University of Balamand Faculty of Medicine & Medical Sciences In Association with St. George Hospital University Medical Center and Mount Lebanon Hospital Balamand University Medical Center 1 Development, Brain and Behavior Normal Development I Zaher Krayem, Psy.D Balamand University Faculty of Medicine St. George Hospital University Medical Center Dept. of Psychiatry & Clinical Psychology Institute for Development Research, Advocacy & Applied Care (IDRAAC) 2 Individual Characteristics These things have been observed to be unique among different people. Genetics Appearance - Size - Attractive/Dismorphic Intelligence Social Skills Body Habits Personality Temperament 3 Temperamental Characteristics In Infancy Activity Level Rythmicity (regularity) Atall the beginning infants are not approachable at Approach or Withdrawal Adaptability Some children need more cues, those do not respond at all may be Threshold of reponsiveness who autistic Intensity of reaction Quality of Mood Distractibility Attention span and persistence There are ways we can help children improve their attention span, although mostly we do have innate attention spans. 4 Infant Temperamental Types Easy Temperament Difficult Temperament Slow to warm up Temperament Cries a lot, is more irritated Take more time to attach and feel comfortable with their caregiver 5 Infant Temperament Goodness of Fit Has to do with the relationship between the parents and the child 6 Development - Longitudinal Developmental Lines - Physical/Gross and Fine Motor Freud, erikson, young, - Cognitive piaget(cognitive and physical growth), all of these people - Language studied aspects of development. - Psychosexual - Interpersonal/Psychosocial - Affective - Moral - Spiritual 7 Longitudinal Models Social Freud Mahler separation-Individuation Erikson Psychosocial Piaget Cognitive Language Motor Kohut is an object relations psychologist, father of psychology, postulates that we internalize Kohut Object Relations self good objects or bad objects, we internalize good relationships that impact our sense of self Others 8 Social Stages of Development 0-12 months infancy 12-36 months Toddler 36-60 months Preschool 7-12 Years School Age Adolescence has expanded into young adulthood, maybe up to 30, especially in new generation. Has to do with culture 12-18 years Adolescence this and the age at which one is able to start a family 18-35 years Young Adulthood 35-65 Years Adulthood 65 years and over - Older Adulthood/Geriatric 9 Freud Psychosexual Development Freud is the father of psychoanalysis. These are his stages. He was expanded by neofreudians such as young, and expanded his work into a more psychosocial model. Oral Anal Phalic Latency Adolescence (genital) Adult (genital) 10 Freud Cont d Oral Stage (0-1 year) Anal Stage (1-3 years) Phallic Stage (3 to 5 or 6 years) (Oedipus Complex) Latency Stage (5 or 6 to puberty) Genital Stage (puberty to adult) Sucking their thumb They are toilet training Oedipus and electra, this is freud’s theory A break from sexuality, more development and learning that is not related to sexuality Until we die 11 TABLE FREUD People’s problem with Freud: too focused on sexual stages, not enough on development Anal in linguo/mainstream culture reffers to orderliness Child in competition with parent over other parent Also LEARNING 12 Mahler Separation-Individuation 1-2 Months - Autistic (0-1mo.) Sleep, symbiotic phases live without mother, complete (enmeshment with mother) Cannot attachment (food and sleep) 5-10 months to separate - S-I phase: hatching (differentiation)Starts from mom 10-16 months - S-I phase: practicing (exploration) 18-24 months - S-I phase: rapprochement: object constancy (2-5 years) Permanence of the is when we know even if the mother is not there, doesn’t mean she has mother. This disappeared forever. Knowing that she exists 13 Mahler Table Know the stages, and a good idea about them, not fully memorize 14 Erikson 6-18 months Trust v Mistrust 18-36 months Autonomy v Shame and doubt 36-72 months Initiative v Guilt 6-12 years Industry v Inferiority 12-18 years Identity v Role confusion Young Adult Intimacy v Isolation Adult Generativity v Stagnation Old Age Integrity v Disgust and Despair 15 Erickson Table Know the table, mainly first three columns, and see some of the similarities to freud stages. Developped after you get past that stage Mainly with peers Coincides with freud latency When one starts deciding what they should be Finding a partner Stagnation usually leads to depression, such as with retirement 16 Piaget Studied development of children, by observing his own kids Sensorimotor (18-24 months) Object permanence