Islington
Primary Care Trust
Dr Eileen Vizard FRCPsych
Consultant Child and Adolescent Psychiatrist, NSPCC
&
Honorary Senior Lecturer, University College London
The Michael Sieff Foundation Conference
21 st & 22 nd September 2010
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Ontogeny recapitulates phylogeny’
Ernst Haeckel(1866) Thomas Huxley (1868)
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• Some truth in these early theories but Haeckel’s theory largely discredited
• However, brain development stages may recapitulate human brain evolution:
“Inside-out” and “Bottom-up”
• Higher/Complex areas control the more reactive primitive lower parts of the brain —less reactive, more thoughtful and less impulsive
• Lower-Excitatory
• HigherModulating’
De Brito 2009
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Lifespan Development
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H
Maturity
8 Ages of Man Erikson 1950
Ego
Integrity vs
Despair
G
Adulthood
Generativity vs stagnation
F
Young
Adulthood
Intimacy vs
Isolation
E
Puberty
Identity vs
Role confusion
D
Latency
Industry vs
Inferiority
C
Locomotor
-genital
B
Muscularanal
A
Oral sensory
Basic trust vs mistrust
Autonomy vs
Shame, doubt
Initiativ e vs guilt
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• Lifespan process of change
Rutter & Rutter 1993
• Much development occurs in early childhood and adolescence
Steinberg & Schwartz 2000; RCPsychs 2006
• Brain development continues in young adult life
Blakemore & Choudhury 2006
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Societal Community Relationship Individual
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Brain development
De Brito 2009
• ‘The maturation of grey matter is best described as a constant “push and pull”. New pathways grow, while others are pruned back
• Pruning is greatly influenced by experience, so it really is a case of “use it or lose it”!
• This makes the brain extremely versatile, and able to
Make changes depending on the demands of the environment.’
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Brain development
De Brito 2009
• ‘Windows of vulnerability = critical time during which brain hones particular skills or functions
• Different windows for different brain regions
• If the chance to practise a skill is missed during
The window, a child may never learn it (or be impaired) ‘
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Studies show adverse effects on the developing brain from abuse and neglect on:
• Brain structure
• Brain function
McCrory et al 2010
But............there is also evidence of ‘catch up’ with brain development when ‘nurture’ improves
And...........child resilience moderates between nature and nurture
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• Positive developmental change occurs across the lifespan notably birth to mid twenties
• Will these developmental changes occur regardless (are they hard wired) or can the environment impact on child development?
• Why do some children survive & recover from major traumas but others succumb?
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Attachment Theory
John Bowlby 1907-1990
Child Psychiatrist,
Psychoanalyst
Animal ethology model for mother child attachment relationships
Psychoanalytical theory to understand the emotional aspects of attachment
Separation & loss impact
‘ A 2 year old goes to the
Hospital’
Bowlby, Robertson &
Rosenbluth 1952
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Child Developmental
Models:
Attachment Theory
Attachment is:
Any form of behaviour that results in a person attaining or maintaining proximity to some other differentiated and preferred individual, usually conceived as stronger and wiser
Bowlby, 1973
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Child Developmental Models: Attachment Theory
‘The photograph shows an infant rhesus monkey with two artificial mothers to which it can cling (see p.74).
It has chosen the one on the right which is covered with a soft towelling in preference to the one on the left made of wire.
Both are pivoted so that the weight of the monkey depresses a switch and the amount of time spent clinging to each can be recorded.’ Broadhurst 1963
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‘In the photograph on the right, the infant rhesus monkey is shown demonstrating the greater importance of mother – infant contact over food (see p.74).
It is reaching across from the cloth ‘mother’ to which it is clinging to reach the milk supplied, in this case, by the wire one’
Broadhurst 1963
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Child Developmental Models: Attachment Theory
................
