case study on child development

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Description of Assignment

During your time at Manor, you will need to conduct a child case study. To do well, you will need to plan ahead and keep a schedule for observing the child. A case study at Manor typically includes the following components: 

• Three observations of the child: one qualitative, one quantitative, and one of your choice. 
• Three artifact collections and review: one qualitative, one quantitative, and one of your choice. 
• A Narrative

Within this tab, we will discuss how to complete all portions of the case study.  A copy of the rubric for the assignment is attached. 

• Case Study Rubric (Online)
• Case Study Rubric (Hybrid/F2F)

Qualitative and Quantitative Observation Tips

Remember your observation notes should provide the following detailed information about the child:

• child’s age,
• physical appearance,
• the setting, and
• any other important background information.

You should observe the child a minimum of 5 hours. Make sure you DO NOT use the child's real name in your observations. Always use a pseudo name for course assignments. 

You will use your observations to help write your narrative. When submitting your observations for the course please make sure they are typed so that they are legible for your instructor. This will help them provide feedback to you. 

Qualitative Observations

A qualitative observation is one in which you simply write down what you see using the anecdotal note format listed below. 

Quantitative Observations

A quantitative observation is one in which you will use some type of checklist to assess a child's skills. This can be a checklist that you create and/or one that you find on the web. A great choice of a checklist would be an Ounce Assessment and/or work sampling assessment depending on the age of the child. Below you will find some resources on finding checklists for this portion of the case study. If you are interested in using Ounce or Work Sampling, please see your program director for a copy. 

Remaining Objective 

For both qualitative and quantitative observations, you will only write down what your see and hear. Do not interpret your observation notes. Remain objective versus being subjective.

An example of an objective statement would be the following: "Johnny stacked three blocks vertically on top of a classroom table." or "When prompted by his teacher Johnny wrote his name but omitted the two N's in his name." 

An example of a subjective statement would be the following: "Johnny is happy because he was able to play with the block." or "Johnny omitted the two N's in his name on purpose." 

• Anecdotal Notes Form Form to use to record your observations.
• Guidelines for Writing Your Observations
• Tips for Writing Objective Observations
• Objective vs. Subjective

Qualitative and Quantitative Artifact Collection and Review Tips

For this section, you will collect artifacts from and/or on the child during the time you observe the child. Here is a list of the different types of artifacts you might collect: 

Potential Qualitative Artifacts 

• Photos of a child completing a task, during free play, and/or outdoors. 
• Samples of Artwork 
• Samples of writing 
• Products of child-led activities 

Potential Quantitative Artifacts 

• Checklist 
• Rating Scales
• Product Teacher-led activities 

Examples of Components of the Case Study

Here you will find a number of examples of components of the Case Study. Please use them as a guide as best practice for completing your Case Study assignment. 

• Qualitatitive Example 1
• Qualitatitive Example 2
• Quantitative Photo 1
• Qualitatitive Photo 1
• Quantitative Observation Example 1
• Artifact Photo 1
• Artifact Photo 2
• Artifact Photo 3
• Artifact Photo 4
• Artifact Sample Write-Up
• Case Study Narrative Example Although we do not expect you to have this many pages for your case study, pay close attention to how this case study is organized and written. The is an example of best practice.

Narrative Tips

The Narrative portion of your case study assignment should be written in APA style, double-spaced, and follow the format below:

• Introduction : Background information about the child (if any is known), setting, age, physical appearance, and other relevant details. There should be an overall feel for what this child and his/her family is like. Remember that the child’s neighborhood, school, community, etc all play a role in development, so make sure you accurately and fully describe this setting! --- 1 page
• Observations of Development :   The main body of your observations coupled with course material supporting whether or not the observed behavior was typical of the child’s age or not. Report behaviors and statements from both the child observation and from the parent/guardian interview— 1.5  pages
• Comment on Development: This is the portion of the paper where your professional analysis of your observations are shared. Based on your evidence, what can you generally state regarding the cognitive, social and emotional, and physical development of this child? Include both information from your observations and from your interview— 1.5 pages
• Conclusion: What are the relative strengths and weaknesses of the family, the child? What could this child benefit from? Make any final remarks regarding the child’s overall development in this section.— 1page
• Your Case Study Narrative should be a minimum of 5 pages.

Make sure to NOT to use the child’s real name in the Narrative Report. You should make reference to course material, information from your textbook, and class supplemental materials throughout the paper . 

Same rules apply in terms of writing in objective language and only using subjective minimally. REMEMBER to CHECK your grammar, spelling, and APA formatting before submitting to your instructor. It is imperative that you review the rubric of this assignment as well before completing it. 

Biggest Mistakes Students Make on this Assignment

Here is a list of the biggest mistakes that students make on this assignment: 

• Failing to start early . The case study assignment is one that you will submit in parts throughout the semester. It is important that you begin your observations on the case study before the first assignment is due. Waiting to the last minute will lead to a poor grade on this assignment, which historically has been the case for students who have completed this assignment. 
• Failing to utilize the rubrics. The rubrics provide students with guidelines on what components are necessary for the assignment. Often students will lose points because they simply read the descriptions of the assignment but did not pay attention to rubric portions of the assignment. 
• Failing to use APA formatting and proper grammar and spelling. It is imperative that you use spell check and/or other grammar checking software to ensure that your narrative is written well. Remember it must be in APA formatting so make sure that you review the tutorials available for you on our Lib Guide that will assess you in this area. 
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1 Chapter 1: Introduction to Child Development

Chapter objectives.

After this chapter, you should be able to:

• Describe the principles that underlie development.
• Differentiate periods of human development.
• Evaluate issues in development.
• Distinguish the different methods of research.
• Explain what a theory is.
• Compare and contrast different theories of child development.

Introduction

Welcome to Child Growth and Development. This text is a presentation of how and why children grow, develop, and learn.

We will look at how we change physically over time from conception through adolescence. We examine cognitive change, or how our ability to think and remember changes over the first 20 years or so of life. And we will look at how our emotions, psychological state, and social relationships change throughout childhood and adolescence. 1

Principles of Development

There are several underlying principles of development to keep in mind:

• Development is lifelong and change is apparent across the lifespan (although this text ends with adolescence). And early experiences affect later development.
• Development is multidirectional. We show gains in some areas of development, while showing loss in other areas.
• Development is multidimensional. We change across three general domains/dimensions; physical, cognitive, and social and emotional.
• The physical domain includes changes in height and weight, changes in gross and fine motor skills, sensory capabilities, the nervous system, as well as the propensity for disease and illness.
• The cognitive domain encompasses the changes in intelligence, wisdom, perception, problem-solving, memory, and language.
• The social and emotional domain (also referred to as psychosocial) focuses on changes in emotion, self-perception, and interpersonal relationships with families, peers, and friends.

All three domains influence each other. It is also important to note that a change in one domain may cascade and prompt changes in the other domains.

• Development is characterized by plasticity, which is our ability to change and that many of our characteristics are malleable. Early experiences are important, but children are remarkably resilient (able to overcome adversity).
• Development is multicontextual. 2 We are influenced by both nature (genetics) and nurture (the environment) – when and where we live and our actions, beliefs, and values are a response to circumstances surrounding us.  The key here is to understand that behaviors, motivations, emotions, and choices are all part of a bigger picture. 3

Now let’s look at a framework for examining development.

Periods of Development

Think about what periods of development that you think a course on Child Development would address. How many stages are on your list? Perhaps you have three: infancy, childhood, and teenagers. Developmentalists (those that study development) break this part of the life span into these five stages as follows:

• Prenatal Development (conception through birth)
• Infancy and Toddlerhood (birth through two years)
• Early Childhood (3 to 5 years)
• Middle Childhood (6 to 11 years)
• Adolescence (12 years to adulthood)

This list reflects unique aspects of the various stages of childhood and adolescence that will be explored in this book. So while both an 8 month old and an 8 year old are considered children, they have very different motor abilities, social relationships, and cognitive skills. Their nutritional needs are different and their primary psychological concerns are also distinctive.

Prenatal Development

Conception occurs and development begins. All of the major structures of the body are forming and the health of the mother is of primary concern. Understanding nutrition, teratogens (or environmental factors that can lead to birth defects), and labor and delivery are primary concerns.

Figure 1.1 – A tiny embryo depicting some development of arms and legs, as well as facial features that are starting to show. 4

Infancy and Toddlerhood

The two years of life are ones of dramatic growth and change. A newborn, with a keen sense of hearing but very poor vision is transformed into a walking, talking toddler within a relatively short period of time. Caregivers are also transformed from someone who manages feeding and sleep schedules to a constantly moving guide and safety inspector for a mobile, energetic child.

Figure 1.2 – A swaddled newborn. 5

Early Childhood

Early childhood is also referred to as the preschool years and consists of the years which follow toddlerhood and precede formal schooling. As a three to five-year-old, the child is busy learning language, is gaining a sense of self and greater independence, and is beginning to learn the workings of the physical world. This knowledge does not come quickly, however, and preschoolers may initially have interesting conceptions of size, time, space and distance such as fearing that they may go down the drain if they sit at the front of the bathtub or by demonstrating how long something will take by holding out their two index fingers several inches apart. A toddler’s fierce determination to do something may give way to a four-year-old’s sense of guilt for action that brings the disapproval of others.

Figure 1.3 – Two young children playing in the Singapore Botanic Gardens 6

Middle Childhood

The ages of six through eleven comprise middle childhood and much of what children experience at this age is connected to their involvement in the early grades of school. Now the world becomes one of learning and testing new academic skills and by assessing one’s abilities and accomplishments by making comparisons between self and others. Schools compare students and make these comparisons public through team sports, test scores, and other forms of recognition. Growth rates slow down and children are able to refine their motor skills at this point in life. And children begin to learn about social relationships beyond the family through interaction with friends and fellow students.

Figure 1.4 – Two children running down the street in Carenage, Trinidad and Tobago 7

Adolescence

Adolescence is a period of dramatic physical change marked by an overall physical growth spurt and sexual maturation, known as puberty. It is also a time of cognitive change as the adolescent begins to think of new possibilities and to consider abstract concepts such as love, fear, and freedom. Ironically, adolescents have a sense of invincibility that puts them at greater risk of dying from accidents or contracting sexually transmitted infections that can have lifelong consequences. 8

Figure 1.5 – Two smiling teenage women. 9

There are some aspects of development that have been hotly debated. Let’s explore these.

Issues in Development

Nature and nurture.

Why are people the way they are? Are features such as height, weight, personality, being diabetic, etc. the result of heredity or environmental factors-or both? For decades, scholars have carried on the “nature/nurture” debate. For any particular feature, those on the side of Nature would argue that heredity plays the most important role in bringing about that feature. Those on the side of Nurture would argue that one’s environment is most significant in shaping the way we are. This debate continues in all aspects of human development, and most scholars agree that there is a constant interplay between the two forces. It is difficult to isolate the root of any single behavior as a result solely of nature or nurture.

Continuity versus Discontinuity

Is human development best characterized as a slow, gradual process, or is it best viewed as one of more abrupt change? The answer to that question often depends on which developmental theorist you ask and what topic is being studied. The theories of Freud, Erikson, Piaget, and Kohlberg are called stage theories. Stage theories or discontinuous development assume that developmental change often occurs in distinct stages that are qualitatively different from each other, and in a set, universal sequence. At each stage of development, children and adults have different qualities and characteristics. Thus, stage theorists assume development is more discontinuous. Others, such as the behaviorists, Vygotsky, and information processing theorists, assume development is a more slow and gradual process known as continuous development. For instance, they would see the adult as not possessing new skills, but more advanced skills that were already present in some form in the child. Brain development and environmental experiences contribute to the acquisition of more developed skills.

Figure 1.6 – The graph to the left shows three stages in the continuous growth of a tree. The graph to the right shows four distinct stages of development in the life cycle of a ladybug. 10

Active versus Passive

How much do you play a role in your own developmental path? Are you at the whim of your genetic inheritance or the environment that surrounds you? Some theorists see humans as playing a much more active role in their own development. Piaget, for instance believed that children actively explore their world and construct new ways of thinking to explain the things they experience. In contrast, many behaviorists view humans as being more passive in the developmental process. 11

How do we know so much about how we grow, develop, and learn? Let’s look at how that data is gathered through research

Research Methods

An important part of learning any science is having a basic knowledge of the techniques used in gathering information. The hallmark of scientific investigation is that of following a set of procedures designed to keep questioning or skepticism alive while describing, explaining, or testing any phenomenon. Some people are hesitant to trust academicians or researchers because they always seem to change their story. That, however, is exactly what science is all about; it involves continuously renewing our understanding of the subjects in question and an ongoing investigation of how and why events occur. Science is a vehicle for going on a never-ending journey. In the area of development, we have seen changes in recommendations for nutrition, in explanations of psychological states as people age, and in parenting advice. So think of learning about human development as a lifelong endeavor.

Take a moment to write down two things that you know about childhood. Now, how do you know? Chances are you know these things based on your own history (experiential reality) or based on what others have told you or cultural ideas (agreement reality) (Seccombe and Warner, 2004). There are several problems with personal inquiry. Read the following sentence aloud:

Paris in the

Are you sure that is what it said? Read it again:

If you read it differently the second time (adding the second “the”) you just experienced one of the problems with personal inquiry; that is, the tendency to see what we believe. Our assumptions very often guide our perceptions, consequently, when we believe something, we tend to see it even if it is not there. This problem may just be a result of cognitive ‘blinders’ or it may be part of a more conscious attempt to support our own views. Confirmation bias is the tendency to look for evidence that we are right and in so doing, we ignore contradictory evidence. Popper suggests that the distinction between that which is scientific and that which is unscientific is that science is falsifiable; scientific inquiry involves attempts to reject or refute a theory or set of assumptions (Thornton, 2005). Theory that cannot be falsified is not scientific. And much of what we do in personal inquiry involves drawing conclusions based on what we have personally experienced or validating our own experience by discussing what we think is true with others who share the same views.

Science offers a more systematic way to make comparisons guard against bias.

Scientific Methods

One method of scientific investigation involves the following steps:

• Determining a research question
• Reviewing previous studies addressing the topic in question (known as a literature review)
• Determining a method of gathering information
• Conducting the study
• Interpreting results
• Drawing conclusions; stating limitations of the study and suggestions for future research
• Making your findings available to others (both to share information and to have your work scrutinized by others)

Your findings can then be used by others as they explore the area of interest and through this process a literature or knowledge base is established. This model of scientific investigation presents research as a linear process guided by a specific research question. And it typically involves quantifying or using statistics to understand and report what has been studied. Many academic journals publish reports on studies conducted in this manner.

Another model of research referred to as qualitative research may involve steps such as these:

• Begin with a broad area of interest
• Gain entrance into a group to be researched
• Gather field notes about the setting, the people, the structure, the activities or other areas of interest
• Ask open ended, broad “grand tour” types of questions when interviewing subjects
• Modify research questions as study continues
• Note patterns or consistencies
• Explore new areas deemed important by the people being observed
• Report findings

In this type of research, theoretical ideas are “grounded” in the experiences of the participants. The researcher is the student and the people in the setting are the teachers as they inform the researcher of their world (Glazer & Strauss, 1967). Researchers are to be aware of their own biases and assumptions, acknowledge them and bracket them in efforts to keep them from limiting accuracy in reporting. Sometimes qualitative studies are used initially to explore a topic and more quantitative studies are used to test or explain what was first described.

Let’s look more closely at some techniques, or research methods, used to describe, explain, or evaluate. Each of these designs has strengths and weaknesses and is sometimes used in combination with other designs within a single study.

Observational Studies

Observational studies involve watching and recording the actions of participants. This may take place in the natural setting, such as observing children at play at a park, or behind a one-way glass while children are at play in a laboratory playroom. The researcher may follow a checklist and record the frequency and duration of events (perhaps how many conflicts occur among 2-year-olds) or may observe and record as much as possible about an event (such as observing children in a classroom and capturing the details about the room design and what the children and teachers are doing and saying). In general, observational studies have the strength of allowing the researcher to see how people behave rather than relying on self-report. What people do and what they say they do are often very different. A major weakness of observational studies is that they do not allow the researcher to explain causal relationships. Yet, observational studies are useful and widely used when studying children. Children tend to change their behavior when they know they are being watched (known as the Hawthorne effect) and may not survey well.

Experiments

Experiments are designed to test hypotheses (or specific statements about the relationship between variables) in a controlled setting in efforts to explain how certain factors or events produce outcomes. A variable is anything that changes in value. Concepts are operationalized or transformed into variables in research, which means that the researcher must specify exactly what is going to be measured in the study.

Three conditions must be met in order to establish cause and effect. Experimental designs are useful in meeting these conditions.

The independent and dependent variables must be related. In other words, when one is altered, the other changes in response. (The independent variable is something altered or introduced by the researcher. The dependent variable is the outcome or the factor affected by the introduction of the independent variable. For example, if we are looking at the impact of exercise on stress levels, the independent variable would be exercise; the dependent variable would be stress.)

The cause must come before the effect. Experiments involve measuring subjects on the dependent variable before exposing them to the independent variable (establishing a baseline). So we would measure the subjects’ level of stress before introducing exercise and then again after the exercise to see if there has been a change in stress levels. (Observational and survey research does not always allow us to look at the timing of these events, which makes understanding causality problematic with these designs.)

The cause must be isolated. The researcher must ensure that no outside, perhaps unknown variables are actually causing the effect we see. The experimental design helps make this possible. In an experiment, we would make sure that our subjects’ diets were held constant throughout the exercise program. Otherwise, diet might really be creating the change in stress level rather than exercise.

A basic experimental design involves beginning with a sample (or subset of a population) and randomly assigning subjects to one of two groups: the experimental group or the control group. The experimental group is the group that is going to be exposed to an independent variable or condition the researcher is introducing as a potential cause of an event. The control group is going to be used for comparison and is going to have the same experience as the experimental group but will not be exposed to the independent variable. After exposing the experimental group to the independent variable, the two groups are measured again to see if a change has occurred. If so, we are in a better position to suggest that the independent variable caused the change in the dependent variable.

The major advantage of the experimental design is that of helping to establish cause and effect relationships. A disadvantage of this design is the difficulty of translating much of what happens in a laboratory setting into real life.

Case Studies

Case studies involve exploring a single case or situation in great detail. Information may be gathered with the use of observation, interviews, testing, or other methods to uncover as much as possible about a person or situation. Case studies are helpful when investigating unusual situations such as brain trauma or children reared in isolation. And they are often used by clinicians who conduct case studies as part of their normal practice when gathering information about a client or patient coming in for treatment. Case studies can be used to explore areas about which little is known and can provide rich detail about situations or conditions. However, the findings from case studies cannot be generalized or applied to larger populations; this is because cases are not randomly selected and no control group is used for comparison.

Figure 1.7 – Illustrated poster from a classroom describing a case study. 12

Surveys are familiar to most people because they are so widely used. Surveys enhance accessibility to subjects because they can be conducted in person, over the phone, through the mail, or online. A survey involves asking a standard set of questions to a group of subjects. In a highly structured survey, subjects are forced to choose from a response set such as “strongly disagree, disagree, undecided, agree, strongly agree”; or “0, 1-5, 6-10, etc.” This is known as Likert Scale . Surveys are commonly used by sociologists, marketing researchers, political scientists, therapists, and others to gather information on many independent and dependent variables in a relatively short period of time. Surveys typically yield surface information on a wide variety of factors, but may not allow for in-depth understanding of human behavior.

Of course, surveys can be designed in a number of ways. They may include forced choice questions and semi-structured questions in which the researcher allows the respondent to describe or give details about certain events. One of the most difficult aspects of designing a good survey is wording questions in an unbiased way and asking the right questions so that respondents can give a clear response rather than choosing “undecided” each time. Knowing that 30% of respondents are undecided is of little use! So a lot of time and effort should be placed on the construction of survey items. One of the benefits of having forced choice items is that each response is coded so that the results can be quickly entered and analyzed using statistical software. Analysis takes much longer when respondents give lengthy responses that must be analyzed in a different way. Surveys are useful in examining stated values, attitudes, opinions, and reporting on practices. However, they are based on self-report or what people say they do rather than on observation and this can limit accuracy.

Developmental Designs

Developmental designs are techniques used in developmental research (and other areas as well). These techniques try to examine how age, cohort, gender, and social class impact development.

Longitudinal Research

Longitudinal research involves beginning with a group of people who may be of the same age and background, and measuring them repeatedly over a long period of time. One of the benefits of this type of research is that people can be followed through time and be compared with them when they were younger.

Figure 1.8 – A longitudinal research design. 13

A problem with this type of research is that it is very expensive and subjects may drop out over time. The Perry Preschool Project which began in 1962 is an example of a longitudinal study that continues to provide data on children’s development.

Cross-sectional Research

Cross-sectional research involves beginning with a sample that represents a cross-section of the population. Respondents who vary in age, gender, ethnicity, and social class might be asked to complete a survey about television program preferences or attitudes toward the use of the Internet. The attitudes of males and females could then be compared, as could attitudes based on age. In cross-sectional research, respondents are measured only once.

Figure 1.9 – A cross-sectional research design. 14

This method is much less expensive than longitudinal research but does not allow the researcher to distinguish between the impact of age and the cohort effect. Different attitudes about the use of technology, for example, might not be altered by a person’s biological age as much as their life experiences as members of a cohort.

Sequential Research

Sequential research involves combining aspects of the previous two techniques; beginning with a cross-sectional sample and measuring them through time.

Figure 1.10 – A sequential research design. 15

This is the perfect model for looking at age, gender, social class, and ethnicity. But the drawbacks of high costs and attrition are here as well. 16

Table 1 .1 – Advantages and Disadvantages of Different Research Designs 17

Consent and Ethics in Research

Research should, as much as possible, be based on participants’ freely volunteered informed consent. For minors, this also requires consent from their legal guardians. This implies a responsibility to explain fully and meaningfully to both the child and their guardians what the research is about and how it will be disseminated. Participants and their legal guardians should be aware of the research purpose and procedures, their right to refuse to participate; the extent to which confidentiality will be maintained; the potential uses to which the data might be put; the foreseeable risks and expected benefits; and that participants have the right to discontinue at any time.

But consent alone does not absolve the responsibility of researchers to anticipate and guard against potential harmful consequences for participants. 18 It is critical that researchers protect all rights of the participants including confidentiality.

Child development is a fascinating field of study – but care must be taken to ensure that researchers use appropriate methods to examine infant and child behavior, use the correct experimental design to answer their questions, and be aware of the special challenges that are part-and-parcel of developmental research. Hopefully, this information helped you develop an understanding of these various issues and to be ready to think more critically about research questions that interest you. There are so many interesting questions that remain to be examined by future generations of developmental scientists – maybe you will make one of the next big discoveries! 19

Another really important framework to use when trying to understand children’s development are theories of development. Let’s explore what theories are and introduce you to some major theories in child development.

Developmental Theories

What is a theory.

Students sometimes feel intimidated by theory; even the phrase, “Now we are going to look at some theories…” is met with blank stares and other indications that the audience is now lost. But theories are valuable tools for understanding human behavior; in fact they are proposed explanations for the “how” and “whys” of development. Have you ever wondered, “Why is my 3 year old so inquisitive?” or “Why are some fifth graders rejected by their classmates?” Theories can help explain these and other occurrences. Developmental theories offer explanations about how we develop, why we change over time and the kinds of influences that impact development.

A theory guides and helps us interpret research findings as well. It provides the researcher with a blueprint or model to be used to help piece together various studies. Think of theories as guidelines much like directions that come with an appliance or other object that requires assembly. The instructions can help one piece together smaller parts more easily than if trial and error are used.

Theories can be developed using induction in which a number of single cases are observed and after patterns or similarities are noted, the theorist develops ideas based on these examples. Established theories are then tested through research; however, not all theories are equally suited to scientific investigation.  Some theories are difficult to test but are still useful in stimulating debate or providing concepts that have practical application. Keep in mind that theories are not facts; they are guidelines for investigation and practice, and they gain credibility through research that fails to disprove them. 20

Let’s take a look at some key theories in Child Development.

Sigmund Freud’s Psychosexual Theory

We begin with the often controversial figure, Sigmund Freud (1856-1939). Freud has been a very influential figure in the area of development; his view of development and psychopathology dominated the field of psychiatry until the growth of behaviorism in the 1950s. His assumptions that personality forms during the first few years of life and that the ways in which parents or other caregivers interact with children have a long-lasting impact on children’s emotional states have guided parents, educators, clinicians, and policy-makers for many years. We have only recently begun to recognize that early childhood experiences do not always result in certain personality traits or emotional states. There is a growing body of literature addressing resilience in children who come from harsh backgrounds and yet develop without damaging emotional scars (O’Grady and Metz, 1987). Freud has stimulated an enormous amount of research and generated many ideas. Agreeing with Freud’s theory in its entirety is hardly necessary for appreciating the contribution he has made to the field of development.

Figure 1.11 – Sigmund Freud. 21

Freud’s theory of self suggests that there are three parts of the self.

The id is the part of the self that is inborn. It responds to biological urges without pause and is guided by the principle of pleasure: if it feels good, it is the thing to do. A newborn is all id. The newborn cries when hungry, defecates when the urge strikes.

The ego develops through interaction with others and is guided by logic or the reality principle. It has the ability to delay gratification. It knows that urges have to be managed. It mediates between the id and superego using logic and reality to calm the other parts of the self.

The superego represents society’s demands for its members. It is guided by a sense of guilt. Values, morals, and the conscience are all part of the superego.

The personality is thought to develop in response to the child’s ability to learn to manage biological urges. Parenting is important here. If the parent is either overly punitive or lax, the child may not progress to the next stage. Here is a brief introduction to Freud’s stages.

Table 1. 2 – Sigmund Freud’s Psychosexual Theory

Strengths and Weaknesses of Freud’s Theory

Freud’s theory has been heavily criticized for several reasons. One is that it is very difficult to test scientifically. How can parenting in infancy be traced to personality in adulthood? Are there other variables that might better explain development? The theory is also considered to be sexist in suggesting that women who do not accept an inferior position in society are somehow psychologically flawed. Freud focuses on the darker side of human nature and suggests that much of what determines our actions is unknown to us. So why do we study Freud? As mentioned above, despite the criticisms, Freud’s assumptions about the importance of early childhood experiences in shaping our psychological selves have found their way into child development, education, and parenting practices. Freud’s theory has heuristic value in providing a framework from which to elaborate and modify subsequent theories of development. Many later theories, particularly behaviorism and humanism, were challenges to Freud’s views. 22

Erik Erikson’s Psychosocial Theory

Now, let’s turn to a less controversial theorist, Erik Erikson. Erikson (1902-1994) suggested that our relationships and society’s expectations motivate much of our behavior in his theory of psychosocial development. Erikson was a student of Freud’s but emphasized the importance of the ego, or conscious thought, in determining our actions. In other words, he believed that we are not driven by unconscious urges. We know what motivates us and we consciously think about how to achieve our goals. He is considered the father of developmental psychology because his model gives us a guideline for the entire life span and suggests certain primary psychological and social concerns throughout life.

Figure 1.12 – Erik Erikson. 23

Erikson expanded on his Freud’s by emphasizing the importance of culture in parenting practices and motivations and adding three stages of adult development (Erikson, 1950; 1968). He believed that we are aware of what motivates us throughout life and the ego has greater importance in guiding our actions than does the id. We make conscious choices in life and these choices focus on meeting certain social and cultural needs rather than purely biological ones. Humans are motivated, for instance, by the need to feel that the world is a trustworthy place, that we are capable individuals, that we can make a contribution to society, and that we have lived a meaningful life. These are all psychosocial problems.

Erikson divided the lifespan into eight stages. In each stage, we have a major psychosocial task to accomplish or crisis to overcome.  Erikson believed that our personality continues to take shape throughout our lifespan as we face these challenges in living. Here is a brief overview of the eight stages:

Table 1. 3 – Erik Erikson’s Psychosocial Theory

These eight stages form a foundation for discussions on emotional and social development during the life span. Keep in mind, however, that these stages or crises can occur more than once. For instance, a person may struggle with a lack of trust beyond infancy under certain circumstances. Erikson’s theory has been criticized for focusing so heavily on stages and assuming that the completion of one stage is prerequisite for the next crisis of development. His theory also focuses on the social expectations that are found in certain cultures, but not in all. For instance, the idea that adolescence is a time of searching for identity might translate well in the middle-class culture of the United States, but not as well in cultures where the transition into adulthood coincides with puberty through rites of passage and where adult roles offer fewer choices. 24

Behaviorism

While Freud and Erikson looked at what was going on in the mind, behaviorism rejected any reference to mind and viewed overt and observable behavior as the proper subject matter of psychology. Through the scientific study of behavior, it was hoped that laws of learning could be derived that would promote the prediction and control of behavior. 25

Ivan Pavlov

Ivan Pavlov (1880-1937) was a Russian physiologist interested in studying digestion. As he recorded the amount of salivation his laboratory dogs produced as they ate, he noticed that they actually began to salivate before the food arrived as the researcher walked down the hall and toward the cage. “This,” he thought, “is not natural!” One would expect a dog to automatically salivate when food hit their palate, but BEFORE the food comes? Of course, what had happened was . . . you tell me. That’s right! The dogs knew that the food was coming because they had learned to associate the footsteps with the food. The key word here is “learned”. A learned response is called a “conditioned” response.

Figure 1.13 – Ivan Pavlov. 26

Pavlov began to experiment with this concept of classical conditioning . He began to ring a bell, for instance, prior to introducing the food. Sure enough, after making this connection several times, the dogs could be made to salivate to the sound of a bell. Once the bell had become an event to which the dogs had learned to salivate, it was called a conditioned stimulus . The act of salivating to a bell was a response that had also been learned, now termed in Pavlov’s jargon, a conditioned response. Notice that the response, salivation, is the same whether it is conditioned or unconditioned (unlearned or natural). What changed is the stimulus to which the dog salivates. One is natural (unconditioned) and one is learned (conditioned).