Pre-operations (2-7 years) Meaning Concrete Operations (7-11 years) Rational and organized thinking. (hierarchy, colors, patterns) Problem solving Formal Operations (12-adulthood) Abstraction and reason Using their senses to discover the environment 17 Piaget Table Slightly more accurate than 2-5 years Egocentrism: view the world from their own POV Conservation: same quantity in different containers 18 Language 6 months Coos, smiles, reaches 12 months First words 18 months Increasing words 24 months 2-3 word sentences 36 months 3 word phrases 8 years Knows person, place, time Able to do mental status exam at 8 (MSA) 19 Gross Motor 4 months Roll over 6 months Sit unassisted 30 months run 36 months Stairs one step/foot, Ride tricycle 6-7 years Ride bicycle 20 Fine Motor 4 weeks hands fisted 6 months Grasps Cube 18 months Tower of 3 cubes 3 years Draws Circle 4 years Draws square Another is that they Grab your finger when you put it forward too 21 Socio economic status SES as an important control variable Maternal Cocaine exposure - many of early reports that children were severely disturbed permanently by this prenatal effect neglected importance of effects of nurture after birth or genetic effects on outcome measures - possibly deleterious consequences on nurture poorly controlled - e.g. prospective nurturing adoptive parents being told that child is hopeless , with consequent nonadoption and multiple foster home placements Fostering may lead to attachment issues 22 Strengths/Resilience Also the concept of post traumatic growth, especially if you’ve discussed it and got over it. So it may lead to growth Too often we overlook strengths when considering health or overlook context when considering extent of stressors Many children grow up healthy even under traumatic experiences Chronic trauma usually more problematic than acute trauma, largely due to the absence of care correlated with chronic trauma (Domestic Violence, ongoing abuse) 23 Normality (necessary concept) There is no normal race, gender, or sexual preference Normality must be defined in the conte t of each person s personal and cultural context Concept around which one should constantl refine one s clinical judgement as a physician Different in different cultures and with different individuals, generations Be culturally sensitive 24 Impairment as an indicator Degree of self-or family-defined impairment or distress used as an indicator of when not healthy Someone will tell us if they’re unhealthy, self reports from patients or family, and not us telling them 25 Because when we know the problem, we will know what to do and how to treat. This is harder and not as easy in psychology Why Do We Need Diagnoses? Standard nomenclature Defined realms of pathology Communication among professionals A label for administrative functions A label for families that - Helps them understand - Places their child in context - Connects them to others 26 Disadvantage of Diagnosis Applies more to psycho, because patients with the same disease will present differently A final common denominator that may not accurately reflect all individual cases Difficult to capture development changes - Do they reflect continuity over time? May be associated with misinformation - Name may either not represent or even misrepresent the actual pathology Serve as a label for administrative functions Diagnostic Labels can be misused 27 Prenatal Development Almost all neurons born before 11 weeks gestation Almost all cell migration complete by 16 weeks gestation Drug exposures, most commonly alcohol and nicotine lead to later behavioral problems (dose-related) Nicotine especially, may lead to ADHD 28 Prenatal Development Nutrition important during prenatal development Full-term or near-full term development important mostly due to hypoxia and related CNS bleeding when birth excessively premature However, outcomes progressively improving with advances in neonatal care Development of parts of the mouth 29 Post-natal Development When doest it really begin? - At delivery? - In utero, near delivery? 