Clinical evaluation of development from birth to five years
Table 6.8 (continued)
Context Recommended Comments
investigations
of DiGeorge syndrome, Williams syndrome,
and pseudohypoparathyroidism, and where
motor delay is due to vitamin D deficiency
Second-line tests
The above first-line investigations PLUS:
Associated abnormal MRI In some cases MRI studies can show a
head size (micro- or Where aCGH not available characteristic signature for metabolic,
macrocephaly), karyotype and specific neurocutaneous and degenerative disorders
seizures, focal molecular genetic tests, and can even give enough information to
neurological e.g. looking for 22q direct subsequent genetic testing
features including deletion in oromotor and
severe oromotor speech dysfunction Key pointers for metabolic disorders in the
impairment and clinical history include consanguinity,
speech abnormality Metabolic investigations: failure to thrive and episodic
Specific history or serum amino acids, neurodevelopmental decompensations
examination findings ammonia, VLCFA, (often during minor illnesses). Examination
suggestive of carnitine, homocysteine, findings may include coarse facial features
neurometabolic disialotransferrin or hepatosplenomegaly
disorders Urine: organic acids,
orotate, GAGs, In Angelman syndrome, characteristic EEG
Specific history or oligosaccharides changes may precede seizures. Diagnosis is
examination findings EEG confirmed by deletion or uniparental disomy
suggestive of on chromosome 15
epilepsy or specific Referral to a paediatric Specific EEG changes also may help in rare
behavioural neurologist/ presentations such as regression in language
phenotypes, e.g. consultation for planning and differentiation of seizure-like episodes
Angelman syndrome further appropriate such as in Rett syndrome
investigations In many countries human immunodeficiency
Regression with or virus (HIV) infections are becoming an
without associated important cause of regression with
features neurological and neuropsychiatric
manifestations usually presenting in the first
3 years of life
CMV, cytomegalovirus; EEG, electroencephalogram; FISH, fluorescence in situ hybridization; GAG, glycosamino-
glycan; MRI, magnetic resonance imaging; U&E, urea and electrolytes; VLCFA, very long-chain fatty acids.
38
General patterns of development
children presenting with significant developmental • Sight: Where examination of the optic discs and
delay, global or domain-specific, have long-term fundi is necessary (e.g. for septo-optic dysplasia
cognitive and functional impairments. or raised intracranial pressure) refer to an
ophthalmologist or paediatrician. All children
CLINICAL DECISION-MAKING AND with significant developmental disorders
SEVERITY OF DEVELOPMENTAL DELAY should be referred to ophthalmology for this
examination.
Developmental delay in any given domain that is
equivalent to 50% or less of the expected mile- • Hearing: Refer to audiology where there is
stones at a given chronological age is always signif- any delay in language development or signifi-
icant and requires further investigations. Children cant learning or other developmental disorders.
with less marked (‘moderate’) delay may or may Some sensorineural losses may be progressive;
not have a developmental disorder. The delay is some children will have persistent middle ear
more likely to be significant if global (i.e. across problems.
several domains including language and cognition)
or where associated with other significant findings • Dysmorphism and malformations: Dysmorphic
or risk factors in the history and examination. features and congenital malformations may sug-
If there are any abnormal physical findings such gest a particular syndrome or aetiology (e.g. fetal
as microcephaly or macrocephaly on neurological alcohol syndrome).
examination, then further investigation would be
warranted without further delay. The context of a • Skin: Look for pigmented and hypopigmented
full social, family and medical history and physi- spots. With significant developmental delay, and
cal examination will help decide whether to watch especially with epilepsy, a Wood’s ultraviolet
and wait, promptly investigate, or refer on to other light examination is required (for ash-leaf skin
specialists for further assessment and intervention. patches in tuberous sclerosis).
PHYSICAL EXAMINATION PLANNING MEDICAL INVESTIGATIONS
The physical examination is generally left to the Part of the responsibility of diagnosing a child
end of the assessment as any upset to the child with developmental disorder is to consider any
would interfere with a subsequent developmental potential contributing medical causes and whether
examination. The following key guidelines should any associated or exacerbating condition, such as
be observed: hypothyroidism in Down syndrome or hearing loss
coexisting with autism, is present. Decisions con-
• Motor function: Determine whether there is cerning further investigations need to be based on
a motor disorder or if any delay is part of a the likelihood of a condition being present, the
global learning difficulty. Observe movement consequences of a missed diagnosis, the benefits of
patterns and posture during the developmental early diagnosis (e.g. genetic advice) and the conse-
examination, interaction and play. Formal quences for parental planning and coping. There
examination of tone, reflexes and power is should be a low threshold for getting hearing or
largely confirmatory. vision checks undertaken.
• Symmetry: Any significant asymmetry of motor Investigations will depend on the type of devel-
skill, tone, reflexes or limb size may indicate opmental disorder and associated findings from
hemispheric dysfunction or other pathology. the history and examination. The diagnostic yield
is highest for global developmental delay with
• Growth: Measure head circumference, height associated history or physical abnormalities on
and weight and plot on a centile growth chart. examination, and lowest for isolated developmen-
Compare the consistency of the parameters and tal problems.
assess the growth rate. Both macrocephaly and
microcephaly may be associated with neurode- The advent of genetic screening tests with
velopmental disorders. Macrocephaly is more increasing breadth – microarray-based compar-
usually familial and it is advisable to measure ative genomic hybridization (array CGH, or
the parents’ head circumference. aCGH) – has led to a significant increase in
positive yield alongside a large number of ‘false
positives’ in the form of benign rearrangements
39
Clinical evaluation of development from birth to five years
of DNA picked up by aCGH. Table 6.8 offers an a date for review and identification of a lead/key
outline of the current evidence-based guidance for worker for the family.
investigations.
REFERENCES
DEVELOPMENTAL DIAGNOSIS
AND MANAGEMENT [1] Shonokoff JP, Phillips DA (eds). (2000) From
Neurons to Neighbourhoods: The Science of Early
Evaluation of a child’s developmental abilities Childhood Development. Washington, DC: National
requires paying attention to factors that may Academy Press.
impinge upon a child’s performance, such as anx-
iety or impulsivity, potentially indicating a need [2] Baron-Cohen S, Wheelwright S, Cox A et al. (2000)
for repeat assessment. Functional difficulties in Early identification of autism by the Checklist for
daily living and the impact of social and biological Autism in Toddlers (CHAT). Journal of the Royal
risk factors are also relevant. Therapy or other Society of Medicine 93, 521–5.
intervention may be required even in the absence
of developmental delay. Good inter-agency liaison [3] Ruff HA, Rothbart MK. (1996) Attention in
can provide additional information on the child’s Early Development: Themes and Variations. Oxford,
behaviour in different settings and is essential Oxford University Press.
where children have complex needs. This may
reveal concerns regarding a child’s protection FURTHER READING
or care. Early discussions with experienced col-
leagues and an inter-agency approach are essential Bee H. (2007) The Developing Child. Boston: Pearson.
for identification or prevention of potential risk to Buckley B. (2003) Children’s Communication Skills:
the child.
From Birth to Five Years. London: Routledge.
Finally, a clear management plan is required, Egan DF. (1990) Developmental Examination of
incorporating referrals and further investigations,
Preschool Children. Oxford: Mac Keith Press.
Hopkins B (ed.) (2005) The Cambridge Encyclopedia of
Child Development. Cambridge University Press.
Sharma A, Cockerill H. (2007) From Birth to Five
Years – Mary D Sheridan (revised and updated). Lon-
don: Routledge.
40
General patterns of development
7
Early Social and Emotional Experience
Matters: The First Year of Life
Howard Steele
Department of Psychology, New School for Social Research, New York, NY, USA
What do infants feel? When, why and with what development include the child’s biological make-
consequences? This chapter is informed by a up, in part determined by prenatal experiences as
functionalist theory of emotion that assumes that much current research highlights [5], the marital
emotions evolved as adaptive, survival-promoting relationship, the wider family network, social
processes with intrapersonal and interpersonal economic factors, neighbourhood and broader
regulatory functions [1–3]. For example, Bowlby cultural forces [6,7]. Yet the architect of this
[4] proposed that fear of the dark, and fear of being multilayered view of contextual influences in child
alone, are adaptive because there is an obvious development, Uri Bronfenbrenner, maintained
link between these events and potential danger. that the family, and in particular the main caregiver
Emotions, in this view, are organizers of personal (typically the mother) is the filter through which
and interpersonal life, enhancing or restricting all other influences have their immediate effect.
development and mental health. The range of
emotions a young child feels, and gives expression Early social interactions between caregivers and
to, stem from the meaning social interactions infants matter greatly because patterns of inter-
impart, and in turn influence the expectations and action become established and consolidated over
appraisals one has vis-a` -vis the self and others. In the first year of life into relationship or attachment
other words, the experience of an emotion may be patterns [8,9] that (i) tend to persist and (ii) have
the result of – or the cause of – social interactions. a potentially long-lasting influence on personality
For example, stranger anxiety (which typically and mental health [10] (see also Chapter 15). Six
appears at 8–9 months of age) may lead an infant core infant emotional responses are highlighted
to cling to the mother and only feel settled when in this chapter, each calling for sensitive responses
she holds the baby close saying ‘I am here for from caregivers. Two appear in the neonatal period
you’. Through repetition, this kind of interaction or soon after – (i) crying and (ii) smiling – and four
will lead the infant to have a sense of trust in others appear in consolidated and consistent ways
the mother, and a hopeful attitude in the face of only in the second half of the first year – (iii) sad-
distress. On the other hand, a different lesson may ness, (iv) surprise, (v) anger and (vi) fear. Normal
be learned when infant stranger anxiety is met with age-related shifts in these emotions are high-
an insistence by the caregiver that she must leave, lighted, notwithstanding individual differences
and the baby must manage on his or her own with linked to deficits in neurobiological make-up, or
the stranger. This interaction, if repeated, may social experience. A core take-home message is
accentuate the child’s anxiety and contribute to a how all children, whatever their make-up, will
sense of mistrust in the mother (and others). Other thrive to the best of their ability if their social
forces that influence infant social and emotional and emotional needs are noticed and responded
to in a way that does not overwhelm, or lead to a
Child Psychology and Psychiatry: Frameworks for practice, Second Edition. Edited by David Skuse, Helen Bruce,
Linda Dowdney and David Mrazek.
2011 John Wiley & Sons, Ltd. Published 2011 by John Wiley & Sons, Ltd.
41
Early social and emotional experience matters: the first year of life
feeling of neglect. Familiarity with the normative descriptions of emotion, in response to infants’
sequence of emotional development in the first emotional expression, is likely to promote chil-
year of life, outlined in this chapter, may aid the dren’s accuracy in labelling and understanding
professional and parent alike in knowing how and emotional expressions, and sequences [13,14].
when to respond to infants’ emotional signalling.
Newborns do not smile, or only appear to smile
CRYING as when the corners of their mouths upturn slightly
in a Mona Lisa way. Such positive expressions are
Newborn babies cry for typically about 30–60 min- fleeting and appear to indicate sensory comfort, for
utes in a 24-hour period. This is about 10–20% of example following a feed, or the passing of wind,
their waking time because newborns (fortunately) or otherwise becoming used to the good feelings
sleep for approximately 16 hours, or two-thirds of having some control over being a body in this
of the day. As with all behaviours, there is a wide world. This fleeting positive expression becomes
range of normal variation, but the 10% of infants more consistent and definite over the first 6–8
who cry for more than 3 hours per day are dis- weeks. By 8–10 weeks, there is progression to
tressed as much as half of their waking time. This what is a somewhat more elaborate closed or open
not only causes great concern to caregivers but is mouth smile linked to familiarity with what the
also linked to postnatal depression, marital stress infant is looking at, either animate (e.g. mother’s
and shaken baby syndrome. Fussiness appears to face) or inanimate (e.g. a mobile over the baby’s
peak at 6 weeks universally [11], but fortunately crib). For caregivers this is a noticeable advance,
very cranky newborns typically become much and infants of 2 months are frequently said to be
more settled by 3 months of age. And babies whose smiling. This unfolds into a full social chuckle in the
cries are responded to promptly and efficiently in 12–16-week period, completing the initial emer-
the first three months, in the context of high marital gence and organization of the smiling response
satisfaction, cry significantly less at 9 months [12]. such that frequent social smiling and laughter
are commonly seen only at 4 months. Positive
Infant cries have been reliably identified by joyful expressions take on an increasingly differen-
scientists, mothers and others as fitting one of tiated range, dependent on the interaction partner.
three types, indicating (i) hunger; (ii) fatigue or The developmental course of the smiling response
(iii) pain, the latter being a short, sharp, elongated appears to be the result of ‘hard-wired’ neurobio-
piercing sound followed by apnoea. The hunger logical programming insofar as smiles develop in
cry is one that builds steadily, while the fatigue babies who are born blind. Yet, the smile of the
cry is more of a whimper. Clearly, being in close person who has never had sight lacks much of the
proximity to an infant helps a caregiver to identify nuance and complexity seen in sighted people, who
correctly the source of the distress, and responding have had the benefit (and risk) of the full range of
promptly with sensitivity is the appropriate action. visually perceived social interaction [15].
SMILING OR JOY SURPRISE, ANGER AND SADNESS
The natural course of the smiling response is an Surprise, anger and sadness represent a chain of
instructional illustration of how emotional capac- emotions that result from a functioning memory
ities steadily and gradually appear only partly in and set of expectations regarding a hoped for
response to the quality of care received. In other experience or interaction. Surprise, indicated by
words, there are well-documented timetables by a vertical oval open mouth and raised eyebrows,
which certain positive and negative emotions show is the natural result when things don’t appear as
themselves on infants’ faces and in their behaviour. they should, or things don’t go our way. And
At the same time, the infant’s capacity for showing when restoration of the hoped for event or inter-
and sharing a wide range of emotions is related action does not follow, surprise can quickly turn
to the face the baby sees on the mother or father to protest or anger, with a characteristic furrowed
or other who assumes the responsibility of provid- brow and gritting of teeth [16]. And, finally, should
ing care. Attentive care, including simple verbal this not lead to a successful restoration of the
hoped for outcome, resignation and sadness, even
42
General patterns of development
depression, may follow [4]. The point here is that been noted repeatedly, particularly when a secure
a rather sophisticated cognitive appraisal process infant–caregiver attachment typifies the pattern of
underpins these emotional expressions, and it is relating. Where fear appears on an infant’s face or
only in the latter half of the first year that we see is indicated by his or her behaviour (e.g. freezing)
definite expressions of these facial expressions of in the presence of the caregiver, evidence suggests
emotion. The caregiver who reads well these emo- that there is a troubling disorganizing element to
tions on the face of his/her baby will know how the child’s relationship with the caregiver, one
valuable it is to speak aloud about the good reasons with long-term adverse mental health correlates
for feeling these emotions, and the diverse ways of (see Chapter 15).
addressing them. Here the point is that research
underlines how vital it is to speak to infants, espe- The identifiable facial expressions of these
cially from 4 months onwards, in a simple clear emotions – joy, sadness, surprise, anger and
way, describing what the infant is doing, appears fear – were noted by Darwin [2] and then shown
to want, and what one (or others) did or are doing to be recognizable around the globe by Ekman
in response. This is the ideal parental response to and his colleagues [16]. At the same time, the
shared or joint attention [1,13]. In this way, infants clarity and organization with which infants show
will learn the rewards of feeling a range of positive these emotions, and later demonstrate verbal
and negative emotions, blended emotions, sequen- labels for them, has been linked to sensitive and
tial and mixed emotions, coming to see the natural responsive care over the first year of life [12,13].
function and value of emotional experience. Deficits in labelling emotion faces have been
noted during middle childhood for those whose
FEAR early experience was deficient [20].
