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NORMAL AND ATYPICAL GROWTH AND DEVELOPMENT

MARY PEARLMAN, M.D.

UNIT 1: INTRODUCTION: WHY LEARN ABOUT NORMAL GROWTH AND DEVELOPMENT

(Slide 1) SW 644: Issues in Developmental Disabilities

(Slide 2) Video of Pearlman

This is Social Work Course 644, Issues in Developmental Disabilities, Normal Growth and Development. One of the questions that we’re often asked by students is why learn development?

(Slide 3) Why Learn Development

Knowledge about development is necessary for a number of things, assessment, goal setting, and treatment strategy choices. In this section, we will talk about all of these.

(Slide 4) Assessment

First, important for assessment, it’s important to have a differential diagnosis. Differential diagnosis is all of the possible causes of a set of symptoms.

(Slide 5) Differential Diagnosis

Now, we’ll look at a familiar example. Here, we have a person with a fever. The partial list of things that could cause fever includes flu, appendicitis, diurnal temperature variation, malaria, malingering, bladder infection, alien possession, and the person has just exercised.


Now, when presented with a symptom, a clinician has to determine which of the many possible causative factors are involved in the symptom in front of them. The effective treatments for different causes are often different. Although we often treat just the symptom, for example, fever with aspirin, that doesn’t get at the root cause.

SEGMENT 2: WHY LEARN ABOUT NORMAL GROWTH AND DEVELOPMENT: EXAMPLES

(Slide 7) Why Learn Development: Examples

Let’s take a developmental example that goes to show how important knowing development is to assessment. Marc is a six-year-old boy. He is brought in for assessment of possible impulsive behavior, not following commands, and kissing peers. He has been held back a year in school for problems with reading and math.

He is a behavioral problem for everyone. He is very active compared to his age peers. He speaks in three-word sentences, he needs supervision to dress, and he can’t button up. He just started riding a tricycle. He can copy a circle, but not a cross.

(Slide 8) Differential Diagnosis: (partial list) So if we look at, again, a partial list a differential diagnosis, we might think about attention deficit disorder, conduct disorder, mental retardation.


Now, this is a copy of the Denver Developmental Screening Exam. Perhaps this can help us with Marc’s assessment.

(Slide 10) Copy of Denver Developmental Screening Exam

Now, remember, this is a screen exam. This is not a diagnostic tool. On the vertical axis, on the left and on the right, what you see are personal-social, fine-motor adaptive, language, and gross motor. What you see on the horizontal axes is the ages of performance from zero to about six, marked off and hash marked.

The behaviors or skills that you can see usually are indicated with graduated shading where you can see the age at which half of the children can perform the behavior.

(Slide 11) Marc 6 year old boy

Now, on the chart, let’s look for needs supervision to dress, and can’t button self. This is under personal-social. If you then follow the chart toward the top, you can see the age that that comes in at. So roughly three. Let’s go to fine-motor adaptive. He can copy a circle. He cannot copy a cross. Let’s look at that. Follow it up. What age? Again, roughly around three. Remember these are ranges when children acquire behaviors.

Language, three-word sentences, no reading, no letters. Let’s look. Well, actually, we can’t find anything, but don’t worry about that. It’s three. Now, we’re going to do gross motor. Let’s look. Oh, look, there’s pedals tricycle. Well, that comes in a little earlier.

(Slide 12) Copy of Denver Developmental Screening Exam

So now, what we have to do is we have to go back and check. How many of the gross motor items can he do that a three-year-old can do? Does he do any beyond that level? After we’ve checked those few other things, we mark them all down on the Denver, and then we draw a line through the behaviors that we have marked that he is capable of.

And then we look at the chronologic age on the horizontal lines top to bottom. This gives us in a screening, generally, kind of fashion, an approximation of where his level of function is. If you want to check to see if that’s a reasonable developmental level, you can ask about some of this surrounding behaviors that might be occurring as consolidated behaviors at ages younger than three or might be starting to be seen as anticipated behaviors in children older than three.


Now, IQ, this is the formula, 100 times the mental age over the chronological age. In this case, it’s 100 times 3 years over 6 years, which equals one-half . . . see I still remember one fraction . . . and that yields an IQ of 50.


Knowledge of development allows us to potentially diagnose Marc as having mental retardation. Social skills are usually consistent with mental age, and Marc’s behavior is similar to other three-year-olds.

SEGMENT 3: WHY LEARN ABOUT DEVELOPMENT... GOAL SETTING

(Slide 15) Why Learn Development

Knowledge of development also helps us with goal setting.

(Slide 16) Goal Setting

Now, back to Marc, they’re trying to teach him to follow commands. This is his current level of functioning. Marc will stop an activity when he’s told no. He will not make his bed independently. He can spend about five minutes learning new material. He can enjoy familiar material for about a half an hour. He cannot read the clock, but he does know day, night, school time, lunchtime, bedtime and suppertime.

(Slide 17) Cartoon

This is probably a somewhat familiar type of situation. These people cannot go anyplace for dinner except McDonald’s until their children learn some behaviors. And so for most of us, learning behavior control, or having our children learn behavior control is very important.


The parents, what they want with Marc, is they want Marc to learn to do chores and to be responsible. They want him to learn to change his bed because he wets his bed. So they put Marc on a behavior program. Marc can earn a star at lunchtime if he puts his dirty PJs down the chute, the dirty sheets down the chute, and if he puts a new sheet on the bed. Mom has clearly demonstrated the steps involved in this skill. Will this behavior program work for Marc?


I don’t think so. The time between the activity and the reward is much too long for a three-year-old. He can stick with a favorite activity for only half an hour. The activity has too many separate parts for a three-year-old to remember. The activity requires fine-motor skills that are too advanced for a three-year-old. And the activity probably requires more strength than Marc has. Marc has button PJs, and he really can’t button PJs yet. So he would need help even with taking them off.

(Slide 20)Cartoon

So here we have a tiny commentary on behavior management programs. Doctor, what do you recommend to parents with a hyperactive two-year-old? Why, of course, 50 yards of rope and Bowditch’s Manual of Knots. And the child observing this says, aha, a behavioral approach. This kind of problem can be prevented with some knowledge of development.


Knowledge of development would suggest more developmental age-appropriate responsible tasks. Responsible tasks for a three-year-old are clearing the dishes from the table to the counter, emptying small wastebaskets, wiping the sink after he brushes his teeth, and putting cans in recycling. That is within a three-year-old’s range of responsibility.


Rewards for a three-year-old have to occur very soon after task completion, about five minutes. They don’t have to be primary reinforcers like candy. Thanks, Marc, you were a big help. We have our chores done. Let’s color.

