Prof. Dr. Dalia Morgan Samia Abdel Rahman
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Prof. Dr. Dalia Morgan Chair of Department of Pediatrics Beni-Suef University Prof. Dr. Samia Abdel Rahman Chair of Department of Physical Therapy for Pediatrics and its Surgery MTI University Dr. Marian Magdy Lecturer of Pediatric Physical Therapy MTI University
Transcript of Prof. Dr. Dalia Morgan Samia Abdel Rahman
Prof. Dr. Dalia Morgan
Chair of Department of Pediatrics
Beni-Suef University
Prof. Dr. Samia Abdel Rahman Chair of Department of Physical
Therapy for Pediatrics and its Surgery
MTI University
Dr. Marian Magdy Lecturer of Pediatric Physical Therapy
MTI University
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والمعلومات للتكنولوجيا الحديثة الجامعة - الطبيعي العلاج كلية رؤية
صرحا تكىٌ لأٌ وانًعهىياث نهتكُىنىخيا انحديثت باندايعت انطبيعي انعلاج كهيت تسعً
انعانًي و نيًي والإق انًحهً انًستىي عهً انطبيعً لاجانع يدال فً اندايعً نهتعهيى رائدا
2025. عاو بحهىل
والمعلومات للتكنولوجيا الحديثة الجامعة - الطبيعي العلاج كلية رسالة
خريديٍ أعداد انً وانًعهىياث نهتكُىنىخيا انحديثت باندايعت انطبيعي انعلاج كهيت تهتسو
بانًعارف ويسوديٍ انعًم سىق أحتياخاث نتهبيت نهًُافست يؤههيٍ انطبيعً انعلاج يدال فً
تعهيًً برَايح خلال يٍ ذنك و انبراهيٍ عهً ائًت انق الإكهيُيكيت نهًًارست انلازيت وانًهاراث
فً الأبتكار و نلأبداع انًستًر وواندعى وانتعهى نهتعهيى انًستًر انتطىيرو تعهيًيا و عهًيا يتًيس
.والأخلاقياث انقيى أطار فً انًثًرة نًدتًعيتا وانًشاركت انعهًً انبحث يدال
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University: Modern University for Technology and Information
Faculty: Physical Therapy
Course Specifications
A. Basic Information
1. Program Title: Physical Therapy
2. Program is offered by: Faculty of Physical Therapy
3. Department responsible for the Course: Physical Therapy for Pediatrics and its Surgery
4. Course Title and Code: Growth and Development (M5929)
5. Year/ Level: year 5/ level 9
6. Credit hours: 2H
Lecture: 2H/W Practical: - Clinical: -
7. Authorization Date of Course Specification: Fall 2021/2022
B. Professional Information
1. Course Aims:
This course aims to:
Demonstrate knowledge of the normal sequence of physical, cognitive, social and personality
development.
Describe the normal variations of the developmental sequence for physical, cognitive, social
and personality development.
2. Intended Learning Outcomes (ILOs): Express the ILOs of the course in terms of:
a. Knowledge and Understanding
Upon successful completion of the course the students should be able to:
a.1. Define different terminology used in the field of human growth and development.
a.2. Recognize the concept of growth and development and factors affecting on growth and
development.
a.3. Describe how to assess growth and maturation.
a.4. Describe the process of pre-natal growth from conception to birth.
a.5. Identify the normal as well as abnormal reflexive maturation.
a.6. Describe developmental changes in gross motor, fine motor and locomotion.
a.7. Identify the normal as well as abnormal, hand functions and gross motor development.
a.8. Identify development and ageing of different body systems.
a.9. Explain social and emotional development.
b. Intellectual Skills
Upon successful completion of the course the students should be able to:
b.1. Classify age stage of humanity across life span.
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b.2. Distinguish between growth, development and maturation
b.3. Differentiate between normal and abnormal changes in aspects of development including
gross motor, fine motor skills, reflexive maturation and locomotion.
b.4. Explain different infantile reflexes and postural reactions.
b.5. Relate inhibition of specific reflexes and appearance of specific reactions to development of
particular voluntary motor skills.
b.6. Explain developmental changes in the skeletal, muscular, and nervous system across life
Span.
c. Professional and Practical Skills
Not applicable
d. General and Transferable Skills
Upon successful completion of the course the students should be able to: d.1. Communicate effectively in both scientific and professional context using verbal, non-verbal and
written means.
d.2. Use information technology as a means of communication for data collection, analysis and for
self-directed learning.
d.3. Communicate accurately, clearly, confidently, and effectively in written and oral assignments.
3. Contents:
No Topics Contact Hours Teaching
Methods Theoretical Practical Clinical
1 Introduction of growth and
development, age stage and physical growth
2 - -
Contact teaching
2 Normal and abnormal physical
growth
2 - - Contact teaching
3 Prenatal growth and development and newborn infant
2 - - Contact teaching
4 Developmental and aging of body
systems
2 - - Contact teaching
5 Maturation of reflexes 2 - - Contact teaching
6 Gross motor development 2 - - Contact teaching
7 Fine motor development 2 - - Contact teaching
8 Cognitive development 2 Contact teaching
9 Social and personality development 2 - - Contact teaching
10 Revision 2 - - Contact teaching
E-learning
4. Teaching and Learning Methods:
Lectures and discussion
Student activity: Assignments and small group discussion.
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5. Student Assessment:
# Assessment Method Assessed ILO
5.1 During semester Quizzes and Final
written exam with supply questions
(define, enumerate, differentiate, describe, explain, calculate) and selection questions
(multiple choice, matching)
a.1-a.6
5.2 Case based questions b.1-6, d.1, d.2
5.3 Final term theoretical exam all
# Assessment method Semester week Weighting (%) Marks
1. Mid-term exam, Quizzes and
Project.
Exam Period 60% 60
2. Final written exam Exam Period 40% 40
Total 100% 100
6. List References:
a. Course Notes: By course instructors.
b. Essential Books (Test Books) Gallahue DL and Ozmum JC (2006): Understanding Motor Development. Boston:
McGraw
Kail RV (2012): Children and Their Development. 6th edition. United States: Pearson.
Haywood KM and Getchell N (2019): Life Span Motor Development. 7th edition.
Human Kinetics.
c. General references
Laura E. Berk (2006): Child Development, 7th edition. Boston: Pearson.
Kail, R. (2010): Human Development: a life-span view. 5th edition. Australia:
Wadsworth Cengage Learning.
Thies, K. (2009): Growth and Development through the Lifespan. 2nd
edition.
Sadbury: Jones and Bartlett.
d. Periodicals, Web Sites, … etc
https://open.umn.edu/opentextbooks/textbooks/750
http://onlinelibrary.wiley.com/journal/10.1111/(ISSN)1467-8624
http://psycnet.apa.org/?fa=main.doiLanding&doi=10.1037/0003-066X.50.2.79
http://ije.oxfordjournals.org/content/32/4/518.short
https://en.wikipedia.org/wiki/Book:Human_growth_and_development
7. Facilities Required For Teaching And Learning:
Lecture room and white board.
CPU and overhead projector.
E-learning.
Course Instructors: Prof. Dr. Dalia Saber Morgan, Prof. Dr. Samia Abdel Rahman and Dr.
Marian Magdy
Course Coordinators: Dr. Marian Magdy.
Approval of Department Council: 20/9/2021
Head of Department: Prof. Dr. Samia Abdel Rahman Signature:
Dean of Faculty: Prof. Dr. Naguib Salem Signature:
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Preface to the First Edition
Welcome to Human 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. We will also look at how our emotions, psychological state, and social
relationships change throughout childhood and adolescence.
Authors
Prof. Dr. Dalia Morgan
Prof. Dr. Samia Abdel Rahman
Dr. Marian M. Shafeek
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CONTENTS
Introduction 3
Normal physical growth 10
Abnormal physical growth 22
Puberty 33
Prenatal development 40
Development and aging of body systems 47
Developmental abnormalities 57
Maturation of reflexes 64
Gross motor development 94
Fine motor development 105
Cognitive development 123
Social and personality development 151
References 176
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INTRODUCTION
Human development is a lifelong process of physical, behavioral, cognitive,
and emotional growth and change. In the early stages of life—from babyhood to
childhood, childhood to adolescence, and adolescence to adulthood—enormous
changes take place.
Terminology
Growth:
It is a quantitative increase in size or body mass and dimension resulting
from an increase in complete already formed body parts.
It is an anatomic phenomenon and quantitative in nature.
There are various measurements that are used to measure growth including
weight, length/height, head circumference, mid upper arm circumference
(MUAC) and the eruption of teeth.
Development:
It is progressive acquisition and maturation of functions and gaining of
various skills (abilities) throughout life span.
It is a physiologic phenomenon and qualitative in nature.
It includes different aspects of development such as motor development,
cognitive (mental) development, social development, personality and sexual
development.
It specifies maturation of functions: It is related to the maturation and
myelination of the nervous system and indicates acquisition of a variety of
skills for optimal functioning of the individual.
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N. B.
Both growth and development go parallel to each other.
Motor Development:
It is a sequential, continuous age-related process whereby movement
behavior changes (whereby an individual progresses from simple
movements to highly organized, complex motor skills, and finally to the
adjustment of skills that accompanies aging).
An example is the development of ambulation from just rolling to bipedal
walking.
Cognitive Development:
It is the development that involves the ways that growth and change in
intellectual capabilities influence a person‘s behavior.
These intellectual abilities include learning, memory, language, problem
solving and intelligence.
Social development:
It is the development that involves the ways in which individuals‘
interactions with others and their social relationships grow, change and
remain stable over the course of life.
For example, babies make eye contact, imitate facial expressions, and
respond to voices. As children age, they interact more with other children
and adults, which helps them to learn additional social skills.
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Personality development:
It is the development that involves the ways that the enduring characteristics
that differentiate one person from another change over the life span.
It is the development of the organized pattern of behaviors and attitudes that
makes a person distinctive.
It occurs by the ongoing interaction of temperament, character, and
environment.
Some examples of these types of character traits include religious, honest,
loyal, devoted, loving, kind, sincere and ambitious.
Motor Control:
It is the process of initiating, directing, and grading purposeful voluntary
movement.
It refers to the nervous system‘s control of the muscles to permit skilled and
coordinated movements.
An example of motor control is picking up a small item with the index finger
and thumb.
Motor Learning:
It is the process of acquiring a skill by which the learner, through practice
and assimilation, refines and makes automatic the desired movement.
It is an internal neurologic process that results in the ability to produce a new
motor task.
Walking is a good example. It is an extremely complex task involving
intricate motor movements, which we generally perform automatically and
with great facility. Driving is another important example.
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Aging:
It is the process occurring with the passage of time, leading to loss of
adaptability or full function and eventually to death.
Growth Stages
Development passes through two main stages (prenatal and postnatal). The
prenatal stage is subdivided into three stages and the postnatal stage is subdivided
into five stages according to age (Table 1).
I. Prenatal (intra-uterine stage):
1. Germinal stage (period of the zygote): 1-2 weeks' gestation
2. Embryonic stage: 3rd
to 8th
weeks of gestation.
3. Fetal stage: from the 9th
to 38th
or 40th
week of gestation.
a. Early fetal stage: from 9th
to 24th
weeks of gestation.
b. Late fetal stage: from 25th
to 38th
or 40th weeks of gestation or until birth.
This stage includes maximum rate of growth (accounting for 30% of adult
height) and is affected by maternal and placental health as well as fetal
insulin
II. Postnatal (extra-uterine stage):
1. Neonate: first 4 weeks of life (28 days).
2. Infancy: from 1 month – 2 years.
3. Childhood: This stage is mainly affected by growth hormone, thyroid
hormone, good health and happiness and genes.
a. Early childhood (preschool): from 2 – 6 years.
b. Late childhood (school or preadolescence): from 6 – 12 years.
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4. Adolescence (12 – 20 years): it is subdivided into early, mid and late
adolescence. It is mainly affected by Testosterone/Estrogen, growth
hormone.
5. Adulthood (20 years and over): it is subdivided into young, middle and late
adulthood.
Table (1): Developmental stages with the corresponding chronological age.
Developmental Stage Approximate Chronological Age
1. Prenatal
Germinal
Embryonic
Fetus
Conception to birth
1-2 weeks' gestation
3- 8 weeks' gestation
9 weeks to birth
2. Neonate First 4 weeks of life
3. Infancy One month to 2 years
4. Childhood
Early childhood (preschool)
Late childhood
(preadolescence)
2 to 6 years
6 to 10/12 years
5. Adolescence
Girls
Boys
9 or 10 to 18 years
10 or 12 to 20 years
6. Adulthood
Young adulthood
Middle adulthood
Late adulthood
18/20 to 40 years
40 to 60 years
60 years and over
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Factors affecting Physical Growth:
1. Race: there is a racial difference in the rate and pattern of growth.
2. Family: height and body frame are inherited from parents.
3. Sex: girls grow faster from the 7th
month to four years and start puberty at
younger age.
4. Chromosomal disorders: as Down syndrome, usually show retarded growth.
5. Socio-economic factors: poor housing and hygiene and poor health can
delay growth.
6. Nutritional status: under-nutrition delays growth, while over-nutrition can
lead to obesity.
7. Chronic illness: e.g. renal, liver and chest diseases.
8. Developmental anomalies: such as cleft palate, pyloric stenosis and renal
anomalies.
9. Chronic infection: such as Tuberculosis (TB) and Brucella .
10. Endocrinal factors:
11. Growth hormones: deficiency causes proportionate short stature, abnormal
mentality and characteristic features.
a. Thyroid hormone deficiency: disproportionate short stature, mental
retardation and coarse face.
b. Proportionate short stature in children with acquired hypothyroidism.
c. Androgens: excess androgens cause tall stature as a child but
proportionate short stature later as an adult.
d. Adrenal cortisol: deficiency causes failure to thrive and asthenia.
e. Excess steroids whether endogenous or exogenous causes short stature with
obesity (Cushing syndrome).
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Aspects of Normal Growth and Development
1. Physical Growth:
The main parameters include weight, length in infants (or height after the
age of 2 years) and head circumferences.
Other parameters include the following:
Body proportions such as upper/lower segment ratio.
Dentition including the primary (deciduous) and secondary (permanent)
dentition.
Vital signs including heart rate, respiratory rate and blood pressure.
Bone age (radiological).
2. Motor development:
It includes gross motor skills (such as sitting, standing and walking etc.) and
fine motor skills (such as hand and finger grip).
3. Cognitive development:
It includes learning, memory, language, intelligence and problem solving
development.
4. Social development:
It includes the development of social relationships.
5. Sexual development:
It includes the stages of puberty.
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NORMAL PHYSICAL GROWTH
Anthropometry is the branch of science involving human growth and body
measurement. Anthropometric measures include height, weight, segment length,
circumferences and body mass index (BMI)-for-age per centile. Although most of
us would consider these measures fairly routine, such measures must be precise if
they are to provide us with reliable information about human growth. Examiners
should rigidly follow standard procedures for taking growth measures. Following
are several common growth and maturation measures, including the accepted
assessment procedure.
Weight
It is essential to monitor growth.
Infant‘s weight must be measured naked and children are measured with the
minimal clothing.
At birth: newborn weights about 3 Kg (normal from 2.5 to 4 Kg).
Normal weight gain is presented in table (1).
Weight calculation equationbetween1 and 6 years = (age x 2) + 8.
Birth weight is doubled at 4 months and tripled at 12 months.
Table (1): Normal weight gain per age.
Age Weight Gain Age Weight Gain
1st 4 months ¾ Kg/month At 4 months 6 Kg
4 – 8 month ½ Kg/month At 8 months 8 Kg
8 – 12 months ¼ Kg/month At 12 months 9 Kg
2nd
year 3 Kg At 2 years 12 Kg
3 – 6 years 2 Kg/year At 6 years 20 Kg
6 – 10 years 2.5 Kg/year At 10 years 30 Kg
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Length and Height
One of the most useful and common measures of growth is that of body
height, or stature. Depending on a child‘s age and ability to stand, measure the
child‘s length or height (Figure 1).
Infants less than 2 years, measure recumbent (lying down) length by length
board (Infantometer).
Children aged 2 years or older and able to stand, measure standing
(standing) height by height board (Stadiometer).
Follow 0.7 cm rule.
The 0.7 cm rule:
Standing height is about 0.7 cm less than recumbent length. If a child less
than 2 years old will not lie down for measurement of length, measure standing
height and add 0.7 cm to convert it to length. If a child aged 2 years or older cannot
stand, measure recumbent length and subtract 0.7 cm to convert it to height.
Figure (1): Measuring tools for length or height of children.
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At birth: 50 cm
During the first 4 years:
6 months: 68 cm
1 year: 75 cm
2 years: 87 cm
3 years: 94 cm
4 years: 100 cm (double birth length).
Between 4 – 9 years, the height increases about 7 cm/year and it will be 135
cm at 9 years.
Between 9 – 12 years, the height increases about 5 cm/year and it will be
150 cm at 12 years (triple birth length).
Body Proportions
Upper segment is measured from the crown to the upper border of
symphysis pubis (setting height).
Lower segment is measured from symphysis to the heel.
Normal proportion:
At birth: 1.7/1
At 3 years: 1.3/1
At 7 years: 1.0/1 equal upper and lower segment.
Value: differentiate proportionate from disproportionate short stature.
Head Circumference
At birth: 35 cm.
6 months: 43 cm.
1 year: 47 cm.
2 years: 49 cm.
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4 years: 50 cm.
6 years: 51 cm.
12 years: 53 cm.
12 cm during the first year.
6 cm only during 11 years.
Fontanelles
In an infant, the space where two sutures join forms a membrane-covered "soft
spot" called a fontanelle (fontanel). The fontanelles allow for growth of the brain
and skull during an infant's first year (Figure 2).
Anterior fontanelle
At birth: 3 fingers (5 cm width from side to side).
6 months: 2 fingers.
1 year: 1 finger.
1.5 years: closed.
Posterior fontanelle closed at birth.
Figure (2): Normal skull of the newborn.
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Measurement
Head circumference is the maximum circumference of the head when the
tape is located immediately superior to the eyebrows (just over the supraorbital
ridge and the glabella in front) and positioned at the back of the head (over the
occipital protuberance), so that the maximum parameter is measured (Figure 3).