Interestingly, the appearance of an organized CONCLUSION
expression of fear is directly linked to the onset
of locomotion around 8–10 months, and the There is a paradox about early social and
cognitive-motoric achievement of object perma- emotional development regarding two matters
nence [17]. With organized knowledge that a of perhaps equal importance to note: (i) Infants
valued object can be out of sight, but remains in are far more perceptive and competent than was
mind, and can be recovered, infants show stranger appreciated 50 years ago, calling for respect and
anxiety [4], or 8-month anxiety [18]. Fearful sensitivity on the part of caregivers from earliest
protest may bring the caregiver back. Clinically, infancy, if not the moment of conception, forwards,
it is a source of concern when a 1-year-old infant and (ii) yet there is little evidence to support the
separates too easily from a caregiver without notion, very popular in 1970, that ‘bonding’ occurs
protest. Once able to move on their own, infants shortly after birth. The latter notion led to much
can easily find themselves in danger, looking (over) concern that no mother (or father) should
over a precipice. Fear is an adaptive response, miss out on the ‘vital’ opportunity to bond with
and one that typically leads to social referencing one’s infant in the seconds, minutes and hours
(looking at the trusted caregiver for cues as to after birth – an anxiety-provoking and unhelpful
how to behave). The powerful social influence of message. Social experience, and attunement
the trusted caregiver has been demonstrated in between caregivers and infants is vital, but mis-
classic experiments involving a visual cliff where takes on the part of caregivers, hopefully not major
a crawling infant is placed atop a flat surface that ones, are inevitable. It is both consistency of care,
looks (to the infant) as if proceeding would entail and reparation following a ruptured, incomplete
falling. It is actually a transparent surface that or confusing interaction [3], that typifies normal
can support the infant. On their own, infants are social development and optimal mental health out-
typically fearful of the apparently imminent fall, comes. Professionals and parents alike can benefit
and will not proceed. Yet, when their mother from this knowledge that occasional conflict is to
signals to them in a positive way, assuring them be viewed as inevitable and repair/resolution – to
it is safe, infants advance, conquering their fear be initiated by the caregiver – is seen as essential.
[19]. This effect of trust in the caregiver has A caregiver who invests in reliably repairing
ruptures in early infancy, following caregiver
43
Early social and emotional experience matters: the first year of life
misunderstanding, interference or neglect, is [10] Sroufe LA. (2005) Attachment and development:
likely to realize the rewards of having a socially A prospective, longitudinal study from birth to
competent child in the future, someone capable adulthood. Attachment and Human Development
of establishing and maintaining meaningful and 7, 349– 67.
healthy social relationships.
[11] Barr RG, Konner M, Bakeman R, Adamson L.
REFERENCES (2008) Crying in !Kung san infants: A test of
the cultural specificity hypothesis. Developmental
[1] Bretherton I, Fritz J, Zahn-Waxler C, Ridgeway D. Medicine and Child Neurology 33, 601– 10.
(1986) Learning to talk about emotions: A function-
alist perspective. Child Development 57, 529– 48. [12] Belsky J, Fish M, Isabella R. (1991) Continuity
and discontinuity in infant negative and posi-
[2] Darwin C. (1872) The Expression of Emotion in tive emotionality: Family antecedents and attach-
Man and Animals. London: Harper Collins. ment consequences. Developmental Psychology 27,
421– 31.
[3] Tronick E. (1989) Emotion and emotional com-
munication in infants. American Psychologist 44, [13] Steele H, Steele M, Croft C, Fonagy P. (1999) Infant-
112– 19. mother attachment at one-year predicts children’s
understanding of mixed emotions at six years. Social
[4] Bowlby J. (1973) Attachment and Loss: Vol. 2, Sep- Development 8, 161–78.
aration, Anxiety and Anger. London: The Hogarth
Press. [14] Steele H and Steele M. (2008) Early attachment
predicts emotion recognition at 6 and 11 years.
[5] O’Connor TG, Heron J, Glover V. (2002) Ante- Attachment and Human Development 10, 379– 93.
natal anxiety predicts child behavioral/emotional
problems independently of postnatal depression. [15] Fraiberg S. (1968) Parallel and divergent patterns in
Journal of the American Academy of Child & Ado- blind and sighted infants. The Psychoanalytic Study
lescent Psychiatry 42, 1470– 7. of the Child 23, 264– 300.
[6] Bronfenbrenner U. (1978) The Ecology of Human [16] Ekman P. (2003) Emotions Revealed. New York:
Development: Experiments by Nature and Design. Henry Holt & Co.
Boston: Harvard University Press.
[17] Piaget J. (1954) The Construction of Reality in the
[7] Mayes LC, Gilliam WS, Sosinsky LS. (2006) The Child. London: Routledge and Kegan Paul.
infant and toddler. In: Andres M and Volkmar
FR (eds), Lewis’s Child and Adolescent Psychiatry: [18] Spitz R. (1950) Anxiety in infancy: A study of its
A Comprehensive Textbook, 4th edn. Philadelphia: manifestations in the first year of life. The Interna-
Walters Kluwer, pp 252– 60. tional Journal of Psychoanalysis 31, 138– 43.
[8] Ainsworth MS, Blehar MC, Waters E, Wall S. (1978) [19] Sorce JF, Emde RN, Campos J, Klinnert MD. (1985)
Patterns of Attachment: A Psychological Study of the Maternal emotional signaling: Its effect on the visual
Strange Situation. Oxford: Lawrence Erlbaum. cliff behavior of 1-year olds. Developmental Psy-
chology 21, 195–200.
[9] Bowlby J. (1960) Grief and mourning in early child-
hood. Psychoanalytic Study of the Child 15, 9–2. [20] Pollak SD, Cicchetti D, Hornung K, Reed A.
(2000) Recognizing emotion in faces: Developmen-
tal effects of child abuse and neglect. Developmental
Psychology 36, 679–88.
44
General patterns of development
8
Language Development
Thomas Klee and Stephanie F. Stokes
Department of Communication Disorders and New Zealand Institute of Language, Brain & Behaviour,
University of Canterbury, New Zealand
WHAT’S NEW
• Researchers are beginning to explore psycholinguistic processing measures, such as
non-word repetition, as clinical markers of language impairment in very young children.
Poor performance on these psycholinguistic tasks (measures of verbal short-term memory) is
indicative of late language onset (‘late talking’). However, the direction of the relationship
between memory and language development remains contentious and further work on the
earliest phases of language learning will shed light on this issue.
• Usage-based models of language development lead to a more integrated view of what
develops when, and holistic assessments of language growth.
• Multidisciplinary work in developmental science (e.g. neural imaging, statistical modelling,
behavioural and molecular genetics, computational modelling) will shed new light on the
mechanisms and phases of language development.
The ability to communicate using language is one PROCESSES AND COMPONENTS
of the most basic human traits. Doing so involves OF LANGUAGE DEVELOPMENT
learning to understand and produce an abstract
and complex linguistic code that provides the foun- The top part of Figure 8.1, adapted from a causal
dation for social interaction, personal relation- model of developmental disorders [1], illustrates
ships, reading and writing, problem-solving, formal the relationship between language development
learning and personal well-being. By the time chil- and some of the factors known to affect it. This sim-
dren enter school at the age of 4 or 5, most have plified model illustrates the interaction between
achieved near adult-like mastery of the sounds and the child’s genetic endowment and his or her envi-
grammar of their native language(s) and are able to ronment, as would be the case in any area of devel-
communicate with others effectively. This chapter opment. In the case of language development, the
presents some of the main developmental mile- human genotype enabled a species-specific endow-
stones in the language development of preschool ment for linguistic processing [2], the precise extent
children developing in a typical manner, and some of which is still not entirely known. The model also
of the factors likely to be involved. First, we begin specifies a key role played by the environment,
with an overview of the territory. both in the form of human (social) interaction
Child Psychology and Psychiatry: Frameworks for practice, Second Edition. Edited by David Skuse, Helen Bruce,
Linda Dowdney and David Mrazek.
2011 John Wiley & Sons, Ltd. Published 2011 by John Wiley & Sons, Ltd.
45
Language development
Genotype Environmental stimulation:
Social interaction, language
Neurobiology
input, etc.
Cognitive mechanisms:
Memory, psycholinguistic
processing, etc.
Cognitive development Psychosocial development Motor development
Language development
Comprehension (receptive language)
Production (expressive language)
Language content: Language form: Language use: Language modality:
Semantics (vocabulary, etc.) Grammar (syntax, morphology ), Pragmatics Spoken language, sign language,
Phonology ( phonemes, prosody)
written language
Figure 8.1 Processes, components and modalities of language development.
and language input. The junction of these can be chain of events by which a message generated by
seen in adults’ use of a speech register known as the brain is neurologically relayed to muscles that
child-directed speech – developmentally sensitive move the structures of the vocal tract.
speech and language adjustments made by parents
and others when talking to children. Both genetic In the figure, language is divided into three
and environmental factors affect the developing components: content, form and use [6]. Language
brain and its neurobiological mechanisms. These content, or semantics, refers to how meaning is
in turn underpin cognitive mechanisms, such as conveyed by linguistic elements such as words,
psycholinguistic processing [3,4] and verbal mem- idioms and sentences. Language form encom-
ory [5], which affect how language develops in the passes grammar and phonology. One aspect of
child. The child’s language ability is also affected grammar involves the rules governing how words
by developments in the cognitive, psychosocial and are combined to form phrases and sentences (syn-
motor domains. tax). For example, the grammar of English requires
that the subject precedes the verb (e.g. ‘I should
The bottom part of the figure depicts various go.’) in declarative sentences while in questions,
components and modalities involved in under- the verb precedes the subject (e.g. ‘Should I go?’).
standing and producing language. Language com- Another aspect of grammar relates to the struc-
prehension (sometimes referred to as receptive ture of words (morphology). For example, in
language in clinical contexts) refers to the pro- English the past tense form of regular verbs is
cess of decoding speech – the chain of events in created by adding the ‘-ed’ inflection to the verb
which sound waves produced by the vocal tract stem (e.g. ‘climbed’). Language form also involves
of a human speaker are received, processed and the language’s sound system (phonology): both
given meaning by a human listener. Language its contrastive sound segments (e.g. phonemes
production (sometimes referred to as expressive such as /p/, /t/ and /k/) and prosodic features
language) refers to the process of encoding – the such as stress and intonation. Language use refers
46
General patterns of development
to the interpersonal, communicative functions of also be due to differences in definitions or research
language during social interaction (pragmatics), methods employed by researchers. For example,
such as a speaker’s communicative intentions. The proposed sequences of speech sound development
model also illustrates various modalities through may be affected by whether children’s speech is
which language can be communicated, such as its recorded during spontaneous conversations with
spoken, signed or written forms. adults or during picture-naming tasks when words
are elicited singly. It can also be influenced by the
This model is implicitly reflected in current theo- methods of data analysis – for example, whether
ries of language development, such as usage-based children’s speech forms are analysed on their own
accounts [7,8], in which general learning processes (phonetic inventory) or in relation to adult forms
and cognitive mechanisms underpinning language (phonemic inventory). Further, the national vari-
development are mediated by environmental ety (e.g. American, British, Australian or New
factors. Cognitive mechanisms include such things Zealand English) or dialect (e.g. African American
as pattern recognition and intention reading. English) of the spoken language will also exert an
Pattern recognition occurs when a child associates effect on the acquisition sequence. In what follows,
new information with something already known, we summarize general patterns of development in
recognizing similarities, such as when the child, typically developing children.
knowing that the utterance ‘eat apple’ describes
that event, says ‘eat bread’ to describe a similar DEVELOPMENTAL PHASES
event. Intention reading includes joint attention,
such as when the adult and child share a focus on After 6–7 months of gestation, the fetus responds
objects, events or interactions, or using pointing to sound, including the human voice, and at birth
and gesturing to indicate objects and events. There infants prefer to listen to sounds heard before birth,
is little differentiation between the lexicon and such as the mother’s heartbeat and her voice. In the
syntax in early language development; rather, the first 6 months of life the infant is highly responsive
child is learning to express relations in the world, to adult interaction, intently watching human faces
such as ‘doggie eat’ to describe a dog eating, and turning in the direction of sounds. Turn-taking
rather than grammatical relations such as subject emerges and infants imitate adult tongue protru-
+ verb. Language development is defined as sion or raspberry blowing and laugh in response to
form-function mappings or construction building. the human voice. By 2 months of age infants can
discriminate between phonemes [11] and produce
MILESTONES OF SPEECH a wide range of speech-like sounds, including those
AND LANGUAGE DEVELOPMENT not present in their own language[s].
It is beyond the scope of this chapter to present Between 6 and 12 months the infant’s motor
detailed charts outlining children’s speech and and cognitive development advances at a rapid
language development. These can be found on pace. Sitting and crawling afford the opportunity
the websites listed at the end of this chapter. to explore the environment, increasing opportu-
nities for object manipulation and learning about
While the sequence of developmental speech object function, shape and taste. The infant also
and language milestones is broadly similar across begins to appreciate the role of others as agents
children, there is wide variability in terms of when of change, as seen by the use of simple commu-
these are reached due to individual differences [9]. nicative gestures, some of which are accompanied
Milestones indicate the average age of children by vocalizations, to indicate and request objects
when they attain particular features of expres- (e.g. pointing) and action (e.g. raising arms to
sive language such as speech sounds, vocabulary be lifted). At 6–7 months babbling emerges (e.g.
and syntactic constructions, as well as features ‘ba ba ba’) and becomes more diversified over
of receptive language. Both genetic and envi- the next few months. At around 9 months conven-
ronmental factors (e.g. the quality or quantity of tional social gestures emerge (e.g. waving goodbye,
language input [10]; the presence of developmental shaking head to indicate rejection). At around
delays or disorders), contribute to variations in the 11 months infants begin to lose the ability to
attainment of particular milestones. Differences discriminate among all phonemes, but begin to
between reported developmental sequences can
47
Language development
discriminate better the speech sounds of their own books. The child understands the locative ‘under’
language environment, fine-tuning their percep- and begins developing an awareness of causality,
tion to be language-specific [11]. At 10 months accompanied by an increase in asking ‘why’ ques-
the average receptive vocabulary size is about 50 tions and producing complex sentences (e.g. ‘he’s
words [12]. crying ‘coz he fell down’), but sometimes with word
order errors.
By 12–18 months the infant begins to under-
stand the intentions of others, engages in joint By 4 years, there is greater print awareness
attention (sharing attention and focus with an and metalinguistic awareness, demonstrated by an
adult) and attends to books for brief periods. appreciation of nursery rhymes. The child begins
Walking now contributes to a greater awareness to ask ‘who’ and ‘where’ questions. Play becomes
of self in space. This facilitates the development rule-based (e.g. role taking) and the child uses lan-
of comprehension of locative words, such as ‘in’ guage to organize and talk about their world (e.g.
and ‘on’, and simple questions like ‘what’s that?’ ‘you be the mummy’). Sentences contain embed-
and ‘where’s your teddy?’ Parents often report ded clauses and are almost adult-like (e.g. ‘don’t
that their child understands most of what is said to touch that ‘coz you’ll break it and I haven’t finished
them, an impression fostered by the child’s use of yet’). The child can now describe basic events, such
comprehension strategies, which capitalize on con- as their birthday party.
text in the absence of understanding exactly what is
said [13]. Basic representational play emerges dur- By 5 years the child understands purpose,
ing this phase (e.g. ‘drinking’ from a toy cup), along function and consequence questions (e.g. ‘how
with some single words. By now most children can can we open that jar?’, ‘what will happen if he
identify some body parts (‘where’s your nose?’) loses his keys?’). With knowledge of how objects
and pictures of family members. By 12 months, are oriented in space comes an understanding of
children’s average receptive vocabulary size is 85 more locatives (‘in front of’, ‘behind’, ‘next to’,
words, increasing to 250 words by 18 months; and ‘through’). The child can hold a conversation and,
by 20 months, some 75% of children are reported with an increase in schema (pattern) knowledge,
by their parents to be combining words [12]. can describe more abstract events, such as what
happens at birthday parties in general or how to
By 24 months representational play includes make a sandwich.
greater symbolism (e.g. using a block for a car).