SEGMENT 4: TREATMENT STRATEGY SOURCES

(Slide 23) Development: Treatment Strategy Choices

Now, on the other side of it, Marc’s bedwetting is truly a problem for the parents. They want him to stop. Is this possible given Marc’s mental age?

(Slide 24) Rx Strategy Choices

Again, we look to development for an answer. Now, here, what we’re using for a source on development is a book, The First Five Years of Life by Gesell. It’s in the bibliography. And we’re looking specifically at the developmental sequences around 36 months that relate to elimination function control.

So what we read in Gesell is at 36 months a child can respond to routine times, goes by himself or herself during the day but announces it. They may hold it too long, dancing up and down and accidentally wet, otherwise known as the pee-pee dance. They need help with buttons. They attempt to wipe themselves, and this is wildly unsuccessful. The median age is 42 months, dry at night. This means a significant minority of children are not toilet trained at night at 42 months.

(Slide 25)Rx Strategy Choices

Knowledge of development suggests that it might be normal developmentally for Marc to still wet at night. The problem that his parents have is that his chronologic age is six years, and his body is fairly big, so he’s producing copious amounts of juice at night. His mental and social age is only three years, so it’s not up to controlling that large volume of fluid. So what are we left with treatment choices? The parents

truly need relief. The parents, number one, will benefit from developmental education.

(Slide 26)Knowledge of Development

Once they have developmental education, they have more options and strategy choices, for example, environmental modification, prevention, positive reinforcement, negative reinforcement, and, of course, there’s always the old standby, punishment.

(Slide 27)Rx choices

An example of environmental modification is wearing pull-up diapers and putting a rubber sheet on the bed. An example of prevention is cutting down how much juice he drinks after dinner. Positive reinforcement is, oh, you used your big-boy pants, thanks. Negative reinforcement, oh, we don’t want to have to wash the sheets.

(Slide 28) These Behavior Management Strategies…

These behavior management strategies need to be used to teach desirable behaviors and not just get rid of undesirable behaviors. Behaviors are taught in successive proximations.

(Slide 29) Cartoon

That means you learn parts of the task. Every little while, you learn a new part of the task. Each successive new teaching, you get closer and closer to the total task as opposed to trying to do the total new learning at once.

(Slide 30)Rx choices

Punishment can be a problem. It may make things worse. The child could get frightened or confused. The child could have more trouble sleeping and more trouble with wetting. Alternatively, the child could get angry and be less compliant and more distant.

(Slide 31)Cartoon [P.S. Mueller]

It’s always preferable to use one of the other devices.

SEGMENT 5: SUMMARY: WHY LEARN ABOUT DEVELOPMENT

(Slide 32)Why Learn Development: Summary

So in summary, why learn development? Well, a knowledge of development is necessary for assessment, goal setting, treatment strategy choices. People knowing about development made a real difference to Marc and his family. They picked the right diagnosis. They picked the right goals and relieved the family’s distress and Marc’s distress over his failure to meet his family’s expectations. They all started

feeling better. Not only that, children with developmental disabilities don’t respond the same way to our interventions. You can see why. If you can pick the right intervention, you can make people feel effective, be effective parents, be effective human beings. Development is really important.

SEGMENT 6: SUMMARY: WHY LEARN ABOUT DEVELOPMENT

(Slide 33) Don Anderson’s Note(Slide 34)Normal Development: Childhood Developmental lines are an important concept. The definition. Developmental line is a skill that can be observed and assessed from birth to death that involves one functional area. The acquisition of skills is an orderly process succeeding skills based on earlier skills in that functional area.

(Slide 35)Normal Developmental: ChildhoodSome examples of developmental lines include motor skills, gross and fine, perceptual skills, impulse control, cognitive skills, play skills, social relations and attachment, and speech and language. The developmental lines all require skills simultaneously. The optimal development of each of the individual developmental lines is dependent on the integration of skills from the other developmental lines. Motor skills, the movement and control of the large muscles is usually referred to as gross motor and the movement and control of the small muscles, usually of the fingers, as in writing, or picking up and raising is referred to as fine motor. Perceptual has to do with the senses. Of course, you know, we do have more than five senses. The usual sight, hearing, taste, touch, smell but there is the kinesthetic sense also, which is a body positional sense. Let me show you how physicians test for the kinesthetic sense in fingers to see whether it's intact if there's a neurologic problem. To test this, you hold the patient's finger still by stabilizing the finger at the bone nearest the hand. Since I only have one hand for you all. Now, stabilize my finger by holding it with my tongue. You hold it from side to side.You have the person close her eyes and then with this hand holding the finger from side to side, you move it up or down or up and then, have the patient identify the position of the finger. You hold it side to side so that the pushing on the finger doesn't give them a clue because that would involve touch rather than kinesthesia. Go ahead and try that and watch it all with a partner. What you'll notice is that you will have no difficulty at all telling the position of your finger. It's a very important sense it helps to stand upright and so on. Cognitive skills are thinking skills. These skills include the adaptive skills, academic skills and self-knowledge. Play is a child's work. Play provides skill rehearsal, exploration of new areas in a risk-free fashion, exploration of alternative methods of problem-solving. Social relations include empathy, judgment, attachment, conscious formation and social understanding of rules of interaction. Affect attunement matching our feelings with that of a significant other is an important way of learning about feelings and the physical world around us. Impulse control, making oneself do what one should do and stopping oneself from doing naughty things is dependent on being able to develop a stimulus barrier, ruling out or tuning irrelevant stimuli. It requires the person to stay regulated, that is to be able to move from a state of sleep, to ready-alert, to the higher ends which might include euphoria or crankiness and over arousal, then moving back down to ready-alert and then back to sleep. You have to be able to do this smoothly as part of impulse control. To have impulse control, a person must be able to establish priorities, to make hierarchies and to direct their attention. We hear a lot about this nowadays as there are many articles about fatal low and that's where these activities occur.

The formal development of language and speech is preceded by the development of lip movements, imitation of sound and lip movements and body and gestural language.

