Adolescents need annual comprehensive health assessments to ensure progression through puberty without major problems (see Chapters 67 and 68). Sexual maturity is an important issue in adolescents. All adolescents should be assessed to monitor progression through sexual maturity rating stages (see Chapter 67). Other issues in physical development include scoliosis, obesity, and trauma (see Chapters 29 and 203). Most scoliosis is mild and requires only observation for progression. Obesity may first manifest during childhood and is an issue for many adolescents.
The use of milestones to assess development focuses on discrete behaviors that the clinician can observe or accept as present by parental report. This approach is based on comparing the patient’s behavior with that of many normal children whose behaviors evolve in a uniform sequence within specific age ranges (see Chapter 8). The development of the neuromuscular system, similar to that of other organ systems, is determined first by genetic endowment and then molded by environmental influences.
Although a sequence of specific, easily measured behaviors can adequately represent some areas of development (gross motor, fine motor, and language), other areas, particularly social and emotional development, are not as easy to assess. Easily measured developmental milestones are well established through age 6 years only. Other types of assessment (e.g., intelligence tests, school performance, and personality profiles) that expand the developmental milestone approach are available for older children but generally require time and expertise in administration and interpretation.
The terms bonding and attachment describe the affective relationships between parents and infants. Bonding occurs shortly after birth and reflects the feelings of the parents toward the newborn (unidirectional). Attachment involves reciprocal feelings between parent and infant and develops gradually over the first year.
Attachment of infants outside of the newborn period is crucial for optimal development. Infants who receive extra attention, such as parents responding immediately to any crying or fussiness, show less crying and fussiness at the end of the first year. Stranger anxiety develops between 9 and 18 months of age, when infants normally become insecure about separation from the primary caregiver. The infant’s new motor skills and attraction to novelty may lead to headlong plunges into new adventures that result in fright or pain followed by frantic efforts to find and cling to the primary caregiver. The result is dramatic swings from stubborn independence to clinging dependence that can be frustrating and confusing to parents. With secure attachment, this period of ambivalence may be shorter and less tumultuous.
Toddlers build on attachment and begin developing autonomy that allows separation from parents. In times of stress, toddlers often cling to their parents, but in their usual activities they may be actively separated. Ages 2 to 3 years are a time of major accomplishments in fine motor skills, social skills, cognitive skills, and language skills. The dependency of infancy yields to developing independence and the “I can do it myself ” age. Limit setting is essential to a balance of the child’s emerging independence.
There is a growing body of evidence that notes that children who are in high quality early learning environments are more prepared to succeed in school. Every dollar invested in early childhood education may save taxpayers up to 13 dollars in future costs. These children commit fewer crimes and are better prepared to enter the workforce after school. Early Head Start (less than 3 years), Head Start (3 to 4 years), and prekindergarten programs (4 to 5 years) all demonstrate better educational attainment, although the earlier the start, the better the results.
Readiness for preschool depends on the development of autonomy and the ability of the parent and the child to separate for hours at a time. Preschool experiences help children develop socialization skills; improve language; increase skill building in areas such as colors, numbers, and letters; and increase problem solving (puzzles).