The toddler shows an understanding of ‘what’ or ATYPICAL LANGUAGE DEVELOPMENT
‘where’ questions (e.g. ‘what x doing?’, ‘where
x going?’) and some children begin to use the While language development is very robust
pronouns ‘me’ and ‘you’ and grammatical markers for most, some children experience delays or
such as the ‘-ing’ verb inflection, plurals (‘cats’) problems in acquiring the sounds, meanings
and past tense ‘-ed’. While the average American and grammatical structures of their language
toddler has an expressive vocabulary size of while others experience difficulty using language
around 300 words by 24 months of age, large socially. Such delays may or may not be transient
individual differences exist (7 to 668 words) [12]. and are often the first signs of a problem related
Similar findings have been reported in 12 other to hearing, cognition or other developmental
languages [14]. It is difficult to estimate the size of domains. They may also be indicative of a primary
children’s vocabulary beyond the age of 2 years. language disorder (see Chapter 29) or a social
Psycholinguistic processing mechanisms can be communication disorder (see Chapter 23).
measured at 2 years, with most children being able
to imitate one-, two- and three-syllable nonsense Pertinent to this chapter is a group of children
words (e.g. ‘doe-per-lut’) [15]. with late onset of language, often referred to as late
talkers. These are 2-year-olds with small expres-
By 3 years of age the child engages in coop- sive vocabularies or no word combinations. Two
erative play. Phonological awareness and other recent large-scale epidemiological studies have
aspects of metalinguistic ability emerge, as seen in identified several factors associated with late onset
word play (e.g. ‘moo’, ‘goo’, ‘boo’). Print awareness of language. In one study [16], male gender, family
emerges and the child can point to familiar words in history of late talking, two or more children in
48
General patterns of development
the family and early neurobiological growth were [6] Lahey M. (1988) Language Disorders and Language
identified; in another study [17], a family history Development. New York: Macmillan.
of speech or language difficulties, non-English-
speaking background and low maternal education [7] Tomasello M. (2003) Constructing a Language: A
were identified. While the majority of late talkers Usage-based Theory of Language Acquisition. Cam-
will eventually catch up with their age peers, some bridge, MA: Harvard University Press.
30–40% may not. Several smaller scale studies
have indicated that poor receptive vocabulary [8] Goldberg A. (2006) Constructions at Work: the
and limited use of gestures may be indicative of Nature of Generalization in Language. Oxford:
more persistent problems but further research Oxford University Press.
is needed. The American Speech-Language-
Hearing Association suggests that children [9] Bates E, Dale PS, Thal D. (1995) Individual differ-
should be referred to a speech and language ences and their implications for theories of language
therapist whenever a parent expresses concern development. In: Fletcher P and MacWhinney B
(see http://www.asha.org/public/speech/disorders/ (eds), The Handbook of Child Language. Oxford:
LateBlooming.htm). Blackwell, pp. 96–151.
FUTURE DIRECTIONS [10] Hart B, Risley TR. (1995) Meaningful Differences
in the Everyday Experience of Young American
Our understanding of language development Children., Baltimore: Brookes.
will be greatly enhanced by advances in, and
application of, new technologies and methods [11] Kuhl PK, Conboy BT, Coffey-Corina S et al. (2008)
to explore neurophysiology, neuroplasticity, Phonetic learning as a pathway to language: new
human growth models and the synergistic roles of data and native language magnet theory expanded
genetic and environmental influences on learning. (NLM-e). Philosophical Transactions of the Royal
New techniques in neural imaging, statistical Society B 363, 979– 1000.
modelling, behavioural and molecular genetics,
and computational modelling are being applied to [12] Fenson L, Marchman VA, Thal DJ et al.
developmental questions. Further innovations and (2007) MacArthur-Bates Communicative Develop-
collaborations across physics, pharmacology, biol- ment Inventories: User’s Guide and Technical Man-
ogy, psychology, neurology, computer science and ual, 2nd edn. Baltimore: Brookes.
engineering will generate new ways of thinking
about development, leading to new discoveries. [13] Chapman R. (1978) Comprehension strategies
in children. In: Kavanagh JE and Strange W
REFERENCES (eds), Implications of Basic Speech and Language
Research for the School and Clinic. Cambridge, MA:
[1] Bishop DVM and Snowling MJ. (2004) Devel- MIT Press, pp. 308– 32.
opmental dyslexia and specific language impair-
ment: same or different? Psychological Bulletin 130, [14] Bleses D, Vach W, Slott M et al. (2008) Early vocab-
858– 86. ulary development in Danish and other languages: a
CDI-based comparison. Journal of Child Language
[2] Bates E. (1999) Language and the infant brain. 35, 619– 50.
Journal of Communication Disorders 32, 195–205.
[15] Stokes SF, Klee T. (2009) The diagnostic accuracy
[3] Gaskell MG and Altmann G (eds). (2007) The of a new test of early nonword repetition for dif-
Oxford Handbook of Psycholinguistics. Oxford: ferentiating late talking and typically developing
Oxford University Press. children. Journal of Speech, Language, and Hearing
Research 52, 872– 82.
[4] Levelt WJM. (1993) Speaking: from Intention to
Articulation. Cambridge, MA: MIT Press. [16] Zubrick SR, Taylor CL, Rice ML et al. (2007) Late
language emergence at 24 months: an epidemiolog-
[5] Gathercole SE. (2006) Nonword repetition and ical study of prevalence, predictors, and covariates.
word learning: the nature of the relationship. Journal of Speech, Language, and Hearing Research
Applied Psycholinguistics 27, 513– 43. 50, 1562– 92.
[17] Reilly S, Wake M, Bavin EL et al. (2007) Predicting
language at 2 years of age: a prospective community
study. Pediatrics 120, e1141– 9.
INTERNET RESOURCES
Child Development Institute – Language Develop-
ment in Children: http://www.childdevelopmentinfo.
com/development/language_development.shtml
49
Language development
National Institute on Deafness and other Communica- American Academy of Pediatrics Healthy Children:
tion Disorders – Speech and Language: http://www. Ages & Stages: http://www.healthychildren.org/
nidcd.nih.gov/health/voice/speechandlanguage. English/ages-stages/Pages/default.aspx
asp#milestones
American Speech-Language-Hearing Association –
Typical Speech and Language Development: http://
www.asha.org/public/speech/development/
50
General patterns of development
9
Development of Social Cognition
Virginia Slaughter
Early Cognitive Development Centre, University of Queensland, Brisbane, Australia
WHAT’S NEW actions by considering what’s going on inside her
mind. She may want to communicate a message.
• Infants as young as 12—18 months have Perhaps she thinks this is a good way to get a
some capacity for mentalizing. Recent recording contract. Maybe she just feels great.
experimental studies in which infants This process of reasoning about what other people
spontaneously help, communicate or feel, want and know, is referred to as mentalizing,
imitate an adult have revealed that mindreading, or using our theory of mind. It is a
infants can take into account what fundamental skill that helps us to understand and
other people feel, want and know. get along with the other people in our social world.
• Individual children differ in the rate at SOCIAL COGNITION IN INFANCY
which they acquire a theory of mind.
Correlational studies indicate that Until recently, most psychologists thought that
those children who are more skilful at the capacity for mentalizing only emerged in the
mentalizing are also somewhat more preschool period, because that is when typically
sophisticated and effective in their developing children begin to pass tests assessing
social lives. their ability accurately to report what is likely to
be in someone else’s mind in differing circum-
• Environmental factors contribute to stances. Whether or not infants and toddlers also
individual differences in social- have a theory of mind has been debated for years.
cognitive skill and the most significant Recent experimental procedures, cleverly mod-
correlate is exposure to mentalistic elled on everyday situations, now confirm that
conversation with parents, siblings and some basic mentalizing is evident in infants’ non-
friends. verbal communication, helping and imitation.
Social cognition in humans is uniquely complex. For instance, in one experimental procedure,
Unlike other mammals, which respond primarily 12- to 18-month-old infants watched an adult write
to each other’s outward behavioural signals, we on a piece of paper with a marker. Then the
look deeper, into each other’s minds, in order marker dropped off the table, unseen by the adult,
to understand one another. For instance, if we who began to search around for it. Already on
witness a stranger breaking into loud song on a the floor were some other items, but the infants
crowded street, we might notice that outwardly, consistently pointed at or retrieved the marker,
she is smiling and acting exuberantly, but our rather than the distractor items [1,2]. This showed
primary reaction would be to interpret her unusual that 1-year-olds could work out the specific item
that the adult wanted. In another experiment, 18-
month-old infants were invited to interact with two
Child Psychology and Psychiatry: Frameworks for practice, Second Edition. Edited by David Skuse, Helen Bruce,
Linda Dowdney and David Mrazek.
2011 John Wiley & Sons, Ltd. Published 2011 by John Wiley & Sons, Ltd.
51
Development of social cognition
adults, who were playing with two different toys. actual location of the toy. Another study using
After a while, the toys were put on a shelf and precisely the same set-up showed that 6- to 8-year-
one of the adults left the room. The remaining old children with an autism spectrum disorder
adult then brought out a new toy, played with it failed to do the same thing; they did not look to the
and then put it on the shelf as well. When the first box where the actor thought the toy was [6]. This
adult returned and pointed toward the three toys shows that automatic, non-verbal mindreading is
on the shelf saying ‘Oh look! Give it to me please!’ disrupted in children with autism, in addition to the
the infants immediately retrieved the new toy – the more explicit social-cognitive and communicative
one that this particular adult had not yet played problems characteristic of the disorder.
with. This indicates that the infants interpreted the
adult’s pointing in terms of what the adult thought SOCIAL COGNITION IN YOUNG CHILDREN
was new and interesting [3].
The research described above shows that in typi-
Sometimes we witness someone trying and fail- cal development, accurate mentalizing is present,
ing to accomplish a simple act. For instance, in some instances within the second year of life.
someone may try to turn on a light switch but A direction for future research is to evaluate
her fingers slip off. In this case we automatically whether and how these early non-verbal theory
mentalize, and see past the external behaviour to of mind skills are linked to the more sophisticated
the underlying intention: She meant to turn on the social cognition that develops later in childhood.
switch. Another recent experiment showed that Although more research is needed, the results of
infants as young as 12 months mentalize in the one such study suggest a positive association [7]
same way [4]. When infants watched an adult try between infants’ imitation of unfulfilled intentions
but fail to turn on a switch, they recognized the (as in the switch task described above) and their
adults’ intention and when given the opportunity, performance on measures of social cognition at 3
they fully turned on the switch. But if the infants years of age.
watched an adult handle the switch without trying
to turn it on, they did not turn it on themselves Soon after children begin to use language, they
thus showing that in the first situation, they were also begin to talk about what they and others feel,
genuinely mentalizing, rather than simply doing want and think. This facile ability to communi-
what might have seemed obvious. cate about what is in our own and others’ minds
has allowed researchers to expand the range of
Besides reading the intentions behind each verbal tests used to assess young children’s social-
other’s actions, we also tend to anticipate each cognitive reasoning. The standard procedure is
other’s intentions and the behaviour they produce. for children to listen to a description of a social
For instance, if you know your friend likes sugar scenario, sometimes accompanied by cartoons or
in his coffee, then as he pours himself a cup acted out with puppets. Once the scenario is in
you are likely to shift your eyes to the sugar place, they are then asked questions about what
bowl, anticipating his mental state as well as his the protagonists feel, want or know, or what they
next move. Recent eye-tracking research shows will do next. While there are potentially as many
that 25-month-olds anticipate in this way and, different versions of these tests as there are unique
furthermore, they can anticipate another person’s social scenarios, a subset of them has recently been
next move even if that person is actually mistaken. made into a highly reliable developmental scale,
In the eye-tracking study, toddlers watched a video illustrated in Table 9.1. The theory of mind scale
in which an actor repeatedly reached to get his toy reveals that 3- to 6-year-old children gradually
out of a box. When the actor wasn’t looking, the master different elements of social cognition in
toy was moved to a different box. Upon the actor’s a predictable sequence [8,9]. Children with clini-
return, the toddlers anticipated his next move and cal diagnoses that are characterized by delays or
looked to the first box, where the actor still thought deficits in social cognition, such as deafness or
his toy was located, rather than to where it really autism, pass the tasks in essentially the same order
was [5]. This experiment shows unmistakable but at a later age. The one exception to scale con-
mentalizing because the toddlers focused on the formity is that children with autism pass the hidden
inner experience of the actor, rather than on the
52
General patterns of development
Table 9.1 Six tests that make up the theory of mind scale. Research shows that the majority of
children acquire these concepts in order from ‘Diverse desires’ to ‘Sarcasm’.
Test Social-cognitive concept assessed Approximate proportion
of 3- to 6-year-old
children who pass
Diverse desires Different people may like and want 95%
Diverse beliefs different things 88%
Knowledge access 79%
False belief Different people can hold different beliefs 49%
Hidden emotion about the same thing 27%
Sarcasm 20%
People who see something also know about
it; if they don’t see then they don’t know
People do things based on what they think,
even if they are mistaken
People can deliberately conceal emotions
by facial expression management
In order to be humorous, people sometimes
say the opposite to what they really mean
emotion task before they pass false belief [8,9]. and rated by their teachers as being most socially
This subtle difference reinforces the conclusion, mature [10]. It is important to note that these find-
following from years of research, that the mental- ings are correlational, so we do not know if skilful
istic concept of false belief is particularly difficult mentalizing causes children to be socially adept and
to grasp for people with autism. popular, or if those qualities put them in the best
position to develop their social-cognitive skills.
INDIVIDUAL DIFFERENCES IN SOCIAL
COGNITION: IMPLICATIONS FOR Other studies indicate that 3- to 8-year-old chil-
CHILDREN’S SOCIAL LIVES dren who perform well on theory of mind tests
are also especially good at keeping secrets, at dis-
Alongside the consistent developmental sequence tinguishing right from wrong in complicated social
for theory of mind concepts outlined in Table 9.1, situations, and at deceiving and lying convincingly
there are measurable individual differences [11]. This last point highlights that mentalizing
amongst children in their rates of social-cognitive enables children to take part successfully in a wide
development. These individual differences have range of social interactions, including potentially
been linked to some specific consequences for negative ones. Thus acquiring a theory of mind
children’s everyday social life. Although the does not necessarily make for a well-adjusted child;
effects are typically small to medium-sized, indeed, more than one study has revealed that play-
meaning that other factors play a role, children ground bullies, who are often somewhat popular
who perform well on theory of mind tests also tend as well as being feared for their manipulative and
to have relatively sophisticated social skills as well aggressive interpersonal tactics, possess good or
as effective social relationships in their daily lives. even superior mentalizing skills [12]. Acquiring a
theory of mind enables children to understand
For instance, studies have shown that mentaliz- their social world, but it appears that individ-
ing is related to social competence in 4- to 8-year- ual children’s temperament and life experiences,
old children. That is, those children who are good among other things, determine how they use that
at working out what others feel, want and think, understanding. Predicting how individual children
are nominated by their peers as being most likeable will use their theory of mind – either prosocially
53
Development of social cognition
or antisocially – is another important direction for well documented; in a nutshell, the more parents
further research [13]. discuss and explain what they and others feel,
want and think, the better their children under-
INDIVIDUAL DIFFERENCES IN SOCIAL stand those concepts. This principle has been
COGNITION: WHERE DO THEY COME documented in many conversational contexts
FROM? from everyday disciplinary encounters (‘It was
really unkind of you to take her dolly; just imagine
Although it is in our nature to look past external how it made her feel’) to mutual reminiscences
behaviour and into each other’s minds, the few (‘Remember when the bird stole the baby’s fruit
genetic studies on social-cognitive development bun right out of her hand? She was so surprised
carried out to date suggest that nurture is more and angry!’) to book-reading (‘Look at that boy’s
important in determining individual differences face in the picture; why does he feel so sad?’). It is
among children. For instance, a major behaviour important to note that the link between children’s
genetic study comparing 1116 monozygotic and theory of mind and parents’ mentalistic conver-
dizygotic 5-year-old twin pairs revealed that the sation extends to children with autism [18] and
majority of individual variation in the children’s deafness [19]. While not yet translated into formal
mentalizing (based on the kinds of tests listed in interventions, training studies have shown that
Table 9.1) was attributable to environment rather exposure to mentalistic conversation boosts social-
than to genes [14]. This finding contrasted with cognitive skill in typically developing children
an earlier, smaller-scale study of 3-year-old twins, [20]. Therefore, parents should be encouraged to
which revealed significant genetic influences on take the time to discuss feelings and thoughts with
mentalizing [15]. More research is necessary to their young children; not only will it make for
reconcile these findings; however, one possibility engaging conversation, but it is likely to benefit
is that genes play a role in early social-cognitive their children’s social-cognitive development.
development, but by the age of 5, children’s theory
of mind is shaped primarily by their personal REFERENCES
experiences.
[1] Warneken F. (2007) and Tomasello M. Helping
One environmental variable that is crucial for and cooperation at 14 months of age. Infancy 11,
theory of mind development is access to language 271– 94.
and conversation about people’s feelings, desires
and thoughts. Mentalizing is consistently corre- [2] Liszkowski U, Carpenter M, Striano T, Tomasello
lated with language ability, and there is also a M. (2006) Twelve- and 18-month-olds point to pro-
specific link between children’s ability to suc- vide information for others. Journal of Cognition
cessfully complete tasks like those described in and Development 7, 173– 87.