Figure (3): Measurements of head circumference.
Dentition
Teething in the lower jaw precedes the upper by 1 month.
There is a wide range in the time of eruption (Table 2 and Figure 4 and 5).
Deciduous teeth are (20) while the permanent teeth are (32).
Table (2): Timing of teeth eruption.
Primary or Deciduous
Teeth Age (month)
Secondary or Permanent
Teeth Age (year)
1. Central incisors 6 1. First molar 6
2. Lateral incisors 8 2. Central incisor 7
3. First molar 12 3. Lateral incisor 8
4. Canines 18 4. First premolar 10
5. Second molar 24 5. Second premolar 11
6. Canine 12
7. Second molar 13
8. Third molar 17 – 22
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Figure (4): Primary or deciduous teeth.
Figure (5): Secondary or permanent teeth.
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Skeletal Maturity (radiological determination of bone age)
Bone maturation is the process whereby the tissue undergoes changes from
the embryonic rudiment of bone to the adult form. Before puberty chronological
age correlates well with bone age but during adolescence bone age is more closely
related to adult maturity levels, so that bone age is related to the timing of puberty
and growth in height in an individual. Hence, two adolescents of the same
chronological age can have different levels of bone maturation owing to
differences in timing of onset of puberty.
Calculation:
Skeletal maturity is calculated through the appearance of ossific centers
(Figure 6), the size and shape of ossific center and the fusion of the
epiphysis with rest of the bone.
At birth (X ray of the knee joint):
Ossific centers around the knee joint are well developed.
Delayed appearance indicates delayed bone age (hypothyroidism).
In early childhood (X ray of the left hand and wrist):
The 1st carpal bone is ossified at the age of 6 months.
Then, there is one ossific carpal center per year.
1 year: 2 ossific centers.
2 years: 3 ossific centers.
In late childhood, there is fusion of epiphysis of distal ends of ulna and
radius.
For accurate calculation special atlases are used.
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Value
Normally bone age corresponds to the age of the child.
Markedly delayed bone age: endocrinal deficiencies (hypothyroidism,
Growth hormone deficiency, androgen deficiency).
Advanced bone age: excess androgen – excess growth hormone –
hyperthyroidism.
Normal bone age with short stature: familial short stature – skeletal
dysplasia.
Figure (6): Hand wrist radiograph (sequence of ossification).
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Vital Signs
Maturation of vital signs including heart rate, respiratory rate and blood
pressure is presented in table (3).
Table (3): Vital signs at different ages.
Heart Rate Respiratory Rate Blood Pressure
Newborn 130 55 80/60
6 months 120 40 80/60
1 year 120 35 80/60
4 years 100 25 80/60
10 years 90 20 110/65
Growth Curves (Charts)
Definition:
Growth curves are the use of graphic assessment of the physical growth of
child (growth monitoring).
Background:
There is a wide range of variations among normal children of the same age.
Each child has its own inherited pattern of growth. Therefore, growth charts are
essential to:
Demonstrate the normal growth variations.
Summarize the growth data so facilitate earlier diagnosis of abnormal
growth e.g. short stature.
Types:
Percentile growth curves (used for follow up of the child during the well
child visits). They are the most commonly used
Standard deviation curves.
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Velocity curves.
Criteria of curves:
1. Made for different aspects of physical growth: height, weight and skull
circumference.
2. Percentile curves vary from:
Boys to girls: charts for boys and other for girls are available.
One country to another: charts for Egyptian children are available.
Age: charts for the first 36 months (World Health Organization-WHO)
growth charts and charts for children 2 – 20 years (Centers for Disease
Control and Prevention- CDC) growth charts and charts for children 2 –
20 years (Figure 7).
3. Each chart is composed of seven percentile curves:
50th
percentile (the median or mean).
25th
percentile (25% of children are below that).
10th
percentile (10% of children are below that).
5th
percentile (5% of children are below that and it is considered the
lowest limit of the normal).
75th
percentile (75% of children are above that).
90th
percentile (90% of children are above that).
95th
percentile (the highest limit of the normal).
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Figure (7): Examples of growth charts.
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Uses:
Single measure gives an idea about the child. An example is body mass
index (BMI)–for-age percentile (BMI= weight in Kg/height in square meter)
(Table 4):
Normal: lie between 5th
percentile and 85th
percentile.
Abnormal: less than 5th
or more than 85th
percentile.
Example: weight under the 5th
percentile is considered underweight while
above 95th
percentile is obese.
Value of repeated serial measures:
1. Assess of growth rate:
Any normal child should lie between the 5th
and 85th
percentiles
Normal child should follow the same percentile level throughout the
growth period.
2. Detect abnormal growth (any deviation from the child own curve).
3. Detecting catch up (if a child‘s growth after a period of illness slows or
retards and then growth accelerates to get the growth rate back to
normal).
Table (4): Body mass index (BMI)–for-age percentile for children.
BMI percentile range Category
Less than 5th
Underweight
5th to 84th Healthy weight
85th to 95th Overweight
Above 95th
Obese
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ABNORMAL PHYSICAL GROWTH
(I) Short Stature
Definition
Short stature is a term applied to a child whose height is below the 5th
percentile for age and sex.
Types
1. Proportionate short stature (normal variants – pathological).
2. Disproportionate:
Short limbs: achondroplasia and hypochondroplasia, rickets, congenital
hypothyroidism.
Short trunk: Morquio‘s disease
Etiology
There are different causes for proportionate short stature; some of them lead
to normal variant which represents 90% of the proportionate short stature (Table 1)
and others lead to pathological short stature which represents 10% of the
proportionate short stature.
Causes of pathological proportionate short stature
1. Genetic and chromosomal disorders:
Down syndrome.
Turner syndrome.
Mucopolysaccharidosis.
Skeletal dysplasia.
Russel Silver syndrome (Figure 1).
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Table (1): Characteristics of normal variant proportionate short stature.
1. Familial (genetic) short
stature
2. Constitutional delay of growth and
puberty
The most common cause of
short stature.
Common problems in boys.
Short parents. Normal height parents.
Short healthy subjects since
birth.
Normal growth velocity.
Normal length at birth, then short
within 2 years (transient decelerated
growth).
Normal bone age. Delayed bone growth.
Normal puberty. Delayed puberty.
Adult height is short. Adult height is normal
Growth hormone therapy may
be useful.
Reassurance is what needed.
2. Endocrinal causes (bone age is markedly delayed)
Growth hormone deficiency.
Panhypopituitarism such as carniopharngioma (rare but must be
excluded).
Isolated growth hormone deficiency.
Insulin growth factor 1 (IGF1) deficiency (Laron syndrome).
Hypothyroidism: congenital / autoimmune thyroiditis.
Hypoparathyroidism
Hypogonadism
Adrenal hormones
Cushing syndrome (Figure 2).
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Adrenal insufficiency.
Hypoparathyroidism
Corticosteroid therapy: a prolonged high dose (equivalent to 5mg
prednisone / day or more leads to short stature (risk is reduced by
alternate day therapy).
3. Severe systemic diseases in infancy and childhood.
Chronic diseases (chronic kidney diseases – cystic fibrosis – liver cell
failure – malabsorption – hemolytic anemia).
Chronic infections: tuberculosis – Bilharziasis.
4. Nutritional starvation (malnutrition)
Nutritional starvation diminishes synthesis of growth factors.
Weight is more affected than height.
5. Social short stature.
Psychological deprivation: disturbed child-mother or family relation
reduces growth hormone release.
Figure (1): Russel Silver syndrome. Figure (2): Cushing syndrome.
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Management
History:
Family history of short stature, delayed puberty or genetic disease.
History of any chronic illness or social problems.
History of steroids intake.
Examination:
1. Measurements.
Length of the parents and sibs as most cases are familial.
Calculate the mid parental height (sum of parents‘ heights/2) (plus 7 in
boys and minus 7 in girls)
The child should be within his/her target centile range = mid parental
height±2SD.
Length of the child and upper segment to lower segment ratio (if
disproportionate = disproportionate short stature).
Height velocity is a more sensitive indicator.
2. Detailed systemic examination to exclude systemic causes.
3. Genetic examination and pubertal staging.
Investigations:
1. Bone age assessment: X-ray of the left hand and wrist will diagnose the
normal variant (family/constitutional) and save unnecessary investigations.
2. Karyotyping in short females to exclude Turner syndrome (45XO).
3. Anti-tissue transglutaminase (positive in Celiac disease).
4. Skeletal survey: if skeletal dysplasia is suspected (e.g. Achondroplasia).
Rickets also should not be missed as a cause.
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5. If bone age is markedly delayed endocrinal assessment is warned including:
thyroid profile – Growth hormone stimulation tests – Steroids and ACTH if
clinically suspected.
6. If pituitary hormonal deficiency is diagnosed (isolated GH deficiency or
Panhypopituitarism), MRI is required to detect craniopharyngioma or brain
anomalies.
(II) Obesity
Definition
If a child stores too much fat they can be classified as obese. A sign of
childhood obesity is a weight well above the average for a child's height and age. A
child is classified as obese if his/her BMI is equal to or greater then 95th
percentile.
Etiology
1. Exogenous obesity: genetic and environmental factors.
2. Endogenous obesity:
Cushing syndrome.
Hypothyroidism.
Hyperinsulinism.
Turner syndrome.
Klinefelter syndrome.
Prader-Willi syndrome (PWS): it is a genetic disorder caused by a loss of
function of specific genes on chromosome 15. In newborns, symptoms
include weak muscles, poor feeding, and slow development. Beginning in
childhood, those affected children become constantly hungry, which
often leads to obesity and type-2 diabetes (Figure 3).
27
Growth hormone deficiency.
Pseudohypoparathyroidism.
Figure (3): Prader-Willi syndrome
(III) Macrocephaly
Definition
It is one of the abnormalities of head growth in which the head
circumference is above the 95th
percentile for age and sex.
Etiology
1. Cranial causes:
a. Familial large head
b. Chronic hemolytic anemia
c. Rickets
d. Achondroplasia and Mucopolysaccharidosis.
2. Intracranial causes (increased intracranial tension):
28
a. Hydrocephalus
b. Subdural hematoma and subdural effusion
c. Brain tumors
d. Neurofibromatosis
e. Cerebral gigantism (Sotos syndrome)
f. Central nervous system (CNS) storage disease such as
mucopolysaccharidosis (hurler‘s syndrome) (Figure 4).
Figure (4): Hurler’s syndrome.
(IV) Microcephaly
Definition
It is one of the abnormalities of head growth in which the head
circumference is below the 5th
percentile for age and sex (Figure 5). Microcephaly
may be true or due to craniostenosis.
29
Typical head size
Microcephaly
Figure (5): difference between typical head size and microcephaly.
Types
[A] True Microcephaly
Primary (genetic):
1. Familial (autosomal recessive).
2. Autosomal dominant.
3. Syndromes (Down : trisomy 21) – (Edwards : trisomy 18) – (Cri du chat :5p)
Secondary (non-genetic or acquired)
Microcephaly is due to destructive processes affecting the brain during fetal
and early infantile life.
1. Prenatal causes:
Congenital infection: e.g. Cytomegalovirus, Rubella.
Irradiation.
Drugs e.g. fetal alcohol syndrome.
2. Perinatal causes:
Hypoxic ischemic injury.
Intracranial haemorrhage.
3. Post-natal causes:
30
Kernicterus.
CNS infections: meningitis – encephalitis.
Intracranial haemorrhage.
[B] Craniostenosis (craniosynostosis)
Definition:
It is a condition in which there is a premature closure of one or more
(generalized) skull sutures (Figure 6). When it is generalized (Multiple sutures) it
causes microcephaly, motor and mental retardation).
Figure (6): Craniosynostosis (unicoronal craniosynostosis).
31
Types:
1. Genetic syndromes: as with exophthalmos in Crouzon‘s syndrome.
2. Isolated congenital defects.
In craniostenosis there is:
Palpable ridge in the region of the prematurely closed sutures.
Papilledema and other manifestations of increased intra cranial tension.
Skull deformities.
Skull X-ray: silver-beaten appearance.
Clinical Evaluation
History:
1. Prenatal: e.g. history of infection, drug intake or exposure of irradiation.
2. Natal: e.g. obstructed delivery.
3. Postnatal: e.g. meningitis.
4. Motor and cognitive development (mental retardation is a common
association).
5. Family history may be positive in familial cases.
Examination:
1. Measure head circumference at birth; small circumference denotes
intrauterine insult. Serial measurements are more important.
2. Associated dysmorphic features and congenital anomalies.
3. Detailed neurological examination.
Investigations:
1. X-ray: small sized head.
2. Craniostenosis: small malformed cranium with silver beaten appearance
3. True microcephaly: small cranium.
32
4. Karyotyping: a test to examine chromosomes in a sample of cells. This test
can help identify genetic problems as the cause of a disorder or disease.
5. TORCH screening (a group of blood tests that detect the presence of
antibodies produced by the immune system in response to these infections):
CMB or Toxoplasmosis.
6. Magnetic resonance imaging (MRI) to determine the degree of structural
abnormalities of the brain (brain atrophy, intracranial calcifications with
Toxoplasmosis and CMV).
33
PUBERTY
Definition
Puberty is period of life characterized by morphological and physiological
changes, which occur in the growing boy or girl as the gonads change from their
infantile to adult state.
Age of onset of puberty:
It varies according to genetic, racial, socioeconomic and nutritional factors.
In developed countries: it is 9-14 years in boys and 8-13 years in girls.
Principle manifestations of puberty:
The adolescent growth spurt: acceleration followed by a deceleration of
growth, terminated by epiphyseal fusion and final adult stature.
Development of gonads.
Development of secondary sexual characters.
Stages of Puberty
There are several stages of puberty (Figure 1). A child goes through many
physical and internal changes during the various stages of puberty.
Sexual Maturity
Breast development (girls): controlled by estrogen (Table 1).
Pubic hair (girls): controlled by adrenal androgen (Table 2).
Axillary hair (controlled by adrenal androgen): males and females are the
same (Table 3).
34
Testicular volume (measured by orchiodemeter), penis and pubic hair (boys)
(Table 4): the growth of tests and penis usually correlates with pubic and
axillary hair (both features under androgen control).
Table (1): Stages of breast development (girls).
Stage Characteristics
1 Preadolescent: elevation of papilla only.
2 Breast bud stage: elevation of breast and papilla as a small mound,
enlargement of the areolar diameter.
3 Further enlargement of breast and areola with no separation of their
contours.
4 Projection of areola and papilla to form a secondary mound above the
level of the breast.
5 Mature stage: projection of nipple – areola of general breast contour.
Table (2): Stages of pubic hair development (girls).
Stage Characteristics
1 Preadolescent: no pubic hair.
2 Sparse growth of pubic hair appearing mainly along the labia.
3 Hair is darker and spread over pubis.
4 Hair is adult in type (coarse and curly)
5 Hair is adult in type and quantity, distributed as an inverse triangle.
35
Table (3): Stages of axillary hair development (boys and girls).
Stage Characteristics
1 No axillary hair
2 Appearance of axillary hair.
3 Adult types
Table (4): Stages of testicular volume development (boys).
Stage Characteristics
1 Preadolescent testicular size 1,2,3 – preadolescent penis size
Preadolescent: no pubic hair.
2 Testicular volume 4 – slight enlargement of the penis.
Sparse growth of pubic hair mainly at the base of penis.
3 Testicular volume 5,6,7 – longer penis.
Hair is darker and spreads over the junction of pubis.
4 Testicular volume 8, 10 –further growth of penis.
Hair is adult in type.
5 Testicular volume 15 – adult size penis.
Hair is adult in quantity and type, spreads to the medial thighs.
36
Figure (1): Stages of puberty.
37
Disorders of Puberty
Disorders of puberty can profoundly impact physical and psychosocial well-
being. There are two main types of puberty disorders that may affect a child:
precocious puberty and Delayed puberty.
[I] Precocious Puberty
Definition:
Precocious puberty is when a child's body begins puberty too soon. When
puberty begins before age 8 in girls and before age 9 in boys, it is considered
precocious puberty.
Types:
1. Normal Variant:
a) Premature thelarche in girls
Simple breast development at the age of 1 – 4 years.
No other signs of puberty and it regresses spontaneously.
Both growth velocity and bone age are normal.
It should be distinguished from precocious puberty in girls.
b) Gynecomastia in boys (breast enlargement)
The commonest cause in pubertal gynecomastia that occurs in 30 – 60%
of boys at time of puberty.
It should be differentiated from local causes (tumors or excess fat) or
hormonal causes that may lead to breast enlargement in boys.
c) Premature adrenarche (premature pubarche)
Development of pubic and axillary hair before the age of puberty due to
earlier maturation of adrenal androgens.
38
If it is associated with growth acceleration or occurs in a child less than 6
years, congenital adrenal hyperplasia or and adrenal tumor must be
excluded.
2. True Precocious Puberty (central) (Gonadotropin dependent)
Characters:
It involves hypothalamic-pituitary gonadal activation.
High gonadotropin level.
It involves both secondary sexual characters and increase in the size and
activity of the gonads.
Spermatogenesis occurs in male and ovulation occurs in female.
Etiology:
Idiopathic (mainly in girls): the commonest.
Secondary (commoner in boys) such as:
Brain tumors – hydrocephalus.
Trauma and radiotherapy.
3. Pseudo Precocious Puberty (Gonadotropin independent)
Characters
It does not involve hypothalamic pituitary activation.
Normal gonadotropin level (prepubertal).
It involves only secondary sexual characters, gonads don‘t increase in size.
Spermatogenesis in male and ovulation in female don‘t occur.
Etiology
Ovarian tumors or excess estrogen in girls.
Testicular tumors or excess androgens in boys.
39
[II] Delayed Puberty
Definition:
Delayed puberty is failure to develop secondary sexual characters by 13
years in girls and 14 years in boys.
Types:
1. Hypogonadotropic hypogonadism
Characters
Low concentration of pituitary gonadotropin (FSH, LH)
Low testosterone in males and low estradiol in females.
Etiology
CNS tumors or radiation.
Head trauma.
2. Hypergonadotropic hypogonadism
Characters
High concentration of pituitary gonadotropin (FSH, LH).
