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

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About the book.

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

Table of Contents

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

Book Details

Faculty resources.

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

Teacher Inquiry Group Resources

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

More DAP Resources

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

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

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

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

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

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

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

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

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

Early Childhood Education: How to do a Child Case Study-Best Practice

• Creating an Annotated Bibliography
• Lesson Plans and Rubrics
• Children's literature
• Podcasts and Videos
• Cherie's Recommended Library
• Great Educational Articles
• Great Activities for Children
• Professionalism in the Field and in a College Classroom
• Professional Associations
• Pennsylvania Certification
• Manor's Early Childhood Faculty
• Manor Lesson Plan Format
• Manor APA Formatting, Reference, and Citation Policy for Education Classes
• Conducting a Literature Review for a Manor education class
• Manor College's Guide to Using EBSCO Effectively
• How to do a Child Case Study-Best Practice
• ED105: From Teacher Interview to Final Project
• Pennsylvania Initiatives

Description of Assignment

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

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

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

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

Qualitative and Quantitative Observation Tips

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

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

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

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

Qualitative Observations

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

Quantitative Observations

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

Remaining Objective 

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

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

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

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

Qualitative and Quantitative Artifact Collection and Review Tips

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

Potential Qualitative Artifacts 

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

Potential Quantitative Artifacts 

• Checklist 
• Rating Scales
• Product Teacher-led activities 

Examples of Components of the Case Study

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

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

Narrative Tips

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

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

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

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

Biggest Mistakes Students Make on this Assignment

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

• Failing to start early . The case study assignment is one that you will submit in parts throughout the semester. It is important that you begin your observations on the case study before the first assignment is due. Waiting to the last minute will lead to a poor grade on this assignment, which historically has been the case for students who have completed this assignment. 
• Failing to utilize the rubrics. The rubrics provide students with guidelines on what components are necessary for the assignment. Often students will lose points because they simply read the descriptions of the assignment but did not pay attention to rubric portions of the assignment. 
• Failing to use APA formatting and proper grammar and spelling. It is imperative that you use spell check and/or other grammar checking software to ensure that your narrative is written well. Remember it must be in APA formatting so make sure that you review the tutorials available for you on our Lib Guide that will assess you in this area. 
• << Previous: Manor College's Guide to Using EBSCO Effectively
• Next: ED105: From Teacher Interview to Final Project >>
• Last Updated: Apr 3, 2024 2:53 PM
• URL: https://manor.libguides.com/ece

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• Case report
• Open access
• Published: 11 September 2017

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

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

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

42k Accesses

2 Citations

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Metrics details

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

Case presentation

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

Conclusions

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

Peer Review reports

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Abbreviations

Attention-Deficit/Hyperactivity Disorder

Disruptive Mood Dysregulation Disorder

Disinhibited Social Engagement Disorder

Post-Traumatic Stress Disorder

Reactive Attachment disorder

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

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CASE REPORT article

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

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

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

Introduction

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

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

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

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

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

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

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

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

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

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

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

Materials and Methods

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

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

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

Diagnostic tools have been used for:

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

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

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

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

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

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

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

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

Demographic Data at First Visit

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

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

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

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

Data for Assessment of the Child's Development

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

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

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

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

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

Progress of the Therapy With the Child

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

Data From Performed Psychological Studies

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

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

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

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

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

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

Family Sociogram

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

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

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

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

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

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

Reflective Parenting PRFQ

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

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

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

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

Mother–Child Relationship

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

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

Parent Couple

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

Married Couple

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

Family System

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

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

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

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

Data Availability Statement

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

Ethics Statement

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

Author's Note

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

Author Contributions

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

Conflict of Interest

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

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

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

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

Reviewed by:

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

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

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

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INFLUENCE OF FAMILY ENVIRONMENT ON DEVELOPMENTAL OUTCOMES IN CHILDREN WITH COCHLEAR IMPLANTS: A MATCHED CASE STUDY

By carrie a. davenport.

1 Department of Speech & Hearing Science, The Ohio State University.

Rachael Frush Holt

This case study analyzes and describes the language, executive function, and psychosocial outcomes of two 6-year-old children with cochlear implants in the context of their respective family environments. Despite having nearly identical audiological histories, their language abilities and social skills are markedly different from one another, exemplifying the variability in outcomes of children with cochlear implants. Families play a critical role in child development. Including analyses of the family environment serves to draw attention to the importance of expanding the variables of potential influence beyond child characteristics to more fully encompass the factors that influence children’s performance in future studies.

INTRODUCTION

Despite prompt diagnosis, early amplification, and timely provision of early intervention services, spoken language and executive function outcomes vary widely among children with cochlear implants (CIs; e.g., Duchesne, Sutton, & Bergeron, 2009 ; Holt, Beer, Kronenberger, Pisoni, & Lalonde, 2012 ; Holt, Beer, Kronenberger, & Pisoni, 2013 ; Svirsky, Robbins, Kirk, Pisoni, & Miyamoto, 2000 ). Some children make substantial gains while others do not. Most investigations of the underlying sources of variance have centralized around audiological factors and child characteristics ( Boons et al., 2012 ). However, the scope of these efforts has begun to expand beyond the child, shining a light on the role of the family and home environment in developmental outcomes in young children who are deaf and hard of hearing ( Hintermair & Sarimski, 2018 ; Ingber & Most, 2012 ; Quittner et al., 2010 ). The purpose of this matched case study is to highlight the value in directing attention outside of the child and their device to the first most proximal ring of influence – the family environment, defined as “the patterns of activities, roles, and interpersonal relations experienced by the developing child” ( Bronfenbrenner, 1977 , p. 22). Doing so facilitates a better, or more full understanding, of the developmental outcomes of children who have similar audiological histories, but whose outcomes are markedly different from one another.

