is a little learning such a dangerous thing? sharing a vision conference springfield, il 1 october...

Is Is A Little LearningA Little Learning

Such Such AA

Dangerous Thing?Dangerous Thing?

Sharing A Vision Conference

Springfield, IL

1 October 2003

The University of Chicago

Bennett L. Leventhal, M.D.

Irving B. Harris Professor of Child and Adolescent Psychiatry

Professor of Psychiatry and Pediatrics

Director, Child and Adolescent Psychiatry

Director, The Sonia Shankman Orthogenic School

Laboratory of Developmental Neurosciences

Is Is A Little LearningA Little Learning

Such Such AA

Dangerous Thing?Dangerous Thing?

A little of what is being learned?

A little who is learning?

What is the basic goal of early learning?

To enhance developmental outcomes

Nature and Nurture

Interdependent concepts (examples) Nonhuman primate studies Effects of abuse on human infants

– effect of nurture on nature Effects of autistic disorder on maternal-

infant interaction– effect of nature on nurture

Additive or Synergistic when genetic parents raise child

Basic Premise

All considerations of all events in childhood

(or in adulthood, for that matter), be they

physiologic, psychological or experientialmust take place

in a developmental context

Why Consider Development?

What is Development?

Longitudinal?

Cross-Sectional?

Development is a Process

Individual and groups of characteristics and variables

acting individually and together.

Phases/Stages– Characterized by most prominent signs of rapid

development within a given developmental line during a given time

– Length of phase determined more by completion of a related set of changes within a developmental line than by number of months or years

– Should not be generally assumed that developmental tasks which are not most prominent are not developing or being used

Critical period

– Development of a function takes place during a restricted time period relative to gestation

– If appropriate stimulation is not present at that time, development will be affected

– Example - Hubel and Wiesel - monocular deprivation of kittens during critical period of visual system development (environmental input and NMDA receptor dependent)

Sensitive period

Times during which loss of appropriate environmental stimulation may have adverse consequences, but which may be overridden by stimulation outside of a narrow window

Example - abused or neglected children, who develop relatively normally after rehabilitation of parents' substance abuse, or after placement in a nurturing, structured adoptive home

Normality (necessary concept)

There is no normal race, gender, or sexual preference

Normality must be defined in the context of each person's personal and cultural context

For example, in Physical Diagnosis you won't be diagnosing your male patients as avaginal

Concept around which one should constantly refine one's clinical judgment as a physician

Examples of normal as average not being healthy

Although most children in Israel or the Palestinian territories may have experienced violence, it does not make it a healthy experience

Is Successful Development

NATURAL?

or

LEARNED?

What is Successful Development?

The optimal use of individual and environmental factors to reach the highest possible level of adaptive

functioning

Individual Characteristics

Genetics Appearance

Size Attractive/Dysmorphic

Intelligence Social Skills Personality Temperament

Developmental Lines

Development - Longitudinal

Developmental Lines Physical/Gross & Fine Motor Cognitive Language Psychosexual Interpersonal/psychosocial Affective Moral Spiritual

Longitudinal Models

Social Freud Mahler – Separation-Individuation Erikson - Psychosocial Piaget - Cognitive Language Motor Kohut – Object Relations Kohlberg – Moral Others

Social Stages of Development

0-12 months - Infancy 12 –36 months - Toddler 36 – 60 months - Preschool 7 – 12 years - School Age 12 – 18 years - Adolescence 18 – ?25 years Young Adulthood 25 – ?65 years - Adulthood 65 years + - Older Adulthood

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

Gross Motor

Roll over at 4 mo. 4 months – roll over 6 months - Sit unassisted 12-15 months - Walk unassisted 30 months - run 36 months - Stairs one step/foot, Ride

tricycle 6-7 years - Ride bicycle

Fine Motor

4 weeks – hands fisted 6 months - Grasps cube 18 months - Tower of 3 cubes 3 years - Draws circle 4 years - Draws square

Development - Cross-sectional

Observation of human development at a given time

Domains are interdependent Quality of integration of domains is

important The "whole" child or adult is subject of

study Pro and con: See forest well, but trees not

as clear

Cross-Sectional Development

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)

Prenatal Development

Nutrition important during prenatal development

Full-term or near-full term developmental failure is mostly due to hypoxia and related to CNS bleeding when birth excessively premature

However, outcomes progressively improving with advances in neonatal care

Post-natal Development

When does it really begin? At delivery? In utero, near delivery?