Let’s think about how classical conditioning is used on us. One of the most widespread applications of classical conditioning principles was brought to us by the psychologist, John B. Watson.

John B. Watson

John B. Watson (1878-1958) believed that most of our fears and other emotional responses are classically conditioned. He had gained a good deal of popularity in the 1920s with his expert advice on parenting offered to the public.

Figure 1.14 – John B. Watson. 27

He tried to demonstrate the power of classical conditioning with his famous experiment with an 18 month old boy named “Little Albert”. Watson sat Albert down and introduced a variety of seemingly scary objects to him: a burning piece of newspaper, a white rat, etc. But Albert remained curious and reached for all of these things. Watson knew that one of our only inborn fears is the fear of loud noises so he proceeded to make a loud noise each time he introduced one of Albert’s favorites, a white rat. After hearing the loud noise several times paired with the rat, Albert soon came to fear the rat and began to cry when it was introduced. Watson filmed this experiment for posterity and used it to demonstrate that he could help parents achieve any outcomes they desired, if they would only follow his advice. Watson wrote columns in newspapers and in magazines and gained a lot of popularity among parents eager to apply science to household order.

Operant conditioning, on the other hand, looks at the way the consequences of a behavior increase or decrease the likelihood of a behavior occurring again. So let’s look at this a bit more.

B.F. Skinner and Operant Conditioning

B. F. Skinner (1904-1990), who brought us the principles of operant conditioning, suggested that reinforcement is a more effective means of encouraging a behavior than is criticism or punishment. By focusing on strengthening desirable behavior, we have a greater impact than if we emphasize what is undesirable. Reinforcement is anything that an organism desires and is motivated to obtain.

Figure 1.15 – B. F. Skinner. 28

A reinforcer is something that encourages or promotes a behavior. Some things are natural rewards. They are considered intrinsic or primary because their value is easily understood. Think of what kinds of things babies or animals such as puppies find rewarding.

Extrinsic or secondary reinforcers are things that have a value not immediately understood. Their value is indirect. They can be traded in for what is ultimately desired.

The use of positive reinforcement involves adding something to a situation in order to encourage a behavior. For example, if I give a child a cookie for cleaning a room, the addition of the cookie makes cleaning more likely in the future. Think of ways in which you positively reinforce others.

Negative reinforcement occurs when taking something unpleasant away from a situation encourages behavior. For example, I have an alarm clock that makes a very unpleasant, loud sound when it goes off in the morning. As a result, I get up and turn it off. By removing the noise, I am reinforced for getting up. How do you negatively reinforce others?

Punishment is an effort to stop a behavior. It means to follow an action with something unpleasant or painful. Punishment is often less effective than reinforcement for several reasons. It doesn’t indicate the desired behavior, it may result in suppressing rather than stopping a behavior, (in other words, the person may not do what is being punished when you’re around, but may do it often when you leave), and a focus on punishment can result in not noticing when the person does well.

Not all behaviors are learned through association or reinforcement. Many of the things we do are learned by watching others. This is addressed in social learning theory.

Social Learning Theory

Albert Bandura (1925-) is a leading contributor to social learning theory. He calls our attention to the ways in which many of our actions are not learned through conditioning; rather, they are learned by watching others (1977). Young children frequently learn behaviors through imitation

Figure 1.16 – Albert Bandura. 29

Sometimes, particularly when we do not know what else to do, we learn by modeling or copying the behavior of others. A kindergartner on his or her first day of school might eagerly look at how others are acting and try to act the same way to fit in more quickly. Adolescents struggling with their identity rely heavily on their peers to act as role-models. Sometimes we do things because we’ve seen it pay off for someone else. They were operantly conditioned, but we engage in the behavior because we hope it will pay off for us as well. This is referred to as vicarious reinforcement (Bandura, Ross and Ross, 1963).

Bandura (1986) suggests that there is interplay between the environment and the individual. We are not just the product of our surroundings, rather we influence our surroundings. Parents not only influence their child’s environment, perhaps intentionally through the use of reinforcement, etc., but children influence parents as well. Parents may respond differently with their first child than with their fourth. Perhaps they try to be the perfect parents with their firstborn, but by the time their last child comes along they have very different expectations both of themselves and their child. Our environment creates us and we create our environment. 30

Theories also explore cognitive development and how mental processes change over time.

Jean Piaget’s Theory of Cognitive Development

Jean Piaget (1896-1980) is one of the most influential cognitive theorists. Piaget was inspired to explore children’s ability to think and reason by watching his own children’s development. He was one of the first to recognize and map out the ways in which children’s thought differs from that of adults. His interest in this area began when he was asked to test the IQ of children and began to notice that there was a pattern in their wrong answers. He believed that children’s intellectual skills change over time through maturation. Children of differing ages interpret the world differently.

Figure 1.17 – Jean Piaget. 32

Piaget believed our desire to understand the world comes from a need for cognitive equilibrium . This is an agreement or balance between what we sense in the outside world and what we know in our minds. If we experience something that we cannot understand, we try to restore the balance by either changing our thoughts or by altering the experience to fit into what we do understand. Perhaps you meet someone who is very different from anyone you know. How do you make sense of this person? You might use them to establish a new category of people in your mind or you might think about how they are similar to someone else.

A schema or schemes are categories of knowledge. They are like mental boxes of concepts. A child has to learn many concepts. They may have a scheme for “under” and “soft” or “running” and “sour”. All of these are schema. Our efforts to understand the world around us lead us to develop new schema and to modify old ones.

One way to make sense of new experiences is to focus on how they are similar to what we already know. This is assimilation . So the person we meet who is very different may be understood as being “sort of like my brother” or “his voice sounds a lot like yours.” Or a new food may be assimilated when we determine that it tastes like chicken!

Another way to make sense of the world is to change our mind. We can make a cognitive accommodation to this new experience by adding new schema. This food is unlike anything I’ve tasted before. I now have a new category of foods that are bitter-sweet in flavor, for instance. This is  accommodation . Do you accommodate or assimilate more frequently? Children accommodate more frequently as they build new schema. Adults tend to look for similarity in their experience and assimilate. They may be less inclined to think “outside the box.”

Piaget suggested different ways of understanding that are associated with maturation. He divided this into four stages:

Table 1.4 – Jean Piaget’s Theory of Cognitive Development

Criticisms of Piaget’s Theory

Piaget has been criticized for overemphasizing the role that physical maturation plays in cognitive development and in underestimating the role that culture and interaction (or experience) plays in cognitive development. Looking across cultures reveals considerable variation in what children are able to do at various ages. Piaget may have underestimated what children are capable of given the right circumstances. 33

Lev Vygotsky’s Sociocultural Theory

Lev Vygotsky (1896-1934) was a Russian psychologist who wrote in the early 1900s but whose work was discovered in the United States in the 1960s but became more widely known in the 1980s. Vygotsky differed with Piaget in that he believed that a person not only has a set of abilities, but also a set of potential abilities that can be realized if given the proper guidance from others. His sociocultural theory emphasizes the importance of culture and interaction in the development of cognitive abilities. He believed that through guided participation known as scaffolding, with a teacher or capable peer, a child can learn cognitive skills within a certain range known as the zone of proximal development . 34 His belief was that development occurred first through children’s immediate social interactions, and then moved to the individual level as they began to internalize their learning. 35

Figure 1.18- Lev Vygotsky. 36

Have you ever taught a child to perform a task? Maybe it was brushing their teeth or preparing food. Chances are you spoke to them and described what you were doing while you demonstrated the skill and let them work along with you all through the process. You gave them assistance when they seemed to need it, but once they knew what to do-you stood back and let them go. This is scaffolding and can be seen demonstrated throughout the world. This approach to teaching has also been adopted by educators. Rather than assessing students on what they are doing, they should be understood in terms of what they are capable of doing with the proper guidance. You can see how Vygotsky would be very popular with modern day educators. 37

Comparing Piaget and Vygotsky

Vygotsky concentrated more on the child’s immediate social and cultural environment and his or her interactions with adults and peers. While Piaget saw the child as actively discovering the world through individual interactions with it, Vygotsky saw the child as more of an apprentice, learning through a social environment of others who had more experience and were sensitive to the child’s needs and abilities. 38

Like Vygotsky’s, Bronfenbrenner looked at the social influences on learning and development.

Urie Bronfenbrenner’s Ecological Systems Model

Urie Bronfenbrenner (1917-2005) offers us one of the most comprehensive theories of human development. Bronfenbrenner studied Freud, Erikson, Piaget, and learning theorists and believed that all of those theories could be enhanced by adding the dimension of context. What is being taught and how society interprets situations depends on who is involved in the life of a child and on when and where a child lives.

Figure 1.19 – Urie Bronfenbrenner. 39

Bronfenbrenner’s ecological systems model explains the direct and indirect influences on an individual’s development.

Table 1.5 – Urie Bronfenbrenner’s Ecological Systems Model

For example, in order to understand a student in math, we can’t simply look at that individual and what challenges they face directly with the subject. We have to look at the interactions that occur between teacher and child. Perhaps the teacher needs to make modifications as well. The teacher may be responding to regulations made by the school, such as new expectations for students in math or constraints on time that interfere with the teacher’s ability to instruct. These new demands may be a response to national efforts to promote math and science deemed important by political leaders in response to relations with other countries at a particular time in history.

Figure 1.20 – Bronfenbrenner’s ecological systems theory. 40

Bronfenbrenner’s ecological systems model challenges us to go beyond the individual if we want to understand human development and promote improvements. 41

In this chapter we looked at:

underlying principles of development

the five periods of development

three issues in development

Various methods of research

important theories that help us understand development

Next, we are going to be examining where we all started with conception, heredity, and prenatal development.

Child Growth and Development Copyright © by Jean Zaar is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License , except where otherwise noted.

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Casebook: Developmentally Appropriate Practice in Early Childhood Programs Serving Children from Birth Through Age 8

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About the book.

• Make connections to the fourth edition of Developmentally Appropriate Practice in Early Childhood Programs 
• Think critically about the influence of context on educator, child, and family actions 
• Discuss the effectiveness of the teaching practices and how they might be improved 
• Support your responses with evidence from the DAP position statement and book 
• Explore next steps beyond the case details 
• Apply the learning to your own situation 

Table of Contents

• Editors, Contributors, and Reviewers
• Introduction and Book Overview | Jennifer J. Chen and Dana Battaglia
• 1.1 Missed Opportunities: Relationship Building in Inclusive Classrooms | Julia Torquati
• 1.2 “My Name Is Not a Shame” | Kevin McGowan
• 1.3 Fostering Developmentally Appropriate Practice Through Virtual Family Connections | Lea Ann Christenson
• 1.4 Counting Collections in Community | Amy Schmidtke
• 1.5 The Joy Jar: Celebrating Kindness | Leah Schoenberg Muccio
• 1.6 Prioritizing Listening to and Learning from Families | Amy Schmidtke 
• 2.1 Julio’s Village: Early Childhood Education Supports for Teen Parents | Donna Kirkwood
• 2.2 Healthy Boundaries: Listening to Children and Learning from Families | Jovanna Archuleta
• 2.3 Roadmap of Family Engagement to Kindergarten: An Ecological Systems Approach | Marcela Andrés
• 2.4 Taking Trust for Granted? The Importance of Communication and Outreach in Family Partnerships | Suzanna Ewert
• 2.5 Book Reading: Learning About Migration and Our Family Stories | Sarah Rendón García 
• 3.1 Pairing Standardized Scale with Observation | Megan Schumaker-Murphy
• 3.2 The Power of Observing Jordan | Marsha Shigeyo Hawley and Barbara Abel
• 3.3 “But What Is My Child Learning?” | Janet Thompson and Jennifer Gonzalez
• 3.4 Drawing and Dialogue: Using Authentic Assessment to Understand Children’s Sense of Self and Observe Early Literacy Skills | Brandon L. Gilbert
• 3.5 The ABCs of Kindergarten Registration: Assessment, Background, and Collaboration Between Home and School | Bridget Amory
• 3.6 Creating Opportunities for Individualized Assessment Activities for Biliteracy Development | Esther Garza
• 3.7 Observing Second-Graders’ Vocabulary Development | Marie Ann Donovan
• 3.8 Writing Isn’t the Only Way! Multiple Means of Expressing Learning | Lee Ann Jungiv 
• 4.1 Engaging with Families to Individualize Teaching | Marie L. Masterson 
• 4.2 Tumbling Towers with Toddlers: Intention and Decision Making Over Blocks | Ron Grady  
• 4.3 What My Heart Holds: Exploring Identity with Preschool Learners | Cierra Kaler-Jones 
• 4.4 “I See a Really Big Gecko!” When Background Knowledge and Teaching Materials Don’t Match | Germaine Kaleilehua Tauati and Colleen E. Whittingham 
• 4.5 Using a Humanizing and Restorative Approach for Young Children to Develop Responsibility and Self-Regulation | Saili S. Kulkarni, Sunyoung Kim, and Nicola Holdman 
• 4.6 Joyful, Developmentally Appropriate Learning Environments for African American Youth | Lauren C. Mims, Addison Duane, LaKenya Johnson, and Erika Bocknek 
• 5.1 Using the Environment and Materials as Curriculum for Promoting Infants’ and Toddlers’ Exploration of Basic Cause-and-Effect Principles | Guadalupe Rivas 
• 5.2 Social Play Connections Among a Small Group of Preschoolers | Leah Catching 
• 5.3 Can Preschoolers Code? A Sneak Peek into a Developmentally Appropriate Coding Lesson | Olabisi Adesuyi-Fasuyi 
• 5.4 Everyday Gifts: Children Show Us the Path—We Observe and Scaffold | Martha Melgoza 
• 5.5 Learning to Conquer the Slide Through Persistence and Engaging in Social Interaction | Sueli Nunes 
• 5.6 “Sabes que todos los caracoles pueden tener bebés? Do You Know that All Snails Can Have Babies?” Supporting Children’s Emerging Interests in a Dual Language Preschool Classroom | Isauro M. Escamilla 
• 5.7 “Can We Read this One?” A Conversation About Book Selection in Kindergarten | Larissa Hsia-Wong  
• 6.1 Take a Chance on Coaching: It’s Worth It! | Lauren Bond 
• 6.2 It Started with a Friendship Parade | Angela Vargas 
• 6.3 The World Outside of the Classroom: Letting Your Voice Be Heard | Meghann Hickey 
• 7.1 Communication as a Two-Way Street? Creating Opportunities for Engagement During Meaningful Language Routines | Kameron C. Cardenv 
• 7.2 Eli Goes to Preschool: Inclusion for a Child with Autism Spectrum Disorder | Abby Hodges
• 7.3 Preschool Classroom Supports and Embedded Interventions with Coteaching | Racheal Kuperus and Desarae Orgo
• 7.4 Addressing Challenging Behavior Using the Pyramid Model | Ellie Bold
• 7.5 Dual Language or Disability? How Teachers Can Be the First to Help | Alyssa Brillante
• 7.6 Adapting and Modifying Instruction Using Reader’s Theater | Michelle Gonzalez
• 7.7 Supporting Children with Learning Disabilities in Mathematics: The Importance of Observation, Content Knowledge, and Context | Renee B. Whelan 
• 8.1 Facilitating a Child’s Transition from Home to Group Care Through the Use of Cultural Caring Routines | Josephine Ahmadein
• 8.2 Engaging Dual Language Learners in Conversation to Support Translanguaging During a Small Group Activity | Valeria Erdosi and Jennifer J. Chen
• 8.3 Incorporating Children’s Cultures and Languages in Learning Activities | Eleni Zgourou
• 8.4 Adapting Teaching Materials for Dual Language Learners to Reflect Their Home Languages and Cultures in a Math Lesson | Karen Nemeth
• 8.5 Studying Celestial Bodies: Science and Cultural Stories | Zeynep Isik-Ercan
• 8.6 Respecting Diverse Cultures and Languages by Sharing and Learning About Cultural Poems, Songs, and Stories From Others | Janis Strasser

Book Details

Faculty resources.

To access tips and resources for teaching the cases, please complete this brief form.  You’ll be able to download the items after you complete the form. 

Teacher Inquiry Group Resources

To access reflection questions to deepen your learning, please click here.

More DAP Resources

To read the position statement, access related resources, and stay up-to-the-minute on all things DAP, visit  NAEYC.org/resources/developmentally-appropriate-practice .

Pamela Brillante,  EdD, is professor in the Department of Special Education, Professional Counseling and Disability Studies, at William Paterson University. She has worked as an early childhood special educator, administrator, and New Jersey state specialist in early childhood special education. She is the author of the NAEYC book The Essentials: Supporting Young Children with Disabilities in the Classroom. Dr. Brillante continues to work with schools to develop high-quality inclusive early childhood programs. 

Jennifer J. Chen, EdD, is professor of early childhood and family studies at Kean University. She earned her doctorate from Harvard University. She has authored or coauthored more than 60 publications in early childhood education. Dr. Chen has received several awards, including the 2020 NAECTE Foundation Established Career Award for Research on ECTE, the 2021 Kean Presidential Excellence Award for Distinguished Scholarship, and the 2022 NJAECTE’s Distinguished Scholarship in ECTE/ECE Award. 

Stephany Cuevas, EdD, is assistant professor of education in the Attallah College of Educational Studies at Chapman University. Dr. Cuevas is an interdisciplinary education scholar whose research focuses on family engagement, Latinx families, and the postsecondary trajectories of first-generation students. She is the author of Apoyo Sacrifical, Sacrificial Support: How Undocumented Parents Get Their Children to College (Teachers College Press). 

Christyn Dundorf, PhD, has more than 30 years of experience in the early learning field as a teacher, administrator, and adult educator. She serves as codirector of Teaching Preschool Partners, a nonprofit organization working to grow playful learning and inquiry practices in school-based pre-K programs and infuse those practices up into the early grades.

Emily Brown Hoffman, PhD, is assistant professor in early childhood education at National Louis University in Chicago. She received her PhD from the University of Illinois at Chicago in Curriculum & Instruction, Literacy, Language, & Culture. Her focuses include emergent literacy, leadership, play and creativity, and school, family, and community partnerships. 

Daniel R. Meier, PhD, is professor of elementary education at San Francisco State University. His publications include Critical Issues in Infant-Toddler Language Development: Connecting Theory to Practice (editor), Supporting Literacies for Children of Color: A Strength-Based Approach to Preschool Literacy (author), and Learning Stories and Teacher Inquiry Groups: Reimagining Teaching and Assessment in Early Childhood Education (coauthor). 

Gayle Mindes, EdD, is professor emerita, DePaul University. She is the author of Assessing Young Children , fifth edition (with Lee Ann Jung), and Social Studies for Young Children: Preschool and Primary Curriculum Anchor, third edition (with Mark Newman). Dr. Mindes is also the editor of Teaching Young Children with Challenging Behaviors: Practical Strategies for Early Childhood Educators and Contemporary Challenges in Teaching Young Children: Meeting the Needs of All Students . 

Lisa R. Roy, EdD, is executive director for the Colorado Department of Early Childhood. Dr. Roy has supported families with young children for over 30 years, serving as the director of program development for the Buffett Early Childhood Institute, as the executive director of early childhood education for Denver Public Schools, and in various nonprofit and government roles.

CASE REPORT article

Case report: a case study significance of the reflective parenting for the child development.

• Department of Psychology, Plovdiv University “Paisii Hilendarski,” Plovdiv, Bulgaria

There are studies that connect the “child” in the past with the “parent” in the present through the prism of high levels of stress, guilt, anxiety. This raises the question of the experiences and internal work patterns formed in childhood and developed through parenthood at a later stage. The article (case study) presents the quality of parental capacity of a family raising a child with an autism spectrum. The abilities of parents (the emphasis is on the mother) to recognize and differentiate the mental states of their non-verbal child are discussed. An analysis of the parental representations for the child and the parent–child relationship is developed. The parameters of reflective parenting are measured. The methodology provides good opportunities for identifying deficits in two aspects: parenting and the functioning of the child itself. Without their establishment, therapy could not have a clear perspective. An integrative approach for psychological support of the child and his family is presented: psychological work with the child on the main areas of functioning, in parallel with the therapy conducted with the parents and the mother, as the main caregiver. The changes for the described period are indicated, which are related to the improvement of the parental capacity in the mother and the progress in the therapy in the child. A prognosis for ongoing therapy is given, as well as topics that have arisen in the process of diagnostic procedures.

Introduction

Attachment theory focuses on parent–child attachment and the effects this relationship has on the child's personality, interpersonal skills, and its capacity to form healthy relationships with adults. According to Bowlby (1969) , parents who are approachable and responsive allow their child to develop a sense of security, thus creating a sound basis for it to learn about the world. The capability of parents to verbalize the feelings and experiences of their child through conversations, reading stories or fairy tales, commenting on everyday situations develops the skills of mentalization in the child ( Ханчева, 2019 ).

In mature age, the ability to mentalize depends on the emotional load of the interpersonal situation. Optimal mentalization implies integration of cognitive knowledge with insights into the emotional world, which allows a man to see more clearly and achieve “emotional knowledge” ( Allen and Fonagy, 2006 ).

The processes of mentalization can be influenced by the “heritage” that is passed down through generations. In their life experience, individuals operate and make their choices not being aware that they repeat the history of their ancestors. In part, these complex relationships can be seen, felt, or anticipated. They are experienced as elusive, insensible, unnamed, or secret, and may leave traumatic traces ( Kellermann, 2001 ).

Tisseron (2011) , associates the process of transmission of traumatic experience from generation to generation with three types of symbolization of experience: affective/sensory/motor, figurative, and verbal. If the event is symbolized in just one of the modalities, the results are associated with violation of mental life. The result becomes a distortion of the parent–child relationships, of their functioning.

The main psychopathological mechanisms that are activated in the transmission of mental content between individuals from generation to generation are associated with the identification and the projective identity. In this case of transmission through generations, insensible patterns, conflicts, scenarios and roles, ideals, and perceptions of the object are identified.

Children of severely traumatic parents reproduce scenes that their parents went through, trying to understand their pain, and at the same time establish a connection with them. They maintain family ties through the integration of parenting experiences. In the meantime, the parent seeks to teach his/her child survival strategies in situations of future persecution, thus passing on his/her traumatic experience ( Baranowsky et al., 1998 ).

Wilgowicz (1999) , introduces the term “vampire complex” describing the impact of unexpressed and insensible experiences passed down from generation to generation. These traumatic experiences form the unconscious connection between the generations which interferes the natural course of the processes of separation and individuation. This complex is associated with experience of the child who in its development turns out to be “locked” in the prison of the parental traumatic experience being neither alive, nor dead, or in other words, unborn.

Krystal (1978) , describes the affective blindness of the principal caregiver as a characteristic of unprocessed traumatic experience ( Den Velde, 1998 ; Коростелева et al., 2017 ). It is associated with incomplete integration of the somatic Self into the Self.

Ammon (2000) , Hirsch (1994) describe in this context the “psychosomatic mother whose behavior is characterized by a lack of understanding of boundaries, intrusiveness, alexithymia, excessive concern for the physical functioning of her child, and at the same time “blind” to its psychic experiences.” Hope et al. (2019) report that maternal depression and complaints of psychological distress are associated with an increased risk of trauma and hospitalization for the age 3–11 years, with the highest being in the period 3–5 years. In another study, Baker et al. (2017) , reported an increased risk of burns, poisoning, and fractures in children aged 0–4 years raised by depressed mothers and/or such found in an anxious episode. Postpartum depression in the mother presupposes a high risk of burns, fractures, poisoning ( Nevriana et al., 2020 ).

The relationship between parental attitudes and child development is influenced by unconscious dynamics of the intrapsychic world of mother and father ( Tagareva, 2019 ). The ability of parents for reflexion and metacognitive monitoring allows them to recognize and regulate, to modulate, to turn into a symbolic (verbal) form the states they observe in their child. This gives an opportunity to comprehend and return in an understandable form to the child interpretation of its state based on understanding and empathy. If this capacity fails, the parent cannot give an adequate and meaningful interpretation of what is happening, because he/she himself/herself gets lost and confused in his/her own (threatening his/her integrity) experiences, and strong, meaningless, overwhelming emotions. The consequences of the lack of a “secure base” in the face of the caregiver may be associated with: low self-esteem, behavior of decompensation under stress, inability to develop and maintain friendships, trust and intimacy, pessimism toward themselves, family, society ( Matanova, 2015 ). The low level of reflexion on the trauma and the unaddressed traumatic experience as the mother's internal position, affect, and are a risk factor for, psychopathology later in the development.

In addition, parenting skills can be further tested when raising a child with Autism Spectrum Disorders in the family. Therapy for this nosology needs to include both psychological work with the child and support for the parents, especially for the mother, who in most cases limits her social roles and devotes herself only to parenthood. This is a serious argument to seek and optimize approaches in clinical practice to support the family environment in which children with neurodevelopmental disorders are raised.

Materials and Methods

This article is designed to present a case of a family with a child diagnosed with Autism Spectrum Disorder, where the non-integrated individual traumatic experience in the mother (N.) affects the quality of her reflective parenting.

The analysis aims to display the status of individual functioning and skills for reflective parenting, as well as the effectiveness of psychological intervention to revive and optimize the relationship mother-child. Although the functioning of the mother is the focus of the present study, an analysis of parenting and the father has also been applied.

The study is a pilot one and marks the start of a project lasting over time.

Diagnostic tools have been used for:

- Assessment of the development and functioning of the child according to the methodology of Matanova et al. ( Matanova and Todorova, 2013 ). The methodology includes research of cognitive, linguistic, social, emotional, and motor sphere of functioning. Based on the identified deficits, it is possible to arrange a therapeutic plan for the child.

- Self-assessment scales for the study of the quality of the parental relationship and the formed internal work patterns (of affection and romantic relationship) of N. with her parents:

° The Parental Reflective Functioning Questionnaire (PRFQ) by Luyten et al. (2017a , b ). The PRF assessment screening tool provides additional evidence of the complexity and multidimensionality of the PRF ( Luyten et al., 2009 ). It contains 18 items intended mainly for use in the study of PRF of parents with children aged 0–5 years. Three different aspects of PRF are evaluated on a 7-point Likert scale. Based on validated factor analysis, the authors identified three theoretically consistent and clinically significant factors, each of which included six items: (1) prementalization modes (PM), (2) certainty about mental states (CMS), (3) interest and curiosity about mental states (IC).

° Assessment of emotional bonding in the parent–child relationship (PBI) Gordon Parker ( Parker, 1979 ; Parker et al., 1979 ). The questionnaire consists of two scales which measure the variables “Care” and “Overcare” or “Control” by evaluating basic parenting styles through the prism of children's perception. It consists of two identical questionnaires of 25 items, one for each parent.

- Family sociogram to report its representation in the current family.

° Version of Eidemiller and Cheremisin ( Eidemiller et al., 2007 ). It is a drawing projective technique exploring several aspects: identify the position of the subject in the system of interpersonal relationships; determine the nature of communication in the family (direct or indirect). Dimensions: Number of family members who fall into the very circle; Size of the circles which mark the members; Disposition of circles (members) relative to each other (location); Distance between circles (members).

The case under study includes: demographic data of the family, anamnesis of the child (data obtained from psychological and medical research), prescribed therapy and progress, “The Time Line” ( Stanton, 1992 )—technique to retrieve significant events from the mother's history during the main stages of her development, located on the “axis of time,” data obtained from her psychological research—hers and her husband's.

N. is married with one child at 2.6 years, with suspected Autism Spectrum Disorder.

Demographic Data at First Visit

Mother (N.)—age: 36 years, education: higher, occupation: technologist.

Father (K.)—age: 39 years, education: higher, occupation: technologist.

Now, the mother is taking care of her child. Only her husband works. They live alone in a small town. The child is separated in his own room.

The child—bears his father's first name. According to parents: does not speak, does not eat independently—“He opens his mouth a little,” walks on tiptoe, does not play with other children, does not obey to commands, gets tired easily. The child attends the nursery until noon (on the recommendation of the director of the institution: “He does not eat”) and the Municipal Center for Personal Development. A social pedagogue works with him.

Data for Assessment of the Child's Development

The child was carried to full-term, born from a second, pathological pregnancy of the mother, laid in bed to avoid miscarriage in the first months. He had a protracted jaundice, which passed after a year and a half. He was not breastfed.

After a consultation with a psychologist, dysfunction was found in the following areas: Sensory: the child does not hold pelvic reservoirs, shows behavior of sensory hunger—needs intensely sensory stimuli; Motor development: with evidence of late walking, the child steps on toes; Cognitive processes: the child has not yet formed a body schema, he tends to suck the thumbs of his lower limbs; he still explores the objective world through oral modality; passivity regarding the choice of a toy if it is not in his filed vision; he does not play with his toys as intended; Emotional and social functioning: he is easily separated from the adult; the emotional expression is poorly differentiated and is played through the body by waving hands; lack of social interest; interaction is possible after prolonged sensory stimulation. Language development: he vocalizes; does not respond to his name.

During the study, the child is calm, passive. When coming into interaction, he retains his interest in the adult, but without any initiative to develop it further.

Electroencephalography was performed, in awake state and with open eyes, which displayed mixed main activity: of diffuse beta waves, and tetha waves 4.5–5 Hz, in the anterior areas: sporadically slower waves 3–4 Hz.

The child was prescribed a therapy with psychologist with live setting twice a week. The therapy with the parents was once a week. It started online prior to the beginning of the therapy with the child due to COVID-19 quarantine. Twenty sessions were held with the child, i.e., work continued for 5 weeks (with setting twice a week). The therapy includes psychological work with the child in the main areas of functioning, established as therapeutic lines of the conducted diagnostics. Ten sessions were held with the parents and the mother. Two of the sessions were held with the parents. The following were studied: their functioning through the different subsystems: marital, parental, child–parental; difficulties in raising a child with an autism spectrum. It was found that the family system organized its resource for therapy only for the child. They realized that their well-being was important for their child's development. The marital subsystem was in the background. A session was held with the father, in which his role as the Third Significant in the child's life was discussed. Seven sessions were held with the mother. In them was unfolded her personal story through early experience, child–parent relationship, main topics of growing up, intimacy, parent–child relationship with her child. The therapy is going on.

