such as shopping and putting baby to bed (2 or 3 years of age), to more extended scenarios involving singular events, such
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as going to the zoo or going on a trip (3 or 4 years of age), to the creation of scenarios that have only been imagined, such as flying to the moon (4 or 5 years of age). By age 3 years, cooperative play is seen in activities such as building a tower of blocks together; later, more structured role play activity, as in playing house, is seen. Play also becomes increasingly governed by rules, from early rules about asking (rather than taking) and sharing (2 or 3 years of age), to rules that change from moment to moment, according to the desires of the players (4 and 5 years of age), to the beginning of the recognition of rules as relatively immutable (5 years of age). Electronic forms of play (games) are best if interactive and educational and should remain limited in duration. Play also allows for resolution of conflicts and anxiety and for cre ative outlets. Children can vent anger safely (reprimanding a doll), take on superpowers (dinosaur and superhero play), and obtain things that Downloaded for mohamed ahmed (dr.mms2020gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright 2024. Elsevier Inc. All rights reserved. 166 Part II u Growth, Development, and Behavior are denied in real life (an imaginary friend or stuffed animal). Cre ativity is particularly apparent in drawing, painting, and other artistic activities. Themes and emotions that emerge in a childs drawings often reflect the emotional issues of greatest importance for the child. Difficulty distinguishing fantasy from reality colors a childs percep tion of what the child views in the media, through programming and advertising. Twenty five percent of young children have a television set or tablet in their bedroom; screen time in the bedroom is associ ated with more hours of watching. The number of hours that most preschoolers watch screens exceeds guidelines (1 hrday for 2 5 year olds). Interactive quality educational programming in which children develop social relationships with the characters can increase learning if paired with adult interaction around the storyline. Exposure to com mercial programming with violent content is associated with behavior problems, and because children younger than 8 years are not able to comprehend the concept of persuasive intent, they are more vulnerable to advertising. Implications for Parents and Pediatricians The significance of language as a target for assessment and intervention cannot be overestimated, because of its central role as an indicator of cognitive and emotional development and a key factor in behavioral regulation and later school success. As language emerges, parents can support emotional development by using words that describe the childs feeling states (You sound angry right now) and urging the child to use words to express rather than act out feelings. Active imaginations will come into play when children offer explanations for misbehavior. A parents best way of dealing with untruths is to address the event, not the child, and have the
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child participate in making things right. Parents should have a regular time each day for reading or looking at books with their children. Programs such as Reach Out and Read, in which clinicians give out picture books along with appropriate guid ance during primary care visits, have been effective in increasing read ing aloud and thereby promoting language development, particularly in lower income families. TV and similar media should be limited to 1 hrday of quality programming for children age 2 5 years, and parents should be watching the programs with their children and debriefing their young children afterward. At risk children, particularly those liv ing in poverty, can better meet future school challenges if they have early high quality child care and learning experiences (e.g., Head Start). Preoperational thinking constrains how children understand expe riences of illness and treatment. Children begin to understand that bodies have insides and outsides. Children should be given simple, concrete explanations for medical procedures and given some control over procedures if possible. Children should be reassured that they are not to blame when receiving a vaccine or venipuncture, and parents should be discouraged from making threats about needles if their child is not cooperating with the exam. An adhesive bandage will help to make the body whole again in a childs mind. The active imagination that fuels play and the magical, animist thinking characteristic of preoperational cognition can also gener ate intense fears. More than 80 of parents report at least one fear in their preschool children. Refusal to take baths or to sit on the toilet may arise from the fear of being washed or flushed away, reflecting a childs immature appreciation of relative size. Attempts to demonstrate rationally that there are no monsters in the closet often fail, inasmuch as the fear arises from preoperational thinking. However, this same thinking allows parents to be endowed with magical powers that can banish the monsters with monster spray or a night light. Parents should acknowledge the fears, offer reassurance and a sense of security, and give the child some sense of control over the situation. Use of the Draw a Person, in which a child is asked to draw the best person the child can, may help elucidate a childs viewpoint. Emotional and Moral Development Emotional challenges facing preschool children include accepting lim its while maintaining a sense of self direction, reigning in aggressive and sexual impulses, and interacting with a widening circle of adults and peers. At 2 years of age, behavioral limits are predominantly external; by 5 years of age, these controls need to be internalized if a child is to function in a typical classroom. Success in achieving this goal relies on prior emotional development, particularly the ability to use internalized images of trusted adults to provide a secure environ ment in times of stress. The love a child feels for important adults is the main incentive for the development of self control. Children learn what behaviors are acceptable and how
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much power they wield vis vis important adults by testing limits. Limit testing increases when it elicits attention, even though that attention is often negative, and when limits are inconsistent. Testing often arouses paren tal anger or inappropriate solicitude as a child struggles to separate, and it gives rise to a corresponding parental challenge: letting go. Exces sively tight limits can undermine a childs sense of initiative, whereas overly loose limits can provoke anxiety in a child who feels that no one is in control. Control is a central issue. Young children cannot control many aspects of their lives, including where they go, how long they stay, and what they take home from the store. They are also prone to lose internal control, that is, to have temper tantrums. Fear, overtiredness, hunger, inconsistent expectations, or physical discomfort can also evoke tan trums. Tantrums normally appear toward the end of the first year of life and peak in prevalence between 2 and 4 years of age. Tantrums lasting more than 15 minutes or regularly occurring more than three times per day may reflect underlying medical, emotional, developmental, or social problems. Parents likely will not be able to reason or teach in the context of an active tantrum, and should offer emotional support dur ing these times, sticking to short and concise explanations (I cant let you hit). Lessons about their behavior or discussions about strategies for future challenges should be delayed until the child is calm and able to engage. Preschool children normally experience complicated feelings toward their parents that can include strong attachment and possessiveness toward the parent of the opposite sex, jealousy and resentment of the other parent, and fear that these negative feelings might lead to abandonment. These emotions, most of which are beyond a childs ability to comprehend or verbalize, often find expression in highly labile moods. The resolution of complicated feelings (a process extending over years) involves a childs unspoken decision to identify with the parents rather than compete with them. Play and language foster the development of emotional controls by allowing children to express emotions and role play. Curiosity about genitals and adult sexual organs is normal, as is masturbation. Excessive masturbation interfering with normal activ ity, acting out sexual intercourse, extreme modesty, or mimicry of adult seductive behavior all suggest the possibility of sexual abuse or inappropriate exposure (see Chapter 17.1). Modesty appears gradually between 4 and 6 years of age, with wide variations among cultures and families. Parents should begin to teach children about private body areas before school entry. Moral thinking is constrained by a childs cognitive level and language abilities but develops as the child builds their identity with trusted adults. Beginning before the second birthday, the childs sense of right and wrong stems from the desire to earn adult approval and avoid negative consequences. The childs impulses are tempered by external forces; the child has not yet internalized societal rules or a sense of justice and fair ness. Over time,
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as the child internalizes parental admonitions, words are substituted for aggressive behaviors. Finally, the child accepts personal responsibility. Actions will be viewed by damage caused, not by intent. Empathic responses to others distress arise during the second year of life, but the ability to consider another childs point of view remains lim ited throughout this period. In keeping with a childs inability to focus on more than one aspect of a situation at a time, fairness is taken to mean equal treatment, regardless of circumstance. A 4 year old will acknowl edge the importance of taking turns but will complain if he or she didnt get enough time. Rules tend to be absolute, with guilt assigned for bad outcomes, regardless of intentions. Implications for Parents and Pediatricians The importance of the preschoolers sense of control over his or her body and surroundings have implications for practice. Preparing the Downloaded for mohamed ahmed (dr.mms2020gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright 2024. Elsevier Inc. All rights reserved. Chapter 26 u Middle Childhood 167 patient by letting the child know how the visit will proceed is reassur ing. Tell the child what will happen, but do not ask permission unless you are willing to deal with a no answer. A brief introduction to pri vate parts is warranted before the genital examination. The visit of the 4 or 5 year old should be entertaining, because of the childs ability to communicate, as well as the childs natural curiosity. Phy sicians should realize that all children are occasionally difficult. Guid ance emphasizing appropriate expectations for behavioral and emotional development and acknowledging normal parental feelings of anger, guilt, and confusion should be part of all visits at this time. Parents should be queried about daily routines and their expectations of child behavior. Providing children with acceptable choices (all options being accept able to the parent) and encouraging independence in self care activities (feeding, dressing, and bathing) will reduce conflicts. Although some cultures condone the use of physical punishment for disciplining of young children, it is not a consistently effective means of behavioral control (Chapter 20). As children habituate to repeated spanking, parents have to spank ever harder to achieve the desired response, increasing the risk of serious injury. Sufficiently harsh pun ishment may acutely inhibit undesired behaviors, but at great long term psychologic cost. Children may mimic the physical punishment that they receive; children who are spanked will have more aggressive behaviors later. Whereas spanking is the use of force, externally applied, to produce behavior change, discipline is the process that allows the child to internalize controls on behavior. Alternative discipline strate gies should be offered, such as the countdown for transitions along with consistent limit setting, time outs and time ins (fun activities with caregiver present and interacting), clear communication of rules, and frequent approval with positive reinforcement of productive play and behavior (see Chapter 20 and
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Tables 20.3 and 20.4). Punishment should be immediate, specific to the behavior, and time limited. Time out for approximately 1 minute per year of age is very effective if children are getting sufficient time in. A kitchen timer or digital phone alarm allows the parent to step back from the situation; the child is free when the timer rings. Although one strategy might not work for all children uniformly, consistency is integral to healthy learning and growth. Visit Elsevier eBooks at eBooks.Health.Elsevier.com for Bibliography. Middle childhood (6 11 years of age) is the period in which children increasingly separate from parents and seek acceptance from teachers, other adults, and peers. Children begin to feel under pressure to con form to the style and ideals of the peer group. Self esteem becomes a central issue, as children develop the cognitive ability to consider their own self evaluations and their perception of how others see them. For the first time, they are judged according to their ability to produce socially valued outputs, such as getting good grades, playing a musical instrument, or hitting home runs. PHYSICAL DEVELOPMENT Growth occurs discontinuously, in three to six irregularly timed spurts each year, but varies both within and among individuals. Growth during the period averages 3 3.5 kg (6.6 7.7 lb) and 6 7 cm (2.4 2.8 in) per year (Fig. 26.1). The head grows only 2 cm in circumference throughout the entire period, reflecting a slowing of brain growth. Myelination contin ues into adolescence, with peak gray matter at 12 14 years. Body habitus is more erect than previously, with long legs compared with the torso. Chapter 26 Middle Childhood Mutiat T. Onigbanjo and Susan Feigelman Growth of the midface and lower face occurs gradually. Loss of decid uous (baby) teeth is a more dramatic sign of maturation, beginning around 6 years of age. Replacement with adult teeth occurs at a rate of about four per year, so that by age 9 years, children will have eight per manent incisors and four permanent molars. Premolars erupt by 11 12 years of age (see Chapter 353). Lymphoid tissues hypertrophy and reach maximal size, often giving rise to impressive tonsils and adenoids. Muscular strength, coordination, and stamina increase progressively, as does the ability to perform complex movements, such as dancing or shooting baskets. Such higher order motor skills are the result of both maturation and training; the degree of accomplishment reflects wide variability in innate skill, interest, and opportunity. Physical fitness has declined among school age children. Sedentary habits at this age are associated with increased lifetime risk of obesity, cardiovascular disease, lower academic achievement, and lower self esteem. The number of overweight children and the degree of over weight have been increasing (see Chapter 65). Only 15 of middle and junior high schools require physical education classes at least three days per week. One quarter of youth do not engage in any free time physical activity, despite the recommendation for at least 1 hour of physical
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activity per day. Perceptions of body image develop early during this period; chil dren as young as 5 and 6 years may express dissatisfaction with their body image; by ages 8 and 9 years many of these youth report trying to diet, often using ill advised regimens. Loss of control (binge) eating occurs among approximately 6 of children at this age. Before puberty the sensitivity of the hypothalamus and pituitary changes, leading to increased gonadotropin synthesis. Interest in gender differences and sexual behavior increases progressively until puberty. Although this is a period when sexual drives are limited, mas turbation is common, and children may be interested in differences between genders. Rates of maturation differ by geography, ethnicity, and country. Sexual maturity occurs earlier for both sexes in the United States. Differences in maturation rates have implications for differing expectations of others based on sexual maturation. Implications for Parents and Pediatricians Middle childhood is generally a time of excellent health. However, children have variable sizes, shapes, and abilities. Children of this age compare themselves with others, eliciting feelings about their physical attributes and abilities. Fears of being abnormal can lead to avoidance of situations in which physical differences might be revealed, such as gym class or medical examinations. However, all children, including those with disabilities, should participate in gym classes. Those with physical disabilities may face special stresses; medical, social, and psy chologic risks tend to occur together. Children should be asked about risk factors for obesity. Participa tion in physical activity, including organized sports or other organized activities, can foster skill, teamwork, and fitness as well as a sense of accomplishment, but pressure to compete when the activity is no lon ger enjoyable has negative effects. Counseling on establishing healthy eating habits and limited screen time should be given to all families. Prepubertal children should not engage in high stress, high impact sports, such as power lifting or tackle football, because skeletal imma turity increases the risk of injury and concussions may have long term sequelae (see Chapter 729). COGNITIVE DEVELOPMENT The thinking of early elementary school age children differs qualita tively from that of preschool children. In place of the magical, ego centric, and perception bound cognition of preschool children, school age children increasingly apply rules based on observable phe nomena, factor in multiple dimensions and points of view, and inter pret their perceptions using physical laws. Piaget documented this shift from preoperational to concrete (logical) operations (see Chapter 19). When 5 year olds watch a ball of clay being rolled into a snake, they might insist that the snake has more because it is longer. In contrast, 7 year olds typically reply that the ball and the snake must weigh the same because nothing has been added or taken away or because the Downloaded for mohamed ahmed (dr.mms2020gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright 2024. Elsevier Inc. All rights reserved. 168
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Part II u Growth, Development, and Behavior A Fig. 26.1 A, Stature (height) for age and weight for boys, age 2 20 years. B, Stature (height) for age and weight for girls, age 2 20 years. (Courtesy National Center for Health Statistics, in collaboration with the National Center for Chronic Disease Prevention and Health Promotion, 2000. http:www.cdc.govgrowthcharts.) Downloaded for mohamed ahmed (dr.mms2020gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright 2024. Elsevier Inc. All rights reserved. Chapter 26 u Middle Childhood 169 B Fig. 26.1, contd Downloaded for mohamed ahmed (dr.mms2020gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright 2024. Elsevier Inc. All rights reserved. 170 Part II u Growth, Development, and Behavior snake is both longer and thinner. This cognitive reorganization occurs at different rates in different contexts. In the context of social inter actions with siblings, young children often demonstrate an ability to understand alternate points of view long before they demonstrate that ability in their thinking about the physical world. Understanding time and space constructs occurs in the later part of this period. The concept of school readiness has evolved. The American Academy of Pediatrics recommends following an interactional relational model in which the focus is on the child, the environment, and the resulting interac tions. This model explicitly asserts that all children can learn and that the educational process is reciprocal between the child and the school. It is developmentally based, recognizing the importance of early experiences for later development. Rather than delaying school entry, high quality early education programs may be the key to ultimate school success. School makes increasing cognitive demands on the child. Mastery of the elementary curriculum requires that many perceptual, cogni tive, and language processes work efficiently (Table 26.1), and children are expected to attend to many inputs at once. The first 2 3 years of elementary school are devoted to acquiring the fundamentals: reading, writing, and basic mathematics skills. By third grade, children need to be able to sustain attention through a 45 minute period, and the cur riculum requires more complex tasks. The goal of reading a paragraph is no longer to decode the words, but to understand the content; the goal of writing is no longer spelling or penmanship, but composition. The volume of work increases along with the complexity. Cognitive abilities interact with a wide array of attitudinal and emo tional factors in determining classroom performance. These factors include external rewards (eagerness to please adults and approval from peers) and internal rewards (competitiveness, willingness to work for a delayed reward, belief in ones abilities, and ability to risk trying when success is not ensured). Success predisposes to success, whereas fail ure impacts self esteem and reduces self efficacy, diminishing a childs willingness to take future risks. Childrens intellectual activity extends beyond the classroom. Beginning in the third
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or fourth grade, children increasingly enjoy strategy games and wordplay (puns and insults) that exercise their growing cognitive and lin guistic mastery. Many become experts on subjects of their own choosing, such as sports trivia, or develop hobbies, such as special card collections. Others become avid readers or take on artistic pursuits. Whereas board and card games were once the usual leisure time activity of youth, video, computer, and other electronic games currently fill this need. Implications for Parents and Pediatricians Pediatricians have an important role in preparing their patients for school entrance by promoting health through immunizations, adequate nutrition, appropriate recreation, and screening for physical, develop mental, and cognitive disorders. The American Academy of Pediatrics recommends that pediatric providers promote the 5 Rs of early edu cation: (1) reading as a daily family activity; (2) rhyming, playing, and cuddling together; (3) routines and regular times for meals, play, and sleep; (4) reward through praise for successes; and (5) reciprocal nur turing relationships. Concrete operations allow children to understand simple explana tions for illnesses and necessary treatments, although they may revert to prelogical thinking when under stress. A child with pneumonia may be able to explain about white cells fighting the germs in the lungs but may still secretly harbor the belief that the sickness is a punishment for disobedience. As children are faced with more abstract concepts, academic and classroom behavior problems emerge and come to the pediatricians attention. Referrals may be made to the school for remediation or to community resources (medical or psychologic) when appropriate. The causes may be one or more of the following: deficits in percep tion (vision and hearing); specific learning disabilities (see Chapters 51 and 52); global cognitive delay (intellectual disability; Chapter 56); deficits in attention and executive function (Chapters 49 and 50); Table 26.1 Selected Perceptual, Cognitive, and Language Processes Required for Elementary School Success PROCESS DESCRIPTION ASSOCIATED PROBLEMS PERCEPTUAL Visual analysis Ability to break a complex figure into components and understand their spatial relationships Persistent letter confusion (e.g., between b, d, and g); difficulty with basic reading and writing and limited sight vocabulary Proprioception and motor control Ability to obtain information about body position by feel and unconsciously program complex movements Poor handwriting, requiring inordinate effort, often with overly tight pencil grasp; special difficulty with timed tasks Phonologic processing Ability to perceive differences between similar sounding words and to break down words into constituent sounds Delayed receptive language and reading skill; attention and behavior problems secondary to not understanding directions; delayed acquisition of letter sound correlations (phonetics) COGNITIVE Long term memory, both storage and recall Ability to acquire skills that are automatic (i.e., accessible without conscious thought) Delayed mastery of the alphabet (reading and writing letters); slow handwriting; inability to progress beyond basic mathematics Selective attention Ability to attend to important stimuli and ignore distractions Difficulty following multistep instructions, completing assignments, and behaving well; problems with peer interaction Sequencing Ability to remember things in order; facility with time concepts Difficulty organizing
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assignments, planning, spelling, and telling time LANGUAGE Receptive language Ability to comprehend complex constructions, function words (e.g., if, when, only, except), nuances of speech, and extended blocks of language (e.g., paragraphs) Difficulty following directions; wandering attention during lessons and stories; problems with reading comprehension; problems with peer relationships Expressive language Ability to recall required words effortlessly (word finding), control meanings by varying position and word endings, and construct meaningful paragraphs and stories Difficulty expressing feelings and using words for self defense, with resulting frustration and physical acting out; struggling during circle time and in language based subjects (e.g., English) Downloaded for mohamed ahmed (dr.mms2020gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright 2024. Elsevier Inc. All rights reserved. Chapter 26 u Middle Childhood 171 and attention deficits secondary to family dysfunction, depression, anxiety, or chronic illness. Children whose learning style does not fit the classroom culture may have academic difficulties and need assess ment before failure sets in. Simply having a child repeat a failed grade rarely has any beneficial effect and often seriously undercuts the childs self esteem. In addition to finding the problem areas, identifying each childs strengths is important. Educational approaches that value a wide range of talents (multiple intelligences) beyond the traditional read ing, writing, and mathematics may allow more children to succeed. The change in cognition allows the child to understand ifwhen clauses. Increased responsibilities and expectations accompany increased rights and privileges. Discipline strategies should move toward negotiation and a clear understanding of consequences, includ ing removal of privileges for infringements. SOCIAL, EMOTIONAL, AND MORAL DEVELOPMENT Social and Emotional Development In middle childhood, energy is directed toward creativity and pro ductivity. Changes occur in three spheres: the home, the school, and the neighborhood. Of these, the home and family remain the most influential. Increasing independence is marked by the first sleepover at a friends house and the first time at overnight camp. Parents should make demands for effort in school and extracurricular activities, cel ebrate successes, and offer unconditional acceptance when failures occur. Regular chores, associated with an allowance, provide an oppor tunity for children to contribute to family functioning and learn the value of money. These responsibilities may be a testing ground for psy chologic separation, leading to conflict. Siblings have critical roles as competitors, loyal supporters, and role models. The beginning of school coincides with a childs further separation from the family and the increasing importance of teacher and peer rela tionships. Social groups tend to be same sex, with frequent changing of membership, contributing to a childs growing social development and competence. Popularity, a central ingredient of self esteem, may be won through possessions (having the latest electronic gadgets or the right clothes), as well as through personal attractiveness, accomplish ments, and actual social skills. Children are aware of racial differences and are beginning to form opinions about racial groups that impact their relationships. Gender identification, which
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began in early child hood, continues to evolve and can have significant implications for peer relationships and self awareness. Some children conform readily to the peer norms and enjoy easy social success. Those who adopt individualistic styles or have visible differences may be teased or bullied. Children with deficits in social skills may go to extreme lengths to win acceptance, only to meet with repeated failure. Attributions conferred by peers, such as funny, stu pid, bad, or fat, may become incorporated into a childs self image and affect the childs personality, as well as school performance. Parents may have their greatest effect indirectly, through actions that change the peer group (changing the childs school or encouraging involve ment in structured after school activities). Children who identify with a gender different from their sex of birth, or whose manner and dress reflect those more typically seen as opposite their birth sex, may be subject to teasing or bullying (Chapter 153). This can magnify the con fusion for these children, who are formulating their own concept of self. In the neighborhood, real dangers, such as busy streets, bullies, violence, and strangers, tax school age childrens common sense and resourcefulness (see Chapter 15). Interactions with peers without close adult supervision call on increasing conflict resolution skills. Media exposure to adult materialism, sexuality, substance use, and violence may be frightening, reinforcing childrens feeling of powerlessness in the larger world. Compensatory fantasies of being powerful may fuel the fascination with heroes and superheroes. A balance between fan tasy and an appropriate ability to negotiate real world challenges indi cates healthy emotional development. Moral Development Although by age 6 years most children will have a conscience (inter nalized rules of society), they vary greatly in their level of moral devel opment. For younger children, many still subscribe to the notion that rules are established and enforced by an authority figure (parent or teacher), and decision making is guided by self interest (avoidance of negative and receipt of positive consequences). The needs of others are not strongly considered in decision making. As they grow older, most will recognize not only their own needs and desires but also those of others, although personal consequences are still the primary driver of behavior. Social behaviors that are socially undesirable are considered wrong. By age 10 11 years, the combination of peer pres sure, a desire to please authority figures, and an understanding of reciprocity (treat others as you wish to be treated) shapes the childs behavior. Implications for Parents and Pediatricians Children need unconditional support as well as realistic demands as they venture into a world that is often frightening. A daily query from parents over the dinner table or at bedtime about the good and bad things that happened during the childs day may uncover prob lems early. Parents may have difficulty allowing the child indepen dence or may exert excessive pressure on their children to achieve academic or competitive success. Children who struggle to meet such expectations may