Past research has been focused on family factors related to speech and language outcomes for children who are deaf or hard of hearing with CIs. However, that focus has been primarily related to ecological characteristics (e.g., family size, socioeconomic status, and primary caregivers’ education level; Geers, Brenner, & Davidson, 2003 ; Geers, Strube, Tobey, Pisoni, & Moog, 2011 ; Holt & Svirsky, 2008 ) and communication modality (e.g., spoken language, manual code of English, sign language, or a combination; Geers et al., 2011 , 2017 ; Holt & Svirsky, 2008 ). An understudied source of variance in language outcomes in deaf and hard of hearing children with CIs is the structural and functional aspects (e.g., broad characteristics of the family envirionment and family functioning) of the environment in which children spend a considerable amount of time—the home.

An Ecological Systems perspective of child development places children centrally within multiple ecosystems—the microsystem, mesosytem, exosystem, macrosystem, and chronosystem—that have expansive, concentric rings of influence ( Bronfenbrenner, 1986 ; Kazak, 1989 ). The most proximal ring of influence to the child is the family microsystem. Examples of other microsystems include the child’s neighborhood, school, and other areas where the child is intimately familiar. The mesosystem consists of the interactions that take place between major microsystems (e.g., school and home); the exosystem, an extension of the mesosystem, consists of formal and informal societal structures that may not directly influence the developing child, but nonetheless influences the developmental process (e.g., mass media, governmental agencies). The macrosystem encompasses the overarching pattern of the micro-, meso-, and exosystems attributed to a particular culture. Finally, the chronosytem is the change or consistency over time related to the characteristics of the individual as well as their environment. Viewed as external systems of influence, these concentric rings contribute to the variability in developmental outcomes in children. Because of its potency as the most proximal microsystem, this matched case study focuses on the family microsystem as a potential source of variance in outcomes in children with CIs.

It is important to note that microsystems do not work unidirectionally. Rather, children experience the microsystem transactionally ( Sameroff, 1975 ) through bidirectional interactions between themselves and family members such that family members influence children and children influence family members. The primary dyad of influence is that between the child and parents/caregivers, but certainly other child-family member relationships influence child development including those with siblings, grandparents, etc. when they are present. Instead of children and caregivers functioning as passive recipients of engagement, the manner in which children respond to a caregiver impacts future interactions and vice versa. The child’s response to communication reinforces parents’ engagement and communicative behaviors, including the quality of language. In turn, the caregivers’ engagement with the child reinforces the caregivers communicative behaviors ( Skinner, 2014 ). Thus, bidirectional social interactions between the child and the family form the foundation for language and social development ( Guralnick, 2011 ).

The Home Environment and Hearing Children’s Development

Because the home environment is the primary microsystem in which children develop, this most proximal ring of influence plays a critical role in the developmental outcomes of young children ( Bradley, Caldwell, & Rock, 1988 ; Elardo, Bradley, & Caldwell, 1975 , 1977 ). An important step in understanding the effects of the family environment on language and cognition has been to identify the specific environmental characteristics that contribute to development in these areas.

A mother typically serves as an infant’s first and primary social communicative partner, presenting an opportunity for maternal facilitation of psycholinguistic development in several ways. Several environmental characteristics have been found to positively impact language and executive function in typically developing children—maternal verbal and emotional responsiveness ( Bradley & Caldwell, 1977 ; Elardo et al., 1977 ), maternal involvement ( Bradley, Caldwell, & Elardo, 1979 ), and provision of play materials ( Bradley & Caldwell, 1977 ; Wachs, 1979 ; Yarrow, Rubenstein, Pedersen, & Jankowski, 1972 ). Maternal responsiveness to infants’ affective communication cues, bids for attention, and vocalizations have been found to support the achievement of language milestones, such as first imitations, first words, and 50 expressive words ( Tamis-LeMonda, Bornstein, & Baumwell, 2001 ). To maximize these opportunities, mothers’ responses to their child must be prompt, contingent, and appropriate (Ainsworth, 1973; Skinner, 1986 ; Watson, 1985 ). Following the child’s lead by responding to the focus of attention and doing so immediately tends to support expressive and receptive language skills ( Kaiser & Hancock, 2003 ; Kaiser et al., 1996 ; Yoder, McCathren, Warren, & Watson, 2001 ).

Maternal involvement includes the provision and structuring of a variety of experiences that facilitate social interaction and intellectual stimulation ( Elardo et al., 1977 ). In the early years of life, mothers demonstrate involvement by keeping their young child close by, visually attending to and monitoring their activities, and narrating daily activities. Later in development, involvement might include activities such as trips to the local library or museum. These types of experiences are correlated with language competence in children as young as 6 months of age; however, correlations are stronger at 24 months ( Elardo et al., 1977 ). Access to toys and other age-appropriate learning materials, including books and musical instruments, stimulate eye-hand coordination and gross motor development, thus supporting child development across several domains, including linguistic, cognitive, and physical ( Bradley, 1993 , 1994 ; Elardo et al., 1977 ; Totsika & Sylva, 2004 ). Conversely, infants and toddlers with restricted access to age-appropriate learning materials in the home exhibit poorer expressive vocabulary and more behavior problems ( Rijlaarsdam et al., 2012 ).

The vast majority (96%) of parents of children who are deaf or hard of hearing have typical hearing ( Mitchell & Karchmer, 2004 ). Recognizing the importance of the microsystem (e.g., family environment) in which children develop, and that social interactions between child and family form the foundation for language and social development ( Guralnick, 2011 ), these parents face a unique challenge in helping their children attain age-appropriate spoken language skills. For these families, an important question arises: given that spoken language is the medium through which many of the effects of the family environment typically occur, what impact does family environment have on the development of young children with CIs, most of whom fundamentally struggle with spoken language development?