Progress of the Therapy With the Child

Decrease of sensory hunger, no tactile simulation is required to activate the child to study the objective reality; General motor skills: reduced toe walking, except in moments of agitation, he walks on a full step on a sensory path. The child jumps on tiptoe, climbing stairs is easier than getting down; Fine motor skills: improved grip (small toys, sticks, without clenching them in the fist); Cognition: recognizes himself in the mirror, experiments on dropping toys (primary circular reactions). Still uses oral inspection of some toys, beginnings of a play by designation (zone of proximal development). The active choice of toys is in progress, he explores freely the specialist room. Object constancy is formed, he seeks an object which he has played with. Lively, interesting. Emotional development: he expresses his joy by shouting and laughing, rejoices when imitated. Expresses anger. Attempts to manipulate by imitating crying. Language development: sporadically pronounces syllables, still does not respond to his name; Peculiarities: likes objects with small holes and pays lasting attention to them. He enters the oral-sadistic stage, bites toys, and gnaws some of them. Learned helplessness.

Data From Performed Psychological Studies

Child–parent relationships and internal work patterns for oneself and for the other (pbi).

The results of the self-assessment questionnaire on emotional closeness in the parent–child relationship with the mother indicate:

With reference to the relations with her mother: high results along the dimension “Overcare/Control” (24 points) and low results along the dimension “Care/Concern” (22 points). From these results it is evident that the mother in childhood is represented as emotionally cold, indifferent, and careless, and at the same time imposing control, intrusiveness, and excessive contact, infantilizing, and hindering the autonomy of N. as a child.

With reference to the relations with her father: high results along both dimensions “Overcare/Control” (32 points) and “Care/Concern” (25 points) what relates to a representation of the father's character as emotionally restrained in his behavior, but at the same time controlling, intrusive, and in attitude which is highly infantilizing and hindering the autonomy of N.

The model of adult attachment, proposed by Bartholomew and Horowitz (1991) , related through the Parker quadrant, for the emotional closeness of a child–parent shows that N. has an active negative internal work pattern for herself along the dimension of “anxiety” and is associated with vulnerability to separation, rejection, or insufficient love. The work pattern of the other is negative, associated with fear of intimacy and social avoidance, i.e., along the dimension of “avoidance.” The attachment style corresponds to style B avoidant, subcategory cowardly avoidant.

In her husband, the internal work pattern is ambivalent. The mother's character from childhood is represented as emotionally restrained and controlling, while the father's is emotionally indifferent, however encouraging autonomy.

Family Sociogram

As a child, she presented inadequate, low self-esteem, and anxiety, an experience of emotional rejection and isolation. The father was the most significant figure, he was more emotionally close. This is also observed in her relations with the maternal grandmother. The size and thickening of the circle, which it is represented with, shows high levels of intrapersonal neuroticism. There are too many figures in the circle: apart from her four-member family, mother, father, brother, and she, it also includes her maternal grandmother and her uncle, the brother of her mother, as the division is in two camps on the basis of proximity-distance: her mother, uncle, and brother are found at one end of the circle, and the other end is occupied by her, her father and grandmother.

As an adult, prior to the birth of her child, her mother was also included in the circle which is associated with a tendency to unsatisfied needs from her.

After the birth of the child, the hierarchy is maintained and there is enough space between the members of the family now.

Through the life cycle of the family and the separation/individuation, this crisis must be lived through and integrated as a new experience. The stages show that in her childhood N. did not have a sound family model, the boundaries between the parent family and the maternal family are permeable. The above configuration could be interpreted as the presence of triangulations in the family system, and as well as intergenerational ones.

Within the romantic couple, in the period of the dyad, N. presents herself and her husband in a line, as the lower part of the test field includes the figure of her mother depicted by a smaller circle. This could be interpreted with the still insufficient density of the family boundaries. Establishing family boundaries (internal and external) is an important task at this stage of family life, as well as creating an optimal balance of proximity and distance; distribution of the roles in the family; establishing the hierarchy; negotiating family rules; coordination of future life plans, as well as joint understanding and acceptance.

It is also confirmed by the results of the interpretation of the family sociogram with the father as well. As a child he presented himself with inadequate, low self-assessment, he was hierarchically placed next to the mother's figure. Prior to the birth of the child, he presented unsatisfied needs from his parental family: no separation, the boundaries between own and native family are permeable. In the present one, the experience in the reality of what is happening is available. There is no differentiation between the relationships, and dissatisfaction with them is present. The child is put in the place of unsolved contradictions.

Reflective Parenting PRFQ

In all three dimensions, the results show values above the average as IC (“interest and curiosity about mental states”) is leading-−85.5%. It is associated with intrusive hypermentalization, i.e., she is difficult to regulate and interpret her own mental states when faced with her unregulated, difficult child. As a sequence, an inadequate reaction in response to his affective signals by the mother is provoked, as well as the presence of low levels distress tolerance. In hypermentalization as a process, there is a tendency to understand or explain mental dynamics based on complex logical constructs, sometimes abstract, notional, and without pragmatic benefit. Its extreme forms are characterized by autistic, groundless fantasizing.

The possibilities for reflective parenting with the father show increased trends in the dimensions of IC (“interest and curiosity about mental states”) and CMS, which is associated with enhanced hypermentalization, as in the mother, in the cases when she does not recognize the vague mental states of her child, however, here is also a desire to understand.

In her story N. unfolds a picture of the transmission of a traumatic experience of rejection/avoidance. The experience of emotional neglect has formed a negative notion of the Self. Through her anger, she repeats the model of her mother, not realizing that her own model is possible.

N. demonstrates a personal style in which fear and anxiety constitute a centrally organizing dimension. Reported phobias are associated with behaviors of shyness, restraint, aptitude for low self-esteem, indecisiveness, uselessness, and emotional inhibition. It is difficult for her to identify anxious thoughts, as well as to connect them with their triggers from reality, to master them and to allow a “decentralized” point of view on anxious situations, what might be the birth and upbringing of a child with arrested development. Avoidance behavior is associated with a remarkably high level of distress and a low level of long-term adaptation. ( Mikulincer and Shaver, 2012 ; Lingiardi and McWilliams, 2017 ). In cognitive theory, this feature (functioning through fear and avoidance) is considered an excellent example of an early maladaptive self-assessment scheme. The theory of mentalization conceptualizes this as an implicit (automatic) mentalizing deficit. In addition, there are difficulties in understanding the mind of others ( Dimaggio et al., 2007 ; Lampe and Malhi, 2018 ). Another major deficit of mentalization is their weak affective consciousness ( Steinmair et al., 2020 ).

Mother–Child Relationship

The relationship with her child is not objective. There is no construct to include references to the related problems outlined in her child. N. includes projective identification against guild as a protective mechanism related to her wishes for the child's future. The relationship with her child is idealized, in her aspiration and strong desire for love, characteristic of her personal structure. In this case, the child serves the mother's deficits and is not perceived objectively. The projection also supports this structure in her fear of rejection. She is parenting by satisfying the child's physical needs without giving the father the opportunity to be introduced to the child's mental life. And, although the projection is central to the father, in describing the relationship with the child, their shared experiences are related to “curiosity,” “play.” The mother's fear of loss, of rejection is the result of the unprocessed mourning. It could be also thought of splitting through the non-integrated image of the early figure of attachment. Presently, she is still demonized, and the father is idealized.

In the described period the child's study of objective reality is activated. recognizable in a mirror. Demonstrates the beginning of a game as intended, expresses joy in interaction, anger. Attempts to manipulate through imitation.

Parent Couple

The possibilities for reflective parenting in both parents are associated with increased hypermentalization, and the father has a desire to understand the mental states of the child.

Married Couple

N.'s internal working models are of a cowardly avoidant style (her husband's internal working model is ambivalent). The level of adherence to therapy is low, a high level of symptom reporting, and a low level of basic confidence. Those who have a negative BPM for themselves and for the other both want and fear of intimacy in the couple. This also presupposes the future occurrence of crisis in N. married couple.

Family System

In families such as the above described, raising a child who is unable to express their own needs in a conventional way, unresolved conflicts from the beginning of their life cycle, can escalate and lead to marital dissatisfaction and dysfunction throughout the family system.

The presented integrative model of psychological support in a family raising a child with an autistic spectrum outlines a picture of improvement in two lines: in the child and in the child–parent relationship. In mother, the process of disidentification, the formation of the transmission of the object, the separation of what has been transmitted to it, allows the history of the past to be restored, therefore gives more freedom to the individual in the shaping of the individuality. Currently, the inserted traumas, even if not one's own, in the subjective experience of conflicts and fantasies, allow to integrate this experience and to turn it from destructive to structuring.

If the traumatic event is mentally processed, symbolized, and inserted in the individual memory as an experience, it receives the status of the past, of memory. It is passed on to generations not only as the content of traumatic experience but also the aptitude of its mental processing and coping with it, which affects the individual development of the child.

N.'s feedback on the therapy so far: “He showed it to us, but I, my fault, my mistake, was that I did not see it.” She finds that now is more observant.

Data Availability Statement

The datasets generated for this article are not readily available because personal data. Requests to access the datasets should be directed to Zlatomira Kostova.

Ethics Statement

Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. Written informed consent to participate in this study was provided by the participants' legal guardian/next of kin. Written informed consent was obtained from the individual(s), and minor(s)' legal guardian/next of kin, for the publication of any potentially identifiable images or data included in this article.

Author's Note

The article presents a research perspective on the possibilities of parental capacity, through the integration of different approaches to understanding human suffering in clinical psychology.

Author Contributions

The author confirms being the sole contributor of this work and has approved it for publication.

Conflict of Interest

The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher's Note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

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Keywords: traumatic experiences, emotional bonding, autistic spectrum disorder, family system, reflective parenting

Citation: Kostova Z (2021) Case Report: A Case Study Significance of the Reflective Parenting for the Child Development. Front. Psychol. 12:724996. doi: 10.3389/fpsyg.2021.724996

Received: 14 June 2021; Accepted: 26 July 2021; Published: 17 August 2021.

Reviewed by:

Copyright © 2021 Kostova. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Zlatomira Kostova, z_kostova@uni-plovdiv.bg

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

Child Growth and Development

(12 reviews)

Jennifer Paris

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Copyright Year: 2018

Last Update: 2019

Publisher: College of the Canyons

Language: English

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Reviewed by Mistie Potts, Assistant Professor, Manchester University on 11/22/22

This text covers some topics with more detail than necessary (e.g., detailing infant urination) yet it lacks comprehensiveness in a few areas that may need revision. For example, the text discusses issues with vaccines and offers a 2018 vaccine... read more

Comprehensiveness rating: 4 see less

This text covers some topics with more detail than necessary (e.g., detailing infant urination) yet it lacks comprehensiveness in a few areas that may need revision. For example, the text discusses issues with vaccines and offers a 2018 vaccine schedule for infants. The text brushes over “commonly circulated concerns” regarding vaccines and dispels these with statements about the small number of antigens a body receives through vaccines versus the numerous antigens the body normally encounters. With changes in vaccines currently offered, shifting CDC viewpoints on recommendations, and changing requirements for vaccine regulations among vaccine producers, the authors will need to revisit this information to comprehensively address all recommended vaccines, potential risks, and side effects among other topics in the current zeitgeist of our world.

Content Accuracy rating: 3

At face level, the content shared within this book appears accurate. It would be a great task to individually check each in-text citation and determine relevance, credibility and accuracy. It is notable that many of the citations, although this text was updated in 2019, remain outdated. Authors could update many of the in-text citations for current references. For example, multiple in-text citations refer to the March of Dimes and many are dated from 2012 or 2015. To increase content accuracy, authors should consider revisiting their content and current citations to determine if these continue to be the most relevant sources or if revisions are necessary. Finally, readers could benefit from a reference list in this textbook. With multiple in-text citations throughout the book, it is surprising no reference list is provided.

Relevance/Longevity rating: 4

This text would be ideal for an introduction to child development course and could possibly be used in a high school dual credit or beginning undergraduate course or certificate program such as a CDA. The outdated citations and formatting in APA 6th edition cry out for updating. Putting those aside, the content provides a solid base for learners interested in pursuing educational domains/careers relevant to child development. Certain issues (i.e., romantic relationships in adolescence, sexual orientation, and vaccination) may need to be revisited and updated, or instructors using this text will need to include supplemental information to provide students with current research findings and changes in these areas.

Clarity rating: 4

The text reads like an encyclopedia entry. It provides bold print headers and brief definitions with a few examples. Sprinkled throughout the text are helpful photographs with captions describing the images. The words chosen in the text are relatable to most high school or undergraduate level readers and do not burden the reader with expert level academic vocabulary. The layout of the text and images is simple and repetitive with photographs complementing the text entries. This allows the reader to focus their concentration on comprehension rather than deciphering a more confusing format. An index where readers could go back and search for certain terms within the textbook would be helpful. Additionally, a glossary of key terms would add clarity to this textbook.

Consistency rating: 5

Chapters appear in a similar layout throughout the textbook. The reader can anticipate the flow of the text and easily identify important terms. Authors utilized familiar headings in each chapter providing consistency to the reader.

Modularity rating: 4

Given the repetitive structure and the layout of the topics by developmental issues (physical, social emotional) the book could be divided into sections or modules. It would be easier if infancy and fetal development were more clearly distinct and stages of infant development more clearly defined, however the book could still be approached in sections or modules.

Organization/Structure/Flow rating: 4

The text is organized in a logical way when we consider our own developmental trajectories. For this reason, readers learning about these topics can easily relate to the flow of topics as they are presented throughout the book. However, when attempting to find certain topics, the reader must consider what part of development that topic may inhabit and then turn to the portion of the book aligned with that developmental issue. To ease the organization and improve readability as a reference book, authors could implement an index in the back of the book. With an index by topic, readers could quickly turn to pages covering specific topics of interest. Additionally, the text structure could be improved by providing some guiding questions or reflection prompts for readers. This would provide signals for readers to stop and think about their comprehension of the material and would also benefit instructors using this textbook in classroom settings.

Interface rating: 4

The online interface for this textbook did not hinder readability or comprehension of the text. All information including photographs, charts, and diagrams appeared to be clearly depicted within this interface. To ease reading this text online authors should create a live table of contents with bookmarks to the beginning of chapters. This book does not offer such links and therefore the reader must scroll through the pdf to find each chapter or topic.

Grammatical Errors rating: 5

No grammatical errors were found in reviewing this textbook.

Cultural Relevance rating: 3

Cultural diversity is represented throughout this text by way of the topics described and the images selected. The authors provide various perspectives that individuals or groups from multiple cultures may resonate with including parenting styles, developmental trajectories, sexuality, approaches to feeding infants, and the social emotional development of children. This text could expand in the realm of cultural diversity by addressing current issues regarding many of the hot topics in our society. Additionally, this textbook could include other types of cultural diversity aside from geographical location (e.g., religion-based or ability-based differences).

While this text lacks some of the features I would appreciate as an instructor (e.g., study guides, review questions, prompts for critical thinking/reflection) and it does not contain an index or glossary, it would be appropriate as an accessible resource for an introduction to child development. Students could easily access this text and find reliable and easily readable information to build basic content knowledge in this domain.

Reviewed by Caroline Taylor, Instructor, Virginia Tech on 12/30/21

Each chapter is comprehensively described and organized by the period of development. Although infancy and toddlerhood are grouped together, they are logically organized and discussed within each chapter. One helpful addition that would largely... read more

Each chapter is comprehensively described and organized by the period of development. Although infancy and toddlerhood are grouped together, they are logically organized and discussed within each chapter. One helpful addition that would largely contribute to the comprehensiveness is a glossary of terms at the end of the text.

From my reading, the content is accurate and unbiased. However, it is difficult to confidently respond due to a lack of references. It is sometimes clear where the information came from, but when I followed one link to a citation the link was to another textbook. There are many citations embedded within the text, but it would be beneficial (and helpful for further reading) to have a list of references at the end of each chapter. The references used within the text are also older, so implementing updated references would also enhance accuracy. If used for a course, instructors will need to supplement the textbook readings with other materials.

This text can be implemented for many semesters to come, though as previously discussed, further readings and updated materials can be used to supplement this text. It provides a good foundation for students to read prior to lectures.

Clarity rating: 5

This text is unique in its writing style for a textbook. It is written in a way that is easily accessible to students and is also engaging. The text doesn't overly use jargon or provide complex, long-winded examples. The examples used are clear and concise. Many key terms are in bold which is helpful to the reader.

For the terms that are in bold, it would be helpful to have a definition of the term listed separately on the page within the side margins, as well as include the definition in a glossary at the end.

Each period of development is consistently described by first addressing physical development, cognitive development, and then social-emotional development.

Modularity rating: 5

This text is easily divisible to assign to students. There were few (if any) large blocks of texts without subheadings, graphs, or images. This feature not only improves modularity but also promotes engagement with the reading.

Organization/Structure/Flow rating: 5

The organization of the text flows logically. I appreciate the order of the topics, which are clearly described in the first chapter by each period of development. Although infancy and toddlerhood are grouped into one period of development, development is appropriately described for both infants and toddlers. Key theories are discussed for infants and toddlers and clearly presented for the appropriate age.

Interface rating: 5

There were no significant interface issues. No images or charts were distorted.

It would be helpful to the reader if the table of contents included a navigation option, but this doesn't detract from the overall interface.

I did not see any grammatical errors.

This text includes some cultural examples across each area of development, such as differences in first words, parenting styles, personalities, and attachments styles (to list a few). The photos included throughout the text are inclusive of various family styles, races, and ethnicities. This text could implement more cultural components, but does include some cultural examples. Again, instructors can supplement more cultural examples to bolster the reading.

This text is a great introductory text for students. The text is written in a fun, approachable way for students. Though the text is not as interactive (e.g., further reading suggestions, list of references, discussion points at the end of each chapter, etc.), this is a great resource to cover development that is open access.

Reviewed by Charlotte Wilinsky, Assistant Professor of Psychology, Holyoke Community College on 6/29/21

This text is very thorough in its coverage of child and adolescent development. Important theories and frameworks in developmental psychology are discussed in appropriate depth. There is no glossary of terms at the end of the text, but I do not... read more

Comprehensiveness rating: 5 see less

This text is very thorough in its coverage of child and adolescent development. Important theories and frameworks in developmental psychology are discussed in appropriate depth. There is no glossary of terms at the end of the text, but I do not think this really hurts its comprehensiveness.

Content Accuracy rating: 5

The citations throughout the textbook help to ensure its accuracy. However, the text could benefit from additional references to recent empirical studies in the developmental field.

It seems as if updates to this textbook will be relatively easy and straightforward to implement given how well organized the text is and its numerous sections and subsections. For example, a recent narrative review was published on the effects of corporal punishment (Heilmann et al., 2021). The addition of a reference to this review, and other more recent work on spanking and other forms of corporal punishment, could serve to update the text's section on spanking (pp. 223-224; p. 418).

The text is very clear and easily understandable.

Consistency rating: 4

There do not appear to be any inconsistencies in the text. The lack of a glossary at the end of the text may be a limitation in this area, however, since glossaries can help with consistent use of language or clarify when different terms are used.

This textbook does an excellent job of dividing up and organizing its chapters. For example, chapters start with bulleted objectives and end with a bulleted conclusion section. Within each chapter, there are many headings and subheadings, making it easy for the reader to methodically read through the chapter or quickly identify a section of interest. This would also assist in assigning reading on specific topics. Additionally, the text is broken up by relevant photos, charts, graphs, and diagrams, depending on the topic being discussed.

This textbook takes a chronological approach. The broad developmental stages covered include, in order, birth and the newborn, infancy and toddlerhood, early childhood, middle childhood, and adolescence. Starting with the infancy and toddlerhood stage, physical, cognitive, and social emotional development are covered.

There are no interface issues with this textbook. It is easily accessible as a PDF file. Images are clear and there is no distortion apparent.

I did not notice any grammatical errors.

Cultural Relevance rating: 4

This text does a good job of including content relevant to different cultures and backgrounds. One example of this is in the "Cultural Influences on Parenting Styles" subsection (p. 222). Here the authors discuss how socioeconomic status and cultural background can affect parenting styles. Including references to specific studies could further strengthen this section, and, more broadly, additional specific examples grounded in research could help to fortify similar sections focused on cultural differences.

Overall, I think this is a terrific resource for a child and adolescent development course. It is user-friendly and comprehensive.

Reviewed by Lois Pribble, Lecturer, University of Oregon on 6/14/21

This book provides a really thorough overview of the different stages of development, key theories of child development and in-depth information about developmental domains. read more

This book provides a really thorough overview of the different stages of development, key theories of child development and in-depth information about developmental domains.

The book provides accurate information, emphasizes using data based on scientific research, and is stated in a non-biased fashion.

Relevance/Longevity rating: 5

The book is relevant and provides up-to-date information. There are areas where updates will need to be made as research and practices change (e.g., autism information), but it is written in a way where updates should be easy to make as needed.

The book is clear and easy to read. It is well organized.

Good consistency in format and language.

It would be very easy to assign students certain chapters to read based on content such as theory, developmental stages, or developmental domains.

Very well organized.

Clear and easy to follow.

I did not find any grammatical errors.

Cultural Relevance rating: 5

General content related to culture was infused throughout the book. The pictures used were of children and families from a variety of cultures.

This book provides a very thorough introduction to child development, emphasizing child development theories, stages of development, and developmental domains.

Reviewed by Nancy Pynchon, Adjunct Faculty, Middlesex Community College on 4/14/21

Overall this textbook is comprehensive of all aspects of children's development. It provided a brief introduction to the different relevant theorists of childhood development . read more

Overall this textbook is comprehensive of all aspects of children's development. It provided a brief introduction to the different relevant theorists of childhood development .

Content Accuracy rating: 4

Most of the information is accurately written, there is some outdated references, for example: Many adults can remember being spanked as a child. This method of discipline continues to be endorsed by the majority of parents (Smith, 2012). It seems as though there may be more current research on parent's methods of discipline as this information is 10 years old. (page 223).

The content was current with the terminology used.

Easy to follow the references made in the chapters.

Each chapter covers the different stages of development and includes the theories of each stage with guided information for each age group.

The formatting of the book makes it reader friendly and easy to follow the content.

Very consistent from chapter to chapter.

Provided a lot of charts and references within each chapter.

Formatted and written concisely.

Included several different references to diversity in the chapters.

There was no glossary at the end of the book and there were no vignettes or reflective thinking scenarios in the chapters. Overall it was a well written book on child development which covered infancy through adolescents.

Reviewed by Deborah Murphy, Full Time Instructor, Rogue Community College on 1/11/21

The text is excellent for its content and presentation. The only criticism is that neither an index nor a glossary are provided. read more

Comprehensiveness rating: 3 see less

The text is excellent for its content and presentation. The only criticism is that neither an index nor a glossary are provided.

The material seems very accurate and current. It is well written. It is very professionally done and is accessible to students.

This text addresses topics that will serve this field in positive ways that should be able to address the needs of students and instructors for the next several years.

Complex concepts are delivered accurately and are still accessible for students . Figures and tables complement the text . Terms are explained and are embedded in the text, not in a glossary. I do think indices and glossaries are helpful tools. Terminology is highlighted with bold fonts to accentuate definitions.

Yes the text is consistent in its format. As this is a text on Child Development it consistently addresses each developmental domain and then repeats the sequence for each age group in childhood. It is very logically presented.

Yes this text is definitely divisible. This text addresses development from conception to adolescents. For the community college course that my department wants to use it is very adaptable. Our course ends at middle school age development; our courses are offered on a quarter system. This text is adaptable for the content and our term time schedule.

This text book flows very clearly from Basic principles to Conception. It then divides each stage of development into Physical, Cognitive and Social Emotional development. Those concepts and information are then repeated for each stage of development. e.g. Infants and Toddler-hood, Early Childhood, and Middle Childhood. It is very clearly presented.

It is very professionally presented. It is quite attractive in its presentation .

I saw no errors

The text appears to be aware of being diverse and inclusive both in its content and its graphics. It discusses culture and represents a variety of family structures representing contemporary society.

It is wonderfully researched. It will serve our students well. It is comprehensive and constructed very well. I have enjoyed getting familiar with this text and am looking forward to using it with my students in this upcoming term. The authors have presented a valuable, well written book that will be an addition to our field. Their scholarly efforts are very apparent. All of this text earns high grades in my evaluation. My only criticism is, as mentioned above, is that there is not a glossary or index provided. All citations are embedded in the text.

Reviewed by Ida Weldon, Adjunct Professor, Bunker Hill Community College on 6/30/20

The overall comprehensiveness was strong. However, I do think some sections should have been discussed with more depth read more

The overall comprehensiveness was strong. However, I do think some sections should have been discussed with more depth

Most of the information was accurate. However, I think more references should have been provided to support some claims made in the text.

The material appeared to be relevant. However, it did not provide guidance for teachers in addressing topics of social justice, equality that most children will ask as they try to make sense of their environment.

The information was presented (use of language) that added to its understand-ability. However, I think more discussions and examples would be helpful.

The text appeared to be consistent. The purpose and intent of the text was understandable throughout.

The text can easily be divided into smaller reading sections or restructured to meet the needs of the professor.

The organization of the text adds to its consistency. However, some sections can be included in others decreasing the length of the text.

Interface issues were not visible.

The text appears to be free of grammatical errors.

While cultural differences are mentioned, more time can be given to helping teachers understand and create a culturally and ethnically focused curriculum.

The textbook provides a comprehensive summary of curriculum planing for preschool age children. However, very few chapters address infant/toddlers.

Reviewed by Veronica Harris, Adjunct Faculty, Northern Essex Community College on 6/28/20

This text explores child development from genetics, prenatal development and birth through adolescence. The text does not contain a glossary. However, the Index is clear. The topics are sequential. The text addresses the domains of physical,... read more

This text explores child development from genetics, prenatal development and birth through adolescence. The text does not contain a glossary. However, the Index is clear. The topics are sequential. The text addresses the domains of physical, cognitive and social emotional development. It is thorough and easy to read. The theories of development are inclusive to give the reader a broader understanding on how the domains of development are intertwined. The content is comprehensive, well - researched and sequential. Each chapter begins with the learning outcomes for the upcoming material and closes with an outline of the topics covered. Furthermore, a look into the next chapter is discussed.

The content is accurate, well - researched and unbiased. An historical context is provided putting content into perspective for the student. It appears to be unbiased.

Updated and accurate research is evidenced in the text. The text is written and organized in such a way that updates can be easily implemented. The author provides theoretical approaches in the psychological domains with examples along with real - life scenarios providing meaningful references invoking understanding by the student.

The text is written with clarity and is easily understood. The topics are sequential, comprehensive and and inclusive to all students. This content is presented in a cohesive, engaging, scholarly manner. The terminology used is appropriate to students studying Developmental Psychology spanning from birth through adolescents.

The book's approach to the content is consistent and well organized. . Theoretical contexts are presented throughout the text.

The text contains subheadings chunking the reading sections which can be assigned at various points throughout the course. The content flows seamlessly from one idea to the next. Written chronologically and subdividing each age span into the domains of psychology provides clarity without overwhelming the reader.

The book begins with an overview of child development. Next, the text is divided logically into chapters which focus on each developmental age span. The domains of each age span are addressed separately in subsequent chapters. Each chapter outlines the chapter objectives and ends with an outline of the topics covered and share an idea of what is to follow.

Pages load clearly and consistently without distortion of text, charts and tables. Navigating through the pages is met with ease.

The text is written with no grammatical or spelling errors.

The text did not present with biases or insensitivity to cultural differences. Photos are inclusive of various cultures.

The thoroughness, clarity and comprehensiveness promote an approach to Developmental Psychology that stands alongside the best of texts in this area. I am confident that this text encompasses all the required elements in this area.

Reviewed by Kathryn Frazier, Assistant Professor, Worcester State University on 6/23/20

This is a highly comprehensive, chronological text that covers genetics and conception through adolescence. All major topics and developmental milestones in each age range are given adequate space and consideration. The authors take care to... read more

This is a highly comprehensive, chronological text that covers genetics and conception through adolescence. All major topics and developmental milestones in each age range are given adequate space and consideration. The authors take care to summarize debates and controversies, when relevant and include a large amount of applied / practical material. For example, beyond infant growth patterns and motor milestone, the infancy/toddler chapters spend several pages on the mechanics of car seat safety, best practices for introducing solid foods (and the rationale), and common concerns like diaper rash. In addition to being generally useful information for students who are parents, or who may go on to be parents, this text takes care to contextualize the psychological research in the lived experiences of children and their parents. This is an approach that I find highly valuable. While the text does not contain an index, the search & find capacity of OER to make an index a deal-breaker for me.

The text includes accurate information that is well-sourced. Relevant debates, controversies and historical context is also provided throughout which results in a rich, balanced text.

This text provides an excellent summary of classic and updated developmental work. While the majority of the text is skewed toward dated, classic work, some updated research is included. Instructors may wish to supplement this text with more recent work, particularly that which includes diverse samples and specifically addresses topics of class, race, gender and sexual orientation (see comment below regarding cultural aspects).

The text is written in highly accessible language, free of jargon. Of particular value are the many author-generated tables which clearly organize and display critical information. The authors have also included many excellent figures, which reinforce and visually organize the information presented.

This text is consistent in its use of terminology. Balanced discussion of multiple theoretical frameworks are included throughout, with adequate space provided to address controversies and debates.

The text is clearly organized and structured. Each chapter is self-contained. In places where the authors do refer to prior or future chapters (something that I find helps students contextualize their reading), a complete discussion of the topic is included. While this may result in repetition for students reading the text from cover to cover, the repetition of some content is not so egregious that it outweighs the benefit of a flexible, modular textbook.

