Infant growth and development


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Infant growth and development

  1. 1. ARTICLEInfant Growth and DevelopmentChris Plauche Johnson, MEd, MD* and Peter A. Blasco, MD† For example, five-word sentences in IMPORTANT POINTS a 2-year-old child who does not fol- 1. Infant development occurs in an orderly and predictable manner that low simple commands may repre- is determined intrinsically. It proceeds from cephalic to caudal and sent echolalia typical of autism. proximal to distal as well as from generalized reactions to stimuli to The sentences are not meaningful specific, goal-directed reactions that become increasingly precise. and have no communicative intent. Extrinsic forces can modulate the velocity and quality of develop- Delays in one developmental mental progress. domain may impair development 2. Each developmental domain must be assessed during ongoing in another domain. For example, developmental surveillance within the context of health supervision. immobility due to neuromuscular Generalizations about development cannot be based on the assessment disorders prevents exploration of the of skills in a single developmental domain (ie, one cannot describe environment and, in turn, impedes infant cognition based on gross motor milestones). However, skills in cognitive development arising one developmental domain do influence the acquisition and assessment through manipulation of objects. of skills in other domains. Last, a deficit in one domain may 3. Speech delays are the most common developmental concern seen by the general pediatrician, yet they often are not well understood or compromise the assessment of skill diagnosed expediently. A sound understanding of the distinction levels in another domain, even between an isolated speech delay (usually environmental and often though development in the second can be alleviated) and a true language delay (a combined expressive domain is normal. For example, and receptive problem that implies more significant pathology) will it is difficult to assess problem- help the clinician refer appropriately for precise diagnosis and solving skills in a child who has appropriate management. cerebral palsy because the child 4. It is essential to understand normal development and acceptable may understand the concept of variations in normal developmental patterns to recognize early matching geometric forms, yet be patterns that are pathologic and that may indicate a possible unable to insert them physically developmental disability. into a formboard. 5. Assessment of the quality of skills and monitoring the attainment Developmental milestones serve of developmental milestones are essential to early diagnosis of as the basis of most standardized developmental disabilities and expedient referral to early intervention assessment and screening tools. programs. Although these screening tools pro- vide the clinician with a structured method of observing the infant’s path unique. Intrinsic influences progress and help define a develop-Introduction mental delay, many lack sensitivity.“Infant” is derived from the Latin include the child’s physical charac- teristics, state of wellness or illness, Parental concern in the face ofword, “infans,” meaning “unable to normal results in developmentalspeak.” Thus, many define infancy temperament, and other genetically determined attributes. Extrinsic screening should not be the period from birth to approxi- Focusing narrowly on discretemately 2 years of age, when lan- influences during infancy originate primarily from the family: the per- milestones may fail to revealguage begins to flourish. It is an atypical organizational processesexciting period of “firsts”—first sonalities and style of caregiving by parents and siblings, the family’s that are involved in the child’ssmile, first successful grasp, first developmental progress. Thus, itevidence of separation anxiety, first economic status with its impact on resources of time and money, and is important to analyze all mile-word, first step, first sentence. The stones within the context of theinfant is a dynamic, ever-changing the cultural milieu into which the infant is born. child’s history, growth, and physicalbeing who undergoes an orderly and examination as part of an ongoingpredictable sequence of neurodevel- Neurodevelopmental sequences can be viewed broadly in terms of surveillance program. Only then isopmental and physical growth. This the traditional developmental mile- it possible to formulate an overallsequence is influenced continuously stones. Developmental milestones impression of the child’s true devel-by intrinsic and extrinsic forces that provide a systematic approach by opmental status and the need forproduce individual variation and which to observe the progress of intervention.make each infant’s developmental the infant over time. Attainment Although milestones form the of a particular skill builds on the foundation of the discussion, the achievement of earlier skills; only primary intent of this article is to* Associate Professor of Pediatrics, TheUniversity of Texas Health Sciences Center, rarely are skills skipped. When this provide broader insights into infantSan Antonio, TX. happens, the advanced skill may developmental processes and to help† Associate Professor of Pediatrics, represent a “splinter” skill, that is, the clinician recognize warningJohns Hopkins University, Baltimore, MD. a deviant developmental pattern. behaviors (“red flags”) indicative224 Pediatrics in Review Vol. 18 No. 7 July 1997
  2. 2. CHILD DEVELOPMENT Infancyof developmental deficits. The mile- learning and shaped the child’s advances in behavioral genetics,stone ages are not repeated in the development. This line of thinking together with recent discoveriestext to allow a more fluid discussion formed the philosophical basis for regarding innate infant abilities,of developmental themes within the Head Start program of the have swung the pendulum backeach domain. Milestones have been 1960s. Freud (1920s) and Erikson in favor of nature as the primaryorganized into domains to assist the (1950s) promoted developmental influence on the developmentalclinician in recognizing their inde- progress as a function of the resolu- process.pendence as well as their interrela- tion of conflict. The quality of thetionships. Tables illustrating all infant’s relationships with key indi-domains at each age can be found in viduals was considered central to Developmental Snapshots:Vaughan (see Suggested Reading). future development. The First Two Years of LifeProblem-solving and language mile- During the second half of the Before dissecting infant develop-stones facilitate early identification century, the name of Piaget became ment into discrete steps withinof cognitive deficits. Adaptive skills almost synonymous with child each developmental domain, it is(ie, skills related to independence development. Piaget was the first to valuable to view the infant atin feeding, dressing, toileting) tradi- describe the infant as having intelli- discrete intervals. These 6-monthtionally have been included within gence. For centuries, it had been “snapshots” are displayed graphi-the fine motor domain. However, assumed that the infant’s mind was cally in Figure 1. This gestaltbecause these milestones are influ- a “blank tablet waiting to be written approach may help the clinicianenced by the social environment, on.” Because infants could not tell make sense of the interrelatednesswe have included them in a “psycho- us what they were experiencing, it of the precise changes within eachsocial domain.” Lists for emotional was believed that they saw and developmental domain.and socialization milestones also areincluded in this domain. In contrastto motor and