Home Environment and the Development of Children who are Deaf and Hard of Hearing

Quality of parent involvement and parent-child interactions have been found to be associated with language and cognitive growth in children who are deaf or hard of hearing with CIs (e.g., Calderon, 2000 ; Moeller, 2000 ; Niparko et al., 2010 ; Quittner et al., 2013 ). This was found both when teachers rated the amount of family engagement on such activities as parental participation in IEP meetings, attendance at school functions, and facilitation or enhancement of child learning at home ( Calderon, 2000 ), and when experimenters quantified child autonomy, positive regard, cognitive stimulation, shared visual attention, and bidirectional interaction during parent-child play interactions ( Niparko et al., 2010 ).

Recent studies have begun to examine the structural and functional dimensions of the family environment and their potential associations with at-risk outcomes in children who are deaf or hard of hearing and use CIs. Holt et al. (2012) examined the home environment and the ways in which family dynamics affect spoken language and executive function outcomes in 45 children with CIs. Levels of parental behavioral control (e.g., the extent to which families implement rules and actions for managing family life, emphasize rules, and demonstrate inflexibility and obvious hierarchy of power) were negatively associated with child receptive vocabulary size. Children in families who displayed a stronger emphasis on an organized home (clear expectations, neat and orderly environment, and transparent organization and structure in planning family activities and responsibilities) demonstrated fewer inhibitory control problems than less organized families.

Holt and colleagues (2012) findings have been supported and extended to the preschool population of children with CIs and hearing aids. Holt et al. (2013) reported that preschool children of families who indicated higher levels of support and lower levels of conflict exhibited fewer behavior problems than families who were less supportive and had higher levels of conflict. School-age children of families with lower levels of conflict demonstrated better receptive vocabularies than children in homes with higher levels of conflict. Moreover, higher levels of organization within the family and lower levels of control was associated with better receptive language outcomes for school-age children.

Whereas families of children with typical hearing and children who are deaf and hard of hearing who use hearing aids or CIs do not differ in gross ways from each other, variability in how families function is related to at-risk spoken language, executive function, and psychosocial outcomes in children with hearing aids and CIs ( Holt et al., in press ). Specifically, the level of supportiveness and enrichment within the family relationships contribute to psychosocial and neurocognitive development in children with hearing loss. In contrast, having objects and experiences available to children in the home that stimulate and support learning and interaction was associated with the development of spoken language in children with hearing aids and CIs ( Holt et al., in press ). Together, these studies suggest that the family environment is an important source of variability in spoken language, executive function, and psychosocial outcomes in children with CIs and hearing aids as a group.

The current matched case study highlights two children who are deaf and use CIs. The children have very similar audiological and intervention histories, but considerably different spoken language and executive function outcomes. This is not unlike what clinical audiologists, neurotologists, speech-language pathologists, early interventionists, teachers, and everyone who works with pediatric CIs recipients encounter on a daily basis: two children with similar demographic risks, but who present with frustratingly different outcomes. An indepth analysis of the structural and functional aspects of each child’s family environment is provided and based on previous work ( Holt et al., 2012 , 2013 , in press), which itself is grounded in Systems Theory ( Kazak, 1989 ), to illustrate that variability in outcomes is a tractable problem when looking at multiple sources of influence: in this case, the family environment. Again, Systems Theory recognizes the importance of the childrens’ environments, in particular the individuals with whom children interact most frequently (i.e., parents/caregivers). Moreover, family environment can be modified with family-oriented communication and education programs, as evidenced by increases in levels of support and improved functioning as well as reductions in levels of conflict and control ( Bruce & Emshoff, 1992 ; Hill & Balk, 1987 ; Mills & Hansen, 1991 ). This matched case study does not suggest that the family is the only source of variability, nor does it suggest that it is the most important. However, based on previous literature, this matched case study provides an opportunity to illustrate what has been observed in group data ( Holt et al., 2012 , 2013 , in press ): family environment is an important source of variability that is malleable and should be considered when working with pediatric patients.

Participants

The paired cases were two children with nearly identical audiological and intervention histories, and their families. Both children and their primary caregivers (their mothers in both cases) were enrolled in a larger investigation on the influence of family environment on developmental outcomes in children with typical hearing, those with hearing aids, and those with CIs (e.g., Holt et al., in press ). Both met the inclusion criteria for participants with CIs in a larger study: 5-8 years of age, severe-toprofound sensorineural hearing loss, receiving CIs before 3 years of age, at least 12 months of CI use, and using listening and spoken language. Both children were tested at 6.1 years of age and both were male.

A questionnaire was used to collect demographic information, includingfamilyincome, people livingin the home, hearing characteristics (i.e., hours of device use), speech-language therapy history (frequency and intensity), educational placement, and communication modality. Parental demographics collected were requested from each child’s primary caregiver in the larger investigation, which resulted in all but two of the primary caregivers being mothers ( Holt et al., in press ), which is fairly standard for our studies. The primary caregivers of the children in the current case study were their mothers. Thus, the parental demographic information collected for these dyads is from their mothers.

Audiological and intervention history: S1.

S1 did not pass his newborn hearing screening bilaterally. Subsequently, he was diagnosed with hearing loss at 1 month of age and fit with hearing aids bilaterally at 3 months of age. The etiology of his hearing loss is unknown and no additional diagnoses were reported. He received his first CI at 10 months and the second at 43 months of age. Parent-report indicated that S1 wore his CIs all waking hours, with the exception of water activities, such as bath time and swimming. At the time of assessment, he had spent 6 months with the current CI MAP. His educational setting was a public school general education kindergarten classroom full time with a personal FM system coupled to his CIs. This was his third year of being fully mainstreamed. He received less than 15 minutes per week of speech-language services, and did so in both individual and group settings. He did not receive educational support from a teacher of the deaf. His primary therapy goal was articulation. No record of his specific devices or processing strategy was gathered.