Working with deprived and desperate children evokes extremely strong maternal or paternal responses in professionals
.......Severe deprivation can’t be ‘cuddled better’ – emotional healing is needed first
.........Profound meaning of touch for deprived (‘touch hungry’/indiscriminately attached) children
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Child Developmental Models: Attachment Theory
Konrad Lorenz 1960
Austrian zoologist re-discovered ‘Imprinting’ by baby animals
Graylag geese hatched & divided into 2 groups: 1.
Mother 2. Lorenz
1.
Chicks hatched with mother immediately started to follow her around
2.
Chicks hatched with
Lorenz did the same and remained
‘attached’ to him long after hatching
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Other Child Developmental Models:
• Many theories in psychology characterize development in terms of stages:
• Jean Piaget developed a complex stage theory of cognitive development to describe how children reason and interact with their surroundings
• Lawrence Kohlberg applied and extended Piaget's stages to describe how individuals develop moral reasoning
• Sigmund Freud analyzed the progression of an individual's unconscious desires as occurring through psychosexual stages
• Anna Freud described developmental stages in a child’s early life based on her experiences in the Hampstead War Nurseries
• Erik Erikson expanded on Freud's psychosexual stages, defining eight psychosocial stages that describe how individuals relate to their social world
• Margaret Mahler 's psychoanalytic developmental theory contained three phases regarding the child's relationship to others, known as object relations
• Dodge’s social information processing model describes ways in which child responds to the environment
** See Royal College of Psychiatrists’ 2006 report for a review of normal child development and child developmental models
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1. PHYSICAL DEVELOPMENT
• Physical maturity & psychological maturity do not correlate
2. INTELLECTUAL DEVELOPMENT
• Average I.Q. does not mean mature judgment
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EMOTIONAL DEVELOPMENT
• Mid to late teens for development of emotional maturity, self control, deferring gratification, insight, empathy, remorse etc
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SOCIAL DEVELOPMENT
• Social factors associated with moral development & with delinquency
• Full moral development in adult life not childhood
RCPsychs 2006
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Physical Change, Posture and Large Movements
5 years
• Runs lightly on toes
• Active and skilful climbing, sliding, swinging, digging and various ‘stunts’.
• Skips on alternative feet
• Dances to music
• Can Stand on one foot 8-10 seconds
• Can hop 2-3 yards forwards on each foot separately
• Grips strongly with each hand
7-8 years
• Can bounce a ball on floor several times. Can ride a bicycle
• Can hop, jump, run skip, and throw
9-10 years
• Increasing strength
• Participation in individual and team sports
11-12 years
• Onset of Puberty
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Reproduced from J. Aldgate, D. Jones, W. Rose & C. Jeffery (2006). The developing world of the child . London, UK: Jessica
Kingsley Publishers

PHYSICAL DEVELOPMENT
Growth & development charts can give vital indications that a child’s physical development is/is not age appropriate.
The neglected/failure to thrive child or the very obese child may show a dramatic improvement on percentile scores when moved into a good foster home.
This can be evidential ‘gold dust’ in care proceedings.
Training in understanding growth & development charts is needed for those acting as experts in care proceedings.
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Understanding and Intellectual Capacity
5 years
• Beginning sense of values, right versus wrong, fairness
• Can evaluate own capabilities with some accuracy
• Counts to ten
7-8 years
• Begins to develop an ability to regulate own behaviour
(ability to wait, check aggression)
• Increasing curiosity
• Emerging morality, and concerns about others opinions of others
• Recognises that the whole comprises its parts
• Now ‘talks to him/herself’ – inner speech as part of growing understanding
9-10 years
• Memory capacity well established
• Several strategies for memorising events and facts
• Increase in logical thinking
• Capacity for inference develops
11-12 years
• Can reason about hypothetical events
• Awareness of other’s different perspectives
• Conscience becomes increasingly refined
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Reproduced from J. Aldgate, D. Jones, W. Rose & C. Jeffery (2006). The developing world of the child . London, UK: Jessica
Kingsley Publishers

INTELLECTUAL
DEVELOPMENT
‘Intelligence is a psychological trait found in all individuals across all cultures and populations.
