SOWK 300 Liberty Dulcans Textbook of Child and Adolescent Psychiatry Discussion assignments.pdf

discussion

Describe the risks and protective factors to infant and toddler

development in relation to what is believed about the birth of

Jesus.

Case Study 3.1

Holly’s Early Arrival

Although Marilyn Hicks had been very careful with her diet, exercise, and prenatal care during

pregnancy, Holly arrived at 26 weeks’ gestation, around 6 months into the pregnancy. Initially

she weighed 3 pounds, 11 ounces, but she quickly lost the 11 ounces. Immediately after birth,

Holly was whisked away to the neonatal unit in the hospital, and her parents had just a quick

peek at her. The assigned social worker’s first contact with Marilyn and Martin Hicks, an

African American couple, was in the neonatal unit. Although Marilyn Hicks began to cry when

the social worker first spoke with her, overall both parents seemed to be coping well and had all

their basic needs met at that time. The social worker left his business card with them and

instructed them to call if they needed anything.

Despite her early arrival, Holly did not show any signs of medical problems, and after 6 weeks in

the neonatal unit, her parents were able to take her home. The social worker wisely allowed the

newly formed Hicks family time to adjust and, in keeping with the policy of the neonatal

program, scheduled a follow-up home visit within a few weeks.

When the social worker arrives at the house, Marilyn Hicks is at the door in tears. She states that

taking care of Holly is much more than she imagined. Holly cries “constantly” and does not

seem to respond to Mrs. Hicks’s attempts to comfort her. In fact, Mrs. Hicks thinks that Holly

cries even louder when her mother picks her up or tries to cuddle with her. Mrs. Hicks is very

disappointed, because she considers herself to be a nurturing person. She is unsure how to

respond to Holly’s “rejection of her.” The only time Holly seems to respond positively is when

Mrs. Hicks breastfeeds her.

Mrs. Hicks has taken Holly to the pediatrician on several occasions and has discussed her

concerns. The doctor told her that nothing is physically wrong with Holly and that Mrs. Hicks

has to be more patient.

Mrs. Hicks confides during this meeting that she read some horrifying material on the Internet

about premature infants. According to the information she read, premature infants often have

difficulty bonding with their caretaker, which in some children may ultimately result in mental

health and emotional problems. Mrs. Hicks is concerned that this is the case with Holly.

The social worker must take into consideration that in addition to her fears, Mrs. Hicks must be

exhausted. Her husband returned to work shortly after the baby came home, and Mrs. Hicks has

not left the house since then. She tried taking a break once when her aunt came for a visit, but

Holly cried so intensely during this time that her aunt refused to be left alone with Holly again.

The social worker must now help Mrs. Hicks cope with the powerful feelings that have been

aroused by Holly’s premature birth, get any needed clarification on Holly’s medical condition,

and find ways to get Mrs. Hicks a break from caregiving. He will also want to help her to begin

to feel more confident about her ability to parent Holly.

Case Study 3.2

Sarah’s Teen Dad

Chris Johnson, an Anglo adolescent, is the only dad in the teen fathers group, facilitated by the

social worker at a local high school, who has sole custody of his infant daughter. Initially Sarah,

Chris’s infant daughter, lived with her mom and maternal grandparents. Chris was contacted by

the social worker from Child Protective Services (CPS), who informed him that Sarah was

removed from the mom’s care because of physical neglect. The referral to CPS was made when

Sarah was seen in a pediatric clinic and the medical staff noticed that she had not gained weight

since the last visit and was generally unresponsive in the examination. Further investigation by

the CPS worker revealed that Sarah was left in her crib for most of the day, and few of Sarah’s

basic daily care needs were being fulfilled. Although Chris’s contact with Sarah had been

sporadic since her birth, he did not hesitate to pursue custody, especially given that the only other

alternative was Sarah’s placement in foster care. Chris’s parents were also supportive of Chris’s

desire to have Sarah live with all of them. However, although they were willing to help, they

were adamant that the responsibility for Sarah’s care belonged to Chris, not them. They were

unwilling to raise Sarah themselves and in fact required Chris to sign a written statement

indicating that he, not they, would assume primary responsibility for Sarah’s care. Chris’s

parents also insisted that he remain in school and earn his high school diploma.

Thus far the situation seems to be working well. At the last medical appointment, Sarah’s weight

had increased significantly, and she responded to the nurse’s attempts to play and communicate

with her. Chris is continuing his education at the alternative high school, which also has a day

care for Sarah. Chris admits that it is much more difficult than he anticipated. He attends school

for half the day, works a part-time job the other half, and then has to care for Sarah in the

evenings. Chris has shared several times in the group that it is a lot for him to juggle. He still

mourns the loss of his freedom and “carefree” lifestyle. Like most of the other teens in the group,

whether they physically live with the child or not, Chris is concerned about doing the best he can

for Sarah; he states that he just wants to be a good dad.

Case Study 3.3

Overprotecting Henry

Irma Velasquez, a second-generation Hispanic American, is still mourning the death of her little

girl Angel, who was 2 years old when she was killed by a stray bullet that came into their home

through the living room window. Although it has been about a year since the incident, no one has

been arrested. The police do know, however, that neither Ms. Velasquez’s daughter nor her

family was the intended victim. The stray bullet was the result of a shoot-out between two rival

drug dealers in the family’s neighborhood.

Ms. Velasquez is just glad that now 14-month-old Henry was in his crib in the back of the house

instead of in the living room on that horrible evening. He had fallen asleep in her lap a few

minutes before, but she had just returned from laying him in his crib when the shooting occurred.

Irma Velasquez confides in her social worker at Victim Services that her family has not been the

same since the incident. For one thing, she and her husband barely speak. His method of dealing

with the tragedy is to stay away from home. She admits that she is angry with her husband

because he does not make enough money for them to live in a safer neighborhood. She thinks

that he blames her because she did not protect Angel in some way.

Ms. Velasquez admits that she is afraid that something bad will also happen to Henry. She has

limited their area in the home to the back bedroom, and they seldom leave the house. She does

not allow anyone, even her sister, to take care of him and confesses that she has not left his side

since the shooting. Even with these restrictions, Ms. Velasquez worries. She is concerned that

Henry will choke on a toy or food or become ill. She still does not allow him to feed himself,

even dry cereal. He has just begun walking, and she severely limits his space for movement. Ms.

Velasquez looks worn and exhausted. Although she knows these behaviors are somewhat

irrational, she states that she is determined to protect Henry. She further states that she just could

not live through losing another child.

Developmental Niche and Typical Infant and Toddler

Development

What happens during the prenatal period and the earliest months and years of a child’s life has a

lasting impact on the life course journey. In the earliest moments, months, and years, interactions

with parents, family members, and other adults and children influence the way the brain and the

rest of the body develop, as do such factors as nutrition and environmental safety. Although it is

never too late to improve health and well-being, what happens during infancy and toddlerhood

sets the stage for the journey through childhood, adolescence, and adulthood. We were all infants

and toddlers once, but sometimes, in our work as social workers, we may find it hard to

understand the experience of someone 3 years old or younger. (Young children are typically

referred to as infants in the first year, but as they enter the second year of life and become more

mobile, they are usually called toddlers, from about 12 to 36 months of age.) As adults, we have

become accustomed to communicating with words, and we are not always sure how to read the

behaviors of the very young child. And we are not always sure how we are to behave with them.

The best way to overcome these limitations, of course, is to learn what we can about the lives of

infants and toddlers.

In all three of the case studies at the beginning of this chapter, factors can be identified that may

adversely affect the children’s development. However, we must begin by understanding what is

traditionally referred to as “normal” development. But because normal is a relative term with

some judgmental overtones, we will use the term typicalinstead, meaning typical in a statistical

sense.