Audiological and intervention history: S2.

S2 also did not pass his newborn hearing screening bilaterally and was diagnosed with hearing loss soon thereafter. The etiology of his hearing loss also is unknown and no additional diagnoses were reported. He was fit with hearing aids at 6 months of age. He received his first CI at 14 months and received the second at 42 months of age. Parent-report indicated that S2 wore his CIs all waking hours, with the exception of water activities, such as bath time and swimming. At the time of assessment, he had spent 5 months with the current CI MAP. His educational setting was in a public general education pre-kindergarten classroom full time with a personal FM system. At the time of assessment, he was in his second year in that particular classroom (and thus, his second year being fully mainstreamed). He received individualized school-based speech-language therapy services three times a week for 1.5 hours, and additional speech-language therapy services 1.5-2 hours twice weekly at a nearby university clinic. His primary therapy goal was language (specific objectives were not available). Teacher of the deaf services were not utilized. No record of his specific devices or processing strategy was gathered.

Audiological history and device intervention history are nearly identical. Both children met the Joint Committee on Infant Hearing (JCIH) 1-3-6 guidelines ( JCIH, 2007 ), received their first CI by 14 months of age and their second CI within 1 month of each other, and wore their devices all waking hours. They diverge in the amount of behaviorally based speech-language pathology intervention they receive and the target goals of that intervention. S1 receives fewer minutes of intervention per week; intervention is focused on articulation and takes place at his school. In contrast S2 receives measurably more minutes per week of intervention targeted at language development, and receives intervention at both his school and a local university clinic. Neither child receives any other kind of intervention. As will become apparent in the Results section, this disparate amount of speech-language-based intervention is due to their relative strengths in language development. Early intervention history was not collected.

Family demographics: S1.

S1’s family reported a household size ofthree: married mother and father, and S1. The family reported a household income between $65,000-79,000 (income was indicated categorically). S1’s mother had completed college and worked as a developmental therapist.

Family demographics: S2.

S2’s family reported a household size of five: unmarried mother and father, 2 siblings (ages 4 and 2 years), and S2. S2’s mother completed high school and stayed at home with the children. The family reported a household income between $24,000-34,000.

Child Language Outcome Measures

Peabody picture vocabulary test–4 (ppvt–4)..

The PPVT-4 ( Dunn & Dunn, 2007 ) is a norm-referenced assessment of receptive vocabulary for ages 2.5 to over 90 years. For each item, the examiner says a word, and the examinee responds by choosing one of four full-color pictures that best illustrates that word’s meaning. The PPVT-4 has been used extensively with children who are deaf and hard of hearing.

Clinical Evaluation of Language Fundamentals–4 (CELF–4).

TheCELF-4 ( Semel, Wiig, & Secord, 2003 ) is a comprehensive norm-referenced language assessment used with children ages 5 to 18 years. All items in each subscale require the examiner to give verbal prompts; the examinee must respond verbally and/or by pointing to a visual display.

Social Skills Measure

The social skills improvement system (ssis) rating scales..

The SSiS ( Gresham & Elliott, 2008 ) is a 79-item parent-report questionnaire that evaluates psychosocial skills (e.g., communication, cooperation, assertion, responsibility, empathy, engagement, self-control), problem behaviors (e.g., externalizing, bullying, hyperactivity andinattention, internalizing, autism spectrum), and academic competence (e.g., reading, math, motivation to learn) in children ages 3-18 years. The parent form was used for this investigation and only the social skills and problem behavior subscales were used. On the Social Skills subscale, scores above 115 are considered advanced and those below 85 are considered clinically delayed. Scores above 115 on the Problem Behaviors subscales are considered clinically elevated.

Child Executive Function Measures

Behavior rating inventory of executive function (brief)..

The BRIEF ( Gioia, Isquith, Guy, & Kenworthy, 2000 ) is an 86-item parent-report questionnaire that assesses executive function skills in children ages 5 to 18 years. Specifically, it asks parents to rate how often behaviors were a problem in the last 6 months. The BRIEF covers eight domains, including Inhibit, Shift, Emotional Control, Initiate, Working Memory, Plan/Organize, Organization of Materials, and Monitor. Higher scores on the BRIEF indicated more concerns regarding a child’s executive function skills.

Family Environment

Home observation measurement of the environment (home)..

The HOME ( Caldwell & Bradley, 2003 ) is used to evaluate the quality and quantity of support and stimulation available to children in the home environment through: 1) a semi-structured interview with a parent/caregiver, and 2) observations of the environment and parent-child interactions in the home. The Middle Childhood version, used with both of these families, consists of 59 items divided into eight subscales: Parental Responsivity, Encouraging Maturity, Emotional Climate, Learning Materials, Enrichment, Family Companionship, Family Integration, and Physical Environment.

Family Environmental Scale (FES).

The FES ( Moos & Moos, 2009 ) is a 90-item self-report true-false questionnaire that is completed by the parent. The FES uses 10 subscales to measure three dimensions of the family environment: Family Relationships, Personal Growth and Goals within the Family, and the Family’s Focus on System Maintenance. The Family Relationship Dimension is comprised of three subscales: Cohesion, Expressiveness, and Conflict. The Personal Growth Dimension consists of five subscales: Independence, Achievement Orientation, Intellectual-Cultural Orientation, Active-Recreational Orientation, and Moral-Religious Emphasis. The System Maintenance Dimension includes two subscales: Organization and Control.