Low Testosterone in males and low Estradiol in females.
It is a primary gonadal failure.
Etiology
Turner (45XO) the most common cause in girls.
Klinefelter syndrome (47XXY) the most common in boys.
Undescended testes.
Orchitis such as mumps.
Trauma.
Radiation.
3. Constitutional delay of growth and puberty: see short stature.
40
PRENATAL DEVELOPMENT
The changes that transform a fertilized egg into a newborn human make up
prenatal development. Prenatal development takes an average of 38 weeks, which
are divided into three stages: the period of the zygote, the period of the embryo,
and the period of the fetus. Each period gets its name from the term used to
describe the baby-to-be at that point in prenatal development.
Stages of Prenatal Development:
1. Period of the Zygote (germinal stage) (Weeks 1–2)
2. Period of the Embryo (embryonic stage) (Weeks 3–8)
3. Period of the Fetus (fetal stage) (Weeks 9–38)
1. Germinal Stage (Weeks 1–2)
Figure (1) traces the major events of the first period of prenatal
development, which begins with fertilization and lasts about two weeks. It ends
when the fertilized egg, called a zygote, implants itself in the wall of the uterus.
During these two weeks, the zygote grows rapidly through cell division and
travels down the fallopian tube toward the uterus. Within hours, the zygote divides
for the first time; then division occurs every 12 hours.
Occasionally, the zygote separates into two clusters that develop into
identical twins. Fraternal twins, which are more common, are created when two
eggs are released and each is fertilized by a different sperm cell.
After about four days, the zygote consists of about 100 cells, resembles a
hollow ball, and is called a blastocyst.
By the end of the first week, the zygote reaches the uterus. The next step is
implantation that the blastocyst implants itself into the uterine wall and establishes
41
connections with the mother‘s blood vessels. Implantation takes about a week to
complete and triggers hormonal changes that prevent menstruation, letting the
woman know she become pregnant.
Although the implanted blastocyst is less than a millimeter in diameter, its
cells begin to differentiate and form different layers of cells. A small cluster of
cells near the center of the blastocyst, the germ disc eventually develops into the
baby. The other cells are destined to become structures that support, nourish, and
protect the developing organism. The layer of cells closest to the uterus becomes
the placenta, a structure for exchanging nutrients and wastes between the mother
and the developing organism.
Figure (1): Germinal stage of prenatal development.
42
2. Embryonic Stage (Weeks 3– 8)
After the blastocyst is completely embedded in the uterine wall, it is called
an embryo. This new period typically begins the third week after conception and
lasts until the end of the eighth week.
During the period of the embryo, body structures and internal organs
develop. At the beginning of the period, three layers form in the embryo:
1. The outer layer (ectoderm) will become hair, the outer layer of skin, and the
nervous system.
2. The middle layer (mesoderm) will form muscles, bones, and the circulatory
system.
3. The inner layer (endoderm) will form the digestive system and the lungs.
The growth and specialization precede so rapidly that the 8-week-old
embryo becomes very different that before and we can see an eye, the jaw, an arm,
and a leg. The brain and the nervous system are also developing rapidly, and the
heart has been beating for nearly a month. Most of the organs found in a mature
human are in place, in some form (The sex organs are a notable exception).
Being only an inch long and weighing a fraction of an ounce, the embryo is
much too small for the mother to feel its presence.
The embryo rests in an amniotic sac, which is filled with amniotic fluid that
cushions the embryo and maintains a constant temperature. The embryo is linked
to the mother by two structures:
1. The umbilical cord that contain blood vessels that join the embryo to the
placenta.
2. The placenta where the blood vessels from the umbilical cord run close to
the mother‘s blood vessels but aren‘t actually connected to them. Instead, the
blood flows through villi, finger-like projections from the umbilical blood
43
vessels (Figure2). Villi lie in close proximity to the mother‘s blood vessels
and thus allow nutrients, oxygen, vitamins, and waste products to be
exchanged between mother and embryo.
Figure (2): Embryonic stage of prenatal development.
3. Fetal Stage (Weeks 9– 38)
The final and longest phase of prenatal development, the period of the fetus,
extends from the ninth week after conception until birth. During this period, the
baby-to-be becomes much larger and its bodily systems begin to work. The
increase in size is remarkable.
At the beginning of this period, the fetus weighs less than an ounce (about
28 grams). At about 4 months, the fetus weighs roughly 4 to 8 ounces, enough for
the mother to feel it move. Pregnant women often describe these fluttering
movements as feeling like popcorn popping or a goldfish swimming inside them.
During the last 5 months of pregnancy, the fetus gains an average of an
additional 7 or 8 pounds before birth.
44
During the fetal period, the finishing touches are put on the body systems
that are essential to human life, such as the nervous, respiratory, and digestive
systems.
By 22 to 28 weeks most systems function well enough that a fetus born at
this time has a chance to survive. However, babies born this early have trouble
breathing because their lungs are not yet mature. They cannot also regulate their
body temperature very well because they lack the insulating layer of fat that
appears in the eighth month after conception. With modern neonatal intensive care,
infants born this early can survive.
Methods of Prenatal Diagnosis
Prenatal diagnosis means diagnosis before birth. It's a way for your doctor to
see if your developing baby has a problem (Table 1).
Table (1): Methods of Prenatal Diagnosis
Procedure Description Primary Uses
1. Ultrasound Sound waves used to
generate an image of
the fetus.
Determine due date and
position of fetus in
uterus; check for
physical deformities,
multiple births, and
child‘s sex
2. Amniocentesis Sample of fetal cells is
obtained from
amniotic fluid.
Screen for genetic
disorders
3. Chorionic villus
sampling (CVS) Sample of tissue is
obtained from the
chorionic (part of the
placenta).
Screen for genetic
disorders.
45
Factors affecting Prenatal Development:
Maternal age (negatively affect development if mom is an adolescent or over
the age of 35).
Emotional states and stress (when a pregnant woman experiences intense
tears, anxieties and other emotions).
Drugs (some drugs are allowed during pregnancy).
Alcohol
Cigarettes
Chemicals
Disease
Poor nutrition
Prematurity and low birth weight
Babies born before the 37th week of pregnancy are considered premature.
Babies who weigh less than 2500 grams (about 5½ pounds) are considered
low birth weight (LBW). Most of these babies are premature. However,
other conditions can cause LBW in a baby born after a full-term pregnancy,
such as smoking during pregnancy. Some babies with LBW are full term but
underweight. Others are premature but also weight less than they should.
Babies who weigh less than 1500 grams (about 3⅓ pounds) are considered
very low birth weight (VLBW). Nearly all of these babies are premature.
Prematurity can cause many types of health problems. The problems are
related to the fact that many of baby‘s organs and basic body systems aren‘t
46
yet fully mature, these problems include breathing problems, damage to the
brain and nervous system, and feeding problems.
Mildly premature infants usually have few or no problems.
Treatment of premature infants has improved steadily over the years. Today,
with advanced neonatal (newborn) intensive care unit (NICU) care,
specialized equipment, and expert care from nurses and neonatologists
(doctors specializing in the care of sick newborns), most premature infants
have an excellent chance of survival.
47
DEVELOPMENT AND AGING OF BODY SYSTEMS
Skeletal System
Early in embryonic life, the skeletal system exists as a "cartilage model'' of
the bones. At the fetal age of 2 months, primary ossification centers appear in the
mid portions of the long bones such as the humerus (upper arm) and femur (thigh)
and begin to form bone cells. The bone shafts ossify outward in both directions
from these primary centers until the entire shafts are ossified at birth.
Postnatal bone growth in length occurs at a secondary ossification center at
each end of the shaft, termed the epiphyseal plate or growth plate (Figure 1).
Growth at the ossification centers ceases at different times in various bones. At the
epiphyseal plates, the cartilage zone eventually disappears, and the shaft, or
diaphysis, of the bone fuses with the epiphysis, this usually occurs at a younger age
in girls than in boys. Once the epiphyseal plates of a long bone fuse, the length of
the bone is fixed. Almost all epiphyseal plates are closed by age 18 or 19.
Though the long bones are growing in length, they also increase in girth, a
process called oppositional growth. This is achieved by the addition of new tissue
layers under the periosteum (a very thin outer covering of the bone). The shaft of a
long bone is narrower than the ends. Therefore, the bone must be reshaped as it
grows in length through a resorption process in the metaphyseal region between
the diaphysis (shaft) and epiphysis.
48
Figure (1): Bone growth.
Skeletal injuries during growth:
Injuries to the growing skeleton rarely have a lifelong impact. In a young
body, for example, broken bones typically heal quickly and efficiently. The
potential exists, though, for severe injury to the epiphyseal plate, result in the early
cessation of growth at the site. A significant difference in the eventual length of the
right and left limbs is possible if the injury occurs early in the growth period.
Skeletal system in older adults
Older adults suffer from a major bone mineral disorder, osteoporosis, that is
characterized by a loss of bone mass and, consequently, bone strength. This
condition increases the risk of fractures, especially at the hip, and adds to the
difficulty of fracture repair.
Prolonged deficiency of calcium in the diet is a major factor in osteoporosis;
deficient osteoblastic activity might be involved. In postmenopausal women,
49
decreased levels of estrogen are implicated because estrogen hormones stimulate
osteoblastic activity. This might account for the higher incidence of osteoporosis in
older adult women than in men. Treatments for osteoporosis include dietary
supplements of calcium, vitamin D, and fluoride.
Evidence also indicates that physically active women, both pre and
postmenopausal, have significantly less osteoporosis and bone loss than sedentary
women have. When a person engages in physical activity, the mechanical forces
applied to the bones help to maintain bone thickness and density. Even moderate
physical activity prevents bone loss in adults and increases bone mineral content in
older adults.
Muscular System
Muscle fibers (cells) grow during prenatal life by hyperplasia, an increase in
the number of muscle cells, and by hypertrophy, an increase in muscle cell size.
Hyperplasia continues for a short time after birth, but thereafter muscle growth
occurs predominantly by hypertrophy.
Increases in muscle fiber diameter come with age and increased body size
but are related also to the intensity of activity to which the muscle is subjected
during growth. Naturally, muscles must increase in length as the skeleton grows,
and this occurs by the addition of sarcomeres at the muscle-tendon junction as well
as by the lengthening of the sarcomeres (Figure 2).
Gender differences in muscle mass and number of fiber nuclei are minimal
during childhood, with muscle mass constituting a slightly greater proportion of
body weight in boys. During and after adolescence, however, gender differences
50
are marked. Muscle mass increases rapidly in boys up to about age 17 but girls add
muscle mass only until age 13. The large gender differences in muscle mass
involve upper body musculature more than leg musculature. For example, the rate
of growth in arm musculature is nearly twice as high for males as for females, but
the difference in calf muscle growth is relatively small which is related to
hormonal influences.
Figure (2): Structure of the skeletal muscle.
Muscular system in older adults
In young adult, the percentage of muscle weight decreases. This does not
reflect a loss of muscle but an increase in fat weight. Changes in diet and physical
activity level are probably responsible for this shift. In old age, both the number
and the diameter (size) of muscle fibers appear to gradually decrease and by very
old age, an individual can lose as much as 50% of the muscle mass possessed in
young adulthood.
51
Adipose System
A common misconception about adipose (fat) tissue is that its presence in
any amount is undesirable. In reality, adipose tissue plays a vital role in energy
storage, insulation, and protection, and the amount of adipose tissue necessarily
increases in early life. Adipose tissue first appears in the fetus at 3.5 months and
increases rapidly during the last 2 prenatal months.
Fat weight during growth increases by both hyperplasia and hypertrophy, but
cell size does not increase significantly until puberty. Many factors could affect the
development of adipose tissue, including maternal weight gain during pregnancy,
early infant feeding, and genetic factors.
The two periods when the number of adipose cells is increasing are during
the first 6 postnatal months, and around puberty. Increases in cell number are
significant because once they are formed, adipose cells persist, even with
malnutrition; that is, the cells may be "empty" of fat, but they still exist. Therefore,
these two periods may be critical in the control of obesity.
Adipose tissue in older adults
Both sexes tend to gain fat weight during the adult years, reflecting changes
in nutrition and activity level. Total body weight begins to decline after age 50, but
this may reflect loss of bone and muscle rather than fat.
52
Endocrine System
Hormones have an important role in regulating growth and maturation.
Growth Hormone
Growth hormone (GH) influences growth during childhood and adolescence
by stimulating protein anabolism so that new tissue can be built. Under the control
of the central nervous system, GH is secreted by the anterior pituitary gland. A
deficiency or absence of GH results in growth abnormalities and in some cases the
cessation of linear growth.
Thyroid Hormones
The thyroid hormones are secreted by the thyroid gland, located in the
anterior neck region. Triiodothyronine (T3) and Thyroxine (T4) influence whole
body growth after birth also Thyrocalcitonin plays a role in skeletal growth by
promoting calcium deposition in bone.
N.B:
The level of thyroid-stimulating hormone (TSH) which secreted from
pituitary glands regulates the secretion of the thyroid hormones.
Gonadal Hormones
The gonadal hormones affect growth and sexual maturation, particularly
during adolescence by stimulating development of the secondary sex
characteristics and the sex organs.
53
Insulin
Insulin has an indirect role in growth. Produced in the pancreas, insulin is
vital to carbohydrate metabolism, stimulating the transportation of glucose and
amino acids through membranes. Its presence also is necessary for the full
functioning of GH.
Endocrine system in older adults
Growth hormone levels seem to be stable throughout life, but during
exercise, older adults can have a more pronounced increase in GH levels
than younger exercisers.
Thyroid function also declines with aging, and thyroid disorders become
more prominent with aging.
Gonadal hormone levels decrease with age. Hormonal supplements have
been successful in countering muscle wasting and osteoporosis in older
adults.
Older adult maintains the younger adult secretion level of insulin, but the
incidence of type II diabetes increases with age.
Nervous System
Early nervous system development is genetically directed. Proliferation and
migration of cells occur prenatally, and cell arborization (branching) and
myelination (an insulating process) take place postnatally.
54
Early development
The critical periods of rapid development occur early in life, prenatally and
during the first year after birth, but nervous system development continues through
puberty (some myelination may occur as late as young adulthood).
N.B:
Plasticity is the ability of neural cells to take on a new function in the event
of trauma.
Brain
Neurons of the brain are formed prenatally, the rapid gains in brain weight
during the first postnatal year by two process:
1. An increase of myelin and glial cells (which support and nourish the
neuron).
2. An increase in the size of neurons and their arborization, or branching.
Lower brain centers
The spinal cord and lower brain structures are more advanced at birth than
the higher brain structures. Those lower brain centers involved in vital tasks, such
as respiration and food intake, are relatively mature and mediate many reflexes and
reactions. These automatic movement responses dominate the fetus's and
newborn's movements.
Myelin
The development of myelin in the nervous system contributes to speedy
conduction of nerve impulses. Myelin cells, composed mostly of fat, wrap
themselves around the outgoing neuron cell process, or axon. The myelin sheath is
55
interrupted periodically by nodes (called nodes of Ranvier) (Figure 3). The neuron
cell membrane is involved in nerve impulse conduction only at the nodes, so the
impulse jumps from node to node. This type of nerve impulse conduction is known
as saltatory conduction, and it is much faster than conduction in non-myelinated
axons. Axons that are as yet unmyelinated in the newborn are probably functional,
but myelination improves the speed and frequency of firing.
A marked increase in the myelination of these peripheral nerves occurs 2 to
3 weeks after birth, and this process continues through the 2nd
or 3rd
year of life.
Myelination proceeds in two directions in the cord: first in the cervical portion,
followed by the progressively lower portions; and then in the motor (ventral)
horns, followed by the sensory (dorsal) horns.
Figure (3): Structure of the neuron.
56
Nervous system in older adults
With ageing, the number of neurons in the nervous system, including the
cerebral cortex decreases. This results in decreased brain weight by old age. This
decrease might be related to a gradual reduction in circulation and in oxygen
utilization in the brain. An older adult can experience these effects as a general
slowing of sensory and motor functions.
Conclusion
Growth is more susceptible to external influence during periods of rapid change.
Some external or environmental influences can be positive and help persons attain
their full growth potential. Others can retard growth or permanently affect growth
and maturation.
57
DEVELOPMENTAL ABNORMALITIES
I. Delayed Motor Development
Delayed motor development is considered when the infant acquires the
motor skills at a time beyond the expected normal range for an example the infant
may support his head at 5 or 6 months instead of 3 months.
Causes:
Mental retardation (genetic or non-genetic).
Chronic systemic illness (chronic chest – cardiac – intestinal – hepatic or
renal).
Growth environmental neglect (rickets – malnutrition – repeated illness).
Cerebral palsy (CP).
Limits for the diagnosis of delayed motor development:
Delayed head support: no head support up to the age of 5 months.
Delayed setting: delayed head support and no sitting up to the age of 10
months.
Delayed standing: delayed head support and sitting with no standing up to
the age 15 months.
Delayed walking: no walking up to the age of 18 months.
Clinical evaluation of infants with delayed motor development should
include assessment of mental development, search for chronic systemic illness and
gross environmental neglect.
58
1. Mental retardation: infants with mental retardation always have a delayed
motor development but the reverse is not true (i.e. delayed motor
development may occur despite normal mental development).
2. Chronic systemic illness: it is important to exclude a chronic systemic
disease for instance, congenital cyanotic heart disease, chronic liver or renal
disease that are commonly associated with growth failure (underweight) and
delayed motor development. Chronic renal failure and renal tubular acidosis
should not be missed in any patient presenting with failure to thrive and
delayed motor development.
3. Gross environmental neglect: rickets and malnutrition are common causes in
low socio-economic classes. Delayed motor development is simply caused
by repeated exposure to infections as repeated gastroenteritis and repeated
chest infections.
4. Cerebral palsy: delayed motor development is a common presentation of CP.
Persistence of primitive neonatal reflexes and exaggerated tendon reflexes
are the most characteristic features. Muscle tone may be increased (spastic
type) or decreased (atonic type). Mental retardation and epilepsy may or
may not be present.
II. Mental Retardation
Mental retardation is one of the most handicapping disorders in pediatric
practices. It is estimated that 3% of population are retarded. Fortunately, the great
majority of them have only mild retardation. Mental retardation can be defined
as cognitive ability that is markedly below average level and a decreased ability to
adapt to one's environment.