cognitive milestones, One principle of development in infancy is that it proceedspsychosocial behaviors are influ- from head-to-toe — thus, arm movement comes beforeenced more by extrinsic factors,making them less well-defined. leg movement. heard little and thought even less, These four snapshots illustrateEvolution of with consciousness as adults knew several generalizations aboutDevelopmental Theory it not existing. Piaget revealed that neuro-developmental maturationDevelopmental theory has been infants were, indeed, capable of over time:shaped by the persistent debate of thinking, analyzing, and assimilat- 1. Responses to stimuli proceedwhether nature (intrinsic forces) or ing. He viewed development as from generalized reflexes involv-nurture (extrinsic forces) is the pre- stage-like cognitive changes. The ing the entire body, as seen in thedominant influence. At the turn of child actively explores objects in an newborn (and fetus), to discretethe century, developmental theories effort to understand his or her envi- voluntary actions that are underpromoted nature as the major influ- ronment. Depending on the develop- cortical direction. This specializa-ence. Gesell (early 1900s) was one mental stage, a child organizes this tion allows the child to moveof the first to study infant develop- information to form new theories from obligatory symmetric reac-ment systematically and establish about the way the world works. tions when attending to a stimu-developmental norms. Development It was not until the last part of lus (ie, vocalizations, arm wav-was seen as a function of neurologic this century that emotional and ing, and kicking) to voluntary,maturation and growth. Because social development began to receive asymmetric, and precise move-advancing age and genetic endow- the same degree of attention as that ments toward a stimulus (ie,ment were the chief mechanisms given to the motor and cognitive grasping with one hand andfor change, babies were believed to domains. Research has revolved inspecting with the other).develop at a predetermined biologi- around theories regarding infantcal pace, with parents needing to expression of emotion (Mandler, 2. Development proceeds fromdo little more than provide a good 1970s), attachment (Bowlby, 1960s; cephalic to caudal and proximalnurturing environment. Mahler, 1970s; and Ainsworth, to distal. Thus, arm movement By mid-century, theories that 1980s), and temperament (Thomas comes under cortical directionstressed the importance of nurture and Chess, 1970s). Once it was rec- and visual guidance before legbegan to prevail. Pavlov (1930s), ognized that newborns could demon- movement. With this, the childWatson (1950s), and Skinner (1960s) strate distress (pain and hunger), progresses from hand-mouth topromoted the opposing view that interest, and disgust, these facial foot-mouth play. The upperdevelopment was a function of expressions have been used to study extremities become increasinglylearning. Operant conditioning information processing in infancy accurate in reaching, grasping,(positive and negative reinforce- prior to the age when thoughts can transferring, and manipulating.ments through social interactions or be verbalized. As the 20th century Distal development is seen whenenvironmental changes) promoted comes to a close, remarkable the infant can isolate and use thePediatrics in Review Vol. 18 No. 7 July 1997 225
  3. 3. CHILD DEVELOPMENT InfancyFIGURE 1. Developmental “snapshots” at 6, 12, 18, and 24 months. index finger to poke and explore 3. Developmental progression is the house independently, opening object parts. When this occurs in from dependence to indepen- doors, maneuvering stairs, and concert with thumb opposition, dence. The totally dependent fetching desired objects. They the fine pincer grasp is mastered. newborn progresses to a toddler can feed and undress themselves Precise release of tiny objects who has mobility and manipula- and even may be toilet trained. follows, so that fundamental tive skills that enable him or her This new autonomy becomes manipulative skills reach adult to explore most of the environ- the foundation for the challeng- levels by the end of infancy. ment. Toddlers can move about ing “twos.”226 Pediatrics in Review Vol. 18 No. 7 July 1997
  4. 4. CHILD DEVELOPMENT Infancy TABLE 1. Average Physical Growth Parameters OCCIPITOFRONTAL AGE CIRCUMFERENCE HEIGHT WEIGHT DENTITION Birth 35.0 cm 50.8 cm 3.0 to 3.5 kg Central incisors—6 mo (13.8 in) (20.0 in) (6.6 to 7.7 lb) Lateral incisors—8 mo +2 cm/mo (0 to 3 mo) +25.4 cm Regains birthweight by 2 wk +1 cm/mo (3 to 6 mo) Doubles birthweight by 5 mo +.5 cm/mo (6 to 12 mo) Mean = 1 cm/mo 1 year 47.0 cm 76.2 cm 10.0 kg First molars—14 mo (18.5 in) (30.0 in) (22 lb) Canines—19 mo +2 cm +12.7 cm Triples birthweight 2 years 49.0 cm 88.9 cm 12.0 to 12.5 kg Second molars—24 mo (19.3 in) (35.0 in) (26.4 to 27.5 lb) Quadruples birthweightPhysical Growth cephaly can be seen with above- DysmorphismGrowth milestones are the most average cognitive capability. Micro- Although most isolated minor dys-predicable, although they must be cephaly associated with genetic or morphic features are inconsequen-viewed within the context of each acquired disorders reflects cerebral tial, the presence of three or morechild’s specific genetic and ethnic pathology and almost always has may indicate the presence of devel-influences. It is essential to plot the cognitive implications. opmental dysfunction. Almost 75%child’s growth on gender- and age- Macrocephaly may be due to of these minor superficial dysmor-appropriate charts. Charts now are hydrocephalus, which is associated phisms can be found by examiningavailable for some ethnic groups as with an increased incidence of cog- the face, skin, and hands. Thewell as for a few genetic syndromes nitive deficits, especially learning presence of both minor and major(eg, Down and Turner syndromes). disabilities. Macrocephaly without abnormalities may indicate a moreFetal weight gain is greatest during hydrocephalus, far from being a serious genetic syndrome. In manythe third trimester. During the first predictor of advanced intelligence, instances, dysmorphic features willfew months of life, this rapid growth also is associated with a higher lead to the diagnosis of a clinicalcontinues, after which the growth prevalence of cognitive deficits. syndrome during the neonatal periodrate decelerates (Table 1). Birth- It may be due to metabolic or and predate the recognition of anyweight is regained by 2 weeks of age anatomic abnormalities. In about neurodevelopmental deficits.and doubles by 5 months. Height 50% of cases, macrocephaly isdoes not double until between 3 and familial, and the implications are4 years of age. Head growth during benign in terms of intellect. When Motor Developmentthe first 5 or 6 months is due to evaluating infants whose macro- To make a meaningful statementcontinued neuronal cell division. cephaly is isolated, the finding of about an infant’s motor competence,Later, increasing head size is due a large head size in one or both the pediatrician should organizeto neuronal cell growth and support- parents can be reassuring. data gathered from the history,ing tissue proliferation. physical examination, and neuro- Height and Weight developmental examination accord- Although the majority of individuals ing to the following schema:RED FLAGS IN who are of below- or above-averagePHYSICAL GROWTH 1) motor developmental milestones, size are otherwise normal, there is 2) the classic neurologic examina-Occipitofrontal Circumference an increased prevalence of develop- tion, and 3) cerebral neuromotorLarge and small head size both are mental disabilities in these two maturational markers (primitiverelative red flags for developmental subpopulations. Many genetic syn- reflexes and postural reactions).problems. Microcephaly is associ- dromes are associated with short Motor milestones are extractedated with an increased incidence of stature; large stature syndromes are from the developmental history asmental retardation, but there is no less common. Again, when consider- well as from observations duringstraightforward relationship between ing deviation from the norm in the the neurodevelopmental examina-small head size and depressed intel- specific child, family characteristics tion. Reference tables of sequentialligence. As a reflection of normal must be reviewed. The concept of gross and fine motor milestonesvariation, microcephaly is not asso- mid-parental height is useful in are necessary (Table 2).ciated with structural pathology of determining whether a given child’s Results of assessment in anythe nervous system or with low size is appropriate for his or her domain is summarized best as indi-intelligence. Furthermore, micro- familial growth pattern. cating a developmental age for thePediatrics in Review Vol. 18 No. 7 July 1997 227