The parent-report questionnaires were mailed to the families’ homes ahead of a home visit with instructions on how to fill out each questionnaire. They were also provided instructions over the telephone during a scheduled phone call. Two research assistants (a Ph.D. student and an Au.D. student, who both were trained by two psychologists, an audiologist, and a speech-language pathologist) completed the home visits. One worked with the children and the other with the primary caregiver. The one who worked with the primary caregiver went over all of the parent-report questionnaires (Demographic questionnaire, SSiS, BRIEF, and FES) to confirm that they were completed in their entirety and to answer any questions the caregiver had about any of them. They also administered the HOME interview and observation. The other research assistant worked with child, administering the PPVT-4 and CELF-4. Any scoring or administration questions were brought to the Primary Investigator (PI) or to one of the psychologists or speech-language pathologists working on the larger project. The PI was always available by cell phone, but this was not required for administration issues for these research assistants, because they were trained well before being sent out into the field.

Child Language

S1’s receptive vocabulary and overall language scores were at or just above the standard mean of 100, indicating that his language was age-appropriate. In contrast, S2’s receptive vocabulary was more than 1 standard deviation below the mean. Moreover, S2 was unable to complete tasks required on the CELF resulting in a basal score, indicating that he has little, if any, mastery of spoken language. See Table 1 for language scores.

Spoken language outcomes.

Note . S2’s standard score of 40 on the CELF is a basal score.

Child Psychosocial and Executive Function Skills

Table 2 displays the results of the psychosocial and child executive function parent-reports. S1 attained a social skills score on the SSiS of 124, indicating social skills in the advanced range. S2 achieved a score of 103, indicating that overall social skills within the average range. S1’s and S2’s SSiS problem behavior scores fell on the low end of the average range at 86 and 89, respectively.

Psychosocial and executive function outcomes.

Note. Text in bold indicates a BRIEF index. All items above the bolded text are sub-domains within that index. Global Executive Composite is a synthesis of both indices.

There were no domains ofthe BRIEF on which S1 or S2 demonstrated areas of clinical concern ( T -scores of 60 or higher). However, on every subdomain of the BRIEF, except for Initiate and Organize Materials, S1’s mother reported fewer problems (lower scores) with executive function than did S2’s mother. Again, S2’s mother’s concerns did not raise to the level of being clinically elevated, but the two children’s executive function profiles differed, particularly for behavior regulation. S1’s behavior regulation (the ability to control one’s response, emotions, and actions to carry out goal-directed behaviors) tended to be better than S2’s.

Table 3 displays HOME Total and subscale scores. S1 and S2’s families received Total HOME scores of 52 and 39, respectively. Families of both children received identical scores on the Encouragement of Maturity and Learning Materials subscales. However, S1’s family received higher scores than S2’s family for Responsivity, Emotional Climate, Family Companionship, Family Integration, Physical Environment, and Enrichment, leading to S1’s family overall having a more enriched home environment than S2’s.

HOME total and subscale scores.

FES subscale scores and subtotals for each dimension are displayed in Table 4 . S1 and S2’s families received comparable scores on the System Maintenance dimension. However, S1’s family scored 10 points higher than S2’s family on the Family Relationships dimension. A 13-point difference on the Expressiveness subscale contributed to the difference between the families’ respective home environments. The widest discrepancy was found on the Personal Growth dimension (subscale difference scores ranged from 10 to 22 points). Whereas S2’s family scored higher on the Independence subscale, S1’s family scored higher on the Achievement Orientation, Intellectual-Cultural Orientation, Active-Recreational Orientation, and Moral-Religious Orientation subscales.

FES scores.

The purpose of the current matched case study is to highlight and illustrate the importance of considering the family environment, and its potential contribution to the persistent variability in outcomes of children with CIs. Given the nearly identical audiological histories of the children in this matched case study, a novice might expect similar spoken language, psychosocial, and executive function outcomes. However, practitioners and researchers familiar with this population will not be surprised at the differences observed in outcomes between these two children. These children serve as a prime example of the reality faced by clinicians, educators, and researchers. Divergent outcomes were found between the two children’s language, executive function, and psychosocial skills. Importantly, differences were found in key aspects of the structural and functional aspects of their respective family environments, some of which have been shown in our research group’s previous work to be related to key at-risk outcomes in this clinical pediatric population ( Holt et al., 2012 , 2013 , in press ).

S1 demonstrated age-appropriate receptive vocabulary and overall language abilities, indicating better spoken language skills than the average CI user, whose spoken language typically falls approximately 1 standard deviation below the mean on these standardized measures (e.g., Ching & Dillon, 2013 ; Geers, Moog, Biedenstein, Brenner, & Hayes, 2009 ; Holt & Svirsky, 2008 ; Niparko et al., 2010 ). In contrast, S2’s spoken language was considerably delayed. His receptive vocabulary was more than 1 standard deviation below the mean. Moreover, he struggled so much with the CELF language test that he was assigned the basal score on the measure, including all of the subtests. It should be noted that the research assistants who tested him indicated that he was focused throughout the language testing; he was unable to do the tasks. S2’s spoken language performance was clearly poorer than his age-matched peers with typical hearing, but also poorer than the average CI recipient his age, as well.