Social workers employed in schools, hospitals, community mental health centers, and other

public health settings are often approached by parents and teachers with questions about

development in young children. To assess whether any of the children they bring to your

attention require intervention, you must be able to distinguish between healthy and problematic

development in three areas: physical, cognitive, and socioemotional development. As you will

see, young children go through a multitude of changes in all three areas simultaneously.

Inadequate development in any one of them—or in multiple areas—may have long-lasting

consequences for the individual.

Keep in mind, however, that what is considered to be healthy is relative to environment and

culture. Every newborn enters a world with distinctive features structured by the social setting

that he or she encounters (Gardiner, 2018). Therefore, all aspects of development must be

considered in cultural context. Each newborn enters a developmental niche, in which culture

guides every aspect of the developmental process (Harkness & Super, 2003, 2006). Parents get

their ideas about parenting and about the nature of children from the cultural milieu, and parents’

ideas are the dominant force in how the infant and toddler develop. Harry Gardiner (2018)

identifies three interrelated components of the developmental niche: physical and social settings

of daily life, child-rearing customs, and caregiver psychology. Exhibit 3.1 provides an overview

of these three important components of the developmental niche encountered by every newborn.

As you review this exhibit, think about the developmental niches encountered by Holly Hicks,

Sarah Johnson, and Henry Velasquez as they begin their life journeys.

Exhibit 3.1 • Components of Developmental Niche

Source: Gardiner, 2018. Lives across cultures: Cross-cultural human development (6th

ed.),Table 2.1, p. 17.

In the United States and other wealthy postindustrial societies, many newborns enter a

developmental niche in which families have become smaller than in earlier eras. This results in a

great deal of attention being paid to each child. Parents take courses and read books about how to

provide the best possible care for their infants and toddlers. Infant safety is stressed, with laws

about car seats, guidelines about the position in which the baby should sleep, and a “baby

industry” that provides a broad range of safety equipment (baby monitors, baby gates, and so on)

and toys, books, and electronics to provide sensory stimulation. Of course, this developmental

niche requires considerable resources, and many families in wealthy nations cannot afford the

regulation car seat or the baby monitor. Chris Johnson is attending school, working, and caring

for Sarah; he probably would be hard-pressed to find time to read parenting books, but he does

find time to attend a group for teen fathers. Irma Velasquez’s concern for Henry’s safety focuses

on protecting him from stray bullets rather than on baby monitors and baby gates. And, of

course, the developmental niches in nonindustrial and newly industrializing countries are very

different from the niche described earlier. For example, anthropologists are studying how an

increasingly migrating workforce is changing the nature of caregiving of infants and toddlers, as

a developmental niche of multiple family caregivers gives way to a more isolated form of one

primary caregiver (see Haviland, Prins, Walrath, & McBride, 2017). Unfortunately, many infants

of the world live in developmental niches characterized by infection, malnutrition, and war.

Please keep these variations in mind as you read about infant and toddler development.

To make the presentation of ideas about infancy and toddlerhood manageable, this chapter

follows a traditional method of organizing the discussion by type of development: physical

development, cognitive development, emotional development, and social development. In this

chapter, emotional development and social development are combined under the heading

Socioemotional Development. Of course, all these types of development and behavior are

interdependent, and often the distinctions blur.

Physical Development

The infant’s first test of physical development occurs about a minute after delivery. The APGAR

test, developed by Virginia Apgar, assesses the newborn’s color, heart rate, reflexes, muscle

tone, and respiratory ability. Medical staff assess the newborn using a scale from 0 to 2 in each

of the five areas. A perfect APGAR score of 10 is rare. A score of 7 or higher indicates only

routine infant care is needed. Infants scored from 4 to 6 may need breathing assistance, and

infants scored below 4 may require immediate medical attention, including lifesaving medical

intervention. Most infants who receive a score below 7 are retested every 5 minutes for up to 20

minutes. (For more information about the APGAR test, see http://americanpregnancy.org/labor-

and-birth/apgar-test.) Although a low APGAR score does not necessarily indicate long-term

health problems or complications in physical development, social workers in child welfare and

health care settings should be familiar with these types of standard assessment tools.

Newborns depend on others for basic physical needs. They must be fed, cleaned, and kept safe

and comfortable until they develop the ability to do these things for themselves. At the same

time, however, newborns have an amazing set of physical abilities and potentials right from the

beginning.

Growth Patterns

In Case Study 3.2, the pediatrician and CPS social worker were concerned that Sarah Johnson

was not gaining weight. With improved care in the home of her father and his parents, Sarah is

making good weight gains and is more alert and responsive. With adequate nourishment and

care, the physical growth of the infant is quite predictable. Infants grow very rapidly throughout

the first 2 years of life, but the pace of growth slows a bit in toddlerhood. Both genetic and

environmental factors can cause some children to grow faster than others. In the first few days

after birth, newborns lose 5% to 10% of their body weight, but after this initial loss, they gain

weight quickly.

Growth during the prenatal and infant periods follows particular patterns, which are called

cephalocaudal development and proximodistal development. The cephalocaudal

development principle of growth refers to the idea that growth proceeds from the head

downward. The head and upper regions of the body develop before the lower regions. At birth

the newborn’s head is about one fourth the total body length, but the head becomes more

proportionate to the body as the infant and toddler grows. The proximodistal

development principle refers to the idea that growth occurs from the center of the body outward.

During prenatal development, the internal organs develop before the arms and legs.

The World Health Organization (WHO) undertook a project, called the Multicentre Growth

Reference Study (MGRS), to construct standards for evaluating children from birth through 5

years of age. One part of that project was to construct growth standards to propose how

children should grow in all countries, of interest because of WHO’s commitment to eliminate

global health disparities. MGRS collected growth data from 8,440 affluent children from diverse

geographical and cultural settings, including Brazil, Ghana, India, Norway, Oman, and the

United States. To be eligible for the study, mothers needed to be breastfeeding and not smoking,

and the environment needed to be adequate to support unconstrained growth.

The researchers found no differences in growth patterns across sites, even though there were

some differences in parental stature. Given the striking similarity in growth patterns across sites,

they concluded that the data could be used to develop an international standard. Across sites, the

average length at birth was 19.5 inches (49.5 cm), 26.3 inches (66.7 cm) at 6 months, 29.5 inches

(75.0 cm) at 12 months, and 34.4 inches (87.4 cm) at 24 months (WHO Multicentre Growth

Reference Study Group, 2006a). By 1 year of age, infant height was about 1.5 times birth height,

and by 2 years, the toddler had nearly doubled the birth height.

Most newborns weigh from 5 to 10 pounds at birth. Infants typically double their weight by age

5 months and triple their weight in the first year. The typical toddler gains 5 to 6 pounds during

the second year and 4 to 5 pounds during the third year. The size of individual infants and

toddlers can vary quite a bit. Some of the difference is the result of nutrition, exposure to disease,

and other environmental factors; much of it is the result of genetics. Some ethnic differences in

physical development have also been observed. For example, Asian American children tend to

be smaller than average, and African American children tend to be larger than average (Tate,

Dezateux, Cole, & the Millennium Cohort Study Child Health Group, 2006). In the past decade

there has been a great deal of concern about rapid weight gain during the first 6 months, which

has been connected to overweight by age 4 and to several chronic diseases in adulthood, but

recent longitudinal research suggests that rapid weight gain in infancy is just as often associated

with later height as with later obesity (Wright, Cox, & Couteur, 2011). The WHO child growth

standards, calculated by different methods, can be found at www.who.int/childgrowth/standards.

