L18 Psychological Medicine Childhood

Overview

This lecture covers development in middle childhood (3-12 years) across physical, motor, cognitive, emotional and social domains, then moves to two clinically-oriented applications: recognising and responding to childhood bullying, and communicating effectively with children and parents in a consultation, including how early identification of developmental delay supports early intervention.

Developmental Tasks and Domains of Middle Childhood

• Core developmental tasks of middle childhood (Masten & Coatsworth, 1998): school adjustment and academic achievement; peer relationships; rule-governed behaviour.
• Development in this period spans five interacting domains: physical, motor, cognitive, emotional, social.

Physical and Motor Development

• Physical development: growing pains as muscles adapt to an enlarging skeleton; all primary (baby) teeth are lost between 6 and 12 years; a balanced diet is important for growth and development; typical onset of puberty is 10-14 years in girls and 12-16 years in boys.
• Motor development, age 6-7: gross motor skills include hopping, jumping, climbing, riding a bike; fine motor skills include tying shoelaces, doing up buttons/zippers, brushing teeth, washing themselves, using a knife and fork (or chopsticks), and holding a pencil in an adult grip.
• Motor development, age 8-12: continued development of balance, coordination and strength.

Cognitive Development

• Key cognitive achievements of middle childhood: Theory of Mind, inhibition, deception, categorisation, conservation, episodic memory.
• Theory of mind / false belief understanding is typically present from around age 4 onward.

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• Conservation tasks (Piagetian, e.g. conservation of number) are typically mastered between about 6 and 11 years, with the exact age depending on which conservation task/metric is used.
• Episodic memory: very young children can form autobiographical memories, but as adults the typical earliest recallable memory dates from age 3-4 years. The preceding period, from which memories are inaccessible, is called infantile amnesia.

Emotional and Language Development

• Emotional development: extending emotional literacy; emotion regulation; empathy; socially sanctioned deception; self-reflection and insight. Children may need help achieving these skills.
• Language and social-communication development in middle childhood: use of long and complex sentences; understanding others’ points of view and expressing agreement or disagreement; keeping a conversation going by giving reasons and explaining choices; starting conversations with adults and children they don’t know; understanding and using passive sentences (e.g. “the thief is chased by the policeman”); improving clarity of speech; increasing sentence length and complexity; improving ability to elaborate on responses.

Social Development and Self-Concept

• Social development: formation of a coherent self-concept; major developments in peer relations (a developmental task); developing morality; increased independence; learning to cooperate; developing a sense of social justice.
• Self-concept: a description of self using internal and external characteristics, shaped by cognitive development plus exposure to experiences and feedback from parents, teachers and peers.
  • Cultural difference in expression: Euro-American children tend to use personal references, e.g. “I am a wonderful and very smart person”; Chinese children tend to use social references, e.g. “I’m my mom and dad’s child, my grandma and grandpa’s grandson.”
• Self-esteem: an evaluative judgement of self, influenced by culture, family, peers and own values.
• Age-related change in self-description (“Who am I?”):
  • 4-8 years: singular, concrete attributes and comparisons, e.g. “I’m a boy,” “I have yellow hair,” “I’m bigger than my baby sister.”
  • 8-11 years: perceived personality traits and psychological qualities rather than physical appearance; self-descriptions become more abstract (e.g. “smart,” “friendly”) and more complex/differentiated, with children able to recognise their own strengths and weaknesses, e.g. “I am better than Alex at reading but he is better than me in Maths.”
• Signs of high self-esteem: positive self-image; confident; makes friends easily and is not anxious with new people; plays well in groups or alone; tries to solve problems independently but asks for help when needed; proud of achievements; can admit and learn from mistakes; tries new things and adapts to change.
• Signs of low self-esteem: negative self-image (may feel bad, ugly, unlikeable or stupid); lacks confidence; finds it hard to make/keep friendships and may feel victimised; feels lonely and isolated; avoids new things and finds change hard; copes poorly with failure; uses self-critical language (e.g. “I’m stupid,” “I can’t do that”); is not proud of achievements and thinks they could always have done better; constantly makes negative comparisons to peers.
• Low self-esteem is linked to anxiety, depression, eating disorders, relationship issues and substance abuse.