SEGMENT 7: NORMAL DEVELOPMENT, INFANCY AND SELF MANAGEMENT(Slide 36) Normal Development: InfancyBabies are born with a whole set of skills, reflexes, readiness to orient the voice oriented to caretaker and some self-management skills. Reflexes, for example, include the moral. A baby is leaning on the table, the examination table, and you slap the table behind the baby's head. The baby will startle, throw out its arm and then the arms kind of wobbly, jiggle in and towards the center of the body. The legs actually move also. A baby monkey often sits right in front of the mother monkey . If a dangerous thing occurred within the baby had that reflex, the baby would end up grasping the mother around the back and hanging under the mother as she run away from the danger. Pain is another reflex that babies have. When pained, baby scrunches its eyes and gets red in the face, howls and windmills its limbs. This attracts social attention so somebody will relieve the pain. Grasp. If you touch the palm of the newborn, it will close its fist around your finger. This reflex helps the baby to hold on to things before it has motor control. The sucking and rooting reflex. If you brush a baby's cheek, it will turn its head in the direction of the touch, then it will start sucking. The two are hooked together. The rooting reflex helps the baby to find the breast, then it could suck to nourish itself. Humans root side to side because usually the way they are laying if they turn their head to the side, they would find the breast. Horses root their heads up and down because they feed, the mamma standing and the baby horse is down here, so they have to lift their head and move it up down to find the breast or nipple or whatever they call it in a horse. Babies also orient the voice. Babies are born with an interest in attending to voice sounds and they orient towards them. At first, they differentially orient to all speech sounds. By 9 months, they preferentially oriented to the speech sounds in the languages that are most familiar in their environment. If it's English, it's English. If it's English and French, it's both of those languages. They actually stop listening to other speech sounds. These orientation to speech sounds helps in the acquisition of one of humanity's most valuable tools, language. Oriented to caretaker also occurs. Babies use variety of cues to localize and identify their caretakers. In an experiment, by day 3, babies will preferentially turn their head toward the nursing pad of their mother versus a nursing pad of a stranger.

(Slide 37) Normal Development: InfancyBabies have self-management skills. These were described by T. Berry Brazelton who developed a neonatal development assessment scale based on these items. In further work, when he shared the result of this assessment with babies caretakers, in follow ups, the parents evidenced more self-confidence and effectiveness in dealing with the infancy period of development. Some self-management skills include sucking. Well, of course, babies don't just suck for nourishment. Some babies can suck their hands at birth and if they're unsettled, they can bring their hand to their mouth. They can't yet isolate the thumb and suck on their hand. Most babies very quickly learn this skill, and again it's a tool for self-settling. Now, we're gonna do a little activity. What I'd like you to do is to close your eyes. I want you to imagine that you're hungry. I got your eyes closed and you know how that feels in your stomach. Now, slowly, start sucking. Keep your eyes closed. Suck. Notice the saliva flowing into your mouth. You know, you're stomach is starting to

feel a little bit better. You feel quieter, maybe a reduction over all tension. That's what babies are doing for themselves and all that is without using a thumb. What the other skills that baby have for self-management includes stimulus suppression or habituation. We already discussed what a baby does with the moral reflex when you slap the table behind it. And if you do that several more times, each succeeding time, the baby's response to that will diminish. This is stimulus suppression which is a tool and part of the process of developing that stimulus barrier that we need for impulse control. We do not have to attend to things that are not dangerous. Habituation which is another name for stimulus suppression is the process of becoming so familiar with a particular stimulus that it no longer elicits the same physiologic reaction you did when originally experienced. So, it's not just what you're thinking. It's the physiologic changes that occur in the body in response to the stimulus. Brazelton went on to ask questions. How easily does a baby get upset? When the baby is deeply asleep, many babies do not respond to light shine on the eyelids or voices in the environment. This is good. This means that they can maintain the state of sleep and get the rest they need and the mother can get her rest. As the baby then moves out of deep sleep and moves toward the light sleep, and you shine a light, I know, his eyelids, the baby wants to maintain that sleep state, so it scrunches its eyelids tightly together. He's trying to keep sleeping. This is a self-management tools, data maintenance. Some babies wake up cranky. Some babies move smoothly from asleep to ready alert. They are ready to be cheerful and ready for interaction. That's is an inherent gift.

(Slide 38) Normal Development: InfancyWhen we talk about inherent gifts, we're talking about a term that people have used, temperament. The definition is a set of innate tendencies or dispositions that underly in effect each person's interactions with people, situations and events.

(Slide 39)Normal Development: Infancy, Temperamental CharacteristicsSo, let's take a peek at temperamental characteristics. These include activity level, rhythmicity, approach withdraw, adaptability, intensity of reaction, threshold of responsiveness, quality of mood, distractibility and attention span. Stella Chess and Alexander Thomas evaluated very young infants. They were evaluated extensively and repeatedly over time. From the first days and months, infants differ on needs characteristics above listed. Temperamental individuality was established by 3 months of age. The temperament is persistent over time. Interestingly, about 40% of babies are easy babies. About 15% of babies are slow to warm up and about 10% of babies are difficult. A difficulty is comprised of irregularity, intensity, negative quality of mood and low threshold of responsiveness. None of these categories are easy or difficult by themselves in the case of pathological outcome. This is because parents struggle to produce goodness of fit between the baby's temperament and their environmental exposure, however difficult babies benefit from their great, great efforts by their caretakers to produce this goodness of fit.Parents need to accommodate their parental expectations in the environment to the child's temperament, whatever it is. Approach withdraw is a good example. If you have a baby who is alarmed by new situations, an accommodation would be to gradually introduce the baby to normalcy. With each small exposure, where the limit is established by the baby's state of arousal, that is you don't want the child to move into crankiness or over arousal while you keep in the middle of wake alert state so the length of exposure is modified by that, but if you do this, the child will accommodate eventually to the novel experience and learn to enjoy it. Pushing them

results in wild screaming. One does not learn well when agitated. Mild anxiety or medium arousal helps learning. Self-management skills are innate. Temperament is innate. Optimal learning environments expand these skills and allow us to learn management that we need for the tasks at the different developmental levels.