The importance of nutrition in infancy cannot be overstated. Nutrition affects physical stature,

motor skill development, brain development, and most every other aspect of development. A

2013 report by the Lancet Maternal and Child Nutrition series (2013) indicates that, globally,

malnutrition contributes to 3.1 million deaths of children age 5 and younger each year. In 2011,

26% of children in low-income countries suffered from stunted growth because of chronic

maternal and child undernutrition. This was down from 40% in 1990, but still a serious global

public health problem. Eastern and western Africa and south-central Asia have the highest

prevalence of stunting. Nutritional deficiencies during the first 1,000 days of the child’s life can

result in damage to the immune system and impair social and cognitive capacities.

Self-Regulation

Before birth, the bodily functions of the fetus are regulated by the mother’s body. After birth, the

infant must develop the capacity to engage in self-regulation (Davies, 2011). At first, the

challenge is to regulate bodily functions, such as temperature control, sleeping, eating, and

eliminating. That challenge is heightened for the premature or medically fragile infant, as Holly

Hicks’s mother is finding. Growing evidence indicates that some self-regulatory functions that

allow self-calming and organize the wake-sleep cycles get integrated and coordinated during the

third trimester, from 30 to 34 weeks’ gestation (Institute of Medicine, 2006). Born at 26 weeks’

gestation, Holly Hicks did not have the benefit of the uterine environment to support the

development of these self-regulatory functions.

As any new parent will attest, however, infants are not born with regular patterns of sleeping,

eating, and eliminating. With maturation of the central nervous system in the first 3 months, and

with lots of help from parents or other caregivers, the infant’s rhythms of sleeping, eating, and

eliminating become much more regular (Davies, 2011). A newborn typically sleeps about 18

hours a day, dividing that time evenly between day and night. Of course, this is not a good fit

with the way adults organize their sleep lives. By about 8 weeks, infants begin to show signs of

day-night sleep rhythms. At the end of 3 months, most infants are sleeping 14 to 15 hours per

day, primarily at night, with some well-defined nap times during the day. Parents also gradually

shape infants’ eating schedules so that they are eating mainly during the day.

There are cultural variations in, and controversies about, the way caregivers shape the sleeping

behaviors of infants. The management of sleep is one of the earliest culturally influenced

parenting behaviors. In some cultures, infants sleep with parents, and in other cultures, infants

are put to sleep in their own beds and often in their own rooms. In some cultures, putting an

infant to sleep alone in a room is considered to be neglectful (Gardiner, 2018). Co-sleeping, the

child sleeping with the parents, is routine in most of the world’s cultures (McKenna, 2002).

Japanese and Chinese children often sleep with their parents throughout infancy and early

childhood (Iwata, Iwata, & Matsuishi, 2013). Research indicates that sleeping with parents

induces shorter bouts of sleep and less sound sleep (Blunden, Thompson, & Dawson, 2011).

Some researchers have speculated that the infant’s lighter and shorter sleep pattern may protect

against sudden infant death syndrome (SIDS). The connection between co-sleeping and SIDS

has been a controversial research issue. One research team conducted a meta-analysis of research

of the issue published from 1970 to 2010; they found that co-sleeping increased the risk for

SIDS, and the risk is highest for infants younger than 12 weeks and when parents smoke

(Vennemann et al., 2012). A more recent study found an association between co-sleeping and

somatic complaints for toddlers ages 18 months to 60 months (Peters, Lusher, Banbury, &

Chandler, 2016). What is not always clear in these studies is whether the infant is sleeping in the

same bed as the parents or whether he or she is sleeping in a type of bassinet attached to the

parental bed. It would seem that the latter would overcome the risks found in the research.

Proponents of co-sleeping argue that it does a better job of meeting the physiological,

psychological, and developmental needs of newborns than sleeping separately (Willinger, Ko,

Hoffman, Kessler, & Corwin, 2003).

Culture plays an important role in how parents manage the sleep patterns of infants (Owens,

2005). Parents in the United States look forward to the time when their infant will sleep through

the night. In contrast, many European parents think of newborn sleep as part of normal

development and do not intervene to shape newborn sleep patterns (Kuther, 2017). Many

approaches to infant sleep training have been proposed, and researchers continue to debate the

merits of different methods. A review of 52 sleep studies found that almost all of the

interventions were effective if applied consistently, but different methods work with different

infants (Sleep Center, 2016). A group of pediatric sleep experts from around the world (including

Israel, China, India, Australia, Spain, Switzerland, Sweden, Italy, and Canada) held the first

meeting of the International Pediatric Sleep Education (IPSE) Task Force in the spring of 2003

(Owens, 2005). Among the findings of this task force are these:

 Pediatric sleep problems are universal. Studies from diverse cultures find that about 25%

of parents report sleep problems in their infants and toddlers.

 Many types of pediatric sleep problems are common in both Eastern and Western

cultures, including bedtime resistance, night wakings, and inadequate sleep.

Feeding is another area in which parents must help infants and toddlers to begin to develop self-

regulation, and there are cultural variations and controversies about breastfeeding versus formula

feeding. Some cultures have historically supported feeding on demand in infancy whereas others

have preferred early attempts to shape infant feeding schedules. Throughout history, most infants

have been breastfed. However, alternatives to breastfeeding by the mother have always existed,

sometimes in the form of a wet nurse (a woman employed to breastfeed someone else’s infant) or

in the form of animal milks. Following World War II, breastfeeding ceased to be the primary

nutritional source for infants because of the promotion of manufactured formula in industrialized

and nonindustrialized countries. Since the 1980s, cultural attitudes have shifted again in favor of

breastfeeding. The American Academy of Pediatrics (AAP) argues that infant nutrition should be

considered a public health issue, not a lifestyle choice (Eidelman & Schanler, 2012). The AAP

recommends that infants be breastfed, or fed with human milk, exclusively for the first 6 months,

followed by continued breastfeeding with some supplementary use of foods until the infant is at

least 1 year old.

Research indicates that breastfeeding offers benefits for mothers and infants. Mothers who

breastfeed have lower rates of diabetes, cardiovascular disease, and depression and are at lower

risk for later ovarian and breast cancer and bone fractures (Godfrey & Lawrence, 2010). Breast

milk has the right amount of fat, sugar, water, and protein for infant development. It contains

immunizing agents that protect against infections (Hetzner, Razza, Malone, & Brooks-Gun,

2009). Breastfeeding is also associated with reduced risk of allergies, gastrointestinal symptoms,

and SIDS (Schulze & Carlisle, 2010). Breastfeeding longer than 6 months is associated with

reduced risk of obesity and childhood cancer (Schulze & Carlisle, 2010). Recent research

indicates that breastfed children have significantly higher IQ scores and larger whole brain, gray

matter, total cortical gray matter, and subcortical gray matter volumes than nonbreastfed children

(Luby, Belden, Whalen, Harms, & Barch, 2016). Although this is a consistent finding, other

researchers have found that the differences are small (Jenkins & Foster, 2014).

Breastfeeding continues to rise in the United States. In 2011, 79% of newborns started

breastfeeding; 49% were breastfeeding at 6 months, and 27% were breastfeeding at 12 months

(Centers for Disease Control and Prevention, 2014a). There are racial, ethnic, and social class

differences in the rate of breastfeeding, suggesting that family, culture, and social policy play a

role in the breastfeeding decision. Countries where women have paid maternity leave for much

of the first year of life (for example, Australia, Denmark, Norway, and Sweden) have very high

breastfeeding rates of 94% and more (Hauck, Fenwick, Dhaliwal, & Butt, 2011). In the United

States and the United Kingdom, the lowest rates of breastfeeding are among low-income women,

young mothers, and mothers with low levels of education. Research indicates that the

employment settings of low-income mothers are less likely than other employment settings to

provide places for women to use breast pumps (Racine, Frick, Guthrie, & Strobino, 2009).