Peer Relations and Bullying

• Healthy peer relations foster empathy, helping behaviour, social/emotional growth and a sense of belonging.
• Bullying is defined by three features: (1) an intentional act of aggression aimed at causing physical, psychological or emotional distress; (2) a disproportionate power imbalance, with the stronger individual or group abusing the weaker one; (3) the behaviour pattern is repeated over time.
• 94% of NZ teachers reported that bullying occurs at their school. Children and families often look to their primary physician for advice on handling these situations.
• Four types of bullying:
  • Physical: hitting, kicking, slapping, pinching, spitting, tripping, pushing, blocking; stealing or destroying possessions; mean/rude hand gestures; unwanted or inappropriate touching.
  • Verbal: name-calling, insults, teasing, intimidation, homophobic or racist remarks, inappropriate sexual comments, taunting, threats of harm.
  • Social: lying and spreading rumours; deliberately leaving someone out; telling others not to be friends with someone; embarrassing someone in public; damaging someone’s social reputation or relationships.
  • Cyber: posting or sending hurtful texts, emails, posts, images or videos; online threats; impersonating others or using their log-in; deliberately excluding others online; spreading rumours online.
• Characteristics and effects by role (Stephens et al., 2018):
  • Bully - characteristics: easily frustrated; positive attitude toward violence; impulsive; perceives threats where none exist.
    • Short-term effects: antisocial personality features; conduct problems and school disengagement; depression; increased suicidal ideation, attempts and completed suicide; vandalism, shoplifting, fighting; substance abuse; school underachievement.
    • Long-term effects: aggression; antisocial behaviour; criminal acts; increased substance abuse; underperformance in employment; severe relationship problems.
  • Victim - characteristics: insecure; may believe they deserve the mistreatment; perceived as weak or different; socially isolated; unassertive.
    • Short-term effects: anxiety (social phobia, OCD, panic disorder); chronic absenteeism; depression; sleep difficulty; increased suicidal ideation, attempts and completed suicide; more likely to carry weapons for safety or retaliation; nightmares/bedwetting; poor academic performance; PTSD; psychosomatic problems (e.g. headache, abdominal pain, especially in the morning); self-harm.
    • Long-term effects: depression and anxiety; high stress and isolation; increased suicidal ideation, attempts and completed suicide; low self-esteem; poor academic achievement; poor psychosocial adjustment; PTSD.
  • Bully-victim (a victim who reactively bullies others, typically younger children) - characteristics: prone to irritating others/creating social tension; quick-tempered and emotionally reactive; reacts to being bullied by fighting back and may claim self-defence.
    • Short-term effects: conduct problems and school disengagement; depression and anxiety; fighting; increased suicidal ideation, attempts and completed suicide; more likely to carry weapons; psychosomatic problems; self-harm; social ostracisation; substance abuse.
    • Long-term effects: depression; increased suicidal ideation, attempts and completed suicide; increased substance abuse; moderate-to-severe impairment in social functioning and intimate relationships; PTSD; psychiatric illness.

Assessing and Responding to Bullying in Practice

• SORT key recommendations for practice (Stephens et al., 2018), all rated evidence level C (consensus, disease-oriented evidence, usual practice, or expert opinion):
  • Ask about bullying when children present with multiple somatic problems, school avoidance, or self-harm.
  • Use indirect, open-ended questioning to increase identification of children who are bullying or being bullied.
  • Include questions about children’s/adolescents’ online lives in the history.
  • Screen patients identified as bullied or as bullies for psychiatric comorbidities.
• A four-step approach to assessing bullying: normalise, then check in, then validate, then encourage elaboration, followed by asking what support/resources the child has and what extra help they might need.
  • Normalise/check in phrasing: “sometimes things happen for kids at school that make them [unhappy, worried, angry etc] and those things can also affect their bodies and the things that they do. Is there anything like that happening for you?”; “Sometimes kids feel [unhappy at school / don’t feel safe / don’t feel treated ok]? Are there ever times you feel that way? Tell me all about that.”
  • Validate/encourage elaboration phrasing: “That sounds [hard/tough/difficult/worrying/tricky etc]. Help me understand more about what is going on.”; “It makes sense you are [having a hard time/not feeling so good/getting upset]. What else can you tell me about what’s been going on and how that is for you?”
  • Resources/help phrasing: “Who knows about what has been happening? / Have you talked to anyone about what’s been going on? / Who is someone that you could talk to / could help you?”; “What do you need for things to be better? What would you like to be different/change? What would help?”

Physician’s Role in Child Development

• Communicating with children and parents across this period:
  • Child as expert: capable of providing useful information in response to open questions, but may not spontaneously signal difficulties or recognise what information the physician needs - pair specific questions with open ones (“child-led interviewing”).
  • Be aware: keep language and ideas concrete; check understanding rather than assuming (ask for examples/elaboration); check expectations.
• Encourage parents to share any concerns about a child’s development or behaviour; ask for examples or a description of a recent occurrence; assess broadly, considering the systems the child functions within.
• Refer for specialist assessment and treatment where indicated.
• Effective early identification of developmental delay, with timely early intervention, can positively alter a child’s long-term trajectory (Scherzer et al., 2012).
• Children at higher risk of being bullied, and who should be screened carefully, include those with a disability, depression, a recent move, or learning/behaviour problems.

  Consider bullying when a child has frequent headaches, abdominal pain, sleep difficulties or enuresis, when a previously stable chronic condition begins deteriorating for unexplained reasons, or when a child becomes non-adherent to their medication regimen.

• Additional resources: ebook “Development During Middle Childhood: The Years From Six to Twelve” (NCBI Bookshelf); Stephens et al. (2018) “Childhood Bullying: Implications for Physicians”; bullyingfree.nz.