Neither child demonstrated evidence of clinically elevated executive function deficits on the BRIEF. However, S1’s mother reported fewer problems related to behavior regulation than S2’s mother. What these results mean is that whereas S2 had typical levels of inhibitory control, shifting behavior, and emotional control (subscales that contribute to behavior regulation), S1 had even better performance in these domains than S2. Metacognition was similar between the two children. However, the individual subscales that contribute to it differed between the two children, reflecting different strengths in each child. S2’s mother tended to report fewer problems with task initiation and organization of materials for her son than did S1’s mother. Conversely, S1’s mother tended to report fewer problems for her son than S2’s mother on working memory, planning/organizing, and monitoring. Compared to previous work ( Beer et al., 2014 ; Holt et al., 2012 , 2013 , in press; Kronenberger, Pisoni, Henning, & Colson, 2013 ), these two children demonstrate similar or slightly better executive function across the domains of the BRIEF than other samples of children with CIs. In many of these studies approximately 30-40% of children have elevated risk for working memory and inhibitory control (e.g., Holt et al., 2013 ; Kronenberger et al., 2013 ; Kronenberger, Beer, Castellanos, Pisoni, & Miyamoto, 2014 ). Both S1 and S2 are more similar to the approximately 60% of children who do not experience clinically elevated executive function scores, despite S2’s considerable language delays.

Similar to their executive function profiles, both children’s social skills scores were not atypical. However, S1’s social skills were in the advanced range whereas S2’s were in the average range. Both children’s problem behavior scores fell within the normal range, albeit at the low end. Together, these executive function and psychosocial results suggest that S1 and S2 do not have clinical concerns regarding their current level of functioning in these domains. However, S1 has some particular areas of strengths. His strong behavior regulation and age-appropriate language skills likely contribute to his outstanding overall social skills. However, aspects of their most influential and proximal circle of environmental influence—the family—also likely influence the differences in these children’s behavioral regulation, language, and social skills.

The Home Environment

The home environments of the two matched children were different from each other in specific ways. First, the families differed in their demographics. The household size for S1 was smaller than that for S2: S1 had no siblings whereas S2 had two siblings, while both had two parents living in the home. S1’s family reported a substantially higher annual income compared to S2’s family. Finally, maternal level of education varied: S1’s mother was a college graduate and S2’s mother had a high school education. Both annual income and maternal education are commonly used as measures of socioeconomic status (SES). Other investigations that have examined family demographics and spoken language outcomes in children who are deaf or hard of hearing who use sensory aids have found that children have faster rates of receptive language development when they are raised in households with higher levels of SES relative to those with lower SES levels ( Holt & Svirsky, 2008 ; Niparko et al., 2010 ). Additionally, smaller family size has been found to be a significant predictor of speech perception skills in children with CIs ( Geers et al., 2003 ). We certainly are not suggesting a causal relationship between higher socioeconomic status, smaller family size, and outcomes in these specific two children or other children with CIs; however, these demographic factors can place added stress on the environment in which children are raised that can indirectly influence the development of children by impacting the social dynamics between parents and children in the home and the experiences and opportunities available to the children.

Looking beyond traditional demographic factors, the structural and functional aspects of the home environments differed in their relative levels of enrichment, with S1’s being more enriched overall than S2’s. Enrichment reflects the family’s provision of materials and activities intended to enhance a child’s learning. This includes the family involving the child in recreational hobbies and encouraging the child to develop a hobby of their own. An enriching family environment also entails the child’s access to various lessons and experiences (i.e., gymnastics, swimming, dance), outings to venues like libraries or museums, opportunities to travel more than 50 miles from their home, and experiencing different methods of transportation (e.g., city bus, airplane). Compared to children from homes with lower SES, children from homes with higher SES home are more likely to be afforded more enriching and diverse experiences, resulting in better language outcomes, particularly vocabulary ( Walker, Greenwood, Hart, & Carta, 1994 ). That being said, monetary resources are not necessary to provide enriching activities and experiences for children; they can make it easier, but they are not a necessity. Everyday family activities such as grocery shopping, cooking, and bath time provide opportunities for enrichment.

Overall, the two families are not grossly different from the samples from Holt et al. (2012 , 2013 , in press ) with CIs on the FES; however, S1’s family scored higher on some subscales than the families in our previous studies, specifically the Achievement Orientation, Active-Recreational Orientation, Cohesion, and Expressiveness subscales. Among the three FES dimensions—Family Relationships, Personal Growth, and System Maintenance—the most prominent difference between S1 and S2’s families lie in Personal Growth. Aside from S2’s family indicating more independence, S1’s family indicated a stronger orientation to achievement, intellectual pursuits, recreation, and morality/religion. Furthermore, S1’s family demonstrated higher levels of cohesion and expressiveness and lower levels of conflict than S2’s family. These findings of higher cohesion and expressiveness are consistent with Holt et al. (in press) , which reported that the risk of spoken language delay in children who are deaf or hard of hearing with CIs and hearing aids may be reduced if the home environment is generally enriching and where expressiveness and family cohesion are higher. This potentially explains S1’s better language outcomes relative to S2. Moreover, for school-age children who are deaf or hard of hearing, like S1 and S2, the manner in which family members relate to each other—demonstrating support and without a lot of conflict—has been found to be positively associated with fewer problems with inhibitory control ( Holt et al., in press ). The executive function and family environment outcomes of the current subjects support these findings.

Interestingly, given their respective language scores, S1 and S2’s families’ scores on the System Maintenance subscale of the FES were the opposite of what would be expected. In light of S2’s low language scores, one would expect the family to demonstrate a lower level of organization and higher level of control based on our previous work ( Holt et al., 2012 , 2013 , in press ). Nevertheless, his family scored higher than S1’s family on organization and lower on control. These results likely reflect the much more complicated way that family environment influences outcomes in individual children. In other words, other moderating/mediating factors that cannot be modeled in a matched case study likely were influencing the relations among these factors. The relations between hearing-related risks, family moderators and mediators, and outcomes are complex and researchers are just now beginning to understand them. However, it should be noted that all families bring strengths to the experience of raising a child who is deaf or hard of hearing. Rather than taking a deficitbased perspective, it is important for researchers and practitioners to recognize those strengths and build on them when coaching families in strategies they can implement to facilitate their child’s language and social-behavioral development. Furthermore, interactions among family members are bidirectional with parents and children influencing one another. The role of the child in these interactions and how they contribute to the environment itself needs to be better studied and understood in future work, perhaps expanding to other members of the family unit.