  5. 5. CHILD DEVELOPMENT Infancy TABLE 2. Motor Development MOS. GROSS MOTOR SKILLS FINE MOTOR SKILLS RED FLAGS 1 Head up in prone Hands tightly fisted 2 Chest up in prone position Retains rattle (briefly) if placed in hand Rolling prior to Head bobs erect if held Hands unfisted half of time 3 months may sitting indicate hypertonia 3 Partial head lag Hands unfisted most of time Rests on forearms in Bats at objects prone Sustained voluntary grasp possible if object placed in ulnar side of hand 4 Up on hands in prone Obtains/retains rattle Rolls front to back Reaches/engages hands in supine No head lag Clutches at objects 5 Rolls back to front Transfers objects hand-mouth-hand Poor head control Lifts head when pulled Palmar grasp of dowel, thumb to sit adducted Sits with pelvic support Anterior protection 6 Sits-props on hands Transfers objects hand-hand Immature rake of pellet 7 Sits without support Radial-palmar grasp of cube W-sitting and bunny Supports weight and Pulls round peg out hopping, may bounces while standing indicate adductor Commando crawls spasticity or Feet to mouth hypotonia Lateral protection Inferior scissors grasp of pellet; rakes object into palm 8 Gets into sitting position Scissors grasp of pellet held between Reaches with one hand thumb and side of curled index finger while 4-point kneeling Takes second block; holds 1 block in each hand 9 Pulls to stand Radial-digital grasp of cube held with Persistence of Creeps on hands and thumb and finger tips primitive reflexes knees may indicate neuromotor disorder Inferior pincer grasp of pellet held between ventral surfaces of thumb and index finger continued228 Pediatrics in Review Vol. 18 No. 7 July 1997
  6. 6. CHILD DEVELOPMENT Infancy TABLE 2. Motor Development (continued) MOS. GROSS MOTOR SKILLS FINE MOTOR SKILLS RED FLAGS 10 Cruises around furniture Isolates index finger and pokes Walks with 2 hands held Clumsy release of cube into box; hand rests on edge Pincer grasp, held between distal pads of thumb and index finger 11 Stands alone Walks with 1 hand held 12 Independent steps Fine pincer grasp of pellet between Failure to develop Posterior protection finger tips protective reactions Marks with crayon may indicate Attempts tower of 2 cubes neuromotor Precise release of cube disorder Attempts release of pellet into bottle 14 Walks well Tower of 2 cubes independently Attains third cube 16 Creeps up stairs Precise release of pellet into small Runs stiff-legged container Climbs on furniture Tower of 3 cubes Walks backwards Stoops and recovers Imitates scribble 18 Push/pulls large object Tower of 4 cubes Hand dominance Throws ball while Crudely imitates single stroke prior to 18 months standing Scribbles spontaneously may indicate Seats self in small chair contralateral weakness 20 Walks up stairs with Completes square pegboard hand held 22 Walks up stairs with rail, Tower of 6 cubes marking time Squats in play 24 Jumps in place Train of cubes without stack Inability to walk up Kicks ball Imitates vertical stroke and down stairs Walks down stairs with may be the result rail, marking time of lack of Throws overhand opportunity Illustrations and accompanying text modified with permission from the Erhardt Developmental Prehension Assessment. In Erhardt RP. Developmental Hand Dysfunction: Theory Assessment, Treatment. 2nd ed. San Antonio, Tex: Therapy Skill Builders; 1994.Pediatrics in Review Vol. 18 No. 7 July 1997 229
  7. 7. CHILD DEVELOPMENT Infancychild. This approach makes it pos- with rolling), to sitting, and then prompted motor activities (eg,sible to consider the child in terms through a standing/ambulating weight-bearing in sitting or stand-of his or her level of functioning sequence (Fig. 2). Motor milestones ing) require adequate strength.compared against chronologic age. do not take into account the quality Thus, weakness may be appreciatedFor example, the developmental of a child’s movement. These best from observing the quality ofquotient (DQ) is the developmental sequences must be considered in the stationary posture and transitionage divided by chronologic age context of the motor portion of the movements. The Gower sign (arisingtimes 100 (see Example below). neurologic examination, including from sitting on the floor to standing,This provides a simple expression observations of station and gait, using the hands to “walk up” one’sof deviation from the norm. A where qualitative features can be legs) is a classic example andquotient above 85 in any domain assessed. However, the neurologic indicative of pelvic girdle andis considered within normal limits; evaluation of tone, strength, deep quadriceps muscular weakness.a quotient below 70 is considered tendon reflexes, and coordination Not until 2 to 3 years of age doesabnormal. A quotient between 70 is difficult in very young infants the neurologic examination becomeand 85 represents a gray area that because of the subjective nature easier and more meaningful aswarrants close follow-up. Values in of the assessments and the infant’s cooperation improves.the upper limit of normal do not limited ability to cooperate. Clinical Station refers to the postureparticularly indicate supernormal experience is essential for obtaining assumed in sitting or standing andabilities. Whether truly gifted ath- accurate and useful information. should be viewed from anterior,letes can be recognized early by use Eliciting reflexes requires lateral, and posterior perspectives,of this method is thought-provoking patience and repeated, yet gentle, looking for body alignment. Gaitbut speculative. trial and error. Muscle tone (passive refers to walking and is examined resistance) and strength (active resis- in progress. Initially, the toddlerGROSS MOTOR DEVELOPMENT tance) are a challenge to distinguish walks on a wide base, slightlyGross motor development proceeds in the contrary infant. The best clues crouched, with the arms abductedfrom a sequence of prone milestones can be obtained from observation, and slightly elevated. Forward(beginning with head up and ending not handling. Spontaneous or progression is more staccato than smooth. Movements gradually become more fluid, the base narrows, Example: Motor Quotient and arm swing evolves, leading to an adult pattern of walking by A 12-month-old boy is seen for health supervision. He is not walking 3 years of age. alone, but he pulls up to stand (9 months), cruises around furniture The motor neuromaturational (10 months), and walks fairly well when his mother holds both hands markers are the primitive reflexes, (10 months). This child has a gross motor age of 10 months at a which develop during gestation chronologic age of 12 months. Should