Table 9.1 and their comprehension and produc-
tion of mentalistic vocabulary. The importance of [3] Moll H. (2007) and Tomasello M. How 14- and
language to mentalizing is perhaps most evident 18-month-olds know what others have experienced.
in the deaf; those deaf children who do not have Developmental Psychology 43, 309– 17.
access to fluent signing partners for daily conver-
sation show social-cognitive delays similar to those [4] Nielsen M. (2009) 12-month-olds produce others’
observed in children with autism. By contrast, deaf intended but unfulfilled acts. Infancy 14, 377– 89.
children who have regular access to signed conver-
sation are comparable to typical hearing children [5] Southgate V, Senju A, Csibra G. (2007) Action
in their social-cognitive development [16]. anticipation through attribution of false belief in
two-year-olds. Psychological Science 18, 587– 92.
The role of language in social-cognitive devel-
opment is further demonstrated by the fact that [6] Senju A, Southgate V, Miura Y et al. (2010) Absence
children’s theory of mind is consistently associated of spontaneous action anticipation by false belief
with their participation in meaningful conversa- attribution in children with autism spectrum disor-
tions about emotions, desires and thoughts with der. Development and Psychopathology 22, 353– 60.
parents, siblings and friends [17]. The influence
of parents’ mentalistic conversation is especially [7] Colonnesi C, Rieffe C, Koops W et al. (2008) Pre-
cursors of a theory of mind: A longitudinal study.
British Journal of Developmental Psychology 26,
561– 77.
[8] Peterson C, Wellman H, Liu D. (2005) Steps in the-
ory of mind development for children with deafness,
autism or typical development. Child Development
76, 502– 17.
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General patterns of development
[9] Peterson C, Wellman H, Slaughter V. The mind [16] Siegal M and Peterson C. (2008) Language and
behind the message: Advancing theory of mind theory of mind in atypically developing children:
scales for typically developing children, and those Evidence from deafness, blindness and autism. In:
with deafness, autism, or Asperger Syndrome. Child Sharp C, Fonagy P, Goodyear I (eds), Social Cog-
Development (in press). nition and Developmental Psychopathology. New
York: Oxford University Press, pp. 81–112.
[10] Peterson C, Slaughter V, Paynter J. (2007) Social
maturity and theory of mind in typically developing [17] Dunn J and Brophy M. (2005) Communication, rela-
children and those on the autism spectrum. Jour- tionships, and individual differences in children’s
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Mind what mother says: Narrative input and theory
[12] Gasser L and Keller M. (2009) Are the competent of mind in typical children and those on the autism
the morally good? Perspective taking and moral spectrum. Child Development 78, 839–58.
motivation of children involved in bullying. Social
Development 18, 798–816. [19] Moeller M and Schjick B. (2006) Relations between
maternal input and ToM understanding in deaf chil-
[13] Ronald A, Happe´ F, Hughes C, Plomin R. (2005) dren. Child Development 77, 751– 66.
Nice and nasty theory of mind in preschool chil-
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664– 84. (2008) The effects of explanatory conversations on
children’s emotion understanding. British Journal
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and individual differences in early understanding of
mind. Psychological Science 10, 429– 32.
55
Social and emotional development in middle childhood
10
Social and Emotional Development
in Middle Childhood
Alan Carr
School of Psychology, Newman Building, University College Dublin, Belfield, Dublin, Ireland
WHAT’S NEW
• There is significant continuity in SED from middle childhood to
adolescence — psychopathological disorders reflecting problematic SED persist; children who
are well adjusted in middle childhood tend to become well adjusted adolescents.
• Recent reviews of early intervention programmes for children at risk of SED problems report
significant positive effects in relation to: participants’ educational success; social
participation; cognitive, social and emotional development; family well-being, and less
involvement in the criminal justice system.
• The most effective early intervention programmes for children at risk of SED problems are
those that are of long duration and intensive, involving more than 500 sessions.
• Supportive family environments foster social and emotional development and buffer
children from the negative long-term effects of bullying.
Social and emotional development (SED) that particularly important developments occur
involves the acquisition of skills for expressing within the emotional and social domains.
emotions, regulating emotions, and managing
social relationships within the family, school THE PRESCHOOL YEARS
and peer group [1,2]. Some of the milestones
associated with these aspects of development During the first year of life there is a gradual
are given in Table 10.1. Middle childhood, the increase in non-verbal emotional expression in
period between 6 and 12 years, occupies a response to all classes of stimuli including those
pivotal position between the preschool years and under the infant’s control and those under the con-
adolescence with respect to SED. During the trol of others. At birth infants can express interest
preschool years rudimentary skills are acquired, as indicated by sustained attention, and disgust in
while in adolescence, sophisticated skills are response to foul tastes and odours. Smiling, reflect-
refined. However, it is during middle childhood ing a sense of pleasure, in response to the human
Child Psychology and Psychiatry: Frameworks for practice, Second Edition. Edited by David Skuse, Helen Bruce,
Linda Dowdney and David Mrazek.
2011 John Wiley & Sons, Ltd. Published 2011 by John Wiley & Sons, Ltd.
56
General patterns of development
Table 10.1 Social and emotional development.
Age Expression of emotions Regulation of emotions Managing emotions
in relationships
Infancy Increased non-verbal Self-soothing Increased discrimination of
0—1 year emotional expression in emotions expressed by
response to stimuli Regulation of attention to others
Toddlerhood under own control and allow coordinated action
1—2 years control of others Turn taking (peek a boo)
Reliance on ‘scaffolding’
Preschool Increased verbal from caregivers during stress Social referencing
2—5 years expression of emotional
states Increased awareness of own Anticipation of feelings
Middle Increased expression of emotional responses towards others
childhood emotions involving
6—12 years self-consciousness and Irritability when parents Rudimentary empathy
self-evaluation such as place limits on expression of
Adolescence shame, pride or coyness need for autonomy Altruistic behaviour
13+ years Increased pretending to
express emotions in play Language (self-talk and Increased insight into
and teasing communication with others) others emotions
used for regulating emotions
Increased use of Awareness that false
emotional expression to expression of emotions can
regulate relationships mislead others about one’s
Distinction made emotional state
between genuine
emotional expression Increased autonomy from Increased understanding of
with close friends and caregivers in regulating emotional scripts and social
managed display with emotions roles in these scripts
others
Increased efficiency in Increased use of social skills
Self-presentation identifying and using multiple to deal with emotions of
strategies are used for strategies for autonomously self and others
impression management regulating emotions and
managing stress Awareness of feeling
multiple emotions about
Regulation of self-conscious the same person
emotions, e.g.
embarrassment Use of information about
emotions of self and others
Distancing strategies used to in multiple contexts as aids
manage emotions if child has to making and maintaining
little control over situation friendships
Increased awareness of Awareness of importance of
emotional cycles (feeling mutual and reciprocal
guilty about feeling angry) emotional self-disclosure in
making and maintaining
Increased use of complex friendships
strategies to autonomously
regulate emotions
Self-regulation strategies are
increasingly informed by
moral principles
57
Social and emotional development in middle childhood
voice appears at 4 weeks. Sadness and anger in sophisticated empathic and altruistic behaviour
response to removing a teething toy are first evi- also begins to develop within the family and peer
dent at 4 months. Facial expressions reflecting fear group during the preschool years.
following separation become apparent at 9 months.
Infants also show an increasingly sophisticated MIDDLE CHILDHOOD
capacity to discriminate positive and negative emo-
tions expressed by others over the course of their During middle childhood (6–12 years), with
first year of life. During the first year of life infants the transition to primary school and increased
develop rudimentary self-soothing skills for regu- participation in peer group activities, children’s
lating their emotions such as rocking and feeding. SED undergoes a profound change. Rather than
They also develop skills for regulating their atten- regularly looking to parents or caregivers to help
tion to allow themselves and their care-takers to them manage their feelings and relationships,
coordinate their actions to soothe them in dis- school-aged children prefer to autonomously
tressing situations. They rely on their care-takers regulate their emotional states and depend more
to provide emotional support to help them man- on their own resources in dealing with their peers.
age stress. The capacity for turn taking in games As they develop through the middle childhood
such as peek-a-boo develops once children have years they show increased efficiency in identifying
the appropriate cognitive skills for understanding and using multiple strategies for autonomously
object constancy. Social referencing also occurs regulating their emotions and managing stress.
towards the end of the first year when children During this process they learn to regulate self-
learn the appropriate emotions to express in par- conscious emotions such as embarrassment and
ticular situations by attending to the emotional to use distancing and distraction strategies to
expressions of their care-takers. manage intense feelings when they have little
control over emotionally challenging situations.
During their second year infants show increased There is increased use of emotional expression
verbal expression of emotional states, and to regulate closeness and distance within peer
increased expression of emotions involving self- relationships. Within this context, children make
consciousness and self-evaluation such as shame, clear distinctions between genuine emotional
pride or coyness. This occurs because their expression with close friends and managed
cognitive skills allow them to begin to think about emotional displays with others.
themselves from the perspective of others. During
the second year of life toddlers show increased During middle childhood children develop an
awareness of their own emotional responses. understanding of consensually agreed emotional
They show irritability – often referred to as the scripts and their roles in such scripts. There is
‘terrible twos’ – when parents place limits on also an increased use of social skills to deal with
the expression of their needs for autonomy and their own emotions and those of others. Children
exploration. In relationships they can increasingly become aware that they can feel multiple conflict-
anticipate feelings they will have towards others in ing emotions about the same person; for example,
particular situations. They also show rudimentary that they can be angry with someone they like.
empathy and altruistic behaviour. They use information and memories about their
own emotions and those of others in multiple
Between the ages of 2 and 5 years children contexts as aids to making and maintaining friend-
increasingly pretend to express emotions in ships. As adolescence approaches they develop
play and when teasing or being teased by other an increasingly sophisticated understanding of the
children. They use language in the form of both place of emotional scripts and social roles in mak-
internal speech and conversations with others ing and maintaining friendships.
to modulate their affective experience. There
is increased insight into the emotions being Cooperative play premised on an empathic
experienced by others and an increased awareness understanding of other children’s viewpoints
that we can mislead others about what we are becomes fully established in middle childhood.
feeling by falsely expressing emotions. More Competitive rivalry (often involving physical or
58
General patterns of development
verbal aggression or joking) is an important part Positive SED
of peer interactions, particularly among boys. This With regard to personal factors, young people are
allows youngsters to establish their position of more likely to develop the skills for emotional
dominance within the peer group hierarchy. Peer expression and regulation and for making and
friendships in middle childhood are important maintaining relationships if they have favourable
because they constitute a source of social support genetic endowments, easy temperaments, ade-
and a context within which to learn about the man- quate cognitive abilities to understand their
agement of networks of relationships. Children feelings and the emotional demands of their
who are unable to make and maintain friendships, important relationships, adequate self-esteem, the
particularly during middle childhood, are at risk capacity to understand social situations accurately
for the development of psychological difficulties. and a well-developed conscience. With regard
to contextual factors, positive SED is more
ADOLESCENCE likely where children have developed secure
attachments; where their parents have adopted
During adolescence from 13 to 20 years there an authoritative parenting style characterized by
is an increased awareness of complex emotional warmth and a moderate level of control; where
cycles, for example feeling guilty about feeling their parents have no major adjustment problems;
angry or feeling ashamed for feeling frightened. and where the family, school, peer group and
In adolescence, youngsters increasingly use com- wider social environments have been supportive.
plex strategies, such as reframing, to autonomously For example, in a UK study Bowes et al. [16] found
regulate emotions. These self-regulation strate- that children from supportive families showed
gies are increasingly informed by moral principles. resilience when bullied in primary school.
However, alongside this concern with morality,
self-presentation strategies are increasingly used Problematic SED
for impression management. Adolescents gradu- Problematic SED may occur where there are
ally become aware of the importance of mutual difficulties with genetic endowment, temperament,
and reciprocal emotional self-disclosure in making cognitive abilities, self-esteem, social cognition
and maintaining friendships. and moral development. Problematic SED is
associated with unfavourable genetic endowments
FACTORS CONTRIBUTING TO SOCIAL indexed by family histories of psychopathology. A
EMOTIONAL DEVELOPMENT childhood history of difficult temperament is also
associated with problematic emotional develop-
Available research indicates that SED in middle ment. With regard to cognitive abilities, children
childhood is influenced by complex interactions with intellectual disabilities tend to acquire skills
among multiple personal and contextual factors. for expressing and regulating emotions and man-
Personal factors include genetic endowment [3], aging relationships at a slower rate than children
temperament [4], cognitive abilities [5], self-esteem without such disabilities. Disproportionately more
[6], social cognition [7] and moral development children with intellectual disabilities, than with-
[8]. Contextual factors include attachment [9], par- out, show challenging behaviour associated with
enting style [10], parental adjustment [11], family emotional regulation problems. Children with low
functioning [12], school environment [13], peer self-esteem, who evaluate themselves negatively,
group relationships [14], and the wider social and have difficulty regulating negative mood states
cultural environment [15]. From a clinical per- and managing relationships. Children who have
spective, in any given case, we may expect more problematic social cognition, notably those who
successful SED where there are more positive than have developed a hostile attributional bias where
negative personal and contextual factors. In con- they inaccurately attribute negative intentions to
trast, where there are more negative than positive others, have difficulties regulating anger and main-
personal and contextual factors, problems with taining positive peer group relationships. Children
SED may occur. who have not internalized social rules and norms
59
Social and emotional development in middle childhood
and developed a conscience, particularly those mood disorders, and internalizing behaviour prob-
with callous unemotional traits, have difficulties lems are associated with difficulties regulating fear
empathizing with others and making and main- and sadness. Disruptive behaviour disorders and
taining social relationships. The foregoing are externalizing behaviour problems are associated
some of the ways in which personal vulnerabilities with difficulties regulating anger and aggression.
can compromise SED in middle childhood. Attention deficit hyperactivity disorder (ADHD)
is associated with problematic impulse control.
Social and emotional development during this All of these types of disorders and behaviour
period may also be compromised by environmental problems are associated with problems making
adversity characterized by difficulties with attach- and maintaining relationships, as are other
ment, parenting style, parental adjustment, family conditions such as autism spectrum disorders and
functioning, the school environment, peer group psychoses. There is significant continuity in social
relationships, and the wider social and cultural emotional development from middle childhood
environment. Problematic SED is more common to adolescence. Those who are well adjusted in
where children have developed insecure attach- middle childhood tend to become well adjusted
ments to their parents or caregivers. Non-optimal adolescents [2], while problems tend to persist into
family environments can also impair SED. Such the teenage years in children who showed social
family environments may be characterized by par- and emotional difficulties in primary school [18].
enting problems, child abuse or neglect; parental
mental health problems or criminality; and family ADDRESSING SED PROBLEMS
conflict or domestic violence. Where there is a poor
match between children’s educational needs and Prevention and treatment programmes have
educational placement, this can have an adverse been developed to address SED problems.
effect on their SED. For example, problems with Successful prevention programmes begin during
SED may be exacerbated where a child with a the preschool years. They involve screening at-risk
specific learning disability, intellectual disability children on the basis of their status of personal
or psychological disorder is placed in a main- and contextual risk factors, and offering complex
stream class without adequate special educational interventions such as family support, parent train-
resources. Schools with inadequate policies and ing and child stimulation that target multiple risk
procedures for managing bullying and victimiza- factors [19]. With regard to treating children with
tion of pupils by peers or teachers can also have a SED problems, it is best to base interventions in
negative effect on SED. Problematic SED may be any particular case on a formulation of factors rel-
exacerbated where children are rejected by their evant to that specific case and the current evidence
peers or where they spend a significant amount base for effective interventions for such difficulties,
of time with antisocial peers. Within the wider because problems with SED are typically caused
social and cultural environment a range of fac- and maintained by the complex interaction of
tors can have a detrimental impact on SED. These multiple personal and contextual factors [20].
include a high level of extrafamilial stress and a
low level of extrafamilial perceived social support, REFERENCES
and also exposure to media (TV, films, computer
games) that model and reinforce the inappropri- [1] Denham S, Wyatt T, Bassett H et al. (2009) Assess-
ate expression of aggression, anxiety, depression, ing social-emotional development in children from
elation and other emotions. a longitudinal perspective. Journal of Epidemiology
and Community Health 63, 137– 52.