Excellent, clear organization. This text closely follows the organization of published textbooks that I have used in the past for both lifespan and child development. As this text follows a chronological format, a discussion of theory and methods, and genetics and prenatal growth is followed by sections devoted to a specific age range: infancy and toddlerhood, early childhood (preschool), middle childhood and adolescence. Each age range is further split into three chapters that address each developmental domain: physical, cognitive and social emotional development.

All text appears clearly and all images, tables and figures are positioned correctly and free of distortion.

The text contains no spelling or grammatical errors.

While this text provides adequate discussion of gender and cross-cultural influences on development, it is not sufficient. This is not a problem unique to this text, and is indeed a critique I have of all developmental textbooks. In particular, in my view this text does not adequately address the role of race, class or sexual orientation on development.

All in all, this is a comprehensive and well-written textbook that very closely follows the format of standard chronologically-organized child development textbooks. This is a fantastic alternative for those standard texts, with the added benefit of language that is more accessible, and content that is skewed toward practical applications.

Reviewed by Tony Philcox, Professor, Valencia College on 6/4/20

The subject of this book is Child Growth and Development and as such covers all areas and ideas appropriate for this subject. This book has an appropriate index. The author starts out with a comprehensive overview of Child Development in the... read more

The subject of this book is Child Growth and Development and as such covers all areas and ideas appropriate for this subject. This book has an appropriate index. The author starts out with a comprehensive overview of Child Development in the Introduction. The principles of development were delineated and were thoroughly presented in a very understandable way. Nine theories were presented which gave the reader an understanding of the many authors who have contributed to Child Development. A good backdrop to start a conversation. This book discusses the early beginnings starting with Conception, Hereditary and Prenatal stages which provides a foundation for the future developmental stages such as infancy, toddler, early childhood, middle childhood and adolescence. The three domains of developmental psychology – physical, cognitive and social emotional are entertained with each stage of development. This book is thoroughly researched and is written in a way to not overwhelm. Language is concise and easily understood.

This book is a very comprehensive and detailed account of Child Growth and Development. The author leaves no stone unturned. It has the essential elements addressed in each of the developmental stages. Thoroughly researched and well thought out. The content covered was accurate, error-free and unbiased.

The content is very relevant to the subject of Child Growth and Development. It is comprehensive and thoroughly researched. The author has included a number of relevant subjects that highlight the three domains of developmental psychology, physical, cognitive and social emotional. Topics are included that help the student see the relevancy of the theories being discussed. Any necessary updates along the way will be very easy and straightforward to insert.

The text is easily understood. From the very beginning of this book, the author has given the reader a very clear message that does not overwhelm but pulls the reader in for more information. The very first chapter sets a tone for what is to come and entices the reader to learn more. Well organized and jargon appropriate for students in a Developmental Psychology class.

This book has all the ingredients necessary to address Child Growth and Development. Even at the very beginning of the book the backdrop is set for future discussions on the stages of development. Theorists are mentioned and embellished throughout the book. A very consistent and organized approach.

This book has all the features you would want. There are textbooks that try to cover too much in one chapter. In this book the sections are clearly identified and divided into smaller and digestible parts so the reader can easily comprehend the topic under discussion. This book easily flows from one subject to the next. Blocks of information are being built, one brick on top of another as you move through the domains of development and the stages of development.

This book starts out with a comprehensive overview in the introduction to child development. From that point forward it is organized into the various stages of development and flows well. As mentioned previously the information is organized into building blocks as you move from one stage to the next.

The text does not contain any significant interface issued. There are no navigation problems. There is nothing that was detected that would distract or confuse the reader.

There are no grammatical errors that were identified.

This book was not culturally insensitive or offensive in any way.

This book is clearly a very comprehensive approach to Child Growth and Development. It contains all the essential ingredients that you would expect in a discussion on this subject. At the very outset this book went into detail on the principles of development and included all relevant theories. I was never left with wondering why certain topics were left out. This is undoubtedly a well written, organized and systematic approach to the subject.

Reviewed by Eleni Makris, Associate Professor, Northeastern Illinois University on 5/6/20

This book is organized by developmental stages (infancy, toddler, early childhood, middle childhood and adolescence). The book begins with an overview of conception and prenatal human development. An entire chapter is devoted to birth and... read more

This book is organized by developmental stages (infancy, toddler, early childhood, middle childhood and adolescence). The book begins with an overview of conception and prenatal human development. An entire chapter is devoted to birth and expectations of newborns. In addition, there is a consistency to each developmental stage. For infancy, early childhood, middle childhood, and adolescence, the textbook covers physical development, cognitive development, and social emotional development for each stage. While some textbooks devote entire chapters to themes such as physical development, cognitive development, and social emotional development and write about how children change developmentally in each stage this book focuses on human stages of development. The book is written in clear language and is easy to understand.

There is so much information in this book that it is a very good overview of child development. The content is error-free and unbiased. In some spots it briefly introduces multicultural traditions, beliefs, and attitudes. It is accurate for the citations that have been provided. However, it could benefit from updating to research that has been done recently. I believe that if the instructor supplements this text with current peer-reviewed research and organizations that are implementing what the book explains, this book will serve as a strong source of information.

While the book covers a very broad range of topics, many times the citations have not been updated and are often times dated. The content and information that is provided is correct and accurate, but this text can certainly benefit from having the latest research added. It does, however, include a great many topics that serve to inform students well.

The text is very easy to understand. It is written in a way that first and second year college students will find easy to understand. It also introduces students to current child and adolescent behavior that is important to be understood on an academic level. It does this in a comprehensive and clear manner.

This book is very consistent. The chapters are arranged by developmental stage. Even within each chapter there is a consistency of theorists. For example, each chapter begins with Piaget, then moves to Vygotsky, etc. This allows for great consistency among chapters. If I as the instructor decide to have students write about Piaget and his development theories throughout the life span, students will easily know that they can find this information in the first few pages of each chapter.

Certainly instructors will find the modularity of this book easy. Within each chapter the topics are self-contained and extensive. As I read the textbook, I envisioned myself perhaps not assigning entire chapters but assigning specific topics/modules and pages that students can read. I believe the modules can be used as a strong foundational reading to introduce students to concepts and then have students read supplemental information from primary sources or journals to reinforce what they have read in the chapter.

The organization of the book is clear and flows nicely. From the table of context students understand how the book is organized. The textbook would be even stronger if there was a more detailed table of context which highlights what topics are covered within each of the chapter. There is so much information contained within each chapter that it would be very beneficial to both students and instructor to quickly see what content and topics are covered in each chapter.

The interface is fine and works well.

The text is free from grammatical errors.

While the textbook does introduce some multicultural differences and similarities, it does not delve deeply into multiracial and multiethnic issues within America. It also offers very little comment on differences that occur among urban, rural, and suburban experiences. In addition, while it does talk about maturation and sexuality, LGBTQ issues could be more prominent.

Overall I enjoyed this text and will strongly consider using it in my course. The focus is clearly on human development and has very little emphasis on education. However, I intend to supplement this text with additional readings and videos that will show concrete examples of the concepts which are introduced in the text. It is a strong and worthy alternative to high-priced textbooks.

Reviewed by Mohsin Ahmed Shaikh, Assistant Professor, Bloomsburg University of Pennsylvania on 9/5/19

The content extensively discusses various aspects of emotional, cognitive, physical and social development. Examples and case studies are really informative. Some of the areas that can be elaborated more are speech-language and hearing... read more

The content extensively discusses various aspects of emotional, cognitive, physical and social development. Examples and case studies are really informative. Some of the areas that can be elaborated more are speech-language and hearing development. Because these components contribute significantly in development of communication abilities and self-image.

Content covered is pretty accurate. I think the details impressive.

The content is relevant and is based on the established knowledge of the field.

Easy to read and follow.

The terminology used is consistent and appropriate.

I think of using various sections of this book in some of undergraduate and graduate classes.

The flow of the book is logical and easy to follow.

There are no interface issues. Images, charts and diagram are clear and easy to understand.

Well written

The text appropriate and do not use any culturally insensitive language.

I really like that this is a book with really good information which is available in open text book library.

Table of Contents

• Chapter 1: Introduction to Child Development
• Chapter 2: Conception, Heredity, & Prenatal Development
• Chapter 3: Birth and the Newborn
• Chapter 4: Physical Development in Infancy & Toddlerhood
• Chapter 5: Cognitive Development in Infancy and Toddlerhood
• Chapter 6: Social and Emotional Development in Infancy and Toddlerhood
• Chapter 7: Physical Development in Early Childhood
• Chapter 8: Cognitive Development in Early Childhood
• Chapter 9: Social Emotional Development in Early Childhood
• Chapter 10: Middle Childhood - Physical Development
• Chapter 11: Middle Childhood – Cognitive Development
• Chapter 12: Middle Childhood - Social Emotional Development
• Chapter 13: Adolescence – Physical Development
• Chapter 14: Adolescence – Cognitive Development
• Chapter 15: Adolescence – Social Emotional Development

Ancillary Material

About the book.

Welcome to Child Growth and Development. This text is a presentation of how and why children grow, develop, and learn. We will look at how we change physically over time from conception through adolescence. We examine cognitive change, or how our ability to think and remember changes over the first 20 years or so of life. And we will look at how our emotions, psychological state, and social relationships change throughout childhood and adolescence.

About the Contributors

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• Int J Popul Data Sci
• v.5(4); 2020

Developmental impacts of the COVID-19 pandemic on young children: a conceptual model for research with integrated administrative data systems

Heather l. rouse.

1 Department of Human Development and Family Studies, 2330 Palmer Building, 2222 Osborn Drive, Ames, Iowa 50011-1084

Rebecca J. Bulotsky Shearer

2 Department of Psychology, University of Miami, P.O. Box 248185, Coral Gables, FL 33124

Sydney S. Idzikowski

3 University of North Carolina at Charlotte Urban Institute, Institute for Social Capital, Sycamore Hall, 9310 Mary Alexander Road, Charlotte, NC 28223

Amy Hawn Nelson

4 Actionable Intelligence for Social Policy (AISP), University of Pennsylvania, 3701 Locust Walk, Philadelphia, PA 19104

Mark Needle

Matthew f. katz, jhonelle bailey, justin t. lane, emily berkowitz, sharon zanti, astrid pena, maggie reeves.

5 Georgia Policy Labs, Georgia State University, 14 Marietta Street NW, 5th Floor, Atlanta, GA 30303

The COVID-19 pandemic made its mark on the entire world, upending economies, shifting work and education, and exposing deeply rooted inequities. A particularly vulnerable, yet less studied population includes our youngest children, ages zero to five, whose proximal and distal contexts have been exponentially affected with unknown impacts on health, education, and social-emotional well-being. Integrated administrative data systems could be important tools for understanding these impacts. This article has three aims to guide research on the impacts of COVID-19 for this critical population using integrated data systems (IDS). First, it presents a conceptual data model informed by developmental-ecological theory and epidemiological frameworks to study young children. This data model presents five developmental resilience pathways (i.e. early learning, safe and nurturing families, health, housing, and financial/employment) that include direct and indirect influencers related to COVID-19 impacts and the contexts and community supports that can affect outcomes. Second, the article outlines administrative datasets with relevant indicators that are commonly collected, could be integrated at the individual level, and include relevant linkages between children and families to facilitate research using the conceptual data model. Third, this paper provides specific considerations for research using the conceptual data model that acknowledge the highly-localised political response to COVID-19 in the US. It concludes with a call to action for the population data science community to use and expand IDS capacities to better understand the intermediate and long-term impacts of this pandemic on young children.

Introduction

The COVID-19 pandemic made its mark on the entire world, upending economies, shifting work and education, and exposing deeply rooted inequities. This is particularly apparent within the United States, where the hyper-localised response system and wavering federal recommendations have had dire consequences. As of July 2021, there are more than 190.5 million global confirmed cases and 4.1 million global deaths, with the US reporting over 34 million of these cases and over 609,000 COVID-related deaths [ 1 ]. Exacerbating the impact is a resulting economic crisis driven by a record 46 straight weeks of first-time unemployment claims topping one million per week [ 2 ]. The fragmented government response to the COVID-19 pandemic has also highlighted deeply rooted economic, health, social, and racial inequity ingrained in the fabric of American society [ 3 ]. Data indicate a disproportionate number of COVID-19 cases and deaths among low-income populations and multi-generational households, with documented higher impacts on BIPOC (Black, Indigenous, and People of Colour) Americans [ 4 , 5 ].

Research on the impacts of COVID-19 is emerging quickly, including focus on secondary and postsecondary students, older adults, and the workforce (e.g. industry effects [ 6 ] impact of virtual schooling format on K-12 learning [ 7 , 8 ], impact on medical training [ 9 ], social isolation of older adults [ 10 ], and mental well-being of college students [ 11 ]). However, there has been little attention to date on the impacts experienced by one of the world’s most vulnerable populations: young children. Science consistently underscores the time from prenatal to age 5 as a critical developmental period for brain architecture [ 12 ]. Foundational capacities that shape children’s future trajectories across all developmental domains are built during this time. In addition to the direct impacts on young children’s health and social development, COVID-related illness, hospitalisations, workforce disconnection or disruption, and mental health needs also directly affect the adults who are the most proximal influence on young children. The potential negative impacts of adult health and economic stressors on parenting and caregiver capacities to meet children’s basic needs cannot be understated. Perhaps one reason these associations have been largely unstudied is due to lack of available data on population-based indices of child well-being that also include data about adult impacts as possible mediating influences.

Administrative data collected by public and private service agencies at the individual child and adult level that are integrated across systems hold potential for addressing these gaps [ 13 ]. Use of integrated data systems (IDS) [ 14 ] to inform policy and practice has become a stated priority at every level of government in the United States, and is a priority recommendation of the National Academy of Sciences to better align science, policy, and practice to advance health equity for young children [ 15 – 19 ]. Unfortunately, the field currently lacks a comprehensive framework to inform such research that is guided by developmental science and aligned with public systems- the absence of which is particularly troubling during the current crisis.

The purpose of this paper is to address these gaps by providing a comprehensive framework to study the impacts of COVID-19 on young children that not only outlines relevant research priorities but also provides a roadmap for using IDS to conduct comprehensive research. This paper has three specific aims. First, it outlines a conceptual data model of developmental resilience pathways that articulates how child development from birth to age five is influenced by individual, family, and community factors. These pathways are informed by developmental theory and prior research on the impacts of public health crises on child development, and emphasise “resilience” as adaptive developmental outcomes in the face of adverse stressors and risks that are mediated by adult and community supports. Second, it outlines administrative data sets with relevant indicators commonly collected by IDS and could be integrated at the individual level for use within the conceptual data model. Importantly, this aim calls attention to the importance of IDS that link parent-child data to provide capacity for studying multigenerational impacts. Lastly, this paper provides considerations for research using the conceptual data model that acknowledge the highly-localised political response to COVID-19 in the US. It emphasises the strengths of an IDS approach for child development research and the opportunity to advance the field of population data science through multi-site investigations of COVID-19 impacts on young children using a common conceptual data model.

Conceptual data model

Our first aim was to articulate a conceptual data model ( Figure 1 ) that underscores important child developmental pathways to resilience, relevant resilience influencers within these pathways (i.e. direct and indirect factors that may serve as risk or protective factors), and pandemic impacts that bi-directionally interact with child development to either enhance or impede child outcomes. In this model, resilience refers to the phenomenon that many children achieve positive developmental and educational outcomes despite experiencing stressful, high-risk, and adverse circumstances. Early adversity includes experiencing risk factors such as child abuse or neglect, homelessness, poverty, or even premature birth that are associated with serious social, emotional, health, or school-related problems. In this model we refer specifically to stressors associated with the pandemic (e.g. job loss, family death or illness, social isolation) that may further hinder developmental trajectories. Developmental research also provides evidence for the positive influence of protective factors, which we call “resilience influencers” in our model, which promote adaptive functioning for children in the face of adversity. Integral to this model is the understanding that underlying inequities in communities and families are nested within these bidirectional influences and so exacerbate pandemic impacts (see the middle ring of Figure 1 ). This model was informed by developmental-ecological theory and research evidence emphasising that the comprehensive study of child development must be cross-sectoral, longitudinal, and population-based, while simultaneously considering the bidirectional, cumulative, and interactive effects among multiple risk and protective experiences over time [ 20 , 21 ].

Conceptual data model of developmental resilience pathways [ 22 ]

This model, which is informed by developmental research, recognises that child competencies (e.g. academic, social-emotional, physical health, well-being) develop bi-directionally over time as children are supported by resources and assets present within proximal and distal contexts. This model aligns with the recent Consensus Study Report from the National Academy of Sciences summarising the importance of early brain development, the cumulative impacts of trauma, and the intractable inequities that render many children substantially more at risk for developmental challenges that are exacerbated by public health crises such as the pandemic [ 23 ]. The nested contexts within this model also reflect Bronfenbrenner’s bio-ecological theory suggesting young children are differentially influenced by experiences within contexts most proximal, such as relationships and interactions with primary caregivers in the home, community, and school environments [ 24 ]. In these contexts, children are influenced directly by relationships with primary caregivers, as well as by access to resources provided by caregivers that affect development (e.g. safe and nurturing families, high quality early learning centers, health care, and economic and housing stability). Contextual influences are both nested and cumulative, whereby impacts are compounded over time and with repeated exposure (particularly in the case of trauma and stress).

Informed by Bronfenbrenner’s theory and the Measures of Success Framework, developed collaboratively by the North Carolina Data Action Team and domain experts from child-serving agencies and universities (2016), the current conceptual data model differentiates five relevant contexts where resilience is most often facilitated (or hindered) for young children [ 25 ]. These five pathways are: learning (e.g. cognitively stimulating care environments, preschool), family (e.g. home environments and caregiver well-being), health (e.g. availability and access to food, supports for mental health and ACES), housing (e.g. stability and safety), and financial (e.g. economic stability, employment). Since 2016, the role of financial well-being and its connection to social mobility and outcomes has become more pronounced in the literature as administrative data sources are more available. The influence of these pathways is bidirectional (arrows go both ways in the model), where the extent to which risks or resources in early contexts influence children depends on children’s own internal developmental capacities, risks, and resources [ 26 ]. Also important from a developmental systems perspective is acknowledging that these pathways necessarily intersect – stressors or supports in one pathway will also affect trajectories and outcomes in other pathways [ 27 ].

As an illustration, in the health pathway there are direct, indirect, and contextual influences that are related to important child outcomes. Direct influences include child illness due to infection or decreased access to health care, or changes in access to quality learning programmes (positive or negative). Potential mediating influences, referred to in Figure 1 as resilience influencers, reflect indirect pathways to child health that could include stressors experienced by families (e.g. caregiver mental health or social isolation). Within and across all pathways, there are both direct and indirect influences on child development. Prior research suggests, for example, that consistent maternal employment when children are young is related to lower levels of child externalising behavior and higher language and literacy skills in elementary school compared to families where employment is sporadic or varied during the early years [ 28 ]. Pandemic-related stressors can lead to loss of employment that reduces family income and stability and influences children’s access to needed resources like food and healthcare, and stable support systems within the family, jeopardising children’s healthy development.

Macro-level contexts (reflected in the outer ring of Figure 1 ) include broader systems impacts such as local and federal policies, regulations, and practices that may affect the financial/material and social/cultural capital resources available within the proximal contexts of family, community, and school. As the US response to this pandemic has highlighted, systemic inequities (middle ring of Figure 1 ) in resource access along the five developmental pathways existed prior to the pandemic and are exacerbated during crisis as the nested contexts interact with compounding effects on young children and their families [ 29 ]. Historical structures (e.g. federal and local housing policy, racial segregation) have concentrated poverty in low-income communities and communities of colour that for generations lack access to resources that support positive child development and mobility. This conceptual data model acknowledges that these historical policy contexts must be considered to fully assess and understand present risk, vulnerability, and resilience in order to empower BIPOC and communities of colour and close opportunity gaps rather than deepen disparities.

Finally, a key aspect of the conceptual model is the importance of incorporating a population-based approach. Epidemiology incorporates a population-based approach to study the distribution and determinants of health (more broadly defined in this case, to include multidimensional child development outcomes). Most often used in disease surveillance to understand which hazards are most relevant for population-level interventions, the approach is well suited to capture relevant events, characteristics, and environmental changes. Importantly, it requires an understanding of how political, social, and scientific factors intersect to exacerbate risk. It relies on data collected from relevant public health sentinels (i.e. front-line workers who have direct contact with populations of interest) across time to model trends, predictors, and outcomes. In a multidimensional framework involving multiple systemic influences, an epidemiological approach requires the integration of multiple sentinel systems to generate information at relevant intersections.

Relevant indicators collected by IDS

Using this conceptual model to address state or local needs requires an alignment of resilience pathways with access to cross-agency linked child- and adult-level data. IDS are designed for this purpose. IDS routinely integrate administrative records collected by public and nonprofit agencies for programme monitoring and fiscal reimbursement and repurpose it for analytics, research, and evaluation. IDS have several key ingredients: (1) they include cross-sectoral records of multiple public agencies that may include health and human service systems, education, public housing, and economic development (among others), providing potential access to a comprehensive set of child and family well-being indicators; (2) they can be longitudinal and population-based, facilitating the study of prevalence and patterns of needs, service utilisation, predictors that relate to programme use, and accumulated costs associated with service use; and (3) they potentially have capacity to link children with their caregivers, creating a unique opportunity for intergenerational research and the careful study of mediating and moderating factors associated with developmental outcomes of young children.

A critical element of IDS is that they are developed and operated either within or in partnership with government stakeholders. As such, they include protocols to maximize data “use” (i.e. translation into practice or policy decisions) as a conditional mechanism for data sharing within their data governance. IDS developed in partnership support rapid knowledge-to-practice development cycles, providing insights about how policy or programme changes in one area affect a group’s outcomes in another. They address gaps in resources and provide a basis for improving social policies and creating new services [ 30 – 33 ]. Cyclical programme and policy evaluation using IDS help ensure continuous impact assessment and quality improvement.

While IDS function in a variety of ways, these common elements provide a valuable landscape to facilitate research about the pandemic impacts on young children using the conceptual data model. Over the last decade, a national network of IDS led by Actionable Intelligence for Social Policy (AISP) has been collaborating to understand how successful IDS operate, documenting best practices in their development and use, and facilitating the growth of new IDS to meet increasing local and state demands for more accessible integrated information to inform policy and practice [ 34 , 35 ]. In consultation with experts across this network, which currently covers over 50% of the US population, Table 1 was constructed to summarise commonly used data systems within IDS and relevant indicators for each developmental resilience pathway in the conceptual data model. While this presents a very US-centered approach focusing on US policies and programmes that collect administrative data, it illustrates what is possible from an international perspective whereby systems collect relevant data about children and families they serve and use it to facilitate policy-relevant research. The list in Table 1 is not exhaustive, but it was designed to cover a range of indicators at the child and family level (see Column 1). Column 2 describes the data system where administrative datasets can be found. Column 3 provides an indication of the levels of data collected (i.e. child, adult, both, or household). Column 4 lists examples of common data elements that could be outcome measures (child) or mediating variables (child, adult, or community) within the developmental pathway, including some elements (e.g. share of renters in neighborhood) that can be aggregated by geography to support place-based insights [ 36 ].

Table 1: IDS Capacities to study developmental resilience pathways

Considerations for research using the conceptual data model.

The primary motivation for developing this conceptual data model is to encourage and inform collaborative research on the impacts of COVID-19 on young children using IDS. This section provides additional direction on how to use the data model with relevant considerations for developing and conducting research that examines the immediate impacts and, perhaps most likely, the longitudinal outcomes that will evolve for these young children over time as impacts of the pandemic are likely to fundamentally alter early developmental trajectories.

We situate these recommendations within the United States because its compounded form of government (i.e. federalism) grants regional power to states, cities, and counties, thereby creating a hyper-localised COVID-19 response. This response system provides a unique context for research since it generates a natural experiment of varied policy and implementation decisions across state, county and city boundaries. This approach could also be taken across international boundaries – so we use the US as an example to highlight the conceptual data model potential. The US government’s devolved response to the pandemic in 2020 empowered state and local jurisdictions to make unilateral decisions regarding stay-at-home orders, business closures, school closures, and disbursement of resources. As such, state-to-state responses and, in some cases, county-to-county responses varied in length, universality, and enforcement. This resulted in high variability across jurisdictions in cases, death counts, and the timeframe of peak infection rates. A difference-in-difference design study of counties on the border of Iowa and Illinois highlights this variability. Results show the case rate per 10,000 residents was approximately equal across border counties until Illinois implemented a stay-at-home order and Iowa did not, resulting in significantly higher case rates on the Iowa side of the border compared to Illinois [ 37 ].

Early evidence from this hyper-localised response also highlights exacerbation of deep-rooted racial and economic inequities. Analysis suggests these disparate impacts are driven by inequitable access to quality healthcare and health insurance coverage; disproportionate levels of BIPOC working in low wage, “front line” jobs without the opportunity to work from home; overrepresentation among populations of individuals incarcerated in correctional and immigration detention facilities; and the presence of pre-existing social determinants of health related to chronic illness [ 38 ]. This is deeply problematic for families with young children who have been forced to balance child care, schooling, and work, often at the expense of their physical and emotional well-being. The racialised impacts of COVID-19 compound pre-existing developmental vulnerabilities faced by children across domains like healthcare, education, housing, labour and justice (see Alexander (2020), Katznelson (2005), and Rothstein (2017) for examples) [ 39 – 41 ].

Given this context and emerging research, we propose two critical areas that should be included in research design using the conceptual data model. First, research needs to document the hyper-localised response and community-level changes that resulted within the research design . It is important to know when or if stay at home orders were put in place, what they entailed, and how long they lasted. How were school closings and remote support for educators, parents and students implemented? What were the infection, hospitalisation and death rates in the locality? A key component to addressing the community context response also requires centering racial equity in the research design. Within Table 2 (which presents potential research questions and relevant IDS elements that could inform research) we have given some examples that can be aggregated by place/spatial analysis/geography to provide rates per population and contextualise findings to the broader spatial boundaries/community.

Table 2: Possible research questions and ids variables for impact research about young children

Second, a focus on children ages 0-5 necessarily requires including important adult factors that serve as mediators for children’s outcomes . IDS that link children and adults is paramount to this research. By linking children with the adults in their household, biological and non-biological caregivers, and other relevant adults in their proximal systems, this research will have the unique capacity to study mediating and moderating factors of COVID-19 impacts on young children. How did the pandemic impact the systems that surround the child (e.g. home environment, housing stability, community resources)? What impacts on caregivers are likely to translate into reduced capacity for parenting support or the provision of resources known to foster optimal development (e.g. socialisation, cognitive stimulation, opportunities for creative exploration)?

In order to consider these two critical areas, it is also important to identify which individual-level data elements can be aggregated to create a place-based or geographic measures. This spatial approach serves to contextualise findings in a way that is relevant to the specific location. Aggregating data by geography provides useful comparisons across population groups and geographic boundaries and facilitates the study of place-based policy and programme responses. This is especially important given that where a child lives strongly predicts so many child and family outcomes [ 42 ]. For example, researchers could aggregate employment records by neighbourhood to identify the areas with the largest share of essential workers by race and ethnicity and then map their proximity to child care centers in the area.

Across each relevant developmental resilience pathway, there are important child, adult and community factors to consider when conducting research on child impacts. In Table 2 , we outline a set of potential research questions that could be answered with IDS using the conceptual data model. Each question includes an articulation of possible dependent variables (child outcomes) and independent variables (e.g. employment status, policy changes, child care closures), as well as possible family and community context mediators that would be important to include and are also collected by administrative data systems. This table includes a range of possible questions that span the conceptual model pathways, but is by no means exhaustive. Following the table, we elaborate on one question to demonstrate potential methodological approaches and research designs that could be used within the model to foster relevant research.

Using the first question from this table as an example, we now briefly elaborate on how this model and related IDS capacities could be used to answer the question How are changes in enrollment and access in quality early learning programmes affecting family stability and child outcomes? The value of an IDS approach to answer this question is that with administrative data collected longitudinally, the immediate, intermediate, and long-term relationships between quality early learning programme participation (or lack thereof) and relevant child outcomes over time can be studied. Children who were preschool age during the COVID shutdown in Spring of 2020 and forced to move to home schooling or virtual instruction in the middle of the school year could be studied and compared to children of the same age who started their preschool experience virtually – or who were delayed with having a preschool experience because there were no open available spots or because families elected to remain at home. For these children, differential impacts on cognitive, behavioral, or emotional outcomes may be studied over time as these children experience different trajectories into elementary school. Since research suggests many early traumatic experiences may not manifest until later behavioral or cognitive challenges emerge [ 43 ], studying longer-term outcomes such as child mental health, school disconnection or behavioral disruption, slowed or delayed cognitive progression, and academic achievement could be extremely relevant.

An IDS approach at a state (or inter-state) level could reveal important community-level moderators in these relationships. County-level differences in how and when community child care, early learning environments, and public education changes occurred could be quantified. Changes in care facility capacity and adaptations in quality to respond to health and safety concerns could be added. When did centers and home-based care close? For how long? How many did or did not reopen doors? Was access limited to essential workers? What were local stay-at-home orders and how did businesses respond? How flexible was work-from-home policy? Of further value could be a cross-state comparison where multiple IDS partnerships collaborate to understand differences in policy response. Studying commonalities and differences across states could reveal important causal mechanisms that underscore how responses directly and indirectly influence child development outcomes.