Self-test

1. List the three developmental tasks of middle childhood identified by Masten & Coatsworth (1998).
2. List the five domains of development covered in this lecture.
3. State the typical age range for puberty onset in girls and in boys.
4. List three fine motor skills typically established by age 6-7.
5. List the six key cognitive achievements of middle childhood highlighted in this lecture.
6. At what age does theory of mind / false belief understanding typically emerge?
7. Describe what a conservation task assesses and the typical age range over which conservation ability develops.
8. Define infantile amnesia and state the typical age of the earliest recallable memory in adults.
9. List three ways children’s language/conversational ability advances during middle childhood.
10. Distinguish how children’s self-descriptions typically differ between ages 4-8 and ages 8-11.
11. Distinguish the Euro-American versus Chinese cultural patterns in self-concept expression described in the lecture.
12. List four signs that might suggest a child has low self-esteem.
13. Define bullying using its three defining features.
14. Distinguish the four types of bullying, giving one example of each.
15. Compare one short-term effect experienced by a bully with one short-term effect experienced by a victim.
16. Describe the four-step approach to assessing bullying in a consultation.
17. A child with previously well-controlled epilepsy begins missing doses and their seizures worsen for no clear medical reason. What should the physician consider, and what other clinical clues might support this suspicion?
18. Describe two principles for communicating effectively with a child patient, according to the “child as expert” approach.
19. Explain how early identification of a developmental or emotional concern (e.g. low self-esteem, bullying, or developmental delay) connects to the physician’s role in improving a child’s long-term outcome.

Answers

Reveal answers

1. School adjustment and academic achievement; peer relationships; rule-governed behaviour.
2. Physical, motor, cognitive, emotional, social.
3. Girls: 10-14 years. Boys: 12-16 years.
4. Any three of: tying shoelaces, doing up buttons/zippers, brushing teeth, washing themselves, using a knife and fork (or chopsticks), holding a pencil in an adult grip.
5. Theory of mind, inhibition, deception, categorisation, conservation, episodic memory.
6. From around age 4 onward.
7. A conservation task assesses whether a child understands that a quantity (e.g. number) stays the same despite a change in appearance/arrangement; it is typically mastered between about 6 and 11 years, with the exact age depending on which task/metric is used.
8. Infantile amnesia is the period before about 3-4 years from which adults cannot recall memories; the typical earliest recallable memory in adults is from age 3-4 years.
9. Any three of: using long/complex sentences; understanding others’ viewpoints and expressing agreement/disagreement; keeping a conversation going by giving reasons and explaining choices; starting conversations with unfamiliar adults/children; understanding and using passive sentences; improved clarity of speech; increased sentence length/complexity; improved ability to elaborate on responses.
10. 4-8 years: singular, concrete attributes and comparisons (e.g. “I’m a boy,” “I’m bigger than my baby sister”). 8-11 years: more abstract personality/psychological descriptions (e.g. “smart,” “friendly”), more complex and differentiated, including recognition of own strengths and weaknesses.
11. Euro-American children tend to use personal references (e.g. “I am a wonderful and very smart person”); Chinese children tend to use social references (e.g. “I’m my mom and dad’s child, my grandma and grandpa’s grandson”).
12. Any four of: negative self-image; lacks confidence; difficulty making/keeping friendships or feeling victimised; loneliness/isolation; avoiding new things/finding change hard; coping poorly with failure; self-critical language; not proud of achievements; constant negative comparison to peers.
13. An intentional act of aggression aimed at causing physical, psychological or emotional distress; a disproportionate power imbalance between the stronger and weaker party; the behaviour is repeated over time.
14. Physical (e.g. hitting, pushing); verbal (e.g. name-calling, threats); social (e.g. spreading rumours, deliberate exclusion); cyber (e.g. posting hurtful content online, online impersonation).
15. Example: bullies show increased conduct problems/school disengagement in the short term, while victims show increased anxiety and psychosomatic problems (e.g. headache, abdominal pain) in the short term.
16. Normalise, then check in, then validate, then encourage elaboration, then ask what support/resources the child has and what extra help they might need.
17. The physician should consider that bullying may be occurring, since a previously stable chronic condition deteriorating for unexplained reasons or new non-adherence to medication is a flagged indicator; supporting clues include frequent headaches, abdominal pain, sleep difficulties, or enuresis.
18. Any two of: treat the child as an expert capable of providing useful information via open questions, but pair specific questions with open ones since the child may not spontaneously signal difficulties (child-led interviewing); keep language and ideas concrete; check understanding rather than assuming, by asking for examples/elaboration; check the child’s expectations.
19. Effective early identification of concerns such as low self-esteem, bullying, or developmental delay, combined with timely early intervention or referral for specialist assessment and treatment, can positively alter a child’s long-term trajectory (Scherzer et al., 2012); the physician’s role (asking open questions, screening at-risk children, referring appropriately) is the mechanism by which such early identification happens.