Societal customs can support or discourage breastfeeding. In Saudi Arabia, a woman may

breastfeed her infant openly and receive no notice, although otherwise she is fully veiled. In

France, topless swimming is culturally acceptable, but breastfeeding in public is not (Riordan &

Auerbach, 1999).

Somewhere around 4 to 6 months, infants begin to eat solid food; the first solid food is usually

iron-fortified cereal mixed with breast milk or formula. Then, pureed vegetables and fruits are

introduced, followed by pureed meat (for meat eaters). Infants don’t always like these new tastes

and textures, and foods may have to be introduced over a dozen times before they are accepted.

As infants become toddlers, their appetites decrease and they begin to feed themselves. Feeding

problems in infants and toddlers are discussed in a later section in this chapter.

Cultural variations exist in beliefs about how to respond when infants cry and fuss, whether to

soothe them or leave them to learn to soothe themselves. When parents do attempt to soothe

infants, interestingly, they seem to use the same methods across cultures: “They say something,

touch, pick up, search for sources of discomfort, and then feed” (Shonkoff & Phillips, 2000, p.

100). Infants who have been consistently soothed usually begin to develop the ability to soothe

themselves after 3 or 4 months. This ability is the precursor to struggles for self-control and

mastery over powerful emotions that occur in toddlerhood. More is said about emotion self-

regulation in a later section. In recent years, there has been an ongoing debate about how

intensive parenting must be during infancy and toddlerhood (Moore & Abetz, 2016).

Parents become less anxious as the infant’s rhythms become more regular and predictable. At the

same time, if the caregiver is responsive and dependable, the infant becomes less anxious and

begins to develop the ability to wait to have needs met.

Toilet training (potty training) is another area where caregivers assist infants and toddlers in their

development of self-regulation. It is often a source of stress and uncertainty for new parents.

Every human culture has mechanisms for disposing of human waste and socializes infants and

toddlers to that method. One of the basic issues in this socialization is whether it should be in the

hands of the child or the caregiver. In places in the world where there are no disposable diapers

and no access to a washing machine, parents, even in the early months, become sensitive to signs

that the infant is about to defecate or urinate and hold him or her over whatever type of toilet is

available. This method, referred to as “assisted infant toilet training,” is expected to work by

about age 6 months. Although this method is not typically followed in the middle- to high-

income countries, there is a current movement in the United States to raise diaper-free babies by

using “elimination communication,” based on timing, cues, and intuition (see the

website www.diaperfreebaby.org). There is no clear consensus in the United States about the

best method for toilet training (Howell, Wyosocki, & Steiner, 2010). The U.S. American

Academy of Pediatrics recommends a child-oriented approach that emphasizes the child’s

interest in toilet training and tries to minimize the demands made by parents. Toddlers are

introduced to a potty-chair and gradually encouraged to sit on it and over time actually use it,

followed by positive rewards.

Sensory Abilities

Full-term infants are born with a functioning sensory system—the senses of hearing, sight, taste,

smell, touch, and sensitivity to pain—and these abilities continue to develop rapidly in the first

few months. Indeed, in the early months the sensory system seems to function at a higher level

than the motor system, which allows movement. The sensory system allows infants, from the

time of birth, to participate in and adapt to their environments. A lot of their learning happens

through listening and watching. The sensory system is interconnected, with various sensory

abilities working together to give the infant multiple sources of information about the world.

Developmental researchers make a distinction between sensation and perception.

Sensation occurs when the senses detect a stimulus. Perception refers to the sense the brain

makes of the stimulus and the awareness of the sensation. Although the infant is equipped with a

full range of senses and ready to experience the world, perception develops over time.

Researchers have examined how infants learn to change behavior in response to sensation and

have identified four mechanisms of learning: habituation, classical conditioning, operant

conditioning, and imitation (Kuther, 2017). Habituation occurs when the repeated exposure to a

stimulus leads to a gradual decline in the intensity, frequency, or duration of response to the

stimulus. Habituation starts before birth (Hepper, 2015). Classical conditioning involves the

association between a conditioned stimulus and an unconditioned stimulus. For example, one

researcher found that when stroking of an infant’s forehead was paired with tasting sugar water,

2-hour-old infants were conditioned to suck in response to having their heads stroked (Blass,

Ganchrow, & Steiner, 1984). Classical conditioning also begins before birth (Herbert, Eckerman,

Goldstein, & Stanton, 2004). In operant conditioning infants learn to behave in ways that are

positively reinforced and avoid behaviors that are punished. For example, infants have been

found to be conditioned to change the rate of sucking on a pacifier to receive a positive

reinforcement such as a tape recording of the mother’s voice or other voices they find pleasing

(Floccia, Christophe, & Bertoncini, 1997). Third trimester fetuses can be operantly conditioned

(Thoman & Ingersoll, 1993). All of us learn by imitating the behaviors of others, but so can

infants. The mirror neuron system is thought to be an inborn capacity to respond to actions of

others by mirroring their actions and is apparent in both newborn humans and monkeys (Cook,

Bird, Catmur, Press, & Heyes, 2014).

Hearing is the earliest link to the environment; the fetus is sensitive to auditory stimulation in the

uterus (Moraru et al., 2011). The fetus hears the mother’s heartbeat, and this sound is soothing to

the infant in the early days and weeks after birth. Newborns show a preference for their mother’s

voice over unfamiliar voices, but one research team found that this is not the case for newborns

whose mothers were anxious or depressed during the third trimester (Figueiredo, Pacheco, Costa,

Conde, & Teixeira, 2010). Early infants can also distinguish changes in loudness, pitch, and

location of sounds, and they can use auditory information to differentiate one object from

another and to track the location of an object (Bahrick, Lickliter, & Flom, 2006). These

capacities grow increasingly sensitive across the first 6 months after birth. Infants appear to be

particularly sensitive to language sounds, and the earliest infant smiles are evoked by the sound

of the human voice (Benasich & Leevers, 2003). Unfortunately, research indicates that

malnutrition during the infant’s first 3 months increases the likelihood of early onset hearing loss

(Olusanya, 2010).

At birth, vision is the least developed sense, but it improves rapidly during the first few months

of life. From the ages of 6 months to 1 year, the infant begins to see objects the same way an

adult does (Mercuri, Baranello, Romeo, Cesarini, & Ricci, 2007). Of course, infants do not have

cognitive associations with objects as adults do. Infants respond to a number of visual

dimensions, including depth, brightness, movement, color, and distance. Human faces have

particular appeal for newborns. Although conflicting evidence exists, research suggests that

several days after birth infants can discriminate between facial expressions (Farroni, Menon,

Rigato, & Johnson, 2007). From 4 to 7 months, infants can recognize expressions, particularly

happiness, fear, and anger (McClure, 2000). Infants show preference for faces, and by 3 months,

most infants can distinguish a parent’s face from the face of a stranger (Nelson, 2001). Ability to

recognize familiar faces is enhanced through positive expression, suggesting an interaction

between expression and infants’ recognition of a familiar face (Turati, Montirosso, Brenna,

Ferrara, & Borgatti, 2011). Some researchers have found that infants are distressed by a lack of

facial movement in the people they look at, showing that they prefer caregivers to have

expressive faces (Muir & Lee, 2003).

Taste and smell begin to function in the uterus, and newborns can differentiate sweet, bitter,

sour, and salty tastes. A preference for sweet tastes is innately present for both preterm and full-

term newborns (Pepino & Mennella, 2006). Research suggests that the first few minutes after

birth is a particularly sensitive period for learning to distinguish smells (Delaunay-El Allam,

Marlier, & Schaal, 2006). Breastfed babies are especially sensitive to their mother’s body odors.

One research team found that newborns undergoing a heel prick were soothed by the smell of

breast milk, but only if the milk came from the mother’s breast (Nishitani et al., 2009).