CONSEQUENCES OF SED PROBLEMS
IN MIDDLE CHILDHOOD [2] Saarni C, Campos J, Cameras L et al. (2008) Emo-
tional development: Action communication under-
Emotional dysregulation is a risk factor for standing. In: Eisenberg N (ed.), Handbook of Child
psychopathology [17], and many types of Psychology, Vol. 3: Social, Emotional and Personal-
psychopathology and behaviour problems are ity Development. New York: Wiley, pp. 226–300.
associated with problematic SED. Anxiety and
[3] Rutter M. (2006) Genes and Behaviour: Nature-
nurture Interplay Explained. Oxford: Blackwell.
60
General patterns of development
[4] De Pauw S, Mervielde I. (2010) Temperament, multilevel studies. Journal of Epidemiology and
personality and developmental psychopathology: A Community Health 60, 149–55.
review based on the conceptual dimensions under- [14] Rubin K, Bukowski W, Parker J. (2006) Peer
lying childhood traits. Child Psychiatry and Human interactions, relationships and groups. In: Eisen-
Development 41, 313–29. berg N (ed.), Handbook of Child Psychology, Vol.
3: Social, Emotional and Personality Development.
[5] Hodapp R, Dykens M. (2009) Intellectual disabil- New York: Wiley, pp. 571– 645.
ities and child psychiatry: Looking to the future. [15] Jenkins J. (2008) Psychosocial adversity and
Journal of Child Psychology and Psychiatry 50, resilience. In: Rutter M, Bishop D, Pine D et al.
99– 107. (eds), Rutter’s Child and Adolescent Psychiatry, 5th
edn. Oxford: Wiley-Blackwell, pp. 377– 91.
[6] Harter S. (2006) The self. In: Eisenberg N (ed.), [16] Bowes L, Maughan B, Caspi A. (2010) et al. Families
Handbook of Child Psychology, Vol. 3: Social, Emo- promote emotional and behavioural resilience to
tional and Personality Development. New York: bullying: Evidence of an environmental effect. Jour-
Wiley, pp. 505–70. nal of Child Psychology and Psychiatry 51, 809–17.
[17] Keenan K. (2006) Emotion dysregulation as a risk
[7] Sharp C, Fonagy P, Goodyer I. (2008) Social Cogni- factor for child psychopathology. Clinical Psychol-
tion and Developmental Psychopathology. Oxford: ogy: Science and Practice 7, 418– 34.
Oxford University Press. [18] Sterba S, Copeland W, Egger H et al. (2010) Longi-
tudinal dimensionality of adolescent psychopathol-
[8] Kochanska G and Aksan N. (2006) Children’s con- ogy: testing the differentiation hypothesis. Journal
science and self-regulation. Journal of Personality of Child Psychology and Psychiatry 51, 871– 84.
74, 1587– 617. [19] Manning M, Homel R, Smith C. (2010) A meta-
analysis of the effects of early developmental
[9] Kerns K. (2008) Attachment in middle childhood. prevention programs in at-risk populations on non-
In: Cassidy J and Shaver P (eds), Handbook of health outcomes in adolescence. Children and Youth
Attachment, 2nd edn. New York: Guilford, pp. Services Review 32, 506– 19.
366– 82. [20] Carr A. (2009) What Works with Children Ado-
lescents and Adults. A Review of Research on
[10] Parke R, Buriel R. (2008) Socialization in the family: the Effectiveness of Psychotherapy. London: Rout-
Ethnic and ecological perspectives. In: Eisenberg ledge.
N (ed.), Handbook of Child Psychology, Vol. 3:
Social, Emotional and Personality Development. FURTHER READING
New York: Wiley, pp. 429–504.
Carr A. (2006) Handbook of Child and Adolescent Clin-
[11] Stein A, Ramchandani P, Murray L. (2008) Impact ical Psychology, 2nd edn. London: Routledge.
of parental psychiatric disorder and physical illness.
In: Rutter M, Bishop D, Pine D et al. (eds), Rutter’s Damon W and Lerner R. (2008) Child and Adoles-
Child and Adolescent Psychiatry, 5th edn. Oxford: cent Development: An Advanced Course. Chichester:
Wiley-Blackwell, pp. 407– 20. Wiley.
[12] Masten A, Shaffer A, Clarke-Stewart A et al.
(2006) How families matter in child development:
Reflections from research on risk and resilience.
In: Clarke-Stewart A and Dunn J (eds), Families
Count: Effects on Child and Adolescent Develop-
ment. The Jacobs Foundation Series on Adolescence.
New York: Cambridge University Press, pp. 5–25.
[13] Sellstrom E and Bremberg S. (2006) Is there a
‘school effect’ on pupil outcomes? A review of
61
Social-cognitive development during adolescence
11
Social-Cognitive Development
During Adolescence
Sarah-Jayne Blakemore
Institute of Cognitive Neuroscience, University College London, London, UK
HUMANS ARE EXQUISITELY SOCIAL states (see Ref. [3] for review). In each case, the
mentalizing task resulted in the activation of a
Humans are an exquisitely social species. We are network of regions including the posterior supe-
constantly reading each other’s actions, gestures rior temporal sulcus (pSTS), the temporo-parietal
and faces in terms of underlying mental states and junction (TPJ), the temporal poles and the dorsal
emotions, in an attempt to figure out what other medial prefrontal cortex (mPFC; see Ref. [4]). The
people are thinking and feeling, and what they agreement between neuroimaging studies in this
are about to do next. This is known as theory area is remarkable and the consistent localization
of mind, or mentalizing. Developmental psychol- of activity within a network of regions including
ogy research on theory of mind has demonstrated the pSTS/TPJ and mPFC, as well as the temporal
that the ability to understand others’ mental states poles, suggests that these regions are key to the
develops over the first four or five years of life. process of mentalizing.
While certain aspects of theory of mind are present
in infancy [1], it is not until around the age of 4 Brain lesion studies have consistently demon-
years that children begin explicitly to understand strated that the superior temporal lobes [5] and
that someone else can hold a belief that differs PFC [6] are involved in mentalizing, as damage
from one’s own, and which can be false [2]. An to these brain areas impairs mentalizing abili-
understanding of others’ mental states plays a crit- ties. Interestingly, one study reported a patient
ical role in social interaction because it enables with large PFC damage whose mentalizing abili-
us to work out what other people want and what ties were intact [7], suggesting that this region is
they are about to do next, and to modify our own not necessary for mentalizing. However, there are
behaviour accordingly. other explanations for this surprising and intrigu-
ing finding. It is possible that, due to plasticity, this
THE SOCIAL BRAIN patient used a different neural strategy in mentaliz-
ing tasks. Alternatively, it is possible that damage
Over the past 15 years, a large number of indepen- to this area at different ages has different con-
dent studies have shown remarkable consistency sequences for mentalizing abilities. The patient
in identifying the brain regions that are involved in described by Bird and colleagues had sustained
theory of mind, or mentalizing. These studies have her PFC lesion at a later age (62 years) than most
employed a wide range of stimuli including sto- previously reported patients who show impair-
ries, sentences, words, cartoons and animations, ments of mentalizing tasks. Perhaps mPFC lesions
each designed to elicit the attribution of mental later in life spare mentalizing abilities, whereas
damage that occurs earlier in life is detrimental.
Child Psychology and Psychiatry: Frameworks for practice, Second Edition. Edited by David Skuse, Helen Bruce,
Linda Dowdney and David Mrazek.
2011 John Wiley & Sons, Ltd. Published 2011 by John Wiley & Sons, Ltd.
62
General patterns of development
It is possible that mPFC is necessary for the 60 40 20 0 −20 −40 −60 −80 −100
acquisition of mentalizing but not essential for
later implementation of mentalizing. Intriguingly, 60 8
this is in line with recent data from developmental
fMRI studies of mentalizing, which suggest that 40 9
the mPFC contributes differentially to mentalizing
at different ages. 20 24
10
DEVELOPMENT OF MENTALIZING DURING 32
ADOLESCENCE
0
There is a rich literature on the development of 25
social cognition in infancy and childhood, pointing
to step-wise changes in social cognitive abilities −20 12
during the first five years of life. However, there
has been surprisingly little empirical research on −40
social cognitive development beyond childhood.
Only recently have studies focused on develop- Figure 11.1 A section of the dorsal medial pre-
ment of the social brain beyond early childhood, frontal cortex (mPFC) that is activated in studies
and these support evidence from social psychology of mentalizing: Montreal Neurological Institute
that adolescence represents a period of significant (MNI) ‘y’ coordinates range from 30 to 60, and
social development. Most researchers in the field ‘z’ coordinates range from 0 to 40. Dots indicate
use the onset of puberty as the starting point for voxels of decreased activity during six mentaliz-
adolescence. The end of adolescence is harder to ing tasks between late childhood and adulthood;
define and there are significant cultural variations. numbers refer to Brodmann areas (see Blake-
However, the end of the teenage years represents more [10] for references). The mentalizing tasks
a working consensus in Western countries. Ado- ranged from understanding irony, which requires
lescence is characterized by psychological changes separating the literal from the intended mean-
in terms of identity, self-consciousness and rela- ing of a comment, thinking about one’s own
tionships with others. Compared with children, intentions, thinking about whether character
adolescents are more sociable, form more com- traits describe oneself or another familiar other,
plex and hierarchical peer relationships, and are watching animations in which characters appear
more sensitive to acceptance and rejection by peers to have intentions and emotions, and thinking
[8]. Although the underlying factors of these social about social emotions such as guilt and embar-
changes are most likely to be multifaceted, one rassment [9]. Adapted from Blakemore [10], with
possible cause is development of the social brain. permission.
Recently, a number of fMRI studies have inves- these studies compared brain activity in young
tigated the development during adolescence of the adolescents and adults while they were performing
functional brain correlates of mentalizing. These a task that involved thinking about mental states
studies have used a wide variety of mentaliz- (see Figure 11.1 for details of studies). In each
ing tasks involving the spontaneous attribution of these studies, mPFC activity was greater in the
of mental states to animated shapes, reflecting adolescent group than in the adult group during
on one’s intentions to carry out certain actions, the mentalizing task compared to the control task.
thinking about the preferences and dispositions of In addition, there is evidence for differential func-
oneself or a fictitious story character, and judging tional connectivity between mPFC and other parts
the sincerity or sarcasm of another person’s com- of the mentalizing network across age [9].
municative intentions. Despite the variety of men-
talizing tasks used, these studies of mental state To summarize, a number of developmental
attribution have consistently shown that mPFC neuroimaging studies of social cognition have been
activity during mentalizing tasks decreases between carried out by different labs around the world, and
adolescence and adulthood (Figure 11.1). Each of there is striking consistency with respect to the
direction of change in mPFC activity. It is not yet
understood why mPFC activity decreases between
adolescence and adulthood during mentalizing
tasks, but two non-mutually exclusive explanations
63
Social-cognitive development during adolescence
have been put forward (see Ref. [10] for details). by fMRI in humans (see Ref. [10] for discussion).
One possibility is that the cognitive strategy for If the neural substrates for social cognition change
mentalizing changes between adolescence and during adolescence, what are the consequences
adulthood. A second possibility is that the func- for social cognitive behaviour?
tional change with age is due to neuroanatomical
changes that occur during this period. Decreases ONLINE MENTALIZING USAGE IS STILL
in activity are frequently interpreted as being DEVELOPING IN MID-ADOLESCENCE
due to developmental reductions in grey matter
volume, presumably related to synaptic pruning. Most developmental studies of social cognition
However, there is currently no direct way to test focus on early childhood, possibly because chil-
the relationship between number of synapses, dren perform adequately in even quite complex
synaptic activity and neural activity as measured mentalizing tasks at around age 4 years. This
(a) Instructions example 1 (b) Instructions example 2
YOUR VIEW DIRECTOR'S VIEW
(c) Experimental trial Move the (d) Control trial Move the
small ball left small ball left
Distractor Irrelevant object
Target
Figure 11.2 (a,b) Images used to explain the Director condition: participants were shown an example
of their view (a) and the corresponding director’s view (b) for a typical stimulus with four objects in
occluded slots that the director cannot see (e.g. the apple). (c,d) Examples of an experimental (c)
and a control trial (d) in the Director condition. The participant hears the verbal instruction: ‘Move
the small ball left’ from the director. In the experimental trial (c), if the participant ignored the
director’s perspective, she would choose to move the distractor ball (golfball), which is the smallest
ball in the shelves but which cannot be seen by the director, instead of the larger ball (tennis ball)
shared by both the participant’s and the instructor’s perspective (target). In the control trial (d),
an irrelevant object (plane) replaces the distractor item. Adapted from Dumontheil et al. [12], with
permission.
64
General patterns of development
can be attributed to a lack of suitable paradigms: Box 11.1 Key points
generally, in order to create a mentalizing task that
does not elicit ceiling performance in children aged • The social brain is involved in
5 and older, the linguistic and executive demands understanding others’ minds.
of the task must be increased. This renders any
age-associated improvement in performance dif- • The social brain develops structurally
ficult to attribute solely to improved mentalizing and functionally in adolescence.
ability. However, the protracted structural and
functional development in adolescence and early • Activity in medial prefrontal cortex
adulthood of the brain regions involved in theory decreases between adolescence and
of mind might be expected to affect mental state adulthood during social cognition tasks.
understanding. In addition, evidence from social
psychology studies shows substantial changes in • Performance on an online theory of
social competence and social behaviour during mind usage task improves during
adolescence, and this is hypothesized to rely on a adolescence.
more sophisticated manner of thinking about and
relating to other people including understanding ACKNOWLEDGEMENTS
their mental states.
The author is supported by a Royal Society Univer-
Recently, we adapted a task that requires the sity Research Fellowship. The author is grateful to
online use of theory of mind information when Narges Bazargani for her help with this manuscript.
making decisions in a communication game, and
that produces large numbers of errors even in REFERENCES
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66
Section 2
Promoting Well-Being
Promoting infant mental health
12
Promoting Infant Mental Health
Christine Puckering
Caledonia House, Royal Hospital for Sick Children, Glasgow, UK
WHAT IS GOOD INFANT MENTAL HEALTH? WHY IS INFANCY SO IMPORTANT?
Infant mental health is more than an absence of It has perhaps seemed paradoxical that the period
mental illness, a concept that is difficult in any case of ‘normal infantile amnesia’ for events before the
to apply to infants. Rather, mental health is a holis- age of about three years could have such a pivotal
tic view of the capacities of an infant that include role in later development. The assumption was
growth, learning and relationships. For an infant it that as the child could not remember this period,
is difficult to imagine an environment in which just what happened during that time could not be of
one of these might be promoted without also serv- any significance. Yet, the evidence suggests that
ing the others. A definition that encompasses this what goes on during this time frame has a powerful
perspective is provided by Zero to Three (a multi- predictive value in relation to neuroanatomical and
disciplinary organization that aims to describe and biological processes, as well as social and emotional
define infant and toddler development): competence. For instance, Chapter 20 outlines how
caregiver abuse and neglect can affect infant brain
the young child’s capacity to experience, regulate development.
and express emotions, form relationships and
explore the environment and learn. All of these There is evidence, too, that early exposure to
capacities will be best accomplished within poor parenting leads to abnormal diurnal cortisol
the context of the caregiving environment patterns, with the normal morning peak and bed-
that includes family, community and cultural time trough being flattened in children who are
expectations for young children. Developing exposed to maltreatment. This blunted pattern of
these capacities is synonymous with healthy cortisol production is seen later in both psychopa-
social and emotional development [1]. thy and substance abusers, and may be associated
with callous unemotional behavioural traits – a
The infant, though physically dependent on its possible mechanism being that under-reactivity
caregivers, has a biological imperative and capac- of the hypothalamic–pituitary axis (HPA) leads
ity to react to and interact with other humans [2]. to underarousal at the distress of others. An
It is now clear that this process shapes not only the attachment-based intervention [5] had the effect
learning and emotional capacity of the infant but of normalizing HPA diurnal patterns in children
the very architecture of the brain, with long-term under 2 years, but was less effective with older
sequelae for infant emotional, social and cognitive children suggesting a sensitive period.
growth. Comprehensive guidance on the embed-
ding of infant development in its wider familial, The social and emotional development of chil-
social and cultural context, as well as various dren may be less obvious than their motor devel-
avenues to interventions, has been provided [3,4]. opment or their communication skills. Yet, the
foundations of social and emotional competence
are also laid down in the early months and years
Child Psychology and Psychiatry: Frameworks for practice, Second Edition. Edited by David Skuse, Helen Bruce,
Linda Dowdney and David Mrazek.