59
Causes
[A] Genetic causes
Chromosomal disorders:
Trisomy syndromes
Deletion syndromes
Sex chromosomal syndromes
Inborn error of metabolism:
Aminoacidopathies
Lipidosis
Mucopolysaccaridosis
Congenital brain anomalies:
Hydrocephalus
Spina bifida
Microcephaly
Neurocutaneous syndrome:
Tuberous sclerosis
Degenerative brain disease:
Degeneration of grey matter
Degeneration of white matter
[B] Non genetic causes
Prenatal causes:
Congenital infections
Congenital hypothyroidism
Radiation
Perinatal and neonatal causes:
Hypoxic ischemic encephalopathy
60
Intracranial haemorrhage
Meningitis
Hypoglycaemia
Postnatal causes:
Post-meningitis
Post-encephalitis
Post-traumatic
Post-hypoxic
Status epilepticus
Hypoglycaemic coma
Hypernatremic dehydration
There are two groups of mental retardation: environmental and organic.
Environmental or subcultural retardation: it occurs for 90% of cases and the
retardation is only mild. No organic cause can be identified, and most cases
belong to low socio-economic classes where many factors cooperate
including malnutrition, infection, poor medical care, lack of good relations
and minimal chance for good education.
Organic retardation: 10% of cases and the retardation is moderate, severe
and profound. The incidence in low and high social classes is the same. The
cause cannot be identified in more than 50% of the cases.
Diagnostic clues for the diagnosis of organic causes of mental retardation:
History:
Prenatal, natal and postnatal events (non-genetic retardation).
Family history for other affected siblings (genetic retardation).
61
Examination:
Abnormal features: chromosomal diseases.
Failure to thrive or abnormal odour of urine: aminoacidopathy.
Eye defects as Cataract: Galactosemia or congenital Rubella.
Congenital heart: chromosomal or congenital Rubella.
Hepatosplenomegaly: congenital infections or Galactosemia.
Microcephaly or macrocephaly.
How to diagnose mental retardation?
Mental retardation is considered when there is gross deviation from the
normal mental development.
In infancy, the main clinical finding is the delayed social development.
Delayed social smile for more than 3 months, delayed laughing for more
than 6 months and delayed recognition of mother for more than 9 – 10
months are signs of retardation. Delayed motor development is always
present as an associated finding.
In early childhood, the most common evident feature is the delayed speech.
The condition is usually associated with delayed sphincteric control.
In late childhood, the main manifestations are learning difficulties and
school underachievement. In this case, acquired hypothyroidism should be
routinely excluded.
As the diagnosis of mental retardation is very traumatic to parents, a more
experienced person should be consulted first. Mental retardation should not be
confused with other conditions presenting with similar features (Table 1).
62
Table (1): Conditions which should not be confused with mental retardation.
Period Conditions
Infancy Delayed social development due to blindness (evaluate vision).
Delayed motor development due to other causes.
Early
childhood
Delayed speech due to deafness (evaluate hearing).
Speech disorders are stuttering.
Late
childhood
School underachievement due to environmental factors.
Learning difficulties due to minimal brain dysfunction (or
attention deficit-hyperactivity syndrome).
Attention deficit- hyperactivity syndrome (ADHS):
It is a common behavioural disorder occurring in 5-10% of school age
children. It is characterized by poor school performance and hyperactivity. These
children are commonly aggressive towards others and emotionally labile with
frequent mood fluctuations. The male/female incidence is 10:1.
What is the degree of retardation?
The degree of retardation can be simply assessed by considering the onset at
which the clinical manifestations appear:
1. Profound and severe retardation: they are discovered in infancy by the
delayed social development. Children with profound retardation need a total
supervision, while those with severe retardation can learn a minimal self-
care. Obliviously these children will not join the ordinary school.
2. Moderate retardation: it is usually discovered in early childhood by delayed
speech. These children also will not join the ordinary school.
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3. Mild retardation: it is usually discovered in late childhood by the school
underachievement and poor learning ability. Most of these children do not
finish the primary education.
The diagnosis should be confirmed by assessment of the intelligence
quotient (IQ) (Table 2). Several tests are available for different ages. The two
commonly used are Stanford-Binet Test and Wechsler Intelligence Scale for
Children (WISC). These two tests are suitable for school age children. For
preschool children; modified Stanford-Binet Test and Wechsler Preschool and
Primary Scale for Children (WPPSI) can be used.
Table (2): Degree of mental retardation by intelligence quotient (IQ).
Degree IQ Remarks
Mild 70 – 51 Need (special class placement)
Moderate 50 – 36 Need (classes for trainable retarded)
Severe 35 – 20 Can learn (a minimal self-care)
Profound Below 20 Need (total supervision)
IQ equals the estimated mental age *100 / chronological age.
What are the investigations to be done?
CT brain.
Screening test such as: T3 and T4 for hypothyroidism, urine reducing
substance in Galactosemia, urine Ferric Chloride test for phenylketonuria.
64
MATURATION of REFLEXES
Definition
A reflex is an involuntary response to an external stimulus, usually to protect
the body. Reflex is a physical non-conscious action.
Difference between reflex and reaction
Reflex is a relatively stereotyped movement or response elicited by a
stimulus applied to the periphery, transmitted to the central nervous system
and then transmitted back out to the periphery. It is an involuntary response
to an external stimulus, usually to protect the body.
A reaction is a voluntary response to an external stimulus and can be trained
to become faster through regular practice. It is a feeling or action in response
to something that has happened.
Importance of reflexes
1. Movement form:
Reflexes are the dominant form of movements from the last four prenatal
months to the first four postnatal months.
2. Survival function:
Human infants essentially helpless. Highly dependent on their caretakers
and reflexes for protection and survival.
Primitive reflexes occur during gestation or at birth and most are
repressed by six months of age.
65
An example is the rooting reflex, which helps breastfed infants to find the
mother's nipple. Babies display it only when hungry and touched by
another person, not when they touch themselves.
Some reflexes serve protective functions i.e. protect body harm, for
example, eye-blink reflex and flexor withdrawal.
3. Developmental function
Reflex integration is essential for normal development. Postural reflexes
believed to be foundation for later voluntary movements.
Response to the reflexes prepares the infant for progressive development
such as rolling over, sitting, crawling, standing, etc (Table 1).
4. Diagnostic function
The presence and strength of a reflex is an important sign of nervous
system development and function. They could determine level of
neurological maturation by their weakness, absence or excessive strength.
Reflexes are age-specific in normal, healthy infants. Therefore, any
deviations from normal time frame may indicate neurological immaturity
or dysfunction.
Example; bilateral absence of Moro reflex may indicate damage to the
CNS while a unilateral absence could indicate an injury due to birth
trauma such as a fractured clavicle or injury to the brachial plexus.
5. Therapeutic function
Some reflexes could be utilized in therapeutic programs for children with
developmental disorders.
Example; postural reactions are used to promote the upright posture.
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Table (1): Developmental functions of reflexes.
Reflex Future Motor Development
Neck righting Rolling
Labyrinthine righting Upright posture
Palmar grasp Grasping
Classification of reflexes
There are main four categories for classification of reflexes:
I. According to the level of CNS maturation.
II. According to their relation to the normal sequence of motor development.
III. According to the type of stimulus.
IV. According to the time of positive response.
I. According to the level of CNS maturation:
1. Spinal reflexes.
2. Brainstem reflexes.
3. Midbrain reflexes.
4. Cortical reactions.
1. Spinal Reflexes
They are ―phasic‖ or movement reflexes that coordinate muscles of the
extremities in patterns of either total flexion or extension.
There may be a positive or a negative response within the first two months
of life. However, positive response after two months of life may be one
indication of delayed reflexive maturation.
67
Complete domination by these primitive spinal reflexes results in a
pedal (prone, supine-lying) creature.
Positive reaction persisting beyond two months of age may be indicative of
delayed maturation of the CNS.
They include flexor withdrawal reflex, extensor thrust and crossed extension
reflexes.
Flexor withdrawal reflex:
Test position: supine with the head in midline and extended legs.
Test stimulus: a noxious stimulus to sole of foot.
Positive response: uncontrolled flexion of the stimulated leg (withdrawal of
foot from stimulus employing hip and knee flexion) (Figure 1).
Negative response: controlled maintenance of stimulated leg in extension or
volitional withdrawal from the irritating stimulus.
Developmental significance: failure to attain and integrate this reflex may
indicate sensorimotor delay and/or CNS depression.
It is mainly to protect the body from damaging stimuli. It is a common
cutaneous reflex consisting of a widespread contraction of flexor muscles
and relaxation of extensor muscle and is characterized by abrupt withdrawal
of a body part in response to painful or injurious stimuli. A relatively
innocuous stimulation of the skin may result in a weak contraction of one or
more flexor muscles and a minimal withdrawal reflex
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Figure (1): Flexor withdrawal reflex.
Extensor thrust reflex:
Test position: supine with the head in midline. One leg in extension and the
opposite is in flexion.
Test stimulus: a noxious stimulus to sole of foot of the flexed leg.
Positive response: uncontrolled extension of the stimulated leg.
Negative response: controlled maintenance of leg in flexion.
Developmental significance: failure to attain and integrate this reflex may
indicate sensorimotor delay and/or CNS depression.
Crossed extension I:
Test position: supine with the head in midline. One leg is flexed, and the
opposite leg is extended.
Test stimulus: passive flexion of the extended leg.
Positive response: on flexion of the extended leg, the opposite or initially
flexed leg will extend.
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Negative response: on flexion of the extended leg, the opposite leg will
remain flexed.
Developmental significance: its persistence could interfere with the
reciprocal kicking and later functional activities.
Crossed extension II:
Test position: supine with the head in midline and lower extremities
extended.
Test stimulus: the therapist stimulates the medial surface of one leg by
tapping.
Positive response: opposite leg adducts, internally rotates and foot plantar
flexes (Typical scissor position).
Negative response: no response of either lower extremity upon stimulation.
Crossed extension III:
Test position: supine with the head in midline and lower extremities
extended (Figure 2).
Test stimulus: the examiner holds one lower extremity at the knee,
maintaining the extremity in extension (above the knee). Then apply firm
pressure to the ball of foot.
Positive response: flexion/abduction and then adduction/extension of
opposite lower extremity as if to push the examiner's hand away.
Negative response: no response of either lower extremity upon stimulation.
Developmental significance:
Asymmetry may indicate insult to one side of the brain, injury to
peripheral nerves of the extremity, or muscle weakness.
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Protective reflex which reappears if needed (Example: steps on broken
glass).
Persistence after 4-5 months will cause a lack of good reciprocal
movements in the lower extremities, and later will interfere with walking.
Figure (2): Crossed extension III reflex.
2. Brainstem Reflexes
They are static ―tonic‖ reflexes in which there is a change in distribution
of muscle tone throughout the body, either in response to a change in the
position of head and body in space, or in the head in relation to the body.
Positive or negative responses may be present in the normal child within the
first four to six months of life.
Positive reactions persisting beyond its normal age limit may be indicative
of delayed motor maturation of the CNS.
Complete domination of these reflexes results in a pedal (prone and supine)
creature.
71
They include asymmetrical tonic neck reflex (ATNR), symmetrical tonic
neck (STNR), tonic labyrinthine reflex, positive supporting reaction,
negative supporting reaction and associated reactions.
Asymmetrical tonic neck reflex:
Test position: supine with the head in midline and both upper and lower
extremities extended.
Test stimulus: the child's head is turned to one side.
Positive response: extension of arm and leg on facial side (an increase in
extensor tone) with flexion of arm and leg on occipital side (a decrease in
the extensor tone) (Figure 3).
Negative response: no response of limbs on either side.
Developmental significance:
It is a precursor to the hand/eye coordination of the infant.
It also prepares the infant for voluntary reaching.
Its persistence interferes with feeding, visual tracking, midline hands use,
bilateral hand use, rolling and crawling.
Its persistence can lead to skeletal deformities such as scoliosis.
Figure (3): Asymmetrical tonic neck reflex.
72
Symmetrical tonic neck reflex:
This reflex has two opposite stimuli with two opposite responses (Figure 4).
Test position: Infant is placed in ventral over the examiner‘s knee or hand
supporting his/her trunk (Quadruped position).
Test stimulus: passive flexion or extension of the head.
Positive response: with flexion of the head, there will be flexion of both
upper extremities (increase of the flexor tone) and extension of both lower
extremities (increase of the extensor tone) while with extension of the head
there will be extension of both upper extremities (increase of the extensor
tone) and flexion of both lower extremities (increase of the flexor tone).
Negative response: no change in the tone of both upper and lower
extremities.
Developmental significance: its persistence interferes with:
Ability to prop on arms in prone position.
Attaining and maintaining hands and knees position.
Crawling reciprocally.
Sitting balance when looking around.
Use of hands when looking at object in hands in sitting position.
Figure (4): Symmetrical tonic neck reflex.
73
Tonic labyrinthine reflex:
This reflex has two test stimuli (Figure 5):
TLR (I)
Test position: supine position.
Test stimulus: supine position itself.
Positive reaction: extensor tone dominates, and when the upper and lower
extremities passively flexed, motion is restricted due to the increased
extensor tone.
Negative reaction: no tone change.
Developmental significance: its persistence interferes with:
Activities which require graded co-activation of flexor and extensor
muscles.
Ability to flex trunk and hips to come to sitting position from supine
position.
Rolling, sitting or standing as it causes full body extension.
TLR (II)
Test position: prone position.
Test stimulus: prone position itself.
Positive reaction: flexor tone dominates, and when limbs passively extend,
motion is restricted due to increased flexor tone.
Negative reaction: No tone change
Developmental significance: it impedes the activities which require graded
co-activation of flexor and extensor muscles. Therefore, its persistence
interfere with:
Ability to initiate rolling.
Ability to prop on elbows with extended hips when prone.
74
Figure (5): Tonic labyrinthine reflex.
Positive supporting reaction:
Test position: infant is held vertically, allowing feet to come into contact
with surface (Figure 6A).
Test stimulus: bouncing the infant several times on the soles of the feet.
Positive reaction: increase of the extensor tone in both legs and plantar
flexion of feet. Genu recurvatum may occur.
Onset/Integration: three / eight months.
Negative reaction: no increase of tone (legs volitionally flex)
Developmental significance: its persistence interferes with stable standing
and ambulation.
Negative supporting reaction:
Test position: Infant held vertically, allowing feet to come into contact with
surface.
Test stimulus: bouncing the infant several times on the soles of the feet or
just weight-bearing position ((Figure 6B).
75
Positive reaction: Increase in flexor tone to begin pre-walking skills, flexion
of one limb to begin to take a step.
Onset/Integration: after 8 months / it continues throughout life.
Negative reaction: stiff extensor tone is elicited, unable to break through to
take a step.
N.B.: normal reaction is sufficient to release of extensor tone to allow
flexion for reciprocation. The abnormal reaction is a continuation of positive
supporting reflex beyond eight months of age. A reaction of excessive
flexion on weight-bearing is abnormal beyond four months of age.
(A)
(B)
Figure (6): Positive (A) and negative (B) supporting reactions.
Associated reaction:
Test position: supine or sitting.
Test stimulus: hand grasp in younger children (have patient squeeze an
object), rapid arm movements in older children. With hemiplegic children,
squeeze an object with an uninvolved hand.
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Positive reaction: overflow of movement to the contralateral side (mirroring
of opposite limb and/or increase of tone in other parts of the body) should
decrease with age.
Onset/Integration: birth/three months, less common after 8-9 years.
Commonly seen in hemiplegic patients.
Negative reaction: no reaction, or minimal reaction or increase of tone in
other parts of the body.
Developmental significance: excessive build-up of movement, or tonal
increases in the opposite extremity indicate brain damage
3. Midbrain Reactions
These are the righting reactions that interact with each other and work
toward establishment of normal head and body relationship in space as well
as in relation to each other.
Their combined actions enable the child to roll over, sit up, get on his
hands and knees, and make him a quadrupedal creature
As cortical control increases, they are gradually modified and inhibited and
disappear towards the end of the fifth year.
They include neck righting, body righting acting on body, labyrinthine
righting, optical righting and amphibian reactions.
Neck righting reaction:
Test position: supine with the head in midline.
Test stimulus: head rotation (turning) to one side (actively or passively).
Positive reaction: log roll to the side lying position (body rotates as a whole
in the same direction as the head) (Figure 7).
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Onset/Integration: birth / six months.
Negative reaction: body will not rotate.
Developmental significance:
This reaction is needed for the child to roll from supine to side lying.
It may persist in some children until they are able to rise straight from
supine rather than rolling.
Asymmetry indicates insult to one side of the brain.
Figure (7): Neck righting reaction.
Body righting acting on body reaction
Test position: supine with the head in midline.
Test stimulus: head rotation (turning) to one side (actively or passively)
Immature response: body rotates as a whole (neck righting), and
not segmentally.
Mature response: segmental rolling of the lower body.
Onset/Integration: Four to six months / 18 months.
Developmental significance:
Asymmetry may indicate insult to one side of the brain.
This reaction directly modifies the neck righting reflex.
78
It is important in acquisition of sitting, quadruped, and standing.
This reaction could be stimulated by rotation of the hip of one side and the
mature response will be segmental rotation of the upper body (Figure 8).
Figure (8): Body righting acting on body reaction.
Labyrinthine & Optical righting acting on head reactions
Labyrinthine righting and optical righting serve to realign the head vertically
when the body is displaced and are mediated respectively by a vestibular and
visual system respectively.
Testing procedures are the same in both reactions; however, labyrinthine
righting is a test with blindfolded eyes (Table 2 and Figure 9).
Both reactions assist the child to maintain head and trunk alignment against
the pull of gravity.
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Table (2): Labyrinthine and optical righting reactions.
Prone Supine Vertical Suspension
Testing position
Hold child
prone in
space.
Hold child
supine in
space.
Hold child from around
pelvis in vertical suspension
in space.
Stimulus Prone in
space.
Supine in
space.
Tilt to the right (or to left).
Positive reaction
Head raises to normal position,
face vertical, mouth horizontal.
Head rights itself to normal
position, face vertical,
mouth horizontal.