this 2-month discrepancy be a and generally disappear between concern? To decide, one should calculate the DQ by using these gross the third and sixth month after motor milestones: birth, and the postural reactions, motor age 10 months which are not present at birth but DQ = × 100 = = 83 develop sequentially between 3 and chronologic age 12 months 10 months of age (Fig. 3). The The motor age and the developmental quotient are good summary Moro, tonic labyrinthine, asymmet- descriptors of the child and have more meaning than plotting each ric tonic neck, and positive support milestone. Because the lower limit is 70, this boy’s DQ falls within reflexes are the most useful clini- the “suspect” or gray zone. In reality, infants falling into the gray zone cally (Fig. 4). As with all true of motor domains usually do quite well and rarely require referral to an reflexes, each requires a specific early intervention program. This is in contrast to those falling in the sensory stimulus to generate the gray zones of the cognitive domains. stereotyped motor response. Normal infants demonstrate these postures 0 Months 1 2 3 4 5 6FIGURE 2. Chronologic progression of gross motor development. Adapted with permission from Piper MC, Darrah J. MotorAssessment of the Developing Infant. Philadelphia, Penn: WB Saunders Co; 1994. Illustrations by Marcia Smith.230 Pediatrics in Review Vol. 18 No. 7 July 1997
  8. 8. CHILD DEVELOPMENT Infancyinconsistently and transiently; those ing becomes more accurate, and bunny hopping, and persistent toewho have central neurologic (ie, objects are brought to the mouth for walking may indicate spasticity.cerebral) injuries show stronger oral exploration. As development Hand dominance prior to 18 monthsand more sustained primitive reflex progresses from proximal to distal, of age should prompt the clinicianposturing. Primitive reflexes are reaching and manipulative skills are to examine the contralateral uppersomewhat difficult to gauge, even enhanced further, and precise manual extremity for weakness associatedin expert hands. The appearance exploration replaces oral exploration. with a hemiparesis.of postural reactions in sequence During the second year, fine motor Analysis of the informationbeginning after 2 or 3 months of age skills are assessed by observing the gathered in these areas makes itis easier to elicit clinically and can manner in which the hands use relatively easy for the practitionerprovide great insight into the neuro- objects as tools (eg, blocks to build to reassure him- or herself (and themotor integrity of young infants. and crayons to draw). The close parents) about a child’s motor com-Postural reactions are sought ineach of the three major categories: association between gross and fine petence or to identify motor impair-righting, protection, and equilibrium. motor skills in the first year of life ment at an early age. Once a motorThese movements are much less evolves into a similar relationship abnormality has been identified,stereotyped than the primitive between problem-solving and fine further assessment of its exactreflexes, and they require a complex motor skills during the second year. nature and etiology is essential. Thisinterplay of cerebral and cerebellar One skill enables or promotes the almost always warrants referral tocortical adjustments to a barrage development of the other. If progress an appropriate subspecialist or sub-of sensory inputs (proprioceptive, in manual dexterity is slow, this may specialty team. Based on clinicalvisual, vestibular) (Figs. 5 and 6). impede cognitive development via examination and history, the astuteThey are easy to elicit in the manipulation of objects. clinician usually can decide intonormal infant but are markedly which category the motor disorderslow in appearance in the infant RED FLAGS IN MOTOR falls: 1) static central nervous systemwho has central nervous system DEVELOPMENT disorders, 2) progressive diseases,damage. It is important to begin the motor 3) spinal cord and peripheral nerve evaluation by observing the infant. injuries, or 4) structural defects.FINE MOTOR DEVELOPMENT Pay particular attention to the hands;In the first year of life, fine motor persistent fisting at 3 months of agedevelopment is highlighted by the often is the earliest indication of Cognitive Developmentevolution of a pincer grasp. During neuromotor dysfunction. Sponta- Cognitive processing skills are thethe second year of life, the infant neous postures (eg, froglegs and substrate for intelligence and includelearns to use objects as tools during scissoring) provide visual clues to a wide range of abilities (Table 3).functional play. There are many hypotonia/weakness and spastic Intellectual development dependsstages in accomplishing these two hypertonus, respectively. Delays in on learning that contains threeskills; selected ones are illustrated the appearance of postural reactions components: attention, informationin Table 2. In the early months, the herald future delays in voluntary processing, and memory (whichupper extremities assist with balance motor development. An infant will includes both encoding and retrievaland mobility. As balance in the sit- be unable to sit or walk indepen- of information). Intellectual develop-ting position improves and the infant dently without intact protective and ment is reflected in advancing abili-assumes biped mobility, the hands equilibrium mechanisms. Abnormal ties to comprehend, reason, andbecome more available for manipula- movement patterns may indicate make judgments. Standardized intel-tion of objects—their ultimate func- pathology. For example, early ligence tests generally measure twotion. Primitive reflexes are inte- rolling (1 to 2 months), pulling forms of intelligence in the school-grated, and the upper extremities directly to a stand at 4 months age child: verbal and performancecome under cortical control. Reach- (instead of to a sit), W-sitting, (or nonverbal). Such standardized 6 7 8 9 10 11 12FIGURE 2. ContinuedPediatrics in Review Vol. 18 No. 7 July 1997 231
  9. 9. CHILD DEVELOPMENT Infancy tests are not available to measure infant intelligence. How then, does one recognize the attributes of ver- bal and nonverbal intelligence in infants? In the past two decades, the discovery of visual habituation techniques to assess infants’ atten- tion was considered a breakthrough in the study of infant cognition. It is exemplified by one study that describes 4-day-old infants listening to a long series of “bee-see-lee” sounds. When a novel “da” sound was heard, the infants responded with a change in heart rate and faster, stronger sucking on a pacifier, thereby indicating that very young infants can perceive differences in vowel sounds. More complex studies using simultaneous auditory and visual stimuli indicate that infants also areFIGURE 3. The declining intensity of primitive reflexes and the increasing role ofpostural reactions represent at least permissive, and possibly necessary, conditions capable of organizing perceptionsfor the development of definitive motor actions. From Capute AJ, Accardo PJ, across sensory modalities (cross-Vining EPG, Rubenstein JE, Harryman S. Primitive Reflex Profile. Baltimore, Md: modal matching) without the lan-University Park Press; 1978. Reprinted with permission. guage skills to describe them. For example, 11-month-old infants were presented a sequence of con- tinuous and interrupted pure tones. Two pictures were in the infants’ view throughout the experiment: one contained a continuous line, the other a dashed line. The infants consistently matched the correct visual stimulus to the auditory one, inferring cross-modal matching and some rudimentary understanding of the concept of interruptedness. Using these techniques, it has