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have behavior problems or psychosomatic complaints. Many children face stressors that exceed the normal challenges of separation and success in school and the neighborhood. Approxi mately 50 of all marriages in the United States end in divorce. In addition, domestic violence, parental substance abuse, and other adverse childhood experiences (ACEs) may also impair a childs ability to use home as a secure base for refueling emotional ener gies. In many neighborhoods, random violence makes the normal development of independence extremely dangerous. Older children may join gangs as a means of self protection and a way to attain recognition and to belong to a cohesive group. Children who bully others and those who are victims of bullying should be evaluated, because bullying is associated with mood disorders, family prob lems, and school adjustment problems. Parents should reduce expo sure to hazards where possible. Because of the risk of unintentional firearm injuries to children, parents should be encouraged to ask parents of playmates whether a gun is kept in their home and, if so, how it is secured. Pediatrician visits are infrequent in this period; therefore each visit is an opportunity to assess childrens functioning in all con texts (home, school, neighborhood). Maladaptive behaviors, both internalizing and externalizing, occur when children do not have safe, secure attachments to adults and stress in any of these environ ments overwhelms the childs coping responses, becoming toxic stress. Because of continuous exposure and the strong influence of media (programming and advertisements) on childrens beliefs and attitudes, parents must be alert to exposures from television and internet. Youth 8 12 years of age spend over 6 hrday with a vari ety of media; half have a TV in their bedroom. Parents should be advised to remove the TV from their childrens rooms, limit view ing to 2 hrday, and monitor what programs children watch. Nearly all children have exposure to mobile technology. Some computer screen time may be necessary for schoolwork and virtual learning. However, the widespread use of social media may have detrimen tal effects including risky health behaviors, cyberbullying, targeted advertisements, and low self esteem. The Draw a Person (for ages 3 10 years, with instructions to draw a complete person) and Kinetic Family Drawing (beginning at age 5 years, with instruc tions to draw a picture of everyone in your family doing some thing) are useful office tools to assess a childs functioning. Visit Elsevier eBooks at eBooks.Health.Elsevier.com for Bibliography. Downloaded for mohamed ahmed (dr.mms2020gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright 2024. Elsevier Inc. All rights reserved. 172 Part II u Growth, Development, and Behavior Growth can be considered a vital sign in children, and aberrant growth may be the first sign of an underlying pathologic condition. The most powerful tool in growth assessment is the growth chart (Figs. 24.1, 24.2, 26.1, and 27.1), used in combination with accurate measurements of height, weight, head circumference, and
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calculation of the body mass index (BMI). TECHNIQUES TO MEASURE GROWTH Growth assessment requires accurate and precise measurements. For infants and toddlers age 2 years, weight, length, and head circum ference are obtained. Head circumference is measured with a flexible tape measure starting at the supraorbital ridge around to the occipital prominence in the back of the head, locating the maximal circum ference. Height and weight measures should be performed with the infant naked, and ideally, repeated measures will be performed on the same equipment. Recumbent length is most accurately measured by two examiners (one to position the child). Hair ornaments and hair styles that interfere with measurements and positioning should be removed. The childs head is positioned against an inflexible measuring board in the Frankfurt plane, in which the outer canthi of the eyes are in line with the external auditory meatus and are perpendicular to the long axis of the trunk. Legs should be fully extended, and feet are maintained perpendicular to the plane of the supine infant. For older children (2 years) who can stand unassisted, standing heights should be obtained without shoes, using a stadiometer with the head in the Frankfurt plane, and the back of the head, thoracic spine, but tocks, and heels approximating the vertical axis of one another and the stadiometer. Measurements obtained using alternative means, such as marking examination paper at the foot and head of a supine infant or using a tape measure or wall growth chart with a book or ruler on the head can lead to inaccuracy and render the measurement useless. Measurements for height and weight should be plotted on the age appropriate growth curve. Comparing measurements with previous growth trends, repeating measures that are inconsistent, and plotting results longitudinally are essential for monitoring growth. Calculation of interim linear height velocity, such as centimeters per year (cmyr), allows more precise comparison of growth rate to the norm (Table 27.1). If a child is growing faster or more slowly than expected, measure ment of body proportions, which follow a predictable sequence of changes with development, are useful. The head and trunk are relatively large at birth, with progressive lengthening of the limbs throughout development, particularly during puberty. The upper to lower body segment ratio (UL ratio) provides an assessment of truncal growth relative to limb growth. The lower body segment is defined as the length from the top of the symphysis pubis to the floor, and the upper body segment is the total height minus the lower body segment. The UL ratio equals approximately 1.7 at birth, 1.3 at 3 years, and 1.0 after 7 years. Higher UL ratios are characteristic of short limb dwarfism, as occurs with Turner syndrome or bone disorders, whereas lower ratios suggest hypogonadism or Marfan syndrome. Arm span also provides assessment of proportionality and is mea sured as the distance between the tips of the middle fingers while the patient stands with the back against the wall with arms outstretched horizontally at a 90
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degree angle to the trunk. This span should be close to height, although the proportion changes with age. GROWTH CURVES The American Academy of Pediatrics (AAP) and the U.S. Centers for Disease Control and Prevention (CDC) recommend use of the 2006 World Health Organization (WHO) growth curves for children age 0 24 months and the 2000 CDC growth curves for children age 2 19 years (https:www.cdc.govgrowthcharts). There are five stan dard gender specific charts: (1) weight for age, (2) height (length and stature) for age, (3) head circumference for age, (4) weight for height (length and stature) for infants, and (5) BMI for age (see Fig. 27.1; see also Figs. 24.1, 24.2, and 26.1). Clinicians should confirm that the correct CDC and WHO growth charts are used in electronic medical records to ensure accurate characterization of growth. The WHO curves describe growth differently than the CDC curves (Fig. 27.2). The WHO curves are growth standards that describe how children grow under optimal conditions, whereas the CDC curves are growth references that describe how children grew in a specific time and place. The WHO growth curves are based on longitudinal growth studies in which cohorts of newborns were chosen from six countries (Brazil, Ghana, India, Norway, Oman, United States) using specific inclusion and exclusion criteria; all infants were breastfed for at least 12 months and were predominantly breastfed for the first 4 months of life. They were measured regularly from birth to 23 months during 19972003. In contrast, the CDC curves are based on cross sectional data from different studies during different time points. Growth curves for children age 2 59 months were based on the National Health and Nutrition Examination Survey (NHANES), which included a cross sec tion of the U.S. population. These data were supplemented with addi tional participants in a separate nutrition surveillance study. Several deficiencies of the older charts have been corrected, such as the overrepresentation of bottle fed infants and the reliance on a local dataset for the infant charts. The disjunction between length and height when transitioning from the infant curves to those for older children is improved. Each chart is composed of percentile curves, which indicate the percentage of children at a given age on the x axis whose measured value falls below the corresponding value on the y axis. The 2006 WHO growth curves include values that are 2 standard deviations (SD) above and below median (2nd and 98th percentiles), whereas the 2000 CDC growth curves include 3rd and 97th percentiles. On the WHO weight chart for boys ages 0 24 months (see Fig. 24.2A), the 9 month age line intersects the 25th percentile curve at 8.3 kg, indicating that 25 of 9 month old males in the WHO cohorts weigh less than 8.3 kg (75 weigh more). Similarly, a 9 month old male weighing more than 11 kg is heavier than 98 of his peers. The median or 50th percentile is also termed the standard value, in the sense that the standard
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length for a 7 month old female is 67.3 cm (see Fig. 24.2B). The weight for length charts (see Fig. 24.1) are constructed in an analogous fashion, with length or stature in place of age on the x axis; the median or standard weight for a female measuring 100 cm is 15 kg. Extremes of height or weight can also be expressed in terms of the age for which they would represent the standard or median. For instance, an 18 month old female who is 74.9 cm (2nd percentile) is at the 50th percentile for a 13 month old. Thus the height age is 13 months. Weight age can similarly be expressed. In assessing adolescents, caution must be used in applying cross sectional charts. Growth during adolescence is linked temporally to the onset of puberty, which varies widely. Normal variations in the tim ing of the growth spurt can lead to misdiagnosis of growth abnormali ties. By using cross sectional data based on chronologic age, the charts combine youth who are at different stages of maturation. Data for 12 year old males include both earlier maturing males who are at the peak of their growth spurts and later maturing ones who are still grow ing at their prepubertal rate. The net results are an artificially blunted growth peak, and the appearance that adolescents grow more gradually and for a longer duration than in actuality. When additional insight is necessary, growth charts derived from longitudinal data, such as the height velocity charts of Tanner and colleagues, are recommended. The longitudinal component of these velocity curves is based on British children from the 1950s and 1960s, and cross sectional data from U.S. children were superimposed. Height velocity curves based on longitudinal data from a multiethnic study conducted at five U.S. sites included SD scores for height velocity for Chapter 27 Assessment of Growth Vaneeta Bamba and Andrea Kelly Downloaded for mohamed ahmed (dr.mms2020gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright 2024. Elsevier Inc. All rights reserved. Chapter 27 u Assessment of Growth 173 A Fig. 27.1 A, Body mass index (BMI) percentiles for boys, age 2 20 years. Downloaded for mohamed ahmed (dr.mms2020gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright 2024. Elsevier Inc. All rights reserved. 174 Part II u Growth, Development, and Behavior B Fig. 27.1 Contd B, BMI percentiles for girls, age 2 20 years. Official Centers for Disease Control and Prevention CDC growth charts, as de scribed in this chapter.) The 85th to 95th percentile is at risk for overweight; 95th percentile is overweight; 5th percentile is underweight. Technical information and interpretation and management guides are available at www.cdc.govnchs. Developed by the National Center for Health Statistics in collaboration with the National Center for Chronic Disease Prevention and Health Promotion, 2000 (http:www.cdc.govgrowthcharts). Downloaded for mohamed ahmed (dr.mms2020gmail.com)
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at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright 2024. Elsevier Inc. All rights reserved. Chapter 27 u Assessment of Growth 175 earlier and later maturing adolescents to facilitate the identification of poor or accelerated linear growth. Specialized growth charts have been developed for U.S. children with various conditions, including very low birthweight (VLBW), small for gestational age, trisomy 21, Turner syndrome, and achondro plasia, and should be used when appropriate. Facilitating identification of obesity, the charts include curves for plotting BMI for ages 2 20 years rather than weight for height (see Fig. 27.1). Methodologic steps have ensured that the increase in the preva lence of obesity has not unduly raised the upper limits of normal. BMI can be calculated as weight in kilograms(height in meters)2 or weight in pounds(height in inches)2 703, with fractions of pounds and inches expressed as decimals. Because of variable weight and height gains during childhood, BMI must be interpreted relative to age and sex; the BMI percentile provides a more standardized comparison. For example, a 6 year old girl with a BMI of 19.7 kgm2 (97th percentile) is obese, whereas a 15 year old female with BMI of 19.7 kgm2 (50th percentile) is normal weight. Normal Growth Height is highly correlated with genetics, specifically parental height. Calculation of sex adjusted midparental height is important when assessing growth in a child to avoid misclassification of abnormal growth. The average difference in stature between males and females is 5 inches (13 cm); therefore 5 inches (13 cm) is subtracted from the fathers height before averaging with mothers height in a female, whereas 5 inches (13 cm) is added to the mothers height before averag ing with the fathers height in a male: Males: (Maternal height 5 inches) Paternal height2 Females: Maternal height (Paternal height 5 inches)2 Furthermore, generally 4 inches (2 SD) is applied above and below this value to provide a genetic target height range. For example, if the mother is 63 inches tall and the father 70 inches tall, the daughters sex adjusted midparental height is 64 inches 4 inches, for a target height range of 60 68 inches. The son of these same parents would have a sex adjusted midparental height of 69 inches, with a range of 65 73 inches. Note that these general guidelines do not address extreme differences between parental heights that may affect indi vidual target height range. Growth can be divided into four major phases: fetal, infantile, childhood, and adolescence. Growth rate varies by age (see Table 27.1). Different factors are of different importance in each phase, and the various contributors to poor growth may feature more in one phase than another. Long term height may be permanently compro mised if one entire phase is characterized by poor growth. Therefore early detection and prevention are critical. Fetal growth is the fast est growth phase, with maternal, placental, fetal, and environmental factors playing key
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roles. Birthweight does not necessarily correlate with adult height, although factors that inhibit fetal growth may have long lasting effects, as seen in children with intrauterine growth retardation. Infantile growth is particularly sensitive to nutrition as well as congenital conditions. Genetic height gradually becomes influential; indeed, crossing of percentiles in the first 2 years of life is common as children begin to approach their genetic potential. Childhood growth is often the most steady and predictable. Dur ing this phase the height percentile is fairly consistent in otherwise healthy children. Adolescent growth is associated with a decrease in growth veloc ity before the onset of puberty; this deceleration tends to be more pronounced in males. During pubertal development, sex hormones Table 27.1 Growth Velocity and Other Growth Characteristics by Age INFANCY CHILDHOOD ADOLESCENCE Birth 12 mo: 24 cmyr 12 24 mo: 10 cmyr 24 36 mo: 8 cmyr 6 cmyr Slowly decelerates before pubertal onset Height typically does not cross percentile lines Sigmoid shaped growth Adolescent growth spurt accounts for about 15 of adult height Peak height velocity Girls: 8 cmyr Boys: 10 cmyr 16 14 12 10 8 6 4 2 0 05 611 1217 1823 05 CDC WHO Low length for age Low weight for age High weight for length 611 1217 1823 05 611 1217 1823 Age (mo) P re va le nc e ( ) Fig. 27.2 Comparison of World Health Organization (WHO) and Centers for Disease Control and Prevention (CDC) growth chart prevalence of low length for age, low weight for age, and high weight for length among children age 24 months, United States, 19992004. , 5th percentile on the CDC charts; 2.3rd percentile on the WHO charts. , 95th percentile on the CDC charts; 97.7th percentile on the WHO charts. (Data from the National Health and Nutrition Examination Survey, 19992004; from Grummer Strawn LM, Reinold C, Krebs NF: Centers for Disease Control and Prevention: Use of World Health Organization and CDC growth charts for children ages 0 59 months in the United States, MMWR Recomm Rep 2010;59RR 9:115.) Downloaded for mohamed ahmed (dr.mms2020gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright 2024. Elsevier Inc. All rights reserved. 176 Part II u Growth, Development, and Behavior (testosterone and estrogen) are the primary drivers of growth and enhance growth hormone secretion, thereby facilitating pubertal growth acceleration. Females typically experience growth acceleration during Tanner stage 3 for breast development, whereas this accelera tion occurs during Tanner stage 4 for pubic hair development in males. Males not only achieve greater height velocities than females during puberty, but also grow approximately 2 years longer than females, both of which contribute to the taller average height of adult males com pared with adult females. Abnormal Growth Growth is a dynamic process. A child measured at the 5th percentile for stature may be growing normally, may be failing to grow, or may be recovering from growth failure,
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depending on the trajectory of the growth curve (Fig. 27.3). Growth failure must be distinguished from short stature. Growth failure is defined as achievement of height veloc ity that is less than expected for a childs age and sex (and pubertal development if relevant) or a downward crossing of more than 2 per centile lines for height on the growth chart. Short stature is defined as growing either below expected genetic potential or growing below 2 SD for age and sex. For some children, however, growth param eters 2 SD may be normal, and differentiating appropriately small vs. pathologically small is crucial. Midparental height, ethnicity, and other factors that may be inherent in the childs genetic height poten tial are important considerations in the assessment of growth. For children with particularly tall or short parents, overdiagnosing and underdiagnosing growth disorders are risks if parental heights are not considered. In the setting of familial short stature or tall stature, more specialized charts can help determine whether a child is even shorter or taller than expected for parental heights, to prevent misdiagnosis of growth disorders. For premature infants, overdiagnosis of growth failure can be avoided by using growth charts developed specifically for this popu lation. A cruder method, subtracting the weeks of prematurity from the postnatal age when plotting growth parameters, does not capture the variability in growth velocity that VLBW infants demonstrate. Although VLBW infants may continue to show catch up growth through early school age, most achieve weight catch up during the second year and height catch up by 3 4 years, barring medical compli cations (see Chapter 119). Abnormal growth may be caused by a variety of factors, including congenital conditions, systemic disease, endocrine disorders, nutri tional deficiency (see Chapter 62), psychosocial conditions, constitu tional delay, or familial disorders (Tables 27.2 and 27.3). In congenital pathologic short stature, an infant may or may not be born small, but growth gradually tapers throughout infancy (see Fig. 27.3). Causes include chromosome or genetic abnormalities (Turner syndrome, skeletal dysplasia, trisomy 21; see Chapters 57 and 99), perinatal infec tion, extreme prematurity, and teratogens (phenytoin, alcohol) (see Chapters 117.4 and 146). Linear growth deceleration with or without changes in weight can occur at the onset or as a result of a systemic illness or chronic inflammation. Medications such as high dose glu cocorticoids may also impact growth. Analysis of growth patterns requires consideration of weight status. Poor linear growth in the set ting of decreasing BMI suggests a nutritional or gastrointestinal issue, whereas poor linear growth in the context of good or robust BMI may suggest a hormonal condition (hypothyroidism, growth hormone defi ciency, cortisol excess). Not all decreased growth is abnormal; variations of growth include constitutional growth (and pubertal) delay and familial short stature. In constitutional growth delay, weight and height decrease near the end of infancy, parallel the norm through middle childhood, and accelerate toward the end of adolescence with achievement of normal adult height. In familial short stature, both the
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infantchild and the parent(s) are small; growth runs parallel to and just below the normal curves. Although tall or accelerated growth may be a variation of normal, unexpected increase in growth may also signal an underlying condi tion (see Table 27.3). Typically, obese individuals grow more quickly than their peers because of peripheral aromatization of estrogen and effects on bone maturation. Despite early taller stature, obese children are not ultimately taller than anticipated for genetic height. Early onset of puberty, growth hormone excess, and sex steroid exposure can also lead to accelerated growth. Several of these conditions may ultimately lead to short stature in adulthood. Genetic conditions associated with tall stature and overgrowth include Sotos, Klinefelter, and Marfan syn dromes (see Chapter 598 and 598.1). H ei gh t 1817161514131211109 ?2 ? ?2 ? mean Children (yr) 243 6 9 12 15 18 21 Infants (mo) Postnatal onset pathologic short stature Constitutional growth delay Familial short stature Prenatal onset pathologic short stature Fig. 27.3 Height for age growth curves of the four general causes of proportional short stature: postnatal onset pathologic short stature, consti tutional growth delay, familial short stature, and prenatal onset short stature. (From Mahoney CP: Evaluating the child with short stature, Pediatr Clin North Am 1987;34:825.) Downloaded for mohamed ahmed (dr.mms2020gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright 2024. Elsevier Inc. All rights reserved. Chapter 27 u Assessment of Growth 177 Evaluation of Abnormal Growth Evaluation of abnormal growth should include confirmation that the data are accurate and plotted correctly. Comparisons should be made with previous measurements. If poor or rapid growth or short or tall stature is a concern, a radiograph of the left hand and wrist to show the bone age can provide information about skeletal maturation. Skeletal development represents physiologic rather than chronologic age. Ref erence standards for bone maturation facilitate estimation of bone age (see Table 23.3). A delayed bone age (skeletal age younger than chrono logic age) suggests catch up potential for linear growth. Advanced bone age suggests a rapid maturation of the skeleton that may lead to earlier cessation of growth. Bone age should be interpreted with the guidance of a pediatric endocrinologist. Skeletal age correlates well with stage of pubertal development and may be helpful in predicting adult height in early or late maturing adolescents. In familial short stature the bone age is normal (comparable to chronologic age), whereas constitutional delay, endocrinologic short stature, and undernutrition may be associ ated with delay in bone age comparable to the height age. Laboratory testing is also useful in assessment of growth and may be tailored to suspected etiology based on the patient history and physical examination. Initial assessment includes comprehen sive metabolic panel, complete blood count, sedimentation rate, C reactive protein, thyroid stimulating hormone, thyroxine, celiac panel, and insulin like growth factor (IGF) I and IGF BP3, which are surrogate markers for growth hormone secretion (see
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Chapter 595). A karyotype to exclude Turner syndrome is an essential com ponent of the evaluation of short stature in females and should be performed even in the absence of characteristic physical features (see Chapter 626.1). If there is concern for abnormal timing of puberty contributing to growth pattern, gonadotropins (luteinizing hormone, follicle stimulating hormone), and estradiol or testosterone may also be assessed. A urinalysis can provide additional information about renal function. Evaluation by a pediatric nutritionist for caloric needs assessment may be useful in patients with malnutrition, underweight status, or slow weight gain. Additional testing and referral to special ists should be performed as indicated. OTHER GROWTH CONSIDERATIONS Obesity Obesity affects large numbers of children (see Chapter 65). The CDC defines obesity as BMI 95th percentile for age and sex, and overweight as BMI 85th to 95th percentile for age and sex. Although widely accepted as the best clinical measure of underweight and overweight, BMI may not provide an accurate index of adiposity because it does not differentiate lean tissue and bone from fat. In otherwise healthy individuals, lean body mass is largely represented by BMI at lower percentiles. BMI 8085 largely reflects increased body fat with a nonlinear relationship between BMI and adiposity. In the setting of chronic illness, increased body fat may be present at low BMI, whereas in athletes, high BMI may reflect increased muscle mass. Measure ment of the triceps, subscapular, and suprailiac skinfold thickness have been used to estimate adiposity. Other methods of measuring fat, such as hydrodensitometry, bioelectrical impedance, and total body water measurement, are used in research, but not in clinical evaluation, but whole body dual energy x ray absorptiometry (DXA) is beginning to emerge as a tool for measuring body fat and lean body mass. Dental Development Dental development includes mineralization, eruption, and exfoliation (Table 27.4). Initial mineralization begins as early as the second trimes ter (mean age for central incisors, 14 weeks) and continues through 3 years of age for the primary (deciduous) teeth and 25 years of age for the secondary (permanent) teeth. Mineralization begins at the crown and progresses toward the root. Eruption begins with the central inci sors and progresses laterally. Exfoliation begins at about 6 years of age and continues through 12 years. Eruption of the permanent teeth may follow exfoliation immediately or may lag by 4 5 months. The timing of dental development is poorly correlated with other processes of growth and maturation. Delayed eruption is usually considered when no teeth have erupted by approximately 13 months of age (mean 3 SD). Common causes include congenital or genetic disorders, endo crine disorders (e.g., hypothyroidism, hypoparathyroidism), familial conditions, and (the most common) idiopathic conditions. Individual teeth may fail to erupt because of mechanical blockage (crowding, gum fibrosis). Causes of early exfoliation include hypophosphatasia, histio cytosis X, cyclic neutropenia, leukemia, trauma, and idiopathic factors. Nutritional and metabolic disturbances, prolonged illness, and certain medications (tetracycline) frequently result in discoloration or malfor mations of the dental enamel. A discrete
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line of pitting on the enamel suggests a time limited insult. Visit Elsevier eBooks at eBooks.Health.Elsevier.com for Bibliography. Table 27.3 Common Causes of Increased Growth and Tall Stature Variation of normal Constitutional tall stature Familial tall stature Endocrine conditions Growth hormone excess Precocious puberty (ultimate height may be decreased) Congenital adrenal hyperplasia Obesity Genetic conditions Marfan syndrome Klinefelter syndrome Sotos syndrome Table 27.2 Common Causes of Decreased Growth and Short Stature Variation of normal Familial short stature Constitutional delay Delayed puberty Nutrition and gastrointestinal conditions Malnutrition Celiac disease Inflammatory bowel disease Genetic conditions Turner syndrome Prader Willi syndrome 22q deletion syndrome Trisomy 21 Skeletal dysplasias: achondroplasia, SHOX haploinsufficiency, osteogenesis imperfecta Endocrine conditions Hypothyroidism Growth hormone deficiency Poorly controlled diabetes mellitus Poorly controlled diabetes insipidus Metabolic bone disease: rickets, hypophosphatasia Glucocorticoid excess Psychosocial causes Renal conditions Renal tubular acidosis Nephrotic syndrome Medications Glucocorticoids Inappropriate sex steroid exposure Antiepileptic medications Downloaded for mohamed ahmed (dr.mms2020gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright 2024. Elsevier Inc. All rights reserved. 178 Part II u Growth, Development, and Behavior Table 27.4 Chronology of Human Dentition of Primary (Deciduous) and Secondary (Permanent) Teeth CALCIFICATION AGE AT ERUPTION AGE AT SHEDDING BEGINS AT COMPLETE AT MAXILLARY MANDIBULAR MAXILLARY MANDIBULAR PRIMARY TEETH Central incisors 5th fetal mo 18 24 mo 6 8 mo 5 7 mo 7 8 yr 6 7 yr Lateral incisors 5th fetal mo 18 24 mo 8 11 mo 7 10 mo 8 9 yr 7 8 yr Cuspids (canines) 6th fetal mo 30 36 mo 16 20 mo 16 20 mo 11 12 yr 9 11 yr First molars 5th fetal mo 24 30 mo 10 16 mo 10 16 mo 10 12 yr 10 12 yr Second molars 6th fetal mo 36 mo 20 30 mo 20 30 mo 10 12 yr 11 13 yr SECONDARY TEETH Central incisors 3 4 mo 9 10 yr 7 8 yr 6 7 yr Lateral incisors Max, 10 12 mo 10 11 yr 8 9 yr 7 8 yr Mand, 3 4 mo Cuspids (canines) 4 5 mo 12 15 yr 11 12 yr 9 11 yr First premolars (bicuspids) 18 21 mo 12 13 yr 10 11 yr 10 12 yr Second premolars (bicuspids) 24 30 mo 12 14 yr 10 12 yr 11 13 yr First molars Birth 9 10 yr 6 7 yr 6 7 yr Second molars 30 36 mo 14 16 yr 12 13 yr 12 13 yr Third molars Max, 7 9 yr 18 25 yr 17 22 yr 17 22 yr Mand, 8 10 yr Mand, Mandibular; max, maxillary. Adapted from a chart prepared by P.K. Losch, Harvard School of Dental Medicine, who provided the data for this table. In healthy development, a child will acquire new skills beginning pre natally and extending into at least young adulthood. The roots of this acquisition of skills lie in the development of the nervous
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system, with additional influences from the health status of other organ systems and the physical and social environment in which the development occurs. Development and its milestones are divided into the streams of gross motor, fine motor, language (expressive and receptive), social language, and self help. Behavior can be categorized into observable, spontaneous, and responsive behaviors in the settings of home, school, and community. Although typical development is associated with wide variability in the age of skill acquisition in each of these streams, specific develop mental and behavioral disorders are seen in approximately 1 of 6 chil dren and may affect the health, function, and well being of the child and family for a lifetime. These disorders include relatively less com mon conditions that often cause severe impairments, such as cerebral palsy and autism, and relatively common conditions such as attention deficithyperactivity disorder, speech language disorders, and behav ioral and emotional disorders that affect as many as 25 of children. The more common conditions are generally perceived as less severe, but these too can have major short term and long term impact on the childs health and daily functioning in the home, school, and commu nity and can affect lifelong well being. Because of their high prevalence in children; their impact on health, social, and economic status; and their effect on the child, the home, and the community, these disorders require the attention of the pediatrician throughout childhood. In addi tion, both the child and the family benefit from the early identification and treatment of many of these conditions, including the most severe. It is therefore incumbent on the primary care clinician to conduct regular developmental surveillance and periodic developmental screening at health supervision visits aimed at early identification and treatment. Among the many types of developmental or behavioral conditions, the most common include language problems, affecting at least 10 of children (see Chapter 53); behavior or emotional disorders, affecting up to 25 of children, with 6 considered serious; attention deficithyper activity disorder, affecting 10 of children (Chapter 50); and learning disabilities, affecting up to 10 (Chapters 51 and 52). Less common and more disabling are the intellectual disabilities (12; Chapter 56); autism spectrum disorders (1 in 36 children; Chapter 58); cere bral palsy and related motor impairments (0.3, or 1 in 345 children; Chapter 638.1); hearing impairment, also referred to as deafness, hard of hearing, or hearing loss (0.12; Chapters 55 and 677); and nonre fractive vision impairment (0.8; Chapter 661). DEVELOPMENTAL AND BEHAVIORAL SURVEILLANCE General health surveillance is a critical responsibility of the primary care clinician and is a key component of health supervision visits. Reg ular developmental and behavioral surveillance should be performed at every health supervision visit from infancy through young adult hood. Surveillance of a childs development and behavior includes both obtaining historical information on the child and family and making observations at the office visit (Tables 28.1 and 28.2). Key historical elements include (1) eliciting and attending to the parents or caregivers concerns around