2011 John Wiley & Sons, Ltd. Published 2011 by John Wiley & Sons, Ltd.
68
Promoting well-being
and have been shown to be the precursors of learn both that they are valued and how to value
later social and emotional behaviour, as well as others. (see Chapters 7 and 15) It is in this secure
the capacity to sustain attention and learn. There atmosphere that children can learn and develop
have previously been challenges to critical or sen- to their optimum. Babies cannot modulate their
sitive periods in human development because the arousal, and depend on an adult to soothe their
resilience and flexibility of human learning argued distress or discomfort when they are overaroused,
against the sort of tight developmental time frames and to provide stimulation when they are drowsy
suggested by animal studies. Early evidence on or underaroused. It is only when the baby is in
children raised in institutions however suggested a state of active attention that it is possible for
that there were at least some broad limits to toler- social interaction and learning to take place. The
ance in social and emotional development. beginnings of social understanding grow from
whether the child is appropriately soothed and
Early research showed that 2-year-old chil- stimulated by a carer as required. The child who
dren, adopted from children’s homes where meets such carefully modulated interaction will
caregiver–child relationships were discour- learn that other people are trustworthy and avail-
aged due to frequent staff changes and high able to help. Babies whose needs for emotional
child:caregiver ratios, were at higher risk of modulation are not met will fail to understand
later emotional-behaviour problems even after their own feelings, fail to read the feelings of
adoption into good homes [6]. More recently, others and fail to regulate their behaviour. When
the English and Romanian adoption studies have arousal is not held in the midrange, that is, it is
shown that children who had spent more than neither over- nor under-stimulated, learning and
their first 6 months in a depriving institution had thinking are also impaired.
substantial IQ deficits that were not ameliorated
by later good experiences in an adoptive family ASSESSING INFANT MENTAL HEALTH
The children from Romanian institutions were
deprived in almost all aspects of their lives, and the One immediate difficulty emerges in describing
duration and extent of deprivation was evident in or measuring infant mental heath, namely, the
stunted brain growth, even in the absence of poor lack of clear and predictive measures. The concept
nutrition. The authors propose that psychosocial of developmental psychopathology has provided
deprivation plays a major role in functional and some helpful leads to intermediate markers, such
structural neuroanatomy [7]. as language development, peer relationships and
social cognition as well as maternal sensitivity,
So powerful now is the evidence for the that are powerful predictors of later good func-
impact of the caregiving environment upon infant tioning [9]. Even where the marker is something
development, that it has been suggested that since as robust as infant cognitive development, this is
the origins of childhood disruptive behaviour difficult to discriminate within the normal range at
disorders lie in epigenetic processes, intervention such an early stage. Due to difficulties of accurate
as ‘near to conception as possible’ is the key to measurement during this period of development,
effective prevention [8]. The emotional well-being very early cognitive measures do not always reli-
and good social skills that lead to satisfying and ably predict later cognitive functioning. Less well-
sustained peer and family relationships during defined measures, such as well-being, will depend
childhood and adolescence, also lead longer term on the identification of intermediate markers, such
to patterns of interaction that will later support as aspects of infant–caregiver interaction.
good relationships with partners, holding down a
job and being a parent. The gold standard of measurement of
infant–caregiver interaction, The Strange Situa-
WHAT LEADS TO GOOD INFANT tion [10], is, however, not applicable before about
MENTAL HEALTH? 12 months of age, hence often a proxy or predictor
of good attachment, such as measurements of
Of course the most fundamental conception of caregiver sensitivity, are substituted. However,
the promotion of infant mental health comes from screening of development is also a commonly used
theories of attachment, as it is within a secure care- method of assessment, as it is difficult to imagine
giving relationship that infants and then children
69
Promoting infant mental health
an environment that promotes good development backward-facing buggies which give the infant
in infancy but would fail to be nurturing in the close proximity and the chance to interact with
social and emotional sphere. the carer, are simple low-cost interventions that
require little or no professional input. Other
Widely used measures of infant mental health relatively simple interventions have been shown
include questionnaires for parents, observational to have a significant impact on parent–child
methods and rating scales [11]. A recent valida- attachment. Baby massage has been suggested to
tion of the Neonatal Perception Inventory has a have some effect on mother–infant interaction,
shown a remarkable continuity of attachment pro- sleep relaxation and stress hormones, though no
cesses, with children of mothers who did not rate direct effect on infant attachment [16].
their babies as ‘better than the average baby’ on a
number of attributes, showing insecure attachment Families with indicated additional needs
styles as adults some 30–40 years later [12]. While A sound meta-analysis of controlled intervention
cognitive development or parent-completed ques- trials [17] has identified common aspects of effec-
tionnaires of temperament or behaviour may not tive interventions that increase parental sensitivity
be perfect indices of infant mental health, for prag- or attachment for families where additional
matic reasons they are used in various US states support is needed. The common features are
where access to treatment resources may depend that programmes focus specifically on attachment
on meeting readily accessible criteria [13]. rather than less specific support. It is evident that
fewer than five sessions may not be sufficient to
WHAT SUPPORTS GOOD INFANT produce change, while participating in more than
MENTAL HEALTH? 16 sessions has diminishing value. The ideal time to
intervene appears to be between 6 and 12 months
Universal interventions of age, a finding that is coherent with finding of the
In most cases, living in a normal family will provide sensitivity of the infant to severe deprivation or
the baby with exactly the responsive care that is abuse at that age. The review cites no direct impact
needed to support attachment. The presence of a on sensitivity for antenatal intervention, though
small number of caring adults who will attend and engaging very needy mothers-to-be antenatally
respond to infant signals reinforces the emotional and for a further 2 years has a substantial payoff,
development of the baby. Some recommendations perhaps through the development of a working
such as immediate skin-to-skin contact after deliv- therapeutic alliance [18]. While most research
ery may have some utility where the relationship was conducted with mothers, similar findings
is in peril, but these have few clearly demonstrated were shown where intervention was with fathers,
effects in well-functioning families, although skin- though including fathers and mothers together
to-skin contact may promote breastfeeding [14]. diminished the effect size for mothers. Video
One intervention that has been shown to be of feedback proved to be a powerful tool and
value is the use of the Brazelton Behavioural increased effect sizes for intervention.
Assessment Scale, which was initially designed as
a measure of neurological intactness. Since it was A number of programmes meet these criteria,
used in maternity wards, with mothers present, it notably Video Interaction Guidance, Circle of
became clear that gaining an understanding of the Security Attachment, and Biobehavioral Catch-
responses of their own baby gave parents a head Up. Mellow Babies, Watch, Wait and Wonder
start in early relationships via understanding what and Parent-infant Psychotherapy also showed the
their baby was like and how they could best soothe potential to improve attachment relationships,
and support him or her. This was further enhanced cognitive development and emotion regulation
by the use of diaries, which prompted parents to in infants [16,19,20]. Inevitably, these intensive
observe their babies closely and led to the devel- programmes require trained practitioners, with
opment of the Touch Points programme [15]. training being both expensive and time consuming.
There are a number of universal or population- Fortunately there is no need for specialist
based interventions that might be described as psychological services for most families. A
public health interventions and that can have normally loving family with a few caring adults
considerable impact. The use of baby slings and involved in the regular care of a baby will almost
70
Promoting well-being
always provide the interaction that a baby needs. neurodevelopmental outcome of children at age
The resilience of the human infant allows a 6 and 7 years who screened positive for language
tolerance of a range of parenting. Where parental problems at 30 months. Developmental Medicine
factors such as postnatal depression, or factors and Child Neurology 48, 361– 6.
in the baby such as prematurity, or social factors [10] Ainsworth MDM, Blehar MC, Waters E, Wall S.
such as poverty or teenage pregnancy, reduce (1978) Patterns of Attachment. Hillsdale: Erlbaum.
the availability of attuned responsiveness, then [11] Puckering C and the Short Life Working Group on
specialist intervention is needed. However, we Infant Mental Health. (2007) Infant Mental Health:
now have very good indicators of how best to A Guide for Practitioners. HeadsUpScotland,
intervene and the evidence to promote the earliest (available at: http://www.headsupscotland.co.uk/
possible intervention. documents/Infant%20Mental%20Health%20-%20
Good%20Practice%20Guide%20-%20Final%20
REFERENCES Edit.pdf).
[12] Broussard ER, Cassidy J. (2010) Maternal percep-
[1] Zero to Three website. http://www.zerotothree.org/ tion of newborns predicts attachment organization
child-development/early-childhood-mental-health/ in middle adulthood. Attachment and Human Devel-
opment 12, 159– 72.
[2] Trevarthen C. (2001) Intrinsic motives for com- [13] Rosenthal J and Kaye N. (2005) State Approaches to
panionship in understanding: Their origin, devel- Promoting Young Children’s Healthy Mental Devel-
opment, and significance for infant mental health. opment. National Academy for State Health Policy.
Infant Mental Health Journal 22, 95–131. [14] Moore ER, Anderson GC, Bergman N. (2007)
Early skin-to-skin contact for mothers and their
[3] Zeanah C. (2009) Handbook of Infant Mental healthy newborn infants. Cochrane Database of Sys-
Health, 3rd edn. New York: Guilford Press. tematic Reviews issue 3; Art. No.: CD003519; doi:
10.1002/14651858.CD003519.pub2.
[4] Shonkoff J and Phillips D (eds) (2000) for National [15] Brazelton TB. (1992) TouchPoints, the Essential
Research Council and Institute of Medicine. Reference to Your Child’s Emotional and Behavioral
From Neurons to Neighborhoods; the Science of Development. Reading, MA: Addison-Wesley.
Early Childhood Development. Washington, DC: [16] Underdown A, Barlow J, Chung V, Stewart-
Board on Children, Youth and Families, National Brown S. (2006) Massage intervention for pro-
Academy Press. moting mental and physical health in infants
under six months. Cochrane Database of System-
[5] Dozier M, Peloso E, Lewis E, Laurenceau J, Levine atic Reviews Issue 4; Art. No.: CD005038; doi:
S. (2008) Effects of an attachment based interven- 10.1002/14651858.CD005038.pub2.
tion on the cortisol production of infants and tod- [17] Bakermans-Kranenburg MJ, van IJzendoorn MH,
dlers in foster care. Developmental Psychopathology Juffer F. (2003) Less is more, meta-analyses of
20, 845–59. sensitivity and attachment interventions in early
childhood. Psychological Bulletin 129, 195–215.
[6] Hodges J and Tizard B. (1989) Social and family [18] Olds DL. (2006) The nurse–family partnership,
relationships of ex-institutional adolescents. Journal An evidence-based preventive intervention. Infant
of Child Psychology and Psychiatry 30, 77– 97 Mental Health Journal 27, 5–25.
[19] Puckering C, McIntosh E, Hickey A, Longford J.
[7] Rutter M and Sonuga-Barke EJ. (2010) Conclu- (2010) Mellow Babies, A group intervention for
sions: overview of findings from the era study, infants and mothers experiencing postnatal depres-
inferences, and research implications. Monographs sion. Counselling Psychology Review 25, 28–40.
of the Society for Research in Child Development 7, [20] Zeanah P, Stafford B, Zeanah CH. (2005) Clinical
212– 29. Interventions to Enhance Infant Mental Health, a
Selective Review. National Center for Infant and
[8] Tremblay RE. (2010) Developmental origins of Early Childhood Health Policy at UCLA.
disruptive behaviour problems, the ‘‘original sin’’
hypothesis, epigenetics and their consequences for
prevention. Journal of Child Psychology and Psy-
chiatry 51, 341– 367.
[9] Miniscalco C, Nygren G, Hagberg B, Kadesjo¨ B,
Gillberg C. (2006) Neuropsychiatric and
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Promoting children’s well-being
13
Promoting Children’s Well-Being
Paul Stallard
Child and Adolescent Mental Health Services, Oxford Health NHS Foundation Trust, Bristol, UK
WHAT’S NEW
• School-based prevention programmes provide an opportunity to widely promote and
maintain the psychological well-being of children.
• The effects of these programmes are, however, variable with those focusing upon anxiety
showing more promise than those focusing upon depression.
• Targeted programmes produce greater immediate treatment effects although the potential
benefits of universal prevention programmes in maintaining healthy status and reducing the
prevalence of new disorders have seldom been assessed.
• Variability within studies indicates the need for methodologically robust research to identify
important mediators and moderators.
• An analysis of costs/benefits and delivery models is required to determine whether
school-based prevention programmes should be widely available and are sustainable in
schools.
Community surveys highlight that psychological psychological well-being. This can be achieved by
problems in children and young people are com- the widespread provision of programmes designed
mon and can significantly impair everyday func- to reduce or mitigate the effects of known mental
tioning [1,2]. If left untreated, problems persist and health risk factors while enhancing protective fac-
increase the likelihood of psychological problems tors at the individual, family and community level.
in adulthood [3,4]. Improving the mental health Prevention programmes, therefore, help children
of children is an important public health objective to become more resilient and better able to cope
and although effective treatments are available the with stress and adversity thereby maintaining their
majority of children, particularly those with emo- healthy status.
tional disorders, remain unidentified and untreated
[5]. Focusing upon the treatment of established dis- PREVENTION
orders will therefore have a limited impact upon
the psychological health of children. Prevention programmes are typically conceptual-
ized as universal, selective or indicated, with each
An alternative approach is that of prevention, having a different focus and aim [6] (Table 13.1).
which aims to reduce the prevalence of psycho- Universal programmes are provided to all
logical problems and disorders while optimizing
Child Psychology and Psychiatry: Frameworks for practice, Second Edition. Edited by David Skuse, Helen Bruce,
Linda Dowdney and David Mrazek.
2011 John Wiley & Sons, Ltd. Published 2011 by John Wiley & Sons, Ltd.
72
Promoting well-being
Table 13.1 Universal, selective and indicated prevention.
Prevention Provision Advantages Disadvantages
Universal prevention, Universal — provided Far-reaching coverage Limited resources used to
e.g. anxiety prevention provide interventions to
programmes for to all regardless of Opportunity for many who are, and will
9/10-year-old children risk status primary prevention, remain, ‘healthy’
Intervention effects are
Selective prevention, i.e. reduce prevalence typically small
e.g. anxiety prevention Face validity, relevance
programmes for of new disorders and engagement can be
children where parents difficulties
are separating Screening not required
Potentially stigmatizing
Indicated prevention, Avoids need for Difficulties in accurately
e.g. children with labelling, which could identifying ‘at-risk’ groups
significant anxiety be stigmatizing within the community
symptoms but not
meeting full diagnostic Low cost/high volume May require screening,
criteria which can be costly and
Targeted — upon Resources focused upon practically complicated
those at increased ‘at-risk’ groups Potentially stigmatizing
risk of developing and unacceptable to some
problems through Opportunity for of the identified group
exposure to known primary prevention
risk factors
Targeted — upon Efficient use of limited
those displaying resources
mild/moderate
problems Provide early
interventions for those
with emergent
problems
Demonstrate larger
treatment effects
members of the target population irrespective maximizing potential), protection (e.g. developing
of risk status, such as children of a certain age. competencies) and intervention (e.g. minimizing
Selective programmes target children at increased impairment). Far-reaching and accessible, they
risk of developing problems through exposure to minimize any potential negative stigma arising
known risk factors – for instance, children of par- from more targeted approaches. However, their
ents with a mental illness. Universal and selective general focus may not be of sufficient depth or
programmes are primarily concerned with promot- dosage to benefit those with more established dis-
ing well-being and in reducing the occurrence of orders. Similarly, from an economic perspective,
new problems. Indicated programmes are early many of those who receive universal interven-
interventions provided on a targeted basis to those tions are already healthy and do not, and will not,
already displaying mild or moderate problems to require any intervention to maintain this status or
prevent them from worsening – for example, chil- maximize their potential.
dren with symptoms of anxiety or depression.
Selective and indicated approaches are more
Each approach has strengths and limitations. targeted, focusing limited resources upon those
Universal programmes offer the greatest potential with potentially greater needs. The effects are
to optimize the well-being of the wider population. often large since initial levels of symptoms and
They provide opportunities for prevention (e.g. the subsequent change are greater. However,
73
Promoting children’s well-being
they require accurate identification of the target programmes were most effective in reducing symp-
group – a particular difficulty where children have toms of depression, with prevention programmes
emotional problems or disorders. led by teachers tending to be the least effective.