been demonstrated that infants younger than 1 year old can form a wide range of fairly complex categorical representations, including those for faces, color, geometric shapes, and orientation of lines. The attempts to measure infant responses precisely, such as thoseFIGURE 4. Clinically useful reflexes. A. Tonic labyrinthine reflex. In the supine posi- described previously, depend ontion, the baby’s head is extended gently to about 45 degrees below horizontal. This sophisticated technology, includingproduces relative shoulder retraction and leg extension, resulting in the “surrender infra-red photography for trackingposture.” With head flexion to about +45 degrees, the arms come forward (shoulder infant eye gaze and pupillary dilata-protraction) and the legs flex. B. Asymmetric tonic neck reflex (ATNR). The sensory tion, videotaping of facial reactions,limb of the ATNR involves proprioceptors in the cervical vertebrae. With active or and electrophysiologic monitoringpassive head rotation, the baby extends the arm and leg on the face side and flexes of heart rate and evoked potentials.the extremities on the occiput side (the “fencer posture”). There also is some mild The primary pediatrician can bestparaspinous muscle contraction on the occiput side that produces subtle trunk estimate infant intelligence by evalu-curvature. C. Positive support reflex. With support around the trunk, the infant is ating problem-solving and languagesuspended and then lowered to pat the feet gently on a flat surface. This stimulusproduces reflex extension at the hips, knees, and ankles so the infant stands up, milestones. Language is the singlecompletely or partially bearing weight. Children may go up on their toes initially best indicator of intellectual poten-but should come down onto flat feet within 20 to 30 seconds before sagging back tial; problem-solving skills are thedown toward a sitting position. From Blasco PA. Pediatric Rounds. 1992;1(2):1– 6. next best measure. Gross motorReprinted with permission. skills correlate least with cognitive232 Pediatrics in Review Vol. 18 No. 7 July 1997
  10. 10. CHILD DEVELOPMENT Infancy The interdependence of language and problem-solving development becomes stronger as the child begins to label objects and actions. Midway through the second year, this ability to label and categorize allows the child to match objects that are the same (car to a car and spoon to a spoon) and later to match an object to its picture. Nonverbal intelligence is assessed by observing the infant interact with test objects. In the older child, it is assessed through standardized pencil and paper tasks FIGURE 6. The infant is seated comfort- or computerized tests.FIGURE 5. Normal parachute reaction. ably, supported about the waist if neces- One aspect of nonverbal cogni-The examiner has suspended the child sary. The examiner gently tilts the childhorizontally by the waist and lowered tive development deserves extra to one side, noting righting of the headhim face down toward a flat surface. The back toward the midline, protective attention: object permanence, a con-arms extend in front, slightly abducted extension of the arm toward the side, and cept studied extensively by the shoulders, and the fingers spread equilibrium countermovements of the arm Prior to the infant’s mastery ofas if to break a fall. From Blasco PA. and leg on the opposite side. From object permanence, a person orPediatric Rounds. 1992;1(2):1–6. Blasco PA. Pediatric Rounds. 1992;1(2): object that moves “out of sight” isReprinted with permission. 1–6. Reprinted with permission. “out of mind”; its disappearance does not evoke a reaction. The abil- ity to maintain an image of a personpotential; most infants who are diag- “manipulating to learn.” Improved develops before that of an object.nosed later with mental retardation macular vision (via myelination of The child will show interest in peek-walk on time. the fovea) and refinement of the a-boo play, and separation anxiety pincer grasp promote inspection will occur when a loved one leavesPROBLEM-SOLVING of progressively smaller objects. the room. Shortly thereafter, the As cognitive abilities continue to child will begin to look for an objectProblem-solving skills consist ofmanipulating objects to solve a advance, the infant learns to shift that has been dropped. At first, anproblem (eg, choosing the correct attention between two objects (one auditory cue when it hits the flooropening for a circular shape in a in each hand), compare, make is necessary to locate it. Later, thethree-piece form board). The infant’s choices, and discard or combine child will experience success inability to solve a problem depends objects. This sensory-motor phase finding an object that was droppedon intact vision, fine motor coordi- of learning is the foundation for from sight and landed silently. Next,nation, and cognitive processing. ongoing nonverbal intellectual the child will progress to finding anDuring the early weeks of life, the development. object that has been hidden under ainfant explores the environment The 1-year-old child recognizes cloth or cup. A more complex taskvisually. Later, these visual experi- objects and associates them with is locating an object that has beenences reinforce movement. As the their functions. Thus, he or she wrapped inside a cloth. Successupper extremities come under visual begins to use them functionally as requires persistence and memory ofguidance, reaching and grasping are “tools” instead of mouthing, bang- the object long enough to completeenhanced. At first, the infant brings ing, and throwing them. This child the three-part unwrapping process.objects to the mouth for oral explo- has left the period of sensory-motor The next skill in this sequence isration. Later, the infant visually play and entered the stage of func- the ability to locate an object underexamines an object held in one hand tional play. Play serves as a window double layers (eg, a cube is placedwhile manipulating it with the other. into the infant’s thoughts and under a cup and then the cup is cov-Isolation of the index finger pro- becomes particularly important dur- ered with a cloth). This is followedmotes more refined manipulation of ing the next stage of symbolic play. by the ability to locate an objectthe various parts of objects, and the At this point, the infant uses toys after serial displacements. In thisinfant becomes successful in discov- that represent real objects in actions task, an object is hidden under oneering how they work (eg, fingering toward him- or herself (putting a toy cover and then changed to anotherthe clapper of the bell). Mouthing of telephone to the ear and vocalizing) one. The younger infant alwaysobjects becomes less appealing. This and later in actions toward dolls or will look for it under the first cover,precise manual-visual manipulation, teddy bears (putting a toy tea cup to even though the position change wastriggered by a heightened curiosity the doll’s mouth). The use of sym- seen. Later, he or she will becomeand facilitated by a longer attention bols lays the foundation for imagi- successful with this task, as long asspan, heralds true “inspection” of nary play. This next stage of play each successive displacement still isobjects. The infant is progressing usually does not appear until 24 to witnessed. Not until the end of thefrom “learning to manipulate” to 30 months of age. second year is the child able toPediatrics in Review Vol. 18 No. 7 July 1997 233