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the childs development or behavior; (2) obtaining a history of the childs developmental skills and behavior at home, with peers, in school, and in the community; and (3) identifying the risks, strengths, and protective factors for development and behavior in the child and family, including the social determi nants of health. During the office visit, the clinician should make and document direct observations of the childs developmental skills and behavioral interactions. Skills in all streams of development should be considered along with observations of related neurologic functioning made on physical examination. With this history and observation, the clinician should create and maintain a longitudinal record of the childs development and behavior for tracking the child across visits. It is often helpful to obtain infor mation from and share information with other professionals involved Chapter 28 Developmental and Behavioral Surveillance and Screening Eliza Gordon Lipkin and Paul H. Lipkin Downloaded for mohamed ahmed (dr.mms2020gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright 2024. Elsevier Inc. All rights reserved. Chapter 28 u Developmental and Behavioral Surveillance and Screening 179 with the child, including childcare professionals, home visitors, teach ers, after school providers, and developmental therapists. This provides a complete picture of the childs development and behavior and allows collaborative tracking of the childs progress. The Developmental and Behavioral Histories Developmental surveillance includes tracking a childs achievement of milestones, which represent key readily recognizable skills that usu ally occur in a predictable sequence and at predictable age ranges dur ing childhood. The developmental skill areas can be divided into gross motor, fine motor, speech and language (expressive and receptive), social language, and self help. Tracking milestones will reveal that most children achieve the milestones in a typical pattern and within typical age ranges. However, the pediatrician or the parent may recog nize concerning patterns of development, such as delay, dissociation, deviation, or regression. Developmental delay occurs when development is occurring in its usual sequence but at a slower rate, with milestones achieved later than the normal range (see Chapter 56). Delay can occur in a single area of development or across several streams and can be expressed as a devel opmental quotient (DQ). The DQ is calculated by dividing the age at which the child is functioning developmentally (developmental age; DA) by chronologic age (CA) and multiplying by 100 (DQ DACA 100). A DQ of 100 indicates that the child is developing at the mean or aver age rate, whereas a DQ below 70 is associated with delays of 2 or more standard deviations from the mean and suggests a significant delay that requires further evaluation. Developmental dissociation indicates delay in a single stream with typical development in other streams. A child with autism may have delays in verbal or social language but normal motor skills. Deviation or deviant development is defined by development occurring out of sequence, as when a child stands before sitting (as in diplegic
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cerebral palsy) or has better expressive vocabulary than receptive understand ing of words (language and autism spectrum disorders). Regression refers to a loss of skills. It may also be identified earlier or more subtly by a slowing or lack of advancement in skills. Although regression is uncommon in most developmental disabilities, regression is described in as many as 25 of children with autism and is also seen in rarer neurologic disorders, such as Rett syndrome and Duchenne muscular dystrophy. Behavioral surveillance is conducted by obtaining a history of a childs behavior and interactions across settings, including home, day care, school, and community, and in situations such as eating, sleeping, and play. In addition, interactions may differ based on who the child is with (parent or guardian, sibling, peers, teachers, strangers). Concerns may include limited engagement or socializing, compliance, tantrums, aggression, destruction, impulsivity, high activity level, decreased auditory or visual attention, and short attention span. Deviations from Table 28.1 Key Components of Developmental and Behavioral Surveillance HISTORY 1. Parental developmental concerns 2. Developmental history a. Streams of developmental milestone achievement i. Gross motor ii. Fine motor iii. Verbal speech and language (1) Expressive (2) Receptive iv. Social language and self help b. Patterns of abnormality i. Delay ii. Dissociation iii. Deviation or deviant development iv. Regression 3. Behavior history a. Interactions i. Familiar settings (e.g., home, school): parents, siblings, other familiar people, peers, other children ii. Interaction in unfamiliar settings (e.g., community): unfamiliar adults and children b. Patterns of abnormality i. Noncompliance, disruption (including tantrums), aggression, impulsivity, increased activity, decreased attention span, decreased social engagement, decreased auditory or visual attention ii. Deviation or atypical behaviors (1) Repetitive play, rituals, perseverative thought or action, self injury 4. Risk factor identification: medical, family, and social history (including social determinants of health) 5. Protective factor identification (also including social determinants) DEVELOPMENTAL OBSERVATION 1. Movement: gross and fine motor skills 2. Verbal communication: expressive speech and language, language understanding 3. Social engagement and response 4. Behavior: spontaneous and responsive with caregiver and with staff 5. Related neurologic function on physical examination Table 28.2 Red Flags in Developmental Screening and Surveillance These indicators suggest that development is significantly delayed or disordered and that the child should be referred to a developmental pediatrician or pediatric neurologist. Any delay in achieving a milestone at the 75th percentile may be considered a red flag and merits further evaluation, vigilant surveillance, or repeat screening. POSITIVE INDICATORS Presence of any of the following: Loss of developmental skills at any age Parental or professional concerns about vision, fixing, or following an object or a confirmed visual impairment at any age (simultaneous referral to pediatric ophthalmology) Hearing loss at any age (simultaneous referral for expert audiologic or ear, nose, and throat assessment) Persistently low muscle tone or floppiness (check creatine kinase) No speech by 15 mo, especially if the child does not try to communicate by other means, such as gestures (simultaneous referral for urgent hearing test) Asymmetry of movements or other features
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suggestive of cerebral palsy, such as increased muscle tone Persistent toe walking Multiple organ involvement Head circumference above the 99.6th centile or below 0.4th centile; also, if circumference has crossed 2 centiles (up or down) on the appropriate chart or is disproportionate to parental head circumference NEGATIVE INDICATORS Activities that the child cannot do: Sit unsupported by 12 mo Walk by 18 mo (check creatine kinase) Walk other than on tiptoes Run by 24 mo Hold object placed in hand by 4 mo (corrected for gestation) Reach for objects by 6 mo (corrected for gestation) Points to show you something interesting by 18 months Adapted from Horridge KA. Assessment and investigation of the child with disordered development. Arch Dis Child Educ Pract Ed. 2011;96:920; Zubler JM, Wiggins LD, Macias MM, et al. Evidenceinformed milestones for developmental surveillance tools. Pediatrics. 2022;149(3):e2021052138. Downloaded for mohamed ahmed (dr.mms2020gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright 2024. Elsevier Inc. All rights reserved. 180 Part II u Growth, Development, and Behavior usual behavior may also occur, including repetitive play, ritualistic behaviors, perseverative thoughts or actions, and self injury. Observation Observations of the childs developmental skills and behavioral inter actions should be made in the examining room, with documentation in the medical record, and combined with the examination of other neurologic functioning, such as muscle tone, reflexes, and posture. Developmental observations may include a childs gross and fine motor movements, both on the floor and on the examination table. Spoken language and response to others communications, as well as interactions and engagement with the parent or guardian, should be noted. If siblings are in the room, the interaction between the child and a sibling may also be informative. Impulsivity, attention prob lems, tantrums, noncompliance, oppositionality, and aggression may be observed along with interactions with the clinician, but one should inquire about whether these behaviors are seen in other settings, given the possible unfamiliarity or discomfort of the child with the health care professional or in healthcare settings. If inquiring about and observing the childs development and behav ior suggests normal or typical patterns of development and behavior, discussions can be held about future milestones and usual behavior management strategies employable at home. If problems or concerns are identified by the parent or clinician, however, formal developmen tal screening, evaluation, or management should be considered, along with early follow up and review. DEVELOPMENTAL AND BEHAVIORAL SCREENING Periodic episodic screening for developmental and behavioral con ditions should be conducted on every child, as done for other health conditions such as anemia, lead poisoning, hearing, and congenital metabolic disorders. Developmental and behavioral screenings are centered on administration of low cost, brief, and standardized tests in the primary care setting. These tests can be implemented by health assistants at age determined visits, with interpretation of the results and referral or treatment initiation by the primary care clinician as indicated. The American Academy of Pediatrics
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provides recommenda tions and guidelines on age specific developmental screening for implementation in the primary care medical home. Developmental screening using a formal, validated, and standardized test is recom mended during health supervision visits at 9, 18, and 30 months. Tests recommended at these ages screen development across all the streams. In addition, an autism screening test is recommended at the 18 and 24 month visits. Tables 28.3 and 28.4 provide recom mended screening tests for general development and for autism. It is also recommended that a child have a screening test administered any time that a parent, guardian, or child health or early childhood professional has concerns identified during developmental sur veillance, or through screening performed at early childhood pro grams. Although routine formal screening before the childs entry into elementary school is not included in current guidelines, the primary care clinician should be vigilant about surveillance regard ing development at the 4 or 5 year old visit and perform formal screening if concerns are identified, because of the potential impact on learning and school services. Each of the screening visits offers special opportunities to identify specific developmental conditions. At the 9 month screening, critical areas of development are vision, hearing, gross motor, fine motor, and receptive language. It is at this age that disabilities may be identified in vision or hearing, as well as cerebral palsy and other neuromotor disor ders. At 18 months, expressive language and social language develop ment are particularly important areas. Conditions identified at this age may include those considered at 9 months, although in milder forms, as well as autism spectrum, language, and intellectual disorders. By the 30 month visit, the childs behavioral interactions become an additional area of focus, with problems emerging tied to attention and disruptive behavior disorders. Although universal screening is not recommended at later ages, developmental surveillance may identify children in need of screening or evaluation for problems in learning, attention, and behavior. Additional screening for behavioral conditions should be considered, although there is currently no recommended consensus on the ages at which behavioral screening should occur. One possibility would be to provide behavioral screening at the 30 month, 4 or 5 year, and 8 year visits to identify problems emerging in the toddler, preschool, and early elementary years. For older children, visits during preadolescent or adolescent ages also offer an opportunity for surveillance and pos sible screening for behavioral and emotional problems meriting pro fessional assistance or intervention. Table 28.5 provides recommended behavior screening tools. Evidence Based Tools Tables 28.3, 28.4, and 28.5 show a range of measures useful for early identification of developmental and behavioral problems. Because well child visits are brief and with broad agendas (health Table 28.3 Standardized Tools for General Developmental Screening SCREENING TEST AGE RANGE ITEMS (NO.) ADMIN TIME (MIN) PUBLICATION INFORMATION Ages Stages Questionnaires 3 (ASQ3)1 2 66 mo 30 10 15 Paul H. Brookes Publishing www.agesandstages.com Parents Evaluation of Developmental Status (PEDS)2 0 8 yr 10 2 10 Ellsworth Vandermeer Press
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877 296 9972 www.pedstest.com Parents Evaluation of Developmental Status: Developmental Milestones (PEDS:DM) Screening Version2 0 8 yr 6 8 items at each age level 4 6 Ellsworth Vandermeer Press 877 296 9972 www.pedstest.com Survey of Well Being of Young Children (SWYC)3 6 Dev: 1 65 mo Autism: 16 35 mo Dev: 10 Autism: 7 Dev: 5 Autism: 5 www.theswyc.org Key reference sources: 1Squires J, Potter L, Bricker D. The ASQ Users Guide, 3rd ed, Baltimore, MD, Paul H. Brookes Publishing, 2009. 2Glascoe FP, Marks KP, Poon JK, et al. (eds). Identifying and addressing developmental behavioral problems: a practical guide for medical and non medical professionals, trainees, researchers and advocates. Nolensville, TN: PEDStest.com, 2013. 3Sheldrick RC, Perrin EC. Evidence based milestones for surveillance of cognitive, language, and motor development. Acad Pediatr. 2013, 13(6):577556. 4Smith N, Sheldrick R, Perrin E. An abbreviated screening instrument for autism spectrum disorders. Infant Ment Health J. 2012;34(2):149155. 5Salisbury LA, Nyce JD, Hannum CD, et al. Sensitivity and specificity of 2 autism screeners among referred children between 16 and 48 months of age. J Dev Behav Pediatr. 2018;39(3):254258. 6Publications and users manual available at www.theswyc.org. Downloaded for mohamed ahmed (dr.mms2020gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright 2024. Elsevier Inc. All rights reserved. Chapter 28 u Developmental and Behavioral Surveillance and Screening 181 surveillance and screening, physical examination, immunization, anticipatory guidance, safety and injury prevention, and develop mental promotion), tools relying on parent completion with office staff administration and scoring are well suited for primary care settings. Such tests may be completed in advance of appointments, either online or in writing, whether at home or while waiting for the pediatric visit to begin. If a test is scored in advance of the visit, the pediatric clinician can enter the room with results in hand for review and discussion, including a description of the childs devel opment and behavior compared with peers, general information on child development and behavior, any areas of concern, refer rals needed, and information to share with the childs daycare, pre school, or other community providers, when applicable. Screening Test Properties Each of the tests provided in Tables 28.3 to 28.5 meets accepted psycho metric test criteria. The test has standardized questions or milestones with norms based on administration to parents of a large sample of children with typical development. These norms allow comparison of an individual childs performance on the test with that of the large sam ple of typically developing children. In addition, the tests demonstrate accepted standards of reliability, or the ability to produce consistent results; predictive validity, or the ability to predict later test perfor mance or development; sensitivity, or accuracy in the identification of delayed development or disability; and specificity, or accuracy in the identification of children who are not delayed. Some of the screening tests are general, evaluating multiple areas of development or behavior (sometimes referred to as broad band). Others are
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domain specific, evaluating one area of development (e.g., language), or disorder spe cific, aimed at identifying a specific developmental disorder (some times referred to as narrow band). BEYOND SURVEILLANCE AND SCREENING Comprehensive Evaluation When a developmental or behavioral concern is identified through surveillance or screening, the primary care clinicians role is to Table 28.5 Standardized Tools for General Behavioral Screening SCREENING TEST AGE RANGE ITEMS (NO.) ADMIN TIME (MIN) PUBLICATION INFORMATION Ages Stages Questionnaire: Social Emotional 2 (ASQ:SE 2) (2015)1,2 2 72 mo 9 age specific forms with 19 33 items 10 Paul H. Brookes Publishing 800 638 3775 www.agesandstages.com Brief Infant Toddler Social Emotional Assessment (BITSEA)3 12 36 mo 42 7 10 Mapi Research Trust https:eprovide.mapi trust.org Pediatric Symptom Checklist17 items (PSC 17b)4 4 16 yr PSC 35 Youth self report: 11 yr 17 5 Massachusetts General Hospital https:www.massgeneral.orgpsychiatry treatments and servicespediatric symptom checklist Strengths and Difficulties Questionnaire (SDQ)5 4 17 yr 3 4 yr old version available Youth self report 11 16 yr 25; 22 for 3 4 yr olds 5 10 www.sdqinfo.org Key reference sources: 1Squires J, Bricker DD, Twombly E. Ages Stages Questionnaires: Social Emotional 2 (ASQ:SE 2): a parent completed, child monitoring system for social emotional behaviors. Baltimore, MD: Paul H. Brookes Publishing, 2016. 2Briggs RD, Stettler EM, Johnson Silver E, et al. Social emotional screening for infants and toddlers in primary care. Pediatrics. 2012;129(2):18. 3Briggs Gowan MJ, Carter AS, McCarthy K, et al. Clinical validity of a brief measure of early childhood socialemotionalbehavioral problems. J Pediatr Psychol. 2013;38(5):557587. 4Murphy JM, Stepanian S, Riobueno Naylor A, et al. Implementation of an electronic approach to psychosocial screening in a network of pediatric practices. Acad Pediatr. 2021;21(4):702709. 5Stone LL, Otten R, Engels RC, et al. Psychometric properties of the parent and teacher versions of the Strengths and Difficulties Questionnaire for 4 to 12 year olds: a review. Clin Child Fam Psychol Rev. 2010;13(3):254274. Table 28.4 Standardized Tools for Language and Autism Screening SCREENING TEST AGE RANGE ITEMS (NO.) ADMIN TIME (MIN) PUBLICATION INFORMATION Communication and Symbolic Behavior Scales: Developmental Profile (CSBS DP): Infant Toddler Checklist1 6 mo 6 years (for language function 6 24 mo) 24 5 10 Paul H. Brookes Publishing 800 638 3775 www.brookespublishing.com Modified Checklist for Autism in Toddlers, Revised with Follow up (M CHAT RF)2 16 48 mo 20 plus follow up interview 5 10 www.mchatscreen.com Screening Tool for Autism in Toddlers and Young Children (STAT)3,4 24 35 mo 12 (avg) 20 30 https:stat.vueinnovations.com Social Communication Questionnaire (SCQ)5,6 4 yr 40 (avg) 5 10 Western Psychological Services www.wpspublish.com Key reference sources: 1Wetherby AM, Prizant BM. Communication and Symbolic Behavior Scales: developmental profile. Baltimore, MD: Paul H. Brookes Publishing, 2002. 2Robins DL, Casagrande K, Barton M, et al. Validation of the Modified Checklist for Autism in Toddlers, Revised with Follow up (M CHAT RF). Pediatrics. 2014;133(1):3745. 3Stone WL, Coonrod EE, Ousley O. Brief report: screening tool for autism in 2 year olds (STAT): development and preliminary data. J Autism Dev Disord. 2000;30:607612 4Stone WL,
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Coonrod EE, Turner LM, Pozdol SL. Psychometric properties of the STAT for early autism screening. J Autism Dev Disord. 2004;34:691701. 5Rutter M, Bailey A, Lord C: The Social Communication Questionnaire (SCQ) Manual. Los Angeles; Western Psychological Services, 2003. 6Corsello C, Hus V, Pickles A, et al. Between a ROC and a hard place: decision making and making decisions about using the SCQ. J Child Psychol Psychiatry. 2007;48(9):932940. Downloaded for mohamed ahmed (dr.mms2020gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright 2024. Elsevier Inc. All rights reserved. 182 Part II u Growth, Development, and Behavior ensure that the child receives an appropriate diagnostic evaluation, related medical testing, and indicated developmental interven tions and medical treatment. When a concern is identified, a full diagnostic evaluation should be performed by a professional with appropriate training and experience. In the case of developmental concerns, this may be a pediatric specialist, such as a neurodevel opmental pediatricianneurologist or a developmental behavioral pediatrician, or a related developmental professional, depending on resources in the local community. Related professionals may include early childhood educators, psychologists, speechlanguage patholo gists, audiologists, physical therapists, and occupational therapists, many of whom are available through the local early intervention system. Such an evaluation would typically include more detailed standardized developmental testing. The primary care physician should ensure that hearing and vision assessments are completed. For the child with motor concerns, the physician should pay par ticular attention to the motor and neurologic evaluation. Children with language delays should have hearing, speech, language, and learning skills (e.g., reading, phonics) evaluated. The primary care clinician should also perform a comprehensive medical evaluation of the child to identify any related health condi tions. Physical examination including head circumference should be reviewed to identify growth abnormalities and dysmorphic features. For the child with motor delay and decreased or normal muscle tone, serum creatine kinase and thyroid function testing are recommended to rule out muscular dystrophy and thyroid dis ease, respectively. When there is increased tone, MRI or referral to a neurologist should be considered. For the child with suspected autism or intellectual disability (or global developmental delay), chromosomal microarray and fragile X testing are recommended (see Chapter 56). Referral and Intervention Children with significant developmental delays or an identified developmental disability are entitled to and usually benefit from early intervention with therapy services directed at delayed or atypical development. The U.S. Individuals with Disabilities Education Act (IDEA) entitles any child with a disability or developmental delay to receive local education and related services, including therapy, from as early as birth, for known or high risk conditions that lead to such delay or disability, through age 21 years. These interventions enhance the childs development through early intervention and fam ily support as well as individualized public education with the goal of improving long term functional outcomes and reducing public costs. The pediatric provider should therefore refer every child with developmental concerns to the
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local early intervention program or agency (ages 0 3 years), public school program ( 3 years), andor local therapy providers. Typical service needs include special educa tion for the child with intellectual or learning concerns, physical or occupational therapy for children with motor delays, speech language therapy for the child with language or social communication difficul ties, and behavioral therapy services for the child with social engage ment or other behavior problems. Likewise, the child with specific behavior concerns should be referred to an appropriate pediatric or behavioral health professional who can perform a thorough evaluation and assist the family to allevi ate the problems or concerns. Such professionals may include those trained in developmental behavioral pediatrics, neurodevelopmen tal disabilities, adolescent medicine, child and adolescent psychiatry, pediatric psychology, psychiatric advanced practice nursing, and social work. Such an evaluation is similar to developmental evaluation in its aim of determining a diagnosis, as well as developing a treatment program that may include psychotherapeutic and medication manage ment. Associated medical or developmental disorders should be con sidered and further evaluated as needed. Ongoing Management Children with developmental or behavioral disorders should be iden tified as children with special healthcare needs in the medical home, with a program of chronic condition management initiated by the clinical program staff, including its medical and nonmedical staff. In doing so, the clinician and family should work together to outline the childs short and long term goals and management plan. This includes a program of regular monitoring and follow up of the childs development and behavior, referrals, treatment, and surveillance for identification and treatment of related medical, developmental, or behavioral comorbidities that may arise. Some children and families may warrant assignment of a case manager or care navigator either within the medical home or in a related local agency. The pediat ric clinician or other medical home staff should participate in care coordination activities as needed and assist the family and other pro fessionals in decision making on medical care, therapies, and educa tional services. The family can be further assisted during the screening and refer ral phases or later with ongoing care by referral to support service programs, such as respite care, parent to parent programs, and advocacy organizations. Some children may qualify for additional state or federal benefit programs, including insurance, supplemen tal security income, and state programs for children with special healthcare needs. Families often seek out information, support, or connection to other families with similarly affected children and find benefit in local or national networks (e.g., Family Voices, Fam ily to Family Health Information centers) and condition specific associations. Implementation The principles and professional guidelines for developmental behavioral surveillance and screening have been solidified to iden tify children with developmental disabilities, including the specific conditions of intellectual disability, autism spectrum disorder, motor disorders, and behavioral emotional problems. Specific algo rithms are included in these guidelines to assist the clinician with implementation. However, primary care clinicians have reported difficulties in putting these into practice, with
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obstacles and barri ers identified and policy changes made to ensure that screening and referral can be implemented. (See Bibliography online for specific guidelines.) Implementation projects have identified key factors for success ful incorporation of developmental surveillance and screening into practice. Successful office based screening requires develop ment of a comprehensive office based system that extends from the childs home to the front office and into the clinic visit, rather than solely centered on the time in the clinic room. This requires utilizing office and medical support staff for scheduling, advance test distribution, and initiation of the surveillance and screening procedures before the health supervision visit. The practice must choose screening tests that are not only valid for screening of the specific condition at the recommended ages, but also appropriate to the population being served (including reading level and language). The tests chosen should be able to be completed by the caregiver in a short time and at low cost. Staff training on billing and coding for these procedures ensures appropriate payment. Practice systems should also be developed for referral and track ing of children who have problems identified through screening. This should include systems for referral to early intervention, community therapy, developmental professionals, and medical consultants. Office representatives or the clinician should establish working relationships with local community programs and resources to assist the child and family. Visit Elsevier eBooks at eBooks.Health.Elsevier.com for Bibliography. Downloaded for mohamed ahmed (dr.mms2020gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright 2024. Elsevier Inc. All rights reserved. Chapter 29 u Child Care 183 Child care impacts the health and development of children and the economic stability of families. For too many young children and their families, affordable high quality child care is not accessible. Pediatri cians have a role in helping children receive safe, enriching care in high quality early childhood education (ECE) settings that allows par ents to be able to work. As an environment in which children learn, grow, and play, child care is a component of the social determinants of health. The major ity of young children regularly spend time in at least one nonparental child care arrangement. Routine exposure to high quality child care provides an opportunity for early education in language, early lit eracy, math, and social skills, as well as for teaching children health promoting behaviors and for identifying early signs of delays or special needs. Inadequate child care supply and poor availability block these opportunities for many children, disproportionately those from low resourced families. Instead, many young children are exposed to a patchwork of child care arrangements that are unstable, unaffordable, and often poorly resourced, adding stress that harms child and family well being. Child care provision is affected by many factors, derived from fam ily demand, child care supply, and childfamily policy. With increasing movement of mothers into the workplace across the globe, the prime reason most families use child
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care is to support employment of both parents. After childbirth, unpaid maternity leave is the typical situa tion among U.S. mothers. The U.S. federal leave program allows for 12 weeks of unpaid job protected leave during pregnancy or after child birth, but only covers approximately 50 of the workforce because companies with 50 employees, with part time employees, and those working in informal labor markets are exempt. Several states and cities have passed paid family leave laws. In part because of the financial burden of an unpaid maternity leave, many mothers return to work, and their children may begin child care in the first few weeks after birth. In a 2000 Family and Medical Leave Act survey, only 10 of respondents reported taking more than 60 days for maternity leave. Approximately 44 of mothers in 20052007 were working by the time their first child was 3 4 months of age, and approx imately 63 of mothers were working by the time their first child was 12 months. Some mothers face work requirements if they are receiving public benefits because of the reforms to welfare passed by the U.S. Congress in 1996. Many mothers feel strong financial motivation or even pressure to work, especially in single parent households, or have strong incentive to work for short and long term financial security. Employment is not the only factor driving child care use; young chil dren of unemployed mothers spend on average 21 hours per week in child care. Many parents want their children to have child care experi ences for the potential benefits that early learning environments can give to their children. Given these realities, child care quality is of great concern, yet the quality of child care and early education environ ments varies widely, and the supply of high quality child care is largely deemed inadequate. The COVID 19 pandemic revealed the fragility of Americas child care system. Relative to adults, young children have been far less likely to suffer severe medical complications from coronavirus infection, and rates of transmission in child care facilities that followed mitiga tion protocols have been low. However, the downstream effects of the pandemic on young children have been acute. Burdensome child care cost and access barriers became exaggerated. Parents of young chil dren report significant concerns about their childrens safety and edu cation during the pandemic and describe significant disruptions and impacts on families well being. Estimates indicate that 1 in every 500 U.S. children have experienced COVID 19 orphanhood or the loss of a caregiving grandparent, further highlighting a crisis in early childhood caregiving. QUALITY, PROVISION, REGULATION, AND ACCESS Child Care Quality High quality child care is characterized by warm, responsive, and stimulating interactions between children and child care providers. These caregivers express positive feelings toward the children; are emo tionally involved, engaged, and aware of the childs needs and sensitive and responsive to their initiations; speak directly with children in a manner that is elaborative and stimulating while being age appropriate; and ask