Negative reaction
Head does not rise
automatically to the normal
position.
Head does not right itself
automatically to the normal
position.
Onset/Integration 1-2 months /
continue.
6 months /
continue.
6-8 months / continue.
Figure (9): Labyrinthine and optical righting acting on head reactions.
80
4. Cortical Reactions
These reactions are mediated by the efficient interaction of cortex, basal
ganglia and cerebellum.
Maturation of equilibrium reactions brings the individual to the human
bipedal stage of motor development.
They are responses to external disturbance (either placing child on unstable
surface, or manual displacement from stationary supporting surface).
Therefore, they are reactive or compensatory reactions.
They occur when muscle tone is normalized and provide body adaptation in
response to the change of center of gravity (COG) in the body. They emerge
from 6th month on in lower level positions (supine, prone) and continue to
develop in more upright positions during first 5 years of live.
The positive reaction at any one level indicates the next higher level of
motor activity possible.
They include equilibrium and protective reactions.
Equilibrium reactions:
They serve to return the child‘s body to a vertical position after
displacement.
They are stimulated by body titling or displacement (anterior, posterior,
lateral or diagonal).
They could be examined by the use of the tilting board.
The body response by the movement of both trunk and extremities that
oppose the displacement to bring the COG within the base of support (BOS).
Response to tilting:
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When the child is supine on tilting surface, a lateral tilt to the right elicits
righting of the head, trunk incurvature to the left (righting trunk) and
abduction of the left arm and leg.
When the child is in upright postures (e.g. sitting, kneeling, standing),
tilting interiorly or posteriorly results in corrective movement in opposite
direction to tilt (i.e., posterior displacement results in contraction of
abdominal, neck flexor, hip flexor, and hamstring to produce anterior
displacement), returning body to an upright position.
They emerge at different onset according to the position from which they are
tested and then continue throughout the life (Table 3 and Figure 10).
Example: dorsiflexion reaction (Table 4).
Table (3): Timing of the equilibrium reactions.
Position Onset (months)
Prone 6
Supine 6
Sitting 8
Four-foot kneeling 10-12
Kneel-standing 15
standing 15-18
Figure (10): Equilibrium reactions in sitting (A), quadruped (B) and standing
(C).
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Table (4): Equilibrium reactions in standing (dorsiflexion).
Position Holding the child in standing by supporting under axilla.
Stimulus Tilt the child backwards slightly while.
Response Righting of head and thorax forward, with foot dorsiflexion.
Onset/Integration 15-18 months / continue throughout the life.
Protective reactions:
Differ from equilibrium reaction in that they protect the body from a fall
rather than correct a displacement.
The amount of displacement required to elicit the protective reactions must
be greater in magnitude than used to elicit the equilibrium reactions.
The response is characterized by extension and abduction of the extremities
in the same direction of fall to protect the body from falling.
They emerge at different onset according to the position and direction from
which they are tested and then continue throughout the life (Table 5 and
Figure 11).
Example: hopping reaction (Table 6).
Table (5): Protective reactions from different positions.
Position Response Onset/Integration
Prone Protective extensor thrust 5-6 months / continue
Sitting Forward response
Lateral response
Backward response
6-7 months / continue
6-11 months / continue
9-12 months / continue
Standing Child will take a few staggering steps
in direction of push to regain balance.
15-18 months / continue
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Figure (11): Protective reactions forward (A), lateral (B) and backward (C).
Table (6): Hopping reaction.
Position Child in standing position. Hold by upper arms.
Stimulus Move to the left or to the right side / move forward / move
backward.
Positive response Righting of head and thorax, hopping steps sideways /
forward / backwards to maintain equilibrium and prevent
falling.
Negative response Head and thorax do not right themselves; no hopping steps
to maintain balance.
Onset/Integration 15-18 months / continue
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II. According to relation to the normal sequence of motor development
Reflexes could be classified according to the normal sequence of motor
development into (Table 7):
1. Apedal reflexes: predominance of primitive spinal and brainstem reflexes
with motor development of a prone or supine-lying creature.
2. Quadrupedal reflexes: predominance of midbrain development with
righting reactions and motor development that of a child, who can right
himself/herself, turn over, assume crawling and sitting positions.
3. Bipedal reflexes: at cortical level of development reveals equilibrium
reactions, with motor development that of a child who can assume the
standing position and ambulate.
Table (7): Relation among maturation of nervous system, reflexive
development and motor development.
Levels of CNS
maturation
Corresponding levels
of reflexive development
Resting levels of motor
development
Spinal and/or
Brainstem
Apedal
Primitive reflexes
Prone lying
Supine lying
Midbrain Quadruped
Righting reaction
Crawling
Sitting
Cortical Bipedal
Equilibrium Reactions
Standing
Walking
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III. According to the type of stimulus
According to the type of stimulus, reflexes could be classified as reflexes
that respond to touch, pressure and pain, kinesthetic stimuli as well as to visual and
auditory stimuli.
1. Reflexes response to touch:
They include palmar, plantar, placing and rooting reflexes.
Palmar grasp reflex
Stimulus: pressure in palm on ulnar side of hand (Figure 12).
Positive response: flexion of 4 fingers (not thumb) causing strong grip.
Negative response: no palmer grasp.
Onset/Integration: Birth / 4 months.
Developmental significance: its persistence will interfere with:
Ability to grasp and release object voluntary.
Weight bearing on open hand for propping responses, crawling and
protective responses.
Plantar reflex
Stimulus: touch base of toes (Figure 13).
Positive response: toe flexion.
Negative response: no toe flexion.
Onset/Integration: 28 weeks of gestation / 9 months.
Developmental significance: its persistence will interfere with:
Ability to stand with feet flat on surface.
Balance reactions and weight shifting in standing.
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Figure (12): Palmar grasp reflex.
Figure (13): Plantar reflex.
Placing reflex
Testing position: baby is held upright.
Stimulus: the top (dorsum) of the foot is brushed against the edge of a table
(Figure 14).
Positive response: the baby will lift the foot and place it on the table.
Negative response: no placing response.
Onset/Integration: birth / 6 weeks of age.
87
Rooting reflex
Stimulus: touch cheek.
Positive response: newborns turns head in direction of stimulus, opens
mouth, and begins to suck when cheek, lip, or corner of mouth is touched
with finger or nipple (Figure 15).
Onset/Integration: birth [it assists in breastfeeding] / 4 months.
Developmental significance: its persistence will interfere with:
Oral-motor development.
Development of midline control of head.
Optical righting, visual tracking and social interaction.
Figure (14): Placing reflex.
Figure (15): Rooting reflex.
2. Reflexes response to pressure and pain:
They include gallant, withdrawal, crossed extension, babinski, magnet reflex
and walking/stepping reflexes.
Gallant reflex
Stimulus: stroking the back lateral to the spine (Figure 16).
Positive response: flexion of trunk towards side of stimulus.
Onset/Integration: birth / 2 months.
88
Developmental significance:
Its persistence could interfere with development of sitting balance.
It could lead to scoliosis.
Babinski reflex
Testing position: supine.
Stimulus: stroke sole or lateral portion of foot.
Positive response: the big toe moves upward or toward the top surface of the
foot. The other toes fan out (Figure 17).
Negative response: great toe turns downward.
Onset/Integration: birth / one year.
Developmental significance: it is a sign for damage to corticospinal tract.
Figure (16): Gallant reflex.
Figure (17): Babinski reflex.
Magnet reflex
Stimulus: pressure on a toe pad with finger.
Positive response: a slow reflex contraction of the lower extremity, which
seems to follow the examiner's hand, as if drawn by a magnet.
Onset/Integration: birth / 2 weeks.
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Walking/stepping reflex
Testing position: child supported in the vertical position.
Stimulus: support the infant upright with the feet touching a hard surface.
Incline the infant forward and gently move the infant forward to accompany
any stepping (Figure 18).
Positive response: alternating, rhythmical, and coordinated steps.
Onset/Integration: 37 weeks‘ gestation / 2nd
month.
Developmental significance: reflex persistence interferes with:
Standing and walking.
Balance reactions and weight shifting in standing.
Development of smooth, coordinated reciprocal movements of lower
extremities.
3. Reflexes response to kinesthetic stimuli:
They include Moro reflex, ATNR, STNR, neck righting reaction and body
righting reaction.
Moro reflex
Stimulus: lifting the baby s shoulders up from the bed at a 45 angle, and
then allowing the baby's head to gently drop back into the other hand i.e.
sudden movement.
Positive response: baby will fling their arms out, fan his fingers, extend his
legs and then quickly pull his arms back in towards his/her body in an
'embrace' position (Figure 19).
Onset/Integration: birth / 4-6 months.
Developmental significance: reflex persistence interferes with:
Head control and sitting development.
90
Balance reactions in sitting.
Eye-hand coordination and visual tracking.
Figure (18): Walking/stepping reflex
Figure (19): Moro reflex.
4. Reflexes response to visual and auditory stimuli:
They include blink reflex, startle reflex and optical righting reactions.
Blink reflex
Position: supine or sitting.
Stimulus: stimulation of the cornea (such as by touching a foreign body), or
bright light, though could result from any peripheral stimulus (Figure 20).
Positive response: an involuntary blinking of the eyelids.
Onset/Integration: throughout life. This reflex should not become inhibited.
Developmental significance: protection of eyes from foreign bodies and
bright lights.
Startle reflex
Stimulus: loud, sudden noise.
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Positive response: similar to Moro response but elbows remain flexed and
hands closed.
Onset/Integration: 2-3 months after Moro disappears / 1 year.
Developmental significance: reflex persistence interferes with:
Sitting balance.
Protective responses in sitting.
Eye-hand coordination and visual tracking.
Social interaction and attention.
Figure (20): Blink reflex.
IV. According to their time of appearance
1. Primitive reflexes
They present at birth, are exhibited by normal infants in response to
particular stimuli and disappear during the first year to be replaced by the
postural reactions.
They are also called infantile, infant or newborn reflexes.
They include spinal reflexes, brainstem reflexes and some automatic
reactions.
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2. Postural reactions
They appear in the second 6 months of first year as a reaction to gravity and
changes in the equilibrium.
They mainly include righting, equilibrium and protective reactions.
Righting reactions emerged first in all positions, at least in their immature
forms, before the development of any protective or equilibrium reactions
in these postures.
However, the development of protective or equilibrium reactions was
over lapping within a given posture and between postures. For example,
protective reactions in sitting develop at the same time as equilibrium
reactions.
In addition, equilibrium reactions began to develop in higher-level (e.g.,
quadruped) and continued to be refined in lower-level positions (e.g.,
supine) simultaneously.
Automatic Movement Reactions
These are a group of reflexes observed in infants and young children which
are not strictly righting reflexes, but are reactions produced by changes in the
position of the head and, hypothetically, involve either the semicircular canals, or
labyrinths, or neck proprioceptors. Like righting reflexes, they appear at certain
stages of development and their persistence, or absence, can be observed
in patients under pathological conditions. They include Moro, Landau and
protective extensor thrust reflexes.
Landau Reflex
Test position: child is held prone in space, supporting thorax.
Stimulus: active or passive head rising
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Positive reaction: spine (trunk) and legs extend (Figure 21).
Negative reaction: spine and legs remain in flexed position.
Onset/Integration: 2 to 4 months / 1 to 2.5 years.
Purpose: assists with neck extension in prone & breaks flexor posture
present at birth; promotes ability to support upper body on forearms & hands
to prepare for standing.
Figure (21): Landau reflex.
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MOTOR DEVELOPMENT
Motor skills are movements and actions of the muscles. They are
categorized into two groups: gross motor skills and fine motor skills. These two
motor skills work together to provide coordination.
1. Gross motor skills
These are involved in the movement and coordination of the arms, legs, and
other large body parts and movements. They participate in actions such as running,
crawling, swimming, etc.
2. Fine motor skills
These are involved in smaller movements in the wrists, hands, fingers, feet,
and toes. They participate in smaller actions such as picking up objects between
the thumb and finger, writing carefully, and even blinking.
Gross motor development
The gross movements come from large muscle groups and whole-body
movement. These skills develop in a head-to-toe order. The children will typically
learn head control, trunk stability, and then standing up and walking. The sequence
of development is the same for all children, but the rate of development varies
from one child to another this variation is caused by genetic, cognitive, physical,
family, cultural, nutritional, educational, and environmental factors. Development
depends on the maturation and myelination of the nervous system. Until that
occurred, no amount of practice can make a child learn the relevant skill. Children
need to practice their skills; therefore, they will grow and strengthen better. They
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need space and time to explore their environment and use their muscles. ―Tummy-
time‖ is a good example of this.
(Tummy time — placing a baby on his or her stomach only while awake and supervised — can
help the baby develop strong neck and shoulder muscles and promote motor skills).
Infancy
At first, infants are only able to lay their belly on the floor but by around two
months they start to gain muscle to raise their head and chest off the ground.
From birth to 3 Months:
While lying on tummy, lifts and holds head up (head control from prone)
(Figure 1A).
Moves legs and arms off of the surface when excited.
Able to bring hands to mouth (Figure 1B).
Able to move fists from closed to open. (At third-month grasp reflex will be
inhibited).
Figure (1): Examples of gross motor milestones during first three months.
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From 4 to 6 Months (Figure 2):
Uses hands to support self while sitting (sitting with support).
Rolls from tummy to back and back to tummy.
Accepts weight bearing on legs while standing with support.
While lying on the back, reaches both hands to play with his feet.
While lying on the back, transfers a toy from one hand to the other.
Figure (2): Examples of gross motor milestones during 2nd
three months.
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From 7-9 Months (Figure 3):
Sits without support (sitting alone).
Sits and reaches for toys without falling.
Shows more control while rolling and sitting.
Starts to move with alternate leg and arm movement e.g. crawling and
creeping.
Figure (3): Examples of gross motor milestones during 3rd
three months.
From 10-12 Months (Figure 4):
Pulls to stand and cruises along with furniture.
Stands alone and takes several independent steps.
Moves in and out of various positions to explore the environment and get
desired toys.
Maintains balance in sitting when throwing objects.
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At this stage, the babies will want to get into everything, so the house needs
to become ‗baby proofed‘.
Research found that the use of baby walkers or devices that help to hold the
baby upright are said to delay the process of walking and distribute normal
pattern of walking (Figure 5).
Figure (4): Examples of gross motor milestones during 4th
three months.
Figure (5): Baby walker.
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Toddler:
Development in the second year of life, toddlers become more meteorically
skilled and mobile. They want to move all over the place. Child development
experts believe that motor activity during the second year is vital to the child's
competent development and that few restrictions, except for safety, should be
placed on their motoric adventures.
From 13-18 Months (Figure 6):
Walks independently.
Squats to pick up a toy.
Figure (6): Independent walking and squatting during early toddler.
At the end of 2 years (Figure 7):
Walks and runs fairly well.
Can jump with both feet.
Can climb stairs without support.
Can kick a ball.
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Figure (7): Jumping and kicking a ball for a 2 years’ old child.
At three years (Figure 8):
Can balance on one foot for a few seconds.
Pedals a tricycle.
Can broad jump 10-24 inches.
Can catch a large ball.
Walks upstairs alternating feet.
Able to walk on tip toes.
Childhood Period
As a preschooler, the child develops depending on his interactions with the
surrounding environment. If the child is in an encouraging environment with
constructive feedback, he or she will develop fundamental motor skills at a faster
rate.
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Typically, females perform better fundamental movement skills at an earlier
age than males. As they grow older, children become more proficient in their tasks.
Figure (8): Some gross motor milestones of 3 years’ old child.
At 4 years (Figure 9):
Kicks a ball forward.
Throws a ball overarm.
Catches a ball that has been bounced
Runs around obstacles.
Able to walk on a line.
Able to hop on one foot.
Go down the stairs with one foot on each step.
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Figure (9): Some gross motor milestones of 4 years’ old child.
At 5 years (Figure 10):
Able to walk upstairs while holding an object.
Walks backward toe heel.
Jumps forward 10 times without falling.
Hangs from a bar for at least 5 seconds.
Steps forward with the leg on the same side as throwing arm when throwing
a ball.
Catches a small ball using hands only.
Climbing well.
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Figure (10): Some gross motor milestones of 5 years’ old child.
At 6 years (Figure 11):
Able to walk on a balance beam.
Able to skip using a skipping rope.
Can cover 2 meters when hopping.
Demonstrates mature throwing and catching patterns.
Mature (refined) jumping skills.
(At this stage, the child becomes even more adventurous).
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Figure (11): some gross motor milestones of 6 years’ old child.
During middle and late childhood:
At this period, children's motor development becomes much smoother and
more coordinated than it was in early childhood. As they age, children
become able to have control over their bodies and have an
increased attention span. Having a child in a sport can help them with
their coordination, as well as some social aspects.
Between the ages of 7 and 12 there is an increase in running speed and
children can skip. Jumping is also acquired better and there is an increase in
throwing and kicking. They can bat and dribble a ball. Gross motor skills
usually continue improving during adolescence.
Adulthood
The peak of physical performance is before 30, between 18 and 26. Even
though athletes keep getting better than their predecessors—running faster,
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jumping higher, and lifting more weight—the age at which they reach their
peak performance has remained virtually the same. After age 30, most
functions begin to decline.
Older adults move slower than younger adults. Exercising regularly and
maintaining a healthy lifestyle can slow this process. Aging individuals who
are active and biologically healthy perform motor skills at a higher level
than their less active, less healthy aging counterparts.
Fine Motor Development
Definition
Fine motor skills are involved in smaller movements that occur in the wrists,
hands, fingers, the feet and toes. They participate in smaller actions such as picking
up objects between the thumb and finger, writing carefully, and even blinking.
Component of Hand Function
Reach: movement of the arm and hand for the purpose of contacting an object
with the hand.
Grasp: attainment of an object with the hand.
Carry: transportation of a hand-held object from one place to another.
Voluntary release: intentional letting go of a hand-held object at a specific
time and place.
In-hand manipulation: adjustment of an object within the hand after grasp.
Bilateral hand use: use of two hands together to accomplish an activity.
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Development of Fine Motor Skills
From birth to 6 months:
Reflexive grasp: it is prominent at birth and gradually disappears at the end
of the 3rd
months of life (Figure 1A).