(Slide 40)Normal Development: Infancy, Tasks of the Infant PeriodThe tasks of the infant period include, of course, feeding and elimination, state regulation, learning about the perceptual and sensory worlds, learning early motor skills, attachment. There are some acquisition of early logic and of course, there are language readiness and imitation skills.All learning that goes on in life causes changes in the brain. An estimated five-fold increase in the density of the dendroids, that's the branches leading from the cell body to another cell, so there's a five-fold increase from birth to age 2. What this means is that there are increased pathways of connectivity that show learning. Connectivity is also enhanced by myelination. The nerve branch becomes wrapped in a layer of special fat, interestingly made from cholesterol which insulates the nerve and increases the speed of conduction of the nerve impulse. It also like in wires prevents short-circuiting so it makes the nerve effective. Experience exerts powerful influence on the formation of synopsis, that is, the gaps between the end of one cell and the beginning of the next cell branch. Knowing how to feed is not a given.A baby has to learn how to find the breast, suck effectively. Put the mouth in the right shape. Feeder the rate that doesn't cost choking. The gut has to learn how to process the food. At first, the bowel movements are large, stinky, yellow-green curds. As they move through the large intestine, there is cramping. Because the baby makes awful faces, gets red in the face and during their bowels are active, usually it's only concentrating on the internal bowel sensations. Until the gut learns to process the food more efficiently, the baby experiences some discomfort. Early logic. There are many types of logic. There is chronologic logic, correlational logic, cause of logic. There is logic about abstract ideas, logic about objects. Children in the early period have a logic about objects and its what we call syncretic logic. If you ask a 4-year-old why the sun is hot, he might say, "The sun is hot because it's yellow and in the sky." The child in syncretic logic squeezes any facts he knows about a subject together and assumes causation. Correlational logic is very similar. For example, people who drink cranberry juice save more money for retirement. I made this up. This is not true.So, if you want a comfortable retirement, you can just drink cranberry juice. Now, there is no proven causal connection between cranberry juice and retirement funds. The two effects occurred at the same time and the same place. There's no positive relation. The baby, in its areas of developmental expertise, can and does learn causational logic. For example, milk comes into my mouth, there will be reduction intention. Now, again, remember our previous activity. We closed our eyes and we were hungry. The stomach had that very jiggly, gassy feeling. You sucked and there was gush into your mouth, it goes down, the very jiggly gets better. Gush better stomach this causalogic at the perceptual level. Further, the gush comes from warm milk smells surrounded. That's mother. Mother is, then, causedly linked with the past outcome up hunger reduction, intention reduction. Attachment begins. The mother, by repeatedly responding to the baby's cries keeps reenforcing a lesson in logic. That is a lesson in attachment. If the response to cries is not reliable, for example, the baby cries herself out before it's fed, often it feeds in a disorganized fashion. Too hasty in choking all lethargically. The connection of cause and effect is too fragile and infrequent and logic falters. Interestingly, neglected children are noted to be cognitively concrete.

(Slide 41)Normal Development: InfancyAttachment begins in infancy. Again, T.Berry Brazelton has offered us a nice look at attachment in an experiment he did, and the papers called reciprocal interaction in the mother-child relationship in the infancy. Attachment isn't inborn drive in infants along with curiosity, hunger, self-preservation and reproduction, that is, infants will engage in behaviors for no other purpose than to facilitate attachment. Attachment is specific to one or several people. When these people are absent, there's an increase negative arousal and seeking behaviors are observed. Since through attachment, gratification of many other drives is facilitated given the baby's help or state. Attachment is most central to normal development of all developmental lines. Additionally, attachment forms the foundation for causational logic, self-concept, learning more self-modulation skills, building conscience and understanding social interactions. I might have a bias. I am a psychiatrist. I have no idea what a physical therapist would think about this research. In the above paper, Brazelton describes the experiment he did with mother and very young infants. Brazelton filmed the mother-child pairs interacting face to face. One camera focused on the baby. The second camera focused on the mother. Items were then coded recording the baby and the mother. Other items include shared gaze, looking away, eyebrow movement, lip movement and lip imitation, cooing and a shared cooing. The interaction begins rather low-level with shared attention, and then slowly build in a crescendo as indicated by the number and intensity of facial movements and sounds. Then, there's a gradual decrescendo and a rest passed. In highly effective mother-child pairs, the baby leads the way and the mother follows the baby's lead as to the intensity in the types of activities. If the mother miscues on he baby, the baby may drop out of the interaction using gaze aversion.I'm going to try and demonstrate this for you. There's a baby here and you'll notice that I am providing head support. The baby is around four months old, at the youngest probably, and the baby still have to usually exert some effort for head control at that age. So we want the baby fed and changed in entirely comfortable good temperature. I'm gonna hold baby's head so that the baby has no distractions and it's free to do this exploratory interaction reciprocally with me. The baby can comfortably see my face. I can comfortably see the baby's face actually. I often do the sitting back in a chair with my knees up so I can rest the baby on my knees while holding the baby and then I also don't have to put up more motoric effort. Then the baby and I are both free to only attend to each other and sort of the whole world drops away. We're sort of alone together, interacting in this space, moving through time. Does that sound like anything else? Yes it does, doesn't it? That's exactly the way I feel about playing duets with people. Anyway, so here's baby. I'm gonna catch the baby's gaze. You watch my face. The baby's looking at me. Oopps, I should take my glasses off. He wiggles his eyebrows. I wiggle my eyebrows. Now, the baby takes a little look at me. I make a little bit. You clever thing. What are you doing? I wiggle my eyebrows. The baby is obviously looking at eyebrows a lot. Wiggling eyebrows. Oh! You didn't hear the baby coo. The baby cooed. What are you doing? [Cooing] The baby has moved its gaze away. We're resting. We're floating, processing the experience. The baby rests for a while and then you restart. Now, if you notice how you feel, you're very absorbed in this kind of an activity, and that's the end. You just want to float. This is quite important to give the baby space to rest and when it gives you clues by slowing down, that you slow down with the baby and let it move into a rest space.

(Slide 42)Normal Development: Infancy, CommunicationYou usually think of communication as involving the mouth and words? But actually, infants do a lot of communication. They talk with their eyes. They're social referencing, drawing the adults attention to an object of interest. There's negation and there's emotional expression. Social referencing. There are many things that a baby does not know about in the world. What's dangerous? Babies partially solve this problem in a questionable situation by looking at the mother, assessing her facial expression, neutral, anxious, happy and the signing whether to continue the activity or not depending on the mother's emotional reaction. This is called social referencing. It occurs between attachment objects throughout the lifespan.If the baby has interest in an object out of its reach, the baby will catch the mother's gaze, look at the object, go back and catch the mother's gaze. "Hi, Mom, would you get that object over here please." Negation is expressed through scrunched eyes and gaze aversion.

(Slide 43)Normal Development: InfancyBy four months of age, a mother can distinguish the meaning of the baby's different cries They have taught each other. usually, by four months of age, the baby can wait to feed if the mother says, "Coming baby". The baby slow down for a few minutes. They can't wait forever.