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questions and encourage childrens ideas and verbalizations. Structural quality features of the setting, including ratio of children to adults, group size, and caregiver education and training, act indirectly on child outcomes by facilitating high quality interactions. It would be highly unlikely, if not impossible, for even the most sensitive and stimulating provider to engage in high quality interactions with each child, if, for example, the provider was the sole caregiver of 10 toddlers. Poor quality child care settings and unsafe environments that do not meet childrens basic physical and emotional needs can result in developmental delays tied to lack of healthy relationships with adults or developmentally inappropriate activities, toxic stress, neglect, or injury or death from fire, building hazards, disease, and inadequate staff over sight. State regulations put a floor on structural quality and basic staff indicators to mitigate risks and safeguard health and safety. Although structural indicators are more easily monitored in licensing, some but not all research suggests only modest relationships of structural indi cators with child outcomes. When it comes to process quality, a body of studies demonstrates small to modest associations with short term child development and some evidence of long term impacts. The early childhood field is focusing increasingly on effective prac tices, evidence based curricula, and programs that are reported to have moderate to large effects on child outcomes. Some specific teacher practices are related to gains in academic and social emotional skills among preschool students. Evidence informed and evaluated ECE curricula with aligned professional development can have substantial impacts on child outcomes across several developmental domains. Primary caregiving, the practice in infant and toddler classrooms of assigning one teacher the primary responsibility for the care of a small group of children and developing relationships with their fami lies, is consistent with research showing that infants who experience stable, consistent, sensitive and responsive care develop more secure attachment relationships and more positive developmental outcomes. Family engagement, in which early educators partner with families to share their unique knowledge of each child to build positive and goal oriented relationships, relates to gains in preschool childrens social and early academic skills and reduced problem behaviors. Integration of Health and Safety Within Quality Practices The American Academy of Pediatrics (AAP), the American Public Health Association, and the National Resource Center for Health and Safety in Child Care and Early Education provide health and safety guidelines in Caring for Our Children (CFOC): National Health and Safety Performance Standards; Guidelines for Early Care and Education Programs, 4th ed. (https:nrckids.orgCFOC; 2019). These national standards represent the best evidence on quality practices and address health and safety as an integrated component of early care and education. The intent is for the guidelines to serve as a resource for states and other entities to improve health and safety standards in licensing and quality rating improvement systems. An additional objective is for the various monitoring agencies and mechanisms to work together to collaboratively safeguard children and minimize or eliminate the duplication and burden
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of complicated and sometimes conflicting procedures and requirements. The current guidelines include sections in 10 areas (Table 29.1). The National Resource Center also provides updated online resources: (1) up to date CFOC Standards Online Database (https:nrckids. orgCFOC and (2) a crosswalk of COVID 19 questions with CFOC Chapter 29 Child Care Laura Stout Sosinsky and Walter S. Gilliam Downloaded for mohamed ahmed (dr.mms2020gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright 2024. Elsevier Inc. All rights reserved. 184 Part II u Growth, Development, and Behavior standards (https:nrckids.orgfilesCFOC.Crosswalk.pdf) to help child care health consultants and providers learn how the CFOC stan dards address provision of safe and healthy early care and education environments during the COVID 19 pandemic. Child Care Settings and Use Public early education programs (such as Head Start and targeted state funded prekindergarten programs) have historically been designed as policy mechanisms to close the school readiness gap among children with fewer resources, whereas child care has been seen as necessary when par ents (usually mothers) work while their children are young. Despite these historical silos, all early care and education settings serve both purposes: they are early learning environments for children and necessary supports for working parents. Quality of care matters for all child care settings, but there are key differences in the structure and provision of care that influence organi zational and business operations, regulatory mandates, and accessibil ity and affordability for families. Child care settings vary widely and fall into four broad categories from the least to the most formal: 1. Relative or friend cares for a child in the relatives or friends home or in the childs home 2. Nonrelative care who comes to the childs home, such as nannies, babysitters, or au pairs 3. Home based child care in which an individual runs a child care business in their own home and cares for a few or several children, often includ ing children of mixed ages, siblings, or the providers own children 4. Center based care, provided in nonresidential facilities for children grouped by age, including preschools, prekindergarten programs, Head Start centers, and child care centers. Child care centers and early education programs are administered by a wide array of businesses and organizations, including for profit providers or companies, religious organizations, public and private schools includ ing early childhood special education programs, nonprofits and other community organizations, cooperatives, employer based child care, and public agencies. Increasingly, publicly funded prekindergarten programs contract with existing community based centers and home based provid ers for program delivery. With a few exceptions (such as faith affiliated child care), center based child care programs must satisfy state licensing laws for safety practices. For other child care options, governmental over sight for health and safety is rarer; many home based child care programs are licensed, whereas many others are unknown to regulatory agencies, and family, friend, and nanny care are almost never regulated. Child care
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licensing and regulation is described in the next section. Approximately 59 of children 5 years and younger and not yet in kindergarten were in at least 1 weekly nonparental child care arrangement, as reported by their parents in the U.S. Census Bureaus 2019 National Household Education Surveys Program. Forty two percent of children less than 1 year of age, 55 of 1 2 year olds, and 74 of 3 5 year olds were in nonparental care. Nearly 60 of those in at least one child care arrangement were in a center based arrangement, 38 were in relative care, and 20 were in non relative care in a private home; children may have been in more than one type of arrangement. Center based arrangements were most common among preschoolers, whereas relative care arrange ments were most common among infants. Child Care Closures The COVID 19 pandemic accelerated a worsening trend of child care closures. In 2012, there were approximately 129,000 center based pro grams serving 6.98 million children from birth through age 5. Between 2014 and 2017, the number of licensed child care programs of all types in the United States decreased to approximately 109,000 centers. The number of listed home based providers (which includes licensed or otherwise regulated providers) decreased by about 25 between 2012 and 2019. In response to COVID 19, by April 2020 new state public health requirements resulted in closing 70 of U.S. child care centers; more than 35 of child care workers became unemployed. Reasons for this include COVID 19 outbreaks and preventative health protocols such as social distancing with limits in group sizes and child:staff ratios. As the pandemic continued, reasons for new or even permanent closures included staffing shortages as well as business models that cannot sup port a programs financial survival at low enrollment rates. However, child masking within the first year of the pandemic was associated with a 1314 reduction in child care closure rates. Licensing, Regulation, Monitoring, and Accreditation State and territory licensing agencies enumerate which providers are subject to licensing to legally operate and monitor those providers compliance with foundational, mandated regulations to protect chil drens safety, health, and well being. Many states and territories also offer systems of child care monitoring that are usually voluntary in nature, such as quality rating and improvement systems (QRIS), and various professional organizations offer voluntary accreditation sys tems to assess whether providers meet higher quality standards, often (but not always) requiring licensure as a prerequisite to participation. Licensing Licensing and regulatory requirements establish the minimum requirements necessary to protect the health and safety of children in Table 29.1 Caring for Our Children Performance Standards: Chapters and Topics 1. Staffing: Child staff ratio, group size, minimum age; background checks (criminal history, sex offender registry, and child abuse and neglect registry checks), qualifications, professional development, training 2. Program Activities for Healthy Development: Developmental activities (general and by age), supervision and discipline, parentguardian relationships, health education 3. Health Promotion and Protection: Health promotion in child care
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(health checks and supervision, physical activity, limiting screen time, safe sleep, oral health); hygiene (diapering, hand hygiene, exposure to bodily fluids); cleaning, sanitizing, and disinfecting; tobacco and drug use; animals; emergency procedures; child abuse and neglect; sun safety and insect repellent; strangulation hazards; management of illness 4. Nutrition and Food Service: General and by age, meal service, seating, and supervision, nutrition learning experiences for children and for parentsguardians, food safety, and more 5. Facilities, Supplies, Equipment, and Environmental Health: Space per child, exits, ventilation, lighting, noise, furnishings, equipment, and more 6. Play AreasPlaygrounds and Transportation: Playground equipment, water play areas, toys 7. Infectious Diseases: Immunizations, respiratory tract infections, enteric (diarrheal) infections and hepatitis A virus, skin and mucous membrane infections, blood borne infections, herpes viruses, interaction with state or local health departments, judicious use of antibiotics 8. Children with Special Healthcare Needs and Disabilities: Inclusion, service plans, coordination and documentation, periodic reevaluation, assessment of facilities for children with special needs, additional standards 9. Administration: Governance, policies, human resources, records 10. Licensing and Community Action: Regulatory policy, licensing agency, facility licensing, health department responsibilities and role, caregiverteacher support, public policy issues and resource development From the American Academy of Pediatrics, American Public Health Association, National Resource Center for Health and Safety in Child Care and Early Education. Caring for Our Children: National Health and Safety Performance Standards; Guidelines for Early Care and Education Programs. 4th ed., Itasca, IL: American Academy of Pediatrics; 2019. (https:nrckids.orgCFOCTOC). Downloaded for mohamed ahmed (dr.mms2020gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright 2024. Elsevier Inc. All rights reserved. Chapter 29 u Child Care 185 child care. Typically, these include basic health and safety standards such as sanitary practices, child and provider vaccinations, access to a healthcare professional, and facilities and equipment hazards and safety, as well as basic structural and caregiver characteristics such as background checks, the ratio of children to staff, group sizes, and minimum caregiver education and training requirements. Most child care centers and preschools and many family child care providers are subject to state licensing and regulation. All states regulate child care centers, as does the District of Columbia, and most states regulate fam ily child care providers. Pediatricians are encouraged to learn about their own states child care licensing rules. Large differences between states mean large differ ences in allowable levels of quality. The most common child:staff ratios are 4:1 for infants, 6:1 for toddlers, and 10:1 for preschoolers. However, some states permit ratios that are 5:1 or 6:1 for infants 9 months of age or younger. State and territory child care licensing regulations are maintained in a searchable National Database of Child Care Licensing Regulations (https:childcareta.acf.hhs.govlicensing) by the National Center on Early Childhood Quality Assurance (NCECQA). The site provides a tool for searching state and territory licensing regulations and agency contact information. Licensing requirements are frequently updated. Unlicensed settings and even licensed providers in states with
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low licensing and regulatory standards may be providing care at quality lev els below professional recommendations. Moreover, various types of programs may be exempt from licensure, such as faith affiliated child care programs, and exemptions are specific to each state; as many as one third of child care centers are legally exempt in some states. Cen ters are often exempted if care is offered by other organizations such as school districts that provide external oversight. The smallest homes (three or four children in care) are often license exempt, encompassing relative, friend, and neighbor caregivers as well as babysitters, nannies, and au pairs. Some of these providers and the families who use them may not even think of themselves as providing child care. The Child Care Development Block Grant (CCDBG) reauthorization in 2014 required states and territories to expand their monitoring of legally exempt providers to protect the health and safety of children receiving subsidized child care. Most states require exempt centers and family child care homes to meet some licensure requirements such as back ground checks and to receive an annual inspection to receive child care subsidy payments. Other Quality Monitoring Systems Several voluntary public and private initiatives require that child care settings meet their own sets of guidelines and regulations in areas considered critical to effective practice and child outcomes to receive either state or federal funding. These diverse initiatives include those that focus on nutrition (the Child and Adult Care Food Program CACFP), inclusion (the Individuals with Disabilities Education Act IDEA), and financial assistance to low income working parents (child care subsidies through the CCDBG). Most states have quality initiatives called QRIS. Publicly funded early education programs, including the federal Head Start and Early Head Start program as well as state and local public prekindergarten have their own program per formance standards. Participating providers benefit in ways that may include technical assistance supports, professional development, and additional funding often tied to the numbers of children served under the program. About 75 of early care and education centers report receiving funds from multiple sources. Providers may also value earning a public facing seal of approval to help families learn about higher quality programs. These programs all monitor eligibility and compliance with program standards. For example, Head Start and most of the state prekindergar ten programs that restrict enrollment to low income families require verification of family eligibility (although some states and cities pre kindergarten programs are universally available to all preschool age children regardless of family income). Other eligibility standards include verification of parental employment for child care subsidies or verification of nutritious food for low income families for receipt of CACFP funds. Other monitoring may cover staffing, meals and snacks, curricula and teaching, and other areas of service delivery. QRIS sys tems work within the infrastructure of the early care and education system to assess, incentivize, and support higher levels of quality. Examples of incentives and supports include tiered subsidy reimburse ment systems in which participating providers who
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achieve levels of quality beyond basic licensing requirements are entitled to higher sub sidy payments, public funding to facilitate accreditation, professional development systems and coaching, and program assessments and technical assistance. Accreditation A smaller portion of providers become accredited by National Asso ciation for the Education of Young Children (NAEYC), National Association for Family Child Care (NAFCC), or other organizations by voluntarily meeting high quality, developmentally appropriate, professionally recommended standards. The accreditation process goes beyond health and safety practices and structural and caregiver characteristics to examine the quality of childcaregiver interactions. Evidence indicates that child care programs that complete voluntary accreditation through NAEYC provide an environment that better facilitates childrens overall development, but few providers are accred ited. This is partly the result of a lack of knowledge, resources, and incentives for providers to improve quality, but it may also be partly because of expenses providers incur in becoming accredited. Child Care Access As one social determinant of health, access to affordable high quality child care that supports child development and meets family needs is critical. Access to child care goes beyond simple supply (numbers of avail able slots) and demand (numbers of young children needing extra familial care). Barriers to access include aspects of affordability, hours of operation, location, transportation, and culturally or linguistically appropriate care. Barriers to access to high quality child care are per vasive among families in which caregivers work irregular, fluctuating, or nontraditional work schedules, families with infants and toddlers, families for whom English is not the primary language spoken at home, and families with children with disabilities or special needs. Two thirds of children 5 years of age and younger have both parents in the workforce or in school or training programs. Nearly 30 of low income mothers of children under 6 years of age work nonstandard hours, but child care supply during nonstandard or irregular hours is extremely limited. Over 30 of parents with children in weekly care report that the arrangement does not cover the hours needed for work very well. Many more report that they are not in the workforce or school, or not working the hours or shifts that they need or want, due to lack of affordable accessible child care. SCREENING AND SUPPORT FOR CHILD DEVELOPMENT AND HEALTH Child Care and Child Behavior Before the COVID 19 pandemic, about 192,000 U.S. young children were being expelled or suspended from child care programs annually for concerns rising from developmentally typical crying and temper tantrums to physical aggression to violations of various zero toler ance policies, such as bringing a water gun to child care. In fact, young children are expelled from child care and preschool programs at a rate more than 3 times that for kindergarten through 12th graders. Young children experiencing any number of adverse childhood events are at significantly increased odds of preschool expulsion, such as exposure to domestic or community violence, family mental illness and substance abuse, poverty, parental divorce, and parental incarceration. These disciplinary exclusions are
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disproportionately applied to young males and to children of color; implicit biases account for at least some of these disproportionalities. These early disciplinary exclusions predict later negative school attitudes, academic failure and grade retention, and later expulsions and suspensions, as well as a 10 fold increase in high school dropout rates and an 8fold increase in later incarceration. Downloaded for mohamed ahmed (dr.mms2020gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright 2024. Elsevier Inc. All rights reserved. 186 Part II u Growth, Development, and Behavior State efforts to reduce early childhood exclusionary discipline include early childhood mental health consultation (ECMHC) models to support child care providers, who are often not well trained in man aging child behavior, as well as build capacity to raise child care quality for all children. ECMHC links a mental health professional with an early education and care provider in an ongoing problem solving and capacity building relationship. ECMHC has been shown to be effec tive in statewide randomized controlled trials, and now exist in sev eral states and cities. Because this is a rapidly evolving area of support, clinicians wishing to provide guidance to parents of young children at risk of early disciplinary exclusion should consider inquiring about the existence of an ECMHC system within their state or locality by contacting their state early childhood department andor statelocal child care resource and referral agency. Local regulations may limit or prohibit the exclusion of children in response to behaviors that may be a symptomatic expression of a diagnosed disability or special education need, providing a potential method for safeguarding a childs ability to receive early care and education, as described in the next section. Children with Special Needs Children with cognitive, physical, or emotional disabilities who require special care and instruction often require particular attention when it comes to their participation in most child care settings. Guiding princi ples of services for children with disabilities advocate supporting chil dren in natural environments, including child care. Furthermore, the Americans with Disabilities Act and Section 504 of the Rehabilitation Act of 1973 prohibit discrimination against children and adults with disabilities by requiring equal access to offered programs and services. Child care can be, and often is, utilized for delivery of support ser vices to children with special needs andor for linking families to ser vices such as early intervention. Furthermore, clinicians can draw on child care providers for important evaluative data regarding a childs well being, as these providers have extensive daily contact with the child and may have broad, professional understanding of normative child development. Child care providers often conduct screenings for developmental milestones and delays using standardized instruments. A child care provider may be the first to identify a childs potential language delay. Child care providers are also necessary and valuable partners in the development and administration of early intervention service plans. However, many child care providers and settings are unprepared
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to identify or administer services for children with special needs. Children with special needs may be eligible for special educational services under IDEA. The purpose of this law is to provide free appro priate public education, regardless of disability or chronic illness, to all eligible children, birth to 21 years of age, in a natural andor least restrictive environment. Eligible children include those with mental, physical, or emotional disabilities who, because of their disability or chronic illness, require special instruction to learn. As a part of these services, a formal plan of intervention is to be developed by the ser vice providers, families, and the childrens healthcare providers. Fed eral funds are available to implement a collaborative early intervention system of services for eligible infants and toddlers between the ages of birth and 3 years and their families. These services include screen ing, assessment, service coordination, and collaborative development of an individualized family service plan (IFSP). The IFSP describes early intervention services for the childs health, therapeutic, and edu cational needs and supports needed by the family. An understanding of the childs routines and real life opportunities and activities, such as eating, playing, interacting with others, and working on developmental skills, is crucial to enhancing a childs ability to achieve the functional goals of the IFSP. Therefore it is critical that child care providers be involved in IFSP development or revision, with parental consent. Child care providers should also become familiar with the childs IFSP and understand the providers role and the resources available to support the family and child care provider. Additionally, IDEA provides sup port for eligible children 3 years of age and older to receive services through the local school district. This includes development of a writ ten individualized education program (IEP), with implementation being the responsibility of the local education agency in either a public or private preschool setting. As with IFSPs, child care providers should become familiar with the preschoolers special needs as identified in the IEP and may become involved, with parental consent, in IEP devel opment and review meetings. In cases where children may have or be at risk of developmental delays, a diagnosis is important for obtaining and coordinating services and further evaluation. To this end, clini cians can partner with child care providers to screen and monitor chil drens behavior and development. Even if a young child is not being provided special educational services, special accommodations may be requested for any child whose access to child care is being adversely impacted by a diagnosable developmental or behavioral disability through Section 504 of the Rehabilitation Act of 1973. Sick Children and Control of Infectious Disease When children are ill, they may be excluded from out of home child care and under state licensure child care programs are required to exclude children with certain conditions. Children in child care are of an age that places them at increased risk for acquiring infectious diseases. Participation in group settings elevates exposure, leading to increased infections,
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especially during the first year of child care expo sure and especially with infants. Children enrolled in such settings have a higher incidence of illness (upper respiratory tract infections, otitis media, diarrhea, hepatitis A infections, skin conditions, and asthma) than those cared for at home, especially in the preschool years; these ill nesses have no long term adverse consequences. Child care providers that follow child care licensure guidelines for handwashing, diapering, and food handling, and manage child illness appropriately, can reduce communicable illnesses. CFOC (2019) and its up to date online supplement and the AAP (Table 29.2) offer guidelines and recommendations regarding the con ditions under which sick children should and should not be excluded from group programs. State laws typically mirror these guidelines but may be stricter in some states. Although exclusion from child care due to mild illness is often unnecessary, their summary of guidelines states that a child should be excluded temporarily from care if the signs or symptoms of the illness does any of the following: u Prevents the child from participating in daycare activities u Results in a level of care that is greater than the staff can provide u Poses a contagion risk of serious diseases to other children and staff For COVID 19 exposure or symptoms or recovery go to https:www.cdc.govcoronavirus2019 nCoVindex.html Health checks should be performed on each child every day. If symp toms develop during child care but do not require exclusion, written or verbal communication after the daycare is appropriate. Emergen cies must be addressed with 911 calls and immediate notification of the family. If nonemergent but requiring exclusion, the parents should be notified to take the child home. Parents should have a backup plan when exclusions occur. Return to child care is usually permissible with out a primary healthcare visit. CFOC also provides guidelines for control of infectious disease out breaks and for exclusion of any child or staff member who is suspected of contributing to transmission of the illness, who is not adequately immunized when there is an outbreak of a vaccine preventable dis ease, or when the circulating pathogen poses an increased risk to the individual. During the first 3 months of the COVID 19 pandemic in the United States, exposure to child care was not associated with an elevated risk of COVID 19 transmission to adult child care providers within the con text of the considerable efforts that were employed to reduce transmis sion. Although enhanced hand hygiene and surface disinfecting were the most common transmission mitigation methods, many child care programs also engaged in daily symptom screening and temperature checks, social distancing efforts, and cohorting (i.e., keeping groups of children separate to help control the speed of transmission). Despite Centers for Disease Control and Prevention (CDC) guidance, mask ing of adults and children were rarely employed; federal guidance and requirements in several states, child care provider COVID 19 vaccina tion rates in June 2021 were only 78.2. COVID 19 modifications and Downloaded for mohamed ahmed
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(dr.mms2020gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright 2024. Elsevier Inc. All rights reserved. C hap ter 2 9 u C hild C are 1 8 7 Table 29.2 Signs and Symptoms for Consideration of Exclusion or Inclusion in Child Care SIGN OR SYMPTOM COMMON CAUSES COMPLAINTS OR WHAT MIGHT BE SEEN NOTIFY HEALTH CONSULTANT NOTIFY PARENT TEMPORARILY EXCLUDE? IF EXCLUDED, READMIT WHEN Cold symptoms Viruses (early stage of many viruses) Adenovirus Coronavirus Enterovirus Influenza virus Parainfluenza virus Respiratory syncytial virus (RSV) Rhinovirus Bacteria Mycoplasma Pertussis Coughing Runny or stuffy nose Scratchy throat Sneezing Fever Watery eyes Not necessary unless epidemics occur (i.e., RSV or vaccine preventable disease like measles or varicella chickenpox) Yes No, unless Fever accompanied by behavior change. Child looks or acts very ill. Child has difficulty breathing. Child has blood red or purple rash not associated with injury. Child meets routine exclusion criteria. Exclusion criteria are resolved. Cough (cough is a body response to something that is irritating tissues in the airway anywhere from the nose to the lungs) Common cold Lower respiratory infection (e.g., pneumonia, bronchiolitis) Croup Asthma Sinus infection Bronchitis Pertussis Noninfectious causes like allergies Dry or wet cough Runny nose (clear, white, or yellow green) Sore throat Throat irritation Hoarse voice, barking cough Coughing fits Not necessary unless the cough is due to a vaccine preventable disease, such as pertussis Yes No, unless Severe cough. Rapid or difficult breathing. Wheezing if not already evaluated and treated. Cyanosis (i.e., blue color of skin or mucous membranes). Pertussis is diagnosed and not yet treated. Fever with behavior change. Child meets routine exclusion criteria. Exclusion criteria are resolved. Diaper rash Irritation by rubbing of diaper material against skin wet with urine or stool Infection with yeast or bacteria Redness Scaling Red bumps Sores Cracking of skin in diaper region Not necessary Yes No, unless Oozing sores that leak body fluids outside the diaper. Child meets routine exclusion criteria. Exclusion criteria are resolved. Diarrhea Usually viral, less commonly bacterial or parasitic Noninfectious causes such as dietary (drinking too much juice), medications, inflammatory bowel disease, or cystic fibrosis Frequent loose or watery stools compared with childs normal pattern. (Note that exclusively breastfed infants normally have frequent unformed and somewhat watery stools or may have several days with no stools.) Abdominal cramps Fever Generally not feeling well Vomiting occasionally present Yes, if one or more cases of bloody diarrhea or two or more children in same group with diarrhea within a week Yes Yes, if Directed by the local health department as part of outbreak management. Stool is not contained in the diaper for diapered children. Diarrhea is causing accidents for toilet trained children. Stool frequency exceeds 2 stools above normal during the time the child is in the program because this may cause too much work for teacherscare givers and make it difficult to maintain good sanitation. Bloodmucus in stool. Black stools.