Both animal and human research tell us that touch plays a very important role in infant

development. In many cultures, swaddling, or wrapping a baby snugly in a blanket, is used to

soothe a fussy newborn. We also know that gentle handling, rocking, stroking, and cuddling are

all soothing to an infant. Regular gentle rocking and stroking are very effective in soothing low-

birth-weight (LBW) babies, who may have underdeveloped central nervous systems. Skin-to-

skin contact between parents and their newborns has been found to have benefits for both infants

and their parents. Preterm babies who have lots of skin contact with their parents, including

gentle touching and massage, gain weight faster, have better temperature regulation, have better

capacity for self-soothing, and are more alert compared with preterm babies who do not receive

extensive skin contact (Feldman, 2004; Jean & Stack, 2012). Infants also use touch to learn about

their world and their own bodies. Early infants use their mouths for exploring their worlds, but

by 5 or 6 months of age, infants can make controlled use of their hands to explore objects in their

environment. They learn about the world and keep themselves entertained by exploring small

details, transferring objects from one hand to the other, and examining the differences in surfaces

and other features of the object (Streri, 2005).

Clear evidence exists that from the first days of life, babies feel pain. Recently, pediatric

researchers have been studying newborn reactions to medical procedures such as heel sticks, the

sticks used to draw blood for lab analysis. One researcher found that newborns who undergo

repeated heel sticks learn to anticipate pain and develop a stronger reaction to pain than other

infants (Taddio, Shah, Gilbert-Macleod, & Katz, 2002). These findings are leading pediatricians

to develop guidelines for managing pain in newborns (Spence et al., 2010). The findings are also

influencing debates about male infant circumcision.

Reflexes

Although dependent on others, newborns are equipped from the start with tools for survival that

are involuntary muscle responses to certain stimuli, called reflexes. Reflexes aid the infant in

adapting to the environment outside the womb. The presence and strength of a reflex is an

important sign of neurological development, and the absence of reflexes can indicate a serious

developmental disorder (Health Encyclopedia, 2018). Given Holly Hicks’s early arrival, it is

likely her reflex responses were thoroughly evaluated.

Newborns have two critical reflexes:

1. Rooting reflex. When infants’ cheeks or the corners of their mouths are gently stroked

with a finger, they will turn their head in the direction of the touch and open their

mouths in an attempt to suck the finger. This reflex aids in feeding, because it guides the

infant to the nipple.

2. Sucking reflex. When a nipple or some other suckable object is presented to the infant,

the infant sucks it. This reflex is another important tool for feeding.

Many infants would probably perish without the rooting and sucking reflexes. Imagine the time

and effort it would require for one feeding if they did not have them. Instead, infants are born

with the ability to take in nutriment.

A number of reflexes disappear at identified times during infancy (see Exhibit 3.2) but in some

cases change into voluntary behavior; others persist throughout adulthood. Both the rooting

reflex and sucking reflex disappear in the first few months. By this time, the infant has mastered

the voluntary act of sucking and is therefore no longer in need of the reflexive response. Several

other infant reflexes appear to have little use now but probably had some specific survival

purposes in earlier times. The presence of an infant reflex after the age at which it typically

disappears can be a sign of damage to the brain or nervous system (Kuther, 2017).

Exhibit 3.2 • Infant Reflexes

Motor Skills

The infant gradually advances from reflex functioning to motor functioning. The development

of motor skills—the ability to move and manipulate—occurs in a more or less orderly, logical

sequence. It begins with simple actions such as lifting the chin and progresses to more complex

acts such as walking, running, and throwing. Infants usually crawl before they walk.

Motor development is somewhat predictable, in that children tend to reach milestones at about

the same age and in the same sequence. As a part of the MGRS, WHO undertook a project to

construct standards for evaluating the motor development of children from birth through 5 years

of age. MGRS collected longitudinal data on six gross motor milestones of children ages 4 to 24

months in Ghana, India, Norway, Oman, and the United States. The milestones studied were

sitting without support, standing with assistance, hands-and-knees crawling, walking with

assistance, standing alone, and walking alone. Because WHO was trying to establish standards

for evaluating child development, healthy children were studied in all five study sites. The

researchers found that 90% of the children achieved five of the six milestones in the same

sequence, but 4.3% of the sample never engaged in hands-and-knees crawling (WHO

Multicentre Growth Reference Study Group, 2006b).

Based on the data collected, MGRS developed “windows of milestone achievement” for each of

the six motor skills, with achievement at the 1st and 99th percentiles as the window boundaries.

All motor achievement within the windows is considered normal variation in ages of

achievement for healthy children. The windows of normal achievement for the six motor skills

studied are reported in Exhibit 3.3. The results reveal that the range of the windows varies from

5.4 months for sitting without support (from 3.8 months at the 1st percentile to 9.2 months at the

99th percentile) to 10.0 months for standing alone (from 6.9 at the 1st percentile to 16.9 at the

99th percentile). This is quite a wide range for normal development and should be reassuring to

parents who become anxious if their child is not at the low end of the window. Many parents, for

example, become concerned if their child has not attempted to walk unassisted by age 1.

However, some children walk alone at age 9 months; others do not even attempt to walk until

almost 18 months.

Exhibit 3.3 • Windows of Milestone Achievement in Months

The physical environment as well as culture and ethnicity appear to have some influence on

motor development in infants and toddlers. MGRS found that girls were slightly ahead of boys in

gross motor development, but the differences were not statistically significant. The researchers

did find small, but statistically significant, differences between sites of the study, however. They

speculate that these differences probably reflect culture-based childcare behaviors, but the cause

cannot be determined from the data, and a genetic component is possible. The earliest mean age

of achievement for four of the six milestones occurred in the Ghanaian sample, and the latest

mean age of achievement for all six milestones occurred in the Norwegian sample (WHO

Multicentre Growth Reference Study Group, 2006c). The U.S. sample mean was in the middle

range on all milestones except for hands-and-knees crawling, where it had the lowest mean

achievement.

A longitudinal study of almost 16,000 infants in the United Kingdom took up this issue of

cultural differences in developmental motor milestones. In this study, Black Caribbean infants,

Black African infants, and Indian infants were, on average, more advanced in motor

development than White infants. Pakistani and Bangladeshi infants were more likely than White

infants to show motor delays. Although the delays among Pakistani and Bangladeshi infants

appear to be explained by factors associated with poverty, the earlier development of Black

Caribbean, Black African, and Indian infants could not be explained by economic advantage.

The researchers suggest that parental expectations and parenting practices play a role in cultural

differences in motor development (Kelly, Sacker, Schoon, & Nazroo, 2006).

The development of motor skills (and most other types of skills, for that matter) is a continuous

process. Children progress from broad capacities to more specific refined abilities. For example,

toddlers progress from eating cereal with their fingers to eating with a spoon.

The Growing Brain

We are living in the midst of a neuroscientific revolution clarifying the important role of the

brain in helping to shape human behavior (Matto, Strolin-Goltzman, & Ballan, 2014). At birth,

the brain is about 25% of its adult weight and grows rapidly throughout infancy, reaching 80% of

adult weight by the age of 2 (Nelson & Luciana, 2008). As the brain grows, it becomes not only

larger but also more complex.