The authors noted variability in the effectiveness
School-based prevention of programmes based upon the same theoretical
In terms of delivering prevention programmes model suggesting that factors other than the pro-
schools provide convenient and familiar locations gramme content or mode of delivery (universal
that are attended by the majority of young people. vs targeted) per se may be important mediators
The integration of emotional health programmes of outcome.
within the school setting and curriculum offers the
potential to discuss openly mental health issues The effectiveness of universal prevention pro-
and to promote psychological concepts and ideas grammes was investigated in a review of 12 studies
as ‘skills for life’. This open and more visible [11]. The results were variable. Five showed signif-
approach serves to normalize common psycho- icant immediate post-intervention improvements
logical problems such as anxiety and depression, on at least one measure of depression, but none
and can help to develop a supportive peer group showed any significant effects at follow-up (i.e. 12
culture where worries and problems can be more months or longer). The authors concluded that
openly acknowledged and discussed. the widespread use of universal depression pro-
grammes in schools would be premature. They
In terms of effectiveness, systematic reviews advocate that further research should be under-
of school-based emotional health prevention pro- taken. The authors highlighted a number of issues,
grammes have found evidence to suggest that many of which were addressed in a recent ran-
universal and targeted/indicated approaches can domized trial involving 5634 adolescents in which
have positive effects upon emotional well-being a CBT-based intervention, ‘beyondblue’, was com-
although the results are variable [7,8]. This chapter pared with no intervention [12]. ‘Beyondblue’
focuses on interventions aimed at two of the was delivered by trained teachers and provided
most common emotional disorders, namely anxiety interventions at individual, school and commu-
and depression. Issues and challenges involved in nity levels. Individually adolescents learned skills
delivering effective prevention programmes are to improve problem-solving, social skills, resilient
presented and discussed. thinking and coping strategies. Within the school
the intervention aimed to build a supportive envi-
DEPRESSION PREVENTION PROGRAMMES ronment by improving social interactions and facil-
itating access to support and professional services.
A Cochrane review of depression prevention pro- Finally, community forums were provided in order
grammes identified 18 psychological interventions to facilitate a greater understanding of emotional
of which 10 were universal and eight were targeted problems and how to seek help. This multi-level
[9]. The methodological quality of the studies was intervention, delivered over 3 years, failed to find
poor resulting in half being excluded from the any significant differences in depressive symptoms
analyses. Interventions were found to be effective when compared with the ‘no intervention’ group.
in comparison to no intervention, with significant This study provides a timely reminder of the
reductions in immediate post-intervention depres- difficulties of implementing psychological inter-
sion scores. The authors suggest further investi- ventions in everyday settings.
gations are warranted alongside methodologically
robust investigations. A more recent review iden- Finally, Horowitz and Garber (2006) suggest
tified 42 trials assessing 28 different programmes that evaluation of depression prevention research
[10]. Of these trials, 26 were universal, 10 indicated has focused upon demonstrating evidence of
and six were selective. The majority (76%) of pro- treatment effects (i.e. reducing levels of depressive
grammes were based upon cognitive behavioural symptoms) rather than on preventive effects, such
therapy (CBT) and involved eight or more sessions as a reduction in the emergence of new cases. Their
(88%). Two-thirds were led by graduate students, meta-analysis of 30 studies found that selective and
mental health practitioners or teachers. Indicated indicated programmes were more effective than
universal programmes. Only four studies provided
any evidence suggesting a preventive effect [13].
74
Promoting well-being
ANXIETY PREVENTION PROGRAMMES anxiety. They are also taught problem-solving and
the principles of contingency management and
The results of school-based anxiety prevention reinforcement in which the child’s courageous and
programmes are more consistent and encouraging. coping behaviour is rewarded rather than their
A recent review [14] identified 27 trials assess- anxious talk and problem avoidance.
ing 20 different programmes; 16 universal, eight
indicated and three selective trials were evaluated. Randomized controlled trials have demon-
The majority (78%) were based upon CBT inter- strated significant post-‘FRIENDS’ reductions
ventions that were mainly led by mental health in anxiety, which have been maintained up to
practitioners (44%) or teachers (26%). Only four 3 years after the intervention [15,16]. Similarly,
studies included children under the age of 9 years. the issue of effectiveness when delivered within
Seventy-eight percent of interventions reported everyday settings has been assessed in a series of
significant post-intervention reductions in symp- small studies, with gains being present for up to 12
toms of anxiety, with universal and targeted pro- months [17,18].
grammes being judged equally effective. There
was considerable variability in effectiveness within FUTURE DEVELOPMENTS AND
individual programmes. Unlike depression preven- CHALLENGES
tion interventions, teacher-led anxiety prevention
interventions were equally as effective as those led Whilst school-based prevention programmes offer
by mental health professionals. The authors sug- the potential to improve the psychological well-
gest encouraging the widespread implementation being of children, further research is required
of school-based anxiety prevention programmes, before their widespread implementation can be
alongside rigorous evaluation of their longer-term advocated. Firstly, from a methodological view-
outcomes. point, sample sizes are often small, medium-term
follow-ups are lacking, and few have included
‘FRIENDS for life’ is one of the better evaluated comparisons with other active interventions. Most
anxiety prevention programmes. The 10-session studies have focused upon adolescents and few
programme is based upon CBT and has versions have been designed for, or included, children
for children (aged 7–11), youths (12–16) and more under the age of 9 years. In terms of programme
recently for young children aged 4–6 years (Fun content, those based upon CBT, particularly for
FRIENDS). The programme is very engaging and anxiety, show most promise although there are
involves a mix of large and small group work, role considerable differences between programmes in
plays, games, activities and quizzes, and teaches length, core components and delivery. Variations
children skills in three main areas. Cognitively, in effectiveness within similar programmes suggest
children are helped to become aware of their the importance of mediating factors relating to
anxiety-increasing cognitions and to replace them programme leaders (e.g. professional experience,
with more helpful and balanced cognitions. Emo- training, rapport and confidence), students (e.g.
tionally, they are helped to understand the anxiety age, gender, engagement) and schools (e.g. class
response and their unique physiological reaction size, emotional health awareness and available
to stressful situations. This helps children to detect support).
early signs of anxiety so that they can intervene to
manage and reduce these unpleasant feelings. The Secondly, it is unclear whether preventive inter-
final component addresses the behavioural domain ventions that are universal are more effective than
and teaches children problem-solving skills and targeted interventions. Universal programmes
the use of graded exposure to systematically face have the potential to maximize psychological
and overcome their worries. FRIENDS can be led well-being. Typically such programmes aim to
by trained teachers or mental health practitioners reduce symptoms, in addition to maintaining
such as school nurses or psychology graduates. psychological health. However, the focus of
evaluation has been on whether they reduce
In addition to the child sessions, parents are symptomatology, rather than on detailing whether
invited to two to four psycho-educational ses- they maintain emotional well-being and protect
sions. These help parents to understand anxiety children from subsequent emotional health
and to develop strategies to cope with their own problems. The longer term primary preventive
75
Promoting children’s well-being
benefits of universal approaches need to be [3] Kim-Cohen J, Caspi A, Moffit TE et al. (2003)
assessed alongside an economic evaluation to Prior juvenile diagnoses in adults with mental dis-
determine the costs/benefits of such approaches. order: developmental follow-back of a prospective-
longitudinal cohort. Archives of General Psychiatry
Thirdly, integrating emotional health preven- 60, 709– 17.
tion programmes within schools poses many practi-
cal issues that will impact upon their sustainability. [4] Woodward LJ and Fergusson DM. (2001) Life
In terms of effectiveness, most studies are effi- course outcomes of young people with anxiety dis-
cacy trials, and the applicability and benefits of orders in adolescence. Journal of the American
these programmes when delivered under less con- Academy of Child and Adolescent Psychiatry 40,
trolled everyday conditions are unclear. Flexible 1086– 93.
programmes that can be delivered within the teach-
ing timetable and within the length of the school [5] Ford T, Hamilton H, Meltzer H, Goodman R. (2008)
semester are required. In terms of programme Predictors of service use for mental health problems
leaders, trained school staff appear to be effec- among British schoolchildren. Child and Adolescent
tive in delivering anxiety prevention programmes Mental Health 13, 32–40.
but less so for depression programmes. Whether
depression programmes require a higher level of [6] Mrazek PJ and Haggerty RJ. (1994) Reducing
expertise and understanding, or whether students Risks for Mental Disorders: Frontiers for Preventive
are less willing to acknowledge or engage with Intervention Research. Washington, DC: National
teachers about more personal issues relating to Academy Press.
low mood requires further investigation. Attention
needs to be paid to the skills and training of the [7] Adi Y, Killoran A, Janmohamed K et al. (2007)
programme leaders and the ongoing supervision Systematic Review of the Effectiveness of Interven-
that will be required to maximize effectiveness and tions to Promote Mental Wellbeing in Children in
maintain intervention fidelity. Primary Education. Report 1: universal approaches
(non-violence related outcomes). London: National
Finally, whilst there are a number of anxiety Institute for Health and Clinical Excellence.
and depression prevention programmes available,
very few have been subject to robust multiple [8] Shucksmith J, Summerbell C, Jones S et al. (2007)
evaluations by different research groups. Defin- Mental Wellbeing of Children in Primary Education
ing the characteristics of effective and sustainable (Targeted/Indicated Activities). London: National
prevention programmes is important. Undoubt- Institute for Health and Clinical Excellence.
edly these will include a number of factors such
as multi-level, developmentally sensitive, engaging [9] Merry S, McDowell HM, Hetrick S, Bir J
interventions that rest upon evidence-based con- et al. (2004) Psychological and/or educational inter-
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flexibly by appropriately trained and supervised and adolescents. Cochrane Database of System-
leaders and be consistent with the ideologies and atic Reviews Issue 2; Art. No.: CD003380; doi:
priorities of the schools involved [19]. 10.1002/14651858.CD003380.pub2.
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77
Fostering resilience in adolescents
14
Fostering Resilience in Adolescents
Angela Veale
School of Applied Psychology, University College Cork, Ireland
WHAT’S NEW
• There has been a shift from looking at variables correlated with resilient outcomes and
processes such as attachment and support networks to understanding individuals dealing
with adversity within resilient systems.
• There is an increasing understanding of the importance and role of cultural processes.
• Future directions will integrate multidisciplinary knowledge gained from genetics,
neuropsychology and cultural psychology about resilience in the developing individual.
• New forms of intervention are moving from promoting resilient individuals to mobilizing
basic protective systems at the individual, family, community and organizational level.
• ‘Prevention science’ seeks to prevent or limit damage at all levels of resilience-supporting
systems.
INTRODUCTION self-efficacy and autonomy; yet the prospect of
engaging in therapy may reinforce unconscious
There is increasing social concern about ‘out fears of being ‘mad’ or a ‘psycho’.
of control’ adolescents who exhibit challenging
behaviour. Many who come to the attention A traditional clinical approach to this group
of the mental health system have experienced of young people would be that of healing psy-
multiple adversities in their lives, such as poverty, chopathology. Fostering resilience offers an alter-
chaotic parenting, residential care, foster care or native lens and involves a fundamental shift from a
school expulsion. They live in systems that lack deficits perspective, focused on individualized neg-
supportive capacity and are resource impover- ative functioning and vulnerability, to a dynamic
ished. Significantly, these adolescents are also systems, strengths-based, participative orientation.
difficult to engage in therapeutic interventions, This chapter outlines new theoretical resilience
particularly because of a fear of stigmatization. frameworks and links them to a psychothera-
There is a developmental challenge inherent in peutically informed participatory action research
this situation – the health-seeking part of the project with ‘hard to reach’ adolescents in an
psyche is outward looking, and strives towards exploration of how resilience can be fostered in
practice and community settings.
Child Psychology and Psychiatry: Frameworks for practice, Second Edition. Edited by David Skuse, Helen Bruce,
Linda Dowdney and David Mrazek.
2011 John Wiley & Sons, Ltd. Published 2011 by John Wiley & Sons, Ltd.
78
Promoting well-being
WHAT DO WE MEAN BY RESILIENCE? For Ungar, therefore, resilience involves both
the capacity of individuals to navigate their
Resilience can be defined as ‘patterns of positive way to obtaining health-sustaining resources
adaptation during or following significant adversity (including opportunities to experience feelings of
or risk’ (Masten et al. [1], p. 118). The definition well-being) and the capacity of the individual’s
requires two judgements – first, that the exposure family, community and culture to provide the
to risk or adversity was serious enough to pose needed resources and experiences in a way that is
a serious threat to healthy development; second, culturally meaningful [6].
that the individual subsequently meets age-related
developmental tasks. Within this framework, there Mobilizing social networks to foster coping
has been a focus characterizing resilient outcomes and resilience
as individual variables (e.g. effective problem- A further useful analysis of how social relation-
solving skills, emotional self-regulation, positive ships foster resilience is provided in the Social
parenting) or processes (e.g. attachment patterns, Convey model [8]. Social convoys are the multiple
family and community interactions). One of the relationships in the lives of children and young
most significant shifts in resilience science over people that facilitate the exchange of affective
the past decade has been a new emphasis on support, self-affirmation and direct aid. Impor-
resilient systems. Here, resilience is seen to be tantly, the model extends the concept of attach-
mediated by risks, protective factors and resources ment relationships to other close relationships and
at multiple levels ranging from the molecular acknowledges that relationships between adults
neurobiological to the social, cultural and polit- and children are characterized by mutuality of sup-
ical [2]. An illustration is provided by analy- port and social exchange. That is, in adult–child
ses of resilience to trauma and stress. One of relationships, children and youth have the capac-
the most consistent research findings has been ity both to give and to receive nurturance and
that close emotional relationships and support- support, and furthermore this is a powerful moti-
ive informal and formal social networks foster vational force in relationship formation and main-
resilience [1,3,4]. Neurobiological research indi- tenance. The model is strengths-based as it posits
cates that emotional support of this kind can an engaged young person who is active in recipro-
reduce uncertainty and stress by impacting upon cal support relationships. This may be particularly
the hypothalamic–pituitary–adrenal (HPA axis) relevant for adolescents engaged in the devel-
and the sympathetic nervous system, which regu- opmental task of negotiating a balance between
late cortisol levels. This in turn enhances coping autonomy and relatedness in relationships [9].
via an impact on brain regulatory systems that
control arousal and thus behavioural and cognitive IMPLICATIONS FOR POLICY AND PRACTICE
responses to stress [5] (see Chapter 20). Masten
and colleagues suggest that systems operate at The models outlined above indicate the impor-
multiple levels and include powerful motivational tance of supporting the agentive, help-seeking,
systems such as the mastery system as well as mastery-oriented capacities of young people as
relational systems at the level of family, commu- they negotiate the support needed from those
nity and society, and that the greatest threat to around them. Several challenges face practitioners
children’s resilience may be adversities that dam- if these models are to be successfully applied.
age or undermine these basic human protective Practitioners need to foster adolescents’ capac-
systems [1]. ities for: mobilizing adaptive support systems;
negotiating access to resources for healthy growth
Agency in resilience and development; and participating in social
Of course, cultures influence definitions of convoys characterized by reciprocal supportive
resilience, and this is explored in Ungar’s multi- relationships. They need also to foster resilience
country resilience project [6,7]. In many cultures, in situations when adolescent support systems
psychological explanatory models of distress are may be damaged, unsupportive or unavailable,
uncommon, and causality is more likely to be as is often the case with the families of ‘hard
attributed to external social or structural factors. to reach’ adolescents. Finally, they need to shift
79
Fostering resilience in adolescents
Box 14.1 Promoting resilience — a participatory action research (PAR) project.