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No urine output in 8 hours. Jaundice (i.e., yellow skin or eyes). Fever with behavior change. Looks or acts very ill. Child meets routine exclusion criteria. Cleared to return by healthcare provider for all cases of bloody diarrhea and diarrhea caused by Shiga toxin producing Escherichia coli, Shigella, or Salmonella serotype Typhi until negative stool culture requirement has been met. Diapered children have their stool contained by the diaper (even if the stools remain loose) and toilet trained children do not have toileting accidents. Stool frequency is no more than 2 stools above normal during the time the child is in the program, or what has become normal for that child when the child seems otherwise well. Exclusion criteria are resolved. Continued D ow nloaded for m oham ed ahm ed (dr.m m s2020 gm ail.com ) at U niversity of Southern C alifornia from C linicalK ey.com by Elsevier on A pril 20, 2024. For personal use only. N o other uses w ithout perm ission. C opyright 2024. Elsevier Inc. A ll rights reserved. 1 8 8 P art II u G row th, D evelop m ent, and B ehavior Table 29.2 Signs and Symptoms for Consideration of Exclusion or Inclusion in Child Carecontd SIGN OR SYMPTOM COMMON CAUSES COMPLAINTS OR WHAT MIGHT BE SEEN NOTIFY HEALTH CONSULTANT NOTIFY PARENT TEMPORARILY EXCLUDE? IF EXCLUDED, READMIT WHEN Difficult or noisy breathing Common cold Croup Epiglottitis Bronchiolitis Asthma Pneumonia Object stuck in airway Exposed to a known trigger of asthma symptoms (e.g., animal dander, pollen) Common cold: stuffyrunny nose, sore throat, cough, or mild fever Croup: barking cough, hoarseness, fever, possible chest discomfort (symptoms worse at night), or very noisy breathing, especially when breathing in Epiglottitis: gasping noisily for breath with mouth wide open, chin pulled down, high fever, or bluish (cyanotic) nails and skin; drooling, unwilling to lie down Bronchiolitis and asthma: child is working hard to breathe; rapid breathing; space between ribs looks like it is sucked in with each breath (retractions); wheezing; whistling sound with breathing; coldcough; irritable and unwell. Takes longer to breathe out than to breathe in. Pneumonia: deep cough, fever, rapid breathing, or space between ribs looks like it is sucked in with each breath (retractions) Object stuck in airway: symptoms similar to croup (listed previously) Exposed to a known trigger of asthma symptoms: a known trigger and breathing that sounds or looks different from what is normal for that child Not necessary except for epiglottitis Yes Yes, if Fever with behavior change. Child looks or acts very ill. Child has difficulty breathing. Rapid or difficult breathing. Wheezing if not already evaluated and treated. Cyanosis (i.e., blue color of skin or mucous membranes). Cough interferes with activities. Breath sounds can be heard when the child is at rest. Child has blood red or purple rash not associated with injury. Child meets routine exclusion criteria. Exclusion criteria are resolved. Earache Bacteria Often occurs in context of common cold virus Fever Pain or irritability Difficulty
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hearing Blocked ears Drainage Swelling around ear Not necessary Yes No, unless child meets routine exclusion criteria. Exclusion criteria are resolved. D ow nloaded for m oham ed ahm ed (dr.m m s2020 gm ail.com ) at U niversity of Southern C alifornia from C linicalK ey.com by Elsevier on A pril 20, 2024. For personal use only. N o other uses w ithout perm ission. C opyright 2024. Elsevier Inc. A ll rights reserved. C hap ter 2 9 u C hild C are 1 8 9 Eye irritation, pinkeye Bacterial infection of the membrane covering one or both eyes and eyelids (bacterial conjunctivitis) Viral infection of the membrane covering one or both eyes and eyelids (viral conjunctivitis) Allergic irritation of the membrane covering one or both eyes and eyelids (allergic conjunctivitis) Chemical irritation of the membrane covering the eye and eyelid (irritant conjunctivitis) (e.g., swimming in heavily chlorinated water, air pollution, smoke exposure) Bacterial infection: pink color of the whites of eyes and thick yellowgreen discharge. Eyelid may be irritated, swollen, or crusted. Viral infection: pinkishred color of the whites of the eye; irritated, swollen eyelids; watery discharge with or without some crusting around the eyelids; may have associated cold symptoms. Allergic and chemical irritation: red, tearing, itchy, puffy eyelids; runny nose, sneezing; watery stringy discharge with or without some crusting around the eyelids. Yes, if two or more children have red eyes with watery discharge Yes For bacterial conjunctivitis No. Exclusion is no longer required for this condition. Healthcare providers may vary on whether to treat this condition with antibiotic medication. The role of antibiotics in treatment and preventing spread is unclear. Most children with pinkeye get better after 5 or 6 days without antibiotics. For other eye problems No, unless child meets other exclusion criteria. Note: One type of viral conjunctivitis spreads rapidly and requires exclusion. If two or more children in the group have watery red eyes without any known chemical irritant exposure, exclusion may be required and health authorities should be notified to determine whether the situation involves the uncommon epidemic conjunctivitis caused by a specific type of adenovirus. Herpes simplex conjunctivitis (red eyes with blisteringvesicles on eyelid) occurs rarely and would also require exclusion if there is eye watering. For bacterial conjunctivitis, once parent has discussed with healthcare provider. Antibiotics may or may not be prescribed. Exclusion criteria are resolved. Fever Any viral, bacterial, or parasitic infection Vigorous exercise Reaction to medication or vaccine Other noninfectious illnesses (e.g., rheumatoid arthritis, malignancy) Flushing, tired, irritable, decreased activity Notes: Fever alone is not harmful. When a child has an infection, raising the body temperature is part of the bodys normal defense against germs. Rapid elevation of body temperature sometimes triggers a febrile seizure in young children; this usually is outgrown by age 6 yr. The first time a febrile seizure happens, the child requires medical evaluation. These seizures are frightening but are usually brief (less than 15 minutes) and do not cause the child any
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long term harm. Parents should inform their childs healthcare provider every time the child has a seizure, even if the child is known to have febrile seizures. Warning: Do not give aspirin. It has been linked to an increased risk of Reye syndrome (a rare and serious disease affecting the brain and liver). Not necessary Yes No, unless Behavior change or other signs of illness in addition to fever or child meets other routine exclusion criteria. Unable to participate. Care would compromise staffs ability to care for other children. Note: A temperature considered meaningfully elevated above normal, although not necessarily an indication of a significant health problem, for infants and children older than 2 mo is above 101F (38.3C) from any site (axillary, oral, or rectal). Get medical attention when infants younger than 4 mo have unexplained fever. In any infant younger than 2 mo, a temperature above 100.4F (38.0C) is considered meaningfully elevated and requires that the child get medical attention immediately, within an hour if possible. The fever is not harmful; however, the illness causing it may be serious in this age group. Exclusion criteria are resolved. Table 29.2 Signs and Symptoms for Consideration of Exclusion or Inclusion in Child Carecontd SIGN OR SYMPTOM COMMON CAUSES COMPLAINTS OR WHAT MIGHT BE SEEN NOTIFY HEALTH CONSULTANT NOTIFY PARENT TEMPORARILY EXCLUDE? IF EXCLUDED, READMIT WHEN Continued D ow nloaded for m oham ed ahm ed (dr.m m s2020 gm ail.com ) at U niversity of Southern C alifornia from C linicalK ey.com by Elsevier on A pril 20, 2024. For personal use only. N o other uses w ithout perm ission. C opyright 2024. Elsevier Inc. A ll rights reserved. 1 9 0 P art II u G row th, D evelop m ent, and B ehavior Table 29.2 Signs and Symptoms for Consideration of Exclusion or Inclusion in Child Carecontd SIGN OR SYMPTOM COMMON CAUSES COMPLAINTS OR WHAT MIGHT BE SEEN NOTIFY HEALTH CONSULTANT NOTIFY PARENT TEMPORARILY EXCLUDE? IF EXCLUDED, READMIT WHEN Headache Any bacterialviral infection Other noninfectious causes Tired and irritable Can occur with or without other symptoms Not necessary Yes No, unless child meets routine exclusion criteria. Note: Notify healthcare provider in case of sudden, severe headache with vomiting or stiff neck that might signal meningitis. It would be concerning if the back of the neck is painful or the child cannot look at his or her belly button (putting chin to chest)different from soreness in the side of the neck. Exclusion criteria are resolved. Itching Ringworm Chickenpox Pinworm Head lice Scabies Allergic or irritant reaction (e.g., poison ivy) Dry skin or eczema Impetigo Ringworm: itchy ring shaped patches on skin or bald patches on scalp. Chickenpox: blister like spots surrounded by red halos on scalp, face, and body; fever; irritable. Pinworm: anal itching. Head lice: small insects or white egg sheaths that look like grains of sand (nits) in hair. Scabies: severely itchy red bumps on warm areas of body, especially between fingers or toes. Allergic
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or irritant reaction: raised, circular, mobile rash; reddening of the skin; blisters occur with local reactions (poison ivy, contact reaction). Dry skin or eczema: dry areas on body. More often worse on cheeks, in front of elbows, and behind knees. In infants, may be dry areas on face and anywhere on body but not usually in the diaper area. If swollen, red, or oozing, think about infection. Impetigo: areas of crusted yellow, oozing sores. Often around mouth or nasal openings or areas of broken skin (insect bites, scrapes). Yes, for infestations such as lice and scabies; if more than one child in group has impetigo or ringworm; for chickenpox Yes For chickenpox: Yes, until lesions are fully crusted For ringworm, impetigo, scabies, and head lice: Yes, at the end of the day Children should be referred to a healthcare provider at the end of the day for treatment. For pinworm, allergic or irritant reactions like hives, and eczema: No, unless appears infected as a weeping or crusty sore Note: Although exclusion for these conditions is not necessary, families should seek advice from the childs health professional for how to care for these health problems. For any other itching: No, unless the child meets routine exclusion criteria. Exclusion criteria are resolved. On medication or treated as recommended by a healthcare provider if treatment is indicated for the condition. For conditions that require application of antibiotics to lesions or taking antibiotics by mouth, the period of treatment to reduce risk of spread to others is usually 24 hours. For most children with insect infestations or parasites, readmission as soon as the treatment has been given is acceptable. Mouth sores Oral thrush (yeast infection) Herpes or coxsackie virus infection Canker sores Oral thrush: white patches on tongue, gums, and along inner cheeks Herpes or coxsackievirus infection: pain on swallowing; fever; painful, whitered spots in mouth; swollen neck glands; fever blister, cold sore; reddened, swollen, painful lips Canker sores: painful ulcers inside cheeks or on gums Not necessary Yes No, unless Drooling steadily related to mouth sores. Fever with behavior change. Child meets routine exclusion criteria. Exclusion criteria are resolved. D ow nloaded for m oham ed ahm ed (dr.m m s2020 gm ail.com ) at U niversity of Southern C alifornia from C linicalK ey.com by Elsevier on A pril 20, 2024. For personal use only. N o other uses w ithout perm ission. C opyright 2024. Elsevier Inc. A ll rights reserved. C hap ter 2 9 u C hild C are 1 9 1 Rash Many causes Viral: roseola infantum, fifth disease, chickenpox, herpesvirus, molluscum contagiosum, warts, cold sores, shingles (herpes zoster), and others Skin infections and infestations: ringworm (fungus), scabies (parasite), impetigo, abscesses, and cellulitis (bacteria) Scarlet fever (strep infection) Severe bacterial infections: meningococcus, pneumococcus, Staphylococcus (methicillin susceptible S. aureus; methicillin resistant S. aureus), Streptococcus Noninfectious causes: allergy (hives), eczema, contact (irritant) dermatitis, medication related, poison ivy Skin may show similar findings with many different causes. Determining cause of rash
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requires a competent healthcare provider evaluation that takes into account information other than just how rash looks. However, if the child appears well other than the rash, a healthcare provider visit is not necessary. Viral: usually signs of general illness such as runny nose, cough, and fever (except not for warts or molluscum). Some viral rashes have a distinctive appearance. Minor skin infections and infestations: see Itching. More serious skin infections: redness, pain, fever, pus. Severe bacterial infections: rare. These children usually have fever with a rapidly spreading blood red rash and may be very ill. Allergy may be associated with a raised, itchy, pink rash with bumps that can be as small as a pinpoint or large welts known as hives. See also Itching for what might be seen for allergy or contact (irritant) dermatitis or eczema. For outbreaks, such as multiple children with impetigo within a group Yes No, unless Rash with behavior change or fever. Has oozingopen wound. Has bruising not associated with injury. Has joint pain and rash. Rapidly spreading blood red rash. Tender, red area of skin, especially if it is increasing in size or tenderness. Child meets routine exclusion criteria. Diagnosed with a vaccine preventable condition, such as chickenpox. On antibiotic medication for required period (if indicated). Infestations (lice and scabies) and ringworm can be treated at the end of the day with immediate return the following day. Exclusion criteria are resolved. Sore throat (pharyngitis) Viral: common cold viruses that cause upper respiratory infections Strep throat Viral: verbal children will complain of sore throat; younger children may be irritable with decreased appetite and increased drooling (refusal to swallow). Often see symptoms associated with upper respiratory illness, such as runny nose, cough, and congestion. Strep throat: signs of the bodys fight against infection include red tissue with white patches on sides of throat, at back of tongue (tonsil area), and at back wall of throat. Unlike viral pharyngitis, strep throat infections are not accompanied with cough or runny nose in children older than 3 yr. Tonsils may be large, even touching each other. Swollen lymph nodes (sometimes called swollen glands) occur as body fights off the infection. Not necessary Yes No, unless Inability to swallow. Excessive drooling with breathing difficulty. Fever with behavior change. Child meets routine exclusion criteria. Note: Most children with red back of throat or tonsils, pus on tonsils, or swollen lymph nodes have viral infections. If strep is present, 12 hours of antibiotics is required before return to care. However, tests for strep infection are not often necessary for children younger than 3 yr because these children do not develop rheumatic heart disease, which is the primary reason for treatment of strep throat. Able to swallow. On medication at least 12 hours (if strep). Exclusion criteria are resolved. Table 29.2 Signs and Symptoms for Consideration of Exclusion or Inclusion in Child Carecontd SIGN OR SYMPTOM COMMON CAUSES COMPLAINTS OR WHAT MIGHT BE SEEN NOTIFY HEALTH CONSULTANT NOTIFY PARENT TEMPORARILY EXCLUDE? IF
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EXCLUDED, READMIT WHEN Continued D ow nloaded for m oham ed ahm ed (dr.m m s2020 gm ail.com ) at U niversity of Southern C alifornia from C linicalK ey.com by Elsevier on A pril 20, 2024. For personal use only. N o other uses w ithout perm ission. C opyright 2024. Elsevier Inc. A ll rights reserved. 1 9 2 P art II u G row th, D evelop m ent, and B ehavior Stomachache Viral gastroenteritis or strep throat Problems with internal organs of the abdomen such as intestine, colon, liver, bladder Nonspecific, behavioral, and dietary causes If combined with hives, may be associated with a severe allergic reaction Viral gastroenteritis or strep throat: Vomiting and diarrhea or cramping are signs of a viral infection of the stomach or intestine. Strep throat may cause stomachache with sore throat, headache, and possible fever. In children older than 3 yr, if cough or runny nose is present, strep is very unlikely. Problems with internal organs of the abdomen: persistent severe pain in abdomen. Nonspecific stomachache: vague complaints without vomitingdiarrhea or much change in activity. If multiple cases in same group within 1 week Yes No, unless Severe pain causing child to double over or scream. Abdominal pain after injury. Bloodyblack stools. No urine output for 8 hours. Diarrhea (see Diarrhea). Vomiting (see Vomiting). Yellow skineyes. Fever with behavior change. Looks or acts very ill. Child meets routine exclusion criteria. Pain resolves. Able to participate. Exclusion criteria are resolved. Swollen glands (properly called swollen lymph nodes) Normal body defense response to viral or bacterial infection in the area where lymph nodes are located (i.e., in the neck for any upper respiratory infection) Bacterial infection of lymph nodes that is more than the normal response to infection near where the lymph nodes are located Normal lymph node response: swelling at front, sides, and back of the neck and ear; in the armpit or groin; or anywhere else near an area of an infection. Usually, these nodes are less than 1 inch across. Bacterial infection of lymph nodes: swollen, warm lymph nodes with overlying pink skin, tender to the touch, usually located near an area of the body that has been infected. Usually these nodes are larger than 1 inch across. Not necessary Yes No, unless Difficulty breathing or swallowing. Red, tender, warm glands. Fever with behavior change. Child meets routine exclusion criteria. Child is on antibiotics (if indicated). Exclusion criteria are resolved. Vomiting Viral infection of the stomach or intestine (gastroenteritis) Coughing strongly Other viral illness with fever Noninfectious causes: food allergy (vomiting, sometimes with hives), trauma, dietary and medication related, headache Diarrhea, vomiting, or cramping for viral gastroenteritis For outbreak Yes Yes, if Vomited more than 2 times in 24 hours Vomiting and fever Vomiting with hives Vomit that appears greenbloody No urine output in 8 hours Recent history of head injury Looks or acts very ill Child meets routine exclusion criteria. Vomiting ends. Able to participate. Exclusion criteria are resolved.