STRENGTHS AND LIMITATIONS

All research designs, including case studies, have inherent strengths and limitations. Case study design presents two main strengths. First, case studies are well suited to the investigation of a complex set of “real world” variables ( Crowe et al., 2011 ; Yin, 2009 ). In the instance of the current paper, family units and their effects on developmental outcomes in children are complex and present an incredible number of variables (e.g., demographically, structurally, functionally). Case study design offers researchers the opportunity to illuminate such complexities, grounding them in theoretical constructs and providing tentative hypotheses that may support future investigations ( Crowe et al., 2011 ). Second, case studies can be particularly effective in advancing the applied fields, such as education and health ( Crowe et al., 2011 ). In the current matched case study, the persistent and variable outcomes of children with CIs have prompted investigation into the family environment as a source of variance (e.g., Holt et al., 2012 , 2013 , in press ). This paper has highlighted the importance of looking beyond child and device characteristics (i.e., hearing level, device use) and family demographic factors (i.e., household income, maternal education level) to those that are present within the most influential first-ring of influence: family factors that exist within the environment and the bidirectional interactions between family members. Highlighting connections between specific family environment factors and outcomes in children with CIs using family systems theory could potentially inform innovative models of family-centered early intervention.

While case study methodology is helpful in illuminating a problem within a body of literature, the ability to generalize the results can be limited. However, thoughtfully placing case studies within the context of larger group design studies increases the confidence of case studies to be able to both expand the body of knowledge in a specific area of research and apply was what is learned from case studies to clinical outcomes. One other limitation is that some of the parental data only applies to the primary caregiver, which in the case of these two children was their mother. However, fathers and co-parenting factors contribute uniquely (independently from mothers) to children’s emotional and behavioral competencies ( Bocknek, Brophy-Herb, Fitzgerald, Schiffman, & Vogel, 2014 ; Lang et al., 2014), their language and cognitive development ( Cabrera, Shannon, & Tamis-LeMonda, 2007 ; Varghese & Wachen, 2016 ), and to their executive function skills ( Meuwissen & Carlson, 2015 ). Thus, our lab is already underway investigating paternal behaviors and cognitions in families of deaf and hard of hearing children with CIs and hearing aids.

Despite advances in early identification of hearing loss and CI technology, variable outcomes in children with CIs persist. Historically, the focus has been on child characteristics (i.e., audiological, communication modality) and family demographic factors (i.e., annual household income, level of parental education) in attempting to uncover the sources of variability in developmental outcomes in children with CIs. Given that nearly half of the variability in outcomes remains to be explained and the recognition that the social environment in which children are raised significantly influences child development and has largely been neglected in the literature on children with CIs and hearing aids, the current paper serves to highlight the need for considering the family characteristics that support spoken language and social-behavioral development in children with CIs.

This matched case study highlights that perhaps one way that families could contribute to resiliency in children with CIs is through providing an enriched home environment with higher levels of cohesion and expressiveness—the primary ways in which S1 and S2’s families differed. This is not singularly about families being able to provide more materials (e.g., toys, objects) or more frequent (or expensive) outings in order promote spoken language and social-behavioral development; enrichment is about more than provision of materials and trips to museums, it is about experiences and interactions between parents and children during those experiences and outings that are supportive. All children, including those who are deaf and hard of hearing, benefit from learning about the world through various experiences; experiences that prompt conversation and interaction, allowing for language and social development to flourish. Furthermore, homes that are cohesive and expressive provide the type of environment that supports the development of strong executive function, language, and social skills to be practiced. In fact, Kronenberger and Thompson (1990) found that family cohesion and stimulation (expressiveness) is associated with positive psychosocial outcomes in another clinical pediatric population —children with chronic physical disabilities.

The current matched case study can support clinicians and early intervention providers who work with families of children who are deaf or hard of hearing. Several evaluation instruments (e.g., FES, HOME) are available to professionals who work with families of children who are deaf or hard of hearing. With proper training, these tools can be utilized in the home environment and incorporated into home visits, tailoring visits to meet the specific needs of individual families. Providers can then tailor their visits to meet the specific needs of individual families by identifying the strengths of a family’s home environment and build on areas where further nurturing can occur. Taking a family-centered approach, early intervention providers may even consider scheduling sessions out in the community where they can model how enriching interactions can be incorporated into activities like bus rides, bike rides, or walks to the local public library or a park. Again, the point is not that families need more “stuff” in order to support their child’s language, executive function, and psychosocial development. Early intervention providers are in a position to coach families in how to support their child’s development through enriching, supportive experiences.

ACKNOWLEDGEMENT

This research was supported in part by a grant from the National Institutes of Health (NIDCD R01 DC014956).

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

• Published: 29 October 2021
• Volume 51 , pages 15–30, ( 2023 )

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• Olivia N. Saracho   ORCID: orcid.org/0000-0003-4108-7790 1  

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

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The author is grateful to Mary Jalongo for her expert editing and her keen eye for the smallest details.

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Saracho, O.N. Theories of Child Development and Their Impact on Early Childhood Education and Care. Early Childhood Educ J 51 , 15–30 (2023). https://doi.org/10.1007/s10643-021-01271-5

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1 Chapter 1: Introduction to Child Development

Chapter objectives.

After this chapter, you should be able to:

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

Introduction

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

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

Principles of Development

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

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

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

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

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

Periods of Development

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

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

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

Prenatal Development

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

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

Infancy and Toddlerhood

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

Figure 1.2 – A swaddled newborn. 5

Early Childhood

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

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

Middle Childhood

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

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

Adolescence

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

Figure 1.5 – Two smiling teenage women. 9

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

Issues in Development

Nature and nurture.