30 Post-natal Development Visual and auditory acuity continuing to develop (proportional to myelination of appropriate tracts) Sleep erratic and then organizes 2-4 mo May be longer than that 31 Post-natal Development Physiological homeostasis is main goal Key first step is feeding, which requires adequate muscle tone for sucking (hypotonia often presents with failure to gain weight) Main goal even as adults 32 Post-natal Development In complete need of caregiver First 2 months social life largely bilateral Parental functioning is important - Goodness of fit - Support systems Time after birth is a sensitive period for developing attachment between caregivers and the infant 33 Post-natal Development Imprinting: Lorenz (genetic) Attachment - Bilateral - Complex behavioral interaction - Begins at birth In nature, there is the concept of of imprinting, a genetic concept that begins at birth depending on the creatures around you when you are born 34 2 4 months 2 month social smile is very overdue for firsttime parents up all night with frequently crying infants Parents begin to more reliably read subtle cues and patterns of child (e.g. communication of hunger vs. needing a diaper change 4 months rolling over increases the risk for falls Interest in objects in environment - Color - movement 35 4 6 months Rolling over at 4 months to sitting up unassisted at 6 months Child develops more three dimensional view of their world but mobility limited By 6 months, children are relatively social without much fear of strangers At 6 months debatable on the nature of the attachment, the more secure the attachment the earlier 36 6 9 Months Emergence of normative separation anxiety and stranger wariness Object permanence Children become more mobile although not usually walking - Creeping - Crawling - Pulling up and standing For most children sleep and eating schedules are relatively organized 37 9 12 Months Exciting time with development of single ords starting ith dada (then mama ) and ith man other single words by 12 months Development of walking from unassisted typically by 12 months Increasing need for child-proofing (although this should occur prenatally) Coinciding with oral stage, puts things in their mouth 38 12 18 Months Generall a time in hich child is in love ith the orld enjo ing ne mobility and its freedom Object permanence by 12 months Joint attention by 12 months (will follow a point by a parent to attend to something other than the parent and child, just because of interest to the parent) This really depends on the child 39 18 36 Months 18 months end of the preceding oral period 18-36 months anal period (psychosexual), autonomy vs. shame and doubt (psychosocial), separationindividuation, reorganization of nervous system (pruning in primary sensory cortex) Getting rid of unneeded neurons, developing an identity 40 18 36 Months Terrible t o s (No) + separate identit Parental response important Child struggle to be soothed by parent without feeling smothered Voracious appetite for learning and trying new things Language - 2-3 word phrases - > than short sentences 41 18 36 Months Ambivalent struggle over autonomy because child still needs parent - Parent has to set limits where necessary (esp. safety issues) - Parent has to help child find a way out of unsolvable conflicts (provide child with easy-to-understand choices) - Parent has to be secure enough not to have to try to win the power struggles Predictable env for the child, makes him feel safe and secure 42 36 48 Months Emergence of focus on more complex relationships and enjoyment of developing skills without focusing on autonomy Begin to directly play with other children but play is often paralleled Language plays a role in play - Can speak in full thoughts sentences Many, but not all children enter nursery school Independence associated with bowel control end of traditional anal period 43 Four year-olds Has mastered toileting, although accidents not uncommon, especially through the night Rapid increases in social interest and competence Nursery school (common, but not compulsory) Conflicts over autonomy are not most prominent conflict, but persist as a concern Fundamentals of spoken language mastered can tell a story and share feelings but still concrete Right around piaget concrete operation 44 Four year-olds Conflicts over autonomy are not most prominent conflict, but persist as a concern Creative period 45 Four year-olds Identify self by gender Gender roles become stereotypic - Internal forces - child feels how they behave is who they are - insecurity leads to conformity - External forces Basically every age 46 Four year-old Learning basic rules of right and wrong Mastery of aggressive impulses often more difficult for boys than girls - ? Due to less well developed social competence in bo s (can t separate out nature from nurture here) vs. preference for aggressive behavior 47 Four year-old Triadic relationships are emergent domain - (present before, but diadic relationships often dominate scene earlier) Competition more prominent Often competition with same sex parent and less conflictual relationships with opposite sex parent Usually among the same sex 48 Five year-old Kindergarten Pre-academic skills - early reading - riting currentl enhanced