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From Aronson SS, Shope TR, (eds). Managing Infectious Diseases in Child Care and Schools: a quick reference guide. 4th ed. Elk Grove Village, IL: American Academy of Pediatrics, 2017. Table 29.2 Signs and Symptoms for Consideration of Exclusion or Inclusion in Child Carecontd SIGN OR SYMPTOM COMMON CAUSES COMPLAINTS OR WHAT MIGHT BE SEEN NOTIFY HEALTH CONSULTANT NOTIFY PARENT TEMPORARILY EXCLUDE? IF EXCLUDED, READMIT WHEN D ow nloaded for m oham ed ahm ed (dr.m m s2020 gm ail.com ) at U niversity of Southern C alifornia from C linicalK ey.com by Elsevier on A pril 20, 2024. For personal use only. N o other uses w ithout perm ission. C opyright 2024. Elsevier Inc. A ll rights reserved. Chapter 29 u Child Care 193 considerations are itemized in the Crosswalk (https:nrckids.orgfiles CFOC.Crosswalk.pdf) and include, for example, discussion of daily symptom checks for children as well as daily screening procedures and exclusion criteria for staff. Most families need to arrange to keep sick children at home neces sitating staying home from work or having backup plans with an alter native caregiver. Alternative care arrangements outside the home for sick children are relatively rare but may include either (1) care in the childs own center, if it offers special provisions designed for the care of ill children (sometimes called the infirmary model or sick daycare), or (2) care in a center that serves only children with illness or temporary conditions. Although it is important that such arrangements empha size preventing further spread of disease, one study found no occur rence of additional transmission of communicable disease in children attending a sick center. Protection and Promotion of Child Health Child care has a role in protecting and promoting child health and well being. Child care providers are often the first to notice signs of child abuse and neglect and are a major source of child welfare refer rals. Findings of increased health related issues in the first year of child care are likely a testament to early detection benefits provided by child care providers. Sudden Infant Death Syndrome A disproportionate number of sudden infant death syndrome (SIDS) deaths occur in child care centers or family based child care homes. Infants who are back sleepers at home but are put to sleep on their front in child care settings have a higher risk of SIDS. Providers and parents should be made aware of the importance of placing infants on their backs to sleep. Asthma and Respiratory Illness Children enrolled in prekindergarten may have a greater risk of asthma diagnosis during prekindergarten but a lower risk in the years following prekindergarten, when compared with children who were not exposed to prekindergarten. Enrollment in prekindergarten may increase the early detection of asthma symptoms. A 10 year follow up of a birth cohort has found no association between child care attendance and respiratory infections, asthma, allergic rhinitis, or skin prick test reactivity. Another study found that in the first year of elementary school, children who had
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attended child care had fewer absences from school, half as many episodes of asthma, and less acute respiratory illness than their peers who had never attended child care. These results are perhaps related to protec tion against respiratory illness through early exposure or a shift in the age related peak of illness, although selection of illness prone chil dren into homecare may play a role. Other factors include children in child care potentially being less exposed to passive smoking than children at home. Vision and Hearing Problems Children enrolled in a citywide universal prekindergarten program had higher probability of diagnosis of vision problems, receipt of treat ment for hearing or vision problems, and receiving an immunization. These effects were not offset by lower rates in the kindergarten year, suggesting that identification and treatment of these conditions was accelerated by enrollment in universal prekindergarten. As hearing and vision problems could potentially delay learning and cause behav ioral problems, early detection and treatment is beneficial for future health and school readiness. Obesity and Promotion of Healthy Behaviors There is insufficient research on longitudinal associations between child care, diet, and physical activity behaviors. Some limited research sug gests a negative or mixed association between child care exposure and healthy behaviors, but the strength of these associations, and whether any causal implications exist, are difficult to tease apart. Other research suggests that child care center based interventions are generally found to be effective in improving physical activity and may be effective at improving dietary behaviors. The CDC identifies child care settings as one of the best places to reach young children with obesity prevention efforts. Through their Spectrum of Opportunities framework (https:www.cdc.govobesity strategieschildcareece.html), they outline how a states early care and education system can embed recommended standards and support for obesity prevention, including nutrition, infant feeding, physical activ ity, and screen time. ROLE OF PEDIATRIC PROVIDERS Consultation, Referrals, and Screening to Improve Access Many parents are first time purchasers of child care with little experi ence and very immediate needs; they may select care in a market that does little to provide them with useful information about child care arrangements. To inform their child care decisions, parents may turn to their childs healthcare provider as the only professional with exper tise in child development with whom they have regular and convenient contact. Primary care clinicians should screen for child care just as they do for other social determinants of health, asking about child care arrangements and offering information about resources to help find and pay for child care to reinforce the importance of child care and increase the chances that children are enrolled in high quality settings. It is difficult for many parents to find high quality child care that they can accept and afford. Many parents also worry how their child will fare in child care (e.g., they may worry that their child will feel dis tressed by the group settings, suffer from separation from the parents, or even be subjected to neglect
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or abuse). Practical concerns of trans portation, scheduling to cover their work or school hours, and reliabil ity are also common. The reliability of the arrangement is often rated as a very important selection factor by a higher proportion of parents than any other factor, followed by availability and staff qualifications. Among those who reported difficulty finding child care, cost was most often the primary reason, followed by lack of open slots, quality, then location or other reasons. Worries about finding quality child care are especially likely among parents with greater barriers to child care access and fewer personally accessible family and community resources. With the coronavirus pandemic, parents may be worried about the transmis sion of COVID 19 and about sporadic disruptions in service caused by quarantines or temporary closures, and unfounded fears about the safety of vaccines or facial masks. Primary care practices can share information with parents about publicly available sources of information to help them find or pay for child care (Table 29.3). For example, they can u Refer low income parents to Head Start, which serves 3 4 year old children, or Early Head Start programs, which serves low income expecting families and their children until their childs third birth day u Refer low income working parents to apply for child care subsidies and financial assistance in their state or county u Refer parents to their local child care resource and referral agency for help finding and selecting child care; these can be located via the national association, Child Care Aware of America (www.childcarea ware.orgfamilies) Some parents may think of child care only as babysitting focusing mainly on whether the child is safe and warm and may not fully appreci ate the potential consequences of unenriched care for their childs cogni tive, linguistic, and social development. These parents may be less likely to select a high quality child care arrangement. Healthcare providers can help parents understand the importance for their childs development of selecting high quality care by describing how it looks and providing referrals and tips on how to find and select high quality child care. Fami lies facing socioeconomic challenges accessing highquality care should be referred to available resources listed previously and in Table 29.3. When a healthcare provider talks with a parent about a child care arrangement, it also is important to consider the individual childs health concerns, dispositions, and physiologic responses to the envi ronment. Like all environments, child care is experienced differently Downloaded for mohamed ahmed (dr.mms2020gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright 2024. Elsevier Inc. All rights reserved. 194 Part II u Growth, Development, and Behavior by different children. When an environment lacks adequate support for a childs unique needs, healthy development can be compromised. Some children may be more vulnerable to low quality child care (or particularly responsive to high quality child care), such as children with difficult or fearful temperaments,
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especially if their home environ ments are characterized by more risk factors, such as poverty or high conflict with a parent. Clinicians can help parents determine how to adjust child care arrangements to best meet their childs specific needs (e.g., allergies, eating and sleeping habits, temperament, and stress regulation capacities). Children Who Are Expelled from Child Care A provider may tell a parent that they will not continue to serve a child because of the childs behaviors. Such expulsions are prohibited in some regulated child care settings, such as Head Start and many state funded prekindergarten programs. In addition to complete ter mination of a childs child care arrangement (expulsion), children are sometimes told that they cannot attend for a certain number of days (suspension) or have their hours of care reduced, sent home from care early, or excluded in other ways. Regardless of the form of the exclusion or its stated reason, the result is often extremely stressful for the child and family, and often the child care provider too. Indeed, parents may lose their jobs due to the resulting lack of reliable child care or resort to dangerous alternatives, such as leaving the child unattended or in an unsafe arrangement. Healthcare providers should play an impor tant role during child care expulsions by supporting families efforts to find alternative care, perhaps through a referral to their local child care resource and referral agency, assessing for any potentially contributory underlying developmental or behavioral concerns, and asking parents about the safety of any alternative care arrangements. (See Standard 2.2.0.8 Preventing Expulsions, Suspensions, and Other Limitations in Services of Caring for Our Children, as well as the most recent policy statement on this issue by the AAP.) Supporting Parents Regarding Childrens Health Parents frequently may ask primary care clinicians about sick children, exposure to and prevention of risks in child care, and support for chil dren with special needs in child care. When children are ill, parents should be advised to follow guidelines for inclusion and temporary exclusion (see CFOF, CDC, and state guidelines) (see Table 29.2). Par ents may disagree with child care staff about whether a child meets or does not meet the exclusion criteria, as a substantial amount of work absenteeism is due to a child illness, showing the impact of lost child care on parental employment. However, professional guidelines in CFOC state that if the reason for exclusion relates to the childs abil ity to participate or the caregivers ability to provide care for the other children, the caregiver should not be required to accept responsibility for the care of the child. Primary care clinicians should emphasize that parents of infants ensure that child care providers put infants on their backs to sleep to prevent SIDS and follow vaccination schedules, including COVID 19 vaccination as it is available to children of younger ages. Most states require compliance with scheduled vaccinations for children to par ticipate in licensed group child care settings. As of October 2021, only three
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states (Connecticut, Illinois, New Jersey, and Washington) plus the District of Columbia required child care providers to be vaccinated against COVID 19 andor participate in regular testing. Helping Families of Children with Special Needs Healthcare providers should work with parents and communicate with other service providers and early intervention staff to identify prob lems, remove access barriers, and coordinate service delivery for chil dren with special needs. They should also encourage involvement of parents and child care providers in developing special education plans such as IEPs and IFSPs. Federal law emphasizes the central role of the family in the development of these plans, and the team writing this plan must consist of the parent or legal guardian and other professionals Table 29.3 Child Care Information Resources ORGANIZATION SPONSOR WEBSITE AND CONTACT INFORMATION All Our Kin https:allourkin.org Caring for Our Children: National Resource Center for Health and Safety in Child Care and Early Education (NRC) American Academy of Pediatrics, the American Public Health Association, and the National Resource Center for Health and Safety in Child Care and Early Education Caring for Our Children, National Health and Safety Performance Standards https:nrckid s.orgCFOC Child Care Aware of America http:www.childcareaware.org Healthy Child Care America American Academy of Pediatrics http:www.healthychildcare.org HealthySteps Zero to Three https:www.healthysteps.org National Association for the Education of Young Children (NAEYC) http:www.naeyc.org National Association for Family Child Care https:nafcc.org National Black Child Development Institute https:www.nbcdi.org National Database of Child Care Licensing Regulations National Center on Early Childhood Quality Assurance (NCECQA) funded by the U.S. Department of Health and Human Services, Administration for Children and Families. https:childcareta.acf.hhs.govlicensing National Indian Child Care Association https:www.nicca.us Office of Child Care (OCC) U.S. Department of Health and Human Services, Administration for Children Families http:www.acf.hhs.govprogramsocc Office of Child Care Technical Assistance Network (CCTAN) U.S. Department of Health and Human Services, Administration for Children Families, Office of Child Care https:childcareta.acf.hhs.gov UnidosUS https:www.unidosus.org Zero to Three https:www.zerotothree.org Downloaded for mohamed ahmed (dr.mms2020gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright 2024. Elsevier Inc. All rights reserved. Chapter 30 u Loss, Separation, and Bereavement 195 that may be involved in the provision of these services, including child care providers. Healthcare providers have an important role to play on these IFSP teams and may attend meetings at the request of the family. Many children with developmental or other special needs that would qualify them for early childhood special education services will present with health concerns, making the healthcare professionals an essen tial part of adequate early education planning. Additionally, healthcare professionals may support a childs civil rights to access public services such as preschool when their access or ability to participate fully in the program are at risk of limitation due to a diagnosable disability, health, or mental health condition. Often this may require writing a letter stat ing the nature of the medical condition and the types of accommoda tions that may improve the childs ability
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to participate more fully in the range of activities offered by the program. By supporting a childs civil rights under Section 504 of the Rehabilitation Act of 1973 and the Americans with Disabilities Act of 1990, clinicians can and should play an integral role for safeguarding the rights of their patients. Consulting and Partnering with Child Care Providers Most state regulations mandate that licensed programs have a formal relationship with a healthcare provider. They can provide consultation to child care providers about measures to protect and maintain the health and safety of children and staff. This may include consultation regarding promoting practices to prevent SIDS; preventing and reduc ing the spread of communicable disease; reducing allergen, toxin, and parasite exposure; ensuring vaccinations for children and staff; remov ing environmental hazards; and preventing injuries. In some cases pediatricians have provided ongoing health and mental health consul tation to child care programs, such through highly successful programs like HealthySteps (https:www.healthysteps.org) and Docs for Tots (https:docsfortots.org). Visit Elsevier eBooks at eBooks.Health.Elsevier.com for Bibliography. All children will experience involuntary separations, whether from illness, death, or other causes, from loved ones at some time in their lives. Relatively brief separations of children from their parents usually produce minor transient effects, but more enduring and frequent sepa ration may cause sequelae. The potential impact of each event must be considered in light of the age, stage of development, and experiences of the child; the particular relationship with the absent person; and the nature of the situation. SEPARATION AND LOSS Separations may be from temporary causes, such as vacations, parental job requirements, natural disasters or civil unrest, or parental or sibling illness requiring hospitalization. More long term separations occur as a result of divorce, placement in foster care, or immigration, whereas permanent separation may occur because of death. The initial reac tion of young children to separation of any duration may involve cry ing, such as a tantrum type, protesting type, and a quieter, sadder type. Childrens behavior may appear subdued, withdrawn, fussy, or moody, or they may demonstrate resistance to authority. Specific problems may Chapter 30 Loss, Separation, and Bereavement Megan E. McCabe and Janet R. Serwint include poor appetite, behavior issues such as acting against caregiver requests, reluctance to go to bed, sleep problems, or regressive behav ior, such as requesting a bottle or bed wetting. School age children may experience impaired cognitive functioning and poor performance in school. Some children may repeatedly ask for the absent parent and question when the absent parent will return. The child may go to the window or door or out into the neighborhood to look for the absent parent; a few may even leave home or their place of temporary place ment to search for their parents. Other children may not refer to the parental absence at all. A childs response to reunion may surprise or alarm an unprepared parent. A parent who joyfully returns to the family may be met by wary or cautious children. After a
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brief interchange of affection, children may seem indifferent to the parents return. This response may indicate anger at being left or wariness that the event will happen again, or the young child may feel, as a result of magical thinking (see Chapter 25), as if the child caused the parents departure. For example, if the parent who frequently says Stop it, or youll give me a headache is hospital ized, the child may feel at fault and guilty. Because of these feelings, children may seem more closely attached to the present parent than to the absent one, or even to the grandparent or babysitter who cared for them during their parents absence. Some children, particularly younger ones, may become more clinging and dependent than they were before the separation, while continuing any regressive behavior that occurred during the separation. Such behavior may engage the returned parent more closely and help to reestablish the bond that the child felt was broken. Such reactions are usually transient, and within 1 2 weeks, children will have recovered their usual behavior and equi librium. Recurrent separations may tend to make children wary and guarded about reestablishing the relationship with the repeatedly absent parent, and these traits may affect other personal relationships. Parents should be advised not to try to modify a childs behavior by threatening to leave. DIVORCE More sustained experiences of loss, such as divorce or placement in foster care, can give rise to the same kinds of reactions noted earlier, but they are more intense and possibly more lasting. Currently in the United States, approximately 40 of first marriages end in divorce. Divorce has been found to be associated with negative parent function ing, such as parental depression and feelings of incompetence; nega tive child behavior, such as noncompliance and whining; and negative parentchild interaction, such as inconsistent discipline, decreased communication, and decreased affection. Greater childhood distress is associated with greater parental distress. Continued parental conflict and loss of contact with the noncustodial parent is common. Two of the most important factors that contribute to morbidity of the children in a divorce include parental psychopathology and disrupted parenting before the separation. The year after the divorce is the period when problems are most apparent; these problems tend to dissipate over the next 2 years. Depression may be present up to 5 years later, and educational or occupational decline may occur even 10 years later. It is difficult to sort out all confounding factors. Children may suffer when exposed to parental conflict that continues after divorce and that in some cases may escalate. The degree of interparental conflict may be the most important factor associated with child morbidity. A contin ued relationship with the noncustodial parent when there is minimal interparental conflict is associated with more positive outcomes. School age children may become depressed, may seem indifferent, or may be extremely angry. Other children appear to deny or avoid the issue, behaviorally or verbally. Most children cling to the hope that the actual
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placement or separation is not real and only temporary. The child may experience guilt by feeling that the loss, separation, or place ment represents rejection and perhaps punishment for misbehavior. Children may protect a parent and assume guilt, believing that their own badness caused the parent to depart. Children who feel that their misbehavior caused their parents to separate may have the fantasy that their own trivial or recurrent behavioral patterns caused their parents to become angry at each other. A child might perceive that outwardly Downloaded for mohamed ahmed (dr.mms2020gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright 2024. Elsevier Inc. All rights reserved. 196 Part II u Growth, Development, and Behavior blaming parents is emotionally risky; parents who discover that a child harbors resentment might punish the child further for these thoughts or feelings. Some children have behavioral or psychosomatic symp toms and unwittingly adopt a sick role as a strategy they hope will reunite their parents. In response to divorce of parents and the subsequent separation and loss, older children and adolescents usually show intense anger. Five years after the breakup, approximately 30 of children report intense unhappiness and dissatisfaction with their life and their reconfigured family; another 30 show clear evidence of a satisfactory adjustment; and the remaining children demonstrate a mixed picture, with good achievement in some areas and faltering achievement in others. After 10 years, approximately 45 do well, but 40 may have academic, social, or emotional problems. As adults, some are reluctant to form intimate relationships, fearful of repeating their parents experience. Parental divorce has a moderate long term negative impact on the adult mental health status of children, even after controlling for changes in economic status and problems before divorce. Good adjustment of children after a divorce is related to ongoing involvement with two psy chologically healthy parents who minimize conflict and to the siblings and other relatives who provide a positive support system. Divorcing parents should be encouraged to avoid adversarial processes and to use a trained mediator to resolve disputes if needed. Joint custody arrange ments may reduce ongoing parental conflict, but children in joint cus tody may feel overburdened by the demands of maintaining a strong presence in two homes. When the primary care provider is asked about the effects of divorce, parents should be informed that different children may have different reactions, but that the parents behavior and the way they interact will have a major and long term effect on the childs adjustment. The con tinued presence of both parents in the childs life, with minimal inter parental conflict, is most beneficial to the child. MOVEFAMILY RELOCATION A significant proportion of the U.S. population changes residence each year. The effects of this movement on children and families are frequently overlooked. For children, the move is essentially involun tary and out of their control. When changes in family structure such as divorce or
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death precipitate moves, children face the stresses cre ated by both the precipitating events and the move itself. Parental sad ness surrounding the move may transmit unhappiness to the children. Children who move lose their old friends, the comfort of a familiar bedroom and house, and their ties to school and community. They not only must sever old relationships but also are faced with develop ing new ones in new neighborhoods and new schools. Children may enter neighborhoods with different customs and values, and because academic standards and curricula vary among communities, children who have performed well in one school may find themselves struggling in a new one. Frequent moves during the school years are likely to have adverse consequences on social and academic performance. Migrant children and children who emigrate from other countries present with special circumstances. These children not only need to adjust to a new house, school, and community, but also need to adjust to a new culture and in many cases a new language. Because chil dren have faster language acquisition than adults, they may function as translators for the adults in their families. This powerful position may lead to role reversal and potential conflict within the family. In the evaluation of migrant children and families, it is important to ask about the circumstances of the migration, including legal status, violence or threat of violence, conflict of loyalties, and moral, ethical, and religious differences. Parents should prepare children well in advance of any move and allow them to express any unhappy feelings or misgivings. Parents should acknowledge their own mixed feelings and agree that they will miss their old home while looking forward to a new one. Visits to the new home in advance are often useful preludes to the actual move. Transient periods of regressive behavior may be noted in pre school children after moving, and these should be understood and accepted. Parents should assist the entry of their children into the new community, and whenever possible, exchanges of letters and visits with old friends should be encouraged. SEPARATION BECAUSE OF HOSPITALIZATION Potential challenges for hospitalized children include coping with sepa ration; adapting to the new hospital environment; adjusting to multiple caregivers; seeing very sick children; and sometimes experiencing the disorientation of intensive care, anesthesia, and surgery. To help miti gate potential problems, a preadmission visit to the hospital can help by allowing the child to meet the people who will be offering care and ask questions about what will happen. Parents of children 5 6 years old should room with the child if feasible. Older children may also ben efit from parents or other family members staying with them while in the hospital, depending on the severity of their illness. Creative and active recreational or socialization programs with child life specialists, chances to act out feared procedures in play with dolls or mannequins, and liberal visiting hours, including visits from siblings, are all help ful. Sensitive, sympathetic, and accepting attitudes toward children and parents
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by the hospital staff are very important. Healthcare providers need to remember that parents have the best interest of their children at heart and know their children the best. Whenever possible, school assignments and tutoring for hospitalized children should be available to engage them intellectually and prevent them from falling behind in their scholastic achievements. The psychologic aspects of illness should be evaluated from the out set, and physicians should act as a model for parents and children by showing interest in a childs feelings, allowing them a venue for expres sion, and demonstrating that it is possible and appropriate to com municate about discomfort. Continuity of medical personnel may be reassuring to the child and family. MILITARY FAMILIES More than 2 million children live in military families in the United States, and approximately 50 of them obtain medical care in the com munity rather than at a military medical facility. Children whose par ents are serving in the military may experience loss and separation in multiple ways. These include frequent relocations, relocation to foreign countries, and duty related separation from parents. The most impact ful experiences have been repeated wartime deployments of parents and the death of parents during military service. All branches of the military have increased their focus on preparing and supporting mili tary families for a service members deployment to improve family cop ing. Military families composed of young parents and young children are at risk for child maltreatment in the context of repeated or pro longed deployments. PARENTALSIBLING DEATH Approximately 58 of U.S. children will experience parental death; rates are much higher in parts of the world more directly affected by war, AIDS, and natural disasters. Anticipated deaths from chronic ill ness may place a significant strain on a family, with frequent bouts of illness, hospitalization, disruption of normal home life, absence of the ill parent, and perhaps more responsibilities placed on the child. Addi tional strains include changes in daily routines, financial pressures, and the need to cope with aggressive treatment options. Children can and should continue to be involved with the sick par ent or sibling, but they need to be prepared for what they will see in the home or hospital setting. The stresses that a child will face include visu alizing the physical deterioration of the family member, helplessness, and emotional lability. Forewarning the child that the family member may demonstrate physical changes, such as appearing thinner or los ing hair, will help the child to adjust. These warnings combined with simple yet specific explanations of the need for equipment, such as a nasogastric tube for nutrition, an oxygen mask, or a ventilator, will help lessen the childs fear. Children should be honestly informed of what is happening, in language they can understand, allowing them choices, but with parental involvement in decision making. They should be encouraged, but not forced, to see their ill family member. Parents who are caring for a dying spouse or child may be too emotionally depleted