SEGMENT 8: NORMAL DEVELOPMENT AND PIAGET'S GOGNITIVE DEVELOPMENT(Slide 44)Normal Development: Childhood, Piaget’s Periods of Cognitive DevelopmentOne of the theoreticians who developed the very useful way of looking at a development in childhood was Piaget and he described the periods of cognitive development that a child goes through from 0 to adult. The first2 years are sensorimotor, 2 to 6 years preoperational, 7 to11 years concrete operational, 12 years to adult formal operational. And then, some adults move into post-operational which Piaget didn't describe but later theoreticians did. In the sensorimotor period, the infant uses its senses and motor abilities to understand the world. There is no conceptual or reflective thought. So when I was talking about logic, i wasn't talking about A+B = C. I'm talking about something that the baby experiences in its body. Okay? An object is known in terms of what the baby can do with it. During this period, the child learns that an object still exists when it's out of sight. This applies both to balls and to mothers. If it's applied to mothers, it's called object permanence. Pre-operational, 2 to 6 years. The child now learns how to use symbolic thinking including language to understand the world in addition to keeping their early sensorimotor exploration skills. The child only understands the world through its own perspective. In symbolic thinking, the child knows that a word, a picture, a toy or an act stands for something in the real world. The word, picture, toy or act is not the real world and manipulating them will not change the real world. For example, if I showed you a picture of a bath tub, you would not put your put in it. No, you can't. It's a representation. It's not the real world that can't be manipulated. During this period, pre-operational period, children are very imaginative and language becomes more and more important for self-expression. The concrete operational period the child applies logical operations that they have learned to interpret the experience rationally rather than intuitively. The child also learns to understand the basic concepts of conservation, classification and scientific ideas. In formal operational period, the child now can think hypothetically until what abstract ideas they can understand principles and as they move in to formal operation of thought, they can mix ideas together and come up with a new idea that they have not seen in the real world.

The visual-perceptual motorline. At birth, the baby can regard the face and have vision. Now, regard the face means look at ... I don't know why we say regards to face, but that's the language. Within the first months, the gaze follows at bright object to midline. Okay, here's midline. If you start with a bright object over here the baby can follow it that far.That means their head is turning in their eyes are turning following the object to midline. At two months, the baby's gaze can follow past midline. At 1-1/2 months, the baby smiles responsively. At 3 months, the baby will smile spontaneously and they can follow an object 180 degrees farther than I can turn my head anymore. At 4 months, the baby will regard a raisin fixedly. That means, look at it. Sort of staring at. This list of visual-perceptual skills is of course based on the average a healthy baby can perform these tasks somewhat earlier or a month or two later. These are taken from the Denver Developmental Screening Exam. What this list tells you is that the baby is usually ready for reciprocal interactive exercise that we recently demonstrated at about the age of three or four months. This list also demonstrates the orderly progression of the acquisition of skills, each based on the previous skill. This list shows the relatedness of the perceptual developmental line and the social developmental line. They depend on each other. In a blind baby, social relatedness emerges and expresses itself more to sound and touch, obviously. Look at Denver Developmental Screening Exam to follow progression of other perceptual skills. Note how the developmental learning in the first two years all depend on sensory experiences and are expressed in the predominantly motoric fashion. This is why Piaget called the first period of development the sensorimotor period.

(Slide 45)Normal Development: ChildhoodLet's look at play as an exemplar of Piagetian theory. At 4 months, the baby grasps rattle and bangs things with the rattle. At 7 months, the baby can play peek-a-boo, takes two blocks, also can pass a block from hand to hand. This being a block, pass from hand to hand. The baby has to learn how to work pass the midline. It's not an easy skill for a baby to learn. At 10 months, the baby plays patty cake and bangs 2 cubes held together in the hands. I won't do this with a remote. All of the above named the baby does over and over with evident enjoyment. As babies play, they are practicing and they get better and better at controlling the arms, the fingers. The progression and activities reflects improved gross motor perceptual, visual and social skills. All the activities are sensorimotor.

SEGMENT 9: NORMAL DEVELOPMENT CHILDHOOD(Slide 46)Normal Development: ChildhoodNow, we're going to look at how gender identity exploration reflects Piagetian cognitive development. At 18 months, a child touches its parents' body parts and learns the label for those body parts and compares those body parts to themselves. At 2 years, a child can be seen wearing dad's hat, carrying the briefcase, going to the door and saying "bye". At three years, the child will express the desire to marry the opposite sex parent. Pardon me, I'm not going to deal with alternative lifestyles despite the fact that 60% of households in America, women are household heads and there are no men around. It'll just take to much time. The 18-month-old is still in sensorimotor and so is exploring the world through their senses. These can lead to someone comfortable social experiences for the parent while bathing if they are not prepared for this learning a bath. Most parents give the child a label for the body part. Then, they point to the child's body and say, "yours" and they point to their body and say, "mine". This thought is a process of individuation and teaching more privacy. Often, women are comfortable

with breast exploration because they've gotten used to the child touching their breast during nursing. Often, babies continue to seek non-nutritive contact that serves the purpose of soothing for sometime after they're weaned. The body part of men that most often entices sensorimotor exploration is a body part that men are not comfortable with having explored.Try to not to slip and hurt yourself on the wet tile as you label body parts and slightly distance your body. A gentle statement of mine or private and creating a distance at about 6 inches between your body and the child's hand usually puts comfortable boundaries around the experience and thoughts start teaching the child that he's an individual and you're an individual. Since children repeat most things that they're learning, do not be surprised to encounter this again. By now, you have installed grab bars in the shower. Each time, repeat the labeling and the distancing. I hope you know that I suggested a small physical distance and not an emotional distance. At the end of this exploration, the child knows which parent she matches. They have learned something about their gender. Do you like the "grab part" part? Let's explore gender identity a little farther. Two years, the child is wearing dad's hat, carrying a briefcase, goes to the door and says "bye". Two-year-old is in the pre-operational stage, Piaget's development. The child is capable of using symbolic thinking, that is that they understand that a symbol can represent something in the real world. When a child puts on a dad's hat and carries the briefcase, they look like dad to their mind. When they go to the door and they say "bye", they're motoring and talking like dad. This is how they represent themselves symbolically as a dad. They are experiencing themselves as being a dad. They are learning "dadness". They're using their sensorimotor skills which they continue to use and they have added their symbolic skills to understand "dadness" in a more complete fashion. Do not be alarmed if the child explores the beingness as of an opposite sex parent. Little boys using make-up or putting on mom's clothes, for example,or a little girl pretending to shave or trying to stand up to urinate. Help the children to learn how to clean up with you. All genders need cleaning skills after all. The child is simply trying to understand what it's like to be a man or woman. This has no impact and does not predict due to sexual orientation. If it is any comfort please note that a favorite game of children is to imitate an animal: a snake, a frog, a dog, practicing how a dog lives, walking on all fours, eats out of a bowl and barking like a dog does not predict your child turning out to be a dog. The 3-year-old, as part of gender identity exploration expresses the desire to marry the opposite sex parent. At 3 years old, the child is starting to develop symbols for things that can't be held, like pushed or detected through the regular senses. The child starts to see the relationships between people, the relationships between people and objects, possessions, mind, most of their own. They do not understand how this relationships are made. They know they're there. "Are you my mommy?" "Yes, I'm your mommy." "Tommy has his own mommy." "Yes, Tommy has his own mommy. Tommy came out of his mommy's body." Though you'd probably wouldn't add that, well, if the kid asks in the question. The child experiences the special relationship between the parents and wants to have one of her own. There is a lot of playing around getting married in a role play at the nursery schools, veils are highly sought-after items and boys are often wrangled into marriages and eating fake or imaginary food. When my son asked me to marry him, I was heart-broken. I remembered how long it took and how we almost didn't seem possible to find a love of my life. No, I'm not a romantic. Anyway, I explained to my son that you can only marry one person, so I couldn't marry him. I also told him he wouldn't be ready to marry for quite a while and that I would be really pretty old and falling apart by then. So, he'd really sure look at younger people. Several days later, he asked me if his