Like every other part of the human body, the brain is made up of billions of cells. Human brains

and brains of other primates contain neurons, or specialized nerve cells that store and transmit

information; they carry sensory information to the brain, and they carry out the processes

involved in thought, emotion, and action. Neurogenesis, the creation of new neurons, begins

before birth. We are born with more than 100 billion neurons, much more than we will ever need

and more than we will ever have again. Some neurons die and new ones are created;

neurogenesis continues throughout life but at a much slower pace than occurs prenatally (Stiles

& Jernigan, 2010). Between the neurons are synapses, or gaps that function as the site

of information exchange from one neuron to another. Synaptogenesis, the creation of synapses,

begins to accelerate during the last trimester of pregnancy and peaks at 2 to 3 years of age, when

the brain has about twice the synapses it will have in adulthood (Pierce, 2011; Urban Child

Institute, 2018). This rapid synaptogenesis results in an overabundance of synapses and a tripling

in brain weight during the first 3 years. The period of overproduction of synapses, or synaptic

blooming, is followed by a period of synaptic pruning, or reduction, of the synapses to improve

the efficiency of brain functioning. It is through this process of creating elaborate communication

systems between the connecting neurons that more and more complex skills and abilities become

possible. Thus, during these early years of life, children are capable of rapid new learning. The

blooming and pruning of synapses process continues well into childhood and adolescence at

different timetables in different regions of the brain. In addition to synaptogenesis, myelination,

a process in which axons and neurons are coated with a fatty substance called myelin, begins

during the first 2 years (Stiles & Jernigan, 2010). Myelination causes faster neural

communication, which results in faster information processing. Myelination progresses most

rapidly between birth and age 4 and continues through adolescence and young adulthood.

The available evidence suggests that both genetic processes and early experiences with the

environment influence the timing of brain development. Brain plasticity has been a major finding

of neuroscientific research of the past few decades. There are two elements of brain plasticity,

also known as neuroplasticity; first, research indicates that the brain changes throughout life; and

second, the brain changes in response to what it experiences—it is shaped by experience

(Farmer, 2009). The human brain is genetically designed to accommodate an incredibly wide

range of human experiences, and the environmental context helps to shape the brain for life in a

particular developmental niche. What is used gets strengthened, and what is not used gets

pruned. The infant and toddler contribute to their own brain development by repeating certain

actions, attending to certain stimuli, and responding in particular ways to caregivers. Newer

research supports a relationship between caregiver–infant interaction and brain structure. For

example, results from one study indicate that the quality of interaction between the infant and

caregiver may have a pronounced effect on the development of the infant brain (Bernier, Calkins,

& Bell, 2016). The research hypothesis was that infants whose mothers demonstrate a higher

quality of interaction at 5 months will have a higher-level brain development at 10 and 24

months, as measured by frontal resting EEG power. The researchers did find a relationship

between quality of mother–infant interaction and frontal brain activity. The higher the quality of

interaction, the higher the level of frontal brain functioning. Scientists continue to conduct new

and innovative research in this area. See Harvard’s Center on the Developing Child

(https://developingchild.harvard.edu) for up-to-date research efforts in this area.

Exposure to speech in the first year expedites the discrimination of speech sounds; exposure to

patterned visual information in the first few years of life is necessary for normal development of

some aspects of vision. Some suggest that the entire infancy period is a crucial and sensitive time

for brain development, given the quantity and speed at which the neurons develop and connect

(Pierce, 2011). Positive physical experiences (feeding, safety, and so on) and positive

psychological experiences (touching, cooing, and playing) activate and stimulate brain activity

(Davies, 2011). Good nutrition and infant stimulation are essential for brain development, and

exposure to environmental toxins, abuse, emotional trauma, and deprivation is hazardous.

Persistent stress for the infant or toddler has been found to result in overdevelopment of areas of

the brain that process anxiety and fear and underdevelopment of other brain areas, particularly

the frontal cortex (Schore, 2002).

Certain risks to brain development are associated with prematurity. Premature infants like Holly

Hicks, born at 24 to 28 weeks’ gestation, have high rates of serious intracranial hemorrhage,

which can lead to problems in cognitive and motor development, including cerebral palsy and

intellectual disability. Less serious intracranial hemorrhage can lead to later behavioral,

attentional, and memory problems (Tam et al., 2011). It is not yet clear whether Holly Hicks

suffered any type of brain hemorrhage and what impact it will have on her development if she

did.

Vaccinations

Vaccinations protect communities as well as individual children from diseases that once spread

rapidly and killed many people. Over the past 50 years, the incidence of childhood illnesses such

as measles, mumps, and whooping cough has dropped significantly because of widespread use of

vaccines to immunize infants and young children. A vaccine is a small dose of a substance used

to stimulate the production of antibodies to provide immunity against one or more diseases.

Vaccines are provided early in life because many preventable diseases are common in infants

and young children whose immune systems are not as well developed as they will be later. The

Centers for Disease Control and Prevention (CDC) recommends that children be vaccinated

against several diseases by the age of 2. Vaccine rates increased significantly from 1994 to 2004

in the United States but have stalled since then (Child Trends, 2014).

A major reason for the stalled vaccination rate is the misconception that vaccines are associated

with autism and other developmental disorders as well as some chronic health problems, leading

some parents to refuse to have their children vaccinated. Extensive research finds no association

between vaccines and autism (see Taylor, Swerdfeger, & Eslick, 2014). One reason that some

parents associate vaccines with autism, other developmental disorders, and some chronic

illnesses is that these conditions tend to emerge during infancy and toddlerhood, the same age

period for the vaccine administration. Research indicates that autism has a strong genetic

component and is also associated with both maternal and paternal age (Idring et al., 2014; Waltes

et al., 2014).

Cognitive Development

As the brain develops, so does its ability to process and store information and to solve problems.

These abilities are known as cognition. When we talk about how fast a child is learning, we are

talking about cognitive development. Researchers now describe the infant as “wired to learn”

and agree that infants have an intrinsic drive to learn and to be in interaction with their

environments. A central element of cognition is language, which facilitates both thinking and

communicating.

Piaget’s Stages of Cognitive Development

To assess children’s cognitive progress, many people use the concepts developed by the best-

known cognitive development theorist, Jean Piaget (1936/1952). Piaget proposed a cognitive-

developmental theory that views humans as active explorers who learn by interacting with the

world. He believed that cognitive development occurs in successive stages, determined by the

age of the child. His overall contention was that as a child grows and develops, cognition

changes not only in quantity but also in quality.

Piaget used the metaphor of a slow-motion movie to explain his theory, which is summarized

in Exhibit 3.4 as follows:

1. Sensorimotor stage (ages birth to 2 years). Infants at this stage of development can look at

only one frame of the movie at a time. When the next picture appears on the screen, infants focus

on it and cannot go back to the previous frame.

2. Preoperational stage (ages 2 to 7). Preschool children and children in early grades can

remember (recall) the sequence of the pictures in the movie. They also develop symbolic

functioning—the ability to use symbols to represent what is not present. However, they do not

necessarily understand what has happened in the movie or how the pictures fit together.

3. Concrete operations stage (ages 7 to 11). Not until this stage can children run the pictures in

the movie backward and forward to better understand how they blend to form a specific

meaning.

Exhibit 3.4 • Piaget’s Stages of Cognitive Development

4. Formal operations stage (ages 11 and beyond). Children gain the capacity to apply logic to

various situations and to use symbols to solve problems. Adding to Piaget’s metaphor, one

cognitive scientist describes formal operations as the ability of the adolescent not only to

understand the observed movie but also to add or change characters and create an additional plot

or staging plan (Edwards, 1992).

The first of Piaget’s stages applies to infants and toddlers. During the sensorimotor period, they

respond to immediate stimuli—what they see, hear, taste, touch, and smell—and learning takes

place through the senses and motor activities. Piaget suggests that infant and toddler cognitive

development occurs in six substages during the sensorimotor period.

 Substage 1: Reflex activity (birth to 1 month).Because reflexes are what the infant can

“do,” they become the foundation to future learning. Reflexes are what infants build on.

 Substage 2: Primary circular reactions (1 to 4 months). During this stage, infants repeat

(thus the term circular) behaviors that bring them a positive response and pleasure. The

infant’s body is the focus of the response, thus the term primary. If, for example, infants

by chance hold their head erect or lift their chest, they will continue to repeat these acts

because they are pleasurable. Infants also have limited anticipation abilities.

