Overview of Development

Whoever touches the life of the child touches the most sensitive point of a whole which has roots in the most distant past and climbs toward the infinite future.

–Maria Montessori

Developmental Stages

What development is not is consistent and unalterable. The normal range of development is broad, and one stage does not neatly finish before the next can begin. However, recalling these stages is much more useful than merely studying for Board examinations. It keeps in mind the need to think developmentally, to consider the areas of development in which a child is doing well, and the areas in which he or she needs intervention. Although seeing hundreds of children (both typical and impaired) is the best way to begin to differentiate normal variations in temperament and fantasy from more concerning symptoms of psychiatric disorder, the tried and true developmental models, particularly that of Erikson, may be useful for the ongoing assessment of a child’s ability to meet and master the developmental tasks at each age. Each time I assess a child or adolescent, I review in my own mind the developmental tasks for the age, and how the child is faring with respect to these. For children and adolescents, treatment is not merely focused on a specific diagnostic disorder, but
on providing interventions that address areas of developmental concern, and helping the child gain the skills and support needed to get on a healthier developmental trajectory.

A basic understanding of human development is fundamental to the psychiatric evaluation in general and most essential in the assessment of children and adolescents. An appreciation for the wide variability among children in terms of development will assist in identifying and targeting areas of developmental concern while minimizing the risk of overdiagnosis and overpathologizing. Normal reactions of one developmental period (such as stranger anxiety in a 1-year-old) when it occurs in another stage (such as similar severe fears in a 5-year-old) may suggest a disorder.

Key Point

I would like to emphasize at the very beginning of the book what I consider to be a key aspect of all of child and adolescent psychiatry which is frequently given short shrift. A thorough evaluation and treatment plan for a child, adolescent, or family needs to highlight areas of strength and resilience, not merely pathology. In child and adolescent psychiatry, many of the children we see have suffered severe psychosocial adversity, family chaos, abuse or neglect, have unsafe behaviors, and meet DSM-IV criteria for multiple disorders. In this context, sorting out the risk factors and pathology may dominate the therapeutic encounter. However, it is the assessment and appreciation of strengths that may most meaningfully build a therapeutic alliance, may provide our most accurate prognostic indicators, and may be the most useful method of choosing appropriate treatment modalities. I have found in each child or adolescent I assess or treat a unique inner “spark”—that part of her or him that is the healthiest, has the most hope, and is most amenable to treatment. Finding that “spark” within the patient may provide insights far beyond those gleaned from diagnosing the disorder.

Child and adolescent psychiatrists are, typically, first adult psychiatrists. It is thus easy to assume that children are just “miniature adults.” A frequent error is in the supposition that our evaluations, diagnoses, and treatment plans can merely be “downsized” for the child or adolescent. In fact, the chronological unfolding of progressive capabilities and processes from infancy onward must be appreciated to understand and treat the patient as a whole. Treatments are different for individuals at different stages of development.

Theories of development have encompassed entire textbooks, so I will distill out the concepts that I believe are most essential in assessing children and adolescents who are referred for emotional or behavioral difficulties. The primary developmental theorists discussed will be Sigmund Freud (psychosexual stages), Erik Erikson (psychosocial stages), and Jean Piaget (cognitive stages). Additionally, some highlights of each of the developmental periods of childhood and adolescence will be mentioned, as well as risk factors for each stage. Table 1.1 compares the three developmental theorists.

Prenatal Development

Each person has 23 double helix strands of the genetic code for all physical characteristics and organ capacities in the body. Traits such as temperament and activity level also have a genetic basis. Although some genes have strong penetrance and express themselves in virtually all environments (such as eye color), much of development is the product of complex gene-environment interactions. Family history of development may give an indication of the genetic makeup and potential vulnerabilities of the fetus. Understanding the nurturing environment assists in gaining an appreciation for the unfolding of the genetic potential in a given individual.

The second trimester of gestation is when neurological and brain development occurs most rapidly. Thus, insults during this time may result in obvious or more subtle functional deficits for the baby. The clinician should inquire about the prenatal period. Exposure to substances (alcohol, substances of abuse, or medications), trauma, or severe stress during pregnancy may be significant to the developing fetus and be a source of vulnerability when the baby is born.