Limitations and challenges

When real-time decisions are needed in government, executive leaders will turn to whatever data they have available. This is particularly true in cases of public emergency such as the COVID-19 pandemic. Jurisdictions with developed IDS have an opportunity (and perhaps even an obligation) to fast-track needed improvements in these systems to ensure they are more frequently and fully used to drive decisions and improve outcomes. This paper has provided a conceptual data model for using IDS for COVID-19 impact research on young children. Full actualisation of this conceptual data model, however, also requires acknowledgement of critical challenges in data access, quality and integration.

Administrative data access

First, the COVID-19 pandemic has shifted some practice around administrative data access and raised new issues [ 44 ]. Remote work, for example, revealed limitations of certain privacy and security measures at a time when limited contact is lifesaving. Sites where data could only be accessed using on-site servers saw their work put on pause indefinitely when stay-at-home orders went into effect. Other efforts were stymied by data sharing agreements that did not allow for remote access, or restricted use to only analytics or research, but not for operational use. These legal “roadblocks” limit how information could be accessed and used in real-time, and by whom. Fortunately, there are other models of data sharing that do not include such roadblocks and could be adopted in future work. For example, sites with secure, remote data access policies, procedures, and legal agreements in place have been able to be more flexible and nimble to the changing needs of the pandemic [ 45 ]. As sites work to update and modernise their crisis response capacity, existing agreements may need to be amended to allow operational use of data in times of crisis or emergency.

Data insufficiency and availability

From the framework of this IDS Conceptual Data Model, there may also be areas where available data points are insufficient to capture the full impact, particularly with respect to issues of social isolation and the complexity of family and household responses to community shutdowns. While policymakers and the media have been particularly focused on the health and economic impacts of the virus, less attention (and consequently, less data collection) has been given to the pandemic’s impact on family resilience or less visible factors like mental health (see, for example, Leeb et al. (2020)) [ 46 ]. Furthermore, with systems of support like education, healthcare, recreation, and religious services being provided virtually, many young children are disconnected from the adults they have contact with under normal circumstances. This lack of contact could mean that traditional data collection efforts may have been altered during the pandemic, which would impact our ability to apply epidemiological models of health development to measure outcomes. For example, without children being around regular mandated reporters of child abuse and neglect, aggregate and individual-level data on child welfare reports and substantiated cases may not provide complete information on the incidence of child abuse and neglect [ 47 , 48 ]. Additionally, these contexts may limit the availability of data routinely gathered through annual educational and health assessments because children were participating virtually. Relatedly, some measures, like school attendance, have questionable validity when services are being offered online. It may be that districts or health clinics adapted their data collection processes for virtual services, but careful attention to these changes in administrative data will be required to ensure that research using them is valid.

Data curation and quality

A third major challenge with IDS research is that data curation and quality varies across IDS sites. With the hyper-localised US response context in mind, understanding how different systems define variables and code and clean them for analytic use is critical, especially for multi-site IDS research. Seemingly similar datasets can vary widely across agencies or geographic regions, making consistent measurement and comparison a challenge. Data may differ in the frequency of data collection, years of data available, ages of children represented, quality of data, and/or definitions of data fields. Due to the lack of standardised measurements for the birth to age five population in particular, many early childhood indicators use different data points as proxies for key constructs such as physical, social and emotional health, and kindergarten readiness. As a result, they are typically measured differently across IDS sites.

Cross-sector data linkage between children and caregivers

A final consideration involves the need for IDS that link data between children and their caregivers . In the context of a pandemic where our conceptual model of influence is largely tied to adult caregiver responses and capacities, it is necessary to link a child’s data to that of their parents and other household/family members. Unfortunately, many IDS do not yet have this capacity [ 49 ]. How family structures change over time (e.g. marriage or divorce, children living in different households, birth or adoption of children) must be captured and documented across data systems in order to create a comprehensive linkage of children and their caregivers. The challenge of linking children to their family units is not only technical, but also relational. Strong governance processes and cross-agency relationships are necessary for partners to understand the importance of household matching and generating consistent measures for two-generation analyses. The good news is that there are IDS that have figured this out, and these systems could serve as models for others to advance their capacities [ 50 ]. In the wake of the COVID-19 pandemic and the upended social and economic realities it has presented, these challenges present a call to the research community that is already engaged (or poised to engage) in IDS research to share best practices in linking child-adult-family data.

The development and use of IDS for research has great potential to inform solutions to our most pressing social problems. In the wake of the US Commission on Evidence-Based Policymaking recommendations (2017), we have seen the role of administrative data reuse expand exponentially [ 51 ]. While this is a good start, it also suggests an ethical obligation to use these data in service of the children and families who have entrusted their care and well-being to the systems poised to respond. In the context of a global pandemic where immediate and long-term impacts are unclear for young children, it is imperative that we utilise these built capacities. The current paper addressed this directly through three primary aims. First, it provided a comprehensive conceptual data model informed by developmental science to advance the field of population data science by generating a common language to study the impacts of COVID-19 on young children using IDS. Second, it illustrated sets of administrative data well poised for pandemic impacts research across the developmental resilience pathways in the model. Last, it outlined research considerations and provided examples of priority questions that could be addressed with cross-sector, longitudinal research using IDS that link children and adults.

We end this discussion with a call to action. IDS are positioned to respond to critical needs through actionable research that informs public health crises like the COVID-19 pandemic. This requires building, expanding, and working within two-way partnerships among the scientific and public service communities. These types of partnership are aligned with the National Academy of Sciences’ charge for more cross-sector initiatives that address the root causes of poor health for young children. Using the conceptual data model provided in this paper, comprehensive research about developmental impacts on young children that are mediated by relevant parent and family factors and situated within localised response systems has potential to inform population-level intervention approaches. Given the fact that the prenatal to early childhood period is one of the most sensitive times for children to get on the right path to meet optimal developmental milestones, mitigating the short and long-term impact of COVID-19 is critical [ 52 ]. This paper provides a framework for facilitating such research.

This paper is also a call to the research community connected with population-level IDS capacities to use them, improve them, and maximise the translation of science to action in partnership with our government leaders who need information to inform intervention and prevention approaches. Multi-site research is needed so IDS leaders in different states, municipalities, and across the globe can learn how varied policy or programme responses relate to different developmental trajectories for children. Paramount to this is maintaining sustainable capacities for long-term research so we can understand the implications of response interventions and continue to study the impacts on child development over time. One-shot research studies will not suffice – we have an opportunity (and obligation) for research partnerships to form as governments continue to strategise their pandemic responses. Such partnerships hold potential to address the future needs of a generation of young children living through the COVID-19 pandemic, who will continue to face challenges in their developmental trajectories if the proper, necessary supports are not provided.

Ethics statement

This work was informed by the on-going work of sites that are members of the AISP Network, and their activities are supported by data governance that includes distributed decision-making among a variety of stakeholders, including government agencies, non-governmental non-profit agencies, community-based organizations, and universities.

The IDS Data Landscape research was approved by the University of Pennsylvania IRB, Integrated Data System Landscape Analysis: Models, Motivations, and Capacity for Cross-Agency Data Sharing, # 834988.

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• Published: 05 June 2024

Structured early childhood education exposure and childhood cognition – Evidence from an Indian birth cohort

• Beena Koshy 1 ,
• Manikandan Srinivasan 2 ,
• Rangan Srinivasaraghavan 1 ,
• Reeba Roshan 1 ,
• Venkata Raghava Mohan 3 ,
• Karthikeyan Ramanujam 2 ,
• Sushil John 4 &
• Gagandeep Kang 2  

Scientific Reports volume  14 , Article number:  12951 ( 2024 ) Cite this article

Metrics details

• Health policy
• Paediatric research
• Paediatrics

Experiences in early childhood form the bedrock of future human potential. In impoverished settings, structured early childhood education (ECE) in preschool years can augment overall childhood and later human abilities. The current study evaluates preschool learning exposure and childhood cognition, using longitudinal follow-up of a community-based birth cohort in Vellore, south India. The birth cohort study site in Vellore recruited 251 newborns between 2010 and 2012 from dense urban settlements and further followed up into childhood. Preschool enrolment details were obtained from parents. Childhood cognition was assessed by Weschler’s preschool primary scale of intelligence (WPPSI) and Malin’s intelligence scale for Indian Children (MISIC) at 5 and 9 years of age respectively. Bivariate and multivariate regression analyses were performed with adjustments for socio-economic status (SES), maternal education, stunting status and home environment. Out of 251 new-borns recruited into the MAL-ED birth cohort, 212 (84.46%) and 205 (81.7%) children were available for the 5 year and 9 year follow-up respectively. At 5 years, structured ECE of 18 to 24 months duration was significantly associated with higher cognition scores, with the highest increase in processing speed [β: 19.55 (11.26–27.77)], followed by full-scale intelligence [β: 6.75 (2.96–10.550)], even after adjustments for SES, maternal cognition, home factors and early childhood stunting status. Similarly adjusted analysis at 9 years showed that children who attended 1.5–2 years of structured ECE persisted to have higher cognition, especially in the performance domain [β: 8.82 (2.60–15.03)], followed by the full-scale intelligence [β: 7.24 (2.52–11.90)]. Follow-up of an Indian birth cohort showed that structured ECE exposure was associated with better school entry cognition as well as mid-childhood cognition. Strengthening ECE through a multi-pronged approach could facilitate to maximize cognitive potential of human capital.

Introduction

Cognition or intelligence can be defined as a ‘combination of multiple abilities in a child’ as proposed by Howard Gardner 1 . The first 1000 days of life starting from the antenatal period in the mother’s womb, to the perinatal period and the first 2 years of life, is crucial for child’s cognitive development, as maximum brain development and maturation happen during this period 2 . Factors such as early childhood malnutrition, infections, perinatal asphyxia, iron deficiency, lead toxicity and poverty are detrimental for cognitive development in children 3 , 4 , 5 . Children from poorer households are more likely to experience unsupportive parenting, lack of caregiver education, more stressful events, lack of stimulating environment including play materials and poor education, which in turn result in poor cognitive development and scholastic performance. This compromise in education and subsequent earning capacity in these children further produces an inter-generational transmission of poverty 2 . On the other hand, positive and stimulating environment prevailing at home and appropriate learning opportunities during preschool years can augment a child’s developmental and cognitive abilities 6 .

Global evidence suggests that early childhood education (ECE) offered at a better quality can positively impact a child’s intellectual, social and emotional development, and continued learning in future 7 , 8 . In a Brazilian cohort, children who received structured ECE, compared to those who did not, had higher cognition scores by 8 units at 5 years of age, after adjusting for home environment and socioeconomic status 6 . Similarly, ECE programmes in low-and-middle income country (LMIC) settings such as in Bangladesh have promoted academic achievements in mathematics, writing and reading domains for children in their primary grades 9 . In a preschool environment, in addition to direct learning opportunities in a structured manner, children can also have peer social interactions which can aid their indirect learning experiences. Thus, a centre-based education for pre-schoolers can help to attain better motor coordination, arithmetic skills, memory and concentration in children and may override many adverse childhood experiences 6 , 10 , 11 .

In India, the National Early Childhood Care and Education (ECCE) policy recommends that children between 3 and 6 years receive early education and care from Anganwadi centres, which are community-based 12 , 13 , 14 . Multi-age grouping is followed in which students of different ages and identified age levels are grouped in a single classroom to provide effective instruction. The medium of interaction in the ECCE centre should be the home language or mother tongue. In the early years, the focus would be on listening and speaking activities, facilitated through free play with peers. In the region where the study was done, the ECCE Programme in Tamil language was conducted 5 days a week and for a minimum of 4 h duration,

The ECE programs typically aim to enhance intellectual and social abilities of children which can form a fulcrum for their subsequent learning development. They had considerable positive short-term effects and somewhat smaller long-term effects on cognitive development more so for children from socio-economically disadvantaged families. Studies have shown that sustained high-quality early care and education can mitigate the consequences of poverty into adulthood 15 , 16 . Nevertheless, some studies and an international review highlight sub-optimal evidence of long-term effects of ECE 17 . Possible reasons for even a school-level ‘fade-out’ of ECE could be the quality of ECE, the absence of sustaining environments later and differing skillsets for learning in different age groups 18 . Another commonly cited explanation of the ‘fade-out’ effect of ECE programs on early academic skills is that it changes with time, and the gains often disappear after children transition to elementary school 15 , 18 . Thus, it is important to understand if structured ECE interventions have a long-term effect on cognition in the later childhood period, as this could help policymakers assess cost–benefit aspects better. In this context, the current study evaluates the association between structured ECE and cognition at 5 and 9 years of age in a birth cohort in Vellore, India. For this study, structured ECE was defined as specific structured language and learning inputs from early childhood curriculum and was provided in this area by both private and government aided schools in preschool settings. It is hypothesised that structured ECE will have a positive association with both 5- and 9 year cognition.

This paper presents the analysis of a birth cohort follow-up, as part of a multi-country cohort study done in eight LMICs evaluating the role of enteric infections in early life on growth and development in children (‘The Etiology, Risk Factors and Interactions of Enteric Infections and Malnutrition and the Consequences for Child Health and Development (MAL-ED) Network Cohort) 19 . The study site in Vellore, India recruited 251 newborns between 2010 and 2012 from dense urban slum settlements following parental consent 20 . Children were intensively followed up through home visits till two years of age to capture information on sociodemographic details, morbidity status, anthropometry, and dietary intake, with subsequent follow-up visits made at 3, 4, 5, 7 and 9 years of age. This study was approved by the Institutional Review Board, Christian Medical College, Vellore for initial recruitment as well as follow-up visits (IRB 6769 for the original cohort and follow-up, IRB 11821 for the 9 year follow-up) and was conducted following the guidelines laid by World Medical Association Declaration of Helsinki. Before each recruitment, we obtained parental informed consent in written format and for the 9-year follow-up, additional child assent.

Exposure variables

To evaluate child’s stunting status, trained Field research assistants (FRA) carried out standardized anthropometry measures using an infantometer for recording the length up to 2 years, and a stadiometer thereafter, till 9 years of age to the nearest cm. Z scores for length/height measurements were calculated based on Multicentre Growth Reference Study standards and children were classified as stunted at each time point if Z scores were below − 2 SD. Maternal intelligence quotient (IQ) raw scores were assessed using Raven’s Progressive Matrices by a single, trained psychologist. The Home Observation for the Measurement of the Environment (HOME) scale was administered by a trained social worker at 2 years to measure overall support received by the child at home from caregivers. At 5 years, caregivers were contacted for information about the number of months of structured ECE received by their children. The socioeconomic status (SES) assessment was based on the Water and Sanitation, Assets, Maternal education, and Income (WAMI) scores.

Outcome measures

A single, trained psychologist conducted cognition evaluation for children in the community study clinic using Weschler’s Preschool Primary Scale of Intelligence (WPPSI) and Malin’s intelligence scale for Indian children (MISIC) at 5 and 9 years respectively 3 , 21 . The WPPSI scale was translated, and pilot-tested in local settings to assess cognition under verbal, performance, and processing speed domains. The MISIC scale which was adapted for use in the Indian setting from the original Wechsler scale, evaluated cognition under verbal and performance domains. Raw scores obtained by children under each domain were converted into IQ scores for analysis.

Statistical analysis

Data was collected in paper forms and entered in the double-entry database system maintained by the central Data coordination centre of the MAL-ED study for the initial part of the birth cohort study. Descriptive statistics were used to summarize sex, SES and early childhood stunting status in percentages. Children living in households with WAMI scores ≥ 33rd percentile were classified as those belonging to relatively high SES. Stunting status of children at 2 and 5 years was used to group children into those who were never stunted, stunted at 2 years but recovered by 5 years, and, persistently stunted at 2 and 5 years. Based on tertile scores of structured ECE attendance expressed in months, children were classified into three groups. Children in group 1 had no exposure to structured ECE, whereas those in groups 2 and 3 attended 1–17 and 18–24 months, respectively in a structured preschool. HOME scores were summarized as median and interquartile (IQR) scores. Child’s IQ scores under each domain were presented as median (IQR) and box plots were used to visualize relationship between IQ scores, and groups based on preschool and structured preschool attendance. Correlation co-efficients were computed to check for correlation between domain scores of cognition measures at 5 and 9 years. To measure the association between structured ECE and IQ scores, bivariate and multivariate regression analyses were performed. The normality of dependent variables was assessed using the Shapiro–Wilk test. Linear regression was performed only for performance IQ (PIQ) at 5 years, while quantile regression was used to fit other domain scores such as verbal IQ (VIQ), processing speed IQ (PSIQ) and full-scale IQ (FSIQ) since normality assumptions for linear regression analysis were not met. Similarly, the predictor model for VIQ at 9 years was based on linear regression, while PIQ and total IQ scores at 9 years were modelled using quantile regression. Multivariable models included independent variables that were statistically significant in bivariate analysis at p < 0.05, and collinearity between the variables was analysed using correlation statistics. R 2 values and the Hosmer–Lemeshow goodness-of-fit test were considered for assessing model fitness in the case of linear regression models. Beta coefficients along with 95% confidence intervals (CI) were reported and a p-value less than 0.05 was considered as statistical significance. Statistical analysis was performed using STATA version 14 (Stata Statistical Software: Release 14, StataCorp LP, College Station, TX).

Ethics approval

This study was approved by the Institutional Review Board, Christian Medical College, Vellore for initial recruitment as well as follow-up visits (IRB 6769 for the original cohort and follow-up; IRB 11821 for the 9 year follow-up). Participants were enrolled after due written informed consent before inclusion in the study. This research was conducted ethically following the World Medical Association Declaration of Helsinki.

A cohort of 251 newborns were recruited as part of the Vellore cohort of MAL-ED by screening 301 pregnant women from the study area between 2010 and 2012. At recruitment, a female preponderance (55%) was observed in the cohort. About 212 (84.46%) and 205 (81.67%) children were available for follow-up at 5 and 9 years 21 and the most common reason for non-participation was migration of the family outside study area. The 5-year recruitment was conducted between 2015 February and 2017 February. The 9 year recruitment was planned between 2019 February and 2021 February. There was a disruption in recruitment for 6–7 months in 2020 due to the Covid-19 pandemic. We completed cognitive and other clinic-based assessments for all children by April 2021.

There was no significant difference in cohort characteristics such as sex and socioeconomic status between the follow-up time points (Table 1 ). Of 212 children followed up at 5 years, 41 (19.34%) were stunted at two years but recovered by 5 years, whereas 58 (27.36%) children were found to be stunted both at two and five years. Proportion of children who attended structured ECE was 54.25% with median months of attendance 8 months.

Median (IQR) WPPSI IQ scores measured at 5 years under verbal, performance, processing speed and full-scale domain were 81 (77–85), 84 (79–90), 103 (88–113) and 84 (79–89) respectively (Fig.  1 ). Bivariate analysis of cognition scores across tertile categories of structured ECE showed that children belonging to the highest tertile (18–24 months of attendance) had significantly higher IQ scores by 3, 6.15, 16 and 7 units in VIQ, PIQ, PSIQ and FSIQ domains respectively at 5 years, compared to those in the lowest tertile (nil attendance to structured preschool) (Table 2 ). Further, multivariate analysis accounting for maternal cognition, HOME scores, SES and early life stunting status showed that structured ECE between 18 and 24 months (highest tertile) was significantly associated with higher cognition scores in children at 5 years, with highest increase in PSIQ domain [β: 19.55 (11.26–27.77)], followed by FSIQ [β: 6.75 (2.96–10.55)], PIQ [β: 5.54 (2.11–8.98)] and VIQ domains [β: 3.32 (0.74–5.91)], compared to those who did not attend structured ECE (lowest tertile). It is notable that children in the second tertile of structured ECE with a median duration of 1–17 months also had higher PIQ and PSIQ in the bivariate analysis compared to those in the lowest tertile (nil attendance), however, this association was not found to be statistically significant in the multivariate analysis (Table 3 ). A sensitivity analysis was conducted categorizing the duration of structured ECE under two different scenarios to support the main analysis based on tertile categorization of ECE exposure. In the first scenario, structured ECE duration was categorized year-wise as per the existing education curriculum in India into ‘no attendance’, ‘1–12 months’ and ‘13–24 months’. Children exposed to 13–24 months of ECE had a significant increase in FSIQ by 4.8 compared to those who did not attend structured ECE [β: 4.82 (2.1–7.5)] in multivariate analysis. In the second scenario, structured ECE duration was divided as quartiles into ‘no attendance’, ‘1–8 months’, ‘8–18 months’ and ‘ > 18 months’ of exposure and included in multivariate analysis. Compared to children who did not have structured ECE, those exposed to ‘8–18 months’ and ‘ > 18 months’ had a significant increase in FSIQ scores by 3.4 [β: 3.4 (0.5–6.3)] and 6.4 [β: 6.4 (3.2–9.6)], respectively (data not shown).

Comparison of cognition scores across tertile groups based on ECE attendance in the MAL-ED cohort.

Median (IQR) cognition scores measured at 9 years under verbal, performance, and total IQ scores were 94.4 (87.2–100.6), 91.6 (82.9–101.2) and 93.4 (85.5–100.2) respectively. Correlation coefficients between verbal IQ, performance IQ and total scores IQ at 5 and 9 years were 0.6, 0.6 and 0.7 respectively (data not shown). Exposure to structured ECE showed a positive association with VIQ, PIQ and total IQ scores at 9 years. In bivariate analysis, children in the highest tertile category (18–24 months) of structured preschool attendance showed about 7–10 points increase in IQ scores across various domains of cognition, with effect size being highest in the PIQ domain compared to those who did not attend structured preschool (Table 4 ). This association remained significant in the multivariate model, with children in the highest tertile category scoring higher IQ scores than those in the lowest tertile, after adjusting for maternal IQ, SES and early-life stunting. Structured preschool exposure for about 18–24 months had the greatest impact on PIQ domain with a higher effect size [β: 8.82 (2.60–15.03)], followed by total IQ [β: 7.24 (2.52–11.90)] and verbal IQ domains [β: 5.25 (1.88–8.62)], compared to those without structured preschool attendance (Table 5 ). Similar to 5 years analysis, a sensitivity analysis was conducted categorizing the duration of structured ECE under two different scenarios. In the first scenario, where structured ECE duration was categorized year-wise into ‘no attendance’, ‘1–12 months’ and ‘13–24 months’, children exposed to 13–24 months of ECE had an increase in FSIQ by 4.5 compared to those who did not attend structured ECE [β: 4.5 (0.3–8.6)] in multivariate analysis. In the second scenario, where structured ECE duration was divided into quartiles, it was observed that children with structured ECE of ‘ > 18–24 months’ had a significant increase in FSIQ scores by 7.7 compared to those who did not have any exposure to ECE [β: 7.8 (3.0–12.4)] (data not shown).

This prospective follow-up study done among children living in an urban Indian slum setting evaluated the association between structured ECE and cognition scores at 5 and 9 years of life. Attending structured ECE was associated with higher cognition scores by 3–19 points at 5 years, with the highest increase seen in the processing speed domain of cognition, despite corrections with maternal cognition, SES, home factors, and early childhood stunting, compared to those who did not attend. This association between structured ECE and cognition remained significant even in later childhood, where an increase in IQ scores by 5–9 points at 9 years was observed after correcting for SES, maternal cognition, home factors, and childhood stunting status.

Global evidence states that early childhood adversities, particularly, poor home environment negatively impact cognitive abilities during childhood and continue to impact even in adult life 22 . In the current birth cohort studied in Vellore, a nurturing home environment in early childhood increased developmental cognition scores, while responsive caregiving resulted in augmented language development as evidenced by a previous publication from the same cohort 23 . It should also be highlighted that developmental trend analysis of this LMIC birth cohort showed a decline in overall developmental scores including that of cognition and language between 6 and 36 months of age, owing to SES, home environments, childhood stunting and low blood iron status 23 . A similar association was reported from a Brazilian cohort where children from healthier home environments had better cognition scores by 5 points in the fifth year of follow-up 6 .

The negative impacts that early childhood adversities have on cognition can be mitigated by appropriate psychosocial stimulation as reported in the same Brazilian cohort, where children attending nursery classes had higher cognition scores by 8 points at follow-up 6 . The present study concurs with this finding where structured ECE was associated with higher full-scale IQ scores by 7 units at 5 years. Another important finding of this study is the sustenance of this positive impact on cognition even at 9 years of age. This finding is in line with a Uruguay study which showed that preschool education had a positive impact on academic achievements both at the time of entering primary school and six years later 24 . Similar persisting effects of good quality ECE were reported from Abecedarian low-income cohort and the ‘1991 NICHD study of early childcare and youth development’, where ECE was associated with significant life success benefits as evidenced by additional years of education, better employment and vocational opportunities, and better wages 15 , 16 .

Preschool years represent a crucial period for the development of cognitive, linguistic, social, and psychomotor competencies in children. Early childhood care and education help to overcome environmental adversities due to impoverishment since the plasticity of the developing brain allows the reorganisation of brain circuits in response to psychosocial stimulation 8 , 25 . Another plausibility for the impact of centre-based early childhood interventions on academic achievements in later life would be based on the ‘cognitive advantage hypothesis’ where children from impoverished settings were able to capitalize the cognitive gains acquired due to interventions into academic achievements later in their life 15 . Aptly, the 75th World Health Assembly included opportunities for early learning in the Nurturing Care Framework to optimise early child development 26 . The current paper adds further evidence to this in terms of the need for a structured learning opportunity in early childhood.

In line with WHO and UNESCO’s recommendation of strengthening ECE as a cost-effective strategy for a country to make sustainable progress, the preschool education programme under the Integrated Child Development Services (ICDS) scheme has percolated in length and breadth of the country reaching out to tens of millions of children in India 8 , 27 , 28 , 29 , 30 .A co-prioritisation of preschool education, along with nutritional rehabilitation, has been highlighted by recent government initiatives and is in the right direction. A study from Maharashtra during 2004–05, introduced an ECE package in Anganwadis which included refresher training sessions to Anganwadi worker and financial support to purchase play materials. This intervention was found helpful in increasing IQ scores by 10 points in children compared to controls and is in concurrence with our findings 31 . Recent evidence from Tamil Nadu demonstrated the effectiveness of introducing an extra worker exclusively concentrating on ECE within the existing Anganwadi system, which resulted in exclusive ECE opportunities and an increase in cognition scores in mathematics, language and executive domains was noted in these children at 18 months, post-intervention 12 . Different methods to provide structured educational inputs in early childhood along with nutritional measures within the ICDS system can be explored by further studies in other Indian states to aid policy decisions for the country.

Genetic influences of cognitive abilities cannot be overlooked. In our current analysis as well as published literature from the same cohort, maternal cognitive capacity was shown to have a significant association not only with child development, and cognitive abilities but also with early childhood home environment 3 , 21 , 23 , 25 . Our analyses in the present study were corrected for maternal cognition recognising this genetic leverage.

There are many limitations to the current analysis. The cohort had a comparatively small sample size. We should also keep in mind that the Wechsler scale used at 5 years of age was not completely adapted for Indian settings. Both cognitive assessment measures used in the current analysis evaluate logical intelligence, but not other components of intelligence including but not limited to emotional intelligence, visuospatial intelligence, musical intelligence, etc. Quality of preschool and primary school education variables were not available for consideration in this study as well. Strengths of the study include minimal loss to follow-up, availability of good quality of early childhood data and India-specific cognitive analysis at 9 years of age.

Conclusions

This cohort study done in an impoverished urban Indian setting has brought out the positive association of attending structured ECE on school entry cognition at 5 years and mid-childhood cognition at 9 years of life. Strengthening ECE through a multi-pronged approach of structured preschool curriculum, provision of adequate play materials, providing trained manpower and enabling centres with information and communication tools could facilitate to maximize the cognitive potential of human capital in India.

Data availability

MAL-ED dataset till 5 years of age is uploaded on www.clinepidb.org . Further dataset can be shared by the Corresponding Author, on reasonable request.

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Acknowledgements

Authors thank children, their families and staff of the MAL-ED Network project.

The Etiology, Risk Factors and Interactions of Enteric Infections and Malnutrition and the Consequence for Child Health and Development Project (MAL-ED) was a collaborative project supported by the Bill and Melinda Gates Foundation (BMGF), the Foundation for the NIH and the National Institutes of Health/Fogarty International Center (Grant number – OPP 47075). The 9 year follow-up of this Mal-ed India cohort was supported by an Intermediate clinical and public health (CPH) research fellowship awarded by the DBT-Wellcome Trust India Alliance to BK. (Fellowship grant number IA/CPHI/19/1/504611). Sponsors/Funders had no role in the study design, data collection and analysis, decision to publish or preparation of manuscript.

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Beena Koshy, Manikandan Srinivasan, Rangan Srinivasaraghavan, Venkata Raghava Mohan and Gagandeep Kang contributed to the study conception and design. Material preparation, data collection and analysis were performed by Beena Koshy, Manikandan Srinivasan, Reeba Roshan, Venkata Raghava Mohan, Sushil John and Karthikeyan Ramanujam. All authors read and approved the final manuscript.

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Koshy, B., Srinivasan, M., Srinivasaraghavan, R. et al. Structured early childhood education exposure and childhood cognition – Evidence from an Indian birth cohort. Sci Rep 14 , 12951 (2024). https://doi.org/10.1038/s41598-024-63861-8

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Theories of Child Development and Their Impact on Early Childhood Education and Care

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Developmental theorists use their research to generate philosophies on children’s development. They organize and interpret data based on a scheme to develop their theory. A theory refers to a systematic statement of principles related to observed phenomena and their relationship to each other. A theory of child development looks at the children's growth and behavior and interprets it. It suggests elements in the child's genetic makeup and the environmental conditions that influence development and behavior and how these elements are related. Many developmental theories offer insights about how the performance of individuals is stimulated, sustained, directed, and encouraged. Psychologists have established several developmental theories. Many different competing theories exist, some dealing with only limited domains of development, and are continuously revised. This article describes the developmental theories and their founders who have had the greatest influence on the fields of child development, early childhood education, and care. The following sections discuss some influences on the individuals’ development, such as theories, theorists, theoretical conceptions, and specific principles. It focuses on five theories that have had the most impact: maturationist, constructivist, behavioral, psychoanalytic, and ecological. Each theory offers interpretations on the meaning of children's development and behavior. Although the theories are clustered collectively into schools of thought, they differ within each school.