Post-natal Development

Physiological homeostasis is main goal

Key first step is feeding, which requires adequate muscle tone for sucking

Post-natal Development 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

Post-natal Development Bonding vs Attachment

Bonding Lorenz like imprinting a critical period

Attachment Bilateral Complex behavioral interaction Begins at birth

2-4 months 2 month social smile is very overdue for first-

time 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

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

6-9 Months Emergence of normative separation anxiety

and stranger wariness

Children become more mobile although not usually walking Creeping Crawling Pulling up and standing

For most children sleep and eating schedules are relatively organized

9-12 Months

Exciting time with development of single words starting with ‘dada’ (then ‘mama’) and with many other single words by 12 months

Development of walking from assisted to unassisted typically by 12 months

Increasing need for child-proofing (although this should occur prenatally)

12-18 Months Generally a time in which child is “in love with

the world” enjoying new 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)

18-36 Month-olds 18-36 months - anal period

(psychosexual), autonomy vs. shame and doubt (psychosocial), separation-individuation

reorganization of nervous system (pruning in primary sensory cortex)

18-36 Months

“Terrible two’s” Parental response important Child struggles to be soothed by parent

without feeling smothered Voracious appetite for learning and

trying new things Language

2-3 word phrases ->short sentences

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

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 parallel

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

Four year-olds

Has mastered toileting, although accidents not uncommon, especially through the night

Rapid increase 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

Four year-olds

Conflicts over autonomy are not most prominent conflict, but persist as a concern

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

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 boys (can’t separate out nature from nurture here) vs. preference for aggressive behavior

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

Five year-old

Kindergarten Pre-academic skills

early reading writing currently enhanced by “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

Five-year old - Academic

early math skills - especially geometric and functional

Counting and alphabet usually solid Early adding, but subtraction not typical

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

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 adolescence

Encopresis - daytime or nighttime defecation– if regular symptomatic of constipation or emotional

conflicts, particularly re: autonomy

Age (years) Psychosexual Psychosocial Separation-Individuation (S-I) CognitiveFreud Erikson Mahler Piaget

0-0.5 Infancy Oral (diadic) Trust v Mistrust Autistic (0-1mo.), symbiotic phases Sensori-motor (S-M)0.5-1 " " " S-I phase: hatching S-M1-1.5 Toddler " " S-I phase: practicing S-M: Object permanence 12 mo.1.5-3 " Anal (diadic) Autonomy v Shame & doubt S-I: rapprochement, object constancy Emergence of symbolic thought3-6 Preschool Oedipal/Elektral Initiative v Guilt Pre-operational thought6-12 School Age Latency Industry v Inferiority Operational thought12-18 Adolescence Adolescence Identity v Identity diffusion Formal operations

Young Adulthood Adulthood Intimacy v IsolationAdulthood " Generativity v Self-absorptionOlder Adulthood " Integrity v Disgust,Despair

Age (years) Social Gross Motor Fine Motor Language

0-0.5 Infancy Social smile (2 mo) Roll over at 4 mo. Hands fisted at 4 weeks Coos0.5-1 " Stranger anxiety Sit unassisted at 6 months Grasps cube at 6 months First words1-1.5 Toddler Walk unassisted 12-15 months Tower of 3 cubes by 18 months Increasing words1.5-3 " "No!" Stairs one step/foot at 3 Draws circle at 3 2 word sentences by 2 years3-6 Preschool Age of play Ride tricycle at 3 Draws square at 4 3 word phrases by 3 years6-12 School Age Peers increasing Ride bicycle at 6-7 Knows person, place, time by 8 years12-18 Adolescence Sep.-Indiv. Part 2

Young AdulthoodAdulthoodOlder Adulthood

Notes:Diadic: relationships focused on child and caregiverTriadic: relationships focused on child, caregiver, and another personObject permanence - can find an object hidden under 2 blanketsObject constancy - can retain a positive, sustaining image of primary caregiver

Interactional Models

Interactional Models - Example

Rutter's study (England) of effects of coeducational schooling on girls with early puberty adverse effect of coeducation only for low

socioeconomic status (SES) girls (increased risk for delinquency (conduct disorder)

Interactional Model - Example

Low birthweight (prematurity) and SES 1500 - 2500 g range, low birthweight leads

to decreased cognitive capacity only in low SES group

below 1500 g SES less important than birthweight for cognitive outcome

< 1500 g maternal risk behavior for prematurity at higher rates in low SES groups

Mediatorsand

Modifiers

Socioeconomic Status (SES)

A generalizable risk factor

Not to be equated with African-American, Asian-American, Appalachian, Liverpoolian

Each society differs in generalizable effects of race, gender, sexual preference on SES

There are NO generalizable effects of race, part of world, part of country, gender, sexual preference on any of the developmental lines listed above or on risk for psychopathology which are independent of SES effects

Strengths

Resilience

Strengths/Resilience 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

Is Impairment an indicator of:

Developmental Failure?