Intelligence is measured as IQ (intelligence quotient) using standardised instruments which give a designated mean of 100 with a range of scores from 20 to over
150.’ RCPsychs 2006
IQ of <120 = Superior
IQ of > 70 = L.D.
Learning Disability strongly correlated with psychiatric disorders and with offending behaviour
Rutter et al 1998
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INTELLECTUAL DEVELOPMENT
• Assessment of Cognitive Functioning, including an IQ assessment, by a Clinical
Psychologist should be an essential prerequisite of the assessment of a young child with complex needs, e.g. for Care proceedings.
• Given the co-morbidity for Psychiatric disorders, a Psychiatric assessment should also be done, taking on board the results of the Cognitive assessment, particularly any
Learning Disability noted.
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EMOTIONAL DEVELOPMENT
• Is dependent on several factors including cognitive development and parenting
• Ability to defer gratification
• Impulse control
• Monitoring own thoughts & behaviour
• Understanding the consequences of own behaviour & impact of this on others
• Understanding complex abstract ideas such as ambivalence or mixed feelings
• Learning to make good moral judgments
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SOCIAL DEVELOPMENT
According to Piaget, this young child is in the sensorimotor stage and primarily explores the world with senses rather than through mental operations.
Her ability to communicate with others is steadily improving at this time along with her hearing & speech.
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Hearing and Speech
5 years
• Speech fluent and grammatical
• Articulation correct except for residual confusions of s/f/th and r/l/w/y groups
• Love stories and acts them out in detail later
• Gives full name, age and home address
• Gives age and (usually) birthday
• Defines concrete nouns by use
• Asks meaning of abstract words
• (12 ‘high frequency’ picture vocabulary or word lists, third cube test, six sentences)
7-8 years
• Can tell left from right, corrects own grammar
• Verbally expresses fantasies, and needs, and wishes
• Start of puns, riddles and word games
9-10 years
• Expresses ideas with complex relationship elements
• Increasingly subtle use of language to express thought, feelings, categories of things and comparisons between them
11-12 years
• Reading capacity now increasingly important for new information
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Reproduced from J. Aldgate, D. Jones, W. Rose & C. Jeffery (2006). The developing world of the child . London, UK: Jessica
Kingsley Publishers

• By ages 6-10 years old most children have developed considerable social skills
• They will still communicate through play which will become collaborative
• They have moved from a more egocentric stage of development to taking an interest in others’ behaviours, feelings and thought processes
• They are still struggling with complex abstract ideas and they lack the ability to take a long term view of life
• Stable personality traits are emerging
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Social Behaviour, Relationships and Play
5 years 7-8 years 9-10 years 11-12 years
• Uses knife and fork
• Washes and dries face and hands, but needs help and supervision for rest
• Undresses and dresses alone
• General behaviour more sensible, controlled and responsibly independent
• Domestic and dramatic play continued from day to day
• Plans and builds constructively
• Floor games very complicated
• Chooses own friends
• Co-operative with companions and understands needs for rules and fair play
• Appreciates meaning of clock time in relation to daily programme
• Tender and protective towards other children and pets. Comforts playmates in distress
• Develops peer and best friend relationships
• Beginning capacity for empathy and concern about others
• Moods more stable
• Gender identity now well established
• Best friends become increasingly important
• Mood now normally regulated and stable
• May develop animal phobias
• Increasing importance of peer friendships, based on shared values and understanding
• Well established empathic concern for others
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Reproduced from J. Aldgate, D. Jones, W. Rose & C. Jeffery (2006). The developing world of the child . London, UK: Jessica
Kingsley Publishers

• Most development occurs in early childhood and adolescence and follows recognised developmental stages or milestones at different ages
Steinberg & Schwartz 2000; RCPsychs 2006
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Infancy
Age Period
Developmental Progression
Principal aspects of change and growth
• Attachment to caregivers
• Gross and fine motor skills
• Communication and early language
• Increasingly complex expressions of emotion
• Differentiation of self from others
• Self control and compliance
Middle Childhood
Adolescence
• Developing friendships with peers
• Increasing complex physical capabilities and coordination
• Capable of long periods of concentration
• Moods becoming more stable, beginning of capacity for empathy and worry
• Developing sense of values (right versus wrong, what is fair, etc.)