Voluntary grasp: it starts around 3 months in the form of palmar grasp by
both hands and at age 5 month, the child can use only one hand for grasp
using the palmar grasp (Figure 1B).
Reaching: it is ineffective in the first 3 months of age but at age 6 months, it
is controlled and could be achieve (Figure 1C).
Possible implications if milestones not achieved:
Poor muscle development and control.
Delayed ability to play independently.
Delayed sensory development due to delayed interaction with toys and other
sensory objects.
Figure (1): Grasp reflex (A), palmer grasp (B) and reaching (C).
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From 6 to 12 months:
Reaches, grasps, puts object in mouth (Figure 2A).
Controlled release of objects.
Static pincer grasp (thumb and one finger) (Figure 2B).
Picks things up with pincer grasp (thumb and one finger).
Transfers objects from one hand to another.
Drops and picks up toys.
Possible implications if milestones not achieved
Poor development of hand and finger strength.
Poor manipulation of objects resulting in delayed play skills.
Delayed sensory development due to lack of sensory play experiences.
Figure (2): Grasping object and putting it in mouth (A) and pincer grasp (B).
From 1 to 2 years:
Builds tower of three small blocks (Figure 3A).
Puts four rings on stick (Figure 3B).
Places five pegs in pegboard (Figure 3C).
Turns pages two or three of a book at a time.
Scribbles (Figure 3D.
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Turns knobs (Figure 3E).
Paints with whole arm movement, shifts hands, makes strokes.
Self-feeds with minimal assistance.
Able to use signing to communicate.
Brings spoon to mouth (Figure 3F).
Holds and drinks from cup independently.
Possible implications if milestones not achieved
Poor development of hand and finger strength.
Delayed independent play skills.
Delayed development of self-care skills (such as eating).
Delayed manipulation skills.
Figure (3): Building tower (A), putting rings on stick (B), placing pegs in
pegboard (C), scribbles (D), turning knobs (E) and bringing spoon to mouth
(F).
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From 2 to 3 years:
Strings four large beads (Figure 4A).
Turns single pages of a book (Figure 4B).
Snips with scissors (Figure 4C).
Holds crayon with thumb and fingers (not fist) (Figure 4D).
Uses one hand consistently in most activities.
Imitates circular, vertical, and horizontal strokes (Figure 4E).
Paints with some wrist action, makes dots, lines, circular strokes.
Rolls, pounds, squeezes, and pulls play dough.
Eats without assistance.
Possible implications if milestones not achieved
Delayed self-care skills (such as eating).
Delayed pre-writing skill development.
Delayed manipulation of small objects such as toys, pencils and scissors.
Frustration when manipulating small toys and objects.
From 3 to 4 years:
Builds tower of nine small blocks (Figure 5A).
Copies circle.
Imitates cross.
Manipulates clay material (rolls ball, makes snakes, cookies) (Figure 5B).
Uses non-dominant hand to assist and stabilize the use of objects.
Snips paper using scissors (Figure 5C).
Possible implications if milestones not achieved
Delayed pre-writing skill development.
Frustration and/or avoidance of pencil-based tasks.
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Poor pencil grasp and pencil control.
Poor self-care skills (such as eating).
Delayed drawing skills.
Figure (4): Stringing large beads (A), turning single pages of a book (B),
sniping with scissors (C), holding crayon with thumb and fingers (D) and
imitating circular, vertical, and horizontal strokes (E).
Figure (5): Building tower of nine small blocks (A), manipulating clay
material (B) and sniping paper using scissors (C).
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From 4 to 5 years:
Cuts on-line continuously.
Copies cross.
Copies square.
Writes name.
Writes numbers 1-5.
Copies letters.
Handedness is well established.
Dresses and undresses independently.
Possible implications if milestones not achieved
Difficulties holding and manipulating a pencil.
Difficulties learning to write name and other letters of the alphabet.
Dependence on caregivers for everyday activities such as dressing.
Frustration and/or avoidance of pencil-based tasks.
From 5 to 6 years:
Cuts out simple shapes.
Copies triangle.
Colors within lines.
Uses a three fingered grasp of pencil and uses fingers to generate movement
(Figure 6A).
Pastes and glues appropriately (Figure 6B).
Can draw basic pictures.
Possible implications if milestones not achieved
Difficulties learning to form letters and numbers correctly.
Poor handwriting.
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Difficulties demonstrating academic ability on paper.
Fatigue during pencil-based tasks.
Frustration and/or avoidance of pencil-based tasks.
Figure (6): Using a 3 fingered grasp of pencil (A) and Pastes and glues (B).
From 6 to 7 years:
Forms most letters and numbers correctly.
Writes consistently on the lines.
Demonstrates controlled pencil movement.
Good endurance for writing.
Can build Lego, K‘nex and other blocks independently (Figure 7A).
Ties shoelaces independently (Figure 7B).
Possible implications if milestones not achieved
Difficulties getting ideas down on paper.
Experiences fatigue during handwriting tasks.
Difficulty keeping up in class due to slow handwriting speed.
Poor legibility of handwriting.
May impact on self-esteem when comparing work to peers.
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Possible frustration and/or behavior difficulties are due to avoidance of
pencil-based tasks.
Figure (7): Lego, K’nex and other blocks (A) and child ties shoelaces (B).
From 7 to 8 years:
Maintains legibility of handwriting for entirety of a story
Possible implications if milestones not achieved
Difficulty completing handwriting tasks in a timely manner.
Experiencing fatigue during handwriting tasks.
Poor academic achievement due to difficulty getting ideas down on paper.
Difficulties due to avoidance of pencil-based tasks.
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Types of Manipulation related to Human Development
(I) ARTISTIC DEVELOPMENT
Drawing always precedes writing letters. Drawing ability is a function of the
child‘s mental age. Reason for immature drawing by young children is because the
brain is not fully developed.
While making art, children develop control of large and small muscle
groups. Making art also helps children develop eye-hand coordination
Development of control of large and small muscle:
The large arm movements required for painting or drawing at an easel or on
large paper on the floor build coordination and strength.
The smaller movements of fingers, hands, and wrists required to cut with
scissors, model clay, or draw or paint on smaller surfaces develop fine motor
dexterity and control.
With repeated opportunities for practice, young children gain confidence in
their use of tools for making art and later for writing.
Development of eye-hand coordination:
As children decide how to make parts fit together into a whole, where to
place objects, and what details to include, they learn to coordinate what they
see with the movements of their hands and fingers.
This eye-hand coordination is essential for many activities, including
forming letters and spacing words in formal writing.
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Stages of Artistic Development
Lowenfeld (1947) argues that there are six stages of artistic development and
that these stages can be witnessed in the artworks of children. According to
Lowenfeld, the six stages of artistic development are:
1. Scribble stage (2 to 4 years):
It is the beginning of art where children learn how to make marks on paper.
It starts with wild scribbles and ends with a circle shape which can then
become all sorts of things like a person, a car, a house or anything else from
the child imagination (they give marks names) (Figure 1).
The most important thing is that the child is learning how to show their ideas
with pictures (it is the development of the ability to visualize in pictures).
Figure (1): Scribble stage of artistic development.
2. Pre-schematic stage (4 to 6 years)
Children drawing become more and more detailed. They begin to see
connections between the shapes that they draw and the physical world
around them.
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They use different geometrical shapes and lines of varying lengths to draw
the objects.
The circle shape from the last stage now becomes even more special. They
may add sticks coming out of the sides for arms and legs of a person or they
may add circles to the bottom to create a car (Circles and lines may be
described as people or objects that are physically present in the child‘s life).
The child now will begin to understand and show how different details make
different pictures (Figure 2).
Their placement of objects on the page however is not always like we may
draw something: it is less important for houses and people to be touching the
ground. Rather, for a child, the importance is that they are included in the
picture.
The way the child uses colors is also different at this stage. They will not
always choose colors that are realistic. Instead they choose colors that they
like when coloring a picture.
Figure (2): Pre-schematic stage of artistic development.
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3. Schematic stage (7 to 9 years)
The details of pictures will be easier to recognize.
There is awareness of the concept of space: objects in the drawing have a
relationship to what is up and what is down (clear separation between the
sky and the ground) (Figure 3).
Drawings at this stage have a clear separation between the sky and the
ground. Often the sky is a strip of blue at the top of the paper, while the
ground is a strip of green at the bottom.
Objects of importance are often drawn larger than objects of lesser
importance (they may draw themselves larger than any other person on the
page because in their eyes they are the most important).
Figure (3): Schematic stage of artistic development.
4. Dawning Realism stage (9 to 11 years)
At this stage, children are beginning to become more critical of their own
work. They now become very aware of the differences between themselves
and others. Therefore, the child may become frustrated with not being able
to make something look exactly like it is in real life.
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Their pictures contain many details that are connected to a specific person or
situation rather than something more general (Figure 4).
Child will begin to understand the idea of perspective (that the farther away
something is the smaller it is, and the closer it is the bigger).
Doing this make the drawings look more realistic.
Figure (4): Dawning realism stage of artistic development.
5. Pseudo-realistic stage (11 to 13 years)
The use of value and light is now apparent in drawings (Figure 5).
Adolescents become very critical of their own success, which is determined
by the level of realism achieved in the drawing.
Frustration is a common occurrence.
It is exceptionally important to encourage students at this stage.
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Figure (5): Pseudo-realistic stage of artistic development.
(II) HAPTIC PERCEPTION
Definition
It is the ability to acquire information about objects with the hands and
recognize objects from handling them. The information may be temperature, size,
texture, weight and/or shape of the objects.
Pattern of haptic perception development:
Temperature and hardness are perceived early during the first six months of
the life.
Texture and weight can be perceived at sometime between 6-12 months of
age.
Shape perception occurs round 12-15 months of age.
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N.B.
Emergence of haptic perception appears to be linked to different types of
hand movements (exploratory procedures).
Any attempt to inhibit a child‘s ability to learn about an object may reduce
certain forms of haptic perception.
(III) HANDWRITING
Handwriting studied through how one holds a writing implement, drawing to
writing progression and stages of writing. In training or retraining handwriting, one
needs to examine the underlying components of the grasp and manipulation.
Underlying Components:
Wrist stabilization.
In-hand manipulation.
Hand arches.
Development of power and skills of the hand.
Training the fingertip force.
Strength training of the intrinsic muscles of the hand.
Common Physical Problems affecting Handwriting:
1. Immature or incorrect grip (posture).
2. Too much muscle tension.
3. Too much or too little wrist stability.
4. Wrist position too flexed or hyperextend.
5. Head titles too much to one side.
6. Paper not positioned correctly.
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Development of Handwriting:
Children pass through predictable stages of handwriting techniques.
The child starts out by holding the instrument with their whole hand and
progress to a finger posture (proximodistal).
The mature grasp of the pencil or crayon is referred to as the dynamic tripod
posture.
One usually masters the dynamic tripod posture by the age of 7.
Major stages of handwriting:
Supinate grasp (four fingers and thumb wrapped around the instruments)
(Figure 6A).
Pronate grasp (palm-down hand position) (Figure 6B).
Dynamic tripod posture (grasp using the thumb, middle finger and index
finger) (Figure 6C).
Figure (6): Palmar supinated grasp (A), distal pronate grasp (B) and dynamic
tripod grasp (C).
N.B.
Development of pencil manipulation is cross-cultural. Japanese children
attained the tripod posture earlier than children in other culture due to eating
with chop sticks.
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Positioning the paper correctly for handwriting:
The paper position and tilt on the desk, for both right and left-handed writers
(Figure 7), can make a big difference to a child‘s handwriting experience and
comfort and yet it is an element which is often neglected.
By positioning and tilting the paper correctly, the writing hand stays in one
comfortable position on the table and the non-writing hand moves the paper
diagonally up the table (while maintaining an appropriate paper tilt angle). With
the non-writing hand moving the paper up the table the writing line stays in the
same place which means eye movements are less, helping to make the writing
experience less tiring and stressful.
If the paper is positioned and tilted correctly, with their writing hand under
the writing line, writers will be able to see more easily what they have just written
and where to place the next letter, word or section of text on the page. This is
especially important for left-handed writers.
Figure (7): Paper position while writing with the left or right hand.
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COGNITIVE DEVELOPMENT
Cognitive development is a field of study in neuroscience and
psychology focusing on a child's development in terms of information processing,
conceptual resources, perceptual skill as well as language learning.
Definition:
The construction of thought processes, including remembering, problem
solving, and decision-making throughout life span. It refers to how a person
perceives, thinks, and gains understanding of his or her world through the
interaction of genetic and learned factors.
Among the areas of cognitive development are information processing,
intelligence, reasoning, language development, and memory.
Approaches for studying Cognitive Development
There are main two approaches for studying cognitive development:
1. Piaget approach
2. Information-processing approach
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[1] Piaget’s Approach to Cognitive Development
Who is Piaget?
Jean Piaget is one of the most effective developmental theorists of the 20th
century. He is a Swiss psychologist, born in 1896, worked for several decades on
understanding children‘s cognitive development and developed the most widely
known theory of cognitive development.
Piaget believed that the child passes through a series of stages of thought
from infancy to adolescence. The stages are qualitatively different from one
another. He believed that the child learns through action (Action = Knowledge).
He stated that humans pass through a series of universal cognitive
developmental stages in a fixed order as follows:
I. Sensorimotor stage
II. Preoperational stage
III. Concrete operational stage
IV. Formal operational stage
Piaget’s Theory
Piaget‘s believed that cognitive development occurs through adaptation.
Adaptation: Adjusting to the demands of the environment and
intellectualizing those adjustments.
Two facets of adaptation: assimilation and accommodation.
1. Assimilation: Children interpret new experiences based upon their
present interpretation of the world. Child assimilates past experience
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which tells the child to use one hand to grab large ball because it worked
with rattles and smaller objects.
2. Accommodation: Adjustments or modifications in the thinking process
that will become a part of a child‘s new cognitive repertoire. Child
accommodates new information. He/she is unable to grasp the ball with
one hand; therefore, he/she accommodates by using two hands or
adapting the one-handed grasp.
Piaget’s Stages of Cognitive Development
(I) Sensorimotor Stage:
It is the initial stage of cognitive development. It covers children ages birth
to 18–24 months old (infancy). Its main characteristics include motor
activity without the use of symbols. All things learned are based on
experiences, or trial and error.
The main goal at this stage is establishing an understanding of object
permanence — in other words, knowing that an object still exists even if you
can‘t see it or it is hidden.
It divided into six sub-stages (Table 1):
1. Simple reflexes.
2. Primary circular reactions.
3. Secondary circular reactions.
4. Coordination of secondary circular reactions.
5. Tertiary circular reactions.
6. Beginning of thought.
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Table (1): Sensorimotor sub-stages of Piaget’s approach to cognitive
development.
Stage Characteristics
1. Simple
Reflexes
• First month of life.
• Various reflexes determine the infant's interaction with the
world.
• Repetition of reflexes helps child to form the foundation for
cognitive understanding.
• Example: Sucking reflex (provides information about the
world = cognitive development). 2. Primary
Circular
Reactions
• 1-4 months of age.
• Cognitive development through repetition of a chance motor
event.
• Conscious effort to repeat movements.
• Infants repeat interesting or enjoyable actions on their own
body (Figure 1).
3. Secondary
Circular
Reactions
• 4-8 months of age.
• Repeated actions meant to bring about a desirable consequence
on the outside world (Figure 2).
• Vocalization increases and imitation begins.
4.
Coordination
of SCR
• 8-12 months of age.
• Employs goal-directed behavior.
• New behaviors facilitated by increasing movement capabilities
– Example: Crawling and creeping.
• Development of object permanence, the realization that people
and objects exist even when they cannot be seen (Figure 3).
5. Tertiary
Circular
Reactions
• 12-18 months of age
• Variation of actions to bring desirable consequences.
• Miniature ―experiments‖ to observe consequences.
• Example: dropping a toy repeatedly, varying the position from
which he/she drops it and observe where it falls (Figure 4).
6. Beginning
of Thought
• 18-24 months of age.
• Capacity for Mental Representation, an internal image of a past
event or object.
• Permits child to understand causality.
• Child gains ability to pretend and Deferred Imitation, in which
a person who is no longer present is imitated by children who
have witnessed a similar act.
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Figure (1): Primary Circular Reactions
(This 3-month-old sees his hands touch,
open, and close. He tries to repeat these
movements, in a primary circular reaction
that helps him gain voluntary control over
his behavior).
Figure (2): Secondary Circular Reactions
(When this 4-month-old accidentally hits a
toy hung in front of her, her action causes it
to swing. Using the secondary circular
reaction, she tries to recapture this
interesting effect).
Figure (3): Before object permanence develops, the infant will not search for
an object.
Before object permanence
After object permanence
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Figure (4): Using a tertiary circular reaction, this baby twists, turns, and
pushes until a block fits through its matching hole in her shape sorter
N.B.:
Piaget believed deferred imitation to result from the child‘s increasing
ability to form mental representations of behavior performed by others.
Summary
During sensorimotor stage of cognitive development:
Infants and toddlers acquire knowledge through sensory experiences and
manipulating objects. A child's entire experience at the earliest period of this
stage occurs through basic reflexes, senses, and motor responses.
There is an increasing awareness of the difference between the self and
others.
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There is a recognition that objects continue to exist even though they are no
longer in view.
There is a production of the mental images that allow the contemplation of
the past, present, and future.
Children go through a period of dramatic growth and learning.
As kids interact with their environment, they are continually making new
discoveries about how the world works.
(II) Preoperational Stage
During this stage (early childhood period), the child learns to use and to
represent objects by images, words, and drawings. Children do not yet
understand concrete logic (unable to think logically), cannot mentally
manipulate information.
Preoperational stage consists of two sub-stages; symbolic function (2 to 4
years) and intuitive thought (4 to 6 years) (Table 2).
Importance of this stage:
Children can talk about people who are traveling, or who live somewhere
else, like Grandma in Alexandria.
They can talk about or draw places they visited, as well as create new scenes
and creatures from their imagination.
They can also use their mental images of things to "play school" or to "play
house."
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Table (2): Preoperational sub-stages of Piaget’s approach to cognitive
development.
Stage Characteristics
1. Symbolic Function 2 to 4 years.
Use of symbols (symbol is a thing that represents
something else) to represent someone/thing –
Example: A rock represents a turtle.