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

Continuity versus Discontinuity

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

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

Active versus Passive

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

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

Research Methods

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

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

Paris in the

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

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

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

Scientific Methods

One method of scientific investigation involves the following steps:

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

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

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

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

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

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

Observational Studies

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

Experiments

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

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

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

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

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

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

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

Case Studies

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

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

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

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

Developmental Designs

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

Longitudinal Research

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

Figure 1.8 – A longitudinal research design. 13

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

Cross-sectional Research

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

Figure 1.9 – A cross-sectional research design. 14

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

Sequential Research

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

Figure 1.10 – A sequential research design. 15

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

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

Consent and Ethics in Research

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

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

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

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

Developmental Theories

What is a theory.

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

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

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

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

Sigmund Freud’s Psychosexual Theory

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

Figure 1.11 – Sigmund Freud. 21

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

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

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

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

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

Table 1. 2 – Sigmund Freud’s Psychosexual Theory

Strengths and Weaknesses of Freud’s Theory

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

Erik Erikson’s Psychosocial Theory

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

Figure 1.12 – Erik Erikson. 23

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

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

Table 1. 3 – Erik Erikson’s Psychosocial Theory

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

Behaviorism

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

Ivan Pavlov

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

Figure 1.13 – Ivan Pavlov. 26

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

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

John B. Watson

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

Figure 1.14 – John B. Watson. 27

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

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

B.F. Skinner and Operant Conditioning

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

Figure 1.15 – B. F. Skinner. 28

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

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

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

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

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

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

Social Learning Theory

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

Figure 1.16 – Albert Bandura. 29

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

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

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

Jean Piaget’s Theory of Cognitive Development

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

Figure 1.17 – Jean Piaget. 32

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

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

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

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

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

Table 1.4 – Jean Piaget’s Theory of Cognitive Development

Criticisms of Piaget’s Theory

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

Lev Vygotsky’s Sociocultural Theory

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

Figure 1.18- Lev Vygotsky. 36

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

Comparing Piaget and Vygotsky

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

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

Urie Bronfenbrenner’s Ecological Systems Model

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

Figure 1.19 – Urie Bronfenbrenner. 39

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

Table 1.5 – Urie Bronfenbrenner’s Ecological Systems Model

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

Figure 1.20 – Bronfenbrenner’s ecological systems theory. 40

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

In this chapter we looked at:

underlying principles of development

the five periods of development

three issues in development

Various methods of research

important theories that help us understand development

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

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

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

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

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

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

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

Impact of Trauma Exposure on Early Adolescent Developmental Tasks

Social development.

Impact of Trauma on Early Adolescent Development

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

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

Cognitive Development and Emotional Regulation

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

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

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

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

ALIVE: A Comprehensive Public Health Intervention for Middle School Students

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

Psychoeducation

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

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

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

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

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

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

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

Case Example 1

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

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

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

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

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

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

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

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

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

Individualized Stress Reduction Intervention

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

Case Example 2

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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DBP Community Systems-Based Cases

Introduction.

Following are case studies of children with typical developmental behavioral issues that may require a host of referrals and recommendations.

Case Studies

Case 1:                    case 2:                      case 3: sophie                     mark                     alejandro.

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Advancing child-centred public policy in brazil through adolescent civic engagement in local governance, mainstreaming adolescent mental health & suicide prevention, adolescents take action to mitigate air pollution in vietnam, adolescent mental health knowledge summary: time for action.

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Science Update: Steroid treatment in late pregnancy does not appear to affect children’s neurodevelopment, NICHD-funded study suggests

Children who were exposed to a steroid at 34 to 36 weeks of pregnancy are no more likely to have cognitive effects than children whose mother did not receive a steroid, suggests a study funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD). The findings help to allay concerns that fetal exposure to a steroid in the uterus—given to speed lung development in case of preterm birth—could affect a child’s neurodevelopment.

The study was conducted by Cynthia Gyamfi-Bannerman, M.D., M.S., and colleagues in the NICHD Maternal-Fetal Medicine Units Network. It appears in the Journal of the American Medical Association .

A previous study concluded that giving a single dose of the steroid betamethasone to pregnant people at risk of giving birth at 34 to 36 weeks of pregnancy significantly reduced the risk of respiratory complications in their newborns. However, the study also found that these infants were more likely to develop hypoglycemia (low blood sugar). Prolonged hypoglycemia in newborns is associated with brain injury . Other research suggests that multiple doses of steroids before birth could affect a child’s neurodevelopment.

For the current study, researchers evaluated children of the previous study’s participants when the children were six years old or older. A psychologist evaluated each child using a variety of tests that measured verbal and nonverbal reasoning and comprehension. A total of 949 children completed the testing (479 in the betamethasone group and 470 in the placebo group).

Both groups of children scored similarly across all measures of the test, called the Differential Ability Scales. A total of 17.1% in the betamethasone group received a score of less than 85, which did not differ significantly from the 18.5% of the placebo group. Similarly, the average score was 96.6 for both groups (compared to a national average of 100). Also similar between the groups were scores for verbal ability, nonverbal ability, spatial ability, social responsiveness, gross motor function, and behavior.

Significance

The authors conclude that giving a steroid to pregnant people at risk for late preterm birth to reduce potential respiratory complications in their infants is not associated with adverse neurodevelopmental outcomes at age 6 or older. The results help support the prescribing of corticosteroids to pregnant people at risk for late preterm birth.

Gyamfi-Bannerman, C, et al. Neurodevelopmental Outcomes After late preterm antenatal corticosteroids: The ALPS follow-up study. The Journal of the American Medical Association. 2024. doi:10.1001/jama.2024.4303