  11. 11. 234 TABLE 3. Cognitive Development LANGUAGE AGE IN MONTHS PROBLEM-SOLVING RECEPTIVE EXPRESSIVE RED FLAGS 1 Fixes on red ring Alerts to sound Throaty noises Failure to alert to environmental stimuli Follows face Cries may indicate sensory impairment Infancy 2 Tracks horizontally past midline Regards speaker Social smile Tracks vertically Coos Vocalizes single vowel sounds CHILD DEVELOPMENT 3 Regards a 1-inch block Chuckles Follows ring circularly Echoes speaker immediately Visual threat Cry varies (hunger, pain) 4 Reaches for objects Orients to voice Laughs out loud Mouths objects “Ah-goo” Shakes rattle Silent and listens to speaker; vocalizes Regards objects while handling when speaker stops 5 Attains dangling ring Orients Bell—I Razzes (raspberries) Failure to reach for objects may indicate Regards pellet Smiles and vocalizes to mirror motor, visual, and/or cognitive deficit Sing-song vocalizations that mimic speaker’s voice 6 Looks to floor when drops toy Babbles: “baba,” “gagaga” Absent babbling may indicate hearing Attains partially hidden object Consonant production without symbolic deficit Removes cloth covering face meaning or communicative intent Discriminates strangers 7 Bangs/shakes toys Orients Bell—II Adult reinforcement begins to give Absent stranger anxiety may be due to Attempts to grasp second cube; meaning to random babbling multiple care providers (eg, neonatal drops first intensive care unit) Pats mirror image 8 Pulls string to obtain ring Enjoys peek-a-boo and “Dada” inappropriately Inspects ring/bell other gesture games Mimics sounds already in repertoirePediatrics in Review Seeks yarn ball after fall; silent landing 9 Rings bell Associates words with “Mama” inappropriatelyVol. 18 Bangs objects on table meanings Waves “bye bye” Uncovers hidden object under cloth 10 Bangs two cubes together Comprehends “no” Dada/Mama appropriately Inability to localize sound may indicate Isolates index finger and explores Orients to name unilateral hearing loss by poking Orients Bell—III Looks at pictures in bookNo. 7 July 1997
  12. 12. 11 Uncovers toy under cup Looks for familiar family First word member when named Imitates simple sounds 12 Looks selectively at round hole Follows command with Immature jargoning Persistent mouthing may indicate lack on form board gesture (“Give me.”) Protoimpertive pointing of intellectual curiosity Removes lid to find toy (goal = desired object)Pediatrics in Review 13 Solves glass frustration task Looks appropriately 2 to 3 words Normal receptive language up to this Unwraps toy in cloth when asked “Where “Oh-oh” point is compatible with hearing loss Functional play is (familiar object)?”Vol. 18 14 Combines two cubes into one Follows command without Names one object hand to take third gesture Says “no” meaningfully Dumps pellet after demonstration Protodeclarative pointing (goal = adult’s attention)No. 7 July 1997 15 Places circle in form board Points to a body part or 3 to 5 words Lack of consonant production may Symbolic play toward self favorite toy Mature jargoning indicate mild hearing loss 16 Pellet in and out without Fetches object from another 5 to 10 words Lack of imitation may indicate deficits demonstration room on request in hearing, cognition, and/or Finds toy hidden under layered covers Points to 1 to 2 body parts socialization Follows observed sequential displacements 18 Matches pairs of objects Points to 3 body parts 10 to 25 words Lack of protodeclarative may indicate Round form in reversed board Points to self Giant-words (“Thank you,” “Stop it,” problem in social relatedness after searching “Let’s go”) Symbolic play directed at doll Names one picture on command 20 Places square in form board Points to several clothing 2 word combinations (noun-noun) Deduces location of hidden object items on request Holophrases (unwitnessed displacement) Selects 2 of 3 familiar objects Points to 6 body parts 22 Completes 3-piece form board Points to 3 to 4 pictures 25 to 50 words Advanced, noncommunicative speech Rapid vocabulary expansion (echolalia, rote phrases) may indicate autism 24 Adapts to form board reversal Two-step commands 50+ words Absent symbolic play may indicate Infancy after 4 trials (“Close the book and 2 to 3 word sentences (noun-verb) problems in cognitive and/or social Sorts objects give the doll to mommy”) Refers to self by name development Matches objects to pictures Comprehends “another” Intelligibility = 50% + Attempts to fold paper Points to 6 pictures Uses “I,” “you,” “me” CHILD DEVELOPMENT Understands me/you235
  13. 13. CHILD DEVELOPMENT Infancydeduce the location of an object ing”). Between 10 and 18 months 1. Prespeech Period (0 to 10 months):that is hidden without observing of age, word counts help in assess- Receptive language is character-the displacement. ing a child’s expressive skills; after ized by an increasing ability to Another important concept domi- 18 months of age, vocabularies localize sounds. Sound localizationnating this period of development is increase exponentially, and it is is assessed by using a noisemakercausality. Initially, the infant acci- difficult to keep up with counts. such as a bell (Fig. 7). Expressivedentally discovers that his or her Language includes receptive language consists of musical-likeactions produce a certain effect and expressive skills. Receptive vowel sounds (cooing) that(eg, kicking the side of the crib skills reflect the ability to under- are interrupted by crying whenactivates a mobile overhead). The stand language; expressive skills the baby has a need. At aboutinfant learns to repeat these actions reflect the ability to make thoughts, 3 months, the infant will beginto obtain the same effects. Later, he ideas, and desires known to others. vocalizing immediately uponor she will vary actions to cause Expression of language can take hearing an adult speak. One ora novel effect (pulling a string to several forms: speech, gestures, two months later the infant isobtain the ring). The concept of sign language, writing, typing, and silent and assumes a posture thatcausality parallels social develop- “body language.” Thus, language implies he or she truly is “listen-ment in which the infant learns to and speech are not synonymous. ing” to the speaker. These infantsmanipulate the environment by cry- Speech is simply the vocal expres- make no vocalizations until theing or smiling to obtain the desired sion of language. A child can have speaker is quiet, mimic thereaction from caregivers. As the normal language and yet be unable speaker, and then quiet againinfant approaches 2 years of age, to speak. Examples include children when the adult speaks. Theyhe or she will learn that apparent who are deaf and children who have appear to enjoy the “vocal tennis”unrelated actions can be combined severe cerebral palsy. The child and repeat this for several produce an effect (eg, winding who has a hearing impairment At approximately 6 months ofa key to make a toy move). may use manual sign language age, the infant adds consonants to to communicate. A child who has the vowel sounds in a repetitiveLANGUAGE DEVELOPMENT normal intelligence but cannot fashion (babbling). Soon theDelays in language development are speak because of oral-motor dys- infant appears to initiate conver-more common than delays in other sations. When a random vocaliza- function related to cerebral palsydevelopmental domains. Parents and tion (eg, “dada”) is interpreted by may use a computer that is activatedpediatricians generally are less the parents as a real word, they with a head stick. Conversely, a show pleasure and joy. In sofamiliar with language milestones. few children talk but fail to use doing, adults give meaning toLanguage is the most difficult speech to communicate (eg, children these first “words” and reinforcedomain to assess by observation who have autism). Their vocaliza- their repeated use.because infants rarely vocalize tions consist of “parrot talk” orspontaneously in the clinician’s echolalia that has no communicative 2. Naming Period (10 to 18 months):office. For this reason, it is essential intent and, thus, does not represent This period is characterized byfor the clinician to obtain a thorough language. the infant’s realization that peopleand accurate language history. The Language development during have names and objects havepediatrician should become familiar infancy can be divided into three labels. It is an important turningwith milestone terminology and periods: prespeech, naming, and point in language development.learn to give examples (eg, “razz- word combination periods. The “dada” and “mama” thatFIGURE 7. Orienting to sound of bell. In the first stage (5 months), when a bell is rung at one side of the infant’s head (A), theinfant turns horizontally to the correct side (B). In the second stage (7 months), when a bell is rung at one side of the head (A),the infant localizes the sound by a compound visual maneuver consisting of a horizontal followed by a vertical component (C).In the third stage (91⁄2 months), when a bell is rung to one side of the head (A), the infant localizes the sound by a single visualmovement (D). From Capute AJ, Accardo PJ. Clin Pediatr. 