• Beginning to regulate behaviour appropriately in different settings
• Able to communicate ideas and expressions of wishes
• Literacy and numeracy skills become established
• Forming a cohesive sense of self-identity
• Increasing ability to reason about hypothetical events
• Forming close friendships within and across gender
• Academic achievement (learning skills required for further education and work)
• Frequently questioning the belief system with which brought up
• Period of experimentation
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Reproduced from J. Aldgate, D. Jones, W. Rose & C. Jeffery (2006). The developing world of the child . London, UK: Jessica
Kingsley Publishers

• To be undertaken by trained staff
• To include mental health, paediatric, educational and social work inputs
• To address strengths & difficulties
• To assess parenting capacity, child developmental needs & environmental factors
• To include direct physical and emotional assessment of the child in question, not just
‘tick box’ questionnaires
• A model exists................................
( DoH 2000 )
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Department of Health. Department for Education and Employment and Home Office. Framework for the assessment of children in need and their families. London: Stationery Office, 2000.
CHILD
Safeguarding &
Promoting
Welfare
Family & Environmental Factors
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• This model can (and should) be modified as needed for sub-groups of children with special needs........................
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NCATS Emerging Severe Personality Disorder (ESPD) Assessment Triangle
(Vizard et al 2007; Vizard 2010) Based on DoH Assessment Framework 2000
•Pre-natal and birth history
•Neuro-cognitive profile
•Early difficult temperament
•Developmental delays
•Unresponsive to punishment
•Poor social skills; callous-unemotional traits; lack of empathy
•Severe behavioural problems –
Torturing animals, sadism, physical and sexual assaults on others
•IQ < 70
CHILD
Safeguarding &
Promoting
Welfare
6+ changes to home placement
Parental mental health
Parental childhood abuse
Parental time in care
Child removed to LA care
Insecure attachment
Inconsistent parenting
Family & Environmental Factors
Cross-generational family history/genetics of ASPD/psychopathy and developmental disorders;
Cruelty/sexual abuse of animals; Child exposed to domestic violence; Schedule 1 offenders in family;
Inadequate sexual boundaries; Adult sadistic and sexually perverted behaviour
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• The key issue is that all aspects of the assessment ‘triangle’ should be addressed in assessment of a child’s development
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To...............................
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Key References
Aldgate, J., Jones, D., Rose, W. & Jeffery, C. (Eds) (2006). The developing world of the child . Jessica Kingsley Publishers. London, UK.
Blakemore, S-J. & Choudhury, S. (2006). Development of the adolescent brain: implications for executive function and social cognition. Journal of Child Psychology & Psychiatry . 47,
296-312
Bowlby, J (1979). The Making and Breaking of Affectional Bonds. Tavistock Publications
Limited, 11 New Fetter Lane, London, EC4P 4EE
Broadbent, P.L. (1963). The Science of Animal Behaviour . Penguin Books. Middlesex,
England
De Brito, S. (2009). Maltreatment & Trauma. Impact on Brain Structure and Function.
Presentation given to the Neuroscience and Intervention Conference, UCL, 31 st October.
Department of Health. Department for Education and Employment and Home Office (2000).
Framework for the assessment of children in need and their families. London: Stationery
Office.
Erikson, E. (1050). Eight ages of man. In Childhood and Society . Harmondsworth. Penguin.
239-266
McCrory, E., De Brito, S. & Viding, E. (2010). Research Review: The neurobiology and genetics of maltreatment and adversity. The Journal of Child Psychology and Psychiatry.
Piaget, J. (1932). The Moral Judgment of the Child . New York. Harcourt.
Royal College of Psychiatrists (2006). Child Defendants. OP56. www.rcpsychs.org.uk
Rutter, M. & Rutter, M. (1993). Developing: Challenge and Continuity across the Lifespan.
Penguin. London.
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