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Downloaded for mohamed ahmed (dr.mms2020gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright 2024. Elsevier Inc. All rights reserved. Chapter 30 u Loss, Separation, and Bereavement 197 to be able to tend to their healthy childs needs or to continue regular routines. Children of a dying parent may suffer the loss of security and belief in the world as a safe place, and the surviving parent may be inclined to impose his or her own need for support and comfort onto the child. However, the well parent and caring relatives must keep in mind that children need to be allowed to remain children, with appro priate support and attention. Sudden, unexpected deaths lead to more anxiety and fear because there is no time for preparation, and expla nations for the death can cause uncertainty. Examples of this may be death of a parent due to a motor vehicle crash, homicide or suicide, sudden health related issue such as a myocardial infarction or stroke, or from infection such as the recent COVID pandemic. Providing sup port to the child is paramount to allow him or her to express sorrow and grief and to have stability in the childs remaining relationships. GRIEF AND BEREAVEMENT Grief is a personal, emotional state of bereavement or an anticipated response to loss, such as a death. Common reactions include sadness, anger, guilt, fear, and at times, relief. The normality of these reactions needs to be emphasized. Most bereaved families remain socially con nected and expect that life will return to some new, albeit different, sense of normalcy. The pain and suffering imposed by grief should never be automatically deemed normal and thus neglected or ignored. In uncomplicated grief reactions, the steadfast concern of the pediatrician can help promote the familys sense of well being. In more distressing reactions, as seen in traumatic grief of sudden death, the pediatrician may be a major, first line force in helping children and families address their loss. Participation in the care of a child with a life threatening or terminal illness is a profound experience. Parents experience much anxiety and worry during the final stages of their childs life. In one study, 45 of children dying from cancer died in the pediatric intensive care unit, and parents report that 89 of their children suffered a lot or a great deal during the last month of life. Physicians consistently underreport childrens symptoms compared with parents reports. Better ways are needed to provide care for dying children. Providers need to maintain honest and open communication, provide appropriate pain manage ment, and meet the families wishes as to the preferred location of the childs death, in some cases in their own home. Inclusion of multiple disciplines, such as hospice, clergy, nursing, pain service, child life spe cialists, social work, and pet therapy, often helps to support patients and families fully during this difficult experience. The practice of withholding
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information from children and parents regarding a childs diagnosis and prognosis has generally been aban doned, because physicians have learned that protecting parents and patients from the seriousness of their childs condition does not allevi ate concerns and anxieties. Even very young children may have a real understanding of their illness. Children who have serious diseases and are undergoing aggressive treatment and medication regimens, but who are told by their parents that they are okay, are not reassured. These children understand that something serious is happening to them, and they are often forced to suffer in silence and isolation because the mes sage they have been given by their parents is to not discuss it and to maintain a cheerful demeanor. Children have the right to know their diagnosis and should be informed early in their treatment. The content and depth of the discussion needs to be tailored to the childs personal ity and developmental level of understanding. Parents have choices as to how to orchestrate the disclosure. Parents may want to be the ones to inform the child themselves, may choose for the pediatric healthcare provider to do so, or may do it in partnership with the pediatrician. A death, especially the death of a family member, is the most dif ficult loss for a child. Many changes in normal patterns of functioning may occur, including loss of love and support from the deceased family member, a change in income, the possible need to relocate, less emo tional support from surviving family members, altering of routines, and a possible change in status from sibling to only child. Relationships between family members may become strained, and children may blame themselves or other family members for the death of a parent or sibling. Bereaved children may exhibit many of the emotions discussed earlier as a result of the loss, in addition to behaviors of withdrawal into their own world, sleep disturbances, nightmares, and symptoms such as headache, abdominal pains, or possibly symptoms similar to those of the family member who has died. Children 3 5 years of age who have experienced a family bereavement may show regressive behaviors such as bed wetting and thumb sucking. School age children may exhibit nonspecific symptoms, such as headache, abdominal pain, chest pain, fatigue, and lack of energy. Children and adolescents may also dem onstrate enhanced anxiety if these symptoms resemble those of the family member who died. Bereavement may be measured by various published scales (Table 30.1). Behavioral patterns of persistent complex bereavement disorder are noted in Table 30.2. The presence of secure and stable adults who can meet the childs needs and who permit discussion about the loss is most important in helping a child to grieve. The pediatrician should help the fam ily understand this necessary presence and encourage the protective functioning of the family unit (Table 30.3). More frequent visits to the healthcare professional may be necessary to address these symptoms and provide reassurance when appropriate. Suggested availability of clergy or
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mental health providers can provide additional support and strategies to facilitate the transitions after the death. Death, separation, and loss as a result of natural catastrophes and human made disasters have become increasingly common events in chil drens lives. Exposure to such disasters occurs either directly or indirectly, where the event is experienced through the media. Examples of indirect exposure include scenes of earthquakes, hurricanes, tsunamis, tornadoes, and terrorist attacks. Children who experience personal loss in disasters tend to watch more media coverage than children who do not. Children without a personal loss watch as a way of participating in the event and may thus experience repetitive exposure to traumatic scenes and stories. The loss and devastation for a child who personally lives through a disas ter are significant; the effect of the simultaneous occurrence of disaster Table 30.1 Example Items from the Three Grief Measurement Tools Assessed Through Cognitive Interviewing CORE BEREAVEMENT ITEMS (CBI) Do you experience images of the events surrounding your loved ones death? Do thoughts of your loved one make you feel distressed? Do you find yourself pining foryearning for your loved one? Do reminders of your loved one such as photos, situations, music, places, etc., cause you to feel loneliness? Do reminders of your loved one such as photos, situations, music, places, etc. cause you to cry about your loved one? Response options: A lot of the time; Quite a bit of the time; A little bit of the time; Never GRIEF COGNITIONS QUESTIONNAIRE FOR CHILDREN (GCQ C) Since my loved one died, I think of myself as a weak person. I should have seen to it that heshe would not have died. I blame myself for not having cared for himher better than I did. It is not nice toward himher, when I will begin to feel less sad. My life is worthless since heshe died. Response options: Hardly ever; Sometimes; Always INTRUSIVE GRIEF THOUGHTS SCALE (IGTS) (During the past 4 wk) How often did you think about the death of your loved one? How often did you find yourself thinking how unfair it is that your loved one died, even though you didnt want to think about it? How often did you have trouble falling asleep because you were thinking about your loved ones death? How often have you had bad dreams related to your loved ones death? How often did you have trouble doing things you like because you were worrying about how you and your family will get along? Response options: Several times a day; About once a day; Once or twice a week; Less than once a week; Not at all From Taylor TM, Thurman TR, Nogela L. Every time that month comes, I remember: using cognitive interviews to adapt grief measures for use with bereaved adolescents in South Africa. J Child Adolesc Mental Health. 2016;28(2):163174, Table 1, p 166. Downloaded for mohamed ahmed (dr.mms2020gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal
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use only. No other uses without permission. Copyright 2024. Elsevier Inc. All rights reserved. 198 Part II u Growth, Development, and Behavior and personal loss complicates the bereavement process as grief reactions become interwoven with posttraumatic stress symptoms (see Chapter 38). After a death resulting from aggressive or traumatic circumstances, access to expert help may be required. Under conditions of threat and fear, chil dren seek proximity to safe, stable, protective figures. It is important for parents to grieve with their children. Some par ents want to protect their children from their grief, so they put on an outwardly brave front or do not talk about the deceased family member or traumatic event. Instead of the desired protective effect, the child receives the message that demonstrating grief or talking about death is wrong, leading the child to feel isolated, grieve privately, or delay grieving. The child may also conclude that the parents did not really care about the deceased because they seem to have forgotten the person so easily or demonstrate no emotion. The parents efforts to avoid talk ing about the death may cause the parents to isolate themselves from their children at a time when the children most need them. Children need to know that their parents love them and will continue to protect them. Children need opportunities to talk about their relatives death and associated memories. A surviving sibling may feel guilty simply because he or she survived, especially if the death was the result of an accident that involved both children. Siblings grief, especially when compounded by feelings of guilt, may manifest as regressive behavior or anger. Parents should be informed of this possibility and encouraged to discuss it with their children. Table 30.2 Developmental Manifestations of Persistent Complex Bereavement Disorder in Children and Adolescents: Developmental Considerations and Symptom Manifestation in Youth CRITERION A CHILD HAS EXPERIENCED THE DEATH OF A LOVED ONE CRITERION B B1: Expression of persistent yearning or longing for the deceased Children have an evolving understanding of the permanence of death, particularly among young children; behavioral expressions of separation distress from surviving caregivers are common, as are reunification fantasies (i.e., wanting to die to be reunited with the parent in the afterlife) B2: Intense sorrow or emotional pain Children focus on the more salient immediate physical environment rather than their own internal state; young children often have difficulties expressing inner mood; overt expressions of emotional pain might be interspersed within seemingly normal mood, which can lead to others incorrectly assuming they are not grieving B3: Preoccupation with the person who died Children might become distressed when separated from the deceased parents belongings; it is common for youth to seek out physical connections to their parent, including sleeping in the parents bed, or wearing their clothing or jewelry B4: Preoccupation with the circumstances of the death Young children might reenact the death through play, sometimes with alternate (i.e., counterfactual) actions that depict what children feel they or others could have done to prevent
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the death; reenacting might also take the form of drawing disturbing scenes or aspects of the death CRITERION C C3: Difficulties related to positive reminiscing about the deceased Childrens ability to reminisce matures with development and is often facilitated by surviving caregivers C4: Bitterness or anger related to the loss Youth might show overall irritability, oppositional behavior, and problem behavior in the context of bereavement; externalizing behaviors are often precipitated by changes to the youths daily routine that are a result of the parents absence (including others assuming the deceased parents roles) C5: Maladaptive self appraisals in relation to the deceased or the death Youth, particularly adolescents, might become preoccupied by a perceived accountability (e.g., blaming others or oneself for their parents death); in young children, this might manifest as magical thinking that their own thoughts or actions caused their parents to die C6: Excessive avoidance of reminders of the loss Avoidance might not always be under a childs control (e.g., a parent might choose not to bring the child to the gravesite, which prevents the child from confronting that reminder) C7: Desire not to live so that they can be with the deceased Children and adolescents often experience suicidal ideation as a means of reunification fantasies, and their reduced understanding of the complexities of death might exacerbate this mindset among young children; suicidal ideation associated with reunification fantasies might not be accompanied by intent or planning; adolescents might engage in risk taking behaviors (e.g., substance use, reckless driving) C8: Difficulty trusting other people since the death Children might have difficulty establishing relationships with new caregivers, which is often reflective of difficulty with new life circumstances, rather than lack of trust; youth might also display overt anger or oppositional and defiant behaviors toward the surviving or new caregiver C9: Feeling alone or detached from others since the death Youth often report feelings of alienation from other peers who have not experienced a similar loss, particularly when reminders of this difference are salient (e.g., seeing other classmates parents coming to a school event); children and adolescents might conceal their own grief reactions to protect their caregivers from additional distress C10: Feeling that life is meaningless or empty without the deceased or the belief that they cannot function without the deceased Developmental regressions (e.g., regression in toileting or language among young children; loss of study skills or emotion regulation in adolescents) are common, as are disruptions to sleep and appetite patterns; adolescents can show a lack of engagement in preparations for adulthood (e.g., applying to jobs) C11: Confusion about their role in life or a diminished sense of their identity Youth can express sadness over lost opportunities they were planning to experience with their deceased caregiver (e.g., riding a bicycle, walking down the aisle at their wedding); adolescents might show disorganization, lack of direction, or both The letters and numbers refer to the symptom within each diagnostic criterion (e.g., criterion B, 4th symptom). Persistent complex bereavement disorder symptom criteria and descriptions have
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been adapted to the context of parental death. From Kentor RA, Kaplow JB. Supporting children and adolescents following parental bereavement: guidance for health care professionals. Lancet Child Adolesc. 2020;4:889898, p 891. Downloaded for mohamed ahmed (dr.mms2020gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright 2024. Elsevier Inc. All rights reserved. Chapter 30 u Loss, Separation, and Bereavement 199 DEVELOPMENTAL PERSPECTIVE Childrens responses to death reflect the familys current culture, their past heritage, their experiences, and the sociopolitical environment. Personal experience with terminal illness and dying may also facili tate childrens comprehension of death and familiarity with mourning. Developmental differences exist in childrens efforts to make sense of and master the concept and reality of death and profoundly influence their grief reactions. Children younger than 3 years have little or no understanding of the concept of death. Despair, separation anxiety, and detachment may occur at the withdrawal of nurturing caretakers. Young children may respond in reaction to observing distress in others, such as a parent or sibling who is crying, withdrawn, or angry. Young children also express signs and symptoms of grief in their emotional states, such as irritabil ity or lethargy, and in severe cases, mutism. If the reaction is severe, failure to thrive may occur. Preschool children are in the preoperational cognitive stage, in which communication takes place through play and fantasy (see Chapter 25). They do not show well established cause and effect reasoning. They may feel that death is reversible, analogous to someone going away. In attempts to master the finality and perma nence of death, preschoolers frequently ask unrelenting, repeated questions about when the person who died will be returning. This makes it difficult for parents, who may become frustrated because they do not understand why the child keeps asking and do not like the constant reminders of the persons death. The primary care pro vider has a very important role in helping families understand the childs struggle to comprehend death. Preschool children typically express magical explanations of death events, sometimes resulting in guilt and self blame (He died because I wouldnt play with him; She died because I was mad at her). Some children have these thoughts but do not express them verbally because of embarrass ment or guilt. Parents and primary care providers need to be aware of magical thinking and must reassure preschool children that their thoughts had nothing to do with the outcome. Children of this age are often frightened by prolonged, powerful expressions of grief by others. Children conceptualize events in the context of their own experiential reality, and therefore consider death in terms of sleep, separation, and injury. Young children express grief intermittently and show marked affective shifts over brief periods. Younger school age children think concretely, recognize that death is irreversible, but believe it will not happen to them or affect them, and begin to understand biologic processes of the human body (Youll die
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if your body stops working). Information gath ered from the media, peers, and parents forms lasting impressions. Consequently, they may ask candid questions about death that adults will have difficulty addressing (He must have been blown to pieces, huh?). Children approximately 9 years and older do understand that death is irreversible and that it may involve them or their families. These chil dren tend to experience more anxiety, overt symptoms of depression, and somatic complaints than do younger children. School age children are often left with anger focused on the loved one, those who could not save the deceased, or those presumed responsible for the death. Contact with the primary care clinician may provide great reassurance, especially for the child with somatic symptoms, and particularly when the death followed a medical illness. School and learning problems may also occur, often linked to difficulty concentrating or preoccupation with the death. Close collaboration with the childs school may provide important diagnostic information and offer opportunities to mobilize intervention or support. At 12 14 years of age, children begin to use symbolic thinking, reason abstractly, and analyze hypothetical, or what if, scenarios systematically. Death and the end of life become concepts rather than events. Teenagers are often ambivalent about dependence and independence and may withdraw emotionally from surviving family members, only to mourn in isolation. Adolescents begin to understand complex physiologic systems in relationship to death. Because they are often egocentric, they may be more concerned about the impact of the death on themselves than about the deceased or other family members. Fascination with dramatic, sensational, or romantic death sometimes occurs and may find expression in copycat behavior, such as cluster suicides, as well as competitive behavior, to forge emotional links to the deceased person (He was my best friend). Somatic expression of grief may revolve around highly complex syndromes such as eating disorders (see Chapter 41) or conversion reactions (Chapter 35), as well as symptoms lim ited to the more immediate perceptions (stomachaches). Quality of life takes on meaning, and the teenager develops a focus on the future. Depression, resentment, mood swings, rage, and risk taking behaviors can emerge as the adolescent seeks answers to questions of values, safety, evil, and fairness. Alternately, adolescents may seek philosophic or spiritual explanations (being at peace) to ease their sense of loss. The death of a peer may be especially traumatic. Families often struggle with how to inform their children of the death of a family member. The answer depends on the childs devel opmental level. It is best to avoid misleading euphemisms and meta phor. A child who is told that the relative who died went to sleep may become frightened of falling asleep, resulting in sleep problems or nightmares. Children can be told that the person is no longer liv ing or no longer moving or feeling. Using examples of pets that have died sometimes can help children gain a more realistic idea of the meaning of death. Parents who have religious beliefs
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may com fort their children with explanations, such as, Your sisters soul is in heaven, or Grandfather is now with God, provided those beliefs are honestly held. If these are not religious beliefs that the parents share, children will sense the insincerity and experience anxiety rather than Table 30.3 Recommendations for Healthcare Professionals for Helping Children After Bereavement Help children and families recognize that there is no correct way to grieve and that every child grieves differently Help caregivers recognize that child grief is not the same as adult grief, and children express their grief reactions in very different ways Help caregivers understand that the circumstances of the death can play a major role in childrens grief reactions, and deaths by homicide or suicide might be especially difficult for children (therefore could require more intensive mental healthcare) Empower caregivers by explaining they can be instrumental in facilitating adaptive grief in their children by providing empathy, reassurance, and a listening ear, and talking openly about the deceased person with their child Help caregivers to use language accessible to children when talking about the death, meaning that they should use simple and straightforward language that is appropriate for the childs developmental stage, and let the child ask questions as opposed to providing a lot of detailed information Provide accurate information to children about the cause of death; children can become preoccupied with thoughts about contagion (e.g., will I catch cancer too?) or worries about the caregivers level of suffering (e.g., did it hurt when my dad had a stroke? ), and healthcare professionals can help children understand the circumstances of the death and assist in alleviating some of these concerns Never underestimate the importance of simply bearing witness to a childs grief; our society often sends children messages that it is not okay to talk about their own grief, and in allowing them the space to do that, healthcare professionals can help to both normalize and validate their reactions. From Kentor RA, Kaplow JB. Supporting children and adolescents following parental bereavement: guidance for health care professionals. Lancet Child Adolesc. 2020;4:889898, p 896. Downloaded for mohamed ahmed (dr.mms2020gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright 2024. Elsevier Inc. All rights reserved. 200 Part II u Growth, Development, and Behavior the hoped for reassurance. Childrens books about death can provide an important source of information, and when read together, these books may help the parent to find the right words while addressing the childs needs. ROLE OF THE PEDIATRIC HEALTHCARE PROVIDER IN GRIEF The pediatric healthcare provider who has had a longitudinal rela tionship with the family will be an important source of support in the disclosure of bad news and in critical decision making, during both the dying process and the bereavement period (see Table 30.3). The involvement of the healthcare provider may include being pres ent at the time the diagnosis is disclosed, at the hospital
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or home at the time of death, being available to the family by phone during the bereavement period, sending a sympathy card, attending the funeral, and scheduling a follow up visit. Attendance at the funeral sends a strong message that the family and their child are impor tant, respected by the healthcare provider, and can also help the pediatric healthcare provider to grieve and reach personal closure about the death. A family meeting 1 3 months later may be help ful because parents may not be able to formulate their questions at the time of death. This meeting allows the family time to ask questions, share concerns, and review autopsy findings (if one was performed), and allows the healthcare provider to determine how the parents and family are adjusting to the death. Instead of leaving the family feeling abandoned by a healthcare sys tem that they have counted on, this visit allows them to have continued support. This is even more important when the healthcare provider will be continuing to provide care for surviving siblings. The visit can be used to determine how the mourning process is progressing, detect evidence of marital discord, and evaluate how well surviving siblings are coping. This is also an opportunity to evaluate whether referrals to support groups or mental health providers may be of benefit. Continu ing to recognize the child who has died is important. Families appreci ate the receipt of a card on their childs birthday, around holidays, or the anniversary of their childs death. The healthcare provider needs to be an educator about disease, death, and grief. The pediatrician can offer a safe environment for the family to talk about painful emotions, express fears, and share memories. By giving families permission to talk and modeling how to address childrens concerns, the clinician demystifies death. Par ents often request practical help. The healthcare provider can offer families resources, such as literature (both fiction and nonfiction), referrals to therapeutic services, and tools to help them learn about illness, loss, and grief. In this way the physician reinforces the sense that other people understand what they are going through and helps to normalize their distressing emotions. The healthcare provider can also facilitate and demystify the grief process by sharing basic tenets of grief therapy. There is no single right or wrong way to grieve. Everyone grieves differently; mothers may grieve differently than fathers, and children mourn differently than adults. Helping family members to respect these differences and reach out to sup port each other is critical. Grief is not something to get over, but a lifelong process of adapting, readjusting, and reconnecting. Parents may need help in knowing what constitutes normal griev ing. Hearing, seeing, or feeling their childs presence may be a normal response. Vivid memories or dreams may occur. The healthcare pro vider can help parents to learn that, although their pain and sadness may seem intolerable, other parents have survived similar experiences, and their pain will lessen over time. Healthcare providers
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are often asked whether children should attend the funeral of a parent or sibling. These rituals allow the family to begin their mourning process. Children 4 years old should be given a choice. If the child chooses to attend, the child should have a desig nated, trusted adult who is not part of the immediate family and who will stay with the child, offer comfort, and be willing to leave with the child if the experience proves to be overwhelming. If the child chooses not to attend, the child should be offered additional opportunities to share in a ritual, go to the cemetery to view the grave, tell stories about the deceased, or obtain a keepsake object from the deceased family member as a remembrance. In the era of regionalized tertiary care medicine, the primary care provider and medical home staff may not be informed when one of their patients dies in the hospital. Yet, this communication is criti cally important. Families assume their primary care provider has been notified and often feel hurt when they do not receive some symbol of condolence. Because of their longitudinal relationship with the family, primary care providers may offer much needed support. There are practical issues, such as the need to cancel previ ously made appointments and to alert office and nursing staff so that they are prepared should the family return for a follow up visit or for ongoing health maintenance care with the surviving siblings. Even minor illnesses in the surviving siblings may frighten chil dren. Parents may contribute to this anxiety because their inabil ity to protect the child who has died may leave them with a sense of guilt or helplessness. They may seek medical attention sooner or may be hypervigilant in the care of the siblings because of guilt over the other childs death, concern about their judgment, or the need for continued reassurance. A primary care visit can do much to allay their fears. Clinicians must remain vigilant for risk factors in each family mem ber and in the family unit as a whole. Primary care providers, who care for families over time, know bereft patients premorbid functioning and can identify those at current or future risk for physical and psy chiatric morbidity. Providers must focus on symptoms that interfere with a patients normal activities and compromise a childs attainment of developmental tasks. Symptom duration, intensity, and severity, in context with the familys culture, can help identify complicated grief reactions in need of therapeutic attention (see Table 30.2). Descrip tive words such as unrelenting, intense, intrusive, or prolonged should raise concern. Total absence of signs of mourning, specifically an inability to discuss the loss or express sadness, also suggests poten tial problems. No specific sign, symptom, or cluster of behaviors identifies the child or family in need of help. Further assessment is indicated if the following occur: (1) persistent somatic or psychosomatic com plaints of undetermined origin (headache, stomachache, eating and sleeping disorders, conversion symptoms, symptoms related
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to the deceaseds condition, hypochondriasis); (2) unusual circumstances of death or loss (sudden, violent, or traumatic death; inexplicable, unbelievable, or particularly senseless death; prolonged, compli cated illness; unexpected separation); (3) school or work difficulties (declining grades or school performance, social withdrawal, aggres sion); (4) changes in home or family functioning (multiple family stresses, lack of social support, unavailable or ineffective function ing of caretakers, multiple disruptions in routines, lack of safety); and (5) concerning psychologic factors (persistent guilt or blame, desire to die or talk of suicide, severe separation distress, disturb ing hallucinations, self abuse, risk taking behaviors, symptoms of trauma such as hyperarousal or severe flashbacks, grief from previ ous or multiple deaths). Children who are intellectually impaired may require additional support. TREATMENT Suggesting interventions outside the natural support network of fam ily and friends can often prove useful to grieving families. Bereave ment counseling should be readily offered if needed or requested by the family. Interventions that enhance or promote attachments and security, as well as give the family a means of expressing and under standing death, help to reduce the likelihood of future or prolonged disturbance, especially in children. Collaboration between pediatric and mental health professionals can help determine the timing and appropriateness of services. Interventions for children and families who are struggling to cope with a loss in the community include gestures such as sending a card or offering food to the relatives of the deceased and teaching children the etiquette of behaviors and rituals around bereavement and mutual support. Performing community service or joining Downloaded for mohamed ahmed (dr.mms2020gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright 2024. Elsevier Inc. All rights reserved. Chapter 31 u Sleep Medicine 201 charitable organizations, such as fund raising in memory of the deceased, may be useful. In the wake of a disaster, parents and older siblings can give blood or volunteer in search and recovery efforts. When a loss does not involve an actual death (e.g., parental divorce, geographic relocation), empowering the child to join or start a divorced kids club in school or planning a new kids in town party may help. Participating in a constructive activity moves the family away from a sense of helplessness and hopelessness and helps them find meaning in their loss. Psychotherapeutic services may benefit the entire family or individual members. Many support or self help groups focus on specific types of losses (sudden infant death syndrome, suicide, widowwidowers, AIDS) and provide an opportunity to talk with other people who have experienced similar losses. Family, couple, sibling, or individual counseling may be useful, depending on the nature of the residual coping issues. Combinations of approaches may work well for children or parents with evolving needs. A child may participate in family therapy to deal with the loss of a sibling and use individual treatment to address issues of personal ambiva lence and guilt related to the death.