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Article Contents

Literature review, alive program, implications for school social work practice.

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Trauma and Early Adolescent Development: Case Examples from a Trauma-Informed Public Health Middle School Program

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Jason Scott Frydman, Christine Mayor, Trauma and Early Adolescent Development: Case Examples from a Trauma-Informed Public Health Middle School Program, Children & Schools , Volume 39, Issue 4, October 2017, Pages 238–247, https://doi.org/10.1093/cs/cdx017

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Middle-school-age children are faced with a variety of developmental tasks, including the beginning phases of individuation from the family, building peer groups, social and emotional transitions, and cognitive shifts associated with the maturation process. This article summarizes how traumatic events impair and complicate these developmental tasks, which can lead to disruptive behaviors in the school setting. Following the call by Walkley and Cox for more attention to be given to trauma-informed schools, this article provides detailed information about the Animating Learning by Integrating and Validating Experience program: a school-based, trauma-informed intervention for middle school students. This public health model uses psychoeducation, cognitive differentiation, and brief stress reduction counseling sessions to facilitate socioemotional development and academic progress. Case examples from the authors’ clinical work in the New Haven, Connecticut, urban public school system are provided.

Within the U.S. school system there is growing awareness of how traumatic experience negatively affects early adolescent development and functioning ( Chanmugam & Teasley, 2014 ; Perfect, Turley, Carlson, Yohannan, & Gilles, 2016 ; Porche, Costello, & Rosen-Reynoso, 2016 ; Sibinga, Webb, Ghazarian, & Ellen, 2016 ; Turner, Shattuck, Finkelhor, & Hamby, 2017 ; Woodbridge et al., 2016 ). The manifested trauma symptoms of these students have been widely documented and include self-isolation, aggression, and attentional deficit and hyperactivity, producing individual and schoolwide difficulties ( Cook et al., 2005 ; Iachini, Petiwala, & DeHart, 2016 ; Oehlberg, 2008 ; Sajnani, Jewers-Dailley, Brillante, Puglisi, & Johnson, 2014 ). To address this vulnerability, school social workers should be aware of public health models promoting prevention, data-driven investigation, and broad-based trauma interventions ( Chafouleas, Johnson, Overstreet, & Santos, 2016 ; Johnson, 2012 ; Moon, Williford, & Mendenhall, 2017 ; Overstreet & Chafouleas, 2016 ; Overstreet & Matthews, 2011 ). Without comprehensive and effective interventions in the school setting, seminal adolescent developmental tasks are at risk.

This article follows the twofold call by Walkley and Cox (2013) for school social workers to develop a heightened awareness of trauma exposure's impact on childhood development and to highlight trauma-informed practices in the school setting. In reference to the former, this article will not focus on the general impact of toxic stress, or chronic trauma, on early adolescents in the school setting, as this work has been widely documented. Rather, it begins with a synthesis of how exposure to trauma impairs early adolescent developmental tasks. As to the latter, we will outline and discuss the Animating Learning by Integrating and Validating Experience (ALIVE) program, a school-based, trauma-informed intervention that is grounded in a public health framework. The model uses psychoeducation, cognitive differentiation, and brief stress reduction sessions to promote socioemotional development and academic progress. We present two clinical cases as examples of trauma-informed, school-based practice, and then apply their experience working in an urban, public middle school to explicate intervention theory and practice for school social workers.

Impact of Trauma Exposure on Early Adolescent Developmental Tasks

Social development.

Impact of Trauma on Early Adolescent Development

Traumatic experiences may create difficulty with developing and differentiating another person's point of view (that is, mentalization) due to the formation of rigid cognitive schemas that dictate notions of self, others, and the external world ( Frydman & McLellan, 2014 ). For early adolescents, the ability to diversify a single perspective with complexity is central to modulating affective experience. Without the capacity to diversify one's perspective, there is often difficulty differentiating between a nonthreatening current situation that may harbor reminders of the traumatic experience and actual traumatic events. Incumbent on the school social worker is the need to help students understand how these conflicts may trigger a memory of harm, abandonment, or loss and how to differentiate these past memories from the present conflict. This is of particular concern when these reactions are conflated with more common middle school behaviors such as withdrawing, blaming, criticizing, and gossiping ( Card, Stucky, Sawalani, & Little, 2008 ).

Encouraging cognitive discrimination is particularly meaningful given that the second social developmental task for early adolescents is the re-orientation of their primary relationships with family toward peers ( Henderson & Thompson, 2010 ). This shift may become complicated for students facing traumatic stress, resulting in a stunted movement away from familiar connections or a displacement of dysfunctional family relationships onto peers. For example, in the former, a student who has witnessed and intervened to protect his mother from severe domestic violence might believe he needs to sacrifice himself and be available to his mother, forgoing typical peer interactions. In the latter, a student who was beaten when a loud, intoxicated family member came home might become enraged, anxious, or anticipate violence when other students raise their voices.

Cognitive Development and Emotional Regulation

During normative early adolescent development, the prefrontal cortex undergoes maturational shifts in cognitive and emotional functioning, including increased impulse control and affect regulation ( Wigfield, Lutz, & Wagner, 2005 ). However, these developmental tasks can be negatively affected by chronic exposure to traumatic events. Stressful situations often evoke a fear response, which inhibits executive functioning and commonly results in a fight-flight-freeze reaction. If a student does not possess strong anxiety management skills to cope with reminders of the trauma, the student is prone to further emotional dysregulation, lowered frustration tolerance, and increased behavioral problems and depressive symptoms ( Iachini et al., 2016 ; Saltzman, Steinberg, Layne, Aisenberg, & Pynoos, 2001 ).

Typical cognitive development in early adolescence is defined by the ambiguity of a transitional stage between childhood remedial capacity and adult refinement ( Casey & Caudle, 2013 ; Van Duijvenvoorde & Crone, 2013 ). Casey and Caudle (2013) found that although adolescents performed equally as well as, if not better than, adults on a self-control task when no emotional information was present, the introduction of affectively laden social cues resulted in diminished performance. The developmental challenge for the early adolescent then is to facilitate the coordination of this ever-shifting dynamic between cognition and affect. Although early adolescents may display efficient and logically informed behaviors, they may struggle to sustain these behaviors, especially in the presence of emotional stimuli ( Casey & Caudle, 2013 ; Van Duijvenvoorde & Crone, 2013 ). Because trauma often evokes an emotional response ( Johnson & Lubin, 2015 ), these findings insinuate that those early adolescents who are chronically exposed will have ongoing regulation difficulties. Further empirical findings considering the cognitive effects of trauma exposure on the adolescent brain have highlighted detriments in working memory, inhibition, memory, and planning ability ( Moradi, Neshat Doost, Taghavi, Yule, & Dalgleish, 1999 ).

Using a Public Health Framework for School-Based, Trauma-Informed Services

The need for a more informed and comprehensive approach to addressing trauma within the schools has been widely articulated ( Chafouleas et al., 2016 ; Durlak, Weissberg, Dymnicki, Taylor, & Schellinger, 2011 ; Jaycox, Kataoka, Stein, Langley, & Wong, 2012 ; Overstreet & Chafouleas, 2016 ; Perry & Daniels, 2016 ). Overstreet and Matthews (2011) suggested that using a public health model to address trauma in schools will promote prevention, early identification, and data-driven investigation and yield broad-based intervention on a policy and communitywide level. A public health approach focuses on developing interventions that address the underlying causal processes that lead to social, emotional, and cognitive maladjustment. Opening the dialogue to the entire student body, as well as teachers and administrators, promotes inclusion and provides a comprehensive foundation for psychoeducation, assessment, and prevention.

ALIVE: A Comprehensive Public Health Intervention for Middle School Students

Note: ALIVE = Animating Learning by Integrating and Validating Experience.

Psychoeducation

The classroom is a place traditionally dedicated to academic pursuits; however, it also serves as an indicator of trauma's impact on cognitive functioning evidenced by poor grades, behavioral dysregulation, and social turbulence. ALIVE practitioners conduct weekly trauma-focused dialogues in the classroom to normalize conversations addressing trauma, to recruit and rehearse more adaptive cognitive skills, and to engage in an insight-oriented process ( Sajnani et al., 2014 ).

Using a parable as a projective tool for identification and connection, the model helps students tolerate direct discussions about adverse experiences. The ALIVE practitioner begins each academic year by telling the parable of a woman named Miss Kendra, who struggled to cope with the loss of her 10-year-old child. Miss Kendra is able to make meaning out of her loss by providing support for schoolchildren who have encountered adverse experiences, serving as a reminder of the strength it takes to press forward after a traumatic event. The intention of this parable is to establish a metaphor for survival and strength to fortify the coping skills already held by trauma-exposed middle school students. Furthermore, Miss Kendra offers early adolescents an opportunity to project their own needs onto the story, creating a personalized figure who embodies support for socioemotional growth.

Following this parable, the students’ attention is directed toward Miss Kendra's List, a poster that is permanently displayed in the classroom. The list includes a series of statements against adolescent maltreatment, comprehensively identifying various traumatic stressors such as witnessing domestic violence; being physically, verbally, or sexually abused; and losing a loved one to neighborhood violence. The second section of the list identifies what may happen to early adolescents when they experience trauma from emotional, social, and academic perspectives. The practitioner uses this list to provide information about the nature and impact of trauma, while modeling for students and staff the ability to discuss difficult experiences as a way of connecting with one another with a sense of hope and strength.

Furthermore, creating a dialogue about these issues with early adolescents facilitates a culture of acceptance, tolerance, and understanding, engendering empathy and identification among students. This fostering of interpersonal connection provides a reparative and differentiated experience to trauma ( Hartling & Sparks, 2008 ; Henderson & Thompson, 2010 ; Johnson & Lubin, 2015 ) and is particularly important given the peer-focused developmental tasks of early adolescence. The positive feelings evoked through classroom-based conversation are predicated on empathic identification among the students and an accompanying sense of relief in understanding the scope of trauma's impact. Furthermore, the consistent appearance of and engagement by the ALIVE practitioner, and the continual presence of Miss Kendra's list, effectively counters traumatically informed expectations of abandonment and loss while aligning with a public health model that attends to the impact of trauma on a regular, systemwide basis.

Participatory and Somatic Indicators for Informal Assessment during the Psychoeducation Component of the ALIVE Intervention

Notes: ALIVE = Animating Learning by Integrating and Validating Experience. Examples are derived from authors’ clinical experiences.

In addition to behavioral symptoms, the content of conversation is considered. All practitioners in the ALIVE program are mandated reporters, and any content presented that meets criteria for suspicion of child maltreatment is brought to the attention of the school leadership and ALIVE director. According to Johnson (2012) , reports of child maltreatment to the Connecticut Department of Child and Family Services have actually decreased in the schools where the program has been implemented “because [the ALIVE program is] catching problems well before they have risen to the severity that would require reporting” (p. 17).

Case Example 1

The following demonstrates a middle school classroom psychoeducation session and assessment facilitated by an ALIVE practitioner (the first author). All names and identifying characteristics have been changed to protect confidentiality.

Ms. Skylar's seventh grade class comprised many students living in low-income housing or in a neighborhood characterized by high poverty and frequent criminal activity. During the second week of school, I introduced myself as a practitioner who was here to speak directly about difficult experiences and how these instances might affect academic functioning and students’ thoughts about themselves, others, and their environment.

After sharing the Miss Kendra parable and list, I invited the students to share their thoughts about Miss Kendra and her journey. Tyreke began the conversation by wondering whether Miss Kendra lost her child to gun violence, exploring the connection between the list and the story and his own frequent exposure to neighborhood shootings. To transition a singular connection to a communal one, I asked the students if this was a shared experience. The majority of students nodded in agreement. I referred the students back to the list and asked them to identify how someone's school functioning or mood may be affected by ongoing neighborhood gun violence. While the students read the list, I actively monitored reactions and scanned for inattention and active avoidance. Performing both active facilitation of discussion and monitoring students’ reactions is critical in accomplishing the goals of providing quality psychoeducation and identifying at-risk students for intervention.

After inspection, Cleo remarked that, contrary to a listed outcome on Miss Kendra's list, neighborhood gun violence does not make him feel lonely; rather, he “doesn't care about it.” Slumped down in his chair, head resting on his crossed arms on the desk in front of him, Cleo's body language suggested a somatized disengagement. I invited other students to share their individual reactions. Tyreke agreed that loneliness is not the identified affective experience; rather, for him, it's feeling “mad or scared.” Immediately, Greg concurred, expressing that “it makes me more mad, and I think about my family.”

Encouraging a variety of viewpoints, I stated, “It sounds like it might make you mad, scared, and may even bring up thoughts about your family. I wonder why people have different reactions?” Doing so moved the conversation into a phase of deeper reflection, simultaneously honoring the students’ voiced experience while encouraging critical thinking. A number of students responded by offering connections to their lives, some indicating they had difficulty identifying feelings. I reflected back, “Sometimes people feel something, but can't really put their finger on it, and sometimes they know exactly how they feel or who it makes them think about.”

I followed with a question: “How do you think it affects your schoolwork or feelings when you're in school?” Greg and Natalia both offered that sometimes difficult or confusing thoughts can consume their whole day, even while in class. Sharon began to offer a related comment when Cleo interrupted by speaking at an elevated volume to his desk partner, Tyreke. The two began to snicker and pull focus. By the time they gained the class's full attention, Cleo was openly laughing and pushing his chair back, stating, “No way! She DID!? That's crazy”; he began to stand up, enlisting Tyreke in the process. While this disruption may be viewed as a challenge to the discussion, it is essential to understand all behavior in context of the session's trauma content. Therefore, Cleo's outburst was interpreted as a potential avenue for further exploration of the topic regarding gun violence and difficulties concentrating. In turn, I posed this question to the class: “Should we talk about this stuff? I wonder if sometimes people have a hard time tolerating it. Can anybody think of why it might be important? Sharon, I think you were saying something about this.” While Sharon continued to share, Cleo and Tyreke gradually shifted their attention back to the conversation. I noted the importance of an individual follow-up with Cleo.

Natalia jumped back in the conversation, stating, “I think we talk about stuff like this so we know about it and can help people with it.” I checked in with the rest of the class about this strategy for coping with the impact of trauma exposure on school functioning: “So it sounds like these thoughts have a pretty big impact on your day. If that's the case, how do you feel less worried or mad or scared?” Marta quickly responded, “You could talk to someone.” I responded, “Part of my job here is to be a person to talk to one-on-one about these things. Hopefully, it will help you feel better to get some of that stuff off your chest.” The students nodded, acknowledging that I would return to discuss other items on the list and that there would be opportunities to check in with me individually if needed.

On reflection, Cleo's disruption in the discussion may be attributed to his personal difficulty emotionally managing intrusive thoughts while in school. This clinical assumption was not explicitly named in the moment, but was noted as information for further individual follow-up. When I met individually with Cleo, Cleo reported that his cousin had been shot a month ago, causing him to feel confused and angry. I continued to work with him individually, which resulted in a reduction of behavioral disruptions in the classroom.

In the preceding case example, the practitioner performed a variety of public health tasks. Foremost was the introduction of how traumatic experience may affect individuals and their relationships with others and their role as a student. Second, the practitioner used Miss Kendra and her list as a foundational mechanism to ground the conversation and serve as a reference point for the students’ experience. Finally, the practitioner actively monitored individual responses to the material as a means of identifying students who may require more support. All three of these processes are supported within the public health framework as a means toward assessment and early intervention for early adolescents who may be exposed to trauma.

Individualized Stress Reduction Intervention

Students are seen for individualized support if they display significant externalizing or internalizing trauma-related behavior. Students are either self-referred; referred by a teacher, administrator, or staff member; or identified by an ALIVE practitioner. Following the principle of immediate engagement based on emergent traumatic material, individual sessions are brief, lasting only 15 to 20 minutes. Using trauma-centered psychotherapy ( Johnson & Lubin, 2015 ), a brief inquiry addressing the current problem is conducted to identify the trauma trigger connected to the original harm, fostering cognitive discrimination. Conversation about the adverse experience proceeds in a calm, direct way focusing on differentiating between intrusive memories and the current situation at school ( Sajnani et al., 2014 ). Once the student exhibits greater emotional regulation, the ALIVE practitioner returns the student to the classroom in a timely manner and may provide either brief follow-up sessions for preventive purposes or, when appropriate, refer the student to more regular, clinical support in or out of the school.

Case Example 2

The following case example is representative of the brief, immediate, and open engagement with traumatic material and encouragement of cognitive discrimination. This intervention was conducted with a sixth grade student, Jacob (name and identifying information changed to ensure confidentiality), by an ALIVE practitioner (the second author).

I found Jacob in the hallway violently shaking a trash can, kicking the classroom door, and slamming his hands into the wall and locker. His teacher was standing at the door, distressed, stating, “Jacob, you need to calm down and go to the office, or I'm calling home!” Jacob yelled, “It's not fair, it was him, not me! I'm gonna fight him!” As I approached, I asked what was making him so angry, but he said, “I don't want to talk about it.” Rather than asking him to calm down or stop slamming objects, I instead approached the potential memory agitating him, stating, “My guess is that you are angry for a very good reason.” Upon this simple connection, he sighed and stopped kicking the trash can and slamming the wall. Jacob continued to demonstrate physical and emotional activation, pacing the hallway and making a fist; however, he was able to recount putting trash in the trash can when a peer pushed him from behind, causing him to yell. Jacob explained that his teacher heard him yelling and scolded him, making him more mad. Jacob stated, “She didn't even know what happened and she blamed me. I was trying to help her by taking out all of our breakfast trash. It's not fair.”

The ALIVE practitioner listens to students’ complaints with two ears, one for the current complaint and one for affect-laden details that may be connected to the original trauma to inquire further into the source of the trigger. Affect-laden details in case example 2 include Jacob's anger about being blamed (rather than toward the student who pushed him), his original intention to help, and his repetition of the phrase “it's not fair.” Having met with Jacob previously, I was aware that his mother suffers from physical and mental health difficulties. When his mother is not doing well, he (as the parentified child) typically takes care of the household, performing tasks like cooking, cleaning, and helping with his two younger siblings and older autistic brother. In the past, Jacob has discussed both idealizing his mother and holding internalized anger that he rarely expresses at home because he worries his anger will “make her sick.”

I know sometimes when you are trying to help mom, there are times she gets upset with you for not doing it exactly right, or when your brothers start something, she will blame you. What just happened sounds familiar—you were trying to help your teacher by taking out the garbage when another student pushed you, and then you were the one who got in trouble.

Jacob nodded his head and explained that he was simply trying to help.

I moved into a more detailed inquiry, to see if there was a more recent stressor I was unaware of. When I asked how his mother was doing this week, Jacob revealed that his mother's health had deteriorated and his aunt had temporarily moved in. Jacob told me that he had been yelled at by both his mother and his aunt that morning, when his younger brother was not ready for school. I asked, “I wonder if when the student pushed you it reminded you of getting into trouble because of something your little brother did this morning?” Jacob nodded. The displacement was clear: He had been reminded of this incident at school and was reacting with anger based on his family dynamic, and worries connected to his mother.

My guess is that you were a mix of both worried and angry by the time you got to school, with what's happening at home. You were trying to help with the garbage like you try to help mom when she isn't doing well, so when you got pushed it was like your brother being late, and then when you got blamed by your teacher it was like your mom and aunt yelling, and it all came flooding back in. The problem is, you let out those feelings here. Even though there are some similar things, it's not totally the same, right? Can you tell me what is different?

Jacob nodded and was able to explain that the other student was probably just playing and did not mean to get him into trouble, and that his teacher did not usually yell at him or make him worried. Highlighting this important differentiation, I replied, “Right—and fighting the student or yelling at the teacher isn't going to solve this, but more importantly, it isn't going to make your mom better or have your family go any easier on you either.” Jacob stated that he knew this was true.

I reassured Jacob that I could help him let out those feelings of worry and anger connected to home so they did not explode out at school and planned to meet again. Jacob confirmed that he was willing to do that. He was able to return to the classroom without incident, with the entire intervention lasting less than 15 minutes.

In case example 2, the practitioner was available for an immediate engagement with disturbing behaviors as they were happening by listening for similarities between the current incident and traumatic stressors; asking for specific details to more effectively help Jacob understand how he was being triggered in school; providing psychoeducation about how these two events had become confused and aiding him in cognitively differentiating between the two; and, last, offering to provide further support to reduce future incidents.

Germane to the practice of school social work is the ability to work flexibly within a public health model to attend to trauma within the school setting. First, we suggest that a primary implication for school social workers is not to wait for explicit problems related to known traumatic experiences to emerge before addressing trauma in the school, but, rather, to follow a model of prevention-assessment-intervention. School social workers are in a unique position within the school system to disseminate trauma-informed material to both students and staff in a preventive capacity. Facilitating this implementation will help to establish a tone and sharpened focus within the school community, norming the process of articulating and engaging with traumatic material. In the aforementioned classroom case example, we have provided a sample of how school social workers might work with entire classrooms on a preventive basis regarding trauma, rather than waiting for individual referrals.

Second, in addition to functional behavior assessments and behavior intervention plans, school social workers maintain a keen eye for qualitative behavioral assessment ( National Association of Social Workers, 2012 ). Using this skill set within a trauma-informed model will help to identify those students in need who may be reluctant or resistant to explicitly ask for help. As called for by Walkley and Cox (2013) , we suggest that using the information presented in Table 1 will help school social workers understand, identify, and assess the impact of trauma on early adolescent developmental tasks. If school social workers engage on a classroom level in trauma psychoeducation and conversations, the information in Table 3 may assist with assessment of children and provide a basis for checking in individually with students as warranted.

Third, school social workers are well positioned to provide individual targeted, trauma-informed interventions based on previous knowledge of individual trauma and through widespread assessment ( Walkley & Cox, 2013 ). The individual case example provides one way of immediately engaging with students who are demonstrating trauma-based behaviors. In this model, school social workers engage in a brief inquiry addressing the current trauma to identify the trauma trigger, discuss the adverse experience in a calm but direct way, and help to differentiate between intrusive memories and the current situation at school. For this latter component, the focus is on cognitive discrimination and emotional regulation so that students can reengage in the classroom within a short time frame.

Fourth, given social work's roots in collaboration and community work, school social workers are encouraged to use a systems-based approach in partnering with allied practitioners and institutions ( D'Agostino, 2013 ), thus supporting the public health tenet of establishing and maintaining a link to the wider community. This may include referring students to regular clinical support in or out of the school. Although the implementation of a trauma-informed program will vary across schools, we suggest that school social workers have the capacity to use a public health school intervention model to ecologically address the psychosocial and behavioral issues stemming from trauma exposure.

As increasing attention is being given to adverse childhood experiences, a tiered approach that uses a public health framework in the schools is necessitated. Nevertheless, there are some limitations to this approach. First, although the interventions outlined here are rooted in prevention and early intervention, there are times when formal, intensive treatment outside of the school setting is warranted. Second, the ALIVE program has primarily been implemented by ALIVE practitioners; the results from piloting this public health framework in other school settings with existing school personnel, such as school social workers, will be necessary before widespread replication.

The public health framework of prevention-assessment-intervention promotes continual engagement with middle school students’ chronic exposure to traumatic stress. There is a need to provide both broad-based and individualized support that seeks to comprehensively ameliorate the social, emotional, and cognitive consequences on early adolescent developmental milestones associated with traumatic experiences. We contend that school social workers are well positioned to address this critical public health issue through proactive and widespread psychoeducation and assessment in the schools, and we have provided case examples to demonstrate one model of doing this work within the school day. We hope that this article inspires future writing about how school social workers individually and systemically address trauma in the school system. In alignment with Walkley and Cox (2013) , we encourage others to highlight their practice in incorporating trauma-informed, school-based programming in an effort to increase awareness of effective interventions.

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• Case report
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• Published: 11 September 2017

A case of a four-year-old child adopted at eight months with unusual mood patterns and significant polypharmacy

• Magdalena Romanowicz   ORCID: orcid.org/0000-0002-4916-0625 1 ,
• Alastair J. McKean 1 &
• Jennifer Vande Voort 1  

BMC Psychiatry volume  17 , Article number:  330 ( 2017 ) Cite this article

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Long-term effects of neglect in early life are still widely unknown. Diversity of outcomes can be explained by differences in genetic risk, epigenetics, prenatal factors, exposure to stress and/or substances, and parent-child interactions. Very common sub-threshold presentations of children with history of early trauma are challenging not only to diagnose but also in treatment.

Case presentation

A Caucasian 4-year-old, adopted at 8 months, male patient with early history of neglect presented to pediatrician with symptoms of behavioral dyscontrol, emotional dysregulation, anxiety, hyperactivity and inattention, obsessions with food, and attachment issues. He was subsequently seen by two different child psychiatrists. Pharmacotherapy treatment attempted included guanfacine, fluoxetine and amphetamine salts as well as quetiapine, aripiprazole and thioridazine without much improvement. Risperidone initiated by primary care seemed to help with his symptoms of dyscontrol initially but later the dose had to be escalated to 6 mg total for the same result. After an episode of significant aggression, the patient was admitted to inpatient child psychiatric unit for stabilization and taper of the medicine.

Conclusions

The case illustrates difficulties in management of children with early history of neglect. A particular danger in this patient population is polypharmacy, which is often used to manage transdiagnostic symptoms that significantly impacts functioning with long term consequences.

Peer Review reports

There is a paucity of studies that address long-term effects of deprivation, trauma and neglect in early life, with what little data is available coming from institutionalized children [ 1 ]. Rutter [ 2 ], who studied formerly-institutionalized Romanian children adopted into UK families, found that this group exhibited prominent attachment disturbances, attention-deficit/hyperactivity disorder (ADHD), quasi-autistic features and cognitive delays. Interestingly, no other increases in psychopathology were noted [ 2 ].

Even more challenging to properly diagnose and treat are so called sub-threshold presentations of children with histories of early trauma [ 3 ]. Pincus, McQueen, & Elinson [ 4 ] described a group of children who presented with a combination of co-morbid symptoms of various diagnoses such as conduct disorder, ADHD, post-traumatic stress disorder (PTSD), depression and anxiety. As per Shankman et al. [ 5 ], these patients may escalate to fulfill the criteria for these disorders. The lack of proper diagnosis imposes significant challenges in terms of management [ 3 ].

J is a 4-year-old adopted Caucasian male who at the age of 2 years and 4 months was brought by his adoptive mother to primary care with symptoms of behavioral dyscontrol, emotional dysregulation, anxiety, hyperactivity and inattention, obsessions with food, and attachment issues. J was given diagnoses of reactive attachment disorder (RAD) and ADHD. No medications were recommended at that time and a referral was made for behavioral therapy.

She subsequently took him to two different child psychiatrists who diagnosed disruptive mood dysregulation disorder (DMDD), PTSD, anxiety and a mood disorder. To help with mood and inattention symptoms, guanfacine, fluoxetine, methylphenidate and amphetamine salts were all prescribed without significant improvement. Later quetiapine, aripiprazole and thioridazine were tried consecutively without behavioral improvement (please see Table  1 for details).

No significant drug/substance interactions were noted (Table 1 ). There were no concerns regarding adherence and serum drug concentrations were not ordered. On review of patient’s history of medication trials guanfacine and methylphenidate seemed to have no effect on J’s hyperactive and impulsive behavior as well as his lack of focus. Amphetamine salts that were initiated during hospitalization were stopped by the patient’s mother due to significant increase in aggressive behaviors and irritability. Aripiprazole was tried for a brief period of time and seemed to have no effect. Quetiapine was initially helpful at 150 mg (50 mg three times a day), unfortunately its effects wore off quickly and increase in dose to 300 mg (100 mg three times a day) did not seem to make a difference. Fluoxetine that was tried for anxiety did not seem to improve the behaviors and was stopped after less than a month on mother’s request.

J’s condition continued to deteriorate and his primary care provider started risperidone. While initially helpful, escalating doses were required until he was on 6 mg daily. In spite of this treatment, J attempted to stab a girl at preschool with scissors necessitating emergent evaluation, whereupon he was admitted to inpatient care for safety and observation. Risperidone was discontinued and J was referred to outpatient psychiatry for continuing medical monitoring and therapy.

Little is known about J’s early history. There is suspicion that his mother was neglectful with feeding and frequently left him crying, unattended or with strangers. He was taken away from his mother’s care at 7 months due to neglect and placed with his aunt. After 1 month, his aunt declined to collect him from daycare, deciding she was unable to manage him. The owner of the daycare called Child Services and offered to care for J, eventually becoming his present adoptive parent.

J was a very needy baby who would wake screaming and was hard to console. More recently he wakes in the mornings anxious and agitated. He is often indiscriminate and inappropriate interpersonally, unable to play with other children. When in significant distress he regresses, and behaves as a cat, meowing and scratching the floor. Though J bonded with his adoptive mother well and was able to express affection towards her, his affection is frequently indiscriminate and he rarely shows any signs of separation anxiety.

At the age of 2 years and 8 months there was a suspicion for speech delay and J was evaluated by a speech pathologist who concluded that J was exhibiting speech and language skills that were solidly in the average range for age, with developmental speech errors that should be monitored over time. They did not think that issues with communication contributed significantly to his behavioral difficulties. Assessment of intellectual functioning was performed at the age of 2 years and 5 months by a special education teacher. Based on Bailey Infant and Toddler Development Scale, fine and gross motor, cognitive and social communication were all within normal range.