1978;17:850. Reprinted with permission.236 Pediatrics in Review Vol. 18 No. 7 July 1997
  14. 14. CHILD DEVELOPMENT Infancy were vocalized randomly have nately points at the adult and the belong to mommy.” Single words been reinforced, so the infant desired object while vocalizing take on multiple meanings and no now begins to use them appropri- (eg, “uh...uh”). Next, the infant longer simply label an object. ately. Infants next recognize and uses the object as a tool to obtain The infant usually does not com- understand their own names and the parent’s attention (protode- bine words into true phrases or the meaning of “no.” This marks clarative pointing). Protodeclara- sentences until he or she has the beginning of exponential tive pointing is a social act; the acquired an expressive vocabu- growth in receptive language. parent is an active and important lary of approximately 50 words. By 12 months of age, some partner in a shared world. Rather Early word combinations are infants understand as many as than acquisition of the object, the “telegraphic” in that they do not 100 words. They also can follow infant’s goal becomes the parent’s contain function words (preposi- a simple command as long as the acknowledgment of the interest- tions, pronouns, and articles). speaker uses a gesture. Early in ing object. For example, when an They do, however, convey the the second year, a gesture no infant hears an airplane overhead, same meaning as the more longer is needed to aid in com- he or she points to it and vocal- mature sentence. For example, prehension of the command. izes to get the parent to look at “Go out,” in the context of the Expressive language progresses it. If the parent does not comply situation, conveys the same at a somewhat slower rate. The with these initial efforts, the meaning as “I want to go out- infant will say at least one “real” infant may approach the parent side.” Telegraphic speech is the word (ie, other than mama, dada, and turn his or her face toward first stage in the child’s ability to or a proper name) before his or her first birthday. At this time, the infant also will begin to Word combination begins approximately 6 to 8 months verbalize with sentence-like after an infant says his or her first words. intonation and rhythm (immature jargoning). As the expressive vocabulary increases, real words are added (mature jargoning). the plane in a more determined “grammaticize” speech, that is, By the end of the naming period, effort to obtain what is some- to form sentences with proper the infant will use approximately times called “joint attention.” morphology and syntax. At this 25 words spontaneously. Finally, the infant will point at an point in development, a stranger During this period, pointing object and vocalize (“uh?”) in an should be able to understand at becomes important to both effort to obtain the proper label least 50% of the infant’s speech receptive and expressive language or name for that object from the (intelligibility). Language blos- skills. Pointing already has listener. This is called “pointing soms after 2 years of age. become a method of exploration for naming.” within the problem-solving 3. Word Combination Period (18 to RED FLAGS IN COGNITIVE domain. The infant beginning to DEVELOPMENT 24 months): Typically, children look in the general vicinity where begin to combine words approxi- Language development provides the the adult is pointing is a receptive mately 6 to 8 months after they clinician with an estimate of verbal language skill. This ability is say their first word. If word com- intelligence; skill development in the facilitated by the infant’s new binations appear much earlier, problem-solving domain provides an realization that objects have they are likely “giant words.” estimate of nonverbal intelligence. If labels. Later, the infant begins to Giant words are two- or three- deficiencies are global (ie, skills are take part in pointing games. He word combinations that the infant delayed in both domains) and signif- or she will point first to family hears frequently, such as “Thank icant (ie, >2 standard deviations members, then objects, body you,” “Stop it,” or “Let’s go.” below the mean), there is a possibil- parts, articles of clothing, and When the infant says one of ity of mental retardation. Mental pictures upon request. These all these, he or she really is treating retardation refers to significant sub- reflect receptive language skills. the phrase as a polysyllabic sin- average general intellectual function- Pointing also is used for gle word. At this stage of devel- ing as measured by standardized language expression. First, the opment the infant does not use tests. By current definition, these infant points at an object and either word separately or in novel deficits must be associated with sig- uses the adult as a tool to retrieve combinations with other words. nificant deficits in adaptive function- the object, referred to by linguists “Holophrases” also are beginning ing. About 3% of the population is as protoimperative pointing. The to appear at this time. For exam- mentally retarded. If the deficiencies infant first points to the object ple, an infant may point to a are very mild (ie, in the low range (eg, a cookie) and then looks mother’s keys and say “mommy” of normal), the child is considered back and forth between the adult instead of saying “keys.” In to be of borderline intelligence or and the object expectantly. At a this context, the single word, a “slow learner.” later stage, he or she directs “mommy,” has a sentence-like When a discrepancy exists attention to the adult and alter- meaning, such as “These keys between problem-solving and lan-Pediatrics in Review Vol. 18 No. 7 July 1997 237