Inadequate Strengths or Resilience?

Can We Create Strength?

What Fosters Resilience?

Principles of Mental Healthin Early Childhood

Centrality of early parent-child relationship

Development as transactional process Intergenerational influences Development in context Multiple pathways Adaptation

Socioemotional Milestones in Young Children

Social reciprocity ( 3-6 mos.) Attachment ( 6-12 mos.) Exploration/mastery (12-18 mos.) Individuation (18-30 mos.) Self-control (30-54 mos.) Cooperative play (30-54 mos.) Empathy (30-54 mos.)

Infant Characteristics

State regulation Soothability Predictability Temperament Robustness Interest in Exploration Social Responsiveness

Infant Risk Factors

Difficult temperament Low birthweight Prenatal exposure to substances Gender Developmental delay Physical health problems

Parenting

Parenting

Biological Social Child-rearing

Parenting

Preparation Biology Maturity Modeling Formal Education

Parenting

Planning Unplanned Planned

Partnerships Alone Mother-father Other models

Parenting Risk Factors

Young age at first birth History of maltreatment/deprivation Maternal depression domestic violence/marital discord multiple, closely spaced births social isolation poverty

Parenting

Goodness of Fit: Individual characteristics of each parent Parent-to-parent Parents to child Parents to extended family Child to extended family Parents to community Child to Community

Dyadic Processes

Reciprocity Emotional engagement Synchrony Goodness of fit attachment

Parent-Child Contributions to Relationship Processes

PARENT: Emotional

availability Sensitivity Predictability Flexibility Psychological

resources

CHILD: Social

responsiveness Readability Regularity Adaptability Developmental

functioning

Responsive Parenting

Read cues accurately Interpret appropriately Respond contingently Awareness/responsiveness to child’s

changing developmental needs Attunement to child’s emotional state Packaging stimulation

Responsive Parenting with Toddlers and Preschoolers

Emotional availability Autonomy support Joint negotiation Consistent limit-setting Flexibility Labelling of emotions Fostering verbal problem-solving

Discipline

Authoritarian

vs

Authoritative

How Young Children Learn To Control Their Behavior

Developmental advances Structure and routine Parental guidance and modeling Experience of manageable challenge

and mastery Experience of social problem-solving

and negotiation of conflict

Child Risk Factors for Developing Behavior Problems

Genetic Prenatal substance exposure cognitive and language delays Temperament: reactive, low

adaptability, social wariness, fussy/irritable

Family Contributors to Young Children’s Behavior Problems

Exposure to violence Low parental supervision/monitoring Inconsistent, ineffective discipline Unresponsive Parenting Absence of proactive adult input in

learning to manage feelings, tolerate frustration and persist

Supporting Healthy Emotional Development in Young Children

Providing safe, secure, consistent environments

Fostering exploration and curiousity Building trusting relationships Nurturing families Helping children know “their place” Engendering hope Fostering development of adaptive skills

Interventions for Young Children

Behavioral Psychotherapeutic Psychopharmacologic

AND

Educational

A few lessons before closing:

Provide an appropriate structure

Activity should be qualitatively and qualitatively appropriate

Provide rules

Not too many

Make them simple and reasonable

Somethings are hard to teach

They still must be taught so that the child at least has an accurate

understanding of the facts

Talk is cheap

But, it is better than not talking at all – and conversing is even better

Be developmentally sensitive

Too much too soon can be as problematic as too little too late

Might is not always right

But, it is still important to understand differences in adult

and child roles and how that impacts learning

Personal resources do make a difference

Despite our wishes to the contrary – we all have limits

We all get angry and frustrated, at least once in a while

Managing frustration is at least as important as managing stress

Experience does make a difference

Not all experiences are good but there are usually ways to make them have some positive value

Fostering successful development is never easy

The absence of frustration and failure means that you either:

Did not try hard enough

Or

You are a liar

Don’t ever under estimate the power of modeling

Both Positive and Negative

Timing isn’t everything

But, time well spent is pretty important

Honesty is best policy

Always tell the truth but being brutally frank is not necessary

Good behavior in the absence of complete comprehension can be

good

And, it may even be adaptive

What you see is not always what you get

Blind reliance on or exposure to the media can be dangerous

Biology is not necessarily destiny

Some biological factors can be modified by experience

The competent, consistent and developmentally appropriate control of the child is never

wrong!

And, contrary to popular opinion, it neither limits development nor

inhibits creativity

Dreaming is good

It is better to have a dream dashed then to have never

dreamed at all

Is Is A Little LearningA Little Learning

Such Such AA

Dangerous Thing?Dangerous Thing?

I hoped you learned a little

I hope that

You did not feel endangered

AND

You are not dangerous