b inventive spelling idea is to encourage expression without constraint of spelling rules and details for which child not ready - early reading, mostly by sight identification 49 Five year-old - Academic - early math skills especially geometric and functional - Counting and alphabet usually solid - Early adding, but subtraction not typical 50 Five year-old Social skills further developing - most children can contain their violence in classroom at this point - disorders of activity and violence such as ADHD and conduct disorder often first diagnosed 51 Five year-old Continence typical, even at bedtime Failure to establish continence first diagnosed - Enuresis daytime or more commonly nocturnal wetting - usually spontaneously remits by Development of medical issues at adolescence this age - Encopresis daytime or nighttime defecation - if regular symptomatic of constipation or emotional conflicts, particularly re: autonomy 52 Six year-old First graders Learn social rules - Classroom - Playground 53 Cognition Mental Status Exam Orientation (emergent 5 to 8) - person (full name, relationships in family) - time day of week, month, year, day of month - place home, school, city, state, country, planet 54 Six year-old Triadic conflicts become less dominant and theory goes that it is resolved by identification with same sex parent (the average result, not only healthy alternative) Under psychoanalytic theory, this completes development of the superego Right vs wrong, punishatory 55 Six year-old Focus on development of peer relationships, although this is usually ithin conte t of parent s e pressed values and preferences Most peer relationships still largely under initiation of parents or parental surrogates such as teachers (school and extracurricular) and neighbours 56 Seven-Ten Year-Olds Education - 7 y/o - beginning arithmetic - beginning to write in cursive - read picture books - 10 y/o - set theory, long division, 3 digit multiplication - writing skills developing to point of beginning to write brief reports - read chapter books - 7 to 10 y/o - interest in trivia, riddles, details develops - pokemon phase (eg. Collecting) 57 Puberty - Physiological organizer for onset of puberty yet to be identified? - Endocrine patterns associated with puberty welldefined - Intense interaction between CNS and peripheral organ development - Hormonal changes likely impact on CNS maturation at this time - Tanner stages of puberty 58 Puberty - VERY IMPORTANT anticipatory guidance with parents about discussing the changes with their children - Examples girls not being prepared for menstruation and fearing death or serious illness or retribution - On more daily basis, adjusting to rapidly changing arm length, breast size, etc. 59 Puberty Cultural Response In many cultures, there is a ritual acknowledgement of the pubertal changes and entry into adulthood is ritualized without adolescence In most US homes, there is a discrepancy between adult size/developing formal cognitive style and permitted autonomy For example in certain African cultures 60 3 stages of Adolescence Early start of puberty to ~ 14 Growth spurt Middle 14 17 Sexual experiences begin Late 18 - ? Sometimes 30 exploration of identity, risk taking. Healthy to have a long adolescence 61 Most adolescents are comfortable with There are always exceptions Their bodies Their new roles The way they are treated by others Their roles in their families The future 62 New imperatives in adolescence Independent identity - Known outside the family - Independent decision-making and problem solving - Develop an individual sense of psychological self New social roles - Personal responsibility - Peer relationships - Friends These are all very imp, peers - Groups and relationships are essential - Dating/Mating Career decisions - Begins early with commitments to certain tracks May be a bit too fast in our cultures 63 Age Grading ascription of social maturity based on chronological age The standard age for all of these is different in different countries Drinking Smoking Driving Work Voting The draft Sex Parenting Criminal responsibility Etc. 64 Adolescents Still need external controls and discipline Must begin to take more control and responsibility Must be able to complete and manage long term planning Learn to tolerate frustration 65 Adolescents Must develop communication skills Must learn to manage abstract concepts effectively Begin to interact in the adult world without all the adult responsibility or authority Manage improving executive functioning and understanding consequences. Make better decisions, and not impulsive decisions as the prefrontal cortex develops at 27 fully 66