PAR project Description Fostering resilience
phases
Phase 1: Twelve weeks of creative arts Sharing of daily hassles and
Defining workshops facilitates: difficulties, and co-constructed art
participation; results in:
question-posing; • Exploration of participants’
data gathering; experiences with police, youth • Enhanced emotional regulation
analyses justice and social integration
• Communication skills
Phase 2: • Identification of priority issues
Planning a social • Information-processing
action • Opportunities to socialize
• Behaviour respectful of group
• Exploration of important themes members and facilitators
• Meeting key policy-makers to
discuss priority issues
• Choice of social action project
• Control of budget line • Develop trust in their ownership
of key project decisions
• Plan and implement social action
project • Enhanced motivation
• Enhanced reflective capacity
• Choose method of action and • Responsible participation
dissemination (produce a DVD)
Phase 3: Skills development culminating in The production of the storylines
Implementing girls’ DVD production ‘Girls Out and DVD mobilized:
social action Loud’, including:
• Individual and collective mastery
• Undertaking social
action — visiting other relevant • Confidence and self-esteem
projects to learn about
consultation with ‘key’ players, • Persistence in the face of doubt
e.g. politicians and community and difficulty
leaders
• More powerful voice (making
• Make videos of project visits oneself heard)
• Interview other young people in • Effective communication
social projects
• Use interviewing skills in visit to
political representatives in
Parliament Buildings, Northern
Ireland Assembly
• Identification of further research
questions and themes
• Design and art skills — videoing
and photography; drawing;
storylines; animated puppet
shows; video editing
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Promoting well-being
PAR project Description Fostering resilience
phases
Present DVD and discuss issues Changes in:
Phase 4: about the justice and care systems
Analysis, with: • Perspective-taking and
reflection and inter-subjectivity
dissemination of • Ombudsman for Children
project findings • Ability to adopt the perspective
• Garda Juvenile Diversion service of the ‘other’ in their
communications
• local police
• local school
• local communities
Subsequently local youth
organization starts participation
initiative, consulting with parents.
Our project participants:
• train staff
• develop consultation work with
parents
away from an emphasis on internal psychological same community. The author, a psychologist, was
processes and clinician/patient-defined interven- principal investigator.
tions, and become one part of the adolescent’s total
resilience system. In practice, this means initiating Summary of the project
processes that facilitate young people in defining The intervention project unfolded in three phases
their own needs, priorities and best interests and in over 24 weeks (Box 14.1). It took the form
mobilizing their social networks and communities of weekly creative arts workshops in which
to support them as they address those needs. experiences of police, youth justice and social
integration were explored. We anticipated that the
MOBILIZING RESILIENCE: AN girls would undertake a leading role in planning
ILLUSTRATIVE EXAMPLE and decision-making: they would choose the art
medium to work in; they would choose, design and
Here I outline a participatory action research implement a social action project that reflected
(PAR) social integration project with nine girls their primary issues of concern; they would
(aged 12–18 years), half of whom had received control an allocated budget for their project.
formal cautions from the police, and who had Throughout, the girls interacted with the outside
also been referred to an intensive support ser- world in ways determined by them – for instance,
vice for young people in crisis. A number were through visits to other social projects and meeting
in foster or residential care, and some had actu- politicians, community leaders and other key
ally been ejected from the latter. The remaining actors to question them about matters of concern.
participants were community peers without formal Their final social project – a DVD outlining their
contact with the police and who were not in crisis. issues with the justice and care systems, and
Facilitator participants included a psychotherapist, social integration – was presented to Ireland’s
a creative artist, and two peer researchers from the Ombudsman for Children, senior members of the
81
Fostering resilience in adolescents
Garda Juvenile Diversion service, local police, exchanged helpful ideas and began to work
schools and community organizations. alongside each other.
• Individual and collective mastery developed. Ini-
Implementing the project tially, participants were reluctant to use the arts
Some of the developmental stages of this project materials – one was so inhibited at the start that
are outlined below. the creative artist held her hand to scaffold
her early drawing attempts. A ‘transformational’
• Getting the girls to engage with the project was came when the creative artist used the clay char-
a key challenge – their experiences of feeling acters that participants had made in a previous
powerless and unheard within the social care session to make an animated computer film.
and justice systems were evident in an early This created great enthusiasm and excitement.
comment by one young participant: From then on, participants’ assurance in their
contribution to the group grew.
If you feel you’re not being heard, there’s no • A sense of ownership of the group had developed
point, you feel there is no point in yourself by session 6: members arrived on time, they
making progress reminded each other to turn off mobile phones
and they more obviously helped each other, par-
Such experiences fed into a manifest reluctance ticularly if someone had missed a session. There
to join in early workshop sessions. It was clear was a sense of focus and flow. The group assumed
that the girls felt they had nothing to contribute significant responsibility for managing their ses-
and found it hard to imagine a project directed sion. One asked ‘how many weeks have we
by them without adults structuring and control- left?’ indicating how they valued the space. One
ling it. We tried engaging them in various ways. requested that no new people should be allowed
For instance, we included a drumming session to join as ‘this is the group now’. Over the next 6
to provide structure and focus while participants weeks, their creative work and discussion about
learned about the project and each other. It was their lives opened up. They developed a puppet
difficult to get them to drum making audible show and took charge of developing storylines.
sounds. It often seemed as if the young people They began photographing their work.
would disengage with the project and that it • Participants underwent remarkable changes as
would be impossible for the group to find direc- they gained in confidence, self-esteem and opti-
tion. This was evidenced in late arrivals, much mism. Emotional control and regulation became
leaving and returning to the room and a lot of apparent – in particular, inhibition of disruptive
mobile phone texting. behaviour. They showed the capacity to plan
• The need to step back and leave the control and think ahead. Relationships between group
and ownership of the project in the girls’ hands members and with the facilitators came to be
quickly became apparent, and gradually they characterized by reciprocity and commitment to
became more engaged. For instance, they swiftly the achieving group aims.
assumed control of choosing and ordering the • Mobilizing supportive resilience systems flowed
end of session food; they developed their own from the girls’ progress and development. As
rules for group meetings, including that mem- they moved from being angry and antagonis-
bers needed to arrive ahead of time so they tic towards authority figures, such as the ‘pigs’
could chat together before the group meeting (police), they were able to engage construc-
started; they chose the sessional art medium they tively in discussions with them. Their new found
would use. First, however, they ‘interviewed’ ability to tolerate multiple perspectives (theirs
the group’s creative artist, seeking information and those of the police) and increased maturity
about his work, examining examples of it, and meant that when they showed their DVD to
asking questions. The group agreed that he was local police, their schools and local community
‘sound’ and they could work with him. projects, they were mobilizing supportive rela-
• Emerging group level properties gradually tionships that would enhance resilience within
become evident as the girls chose art activities, their immediate microsystems.
82
Promoting well-being
CONCLUSION REFERENCES
Specific examples of the girls’ enhanced resilient
capacities are outlined in Box 14.1. In summary, [1] Masten AS, Cutuli JJ, Herbers JE et al. (2009)
our experience gained through this project has Resilience in development. In: Snyder CR and Lopez
shown us that fostering resilience with ‘hard to SJ (eds), Oxford Handbook of Positive Psychol-
reach’ adolescents means giving them a good or ogy, 2nd edn. Oxford: Oxford University Press, pp.
positive experience of power, control, ownership 117 – 31.
of decision-making and resource management in a
way that stimulates their feelings of mastery (their [2] Masten AS and Obradovic J. (2008) Disaster prepa-
mastery system). They gain a sense that they are ration and recovery: Lessons from research on
able to impact on their world in ways that are resilience in human development. Ecology and
chosen by them and meaningful to them, and that Society 13, 9–; available online at: http://www.
they can actively mobilize others to support them ecologyandsociety.org/vol13/iss1/art9/.
(Box 14.2). These processes, so important in devel-
oping resilience when in difficult circumstances, [3] Luthar SS and Brown PJ. (2007) Maximizing
may inadvertently be undermined by many of our resilience through diverse levels of inquiry: Prevailing
more traditional clinical practices. As researchers paradigms, possibilities, and priorities for the future.
and practitioners, our moment of enlightenment Development and Psychopathology 19, 931–55.
in this project came when the young people told
the Irish Ombudsman for Children ‘This was our [4] Dolan P. (2008) Prospective possibilities for building
project’ and their sense of ownership was publicly resilience in children, their families and communities.
celebrated and claimed. Child Care in Practice 14, 83–91.
Box 14.2 Implications for clinical [5] Ozbay F, Fitterling H, Charney D et al. (2008) Social
practice support and resilience to stress across the life span: a
neurobiologic framework. Current Psychiatry Report
Fostering resilient systems adds multiple 10, 304– 10.
layers of complexity to clinical practice.
It also positions the clinician and men- [6] Ungar M. (2008) Resilience across cultures. British
tal health organization as one element of Journal of Social Work 38, 218– 35.
the adolescent’s resilience system. Within
that, what is the role of clinicians in fos- [7] Ungar M. (2010) Cultural dimensions of resilience
tering resilience in the system? among adults. In: Reich JW, Hall JS, Zautra AJ
(eds), Handbook of Adult Resilience. New York:
Guilford Press, pp. 404– 23.
[8] Levitt MJ. (2005) Social relations in childhood and
adolescence: The convoy model perspective. Human
Development 48, 28–47.
[9] Mahler MS. (1977) Separation-Individuation:
Selected Papers of Margaret S. Mahler. New York:
Aronson.
83
Section 3
Attachment and
Separation
Attachment and separation
15
Attachment Theory: Research
and Clinical Implications
Pasco Fearon
Research Department of Clinical, Educational and Health Psychology, University College London,
London, UK
WHAT IS ATTACHMENT? communication (e.g. calling, crying); (ii) proximity
seeking (e.g. crawling, walking, reaching) and (iii)
Broadly speaking, attachment refers to the ten- contact maintenance (e.g. clinging). Monitoring
dency, particularly but not exclusively, of infants the whereabouts and availability of an attachment
and young children to rely on a parent figure for figure may also be described as attachment
comfort and support when frightened, stressed or behaviour. Attachment is characterized by
ill. It is thought to be a form of biobehavioural heterotypic continuity, meaning that while it evi-
adaptation, shaped by the forces of natural selec- dences continuity over time in its basic functional
tion to maximize survival and eventual repro- organization, the specific child behaviours used
duction, and the key features of attachment are to achieve comfort or security change radically
similar across many mammalian species, particu- in complexity and sophistication as children
larly the higher primates. The field of attachment mature [4].
owes much to John Bowlby [1], who articulated
an evolutionary account of attachment, and Mary Thus, attachment behaviour performs a kind of
Ainsworth [2], who pioneered its study in natural- homeostatic function (Figure 15.1), and to oper-
istic contexts. ate efficiently it needs to be guided by information
about the environment, for example the nature and
It is important to distinguish between attach- location of the threat, the caregiver’s whereabouts,
ment behaviour and an attachment bond. It is and contextual information as to the potential
generally recognized that one cannot classify a efficiency of various forms of action, etc. Devel-
behaviour as an attachment behaviour from its oping this idea, Bowlby proposed that during
outward appearance alone. Instead, attachment repeated experiences within an attachment rela-
behaviours are defined as such by recognizing their tionship, children develop internal working models
function. They are thus any organized, systematic of attachment that guide their thinking, feeling and
behaviour that is triggered by the appearance of behaviour in attachment situations, and this shapes
a potential threat or stressor and that predictably the way they approach close relationships – and
serves to achieve proximity to a selected caregiver see themselves within them – in the future.
[3]. This means that all manner of behaviours can
serve the general purpose of achieving comfort An attachment bond [5] refers to the longer-
and security for children, and some may be quite term, stable tendency to seek out a selected parent
idiosyncratic to a particular child. figure in times of stress. The processes that lead to
the establishment of a long-term attachment bond
Attachment behaviours generally are divided are quite different to those that trigger attachment
into three classes: (i) signalling or distal behaviour. Crucially, certain forms of disturbance
Child Psychology and Psychiatry: Frameworks for practice, Second Edition. Edited by David Skuse, Helen Bruce,
Linda Dowdney and David Mrazek.
2011 John Wiley & Sons, Ltd. Published 2011 by John Wiley & Sons, Ltd.
85
Attachment theory: research and clinical implications Exploration
reduces
Perceived threat Attachment system Proximity seeking
reduces Contact (physical or psychological)
Figure 15.1 Schematic diagram of the homeostatic function of attachment.
in attachment probably result from disruptions in latter category that has attracted the most atten-
the formation of attachment bonds (e.g. disinhib- tion clinically, as it appears most closely related to
ited attachment disorder), while others result from more severe forms of adverse parental care, and to
experiences or influences that alter how attach- raised risk of psychopathology [6]. The prevalence
ment behaviour is organized and triggered (e.g. of the different insecure subtypes varies consider-
disorganized attachment). ably across cultures [7]. A host of similar measures
have been developed for assessing attachment in
ATTACHMENT VARIATIONS AND THEIR older children [8].
MEASUREMENT
CAUSES OF VARIATION IN ATTACHMENT
Normative attachment patterns
Mary Ainsworth’s Strange Situation Procedure is Ainsworth originally proposed that the extent
the most commonly used tool for studying attach- to which the parent was sensitive and responsive
ment behaviour [2]. Involving an encounter with a to the child’s attachment signals was the critical
stranger and 2–3-minute separations from a par- determinant of attachment security (see Table 15.2
ent in an unfamiliar setting, it is used with infants for exemplars of sensitivity) [2]. Since then, this
aged approximately 11–18 months. The reliable hypothesis has been supported by an impressive
and valid Ainsworth coding system quantifies four database of longitudinal studies [9]. Furthermore,
dimensions of attachment behaviour, each rated randomized controlled trials of clinical interven-
on a seven-point scale. It also enables raters to tions designed to improve sensitive parenting have
make categorical judgements about the style or been shown to increase the likelihood of secure
classification of attachment behaviour displayed attachment, suggesting the association is a causal
by individual children (Table 15.1). These divide one [10]. However, many authors have noted that
into two broad classifications – ‘secure’ (Type B) the effect sizes in correlational studies or clinical
and three types of ‘insecure’ attachment: Type A trials are not large and that other factors – either
(Avoidant), Type C (Resistant) and Type D (Dis- different aspects of parenting or different types
organized). These classifications have become a of causal influence altogether – probably play
major focus of research, with findings indicating a role. While sensitive care may be thought of
that the majority of infants in low-risk circum- as the most important proximal determinant of
stances (approximately 65%) are described as attachment security, a host of more distal or
‘secure’; approximately 15% as Avoidant; 10% contextual factors also appear to be consistently
as Resistant and 15% as Disorganized. It is this associated with security and insecurity, including
parental depression, social support, marital quality
86
Attachment and separation
Table 15.1 Attachment behaviour rating scales and classifications for the Strange Situation
Procedure [2].
Interactive behaviour scales The intensity and persistence to make contact on reunion with
Proximity seeking the caregiver. An infant scoring high on this scale makes a
Contact maintenance purposeful approach to the caregiver and takes initiative to
make contact
Resistance
Avoidance The persistence in maintaining contact with the caregiver once it
Disorganized/ disoriented is achieved. A high score on this scale is given when an infant
displays resistance to being put down (e.g. clinging), persistent
efforts to remain close to the caregiver, or any sign the infant is
not ready to terminate contact (e.g. a sinking embrace to
mother)
The intensity and duration of angry behaviour and resistance of
contact directed towards the caregiver. Examples include
pushing away, batting away, arching back, squirming to get down
The intensity, duration and promptness of attempts to avoid
contact/interaction with the caregiver. Examples of avoidance
are averting gaze, moving away and ignoring the caregiver
Anomalous behaviour, e.g.: sequential or simultaneous displays
of contradictory behaviour; undirected, misdirected or
incomplete behaviours; stereotypies, freezing, disorientation;
fearful responses in presence of the caregiver
Infant attachment classification profiles
Secure Secure infants use the caregiver as a secure base for exploration
Insecure-Avoidant and as a source of comfort when needed. The infant is visibly
Insecure-Ambivalent aware of the caregiver’s absence at separation. At reunion, the
Insecure-Disorganized infant greets the caregiver with an approach, smile, gesture or
vocalization and seeks contact with the caregiver if distressed.
Contact is comforting and infant is able to return to play
An avoidant infant appears to be more interested in the
environment than the caregiver throughout the procedure.
During separation from the caregiver the infant is typically not
upset. Upon reunion, the infant will ignore or actively avoid
contact
An ambivalent infant prefers to maintain contact with the
caregiver than to explore the environment, or exploration is
limited. During separation the infant will be distressed. At
reunion the infant displays angry behaviours towards the
caregiver and/or is inconsolable. Contact with the mother is not
effective in regulating the infant’s state or supporting a return to
play
The infant’s behaviour lacks an organized, coherent strategy in
relation to the caregiver. See above for behavioural descriptions
87