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The question of pharmacologic intervention for grief reactions often arises. Explaining that medication does not cure grief and often does not reduce the intensity of some symptoms (separation distress) can help. Although medication can blunt reactions, the psy chologic work of grieving still must occur. The physician must con sider the patients premorbid psychiatric vulnerability, current level of functioning, other available supports, and the use of additional therapeutic interventions. Medication as a first line of defense rarely proves useful in normal or uncomplicated grief reactions. In certain situations (severe sleep disruption, incapacitating anxiety, intense hyperarousal), an anxiolytic or antidepressant may help to achieve symptom relief and provide the patient with the emotional energy to mourn. Medication used in conjunction with some form of psy chotherapy, and in consultation with a psychopharmacologist, has optimal results. Children who are refugees and may have experienced war, vio lence, or personal torture, while often resilient, may experience post traumatic stress disorder if exposures were severe or repeated (see Chapters 15.3 and 38). Sequelae such as depression, anxiety, and grief need to be addressed, and mental health therapy is indicated. Cognitive behavioral therapy, use of journaling and narratives to bear witness to the experiences, and use of translators may be essential. SPIRITUAL ISSUES Responding to patients and families spiritual beliefs can help in comforting them during family tragedies. Offering to call mem bers of pastoral care teams or their own spiritual leader can pro vide needed support and can aid in decision making. Families have found it important to have their beliefs and their need for hope acknowledged in end of life care. The majority of patients report welcoming discussions on spirituality, which may help individual patients cope with illness, disease, dying, and death. In addressing spirituality, physicians need to follow certain guidelines, including maintaining respect for the patients beliefs, following the patients lead in exploring how spirituality affects the patients decision making, acknowledging the limits of their own expertise and role in spirituality, and maintaining their own integrity by not saying or doing anything that violates their own spiritual or religious views. Healthcare providers should not impose their own religious or non religious beliefs on patients, but rather should listen respectfully to their patients. By responding to spiritual needs, clinicians may bet ter aid their patients and families in end of life care and bereave ment and take on the role of healers. Visit Elsevier eBooks at eBooks.Health.Elsevier.com for Bibliography. BASICS OF SLEEP AND CHRONOBIOLOGY Sleep and wakefulness are a highly complex and intricately regulated neurobiologic system that both influences and is influenced by all phys iologic systems in the body, as well as by the environment and socio cultural practices. The concept of sleep regulation is based on what is usually referred to as the two process model because it requires the simultaneous operation of two basic, highly coupled processes that govern sleep and wakefulness. The homeostatic process (Process S), regulates the length and depth of sleep and is thought to be related
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to the accumulation of adenosine and other sleep promoting chemicals (somnogens), such as cytokines, during prolonged periods of wake fulness. This sleep pressure appears to build more quickly in infants and young children, thus limiting the duration that wakefulness can be sustained during the day and necessitating periods of daytime sleep (i.e., naps). The endogenous circadian rhythms (Process C) influ ence the internal organization of sleep and the timing and duration of daily sleepwake cycles and govern predictable patterns of alertness throughout the 24 hour day. The master circadian clock or circadian pacemaker that controls sleepwake patterns, of which melatonin secretion is the principal bio marker, is located in the suprachiasmatic nucleus in the anterior hypo thalamus. In addition, circadian clocks are present in virtually every cell in the body, which in turn govern the timing of multiple other physiologic systems (e.g., cardiovascular reactivity, hormone levels, renal and pulmonary functions). Because the human circadian clock is slightly longer than 24 hours, intrinsic circadian rhythms must be synchronized or entrained to the 24 hour day cycle by environmental cues called zeitgebers. The dark light cycle is the most powerful of the zeitgebers; light signals are transmitted to the suprachiasmatic nucleus via the circadian photoreceptor system within the retina (functionally and anatomically separate from the visual system), which switch the pineal glands production of the hormone melatonin off (light) or on (dark). Circadian rhythms are also synchronized by other external time cues, such as timing of meals and clock time. Sleep propensity, the relative level of sleepiness or alertness experi enced at any given time during a 24 hour period, is partially determined by the homeostatic sleep drive, which in turn depends on the duration and quality of previous sleep and the amount of time awake since the last sleep period. Interacting with this sleep homeostat is the 24 hour cyclic pattern or rhythm characterized by clock dependent periods of maximum sleepiness and maximum alertness. There are two periods of maximum sleepiness, one in the late afternoon (approximately 3:00 5:00 pm) and one toward the end of the night (around 3:00 5:00 am), and two periods of maximum alertness, one in mid morning and one in the evening just before the onset of natural sleep, the so called for bidden zone or second wind phenomenon, which allows for the main tenance of wakefulness in the face of an accumulated sleep drive. There are significant health, safety, and performance consequences of failure to meet basic sleep needs, termed insufficientinadequate sleep or sleep loss. Sufficient sleep is a biologic imperative, necessary for optimal brain and body functioning. Slow wave sleep (SWS) (i.e., N3, delta, or deep sleep) appears to be the most restorative form of sleep; it is entered relatively quickly after sleep onset, is preserved in the face of reduced total sleep time and increases (rebounds) after a night of restricted sleep. These restorative properties of sleep may be linked to the glymphatic system, which increases clearance of metabolic waste Chapter 31 Sleep
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Medicine Judith A. Owens and Seyni Gueye Ndiaye Downloaded for mohamed ahmed (dr.mms2020gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright 2024. Elsevier Inc. All rights reserved. 202 Part II u Growth, Development, and Behavior products, including amyloid, produced by neural activity in the awake brain. Rapid eye movement (REM) sleep (stage R or dream sleep) appears to be involved in numerous important brain processes, including completion of vital cognitive functions (e.g., consolidation of memory), promoting the plasticity of the central nervous system (CNS), and protecting the brain from injury. Sufficient amounts of these sleep stages are necessary for optimal cognitive functioning and emotional and behavioral self regulation. Partial sleep loss (i.e., sleep restriction) on a chronic basis accumu lates in a sleep debt and over several days produces deficits equivalent to those seen under conditions of one night of total sleep deprivation. If the sleep debt becomes large enough and is not voluntarily repaid by obtaining sufficient recovery sleep, the body may respond by overrid ing voluntary control of wakefulness. This results in periods of decreased alertness, dozing off, and unplanned napping, recognized as excessive daytime sleepiness (EDS). The sleep restricted individual may also expe rience very brief (several seconds) repeated daytime microsleeps, of which the individual may be completely unaware, but which nonetheless may result in significant lapses in attention and vigilance. There is also a relationship between the amount of sleep restriction and performance on cognitive tasks, particularly those requiring sustained attention and higher level cognitive skills (executive functions; see Chapter 49), with a decay in performance correlating with declines in sleep amounts. It has also been recognized that what may be globally described as deficient sleep involves alterations in both amount and timing of sleep. Misalignment of intrinsic circadian rhythms with extrinsic soci etal demands, such a shift work and early school start times, is associ ated with deficits in cognitive function and self regulation, increased emotional and behavioral problems and risk taking behaviors, and negative impacts on health, such as increased risk of cardiovascular disease, obesity, and metabolic dysfunction. Insufficient quantity of sleep, mistimed sleep, and poor quality sleep frequently result in EDS and decreased daytime alertness levels. Sleepi ness in children may be recognizable as drowsiness, yawning, and other classic sleepy behaviors as well as resumption of napping in older children and extending sleep when given the opportunity such as on weekends. If a child can sleep more, they need more sleep. EDS can also manifest as mood disturbance, including irritability, emotional lability, low frustration tolerance and depressed or negative mood; fatigue and daytime lethargy, including increased somatic complaints (headaches, gastrointestinal disturbances); cognitive impairment, including prob lems with memory, attention, concentration, decision making, and problem solving; daytime behavior problems, including hyperactivity, impulsivity, and noncompliance; and academic problems, including chronic tardiness related to insufficient sleep and school failure. While sleepiness and fatigue may overlap in their clinical presentation, sleepi ness
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is characterized by the propensity to fall asleep, particularly under conditions of low stimulation (e.g., riding in the car), while fatigue is often described as a state of low energy, decreased motivation, and exhaustion. DEVELOPMENTAL CHANGES IN SLEEP Sleep disturbances, as well as many characteristics of sleep itself, have some distinctly different features in children from sleep and sleep dis orders in adults. Changes in sleep architecture and the evolution of sleep patterns and behaviors reflect the physiologicchronobiologic, developmental, and socialenvironmental changes that are occurring across childhood. These trends may be summarized as the gradual assumption of more adult sleep patterns as children mature (Figs. 31.1 and 31.2): 1. Sleep is the primary activity of the brain during early development; for example, by age 2 years, the average child has spent 9,500 hours (approximately 13 months) asleep vs 8,000 hours awake, and be tween 2 and 5 years, the time asleep is equal to the time awake. 2. There is a gradual decline in the average 24 hour sleep duration from infancy through adolescence, which involves a decrease in both di urnal and nocturnal sleep amounts. The decline in daytime sleep (scheduled napping) results in termination of naps typically by age 5 years, although there is clearly considerable variability in the age at which children cease napping. There is also a gradual continued decrease in nocturnal sleep amounts into late adolescence; however, adolescents still require 8 10 hours of sleep per night. 3. There is also a decline in the relative percentage of REM sleep from birth (50 of sleep) through early childhood into adulthood (25 30), and a similar initial predominance of SWS that peaks in early childhood, drops off abruptly after puberty (4060 decline), and then further decreases over the life span. This SWS preponderance in early life has clinical significance; for example, the high prevalence of partial arousal parasomnias (sleepwalking and sleep terrors) in preschool and early schoolage children is related to the relative increased percentage of SWS in this age group. 4. The within sleep ultradian cycle lengthens from about 50 minutes in the term infant to 90 110 minutes in the school age child. This has clinical significance in that typically a brief arousal or awaken ing occurs during the night at the termination of each ultradian cycle. As the length of the cycles increase, there is a concomitant decrease in the number of these end of cycle arousals (night wak ings). 5. A gradual shift in the circadian sleepwake rhythm to a delayed (later) sleep onset and offset time, linked to pubertal stage rather than chronologic age, begins with pubertal onset in middle child hood and accelerates in early to mid adolescence. This biologic phe nomenon often coincides with environmental factors, which further delay bedtime and advance wake time and result in insufficient sleep duration, including exposure to electronic screens in the evening, social networking, academic and extracurricular demands, and early (before 8:30 am) high school start times. In addition, the accumula tion of
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the homeostatic sleep drive across the day slows and both sensitivity and exposure to evening light increases (especially blue spectrum light from electronic devices) during adolescence, con spiring to further delay sleep onset. 6. Increasing irregularity of sleepwake patterns is typically observed across childhood into adolescence; this is characterized by increas ingly larger discrepancies between school night and nonschool night bedtimes and wake times, and increased weekend oversleep in an attempt to compensate for chronic weekday sleep insufficiency. This phenomenon, often referred to as social jet lag, not only fails to adequately address performance deficits associated with insuf ficient sleep on school nights but further exacerbates the normal adolescent phase delay and results in additional circadian disruption (analogous to that experienced by shift workers). Table 31.1 lists normal developmental changes in childrens sleep. COMMON SLEEP DISORDERS Childhood sleep problems may be conceptualized as resulting from (1) inadequate duration of sleep for age and sleep needs (insufficient sleep quantity); (2) disruption and fragmentation of sleep (poor 2 0.0 1.0 2.0 3.0 4.0 5.0 6.0 7.0 8.0 4 6 Avg 1SD 1SD 2SD 2SD 8 10 12 14 16 18 20 22 24 Age (mo) D ay tim e sl ee p (h r) Fig. 31.1 Daytime sleep duration in infants ages 3 24 mo. SD, Stand ard deviation. (From Paavonen EJ, Saarenp Heikkil O, Morales Munoz, I, et al. Normal sleep development in infants: findings from two large birth cohorts. Sleep Med. 2020;69:145154. Fig. 2, p 149.) Downloaded for mohamed ahmed (dr.mms2020gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright 2024. Elsevier Inc. All rights reserved. Chapter 31 u Sleep Medicine 203 sleep quality) as a result of frequent, repetitive, and brief arousals during sleep; (3) misalignment of sleepwake timing with circadian rhythms; or (4) CNS mediated hypersomnia (EDS and increased sleep needs). Insufficient sleep is usually the result of difficulty ini tiating (delayed sleep onset) or maintaining sleep (prolonged night wakings) but, especially in older children and adolescents, may also represent a conscious lifestyle decision to sacrifice sleep in favor of competing priorities, such as homework and social activities. The underlying causes of delayed sleep onsetprolonged night wakings or sleep fragmentation may in turn be related to primarily behavioral factors (e.g., bedtime resistance resulting in shortened sleep dura tion) or medical causes (e.g., obstructive sleep apnea OSA causing frequent, brief arousals). Certain pediatric populations are relatively more vulnerable to acute or chronic sleep problems. These include children with chronic illnesses or pain conditions (e.g., cystic fibrosis, asthma, idiopathic juvenile arthritis) and acute illnesses (e.g., otitis media); children taking stimulants (e.g., psychostimulants, caffeine), sleep disrupting medications (e.g., corticosteroids), or daytime sedating medications (some anticonvulsants, agonists); hospitalized chil dren; and children with a variety of psychiatric disorders, including attention deficithyperactivity disorder (ADHD), depression, bipo lar disorder, and anxiety disorders. Children with neurodevelop mental disorders such as autism, intellectual disability, blindness, and some chromosomal syndromes (e.g., Smith Magenis,
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fragile X) have especially high rates of sleep disturbances for a wide variety of reasons. They may have comorbid medical issues or may be tak ing sleep disrupting medications, may be more prone to nocturnal seizures, may be less easily entrained by environmental cues and thus more vulnerable to circadian disruption, and are more likely to have psychiatric and behavioral comorbidities that further pre dispose them to disrupted sleep. Children from low socioeconomic households or minoritized racial and ethnic groups, as well as chil dren in alternative care such as foster placement, are more likely to experience, are less likely to be diagnosed and treated, and are more vulnerable to the negative impact of sleep disorders resulting in significant sleep health disparities. Insomnia of Childhood Insomnia is defined as difficulty initiating andor maintaining sleep that occurs despite age appropriate time and opportunity for sleep and results in some degree of impairment in daytime functioning for the child andor family (ranging from fatigue, irritability, lack of energy, and mild cognitive impairment to effects on mood, school performance, and quality of life). Insomnia may be of a short term and transient nature (usually related to an acute event) or may be characterized as long term and chronic. Insomnia is a set of symp toms with many possible etiologies (e.g., pain, medication, medical psychiatric conditions, learned behaviors). As with many behavioral issues in children, insomnia is often primarily defined by parental concerns rather than by objective criteria and therefore should be viewed in the context of family (maternal depression, stress), child (temperament, developmental level), and environmental (cultural practices, sleeping space) considerations. While current terminology (Diagnostic and Statistical Manual of Mental Disorders, 5th edition, 2015; International Classification of Sleep Disorders, 3rd edition, 2014) groups most types of insom nia in both children and adults under a single category of Chronic Insomnia Disorder, the descriptor of Behavioral Insomnia of Child hood and its subtypes (Sleep Onset Association and Limit Setting) remains a useful construct in clinical practice, particularly for young children (0 5 years). One of the most common presentations of insomnia found in infants and toddlers is the sleep onset associ ation type. In this situation the child learns to fall asleep only under certain conditions or associations, which typically require parental presence, such as being rocked or fed, and does not develop the ability to self soothe. During the night, when the child experiences the type of brief arousal that normally occurs at the end of an ultra dian sleep cycle or awakens for other reasons, the child is not able to get back to sleep without those same associations being pres ent. The infant then signals the parent by crying (or coming into the parents bedroom if the child is ambulatory) until the necessary associations are provided. The presenting complaint is typically one of prolonged night waking requiring caregiver intervention and resulting in insufficient sleep (for both child and caregiver). Management of night wakings should include establishment of a set sleep schedule
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and bedtime routine and implementation of a behavioral program. The treatment approach typically involves a program of rapid withdrawal (extinction) or more gradual with drawal (graduated extinction) of parental assistance at sleep onset and during the night. Extinction (cry it out) involves putting the child to bed at a designated bedtime, drowsy but awake, to maxi mize sleep propensity and then systematically ignoring any protests by the child until a set time the next morning. Although it has con siderable empirical support, extinction is often not an acceptable choice for families. Graduated extinction (aka check ins, Fer ber method, sleep training) involves gradually weaning the child from dependence on parental presence; typically, the parent leaves the room at lights out and then returns or checks periodically at fixed or successively longer intervals during the sleepwake transi tion to provide brief reassurance until the child falls asleep. The exact interval between checks is generally determined by the par ents tolerance for crying and the childs temperament; the goal is to allow enough time between checks for the child to fall asleep independently while avoiding extended time intervals that result in continued escalation of protest behaviors such as screaming and Fig. 31.2 Nighttime sleep duration in infants ages 3 24 mo. SD, Stand ard deviation. (From Paavonen EJ, Saarenp Heikkil O, Morales Munoz, I, et al. Normal sleep development in infants: findings from two large birth cohorts. Sleep Med. 2020;69:145154. Fig. 3, p 149.) 2 6.0 7.0 8.0 9.0 10.0 11.0 12.0 13.0 4 6 Avg 1SD 1SD 2SD 2SD 8 10 12 14 16 18 20 22 24 Age (mo) N ig ht tim e sl ee p (h r) Downloaded for mohamed ahmed (dr.mms2020gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright 2024. Elsevier Inc. All rights reserved. 204 Part II u Growth, Development, and Behavior Table 31.1 Normal Developmental Changes in Childrens Sleep AGE CATEGORY SLEEP DURATION AND SLEEP PATTERNS ADDITIONAL SLEEP ISSUES SLEEP DISORDERS Newborn (0 2 mo) Total sleep: 10 19 hr per 24 hr (average, 13 14.5 hr), may be higher in premature babies. Bottle fed babies generally sleep for longer periods (2 5 hr bouts) than breastfed babies (1 3 hr). Sleep periods are separated by 1 2 hr awake. No established nocturnal diurnal pattern in first few wk; sleep is evenly distributed throughout the day and night, averaging 8.5 hr at night and 5.75 hr during day. American Academy of Pediatrics issued a revised recommendation in 2016 advocating against bed sharing in the first year of life, instead encouraging proximate but separate sleeping surfaces for mother and infant for at least the first 6 mo and preferably first year of life. Safe sleep practices for infants: Place baby on his or her back to sleep at night and during nap times. Place baby on a firm mattress with well fitting sheet in safety approved crib. Do not use pillows
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or comforters. Standards require crib bars to be no farther apart than 2 38 in. Make sure babys face and head stay uncovered and clear of blankets and other coverings during sleep. Most sleep issues perceived as problematic at this stage represent a discrepancy between parental expectations and developmentally appropriate sleep behaviors. Newborns who are extremely fussy and persistently difficult to console, as noted by parents, are more likely to have underlying medical issues such as colic, gastroesophageal reflux, and formula intolerance. Infant (2 12 mo) Recommended sleep duration (4 12 mo) is 12 16 hr (note that there is great individual variability in sleep times during infancy). Sleep regulation or self soothing involves the infants ability to negotiate the sleepwake transition, both at sleep onset and following normal awakenings throughout the night. The capacity to self soothe begins to develop in the first 12 wk of life and is a reflection of both neurodevelopmental maturation and learning. Sleep consolidation, or sleeping through the night, is usually defined by parents as a continuous sleep episode without the need for parental intervention (e.g., feeding, soothing) from the childs bedtime through the early morning. Infants develop the ability to consolidate sleep between 6 wk and 3 mo. Behavioral insomnia of childhood; sleep onset association type Sleep related rhythmic movements (head banging, body rocking) Toddler (1 2 yr) Recommended sleep amount is 11 14 hr (including naps). Naps decrease from two to one nap at average age of 18 mo. Cognitive, motor, social, and language developmental issues impact sleep. Nighttime fears develop; transitional objects and bedtime routines are important. Behavioral insomnia of childhood, sleep onset association type Behavioral insomnia of childhood, limit setting type Preschool (3 5 yr) Recommended sleep amount is 10 13 hr (including naps). Overall, 26 of 4 yr olds and just 15 of 5 yr olds nap. Persistent cosleeping tends to be highly associated with sleep problems in this age group. Sleep problems may become chronic. Behavioral insomnia of childhood, limit setting type Sleepwalking, sleep terrors, nighttime fearsnightmares, obstructive sleep apnea syndrome Middle childhood (6 12 yr) Recommended sleep amount is 9 12 hr. School and behavior problems may be related to sleep problems. Media and electronics, such as television, computer, video games, and the internet, increasingly compete for sleep time. Irregularity of sleepwake schedules reflects increasing discrepancy between school and nonschool night bedtimes and wake times. Nightmares Obstructive sleep apnea syndrome Insufficient sleep Adolescence (13 18 yr) Recommended sleep amount is 8 10 hr. Later bedtimes; increased discrepancy between sleep patterns on weekdays and weekends Puberty mediated phase delay (later sleep onset and wake times), relative to sleepwake cycles in middle childhood Earlier required wake times Environmental competing priorities for sleep Insufficient sleep Delayed sleepwake phase disorder Narcolepsy Restless legs syndrome periodic limb movement disorder All recommended sleep amounts from Paruthi S, Brooks LJ, DAmbrosio C, et al. Recommended amount of sleep for pediatric populations: a consensus statement of the American Academy of Sleep Medicine. J Clin Sleep
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Med. 2016;12:785786. gaggingvomiting. This allows the infant or child to develop the skills necessary for self soothing at bedtime and also during the night. Sleep training is typically not instituted until about 6 months of age, but the practice of putting the infant to sleep drowsy but awake starting at 3 4 months to encourage self soothing may avoid the need for later intervention. In older infants and young chil dren, the introduction of more appropriate sleep associations that will be readily available to the child during the night (transitional Downloaded for mohamed ahmed (dr.mms2020gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright 2024. Elsevier Inc. All rights reserved. Chapter 31 u Sleep Medicine 205 objects, such as a blanket or toy), in addition to positive reinforce ment (stickers for remaining in bed), is often beneficial. As healthy, normally growing full term infants no longer need night feedings from a nutritional standpoint, if the child has become habituated to awaken for nighttime feedings (learned hunger), these feedings should be eliminated (either cold turkey or by gradually decreas ing volume and the milk:water ratio). Parents must be consistent in applying behavioral interventions to avoid inadvertent, intermittent reinforcement of night wakings. They should also be forewarned that crying behavior often temporarily escalates at the beginning of treatment (postextinction burst). Bedtime problems, including stalling and refusing to go to bed, are more common in preschool age and older children. This type of insomnia is frequently related to inadequate limit setting at bedtime such as an inability or unwillingness to set consistent bedtime rules, and enforce a regular bedtime. In some cases, caregivers have adopted an inconsistent approach to night wakings that involves intermittently allowing the child to share their bed. This type of sleep problem may be associated with parental difficulty in setting limits or managing behavior in general and may be exacerbated by a childs tendency to engage in oppositional behavior. In some cases, the childs resistance at bedtime is the result of an underlying problem in falling asleep that is caused by other factors (medical conditions such as asthma or medica tion use; a sleep disorder such as restless legs syndrome; anxiety) or a mismatch between the childs intrinsic circadian rhythm (night owl) and parental expectations regarding an appropriate bedtime. Successful treatment of limit setting sleep problems generally involves a combination of parent education regarding appropriate limit setting, decreased parental attention for bedtime delaying behavior, establishment of bedtime routines, and positive reinforcement (sticker charts) for appropriate behavior at bedtime and during the night. For problematic night wakings, it is essential for caregivers to have a con sistent response (e.g., returning the child to their bedroom after every night waking). Other behavioral management strategies that have empirical support include bedtime fading, or temporarily setting the bedtime closer to the actual sleep onset time and then gradually advancing the bedtime to an earlier target bedtime. Older children may
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benefit from being taught relaxation techniques to help themselves fall asleep or back to sleep more readily. Following the principles of healthy sleep practices for children is essential (Table 31.2). A third type of childhood insomnia is related to a mismatch between parental expectations regarding time in bed and the childs intrinsic sleep needs. If, as illustrated in Figure 31.3, a childs typical sleep time is 10 hours but the sleep window is set for 12 hours (7 pm to 7 am), the result is likely to be a prolonged sleep onset of 2 hours, an extended period of wakefulness during the night, or early morning waking (or a combination); these periods are usually characterized by normal wakefulness in the child that is not accompanied by excessive distress. This situation is important to recognize because the solution (reducing the time in bed to actual sleep time) is typically simple and effective. Another form of insomnia that is more common in older chil dren and adolescents has often been referred to as psychophysiologic, primary, or learned insomnia. Primary insomnia occurs mainly in adolescents and is characterized by a combination of learned sleep preventing associations and heightened physiologic arousal resulting in a complaint of sleeplessness and decreased daytime functioning. A hallmark of primary insomnia is excessive worry about sleep and an exaggerated concern of the potential daytime consequences. The physi ologic arousal can be in the form of cognitive hypervigilance, such as racing thoughts; in many individuals with insomnia, an increased baseline level of arousal is further intensified by this secondary anxi ety about sleeplessness. Treatment usually involves educating the ado lescent about the principles of healthy sleep practices (Table 31.3), institution of a consistent sleepwake schedule, avoidance of daytime napping, instructions to use the bed for sleep only and to get out of bed if unable to fall asleep (stimulus control), restricting time in bed to the actual time asleep (sleep restriction), addressing maladaptive cognitions about sleep, and teaching relaxation techniques to reduce anxiety (cog nitive behavioral therapy for insomnia CBT I). The keys to successful behavioral sleep interventions involve form ing an alliance with the family, negotiating tailored solutions that are more likely to be effective if families can be successful in implementing them, and setting appropriate agreed on treatment goals with planned follow up. Behavioral treatments for insomnia, even in young children, appear to be highly effective and well tolerated. Several studies have failed to demonstrate long term negative effects of behavioral strategies such as sleep training on parentchild relationships and attachment, psychosocial emotional functioning, and chronic stress. It should also be emphasized that, as in adults, behavioral interventions are the first line treatment for insomnia in children, and in general, hypnotic medi cations or supplements such as melatonin are infrequently needed and should only be used as an adjunct to behavioral therapy to treat insom nia in typically developing and healthy children. If cognitive behav ior therapy and sleep hygiene practices are ineffective in children with autism spectrum
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disorders or ADHD, melatonin may be an additional effective therapy. Sleep need (10 hours) Time in bed (12 hours) ASLEEP AWAKE ASLEEP ASLEEP AWAKE AWAKE Bedtime 1900 Wake time 0700 ASLEEP Fig. 31.3 Mismatch between sleep needsduration and time in bed, resulting in insomnia. Table 31.2 Basic Principles of Healthy Sleep for Children 1. Have a set bedtime and bedtime routine for your child. 2. Bedtime and wake up time should be about the same time on school nights and nonschool nights. There should not be more than about 1 hr difference from one day to another. 3. Make the hour before bed shared quiet time. Avoid high energy activities, such as rough play, and stimulating activities, such as watching television or playing computer games, just before bed. 4. Dont send your child to bed hungry. A light snack (e.g., milk and cookies) before bed is a good idea. Heavy meals within 1 hr or 2 of bedtime, however, may interfere with sleep. 5. Avoid products containing caffeine for at least several hours before bedtime. These include caffeinated sodas, coffee, tea, and chocolate. 6. Make sure your child spends time outside every day, whenever possible, and is involved in regular exercise. 7. Keep your childs bedroom quiet and dark. A low level night light is acceptable for children who find completely dark rooms frightening. 8. Keep your childs bedroom at a comfortable temperature during the night (24C 75F). 9. Dont use your childs bedroom for time out or punishment. 10. Keep the television out of your childs bedroom. Children can easily develop the bad habit of needing the television to fall asleep. It is also much more difficult to control your childs viewing if the set is in the bedroom. Downloaded for mohamed ahmed (dr.mms2020gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright 2024. Elsevier Inc. All rights reserved. 206 Part II u Growth, Development, and Behavior Obstructive Sleep Apnea Sleep disordered breathing (SDB) in children encompasses a broad spectrum of respiratory disorders that occur exclusively in sleep or that are exacerbated by sleep, including primary snoring and upper air way resistance syndrome, as well as apnea of prematurity (see Chapter 125) and central apnea (see Chapter 468.2). OSA, the most important clinical entity within the SDB spectrum, is characterized by repeated episodes of prolonged upper airway obstruction during sleep despite continued or increased respiratory effort, resulting in complete (apnea) or partial (hypopnea; 30 reduction in airflow accompanied by 3 O2 desaturation andor arousal) cessation of airflow at the nose and or mouth, as well as disrupted sleep. Both intermittent hypoxia and the multiple arousals resulting from these obstructive events likely con tribute to significant metabolic, cardiovascular, and neurocognitive neurobehavioral morbidity. Primary snoring is defined as snoring without associated ventila tory abnormalities on overnight polysomnogram (PSG) (e.g., no apneas or hypopneas, hypoxemia, hypercapnia) or respiratory related arousals and is a manifestation of the vibrations of
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the oropharyngeal soft tissue walls that occur when an individual attempts to breathe against increased upper airway resistance during sleep. Although gen erally considered nonpathologic, primary snoring in children may still be associated with subtle breathing abnormalities during sleep, includ ing evidence of increased respiratory effort, which in turn may be asso ciated with adverse neurodevelopmental outcomes that may be similar to those associated with OSA. Etiology OSA results from an anatomically or functionally narrowed upper airway; this typically involves some combination of decreased upper airway patency (upper airway obstruction andor decreased upper air way diameter), increased upper airway collapsibility (reduced pharyn geal muscle tone), and decreased drive to breathe in the face of reduced upper airway patency (reduced central ventilatory drive) (Table 31.4). Upper airway obstruction varies in degree and level (i.e., nose, naso pharynxoropharynx, hypopharynx) and is most frequently caused by adenotonsillar hypertrophy, although tonsillar size does not necessarily correlate with degree of obstruction, especially in older children. Other causes of airway obstruction include allergies associated with chronic rhinitis or nasal obstruction; craniofacial abnormalities, including hypoplasia or displacement of the maxilla and mandible; gastroesopha geal reflux with resulting pharyngeal reactive edema (see Chapter 369); nasal septal deviation (Chapter 425); and velopharyngeal flap cleft pal ate repair. Reduced upper airway tone may result from neuromuscular diseases, including hypotonic cerebral palsy and muscular dystrophies (see Chapter 649), or hypothyroidism (Chapter 603). Reduced central ventilatory drive may be present in some children with Arnold Chiari malformation (see Chapter 631.09); rapid onset obesity with hypo thalamic dysfunction, hypoventilation, and autonomic dysregulation (Chapter 65); and meningomyelocele (Chapter 631.04). In other situ ations, the etiology is mixed; individuals with Down syndrome (see Chapter 57), because of their facial anatomy, hypotonia, macroglossia, and central adiposity, as well as the increased incidence of hypothy roidism, are at particularly high risk for OSA, with some estimates of prevalence as high as 70. Although children with OSA may be of normal weight, a large percentage are overweight or obese, and many of these children are school age or younger. There is a significant correlation between weight and SDB (e.g., habitual snoring, OSA, sleep related hypoventi lation). Although adenotonsillar hypertrophy also plays an important etiologic role in overweightobese children with OSA, mechanical fac tors related to an increase in the amount of adipose tissue in the throat (pharyngeal fat pads), neck (increased neck circumference), and chest wall and abdomen can increase upper airway resistance, worsen gas exchange, and increase the work of breathing, particularly in the supine position and during REM sleep. A component of blunted central ven tilatory drive in response to hypoxiahypercapnia and hypoventilation may occur as well (see Chapter 468.2), particularly in children with morbid or syndrome based (e.g., Prader Willi) obesity. Overweight and obese children and adolescents are at particularly high risk for Table 31.4 Anatomic Factors That Predispose to Obstructive Sleep Apnea Syndrome and Hypoventilation in Children NOSE Anterior nasal stenosis Choanal stenosisatresia Deviated nasal septum Seasonal or perennial rhinitis Nasal polyps, foreign body,
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