J’s adoptive mother and in-home therapist expressed significant concerns in regards to his appetite. She reports that J’s biological father would come and visit him infrequently, but always with food and sweets. J often eats to the point of throwing up and there have been occasions where he has eaten his own vomit and dog feces. Mother noticed there is an association between his mood and eating behaviors. J’s episodes of insatiable and indiscriminate hunger frequently co-occur with increased energy, diminished need for sleep, and increased speech. This typically lasts a few days to a week and is followed by a period of reduced appetite, low energy, hypersomnia, tearfulness, sadness, rocking behavior and slurred speech. Those episodes last for one to 3 days. Additionally, there are times when his symptomatology seems to be more manageable with fewer outbursts and less difficulty regarding food behaviors.

J’s family history is poorly understood, with his biological mother having a personality disorder and ADHD, and a biological father with substance abuse. Both maternally and paternally there is concern for bipolar disorder.

J has a clear history of disrupted attachment. He is somewhat indiscriminate in his relationship to strangers and struggles with impulsivity, aggression, sleep and feeding issues. In addition to early life neglect and possible trauma, J has a strong family history of psychiatric illness. His mood, anxiety and sleep issues might suggest underlying PTSD. His prominent hyperactivity could be due to trauma or related to ADHD. With his history of neglect, indiscrimination towards strangers, mood liability, attention difficulties, and heightened emotional state, the possibility of Disinhibited Social Engagement Disorder (DSED) is likely. J’s prominent mood lability, irritability and family history of bipolar disorder, are concerning for what future mood diagnosis this portends.

As evidenced above, J presents as a diagnostic conundrum suffering from a combination of transdiagnostic symptoms that broadly impact his functioning. Unfortunately, although various diagnoses such as ADHD, PTSD, Depression, DMDD or DSED may be entertained, the patient does not fall neatly into any of the categories.

This is a case report that describes a diagnostic conundrum in a young boy with prominent early life deprivation who presented with multidimensional symptoms managed with polypharmacy.

A sub-threshold presentation in this patient partially explains difficulties with diagnosis. There is no doubt that negative effects of early childhood deprivation had significant impact on developmental outcomes in this patient, but the mechanisms that could explain the associations are still widely unknown. Significant family history of mental illness also predisposes him to early challenges. The clinical picture is further complicated by the potential dynamic factors that could explain some of the patient’s behaviors. Careful examination of J’s early life history would suggest such a pattern of being able to engage with his biological caregivers, being given food, being tended to; followed by periods of neglect where he would withdraw, regress and engage in rocking as a self-soothing behavior. His adoptive mother observed that visitations with his biological father were accompanied by being given a lot of food. It is also possible that when he was under the care of his biological mother, he was either attended to with access to food or neglected, left hungry and screaming for hours.

The current healthcare model, being centered on obtaining accurate diagnosis, poses difficulties for treatment in these patients. Given the complicated transdiagnostic symptomatology, clear guidelines surrounding treatment are unavailable. To date, there have been no psychopharmacological intervention trials for attachment issues. In patients with disordered attachment, pharmacologic treatment is typically focused on co-morbid disorders, even with sub-threshold presentations, with the goal of symptom reduction [ 6 ]. A study by dosReis [ 7 ] found that psychotropic usage in community foster care patients ranged from 14% to 30%, going to 67% in therapeutic foster care and as high as 77% in group homes. Another study by Breland-Noble [ 8 ] showed that many children receive more than one psychotropic medication, with 22% using two medications from the same class.

It is important to note that our patient received four different neuroleptic medications (quetiapine, aripiprazole, risperidone and thioridazine) for disruptive behaviors and impulsivity at a very young age. Olfson et al. [ 9 ] noted that between 1999 and 2007 there has been a significant increase in the use of neuroleptics for very young children who present with difficult behaviors. A preliminary study by Ercan et al. [ 10 ] showed promising results with the use of risperidone in preschool children with behavioral dyscontrol. Review by Memarzia et al. [ 11 ] suggested that risperidone decreased behavioral problems and improved cognitive-motor functions in preschoolers. The study also raised concerns in regards to side effects from neuroleptic medications in such a vulnerable patient population. Younger children seemed to be much more susceptible to side effects in comparison to older children and adults with weight gain being the most common. Weight gain associated with risperidone was most pronounced in pre-adolescents (Safer) [ 12 ]. Quetiapine and aripiprazole were also associated with higher rates of weight gain (Correll et al.) [ 13 ].

Pharmacokinetics of medications is difficult to assess in very young children with ongoing development of the liver and the kidneys. It has been observed that psychotropic medications in children have shorter half-lives (Kearns et al.) [ 14 ], which would require use of higher doses for body weight in comparison to adults for same plasma level. Unfortunately, that in turn significantly increases the likelihood and severity of potential side effects.

There is also a question on effects of early exposure to antipsychotics on neurodevelopment. In particular in the first 3 years of life there are many changes in developing brains, such as increase in synaptic density, pruning and increase in neuronal myelination to list just a few [ 11 ]. Unfortunately at this point in time there is a significant paucity of data that would allow drawing any conclusions.

Our case report presents a preschool patient with history of adoption, early life abuse and neglect who exhibited significant behavioral challenges and was treated with various psychotropic medications with limited results. It is important to emphasize that subthreshold presentation and poor diagnostic clarity leads to dangerous and excessive medication regimens that, as evidenced above is fairly common in this patient population.

Neglect and/or abuse experienced early in life is a risk factor for mental health problems even after adoption. Differences in genetic risk, epigenetics, prenatal factors (e.g., malnutrition or poor nutrition), exposure to stress and/or substances, and parent-child interactions may explain the diversity of outcomes among these individuals, both in terms of mood and behavioral patterns [ 15 , 16 , 17 ]. Considering that these children often present with significant functional impairment and a wide variety of symptoms, further studies are needed regarding diagnosis and treatment.

Abbreviations

Attention-Deficit/Hyperactivity Disorder

Disruptive Mood Dysregulation Disorder

Disinhibited Social Engagement Disorder

Post-Traumatic Stress Disorder

Reactive Attachment disorder

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Romanowicz, M., McKean, A.J. & Vande Voort, J. A case of a four-year-old child adopted at eight months with unusual mood patterns and significant polypharmacy. BMC Psychiatry 17 , 330 (2017). https://doi.org/10.1186/s12888-017-1492-y

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A, The similarity network fusion (SNF) pipeline was used to construct similarity matrices for each network-measure pair, which were subsequently fused and clustered. B, This procedure was repeated over a wide range of SNF hyperparameters ( K and μ), each time for a prespecified number of clusters, N , ranging from 2 to 10. Stable solutions were identified using the z-Rand similarity index and used to construct a participant coassignment matrix. C, This procedure was repeated for 10 000 subsamples of participants, taking the median across all coassignment matrices. D, Hierarchical clustering was used to identify the emergence of 2 to 10 clusters from the final coassignment matrix.

Dendrograms showing the emergence of the 6 clusters in the Province of Ontario Neurodevelopmental (POND) network and Healthy Brain Network (HBN) data sets. The circle colors correspond to the number of specified clusters, and their size is proportional to the percentage of participants included in the subgroup. For each layer of the dendrogram, Mann-Whitney U or t tests were used to identify pairwise differences in sample characteristics between the leaf clusters (letters A through J in uppercase and lowercase for POND and HBN, respectively); the directionality of significant ( P  < .05) effect sizes are identified, with red indicating the leaf cluster with an increase in the clinical measure and blue indicating a decrease. ADHD indicates attention-deficit/hyperactivity disorder; ASD, autism spectrum disorder; FSIQ, full-scale intelligence quotient; SCQ, Social Communication Questionnaire; SES, socioeconomic status; SWAN-HI, Strengths and Weaknesses of ADHD—Symptoms and Normal Behavior Hyperactivity/Impulsivity subscale; SWAN-I, Strengths and Weaknesses of ADHD—Symptoms and Normal Behavior Inattention subscale; TOCS, Toronto Obsessive-Compulsive Scale.

a Corrected P  = .06.

The effect size of significant (ie, corrected P  < .05) differences in network-averaged measures of segregation and integration between the Province of Ontario Neurodevelopmental (POND) and Health Brain Network (HBN) subgroups that differed in intelligence and hyperactivity and impulsivity.

eFigure 1. Cortical and Subcortical Parcellation Used in the Analysis

eFigure 2. The Calinski-Harabasz Index for Each Clustering Solution for the POND (A) and HBN (B) Clustering

eFigure 3. POND (A) and HBN (B) Dendrograms

eFigure 4. Distributions of Intelligence and Hyperactivity/Impulsivity, Separated for Males and Females, for the Subgroups Showing Replicable Differences

eTable 1. MRI Protocols for the T1-Weighted and Resting-State Data Acquired Using the 3 Scanners

eTable 2. Normality Test Statistics for the Continuous Measures Describing the POND and HBN Sample Characteristics and the Clinical Behavioural Measures

eTable 3. Race and Ethnicity Data for the POND and HBN Data Sets

eTable 4. Descriptive Statistics of the Participant Demographics and Clinical Behavioural Measures Comparing the POND and HBN Data Sets, With Corresponding Statistics Identifying Significant (p<0.05) Differences Between the Data Sets, With the Directionality of the Difference Highlighted

eTable 5. Descriptive Statistics of the Participant Demographics and Clinical Behavioural Measures for Each Leaf Cluster for Each Layer of the POND Dendrogram

eTable 6. Descriptive Statistics of the Participant Demographics and Clinical Behavioural Measures for Each Leaf Cluster for Each Layer of the HBN Dendrogram

eTable 7. Statistical Details of the Mann Whitney U and t Tests and χ 2 Tests Examining Differences in Sample Characteristics Between the Leaf Clusters in Each Layer of the POND Dendrogram

eTable 8. Statistical Details of the Mann Whitney U and t Tests and χ 2 Tests Examining Differences in Sample Characteristics Between the Leaf Clusters in Each Layer of the HBN Dendrogram

eTable 9. Descriptive Statistics of the Network-Averaged Measures of Segregation and Integration for Each Leaf Cluster for Each Layer of the POND Dendrogram

eTable 10. Descriptive Statistics of the Network-Averaged Measures of Segregation and Integration for Each Leaf Cluster for Each Layer of the HBN Dendrogram

eTable 11. Statistical Details of the Tests Examining Differences in the Network-Averaged Measures of Segregation and Integration Between the Leaf Clusters in Each Layer of the POND Dendrogram

eTable 12. Statistical Details of the Tests Examining Differences in the Network-Averaged Measures of Segregation and Integration Between the Leaf Clusters in Each Layer of the HBN Dendrogram

eTable 13. Statistical Details of the Tests Examining Differences in the Network-Averaged Measures of Segregation and Integration Between the Leaf Clusters From the HBN Dendrogram That Differed in Hyperactivity/Impulsivity Problems (Subgroup d and g)

eReferences.

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Vandewouw MM , Brian J , Crosbie J, et al. Identifying Replicable Subgroups in Neurodevelopmental Conditions Using Resting-State Functional Magnetic Resonance Imaging Data. JAMA Netw Open. 2023;6(3):e232066. doi:10.1001/jamanetworkopen.2023.2066

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Identifying Replicable Subgroups in Neurodevelopmental Conditions Using Resting-State Functional Magnetic Resonance Imaging Data

• 1 Autism Research Centre, Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, Toronto, Ontario, Canada
• 2 Institute of Biomedical Engineering, University of Toronto, Toronto, Ontario, Canada
• 3 Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
• 4 Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
• 5 Department of Psychiatry, The Hospital for Sick Children, Toronto, Ontario, Canada
• 6 Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario, Canada
• 7 Department of Psychiatry, Western University, London, Ontario, Canada
• 8 Department of Psychology, Queen’s University, Kingston, Ontario, Canada
• 9 Centre for Neuroscience Studies, Queen’s University, Kingston, Ontario, Canada
• 10 Department of Psychiatry, Queen’s University, Kingston, Ontario, Canada
• 11 Program in Neurosciences & Mental Health, The Hospital for Sick Children, Toronto, Ontario, Canada
• 12 Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Ontario, Canada
• 13 Department of Psychology, University of Toronto, Toronto, Ontario, Canada
• 14 Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
• 15 Wellcome Centre for Integrative Neuroimaging, FMRIB, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
• 16 Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada

Question   Are subgroups derived from measures of brain function among children and adolescents with neurodevelopmental conditions replicable across independently collected data sets?

Findings   In this case-control study using resting-state data from 2 network data sets with a total of 1102 individuals aged 5 to 19 years with and without neurodevelopmental conditions, subgroups with similar biology that differed significantly in intelligence as well as hyperactivity and impulsivity problems were identified. However, these groups showed no consistent alignment with diagnostic categories.

Meaning   In this study, homogeneity in the neurobiology of neurodevelopmental conditions corresponded to behavior, not diagnostic category; these findings are replicable in independent cohorts, taking an important step toward translating neurobiological subgroups into clinical settings.

Importance   Neurodevelopmental conditions, such as autism spectrum disorder (ASD), attention-deficit/hyperactivity disorder (ADHD), and obsessive-compulsive disorder (OCD), have highly heterogeneous and overlapping phenotypes and neurobiology. Data-driven approaches are beginning to identify homogeneous transdiagnostic subgroups of children; however, findings have yet to be replicated in independently collected data sets, a necessity for translation into clinical settings.

Objective   To identify subgroups of children with and without neurodevelopmental conditions with shared functional brain characteristics using data from 2 large, independent data sets.

Design, Setting, and Participants   This case-control study used data from the Province of Ontario Neurodevelopmental (POND) network (study recruitment began June 2012 and is ongoing; data were extracted April 2021) and the Healthy Brain Network (HBN; study recruitment began May 2015 and is ongoing; data were extracted November 2020). POND and HBN data are collected from institutions across Ontario and New York, respectively. Participants who had diagnoses of ASD, ADHD, and OCD or were typically developing (TD); were aged between 5 and 19 years; and successfully completed the resting-state and anatomical neuroimaging protocol were included in the current study.

Main Outcomes and Measures   The analyses consisted of a data-driven clustering procedure on measures derived from each participant’s resting-state functional connectome, performed independently on each data set. Differences between each pair of leaves in the resulting clustering decision trees in the demographic and clinical characteristics were tested.

Results   Overall, 551 children and adolescents were included from each data set. POND included 164 participants with ADHD; 217 with ASD; 60 with OCD; and 110 with TD (median [IQR] age, 11.87 [9.51-14.76] years; 393 [71.2%] male participants; 20 [3.6%] Black, 28 [5.1%] Latino, and 299 [54.2%] White participants) and HBN included 374 participants with ADHD; 66 with ASD; 11 with OCD; and 100 with TD (median [IQR] age, 11.50 [9.22-14.20] years; 390 [70.8%] male participants; 82 [14.9%] Black, 57 [10.3%] Hispanic, and 257 [46.6%] White participants). In both data sets, subgroups with similar biology that differed significantly in intelligence as well as hyperactivity and impulsivity problems were identified, yet these groups showed no consistent alignment with current diagnostic categories. For example, there was a significant difference in Strengths and Weaknesses ADHD Symptoms and Normal Behavior Hyperactivity/Impulsivity subscale (SWAN-HI) between 2 subgroups in the POND data (C and D), with subgroup D having increased hyperactivity and impulsivity traits compared with subgroup C (median [IQR], 2.50 [0.00-7.00] vs 1.00 [0.00-5.00]; U  = 1.19 × 10 4 ; P  = .01; η 2  = 0.02). A significant difference in SWAN-HI scores between subgroups g and d in the HBN data was also observed (median [IQR], 1.00 [0.00-4.00] vs 0.00 [0.00-2.00]; corrected P  = .02). There were no differences in the proportion of each diagnosis between the subgroups in either data set.

Conclusions and Relevance   The findings of this study suggest that homogeneity in the neurobiology of neurodevelopmental conditions transcends diagnostic boundaries and is instead associated with behavioral characteristics. This work takes an important step toward translating neurobiological subgroups into clinical settings by being the first to replicate our findings in independently collected data sets.

Autism spectrum disorder (ASD), attention-deficit/hyperactivity disorder (ADHD), and obsessive-compulsive disorder (OCD) are neurodevelopmental conditions clinically defined based on distinct behavioral criteria. 1 However, an increasing body of evidence suggests that these conditions are highly heterogeneous in biology and phenotype within each condition 2 - 4 and significantly overlapping. 5 - 12 These observations pose significant challenges to traditional case-control studies, especially with relatively small sample sizes, 13 and have resulted in discrepant findings across various studies. For example, investigations attempting to characterize the functional connectome in individuals with ASD, ADHD, and OCD compared with typically developing (TD) populations are highly mixed. 14 - 16 The seemingly contradictory findings reflect the heterogeneous nature of these conditions 17 , 18 as well as suggest that differences in the topography of the functional connectome, such as integration and segregation between resting state networks, may better explain connectivity patterns in neurodevelopmental conditions rather than the strength of individual connections. 19 - 23 These topographical differences have frequently been described in all 3 conditions, 24 - 26 and there is increasing evidence that these differences are shared across conditions. 9 , 10

To disentangle these findings, a shift from traditional case-control designs to data-driven approaches, which transcend diagnostic boundaries to identify groups that are homogeneous in their neurobiology, is necessary. An emerging body of literature using data-driven approaches supports the idea that the diagnostic categories of ASD, ADHD, and OCD are not associated with unique underlying neurobiological mechanisms 27 , 28 and often do not predict treatment outcome. 29 This motivates the need for the discovery of homogeneous groups that can accelerate the development of targeted and personalized treatment approaches, interventions, supports, and accommodations that fit the diverse profiles of strengths and needs of children with neurodevelopmental conditions.

To this end, several studies have used measures of brain function or structure to identify transdiagnostic subgroups of neurodevelopmental conditions, consistently demonstrating a misalignment between data-driven groupings and existing diagnostic categories. 9 , 10 , 12 , 27 , 28 , 30 - 32 The first contribution of this article is to characterize the heterogeneity across neurodevelopmental conditions by identifying cross-diagnosis subgroups of children and adolescents with and without neurodevelopmental conditions using measures of integration and segregation of the functional connectome.

Despite the promise of data-driven approaches and the encouraging preliminary reports, the replicability and generalizability of these findings remains an open question in the field 33 and a critical gap to clinical translation of the findings. 13 , 34 To date, this issue has been addressed partly by using subsampling within a data set to enhance generalizability 27 , 28 ; however, to our knowledge, subgroupings within neurodevelopmental conditions based on neuroimaging data have not been replicated across independently collected data sets. The second contribution of this article is to be the first, to our knowledge, to address this replication gap by examining subgroups across 2 large, independently collected, cross-condition data sets, namely the Province of Ontario Neurodevelopmental Disorders (POND) network and the Healthy Brains Network (HBN).

Both the POND network and HBN studies were approved by the appropriate research ethics boards, and the current study was approved by the Holland Bloorview Kids Rehabilitation Hospital’s research ethics board; written informed consent and/or verbal assent was obtained from the primary caregivers and/or participants (eMethods in Supplement 1 ). This study followed the Strengthening the Reporting of Observational Studies in Epidemiology ( STROBE ) reporting guideline for case-control studies.

For the primary cohort, participants were drawn from the POND Network data set (exported April 2021) 35 , and data from the Healthy Brain Network 36 , 37 was used as the replication cohort (exported November 2020) (eMethods in Supplement 1 ). Overall, 717 POND participants (210 with ADHD; 300, ASD; 69, OCD; and 138, TD) and 966 HBN participants (672, ADHD; 111, ASD; 12, OCD; and 171, TD) aged between 5 and 19 years were included in the current study based on successful completion of the resting-state and anatomical imaging protocols and presence of phenotypic data. Details on phenotypic measures used to characterize the POND and HBN samples are provided in the eMethods in Supplement 1 .

Both datasets used self- or parent-reported race and ethnicity, per the protocols of the larger POND and HBN studies. In the POND data set, racial groups were defined according to the Canadian Institute for Health Information standards and included Black, East Asian, Indigenous, Latino, Middle Eastern, other, South Asian, Southeast Asian, and White. Participants were classified into multiple categories if they were of mixed race; those who did not identify as one of the groups were categorized as other. In the HBN data set, categories were defined according to US Census guidelines and included American Indian or Alaskan Native, Asian, Black, Hispanic, 2 or more races, Native Hawaiian or other Pacific Islander, other, and White. Participants of mixed race were classified as such, and thus participants were only assigned to 1 category; those who did not identify as any of the census groups were categorized as other. Due to low sample size, categories for both datasets were collapsed into minoritized racial and ethnic group and White for statistical tests.

Five minutes of resting-state data and anatomical brain images were collected as part of the POND and HBN studies and preprocessed. Propensity scores were used to match the POND and HBN participants who passed quality control on age, sex, and motion. Full details on data acquisition, preprocessing, and propensity score matching can be found in eMethods and eTable 1 in Supplement 1 .

Connectome nodes were defined using the cortical atlas from Schaefer et al, 38 supplemented by the Melbourne subcortical atlas, 39 as this parcellation scheme is highly representative across alternative connectome construction pipelines, 40 resulting in 232 nodes. The parcels were categorized into 8 functional networks: visual, somatomotor, dorsal attention, ventral attention and salience, limbic, frontoparietal control, default mode, and subcortical (eFigure 1 in Supplement 1 ). Pairwise Pearson correlations between parcel-averaged preprocessed time series were computed as the edge weights between pairs of nodes. The edge weights were harmonized to account for acquisition site effects across both data sets, and the influence of scanner, age, and sex were removed (eMethods in Supplement 1 ). The connectomes were thresholded to remove spurious connections and produce more biologically plausible connectomes. 40 , 41 For each participant, nodal measures of integration (betweenness centrality 42 , 43 ) and segregation (clustering coefficient 42 ) were extracted and z scored.

Clustering was performed separately on the POND and HBN data sets, and the pipeline is presented in Figure 1 . In the first section ( Figure 1 A), similarity network fusion (SNF 44 ) was used to compute similarity matrices for each measure-network pair (eg, segregation of the visual network) using the Euclidean distance across all nodal measures belonging to the network and SNF’s K -nearest neighbors weighted similarity kernel. The 16 similarity matrices (8 networks × 2 measures) were then fused using SNF, from which spectral clustering can be used to identify a prespecified number of subgroups.

Due to SNF’s dependence on 2 free hyperparameters (μ and K ), 10 000 clustering solutions were obtained using different combinations of hyperparameters ( Figure 1 B and eMethods in Supplement 1 ). A participant coassignment matrix was then generated by computing the percentage of times 2 participants were clustered in the same subgroup across cluster solutions that were stable across the hyperparameter space.

The clustering procedure was performed on 10 000 subsampling iterations to increase robustness of the final clustering solution, selecting 63.2% of the sample in each iteration; a final coassignment matrix was constructed by computing the median across all subsampling iterations ( Figure 1 C). Hierarchical clustering was performed on the final coassignment matrix ( Figure 1 D) to identify subgroups across the full range of number of clusters (2-10). Hierarchical clustering constructs a rooted tree, or a dendrogram, consisting of layers of nodes: the first layer contains a single cluster, representing the trivial solution, and the n th layer contains n clusters, representing the n th-cluster solution 45 ; in each layer, a root cluster is split into 2 leaf clusters. The optimal number of clusters was identified using the Calinski-Harabasz index. 46

Differences in the demographic and behavioral measures were compared among the diagnostic groups within each data set as well as compared between data sets. For the continuous measures, Kruskal-Wallis tests or 1-way analysis of variance were used, depending on normality (eTable 2 in Supplement 1 ); for significant omnibus tests ( P  < .05), post hoc testing was carried out using the Dunn procedure with Bonferroni-corrected P values (corrected P   < .05). For nominal categorical variables (sex and acquisition scanner), χ 2 tests were performed with post hoc pairwise z tests of independent proportions (corrected P  < .05). For ordinal categorical variables (socioeconomic variables in the POND data set), ordinal regression was performed, testing for all pairwise between-group differences (corrected P  < .05).

To determine which brain measures were associated with the split from a root cluster into its 2 leaf clusters in each layer, we tested for a difference in means between each pair of leaf clusters in their network-averaged measures of segregation and integration. Given that we are using the same data to both define the groups via clustering and perform downstream testing, traditional statistical tests such as Mann-Whitney U and t tests would lead to inflated type I errors, as they only control for such error rates when groups are defined a priori. 47 Thus, we used the clusterpval 48 package in R version 4.2.1 (R Project for Statistical Computing) to produce test statistics and P values that are corrected for double-use of the data; the generic implementation was used, which approximates the corrected P values using Monte Carlo sampling, and the resulting P values were corrected for multiple comparisons (corrected P  < .05). Mann-Whitney U or t tests and χ 2 tests were used to determine differences between leaves in the demographic and behavioral measures.

For all significant tests, effect sizes were reported. For continuous measures, eta-squared (η 2 ) effect sizes were used, using the ranked data for nonnormally distributed data. For categorical variables, Cramer V effect sizes were reported, while for ordinal variables, pseudo- R 2 values were reported. 49

The final data set included 551 POND participants (164 with ADHD; 217, ASD; 60, OCD; 110, TD; median [IQR] age. 11.87 [9.51-14.76] years; 393 [71.2%] male participants; 20 [3.6%] Black, 28 [5.1%] Latino, and 299 [54.2%] White participants) and 551 HBN participants (374 with ADHD; 66, ASD; 11, OCD; 100, TD; median [IQR] age, 11.50 [9.22-14.20] years; 390 [70.8%] male participants; 82 [14.9%] Black, 57 [10.3%] Hispanic, and 257 [46.6%] White participants). The final sample was reached by performing propensity matching on the individuals who passed quality control (592 POND and 756 HBN individuals) to match the data sets on age, sex, and head motion. Descriptive statistics of the POND and HBN sample characteristics are provided in Tables 1 and 2 , respectively. Complete race and ethnicity data for each data set are presented in eTable 3 in Supplement 1 .

Compared with the POND sample, the HBN sample had a significantly higher proportion of ADHD and a lower proportion of ASD and OCD diagnoses (χ 2  = 197.74; P  < .001; V  = 0.42). Furthermore, the HBN sample had significantly more participants belonging to minoritized racial and ethnic groups (χ 2  = 6.50; P  = .01; V  = 0.09), lower full-scale IQ ( U  = 1.15 × 10 5 ; P  = .01; η 2  = 7.44 × 10 −3 ), and fewer social communication difficulties ( U  = 1.26 × 10 5 ; P  = .03; η 2  = 1.71 × 10 −3 ) and hyperactivity and impulsivity problems, measured by the Strengths and Weaknesses ADHD Symptoms and Normal Behavior Hyperactivity/Impulsivity subscale (SWAN-H/I; U  = 1.09 × 10 5 ; P  < .001; η 2  = 0.03). eTable 4 in Supplement 1 includes full details.

The Calinski-Harabasz index indicated that the 6- and 10-cluster solutions were optimal for POND and HBN, respectively (eFigure 2 in Supplement 1 ). Visual representations of the emergence of the 6 clusters in the POND and HBN data sets are presented in Figure 2 , and statistical results appear in eTables 5 to 8 in Supplement 1 . Significant differences between the leaf clusters in network-averaged measures of segregation and integration for each layer in the POND and HBN dendrograms are shown in eFigure 3 and eTables 9 to 12 in Supplement 1 .

For both POND and HBN data sets, the 2-cluster solution split the sample into 2 groups (POND: subgroups A and B; HBN: subgroups a and b). Subgroups B and b had increased segregation in all resting-state networks; increased integration in the somatomotor, dorsal attention, limbic and default mode networks; and decreased integration in the frontoparietal control network and subcortical regions compared with subgroups A and a ( Figure 3 A and B). Although integration of the visual network was also observed to be decreased in the HBN data set, this was not replicated in the POND data set. A difference in IQ scores was observed (full-spectrum IQ, POND: U  = 2.86 × 10 4 ; P  = .04; η 2  = 0.01; full-spectrum IQ, HBN: t  = −2.37; P  = .02; η 2  = 0.01), with subgroups B and b having increased IQ scores compared with subgroups A and a (median [IQR] IQ scores, B vs A: 104.00 [92.00-114.00] vs 100.00 [88.00-110.00]; mean [SD] IQ scores, b vs a: 100.63 [16.98] vs 97.08 [16.55]) (eFigure 4 in Supplement 1 ). In both data sets, there were no differences in the proportion of each diagnosis between the leaves.

In subsequent layers of the dendrogram, consistent results were also observed with respect to cluster splits resulting in differences in hyperactivity and impulsivity symptoms as measured by SWAN-HI. In the third layer of the POND dendrogram, a significant difference in SWAN-HI ( U  = 1.19 × 10 4 ; P  = .01; η 2  = 0.02) was identified between the 2 leaf subgroups (C and D), with subgroup D having increased hyperactivity and impulsivity traits compared with subgroup C (median [IQR], 2.50 [0.00-7.00] vs 1.00 [0.00-5.00]). In the HBN dendrogram, the leaves in the third layer (subgroups c and d) also showed a difference in hyperactivity and impulsivity, but the difference was not statistically significant ( U  = 1.13 × 10 4 ; P  = .06; η 2  = 0.01). A significant difference in symptoms was observed in the fifth layer (subgroups g and h: U  = 2.68 × 10 3 ; P  = .02; η 2  = 0.03). To contrast with POND, the 4 HBN subgroups (c, d, g, and h) were compared, and a difference in hyperactivity and impulsivity problems was identified ( W  = 10.81; P  = .01; η 2  = 0.02), with post hoc tests identifying that subgroup g had significantly higher hyperactivity and impulsivity compared with subgroup d (median [IQR], 1.00 [0.00-4.00] vs 0.00 [0.00-2.00]; corrected P  = .02). Thus, POND subgroup D and HBN subgroup g were identified as having increased SWAN-HI scores compared with POND subgroup C and HBN subgroup d (eFigure 4 in Supplement 1 ). Differences in the brain measures were compared between the 2 subgroups for both POND and HBN ( Figure 3 C and D; eTable 13 in Supplement 1 ). In both data sets, we observed increased segregation in all networks in the subgroup with higher hyperactivity and impulsivity, with the largest effect sizes occurring in the somatomotor and default mode networks in both data sets, along with the dorsal attention network in HBN. Increased integration in the motor and default mode networks and decreased integration in the frontoparietal and subcortical networks were also observed in both data sets. Despite these subgroups differing in symptoms associated with ADHD, we observed no differences in the proportion of each diagnosis between the subgroups in either data set.