Infancy (Birth to 1 Year)

Sigmund Freud characterized infancy as the Oral Stage of development, during which time the mouth and eating were of dominant importance. This stage is marked by extreme dependency, urgency of needs, low frustration tolerance, and no consideration of others. Erik Erikson, in his psychosocial stages of development, postulated the normative crisis of infancy as

that of Basic Trust vs. Mistrust. The capacity for basic trust is achieved when the infant feels safe and well cared for by his or her caregivers. Infants gain a sense of security by having their physical needs cared for in a sensitive manner, according to John Bowlby. This caring and mutual bonding is the key to secure attachment.

Table 1.1. Comparison of Developmental Theorists

Age	Sigmund Freud	Erik Erikson	Jean Piaget
	Psychoanalytic drive theory Psychosexual stages	Psychoanalytic theory Psychosocial stages	*Cognitive stages of development*
0–1	*Oral Stage* (birth to 12–18 mo) Primary site of gratification and tension in oral area (mouth, lips, tongue) Sucking and biting	*Trust vs. Mistrust* (birth to 12–18 mo) Trust depends on reliability of care provided by caretaker Frustration associated with weaning Optimism and hope derive from basic trust	*Sensorimotor Phase* (birth–2 yr) Modification of reflexes; cross modal fluency Association between means and ends Object permanence; objects still exist even if obscured from view Mastery motivation (10–12 mo); child seeks to master challenges
1–3	*Anal Phase* (12–18 to 36 mo) Primary site of tension and gratification is anal area Toilet training	*Autonomy vs. Shame* (12–18 to 36 mo) Increased capacities (motor, sphincter, language, etc.) Need for consistent limits from caretaker Shame occurs with lack of self-control Self-doubt evolves from parental shaming	Can infer cause and effect (1–2 yr) Schemas (units or categories of cognition) Assimilation (incorporation of new knowledge) and accommodation (modification of schema to adapt to new stimuli)
3–5	*Phallic-Oedipal Phase* (3–5 yr) Primary site of tension and gratification–genitals Castration anxiety, fear of genital loss or injury (interest in Band-Aids) Oedipus complex: Child desires intimacy with parent of opposite sex; to be rid of same-sex parent	*Initiative vs. Guilt* (3–5 yr) Initiative, enjoyment of activity and accomplishments Guilt over aggressive urges Resolution of oedipal conflict via role identification Sibling rivalry common	*Preoperational Phase* (2–6 yr) Language acquisition and symbolic reasoning Egocentrism; see world exclusively from own perspective Thinking is transductive (causality inferred from temporal or spatial proximity) Magic thinking (prelogical)
6–11	*Latency Stage* (6–11 yr) Relative quiescence of libidinal drives Sexual drives channeled into socially appropriate activities (i.e., school work, sports) Further development of ego functions Formation of superego Focus on same-sex relationships	*Industry vs. inferiority* (6–11 yr) School is important Child is busy creating, building, accomplishing Danger of sense of inferiority and inadequacy of child; feels unable to compete with regard to skills (e.g., academic, sports) and status among peers Socially decisive age	*Concrete Operations* (6–11 yr) Emergence of logical, cause and effect thinking Reversibility of events and ideas Switch from egocentric to social speech Ability to see another’s point of view Conservation of volume and quantity Rigid interpretation of rules
11 +	*Adolescent Genital Phase* (11 or 12 yr and beyond) Final stage of psychosexual development Recapitulates earlier phases Separation from family Identify formation Biological capacity for orgasm and psychological capacity for true intimacy develop	*Identity vs. Role Confusion* (11–18 yr) Group identity (peers) primary Developing ego identity (sense of inner sameness) Preoccupation with appearance Moodiness and reactivity Danger of role confusion; uncertainty about sexual and vocational identity	*Formal Operations* (11 yr+) Hypothetical/deductive abstract reasoning Elaboration of information processing Metacognitive capacity; can think about thinking Ability to grasp concept of probabilities