nursery school teacher who he is very attached to, was younger than I was. I said, "Yes, I think she is." He went to school and proposed to her and she reported this to me and she had to deal with turning him down. Anyway, so she reinforced my advice, look for somebody younger. There was a young lady who lived with us who baby sat down several hours a week for my son and the two of them just really love each other. Anyway, soon enough, he proposed to her. She was a little surprised so I had to explain the development to her and we both suggested and they'd looked for somebody younger. I worked his way down and finally, I asked him why he didn't want to marry any girls his own age. And he said, "Well, they can't take care of me." Now, a priest could say , "Very rough a thing" which is like, well, that's all men are looking for, after all. But what are women really looking for? That's why babies want it.

SEGMENT 10: NORMAL DEVELOPMENT CHILDHOOD LANGUAGE & SYMBOL FORMATION(Slide 47)Normal Development: ChildhoodNow, let's think about language and symbol formation. To help us think about this, we're going to consider "truckness". What do babies do is "trucksism".They move from infancy and toward symbol formation. They suck on in mouth the truck, they bang the truck, they roll the truck on a fabric and spin the wheels. They watch a real truck outside and say, "truck". Now, using your understanding of the play faces the infant goes through and sensorimotor development, let's look at the emerge of symbol information. A single word equals a single object in real world. The word in the toddler's brain stands for objects in the real world. All right. So here I say, the baby is thought that here's the truck coming, it's going on the back of the couch. At the corner, there's a truck coming up the street. Kid's really are looking. You see, that's symbol formation. Well, the child often makes their own labels for things. For example, it would be unusual for a child to call a truck "arvrrrm" or "uurrrmmm". My daughter called tomorrow "sun go moon". I won't tell you, she called bowel movements "peepee snake" because it was an excretory product that was shaped in a lengthwise fashion. Children often make up these wonderful words. Also, children tend at first, to learn one label per category. So for a long a time, not too long, several months at least, all four legged-animals or whatever the name of the first four-legged animal the child learn was cows are dogs, goats are dogs, pigs are dogs, horses are dogs and then eventually, they learn the specific names of the specific animals. Prior to pre-operational symbol formation, children do work on representational tasks. My daughter and I used to enjoy the path of Bunny book. The book has a dad with a rough beard that you can feel. There's a ring to put your finger through. The bunny has soft fur. So you can see this book has a lot of sensorimotor orientation. There's also a picture of a bathtub, A child, when they look at a picture can either think that that picture is the real thing but the child can realize that the picture represents or stands for the real thing. You can see a child be confused and explore this concept. One evening , we were looking at the bath tub picture when she suddenly pushed back against me and repeatedly tried with a growing frustration to put her put in the bath tub by putting her foot in the picture. At that point,. she did not realize that the picture was representational. She still thought that was the real thing. There are many things in our child's life that are representational. Words, pictures, and later writings are of course representational. You can observe the same miracle of sun understanding when one learns the letters that he's reading, sounding out become a sound that actually sound like a label that he knows then, they realized this stands for an object. CAT -c-a-t, cat. Cat. Writing, symbol formation. Attachment is an enduring emotional connection that produces the desire for

continual contact as well as feelings of distress during separation. Margaret Mahler in her developmental theory attended a lot to attachment. Mary Ainsworth developed a paradigm for assessing attachment. Secure attachment provides comfort, confidence, a base for exploration that allows the child to learn about himself, how to sell himself, what his preferences are and that he's valued. Secure attachment teaches the child how to relate to others. When a child is secure and not distracted by battling needs, that child has an inner feeling of well-being. Later, we see the child attach the word 'good" to that state. The child child feels comfortable in familiar surroundings wanted to sure that the attachment object is available. How often have we seen an infant to terminally gaze at the door the mother had disappeared through? The child looks serious and intent and stops playing. When mother reappears in the door, the child's face relaxes and the child freakily makes a sound to attract the mother's gaze, then the child resettles to play. Development of attachment, we see some of the following things. At 6 months, we social referencing. At 9 months, shyness with strangers. At 9 months, we also have object constancy, that is the child knows something exists even when they can't directly see it. At 4 months, we see they emerge some strange anxiety. At 2 years, individuation struggles with the caretaker and at 3 years, the child is more comfortable staying with familiar strangers and has some enhanced self-settling skills. We talked already al little bit about the definition of social referencing. At 9 months, children are shy with strangers. The child becomes aware people are not mom. A new person enters the room, the child holds quite still and gazes fixedly at the person. Often the child would check back, look at mom, gaze at the stranger, look at mom and gaze at the stranger again. The patient of mine had a baby that I knew and played with for about two months on. The baby and I enjoyed each other. I could hold her while mom took care of her older sib. When she was around 9 months, we were playing, and she leaned over to see something and supported herself. and by hanging on my prodigious and sturdy nose. Suddenly, she stopped playing, looked at me keenly and then looked at her mother and reached for her mother. She wanted to leave the stranger. Mother rand I looked a lot a like, however, mother did not have such a formidable nose. It must have helped difference in mother's nose to hang off of. The baby did not realize, I was not her mother until she grabbed and hang off of my nose. We both nearly died laughing. Remember, object constancy we've already defined. Stranger anxiety is an intense desire to stay with the mother and resistance to going with other people. Protest is the baby's way of showing us they feel not good which later become the bad label. The attachment object is very linked to feelings of good and bad. The terrible 2s, who hasn't' t heard of them? What is so bad about the 2's. The child has limited language. the child is getting more aware of specific likes and dislikes. The child experiences the need for things now and has no sense of time and can't wait. The child cannot make choices between two things at once. The child is a toddler and is getting around the house and hearing the word "no more". The person who tells the child "no" most frequently is an attachment object. The child wants this, the mother wants that. The child is individuating. "No" produces a bad feeling between the child and the parent. The child can't have that nice, sparkling knife. The mother is not available right this minute to comfort. When the mother says "no", it creates a distance between the mother and the child and the baby does not feel like going to the mother to be comforted. So, the child feels worse. The child at two can't yet stop herself from doing things, She might repeat to herself, "bad baby, bad baby, no" while going to eat the dog food but she really can't stop herself. At this phase, what we do is we simplify the household trying to minimize the