The ability to use a mental symbol, a word, or object to
represent something not present.
The child has mental representations and is able to
pretend (Figure 6).
Children master the ability to picture, remember,
understand, and replicate objects in their minds that are
not immediately in front of them (can draw a picture of
or pretend to play with a kitten that is no longer there)
– Example: Reading to baby.
2. Intuitive Thought 4 to 7 years.
Children tend to become very curious and ask many
questions; begin the use of primitive reasoning.
There is an emergence in the interest of reasoning and
wanting to know why things are the way they are.
It is the emergence of language.
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Figure (6): Symbolic function sub-stage of the preoperational cognitive stage
of Piaget.
Children in the preoperational stage cannot understand the following
cognitive tasks: conservation, seriation and transitivity. Children also have
deficiencies in logical thinking; therefore, they display egocentrism, centration and
animism.
Conservation
It is the recognition that properties of an object or substance do not change
when its appearance is altered in some superficial way.
The person's ability to understand that certain physical characteristics of
objects remain the same, even if their appearance has changed.
Preschoolers do not understand this concept.
Examples: number and liquid conservation tests (Figure 7).
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Seriation
It is the ability to put number of objects in order according to their size,
weight or numerousness (understanding less than and more than) (Figure 8).
Ability to arrange a set of variables by a certain characteristic – Example:
Recognize height can determine position in a game of basketball.
Children in this preoperational stage do not understand seriation; therefore,
they cannot arrange objects by sequence.
Liquid Conservation Test
Number Conservation Test
Figure (7): Examples of conservation tests.
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Figure (8): Examples of seriation of shape, color and size.
Transitivity
It is the use of logic to find the missing piece.
Example: If "A" is shorter than "B" and "B" is shorter than "C", children in
the preoperational stage don't understand that "A" is also shorter than "C" or
"C" is longer than "A". They also don't understand that "A" is the shortest
and "C" is the longest (Figure 9).
This could be applied for quantities, numbers, weights…etc.
Egocentrism
It is the thinking that doesn‘t consider others‘ viewpoints.
The child is not able to take the perspective of others. A child at this stage
thinks that everyone sees, thinks, and feels just as they do.
Children have failure to realize that others may hold thoughts, feelings, and
points of view different from their own.
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Example: Children have a hard time understanding why playing with a
musical toy could increase their mother's headache when they're having so
much fun.
Piaget developed the Three-Mountain Task to determine the level of
egocentrism displayed by children. Children view a 3-dimensional mountain
scene from one viewpoint and are asked what another person at a different
viewpoint would see in the same scene (Figure 10).
Figure (9): Example of transitivity.
Figure (10): Three mountains egocentrism test: Timmy’s egocentrism
prevents him from seeing Davie’s perspective…He would draw the big
mountain.
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Centration
This is a tendency to focus on a single aspect of a problem rather than
looking at the whole picture (Figure 11).
Preschooler‘s focus is on the superficial, obvious elements: what you see is
what you think.
Example: A child may complain that there is little ice cream left in a big
bowl and will be satisfied if the ice cream is transferred to a little bowl, even
though nothing is added, because he only considers how full the bowl
appears to be.
N.B.
Centration (tendency to focus on a single aspect of a problem rather than
looking at the whole picture) prevents preschoolers to master conservation
(the recognition that properties of an object or substance do not change when
its appearance is altered in some superficial way).
Animism
It is giving life-like characteristics to inanimate (non-living) objects.
Children believe that things are alive or have human characteristics (Figure
12).
Example: hitting head on the table and blaming the table – ―bad table‖.
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Figure (11): Centration (A tendency to focus on a single aspect of a problem).
Figure (12): Animism (giving life-like characteristics to inanimate objects).
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(III) Concrete Operational Stage
It is the period between 7 and 11 years of age.
It is characterized by active and appropriate use of logic. Therefore; there is
development of reversibility, conservation, seriation, transitivity,
decentration and classification.
Reversibility
Ability to mentally modify, organize, or even reverse thought processes –
Example: Can reverse the order of the ball as they go through the tube
(Figure 13).
The ability to recognize that numbers or objects can be changed and returned
to their original condition. 5+3=8 so, 3+5=8 and 8-5=3
Example: a child understands that a favorite ball that deflates is not gone but
can be filled with air again and put back into play.
Figure (13): Reversibility demonstrated by children during the concrete
cognitive stage of Piaget.
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Conservation
It is the recognition that properties of an object or substance do not change
when its appearance is altered in some superficial way (Table 3).
Table (3): Tests of different types of conservation.
Type of
Conservation Initial Presentation Transformation
Volume Two equal glasses of liquid.
Pour one into a taller, narrow glass.
Number Two equal lines of checkers.
Increase spacing of checkers in one line.
Matter Two equal balls of clay.
Squeeze one ball into a long, thin shape.
Length Two sticks of equal length.
Move one stick.
Decentration
It is the ability to take multiple aspects of a situation into account.
The ability to move away from one system of classification to another one as
appropriate.
Example: two cars with different roots‘ length (Figure 14).
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Classification
It is the hierarchical classification; the ability to simultaneously sort things
into general and more specific groups, using different types of comparisons
(Figure 15).
Figure (14): Decentration demonstrated by children during the concrete
cognitive stage of Piaget.
Figure (15): Classification demonstrated by children during the concrete
cognitive stage of Piaget.
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(IV) Formal Operational Stage
It begins at 11-12 years.
Children could consider ideas that are not based on observable objects or
experiences.
The beginning of thinking abstractly, reasoning logically (scientific
thinking) and drawing conclusions from the information available: A
problem-solving style that allows child to choose between possible solutions
and then pick the best one.
People are most likely to think abstractly in situations in which they have
had extensive experience.
It is important to note that not everyone reaches this stage at the same time:
about 40:60% of college students fail Piaget‘s formal operational problems.
It is also possible and even likely for an adolescent to be operating at a
formal operational thinking level in one area and at a concrete or pre-
operational thinking level in another area.
Egocentrism in Thinking
During the formal operational stage most adolescents exhibit egocentrism in
thinking; a state of self-absorption in which the world is viewed from one‘s
own point of view.
This makes adolescents highly critical, unwilling to accept criticism and
quick to find faults with others‘ behaviors. This may lead to imaginary
audience and personal fable.
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Imaginary Audience:
It is a belief that others are concerned with our appearance and behaviors.
This makes them susceptible to peer influence.
Personal Fable:
It is the view held by some adolescents that what happens to them is unique,
exceptional and shared by no one else). This makes them think "because I
am unique, I am not subject to consequences other will experience".
Excessive personal fable makes adolescents ignore threats to health like
decalcification of teeth from poor oral hygiene. They think- others may have
to worry about, but they don‘t.
[2] Information-Processing Approach to Cognitive Development
This approach seeks to identify the way that individuals take in, use, and
store information. This approach seeks to identify the way that individuals take in,
use, and store information.
It has three basic aspects:
Encoding: The process by which information is initially recorded in a form
usable to memory.
Storage: The maintenance of material saved in memory.
Retrieval: The process by which material in memory storage is located,
brought into awareness, and used.
Memory:
It is the process by which information is initially recorded, stored, and
retrieved. Infant's memories improve with age. Hints can reactivate memories that
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at first seem lost. More memory retrieval leads to more memory enduring.
Prefrontal cortex and parts of hippocampus of the brain are important for memory
and are not completely mature until 20-24 months of age.
Infantile amnesia: The lack of memory for experiences that occurred prior to 3
years of age.
Types of memory:
1. Explicit Memory: Conscious memory that can be recalled intentionally (not
before six months).
2. Implicit Memory: Unconscious memory that can be recalled automatically
(such as motor skills and habits).
Intelligence:
It is the cognitive ability of an individual to learn from experience, to reason
well, to remember important information, and to cope with the demands of daily
living. It is the global capacity of a person to act purposefully, to think rationally,
and to deal effectively with his/her environment.
Approaches used to detect differences in intelligence during infancy:
Developmental Quotient by Arnold Gesell
Bayley Scales of Infant Development
Cross-modal Transference
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Developmental Quotient:
It assesses performance in 4 domains
Motor skills (balancing, sitting)
Language use (speaking, sounds)
Adaptive behavior (alertness, exploration)
Personal-social behavior (feeding, dressing)
Bayley Scales of Infant Development
It evaluates an infant's development from 2 to 42 months on two areas:
Mental abilities (senses, perception, memory, learning, problem solving,
language).
Motor abilities (gross and fine motor skills).
Cross-modal Transference
The ability to identify a stimulus that has previously only been experienced
through one sense using another sense.
During late childhood
Children become increasingly sophisticate in holding of information:
Grade 1 students learn basic math tasks (addition and subtraction of
single digit number) and spell simple words such as dog.
Grade 6 students are able to work with fraction and decimals and spell
more complex words.
There is more improvement in the short memory.
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There is a development of mnemonics: technique of organizing information
to be easily remembered. Example: thirty days for SAJN (S; September, A;
April, J; June, N; November).
Development of Language
Definition
Language is the systematic, meaningful arrangement of symbols that
provides the basis for communication. It is the communication of thoughts and
feelings through a system of arbitrary signals, such as voice sounds, gestures, or
written symbols.
Components of Language
There are three major components of language. These components are form,
content, and use. The three language components are composed of five separate
skills: form involves three sub-components of syntax, morphology, and phonology;
content is also known as semantics and use is also known as pragmatics.
Integration of the three components is referred to as language competence.
Form: rules by which a given communications system is governed; the
―how‖ of language.
Content: the meaning component; the ―what‖ of language
Use: reason, purpose: the ―why‖ of language.
Phonology
Phonology is the first stage of learning language.
It is the basic sounds of language, called phonemes that can be combined to
produce words and sentences.
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Phonology looks at the sound of speech and the shaping of syllables. The
sound for /p/ is different depending on its placement in a word and the
vowels near it. For example, /p/ can vary in sound in such words as pea,
poor, and soup. Each word contains /p/ but the sound is slightly different.
Sequencing also changes the of words the -ed sound is different in ―jogged‖
than it is in ―walked‖ the first has a /d/ sound while the second has a /t/
sound
Morphology
The second part of language develop is morphology.
It is focused on the organization of words. It is the smallest units of language
that have meaning.
Morphemes are the smallest grammatical units possible. Examples of
morphemes would be any letter or vowel of the English alphabet.
There are two types of morphemes:
Free morphemes can stand only. Examples include many words such as
boy, small, and sad. These morphemes do not need any help to make
sense.
Bound morphemes must be connected to a larger word to make sense.
Examples include prefixes and suffixes such as un-, non-, -ly, -s.
Syntax
It is the rules for the structure of a sentence (Combining words and phrases
to form sentences).
Syntax deals with such details such as sentence organization, the order of
clauses, relationships between words, elements of a sentence, etc.
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It also determines which word combinations are acceptable. For example, if
I say, ―He went to town.‖ it is acceptable, however, if I say, ―town to went
he‖ it does not work because of the syntax of English.
There are certain common rules of syntax. A sentence must contain a noun
phrase and a verb phrase. Using our previous example ―He went to town‖
contains a noun phrase ―He‖ and a verb phrase ―went to town.‖ Another
example would be the ―The big dog ran to the house.‖ The noun phrase for
this example is ―The big dog‖ and the verb phrase is ―ran to the house.‖
Semantics
The fourth part of language development is learning the meaning of words,
or semantics.
The rules that govern the meaning of words and sentences.
As young children are learning language, they may find it more difficult to
choose appropriate words to convey their message. They may use a word
that is similar to what they are trying to convey. For example, the child may
call a worm a snake. Snake and worm would most likely mean the same
thing to him. As children age and their vocabulary improves, they begin to
use correct or more precise words.
Pragmatics
The last part of language development is pragmatics.
It is the knowledge and ability to use language functionally in social or
interactive situations (aspect of language relating to communicating
effectively & appropriately with others).
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Types of Speech:
1. Private Speech: Speech spoken and directed to oneself.
2. Social Speech: Speech directed toward another and meant to be understood
by that person.
Parts of Language
1. Linguistic comprehension: The understanding of speech.
2. Linguistic production: The use of language to communicate.
At all ages in life, comprehension develops ahead of production (Figure 16).
There is a five-month lag between the time toddlers can comprehend 50 words and
the time that they can produce that many. Comprehension requires children to
recognize the meaning of a word. But in the light of production, children must
recall or actively retrieve from their memories. They not only have to remember
the word but also the meaning of the word. These two concepts are still related.
When a child's speed and accuracy of word comprehension is faster, then they
show a more rapid growth of words understood and later produced.
Figure (16): Parts of language.
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Sequence of Language Development:
The stages of language development are one of the important parts of
linguistics. Language plays a vital role to communicate with each other, from one
country to another country. Every language has its individual characteristics and
objectives. A child acquires a language or mother tongue through different
stages. After finishing all the stages, the child can acquire his or her mother
tongue.
Language development passes through four stages:
1. Pre-linguistic communication
2. Babbling
3. Holophrases
4. Telegraphic speech
1. Pre-linguistic communication
The pre-linguistic stage is the core of child language acquisition.
It begins from a child‘s birth up to six months.
Infants learn how to communicate with others through sounds, facial
expressions, gestures and imitations.
Example:
Receptive language skills: Infant responds to quiet voice (calms/soothes to
voice), listens and looks at speaker as well as localizes speaker by watching
lips and mouth.
Expressive language skills: Infant uses crying and cooing to express pleasure
and pain.
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2. Babbling
It is a universal phenomenon of speech-like but meaningless sounds at about
six months that may continue to about 1 year.
Children produce random sounds with their speech organ.
It begins with easy sounds (b - p) and proceeds to more complex sounds (d -
t).
By age 9 months, it differs according to the language to which the infant is
exposed.
3. Holophrases
It begins when a child becomes one year or one and half-year.
In this stage children used to pronounce from one word.
First words are typically one-word utterances that depend on the context in
which they are used to determine meaning.
4. Telegraphic speech
At about two years, infant uses two-words sentence in a manner called
telegraphic speech.
Infants are linking words in sentences using telegraphic speech where words
not critical to the message are left out.
This speech ability is limited to nouns.
The infant will only use the important content words and omits grammatical
words, such as conjunctions and prepositions.
Examples:
To ask for more: More milk.
Say no to something: No water.
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N.B:
By 15 months the average child has a vocabulary of 15 words.
Between 16 and 24 months a child's vocabulary increases to 100 words.
Language development is produced through a combination of genetically
determined predispositions & environmental circumstances that help teach
language.
During early childhood period:
Syntax increases as it doubles each month.
Frequent use of plurals and possessives.
Grammar principles are understood.
Private speech allows problem-solving.
Pragmatics allows an understanding of the basics of conversation.
Preschoolers begin social speech.
During late childhood period:
Vocabulary increases.
Mastery of grammar improves.
Pronounce words quite accurately.
Difficulty in decoding sentences when the meaning depends on
intonation i.e tone of voice.
Improvement in conversational skills.
Bilingualism: The ability to speak two languages.
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SOCIAL AND PERSONALITY DEVELOPMENT
Social and personality development emerges through the interaction of
social influences, biological maturation, and the child‘s representations of the
social world and the self. This interaction is illustrated in a discussion of the
influence of significant relationships, the development of social understanding, the
growth of personality, and the development of social and emotional competence in
childhood.
Definition
Social development:
Development that involves the ways in which individuals‘ interactions with
others and their social relationships grow, change and remain stable over the
course of life.
Personality development:
Development involving the ways that the enduring characteristics that
differentiate one person from another change over the life span.
Aspects of Social and Personality Development
Emotions
Identity
Psychosocial development
Friendships
Play
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EMOTION
Definition
In psychology, emotion is often defined as a complex state of feeling that
results in physical and psychological changes that influence thought and
behavior.
It is a feeling such as happiness, love, fear, anger, or hatred, which can be
caused by the situation that you are in or the people you are with. Emotion is
the part of a person's character that consists of their feelings.
Aspects of Emotion
Emotion is associated with a range of psychological phenomena, including
anxiety, smile, empathy, attachment and temperament.
ANXIETY
It is a feeling of uneasiness and worry, usually generalized and unfocused as
an overreaction to a situation that is only subjectively seen as threatening.
There are two types of anxiety demonstrated during infancy:
1. Stranger anxiety:
It is the caution and wariness displayed by infants when encountering an
unfamiliar person. It starts at six months and declines at nine months, but it may
recur afterwards until the age of 24 months. Infants with more experience with
strangers tend to show less anxiety.
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2. Separation anxiety:
It is the distress displayed by infants when a customary care provider
departs. It usually begins about eight or nine months and peaks at 14 months and
usually ends around two years old.
SMILE
A facial expression in which the eyes brighten and the corners of the mouth
curve slightly upward and which expresses especially amusement, pleasure,
approval, or sometimes scorn. It is a pleasant or encouraging appearance.
The infant‘s first smiles are relatively indiscriminate (smile at anything).
By 6-9 weeks babies exhibit the social smile; smiling in response to
someone else's smile.
By 18 months, social smiling is directed more toward moms and other
caregivers
Infants are sensitive to the emotional expressions of others by end of 2nd
year.
EMPATHY
Empathy is an emotional response that corresponds to the feelings of another
person. It is the intellectual identification of the thoughts, feelings, or state of
another person.
It is the ability to sense other people's feelings. It develops by two years.
ATTACHMENT
Attachment is the positive emotional bond that develops between a child
and a particular individual.
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The attachment relationship is developed in the first few months of life when
the infant receives dependable and loving responses from the primary caregiver in
response to attachment behaviors such as crying, grasping, moving towards, and
smiling. Attachment is directly related to how responsive, or sensitive, the
caregiver is to the infant's needs. This is known as caregiver sensitivity.
Types of Attachment:
There are main four attachment styles (Table 1).
1. Securely attached children
Securely attached children are those who use mother as a home safe base
and are at ease as long as she is present, exploring when they can see her,
upset when she leaves, and go to her when she returns. They constitute 2/3
of children.
The secure attachment style signifies a warm and loving bond between
parent and child. The child feels loved and cared for and develops the ability
to form healthy relationships with those around them.
Children with secure attachment styles are active and demonstrate
confidence in their interactions with others.