 Substage 3: Secondary circular reactions (4 to 8 months). As in the second substage, the

focus is on performing acts and behaviors that bring about a response. In this stage,

however, the infant reacts to responses from the environment. If, for example, 5-month-

old infants cause the rattle to sound inadvertently as their arms move, they will continue

attempts to repeat this occurrence.

 Substage 4: Coordination of secondary circular reactions (8 to 12 months). The mastery

of object permanence is a significant task during this stage. Piaget contended that

around 9 months of age, infants develop the ability to understand that an object or a

person exists even when they don’t see it. Piaget demonstrated this ability by hiding a

favored toy under a blanket. Infants are able to move the blanket and retrieve the toy.

Object permanence is related to the rapid development of memory abilities during this

period and is necessary for mental representation to develop (Bruce & Vargas, 2013).

Two other phenomena are related to this advance in memory. Stranger anxiety—also

called stranger wariness or stranger fear—in which the infant reacts with fear and

withdrawal to unfamiliar persons, has been found to occur at about 6 to 9 months across

cultures. Many first-time parents comment, “I don’t know what has gotten into her; she

has always been so outgoing.” Babies vary in how intensely they react to the strange

situation and in how they express their anxiety (Rieser-Danner, 2003). Twin studies

suggest that different patterns of stranger anxiety are influenced by genetics (Brooker et

al., 2013). Culture also influences stranger anxiety, as do other factors such as

experiences with strangers, and the mother’s stress reactivity and anxiety, with infants

whose mothers report greater stress reactivity showing higher rates of stranger anxiety

(Brooker et al., 2013). Infants react more positively to strangers when the stranger

approaches slowly and is sensitive to the infant’s signals, and in the presence of

caregivers. Separation anxiety also becomes prominent in this period. The infant is able

to remember previous separations and becomes anxious at the signs of an impending

separation from parents. With time, the infant also learns that the parent always returns.

 Substage 5: Tertiary circular reactions (12 to 18 months). During this stage, toddlers

begin to experiment with new behaviors to see the results. They become little scientists

who engage in trial-and-error exploration. For example, if the first button on the talking

telephone does not make it talk, they will continue to press other buttons on the phone

until they find the correct one.

 Substage 6: Mental representation (18 months to 2 years). Piaget described toddlers in

this stage as actually able to use thinking skills in that they retain mental images of what

is not immediately in front of them. For example, the toddler will look in a toybox for a

desired toy and move other toys aside that prohibit recovery of the desired toy. Toddlers

can also remember and imitate observed behavior, a skill called deferred imitation. For

example, toddlers roll their toy lawn mower over the lawn, imitating their parents’ lawn

mowing.

As much as Piaget’s work has been praised, it has also been questioned and criticized. Piaget

constructed his theory based on his observations of his own three children. Thus, one question

has been how objective he was and whether the concepts can really be generalized to all

children. Also, Piaget has been criticized for not addressing the influence of environmental

factors—such as culture, family, and significant relationships and friendships—on cognitive

development. However, for the past 30 years, researchers around the world have put Piaget’s

theory to the test. This research literature is immense but has been summarized by several

reviewers (see, for example, Bronfenbrenner, 1993; Rogoff & Chavajay, 1995; Segall, Dasen,

Berry, & Poortinga, 1999). Piaget’s sensorimotor stage has been studied less than his other

cognitive stages, but the existing research tends to support Piaget’s theory, even though some

minor cultural differences are noted (Gardiner, 2018). For example, some research has found that

African infants receive more social stimulation and emotional support than European and

American infants, and European and American infants get more experience with handling

objects. This leads to African infants and toddlers developing more social intelligence and

European and American children developing more technological intelligence (cited in Gardiner,

2018). This supports the idea of the importance of the developmental niche but, overall, suggests

much more similarity than difference in cognitive development across developmental niches

during infancy and toddlerhood.

Research findings have called into question some aspects of Piaget’s theory. For example, Piaget

described young children as being incapable of object permanence until at least 9 months of age.

However, infants as young as 3½ and 4½ months of age have been observed who are already

proficient at object permanence (Ruffman, Slade, & Redman, 2005). Other researchers

(Munakata, McClelland, Johnson, & Siegler, 1997) have found that although infants seem aware

of hidden objects at 3½ months, they fail to retrieve those objects until about 8 months of age.

These researchers suggest that cognitive skills such as object permanence may be multifaceted

and gradually developed (Baillargeon, 2004). Cognitive researchers have been interested in the

development of object permanence in children with very low birth weight and in children with a

range of intellectual and physical disabilities. One research team found that toddlers born full-

term were more than 6 times more likely to have developed object permanence than children

born prematurely with very low birth weight (Lowe, Erickson, MacLean, & Duvall, 2009). Susan

Bruce and Zayyad Muhammad (2009) reviewed the research on the development of object

permanence in children with intellectual disability, physical disability, autism, and blindness.

They concluded that this research indicates that children with these disabilities develop object

permanence in a similar sequence as children without disabilities, but at a slower rate. They also

found evidence that children with severe disability benefit from systematic instruction in object

permanence. Bruce and Vargas (2013) provide a case example of a successful team effort to

teach object permanence to a 4-year-old girl with severe multiple developmental delays and

visual impairment. It is interesting to note that much of the recent research on object permanence

studies nonhuman animals. For example, one research team who studied Piagetian object

permanence in carrion crows found support for Piagetian stages of cognitive development in this

avian species (Hoffman, Rüttler, & Nieder, 2011).

Information Processing Theory

Piaget’s cognitive-developmental theory has been very influential, but it leaves many aspects of

cognitive functioning unexplained. Piaget sought to explain the stages by which cognition

develops, but information processing theory is interested in the mechanismsthrough which

learning occurs, focusing specifically on memory encoding and retrieval (Oppenheimer & Kelso,

2015). It sees the mind as having distinct parts. Information processing theory can be thought of

as a sensory theory because it depicts information as flowing passively from the external world

through the senses to the mind. By contrast, Piaget’s cognitive-developmental theory can be

considered a motor theory because it sees the mind as playing an active role in processing

information—not merely recording it but actively constructing the nature of the input it receives

(Walsh, 2019). Both theories have merit and contribute to our understanding of human cognition.

Information processing theory sees the mind as composed of three mental states: sensory

memory, working memory, and long-term memory. Sensory memory takes in sensory

information and holds it in its original form. Because a great deal of information is taken in,

much of it is discarded. Working memory, also called short-term memory, holds and processes

information that is “worked on” in some way: considered, comprehended, encoded, or recalled.

All conscious mental activity occurs in working memory. Research indicates that infants as

young as 5 or 6 months can remember and manipulate information to ascertain the locations of

hidden objects (Reznick, Morrow, Goldman, & Snyder, 2004). The typical infant makes great

strides in the development of working memory from 6 to 8 months of age (Kwon, Luck, &

Oakes, 2014). As information is manipulated in working memory, it becomes more likely to

enter long-term memory. Long-term memory has unlimited storage and can hold information

indefinitely. Information is not processed in long-term memory; it is simply stored until it is

retrieved and returned to working memory (Oppenheimer & Kelso, 2015). Exhibit 3.5 provides a

visual representation of the information processing system.

Exhibit 3.5 • Information Processing System

Categorization, a cognitive skill that begins to develop in the first year of life, is an important

cognitive skill developed during infancy and toddlerhood in both Piaget’s cognitive-

developmental theory and information processing theory. Categorization, or recognizing

similarities in groups of objects, is a fundamental element of information processing. There is

evidence that by 6 months, infants begin to see patterns in and make distinctions about human

faces (Ramsey, Langlois, Hoss, Rubenstein, & Griffin, 2004). There is also evidence that by 3

months of age, infants can make a distinction between people and inanimate objects. They have

been observed to smile and vocalize more and become more active when they are interacting

with people than when interacting with inanimate objects (Rakison & Poulin-Dubois, 2001).