In subsequent layers of the POND dendrogram, we observed differences in the proportion of diagnoses between the leaf clusters in the 4- and 5-cluster solutions. However, these diagnostic differences were not replicated in the HBN data set.

In this study, we used measures derived from the brain’s functional networks to identify data-driven transdiagnostic subgroups of children and adolescents with and without neurodevelopmental conditions to characterize the heterogeneity across the conditions; these data-driven subgroups were then described using demographic and clinical indices. We identified subgroups in 2 independently collected data sets—POND and HBN—and, focusing on findings that were present in both cohorts, found subgroups that differed in intelligence and hyperactivity and impulsivity symptoms but not diagnosis.

Research on neurodevelopmental conditions has classically operated under the assumption that diagnostic labels are the ground truth. However, there is increasing awareness of the biological and symptom heterogeneity within conditions and overlap across conditions, which has raised concerns about the appropriateness of service provision systems in health care that are based on diagnostic labels. 50 , 51 Our work joins the growing body of literature supporting transdiagnostic approaches for accommodating the variability and complexity of these conditions and provides support for categorizing individuals on biology to identify better targets for treatments and interventions.

Furthermore, to our knowledge, we are the first to replicate our discovered transdiagnostic subgroups across 2 independently collected data sets, showing that similar subgroups with specific brain signatures can be identified that are accompanied by replicable phenotypic differences. With a mounting body of work challenging the reproducibility of brain-behavior relations 13 , 34 and brain-based subtyping, 52 replicating clustering results is essential to establish the robustness necessary to translate the groupings to clinical settings, particularly given the heterogeneity in both brain and behavior in neurodevelopmental conditions. While previous studies have established transdiagnostic subgroupings using neuroimaging, 9 , 12 , 27 , 28 , 30 - 32 , 53 these results should be interpreted cautiously in the absence of replication. We explicitly address their shortcomings by evaluating subgroup replicability in 2 independent data sets.

Our discovered brain-based subgroups spanned the spectrum of neurodiversity, including typical development, and do not align with existing categorical boundaries. Specifically, we identified subgroups with similar biology that differed significantly in intelligence and hyperactivity and impulsivity problems yet showed no consistent alignment with the current diagnostic categories. The identification of neurobiologically defined subgroups that align poorly with the current behavior-based diagnostic categories contributes to the work criticizing the lack of correspondence of these categorical descriptors with biology. 9 , 11 , 27 , 28 , 30 , 32 , 53 The TD individuals were also spread across all identified brain-based subgroups, emphasizing that an overlap in neurobiology exists not only across conditions, but also across typical development, aligning with emerging studies highlighting the similarities, rather than differences, in resting-state brain function between populations with neurodevelopmental conditions and TD populations. 9 , 10 , 54

We identified replicable subgroups differing in intelligence, between which no differences in diagnosis (including those with no diagnosis) were observed. The distribution of each diagnosis across the subgroups aligned with the diversity in traits observed in neurodevelopmental conditions. For example, although neurodevelopmental conditions demonstrate overall reduced intelligence compared with their TD peers, 55 - 57 those with ASD have been shown to also have a higher probability of scoring in the superior intelligence range. 55 We also identified subgroups in both data sets who differed in hyperactivity and impulsivity traits. Even though these traits are traditionally considered characteristic of ADHD, we did not observe a difference in proportion of diagnostic categorization between these subgroups in either data set. This is consistent with the finding that hyperactivity and impulsivity are shared characteristics across neurodevelopmental conditions. 58 - 60 The identification of subgroups that differ in these behavioral characteristics, rather than by diagnosis, supports using continuous measures of behavior to study neurodevelopmental differences rather than relying on the current discrete categorical categories.

These differences in intelligence and hyperactivity and impulsivity symptoms were accompanied by pervasive differences in the brain’s functional segregation and integration. Networks involved in intelligence are distributed throughout the brain to support distinct information processing stages. 61 Similarly, there was no convergence in the spatial patterns of functional brain connectivity associated with ADHD in the literature, 17 and ADHD traits have been reported to be more associated with brainwide connectivity than with local connectivity. 62 Thus, our findings support the distributed involvement of brain regions in intelligence and hyperactivity and impulsivity symptoms.

We observed increased segregation in all brain networks coupled with predominantly increased integration in the subgroups with increased intelligence. Simultaneous increases in both segregation and integration occurs throughout development as hubs in the brain’s network shift from primary to cognitive brain regions to support cognitive development. 63 , 64 Opposite to the other networks, the integration of the frontoparietal control and subcortical networks was decreased in the subgroup with increased intelligence. The specific pattern of involvement in these brain networks in intelligence aligns with the parieto-frontal integration theory of intelligence 61 that has been extended to include subcortical structures. 65 , 66

The subgroup with increased hyperactivity and impulsivity demonstrated widespread increased segregation and patterns of both increased (eg, motor) and decreased (eg, subcortical) integration. To our knowledge, no study has identified alterations in the topography of the brain’s resting-state functional network that are specific to hyperactivity and impulsivity in ADHD. The few studies examining the associations between hyperactivity and impulsivity and functional connectivity have implicated connections between striatal regions and regions in the motor network. 67 - 69 The significant and opposite associations of integration we observed in these networks reinforces their specific involvement to hyperactivity and impulsivity symptoms.

This study has limitations. Our study focused on brain function; however, differences between individuals with and without neurodevelopmental conditions have been observed in measures of both brain function and structure as well as in other domains. Thus, our study is limited by focusing on only one aspect of the brain, and our identified subgroups may not be homogeneous in other measures. There was a limited number of participants with OCD compared with the other diagnostic groups, and most behavioral measures used to characterize the data-driven subgroups were parent-rated reports, which may not be impartial. Furthermore, our age range is restricted to children and adolescents, a developmental period when significant changes are occurring; future work should extend the age range into adulthood and examine how the identified subgroups change throughout development. We have also only used a single 5-minute resting-state scan from the HBN data set when 2 were available and passed quality control; future work could evaluate the within-participant stability of our subgroups between multiple resting-state scans. The removal of nuisance covariates (age, sex, head motion, and acquisition scanner) also may inadvertently remove signal of interest yet was necessary to ensure subgroups were not defined by these covariates. Additionally, the study design was cross-sectional, and future studies should incorporate longitudinal data to examine the stability of the clusters over time. It is important to note that the findings of this study are based on neurobiological profiles quantified through measurements of brain function. As such, these results do not reflect broader considerations for existing diagnostic categories including issues of self-identity and service provision. Consultations and partnerships with neurodiverse populations are needed to appropriately contextualize and translate these findings into clinical practice. We recognize the different language preferences for referring to autistic identity (identity-first language and person-first language). We use both in this paper to reflect the diversity of perspectives.

To our knowledge, this is the first study to identify transdiagnostic subgroups replicated across 2 independent data sets. With the reliability of associations between brain and behavior being increasingly questioned in the literature, stratification techniques are a useful way of increasing power by identifying more homogeneous subgroups within the sample to target treatments and interventions. The replication of exact subgroups across different samples with varying diagnostic and behavioral characteristics is an essential step in ensuring robustness prior to implementing the groupings into clinical settings. Finally, our study suggests that homogeneity in neurobiology transcends diagnostic boundaries, promoting a shift in the research community away from classic case-control designs that rely on diagnostic categories, which have increasingly been shown not to reflect distinct biological and phenotypic constructs.

Accepted for Publication: January 22, 2023.

Published: March 13, 2023. doi:10.1001/jamanetworkopen.2023.2066

Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2023 Vandewouw MM et al. JAMA Network Open .

Corresponding Author: Azadeh Kushki, PhD, Autism Research Centre, Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, 150 Kilgour Rd, Toronto, ON M4G 1R8, Canada ( [email protected] ).

Author Contributions: Drs Kushki and Anagnostou had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Vandewouw, Crosbie, Kelley, Lerch, Anagnostou, Kushki.

Acquisition, analysis, or interpretation of data: Vandewouw, Brian, Schachar, Iaboni, Georgiades, Nicolson, Ayub, Jones, Taylor, Lerch, Anagnostou, Kushki.

Drafting of the manuscript: Vandewouw, Nicolson, Anagnostou, Kushki.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Vandewouw, Georgiades, Lerch, Anagnostou, Kushki.

Obtained funding: Crosbie, Schachar, Georgiades, Ayub, Lerch, Anagnostou, Kushki.

Administrative, technical, or material support: Brian, Schachar, Iaboni, Nicolson, Kelley, Ayub, Taylor, Anagnostou, Kushki.

Supervision: Brian, Taylor, Anagnostou, Kushki.

Conflict of Interest Disclosures: Dr Nicolson reported receiving grants from Brain Canada, Hoffman La Roche, Otsuka Pharmaceuticals, and Maplight Therapeutics outside the submitted work. Dr Anagnostou reported receiving grants from Roche and Anavex; receiving nonfinancial support from AMO Pharma and CRA-Simons Foundation; and receiving personal fees from Roche, Impel, Ono, and Quadrant outside the submitted work; in addition, Dr Anagnostou had a patent for Anxiety Meter issued 14/755/084 (United States) and a patent for Anxiety Meter pending 2,895,954 (Canada) as well as receiving royalties from APPI and Springer. Dr Kushki reported receiving grants from National Science and Engineering Research Council during the conduct of the study; in addition, Dr Kushki had a patent for Anxiety Meter with royalties paid from Awake Labs. No other disclosures were reported.

Funding/Support: Funding was provided by the Ontario Brain Institute to Drs Anagnostou and Lerch, Canadian Institutes of Health Research to Ms Vandewouw, and New Frontiers in Research Fund to Dr Kushki.

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Data Sharing Statement: See Supplement 2 .

Additional Contributions: We would like to thank all participants and their families for their involvement in this study. We would also like to thank Province of Ontario Neurodevelopmental Disorders staff at all sites for their invaluable assistance in data collection; these individuals were compensated for their time. This article was prepared using a limited access data set obtained from the Child Mind Institute Biobank, the Healthy Brain Network. This article reflects the views of the authors and does not necessarily reflect the opinions or views of the Child Mind Institute.

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Case Scenarios and Likelihood to Consider ARP

General attitudes and reported-practice about arp, conclusions, acknowledgments, antireflux procedures in children with neurologic impairment: a national survey of physician perspectives.

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Tammie Dewan , Vishal Avinashi , Paul Beaudry , Marie-Joëlle Doré-Bergeron , Nathalie Gaucher , Kate Nelson; Antireflux Procedures in Children With Neurologic Impairment: A National Survey of Physician Perspectives. Hosp Pediatr June 2024; 14 (6): 413–420. https://doi.org/10.1542/hpeds.2023-007643

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Decision-making about antireflux procedures (ARPs) to treat gastroesophageal reflux disease in children with neurologic impairment and gastrostomy tubes is challenging and likely influenced by physicians’ experience and perspectives. This study will explore physician attitudes about ARPs and determine if there are relationships to clinical practice and personal characteristics.

This is a national observational cross-sectional study that used an electronic questionnaire addressing reported practice, attitudes regarding the ARPs, and responses to clinical vignettes. Participants were physicians in Canadian tertiary-care pediatric settings. Descriptive statistics were used to analyze physician attitudes. Multivariable logistic regression modeling was used to determine associations between physician and practice characteristics and likelihood to consider ARP.

Eighty three respondents represented 12 institutions, with a majority from general or complex care pediatrics. There was a wide disparity between likelihood to consider ARP in each clinical scenario. Likelihood to consider ARP ranged from to 19% to 78% depending on the scenario. Two scenarios were equally split in whether the respondent would offer an ARP. None of the demographic characteristics were significantly associated with likelihood to consider ARP. Often, gastrojejunostomy tubes alone were considered (56% to 68%).

There is considerable variability in physician attitudes toward and recommendations regarding ARPs to treat gastroesophageal reflux disease. We did not find a significant association with clinical experience or location of practice. More research is needed to define indications and outcomes for ARPs. This is a scenario where shared decision-making, bringing together physician and family knowledge and expertise, is likely the best course of action.

Gastroesophageal reflux disease (GERD) is an important comorbidity for children with neurologic impairment (NI), affecting up to 75%. 1 , 2   GERD refers to the passage of gastric contents into the esophagus leading to troublesome symptoms and/or complications. 3   GERD can impair nutrition, contribute to lung disease through secondary aspiration, and cause significant pain. 4 , 5 – 8   The diagnosis of GERD in children with NI is complicated by their frequent inability to self-report symptoms, lack of a gold standard diagnostic test, and variable definitions across the literature. 3 , 9   In addition, GERD symptoms frequently overlap with those of other conditions in this population, such as intestinal dysmotility, feeding intolerance, and visceral hyperalgesia. 10   For the purposes of this study, symptoms such as vomiting, aspiration, and pain will be described as “GERD symptoms,” acknowledging that there may be other conditions contributing to the clinical presentation. This is consistent with real-world practice wherein physicians are often managing this cluster of symptoms without a discrete and confirmed diagnosis.

In cases of refractory GERD, guidelines recommend consideration of antireflux procedures (ARPs) - such as fundoplication and postpyloric feeding through gastrojejunostomy tubes (GJTs). 3 , 9   However, these guidelines are difficult to apply to children with NI and gastrostomy feeds considering their comorbidities, fragility, and frequent communication impairments. Further, evidence for ARPs is weak with no clinical trials comparing ARP to medical therapy or comparing GJT to fundoplication. Observational data are conflicting in terms of the impact of ARPs on lung disease 2 , 11 – 13   and which ARP is superior at improving symptoms and mitigating complications of GERD. 14   Further, adverse events with ARPs are more common in children with NI, including major complications such as intussusception with GJTs and wrap migration or failure with fundoplication. 15  

Given the lack of evidence regarding ARPs, decision-making is challenging. There are no targeted tools or algorithms to support clinical decision-making regarding the use of ARPs in children with NI and gastrostomy. In making decisions, physicians are influenced by their own attitudes about different treatment options, organizational culture and constraints, and demographic and clinical characteristics of the child and family. 15 , 16   A deeper understanding of these perspectives is needed to design and implement much-needed prospective studies and clinical trials. This study will specifically explore physician attitudes and reported practice regarding the ARP treatment options (fundoplication and GJTs) for GERD in children with NI and gastrostomy tubes in association with salient physician characteristics such as professional location and years of practice.

We conducted a cross-sectional electronic survey study of physicians who practice at tertiary-care pediatric hospitals in Canada between November 2021 and February 2022. The design and administration of the survey followed guidelines developed by Burns et al. 17   This study was approved by the Conjoint Health Research Ethics Board at our institution.

The survey was codeveloped by a pediatric surgeon, a pediatric gastroenterologist, a pediatric emergency medicine/palliative care physician, and complex care/hospitalist physicians based on clinical experience and review of existing literature. This multispecialty team determined the survey topics, question stems (including clinical scenarios), and the response options for each question. The survey contained 3 sections: (1) participant demographics; (2) general questions about ARPs (diagnostic tests, potential risks and harms, perceived barriers); and (3) case-based questions designed to imitate “real world” clinical practice ( Fig 1 ). Following a clinical vignette, respondents were asked to report their likelihood to consider an ARP and what treatments or interventions they would attempt before an ARP (full questionnaire in Supplemental Fig 5 ). The vignettes corresponded broadly to the following clinical scenarios: (1) severe aspiration events (“Severe Asp”); (2) moderate aspiration events (“Mod Asp”); (3) failure to thrive because of vomiting or GERD (“FTT”); and (4) pain possibly secondary to GERD (“Pain”). A 4-point Likert scale was used with space for written comments after each question.

Clinical scenarios and likelihood to consider ARP.

This instrument was pilot tested in 5 cognitive interviews with relevant pediatric specialists and subspecialists for content validity, question clarity, item interpretation, and item redundancy. Revisions were made after each interview. After the fifth interview, no further modifications were required. This survey was also reviewed by an expert in survey design. A final survey was created consisting of 8 demographic questions, 7 general ARP questions, and 4 clinical scenarios with 6 questions each. The survey was translated into French by a member of our research team with both French and English language proficiency.

Qualtrics software was used to administer the survey, collect, and store data. Invitations to participate were distributed by e-mail to all members of the relevant divisions at the 14 pediatric hospitals across Canada. Pediatric surgeons were recruited by e-mail invitation through the Canadian Association of Pediatric Surgeons. Potential participants were contacted using Dillman’s tailored design method for mixed-mode surveys. 18   The introductory e-mail contained a link where the recipient could indicate their eligibility and express interest. A survey link was sent directly to each individual respondent to allow for tracking of response rates. A total of 3 reminders were sent at 1-week intervals. An implied consent form was presented before the survey.

Respondents were physicians who practice at tertiary-care pediatric hospitals in Canada and represent 1 of the following subspecialty groups: hospital or general pediatricians, complex care pediatricians, pediatric gastroenterologists, and pediatric surgeons. These subspecialties were chosen as those most likely to be involved in decision-making regarding the management of GERD in this complex population of children. The study is limited to tertiary care hospitals as these sites typically have access to ARPs. Additional eligibility criteria included the respondent having treated a child with GERD, NI, and enteral feeding in the past year and having the ability to respond in either English or French.

Descriptive statistics were calculated, including means with SD and interquartile ranges for continuous variables, and count with proportions for categorical variables. The primary outcome variable of likelihood to consider an ARP was coded as 2 categories (consider and do not consider) and physician characteristics were coded as years in practice (<10, 11–20, ≥30), subspecialty (hospital pediatrics or complex care, gastroenterology, surgery) and location of practice (province).

Bivariable association between potential predictor variables and likelihood to consider an ARP in each clinical scenario were determined using χ-square tests. In bivariable analyses, a significant level of 0.3 was used for variable selections. Any variable with P value < .3 was planned to be included in the multivariable models (although no associations reached this threshold). Multivariable logistic regression modeling was, therefore, conducted including all variables because of their clinical importance to determine if there were any independent effects on the primary outcome of physician consideration of ARP. Multiple imputation technique was used in a sensitivity analysis to account for any missing or incomplete information obtained from the surveys.

A total of 119 physicians indicated eligibility via the invitation link. Of those, 83 provided at least partial responses giving a response rate of 70%. Full responses were available for 76. Table 1 presents respondent characteristics. The majority of respondents represented hospital pediatrics, complex care, and/or general pediatrics, whereas 15% ( n = 15) of respondents identified as gastroenterologists and 5% ( n = 4) as pediatric surgeons. There was representation in this sample from every province with a tertiary care pediatric hospital and a total of 12 institutions.

A summary of the clinical scenarios and likelihood to consider ARP is shown in Fig 1 . Two of the scenarios (#1 – Severe Asp and #4 - Pain) were equally split with approximately half of respondents indicating that they were very or somewhat likely to consider ARP ( n = 45, 56% for scenario 1 and n = 44, 57% for scenario 4), whereas the other half were somewhat or very unlikely to consider. Respondents were less likely to consider ARPs for scenario 2 (Mod Asp), wherein only 19% ( n = 15) of them would consider this intervention. Scenario 3 (FTT) was most favored for ARP with 78% ( n = 60) of respondents indicating they were very or somewhat likely to consider. When asked which ARP they are likely to present as an option (fundoplication or GJT), most respondents would offer GJT only (22% to 49%), whereas very few would offer only fundoplication (4% to 8%) ( Supplemental Table 3 ). On bivariable analysis, none of the potential predictor variables studied were significantly associated with the respondents’ likelihood to consider an ARP in any of the clinical scenarios ( Supplemental Table 4 ). Multivariable logistic regression was performed including all variables (because of suspected clinical importance) with a cutoff of statistical significance at P < .05. This likewise did not reveal any independent predictors of physician likelihood to consider ARP in any clinical scenario. There were missing responses in 7 surveys (8%), but sensitivity analysis suggested this does not significantly impact our results (Supplemental Information).

There were no respondents who indicated they would proceed immediately to ARP in any scenario, instead suggesting a wide range of diagnostic investigations or treatments to be considered before ( Table 2 ). The most common intervention was feeding changes (including changing rate or volumes or switching to continuous feeding) with 49% to 90% of respondents choosing this option. Prokinetics were also commonly trialed, particularly in scenarios 1, 3, and 4 (73%, 86%, and 78% respectively). Some respondents would trial baclofen (13% to 32%), NJ tube feeds (23% to 52%), formula changes (38% to 76%), or blenderized diets (24% to 54%). Depending on the scenario, up to half of respondents (19% to 54%) also indicated they would attempt to treat a comorbid condition, most commonly sialorrhea.

Treatments and Interventions Before ARP

Scenario 1 ( n = 80), scenario 2 ( n = 78), scenario 3 ( n = 77), scenario 4 ( n = 77).

Including medications (new or increased doses), subspecialist consultation (respirology, gastroenterology), additional investigations (sialogram, upper gastrointestinal series, gastric emptying scan, videofluoroscopic feeding study, bedside feeding assessment, immunodeficiency workup, metabolic testing, pH probe, impedance study, endoscopy), chest physio or airway clearance or cough assist, constipation treatment.

In terms of diagnostic testing before ARP, over half of respondents would order an upper gastrointestinal series for either GJT ( n = 53, 64%) or fundoplication ( n = 57, 69%). About one third would complete a gastric emptying scan ( n = 30, 35% for GJT; n = 37, 45% for fundoplication) and progressively smaller numbers would request impedance studies ( n = 16, 19% for GJT; n = 35, 42% for fundoplication), fluoroscopic evaluation of feeding and swallowing or videofluoroscopic feeding study ( n = 30, 36% for GJT; n = 21, 25% for fundoplication) or pH probes ( n = 12, 14% for GJT; n = 24, 29% for fundoplication) ( Supplemental Fig 4 ). Aside from feeding and swallowing studies, all other diagnostic tests were more commonly ordered before fundoplication compared with GJT.

Respondents were asked about the perceived risks associated with fundoplication. Most were concerned the procedure would be ineffective ( n = 60, 72% moderately or very concerned) or cause worsening GERD symptoms ( n = 67, 81% moderately or very concerned) ( Fig 2 ). For GJT, the highest levels of concern were regarding the need for continuous feeding ( n = 62, 75% moderately or very concerned), need for emergent GJT changes ( n = 60, 72% moderately or very concerned), and major late complications such as intussusception ( n = 52, 63% moderately or very concerned) ( Fig 3 ).

Concern for risks and harms of fundoplication.

Concern for risks and harms of GJT.

The majority of respondents indicated that it was very easy or somewhat easy ( n = 57, 77%) to access GJT although one-quarter had difficulty accessing this procedure. Only half reported that it was very or somewhat easy ( n = 39, 51%) to access fundoplication at their institution. Most respondents (70%) were concerned about the ability of patients or families to access tertiary care sites for either routine or emergent GJT care.

This study provided a broad overview of the opinions and reported-practice of tertiary-care based physicians across Canada with respect to the use of ARPs among children with NI and gastrostomy tubes. A substantial majority of respondents were pediatricians practicing in hospital medicine or complex care, corresponding to the higher numbers of these specialists in Canada. Our results, thereby, predominantly reflect the perspectives of this group. We discovered considerable practice variability with no clear relationship to subspecialty, experience, or location of practice, although we may not have achieved sufficient power to detect these differences. Some responses reflected issues with access to ARPs because of a variety of geographic barriers (distribution of population) and resource limitations (surgeon or radiologist availability), which likely also impact physician practice. The scenario considered most amenable to ARP was scenario 3 (FTT), which is consistent with available guidelines recommending ARP for refractory GERD symptoms and failure of intragastric feeds. 3 , 16   Even still, nearly one-quarter of respondents would not offer an ARP in this scenario, raising questions about guideline awareness and adherence. The scenario that had the lowest likelihood of ARP was scenario 2 (Mod Asp), which presented a child with chronic lung disease and infrequent episodes of aspiration pneumonia. Interestingly, scenarios 1 (Severe Asp) and 4 (Pain) were evenly split in in terms of likelihood to consider ARP. To some degree, this variability may reflect the lack of evidence available to guide clinical decision-making, which is an established contributor to practice variability. 17   No randomized controlled trials have established the effectiveness of GJT or fundoplication compared with nonsurgical management in children with NI and gastrostomy feeds. Observational studies have mainly conducted head-to-head comparison of GJT and fundoplication, 14 , 18   including a meta-analysis (2015) finding no difference in mortality or frequency of pneumonia. 19   Interestingly, most physicians did not consider ARPs to be second-line treatment, instead suggesting many other interventions they would attempt before ARP. For instance, many would trial prokinetics before ARP even though existing guidelines do not recommend prokinetic agents for treatment of GERD (except in severe refractory cases). 3 , 9  

Respondents rated high levels of comfort with ARPs even though their reported practice varied considerably. We hypothesized that practices were often concordant within an institution and/or subspecialty but varied between them. Internally consistent practices could result in higher levels of physician comfort even with a lack of evidence. However, this association was not confirmed in our results. Other research suggests a dissociation between physician-reported comfort and clinical decision-making. 20 , 21   It would thereby be possible to have comfort even if decision-making was not optimal or evidence-based. We cannot exclude the possibility that some variation could be because of different interpretations of the clinical scenarios. However, our results are supported by prior studies that report similar degrees of practice variation in the treatment of GERD. A large cross-sectional study in the United States revealed that the odds of undergoing an ARP in the southwest were twice that of the northeast, even after adjusting for age, case-mix, and case-volume. 22   Another study by Goldin et al reported changing rates of ARPs in relation to common procedures, such as appendectomies, at 36 children’s hospitals in the United States between 2001 and 2006. The overall decline in ARPs was unequally distributed with institutional rates that ranged from 40 fewer per year to 10 greater per year in comparison with 2001. 11   A national survey of pediatric surgeons also found that about 80% of them required an upper gastrointestinal series before ARP and only 13% required a pH probe, similar to the proportions in our study. 23  

Existing evidence cannot determine who would benefit from an ARP, particularly in children with NI and other complex needs. There is a need for future research including large prospective, comparative studies that can determine crucial outcomes, such as impact on respiratory morbidity and GERD symptoms. Another area that is under-explored is the impact of ARP on child and family quality of life. One small prospective study suggested improvement with fundoplication in the short term. 24   Another interview study with parents whose child had undergone ARP better reflected the complexity of these scenarios, highlighting how feeding tolerance, caregiving requirements, continuous feeding, and changes in health care utilization could also mediate the impact of these procedures on quality of life. 25   It is also concerning that physicians may be under-appreciating and, thereby, under-treating GERD symptoms, particularly in scenario 4 (Pain). Existing evidence suggests that pain and other distressing symptoms are often overlooked in children with NI and other complex conditions, 26 – 28   whereas physicians may be more comfortable making decisions in the face of “objective” evidence, such as episodes of aspiration pneumonia or growth failure (as in scenarios 1 and 3).

Even as we strive to build a stronger evidence base informing the use of ARPs, the clinical issues and dilemmas persist. The complexity of these children’s care and the nonspecific nature of these symptoms alongside social and logistical variables complicates the development of guidelines and standardization on the use of ARPs. Intentional shared decision-making (SDM) is a valuable approach that could acknowledge the limitations of current evidence and allow for patient and parent values, goals, and preferences to be emphasized and incorporated. 29   One framework suggests that for medical decisions where there is more than 1 reasonable option without a clearly favorable benefit to burden ratio, an in-depth exploration of family preferences can ensure that child and parent values align with the chosen option. 30   Children with medical complexity (including NI) are less likely to be engaged in SDM, 31 , 32   potentially because of the difficulty predicting outcomes in the setting of multiple comorbidities. However, these parents appreciate the complexity of these decisions and highly value their own involvement. 32   Uncertainties in the decision for ARP and the child’s course should be acknowledged, which can further facilitate parents’ participation and comfort. 32  

Although 70% of individuals indicating eligibility were included, this study enrolled a relatively small sample skewed largely toward pediatric hospital medicine and complex care physicians, limiting generalizability to other subspecialties. These nuanced and complex clinical scenarios are difficult to describe in a brief vignette. The diagnosis of GERD may not have been obvious, but vignettes were intentionally designed to reflect “real world” scenarios where formal diagnostic testing is seldom used. The survey underwent a structured, iterative process of development, including cognitive interviewing but not formal clinical sensibility testing, which would have strengthened our findings. The style of the questions may have inhibited respondents from communicating more details about their perspectives, although there was space for written comments after each question. The distribution of responses, with some scenarios having more positive responses for ARP, suggests that the questions could discriminate different practice styles. However, it remains possible that some of the variation in responses is related to different interpretations of the clinical scenarios. Other treatment options for GERD were not addressed in this study (such as surgical jejunostomy tube) as they are infrequently used in Canada. No concerns about this omission were raised in the cognitive interviews.

With the lack of evidence regarding the impact of ARPs on clinical and patient-centered outcomes, considerable variability exists in physician perspectives and reported practice. Strengthening the evidence base with prospective studies should be prioritized. As with many complex medical decisions, SDM would acknowledge the limitations in our knowledge and best incorporate patient and family preferences, values, and goals when approaching decisions about ARP.

We thank Dr Brent Hagel, Dr Tamara Simon, Dr Marialena Mouzaki, and Dr Sarah Lai for their assistance in developing and testing the questionnaire; and the contributions of our survey respondents.

The first draft of this manuscript was written by Dr Dewan. This study was presented as a poster presentation at the American Academy of Cerebral Palsy and Developmental Medicine conference in 2023. There are no prior publications or other submissions with any overlapping information, including studies and patients.

FUNDING: This study is supported by the University of Calgary and the Alberta Children’s Hospital Research Institute. These organizations had no role in study design, study conduct, writing or publication.

CONFLICT OF INTEREST DISCLOSURES: None of the authors have any conflict of interest related to this study.

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