Those who develop secure attachment styles in childhood are likely to carry
this healthy way of bonding into adulthood and have no problem building
long-term relationships without fear of abandonment.
2. Avoidant children
Avoidant children are those who do not seek proximity to the mother; after
she leaves, they seem to avoid her when she returns as if they are angered by
her behavior. They constitute 20% of children.
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Children who have developed under the ‗avoidant‘ style have learned to
accept that their emotional needs are likely to remain unmet and continue to
grow up feeling unloved and insignificant.
They often struggle with expressing their feelings and find it hard
understanding emotions – in adulthood; they tend to avoid intimate
relationships.
3. Ambivalent children
Ambivalent children are those who display a combination of positive and
negative reactions to their mothers; they show great distress when the
mother leaves, but upon her return they may simultaneously seek close
contact but also hit and kick her.
Those who developed under the ‗ambivalent‘ attachment style, tend to carry
what they have learned into adulthood, and very often feel unloved by their
partners whilst finding it difficult to express love and connection
themselves.
People who developed attachments under this style are usually emotionally
dependent in adulthood.
4. Disorganized-disoriented children
Disorganized-disoriented children are those who show inconsistent,
contradictory behavior, such as approaching the mother when she
returns but not looking at her. They may be the least securely attached
children of all.
Children developed under the ‗disorganized‘ attachment style, tend to
avoid intimate relationships as adults and can very easily explode and
have a difficult time controlling their emotions.
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Table (1): Types of attachment and associated behaviors.
Attachment
Types Caregiver Behaviors Child Behaviors
Secure React quickly and
positively to child‘s
needs
Responsive to child‘
needs
Distressed when caregiver
leaves
Happy when caregiver returns
Seek comfort from caregiver
when scared or sad.
Avoidant Unresponsive, uncaring
Dismissive
No distress when caregiver
leaves
Does not acknowledge return
of caregiver
Does not seek contact with
caregiver
Ambivalent Response to child
inconsistently
Distress when caregiver leaves
Not comforted by return of
caregiver
Disorganized-
disoriented
Abuse or neglectful
Responds in frightening,
or frightened ways
No attaching behaviors
Often appear dazed, confused
or apprehensive in presence of
caregiver
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Development of attachment:
Baby's attachments develop in the following sequence (Figure 1):
Asocial or pre-attachment (0 - 6 weeks)
Very young infants are asocial in that many kinds of stimuli, both social and
non-social, produce a favorable reaction, such as a smile (similar responses
to objects and people).
Indiscriminate Attachments (6 weeks to 7 months)
Infants indiscriminately enjoy human company (Preference for human
company), and most babies respond equally to any caregiver. They get upset
when an individual ceases to interact with them.
From 3 months infants smile more at familiar faces and can be easily
comfortable by a regular caregiver.
Specific Attachment (7 - 9 months)
Special preference for a single attachment figure (Infants show a preference
for one caregiver).
The baby looks to particular people for security, comfort, and protection. It
shows fear of strangers (stranger fear) and unhappiness when separated from
a special person (separation anxiety).
Some babies show stranger fear and separation anxiety much more
frequently and intensely than others, nevertheless, they are seen as evidence
that the baby has formed an attachment. This has usually developed by one
year of age.
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Multiple Attachment (10 months and onwards)
Attachment behaviors are displayed towards several different people
including mothers, fathers, grandparents, siblings and neighbors.
The baby becomes increasingly independent and forms several attachments.
By 18 months the majority of infants have formed multiple attachments.
The multiple attachments formed by most infants vary in their strength and
importance to the infant.
Figure (1): Development of attachment.
TEMPERAMENT
A set of in-born traits that organize the child‘s approach to the world. It s an
aspect of personality concerned with emotional dispositions and
reactions. Temperament is used to describe the prevailing or typical mood in a
person.
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Types of Temperament
There are three major types of temperament: easy, difficult, and slow-to-
warm-up. They constitute 65% of children, the remaining 35% cannot be
consistently categorized.
1. Easy
Babies have positive moods; their body functions operate regularly, and they
are adaptable.
Babies quickly establishing regular routines in infancy and adapts easily to
new experiences.
It describes about 40% of children.
2. Difficult
Babies have negative moods and are slow to adapt to new situations
When confronted with a new situation, they tend to withdraw.
It describes about 10% of children.
3. Slow-to-warm-up
Babies are inactive, showing relatively calm reactions to their environment.
Their moods are generally negative, and they withdraw from new situations,
adapting slowly.
It describes about 15% of children.
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IDENTITY
Definition
Identity is an individual‘s sense of self defined by (a) a set of physical,
psychological, and interpersonal characteristics that is not wholly shared with any
other person. Identity implies all of the beliefs, ideals, and values that help shape
and guide a person's behavior. It includes self-awareness, gender identity, self-
concept and self-esteem. Consequences of troubling identity during adolescent
may lead to depression and/or suicide.
Self–awareness
Self-awareness [or who I am?] is the knowledge of self.
It begins to grow during infancy around 12 months and becomes much more
developed by approximately 18 to 19 months of age.
It is assessed by the mirror and rouge task (Figure 2). Most infants touch
their nose to attempt to wipe off the rouge at 15:19 months.
Figure (2): Mirror and rouge test to examine self-awareness.
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Gender identity:
During early childhood there is a developing of maleness and femaleness
identity. Gender, the sense of being male or female, is well established in
preschoolers.
Gender identity is manifested in play where preschool boys increasingly
play with boys and girls tend to play with girls.
Gender out-weighs ethnic variables when it comes to play: an Asian
American boy would prefer to play with an African American boy than with
an Asian American girl.
Preschoolers begin to develop expectations about appropriate behavior for
boys and girls: they expect males to be more independent, forceful and
competitive and females to be warm and submissive.
Self-concept
Self-concept is how person perceive his/her behavior, abilities, and unique
characteristics.
During late childhood, children continue their efforts to answer the question
―Who am I?‖ as they seek to understand the nature of the self. They start to
view themselves in terms of psychological attributes in addition to their
physical attributes.
Children‘s self-concept becomes general self-concept (Figure 3).
Self-esteem
It is a confidence in oneself, a satisfaction of what one is and the self-respect
that that confidence brings.
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It decreases as the child transmits from elementary school to the middle
school then increases again.
Similar terms include self-respect, self-love, self-regard, self-confidence,
self-integrity and self-worth.
Cycle of self-esteem
If self-esteem is low in late childhood, the result can be a cycle of failure.
If a child has low self-esteem and expects to do poorly on a test, he/she may
experience anxiety and not do as well, which confirms the negative self-
view (Figure 4).
Parents can break this cycle using warm and supportive style.
Social Comparison
It is the evaluation of one‘s own behavior, abilities, expertise, and opinions by comparing them to those of other.
Children especially during late childhood look to others who are
similar to themselves. Sometimes children make downward social
comparisons with others who are obviously less competent or
successful to raise or protect their self-esteem.
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Figure (3): Diagram of self-concept model.
Figure (4): Cycle of low self-esteem.
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PSYCHOSOCIAL DEVELOPMENT
Psychosocial development is just a fancy phrase that refers to how a
person‘s individual needs (psycho) mesh with the needs or demands of society
(social). Erikson's theory described the impact of social experience across the
whole lifespan. Erikson was interested in how social interaction and relationships
played a role in the development and growth of human beings.
Erikson maintained that personality develops in a predetermined order
through eight stages of psychosocial development (Table 2 and Figure 5), from
infancy to adulthood. During each stage, the person experiences a psychosocial
crisis which could have a positive or negative outcome for personality
development.
Table (2): Stages of Erik Erikson's theory of psychosocial development.
Stage Period and Age
1. Trust vs. Mistrust Infancy: birth to 1 year
2. Autonomy vs. Shame and Doubt Infancy: 1-2 years
3. Initiative vs. Guilt Early childhood: 3-5 years
4. Industry vs. Inferiority Late childhood: 6-11 years
5. Identity vs. Confusion Adolescences: 12-14 years
6. Intimacy vs. Isolation Young adulthood: 20-40 years
7. Generativity vs. Stagnation Middle adulthood: 40-60 years
8. Integrity vs. Despair Late adulthood: over 60 years
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Figure (5): Stages of Erik Erikson's theory of psychosocial development.
1. Trust vs. Mistrust
This stage begins at birth and continues to approximately one year.
During this stage, the infants are uncertain about the world in which they
live and look towards their primary caregivers for stability and consistency
of care. Therefore, they develop a sense of trust or mistrust, depending on
how well their needs are met by their caregivers.
If the infants receive consistent, predictable and reliable care, they will
develop a sense of trust which will carry with them to other relationships,
and they will be able to feel secure even when threatened.
If the care has been inconsistent, unpredictable and unreliable, then the
infants may develop a sense of mistrust, suspicion, and anxiety. In this
situation the infants will not have confidence in the world around them or in
their abilities to influence events.
Success in this stage will lead to the virtue of hope.
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2. Autonomy vs. Shame and Doubt
This stage occurs between the ages of 1 to approximately 2 years.
Children at this stage are focused on developing a sense of personal control
over physical skills and a sense of independence.
Children develop either ―independence and autonomy‖ (if they are allowed
the freedom to explore) or ―shame and doubt‖ (if they are restricted and
overprotected).
By allowing kids to make choices and gain control, parents and caregivers
can help children develop a sense of autonomy.
Erikson believed that achieving a balance between autonomy and shame and
doubt would lead to will, which is the belief that children can act with
intention, within reason and limits.
Success in this stage will lead to the virtue of will.
3. Initiative vs. Guilt
This stage occurs between the ages of 3 to approximately 5 years.
During the initiative versus guilt stage, children assert themselves more
frequently through directing play and other social interaction. It
encompasses changes in the understanding individuals have of themselves as
members of society, and in their comprehension of the meaning of others‘
behavior.
Central to this stage is play, as it provides children with the opportunity to
explore their interpersonal skills through initiating activities. Children begin
to plan activities, make up games, and initiate activities with others. If given
this opportunity, children develop a sense of initiative and feel secure in
their ability to lead others and make decisions.
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During this stage, children experience conflict between independence of
action and the sometimes negative results of that action. Conflict occurs
between the desire to become more independent and autonomous and the
guilt that may occur.
Preschoolers with supportive parents will be independent and autonomous
while preschoolers with restrictive, overprotective parents will feel shame
and self-doubt.
4. Industry vs. Inferiority
This stage occurs between the ages of 6 to approximately 11years.
Through social interactions, children begin to develop a sense of pride in
their accomplishments and abilities.
Children need to cope with new social and academic demands. Success leads
to a sense of competence, while failure results in feelings of inferiority.
School and social interaction play an important role during this time:
children who are encouraged and commended by parents and teachers
develop a feeling of competence and belief in their skills. Those who receive
little or no encouragement from parents, teachers, or peers will doubt their
abilities to be successful.
Successfully finding a balance at this stage of psychosocial development
leads to the strength known as competence, in which children develop a
belief in their abilities to handle the tasks set before them.
Therefore, this stage is characterized by a focus on efforts to attain
competence in meeting the challenges presented by parents, peers, school,
and the complexities of the world.
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5. Identity vs. Confusion
The fifth psychosocial stage takes place during the often turbulent teenage
years.
This stage plays an essential role in developing a sense of personal identity
(conscious sense of self that adolescents develop through social interaction,
which is constantly changing due to new experiences and information they
acquire in their daily interactions with others) which will continue to
influence behavior and development for the rest of a person's life.
During adolescence, children explore their independence and develop a
sense of self. Those who receive proper encouragement and reinforcement
through personal exploration will emerge from this stage with a strong sense
of self and feelings of independence and control. Those who remain unsure
of their beliefs and desires will feel insecure and confused about themselves
and the future.
6. Intimacy vs. Isolation
This stage takes place during young adulthood between the ages of
approximately 20 to 40 years.
Young adults need to form intimate, loving relationships with other people.
Success leads to strong relationships, while failure results in loneliness and
isolation.
Those who are successful at this step will form relationships that are
enduring and secure.
Remember that each step builds on skills learned in previous steps. Erikson
believed that a strong sense of personal identity was important for
developing intimate relationships. Studies have demonstrated that those with
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a poor sense of self tend to have less committed relationships and are more
likely to struggler with emotional isolation, loneliness, and depression.
Successful resolution of this stage results in the virtue known as love. It is
marked by the ability to form lasting, meaningful relationships with other
people.
7. Generativity vs. Stagnation
This stage takes place during middle adulthood between the ages of
approximately 40 to 60 years.
Adults need to create or nurture things that will outlast them, often by
having children or creating a positive change that benefits other people.
Success leads to feelings of usefulness and accomplishment, while failure
results in shallow involvement in the world.
During adulthood, adults continue to build their lives, focusing on their
career and family. Those who are successful during this phase will feel that
they are contributing to the world by being active in their home and
community. Those who fail to attain this skill will feel unproductive and
uninvolved in the world.
8. Integrity vs. Despair
The final psychosocial stage occurs during old age and is focused on
reflecting back on life.
This stage is focused on reflecting back on life.2 At this point in
development, people look back on the events of their lives and determine if
they are happy with the life that they lived or if they regret the things they
did or didn't do.
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Older adults need to look back on life and feel a sense of fulfillment.
Success at this stage leads to feelings of wisdom, while failure results in
regret, bitterness, and despair. Those who are unsuccessful during this stage
will feel that their life has been wasted and may experience many regrets.
FRIENDSHIP
The feeling of wanting to be part of a group and liked by others is natural.
One way we meet our need for connection is through our friendships. Friendship
means different things to different people depending on age, gender, and cultural
background. Common among all friendships is the fact that they are interpersonal
relationships of choice. Friendship has different stages, each with specific
characteristics.
Stages of Friendships
1. During Infancy:
During this stage, it‘s hard to talk about friendship in the strict sense. Infants
start and maintain more interactions with people they know than with people
they don‘t. This preference implies that children trust people they can
identify.
It is the beginning of friendships, where the child chooses who to play
with and who to demonstrate affection to.
2. During Childhood:
During early childhood period, children understand and analyze friendships
from an egocentric point of view. They don‘t differentiate between their own
perspective and the perspective of others. Generally, children are friends
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with those who live close to them, or with classmates. In summary, they are
unstable relationships based on proximity. Parents and caregivers control
and direct children‘s friendships at this age.
There is sex segregation (lack of cross-gender interaction). Therefore; boys‘
and girls‘ friendships are restricted to members of their own sex. Children s
friendships are almost entirely sex-segregated.
During late childhood period, there is an evoke of social competence (The
collection of social skills that permit individuals to perform successfully in
social settings). Those with higher social competence are known as popular
children and make good friendships.
Characteristics of popular children:
They are helpful and cooperative.
They have a good sense of humor.
They have good emotional understanding.
They ask for help when necessary.
They are not overly reliant on others.
They can adapt to social situations.
They can read others‘ nonverbal behavior and control their own.
3. During Adolescents
Adolescence is the most important period for peer relationship.
Characteristics:
Social comparison: They provide each other with opportunity to compare
and evaluate opinions, abilities and even physical change.
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Reference groups (groups of people with whom one compares oneself).
Adolescence present a set of norms or standards against which adolescents
can judge their abilities and social success.
Gender relationship: There is moving from sex segregation to the interest in
other sex.
PLAY
Play is an important part of the children development. Through play
children learn about shapes, colors, cause and effect, and themselves. Besides
cognitive thinking, play helps the child learn social and psychomotor skills. It is a
way of communicating joy, fear, sorrow, and anxiety.
It is a universal language of childhood and the key that helps unlock the door
to learning
Definition
Play is the work of children. It consists of those activities performed for self-
amusement that have behavioral, social, and psychomotor rewards. It is child-
directed, and the rewards come from within the individual child; it is enjoyable and
spontaneous.
Functions of Play
While playing, children learn and develop important skills they will continue
to use throughout their lifetime. Play has a major role in children development
including physical, cognitive, social and personality development (Table 3).
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Table (3): Functions of play.
Aspect Effect of Play
Physical
development
Developing both fine and gross motor skills.
Cognitive
development
Children gain knowledge through their play. They exercise
their abilities to think, remember, and solve problems.
Social
development
Role play could decrease anxiety and increase self-
awareness.
As the infant begins to play with others and with objects, a
realization of self as separate from others begins to develop.
Personal
development
When children engage in play with their peers and families,
they begin to learn some behaviors are acceptable while
others are unacceptable.
Development
There are six stages of play during periods of development, all of which are
important for child‘s development. All of the stages of play involve exploring,
being creative, and having fun. This list explains how children‘s play changes by
age as they grow and develop social skills (Figure 6).
1. Unoccupied Play (Birth-3 Months):
At this stage baby is just making a lot of movements with the arms, legs,
hands, feet, etc.
Infants are learning about and discovering how their body moves.
2. Solitary Play (Birth-2 Years):
This is the stage when a child plays alone. They are not interested in playing
with others quite yet.
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It involves simple, repetitive activities that are, doing something for the sake
of being active such as playing with dolls, skipping and jumping rope.
3. Spectator/Onlooker Behavior (2 Years):
During this stage a child begins to watch other children playing but does not
play with them.
The child may engage in forms of social interaction, such as conversation
about the play.
4. Parallel Play (2+ Years):
When a child plays alongside or near others but does not play with them.
Children may play with similar toys, in a similar manner, but do not interact
with each other.
5. Associate Play (3-4 Years):
When a child starts to interact with others during play, but there is not a
large amount of interaction at this stage.
Children begin to play together but in a loose sense rather than by organising
games together.
For example, kids might all be playing on the same piece of playground
equipment but all doing different things like climbing, swinging, etc.
6. Cooperative Play (4+ Years):
When a child plays together with others and has interest in both the activity
and other children involved in playing.
Children play together; they create organised make-believe games such as
doctors and nurses, mommy's and daddy's or teachers.
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Unoccupied Play
Solitary Play
Onlooker Play
Parallel Play
Associative Play
Cooperative Play
Figure (6): Different stages of play.
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References
Haywood K, Haywood KM and Getchell N (2019): Life Span Motor
Development. 7th
ed. Human Kinetics.
Payne Vg, Yan JH. and Block M (2010): Human Motor Development
in Individuals with and without Disabilities. Nova Science Publishers,
Inc. New York.