challenges. To repeat the experience, the child learns language to mediate desires, the ability to understand dangers such as hot and learns that mom might get mad but she never goes away. Getting into a disagreement with mom is not such a complete disaster. The child learns she can remain calmer and the terrible 2's pass away. At three years old, the kids can be comfortable with familiar strangers and part of this is because they can do mediation through language. They are quite secure mom won't go away. They have internalized a lot of the settling skills that they learn though attachment. And they have an increased understanding of and appreciation about time. Time is a very important part of dealing with separation and going to school. If mom disappears for too long a time, the child will look for her. Time, day, night, breakfast times, snack times, circle times, rest time. These are how a child divides his day. Knowing order of time helps the child time to wait, enjoying the activities and helps the child to wait. Having an alternative attachment object at the school makes the child comfortable and secure and makes separation easier. The child can also use some of their internalized settling skills: sucking the thumb, rocking is associated with being taken cared of and is comforting. The famous blanky which is a transitional object is closely linked to the mother. Because the blanky was used every time the mother was holding the baby the bay got feel comfortable, so it's associated with mother, settling good. So blankets help kids manage separation. Children will sing themselves songs their mother sang to them to evoke that feeling under stress when they're stressed. In a disagreement with a teacher, I have heard the child tell the teacher that she's wrong, Momma said so. Of course the mother was nowhere around but the mother was in the child's head. By 3 years, many of the things that the child has learned, attachment, language, time, self-settling skills are in place so the child can go and explore the small safe world represented by the school.

SEGMENT 11: NORMAL DEVELOPMENT AND ATTACHMENT THEORY(Slide 48)Normal Development: ChildhoodAttachment theory and Piagetian theory helps us understand conscience development. Development of the conscience was described by Kohlberg and the stages that I'm using are modified from Kohlberg stage. Stage 1 and 2, person does what's the right due to fear of punishment or fear losing something that they need or what is pleasurable. Stage 3 and 4, one does what is right because it's the rule. It's conventional. Stage 5 and 6, person can balance conflicting principles about the right thing to do. And then there's the non-Kohlbergian ultimate period,post-conventional. Now, the pre-conventional person thinks in terms of their own welfare. The conventional, the individual considers social standards and morals to be the primary arbiters of moral values. Post-conventional, stage 5 and 6 the individual follows moral principles that may supersede the standards of society or the wishes of the individual. Stage 1 and 2, pre conventional moral reasoning emerge from ages 0 to 7. What is a child of 0 to7 consider the most in their welfare? In an attached child, the main welfare is maintaining a positive attachment with important attachment figures. In infancy and toddlerhood, these attachment figures are their primary caretakers. As the child moves into the school environment, teachers and other authority figures are added to the array of attachment objects. If a 7-year-old conventional period takes another child's eraser, the teacher makes the child give it back, makes the child apologize and then tells the child to imagine how they would feel if someone took their eraser. The child complies because they want the attachment figure to be pleased with them. Following through on this, the child now learns not to steal but has learned empathy for others. Originally, the child thought having the coveted eraser would make them

feel good. After they deal with the attachment object, they realized that what actually makes them feel good is having a social outlook, empathy for others, pleasing authority figures. The child gets anti-stealing because it would reduce their welfare despite their desire for that eraser. Stage 3 & 4, conventional moral reasoning. In conventional moral reasoning, the individual considers social standards and laws to be the primary arbiter of moral values. Many children start the process of conventional moral reasoning around age 7 years. This is in keeping with what's going on cognitively in the child's mind. Seven years is the beginning of concrete operational thought. The child understands and applies logical operations or principles to interpret experience as objectively and rationally rather than intuitively.Let me give an example of problem-solving that is rule-bound. My son likes to take small cans of apple sauce in his lunch. I usually seny along a plastic spoon because I don't wanna lose my silver. One day, we didn't have any plastic spoons, so when I put the apple sauce in his lunch, I said, 'Well, just go to hot lunch line and grab a spoon there." He says, "Oh, oh no,mom. I can't do that. I don't want the apple sauce."

I said, "What do you mean, you can't get a spoon?" And he said, "Well, that's the rule." I said, "What is the rule?" He said. "The rule is you line up and if you're in the cold lunch line, you stay in the cold lunch line. If you're in the hot lunch line, you stay in the hot lunch line." I said, "Well, I don't know, I bet you they will let you get a spoon". He said, "Please, please. No, mom don't make me do that." So he was getting caught between the attachment figure authority figure at home and the attachment figure authority figure at school. Well, that's not a good thing to do to a kid. So I stuck the apple sauce in my pocket and took him to school and I went to talk to his teacher. You should know was not a dragon. She's a real doll. Anyway, so I told her what was going on and he said that I could imagine her of not letting the person go get the spoon. She said, "Oh, no. Kids do that all the time." I said, "Would you please explain to him how it works because here, you're the authority, he's not gonna believe me." Now, what happened? He watched what happened everyday. Every day, there was a routine . Kids lined up, hot line, cold line . He probably wasn't watching never saw a kid go from one line to another. He assumed that the rule was you stayed in your line and he was sort of a rule-following kid. Kids interpret rules absolutely and rigidly and adults who are in this stage of development of conventionality of moral reasoning also interpret rules rigidly. At the stage 5 and 6. The person at stage 5 & 6 can balance conflicting principles about the right thing to do. The person follows moral principles that may supersede the standards of society or the wishes of an individual. With Kohlberg, they had a study to find out what percentage of young adult Harvard males were using formal operations in their problem-solving, he came up with 25%. Obviously, there is no specific age for the acquisition of this moral reasoning skill. What factors influence developing this skill? Being capable of Piagetian formal operational thought, formal operational thought. Formal operational thought is based on sound intelligence, having a severe mental illness can interfere with the acquisition, having mental retardation makes it impossible, having a rich educational experience that supports thinking analysis after the basic facts are learned. Families that explain how societal and world work and promote discussion of the individual feelings about these things, families that promote hypothetical thinking and understanding others' points of view. All of these things promote this level of conscience development. Attachment is indispensable. A caretaker nourishes, calms, teaches language, protects, socializes, disciplines and provides structure. Parents teach children how to deal with their feelings, have impulse control, how to wait, how to have empathy with others and to use the child's attachment to them as the lever for influence control to