  15. 15. CHILD DEVELOPMENT Infancyguage abilities, with only language netic resonance imaging (performed with his or her receptive skills. Abeing deficient, one must consider because of atypical head growth or child who speaks in five-word sen-the possibility of a hearing impair- because of a known cerebral insult) tences but does not understand sim-ment or a communication disorder. indicate that the child is at risk for ple commands is at risk of having aIf either language or problem-solv- intellectual deficits. pervasive developmental skills is deficient, the child is at Although a cognitive deficit is The advanced speech may not behigh risk for manifesting a learning the most common reason for lan- functional or have communicativedisability later. A learning disability guage delay, all children who have intent. Finally, some parents willrefers to academic achievement that delayed language development excuse their child’s lack of speechis substantially below what would should receive audiologic testing because of an “Uncle Albert” whobe expected from a person’s general to rule out hearing loss. The child didn’t speak until he was 4 yearsintellectual potential. Approximately who has a hearing loss will demon- old but grew up to be a rocket5% to 7% of school-aged children strate normal expressive language scientist. In reality, this is veryhave learning disabilities. A learning skills through the babbling stage rare. Normal receptive languagedisability cannot be diagnosed for- (6 months). He or she will begin to skills in a child who has speechmally until the child reaches school babble on time, but lack of auditory delay would be reassuring and typically are easy to demonstrate. Other problems may masquerade . . . all children whose language development is delayed as cognitive delay or impair the should receive audiologic testing. assessment of cognitive abilities. Problem-solving tasks require intact fine motor skills. Having poor fine motor skills puts the child at a dis-age and demonstrates an inability to reinforcement for these vocalizations advantage with certain manipulativekeep up in one or more academic results in their disappearance and a tasks used to assess nonverbal cog-areas. Thus, a reading disability can- general decline in verbal expression. nition. Due to cerebral palsy, a childnot be diagnosed until at least age Receptive language abilities con- may not be able to place a square6 or 7 years when children normally tinue to progress normally for a feware expected to read. A delay in lan- more months. A 1-year-old who is form in a form board; however, heguage development is a “red flag” deaf will follow a command with or she might be able to indicate theand should prompt careful monitor- a gesture (relying solely on the correct position by pointing or bying and further evaluation if the gestural cue) and may seem to hear. eye gaze. Thus, the child actuallychild later demonstrates reading This ability to use environmental could “pass” the form board item indifficulties in school. The neurologic cues can fool parents and profes- the problem-solving assessment.substrate for specific learning dis- sionals and is one of the chief Similarly, visual impairment canabilities involves patchy dysfunction reasons that the average age of interfere with a child’s ability toin cortical information processing diagnosis of a severe hearing loss is perform many problem-solvingthat results in specific difficulties 2 years. Children who have a mild tasks successfully.with academic tasks. hearing loss will present even later Unless the deficiencies are with articulation errors, inability tosevere during infancy, a child rarely localize sounds, or “attentional prob- Psychosocial Developmentpresents with a parental concern of lems.” An infant who is deaf will Emotional, social, and adaptive“cognitive delay.” Concerns usually attempt to communicate by using milestones have been assimilatedpresent as speech delays, but such gestures. If a child has delayed from multiple sources (Table 4).complaints are infrequent before speech and fails to demonstrate a These milestones are more variable24 months of age. The average age desire to communicate, a more than those in motor and cognitiveat which mental retardation is diag- pervasive problem, such as autism, domains because of the greaternosed is 3 to 4 years. Usually, the should be considered. Although chil- influence of environmental factorsmore severe the degree of impair- dren who have autism may demon- (nurture). An infant inherits a set ofment, the earlier the diagnosis is strate protoimperative pointing emotional-social characteristics andmade. Because the majority of chil- (eg, pointing to obtain food or drink), a style of interacting, but these aredren who are mentally retarded are they rarely point to the object for the modified by parenting style, “good-in the mild category, most children purpose of having the adult join in ness of fit,” and the social environ-are diagnosed well after infancy. the pleasure of admiring an interest- ment. Emotions include the infant’sSome are not diagnosed until they ing object (protodeclarative point- feelings as well as the expression ofenter school. The child who is born ing) or point to obtain the name of these feelings. Social milestoneswith dysmorphic features and has a an object. Prodeclarative pointing is include the steps necessary to formrecognizable syndrome known to be a social action, and one of the cardi- interpersonal relationships. Tempera-associated with mental retardation nal features of autism is the lack of ment influences social relationshipswill be diagnosed earlier regardless social relatedness. Another red flag and generally reflects a consistentof the degree of impairment. Addi- is the finding that a child’s expres- pattern (or style) in “how” a childtionally, abnormal findings on mag- sive skills are advanced compared reacts. It is different from the238 Pediatrics in Review Vol. 18 No. 7 July 1997
  16. 16. CHILD DEVELOPMENT Infancy TABLE 4. Psychosocial Development AGE IN MONTHS EMOTIONAL SOCIAL ADAPTIVE RED FLAGS 1–3 Interest Understands relationships State regulation Irritability Disgust between voices and faces Requires only one Sleep/eating disturbances Distress (pain, hunger) Bonding (parent → infant) night feeding Enjoyment (social smile) Smiles reciprocally Follows moving person with eyes 3–6 Anger Recognizes mother Absent smile may Happiness Attachment (infant → parent) indicate visual loss, Joy Anticipates food on sight attachment problems, Pleasure Smiles spontaneously or maternal depression Sadness Displeasure 6–9 Personality unfolds Discriminates emotional Gums/swallows cracker Absent stranger anxiety Fear facial expressions and Places hands on bottle may be due to multiple reacts differently Takes solids well care providers Preference for a given Finger feeds dry cereal (eg, NICU care) person Stranger anxiety Understands means-to-an-end relationship in social interactions (act→clap →repeat act) 9–12 Assertiveness Differential fear response Holds bottle Cautiousness based on gender and age Holds, bites, chews Concept of self cracker/cookie Social interactions become Drinks from cup held intentional and goal-directed for him or her Separation anxiety 12–15 Shyness Solitary play Cooperates with dressing Empathy Begins formation of Drinks from cup; Sharing relationships some spillage Self-comfort • Love Removes socks/hat (eg, attachment • Friendship to blanket) • Acquaintance • Strangers Offers ball to mirror image Kisses by simply touching lips to skin or licks 15–18 Shame/guilt Self-conscious period; Uses spoon; some Lack of social Contempt “coy” stage spillage relatedness may Hugs parents indicate autism 18–21 Associates feelings First application of attributes Drinks from cup with verbal symbols to self (eg, good, little, without spilling Begins to have thoughts naughty) Moves about house about feelings Initiates interaction by calling without adult to adult Emerging independence Kisses with a pucker Removes a garment 21–24 Beginning “socialization” Imitates others to please them Replaces some objects Persistent poor transitions of emotional expression Recursive nature of social where they belong may indicate a pervasive by social/cultural thought (ie, thinking about Uses spoon well developmental disorder influences “How I behave to you Opens door by turning • modulation of emotion and you to me”) knob • masking of emotion Parallel play Removes clothes without Infant’s reaction to Tolerates separation; buttons ambiguous events is will continue activity Unzips zippers shaped by emotional Puts shoes on part way reactions of othersPediatrics in Review Vol. 18 No. 7 July 1997 239