learn all of these things. Any good parent tries to use their power for the good of the child in their culture and never for their own benefit. I wouldn't offend those who believe deeply in God. Is being a conventional moral problem solver make the person bad? No. Is it a lower order of being? Is it like getting a C instead of an A? No. A person is who they are, and there is a place for each of these ways of moral reasoning. However, there are some dilemmas that do require post conventional moral reasoning to think them through. So, let's take an example, and of course the example that I'm gonna pick is one that you're all probably also very familiar with, euthanasia. Euthanasia involves competing moral principles. When you have competing principles, then you have to employ moral reasoning.Okay? If you're thinking is conventional, it's very clear that the rules says "Thou shall not kill". That's the answer. If you're a doctor and you have people streaming in front of you who come from all different beliefs and backgrounds and if you believe that you can't impose your moral judgments on other people, you have to find a different way of thinking these things through.. So, one of the principles involved or the moral imperatives. "Thou shall not kill". Life is valuable. We have a duty to alleviate suffering. Suffering can enhance our emotional and spiritual growth, but only if its supportive. Otherwise, it causes bitterness and personal aggression and spiritual regression. An individual has free will. With an informed conscience and with faith, the conscience is the final and determined morality. Post-conventional moral reasoner will consider each case independently, look carefully at family beliefs and feelings, keeping the person from making a decision that would isolate them from their social attachments, from their family, from their beliefs. They will also look for other practical solutions to the problem that might help the person even avoid the dilemma. For example, studies show that a lot people seek euthanasia because they worry about being imposition on family and increase in resources for caretaking nature will in some people make the desire for euthanasia go away. Also, it's been demonstrated that proper treatment of terminal pain or any kind of pain for that matter makes the person less willing to give up life. What we want to do is give people as much time as possible to think things through their values, how to deal with their family, their culture, their religious beliefs, so that they can come to a solution that they are the most comfortable with. We can help suggest resources that are experienced that dealing with these problem. Now, what is the proper solution to the euthanasia dilemma? The proper solution is the process

SEGMENT 12: NORMAL DEVELOPMENT AND SOCIALIZATION SKILLS(Slide 49)Normal Development: ChildhoodSocialization skills at different ages. At 0-18 mos., the child has no understanding of cause and effect and no impulse control ;so it does very little good to punish the child. By 3 years, the child responds to know in routines, readily will attempt to suggest alternative behaviors. Time outs are effective. It shouldn't be more than 30 seconds and the child also will respond to stop the world that is not getting to do an activity they wanted to do if they misbehave. The 3-year-old is very, very responsive to language. They really have a limited sense of responsibility. They simply can't stand it when they're in a disagreement, an emotional disagreement with their parents. So, because they think they're so bad, and when a 3-year-old thinks things are bad, they mean very bad. Bad children could be lost or left behind or go to jail. Totally black and white, you know, because they're still in that pre-conventional period. So, around 4, we hear a lot of "I didn't do it. no, she did it. Chippy did it." In the face of the frank and visible evidence to the contrary. Is the child lying? Nope. The child is using the defense of a psychotic denial. Now, for a 4-year-old, that's normal. Don't

get worried. They get so anxious of the notion of being in a fight with their parent as and having been that bad if they completely forget that they did it. Don't try to make the kid admit it. Just explain why such and such is not allowed and help the child to help you fix it. Mostly, when children are bad, it's sort of an accident. Maybe they didn't know the rules. They didn't have an alternative strategy and really needed something, they didn't appreciate the consequences of their act, and sometimes their impulse control is just not good enough. Rarely, rarely are they doing something just to get you. Seven years. The socialization skills of seven years. The seven-year-old obeys the best in routines. They will try and avoid undesirable tasks. They will argue to get what they want. Fairness is a biggie concept. Remember they're moving into feeling very good about rules and rules make the order in life. They are starting to get a sense of property and they are starting to have more empathy for another's feelings if those feelings are pointed out. Conflicts tend to central around peer disagreements and tasks follow through. Early puberty. Many people have applied the term "mind meltdown" to that period because of sudden growth of the brain. The child actually may become more emotional and impulsive unless good at compliance than they had been the year previous. They can be quite a surprise if you are not expecting it. Imaginary play. The 14-month-old can roll a ball back and forth with an adult, recognizes age peers and shows an interest on them. They do do some parallel play. An 18-month-old will imitate housework and they will do semi-symbolic microcosmic play. Two-year-olds take turns. Three-year-olds will do role play in an imaginary doll or truck play. I know you're dying of curiosity what is microcosmic semi-symbolic play.It's just the child does with her doll, which she knows represents the child. The exact same thing that is done in her environment to her. For example, the child holds her dolly over the potty chair and says, "Go poopy. That's it". So, this will be occurring in 18 months so we know a child is representational and is capable of that but is not yet truly symbolic, which is why they say semi-symbolic. Role-play consists of dress up and going through the roles in the activity seen in their life. However, there's usually addition of wishes and desires that come from the inside the child. And they're not just a mimicking or a rote repetition of the world around them. The child plays with dolls or trucks in much the same way. There's a little story sequence that comes from inside of child's mind who are often several characters in the drama and the characters will talk with and interact with each other. As the child matures, the play becomes more elaborative. Age developmental themes and concerns emerge such as what to do about aggression, how to get revenge on a bully. This imaginary play allows for release of unacceptable feelings and actions and also, it allows the child to explore various emotional postures in social situation.

SEGMENT 13: AUTISM AND ATYPICAL DEVELOPMENTAL COURSE

(Slide 50)Normal Development: Childhood

It's hard to say "Look for this" in autism. In autism, what we see often is the result of the lack of a skill that should normally be there or sometimes a compensation for that missing skill. In an assessment, if you look for items of normal development, if they are not there, then you should get curious about that and you should look for earlier developmental level then where the person at autism is at and see if they hit those developmental milestones. If they didn't or if their expression as milestones was very different, that's a clue. The developmental lines that are most subject to impairment in autism are social skills and communication along with restricted rigid interests in stereotype behaviors.

This is why I have emphasized social and cognitive skills in the development I've discussed. I could easily produce a lecture of this long or longer about speech and language. Untrained as I am in physical therapy, I would even take a whack at motor skills and perceptual skills because they are so important. Knowing development would give you your best clues to sorting out the impairments that plague the person with autism. The suggestions that I have made about supporting attachment in the infant, teaching the child, disciplining a child often do not work as effectively in autism. Many skills have to be taught more specifically and in smaller bites to children with autism. Problems with state regulation and understanding of language often make behavior management more dependent on environmental management, that is, we have to change the environment to make it less challenging for the person with autism. Parents and teachers state of another techniques that they tried just don't work. To some extent, that is true. They don't work. It takes longer. Knowledge about how a child acquires impulse control, how a child learns will help you to understand how to make modifications in the parents and the teachers perfectly good skills so they can become effective at supporting the autistic child.

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