Research has also found that 4½-month-old babies indicate recognition when two objects are

different from each other (Needham, 2001). As toddlers develop language skills, they use

language as well as visual cues to categorize objects (Nazzi & Gopnik, 2001).

Language Development

Some of the developmental milestones for language development are listed in Exhibit 3.6. It is

hypothesized that the left hemisphere of the human brain is the part poised to receive and

produce language. There is some research evidence for this hypothesis and some evidence that,

compared with other toddlers, the large majority of toddlers diagnosed with autism exhibit right-

hemisphere dominance in responses to language (Pierce, 2011). Although babies seem to be born

ready to begin processing language and infants communicate with their caretakers from the

beginning (primarily by crying), language development truly begins around 2 months of age. The

first sounds, cooing, are pleasing to most parents. By about age 4 to 6 months, infants babble.

Initially, these babbles are unrecognizable. Eventually, at about 8 to 12 months, infants make

gestures to indicate their desires. The babble sounds and gestures together, along with caretakers’

growing familiarity with the infant’s “vocabulary,” make it easier for infants to communicate

their desires. For example, 12-month-old infants may point to their bottle located on the kitchen

cabinet and babble “baba.” The caretaker soon learns that “baba” means “bottle.”

The period from 16 to 24 months typically corresponds to a spurt in vocabulary development,

with new words being learned rapidly. Piaget asserts that children develop language in direct

correlation to their cognitive skills. Thus, most of the words spoken at this age relate to people

and significant objects in the toddler’s environment. These include words such

as mama, dada, cat, and sissy (sister), for example. Across cultures, there is an overall bias in

infancy to use nouns (Gardiner, 2018). Toddlers’ first words also include situational words such

as hot, no, and bye. At about 21 months, toddlers begin to combine two words together to form

simple sentences such as “Mommy milk.” For example, children can say “all gone” as they

develop an understanding of object permanence (Berk, 2012). Even with these skills, toddlers

may be difficult to understand on occasion. From age 2 to 3, toddlers begin to put together

sentences of more than two words.

Exhibit 3.6 • Selected Milestones in Language Development

Cindy, the mom of 24-month-old Steven, describes collecting her son from day care. During the

trip home, Steven initiated conversation with Cindy by calling out “Mama.” He began to “tell”

her about something that Cindy assumes must have occurred during the day. Steven continued to

babble to his mother with animation and laughs and giggles during the story. Although Cindy

laughed at the appropriate moments, she was unable to understand most of what Steven was

sharing with her.

The most important thing adults can do to assist with language development is to provide

opportunity for interactions. Adults can answer questions, provide information, explain plans and

actions, and offer feedback about behavior. Adults can also read to infants and toddlers and play

language games. The opportunity for interaction is important for deaf children as well as hearing

children, but deaf children need interaction that involves hand and eye, as with sign language

(Shonkoff & Phillips, 2000). Researchers have found that when talking with infants and toddlers,

adults and even older children will engage in behaviors that facilitate language development;

they tend to speak in a high pitch, use shorter sentences, and speak slowly (Singh, Morgan, &

Best, 2002). However, there appear to be cultural differences in how adults communicate with

infants and toddlers, and it is not clear how these differences affect language acquisition

(Sabbagh & Baldwin, 2001).

Although newborns show a preference for the language of the parents, research indicates that

early infants are capable of recognizing and making sounds from a wide range of languages.

However, as they have repeated interactions with caregivers and family members, they

strengthen the neural connections for the sounds of the language(s) spoken in the home

environment, and the neural connections for sounds from other languages are lost (Hoff, 2009).

Miraculously, infants and toddlers who are bilingual from birth learn two languages as fast as

monolingual infants learn one (Kovács & Mehler, 2009). Of course, ability in any language is

not retained unless the environment provides an opportunity for using the language.

Socioemotional Development

Infants and toddlers face vital developmental tasks in the emotional arena (some of which are

listed in Exhibit 3.7), as well as in the social arena. Development during these early ages may set

the stage for socioemotional development during all other developmental ages. This section

addresses these tasks.

Erikson’s Theory of Psychosocial Development

Erik Erikson’s (1950) theory explains socioemotional development in terms of eight consecutive,

age-defined stages. Each stage requires the mastery of a developmental task. Mastery at each

stage depends on mastery in the previous stages. If the “task facilitating factors” for a stage are

absent, the individual will become stuck in that stage of development.

Exhibit 3.7 • Selected Milestones in Emotional Development

Each of Erikson’s stages is overviewed in Exhibit 3.8 and discussed in the chapter regarding the

part of the life course to which it applies. The following two stages are relevant to infants and

toddlers.

1. Trust versus mistrust (ages birth–1½). The overall task of this stage is for infants to develop a

sense that their needs will be met by the outside world and that the outside world is an okay

place to be. In addition, the infant develops an emotional bond with an adult, which Erikson

believes becomes the foundation for being able to form intimate, loving relationships in the

future. Erikson argues the need for one consistent mother figure. The most important factor

facilitating growth in this stage is consistency in having physical and emotional needs met: being

fed when hungry, being kept warm and dry, and being allowed undisturbed sleep. In addition, the

infant has to be protected from injury, disease, and so on and receive adequate stimulation.

Infants who develop mistrust at this stage become suspicious of the world and withdraw, react

with rage, and have deep-seated feelings of dependency. These infants lack drive, hope, and

motivation for continued growth. They cannot trust their environment and are unable to form

intimate relationships with others. Given Ms. Velasquez’s view that the outside world is not a

safe place, described at the beginning of the chapter, her young son, Henry, is at risk of

developing feelings of mistrust.

2. Autonomy versus shame and doubt (ages 1½–3). A child with autonomy has a growing sense

of self-awareness and begins to strive for independence and self-control. These children feel

proud that they can perform tasks and exercise control over bodily functions. They relate well

with close people in the environment and begin to exercise self-control in response to parental

limits. To develop autonomy, children need firm limits for controlling impulses and managing

anxieties but at the same time still need the freedom to explore their environment. Exhibit

3.9 summarizes possible sources of anxiety for toddlers (Davies, 2011). Toddlers also need an

environment rich with stimulating and interesting objects and with opportunities for freedom of

choice. Adults must accept the child’s bodily functions as normal and good and offer praise and

encouragement to enhance the child’s mastery of self-control. At the other end of the spectrum

are children who doubt themselves. They fear a loss of love and are overly concerned about their

parents’ approval. These children are ashamed of their abilities and develop an unhealthy kind of

self-consciousness.

Exhibit 3.8 • Erikson’s Stages of Psychosocial Development

Exhibit 3.9 • Possible Sources of Anxiety for Toddlers

Erikson does not address whether tasks that should be mastered in one stage can be mastered

later if the facilitating factors—such as a dependable, nurturing caregiver—are introduced. For

example, we know that Sarah suffered neglect until Chris Johnson and his parents provided a

dependable, nurturing environment for her. At what point is it too late to undo psychosocial

damage? Critics also question Erikson’s emphasis on the process of individualization, through

which children develop a strong identity separate from that of their family. Many believe this to

be a North American, Western value and therefore not applicable to collectivistic societies such

as many African, Latin, and Asian societies or to collectivistic subcultures in the United States.

Emotion Regulation

Researchers have paid a lot of attention to the strategies infants develop to cope with intense

emotions, both positive and negative. They have noted that infants use a range of techniques to

cope with intense emotions, including turning the head away, sucking on hands or lips, and

closing their eyes. By the middle of the second year, toddlers have built a repertoire of ways to

manage strong emotions. They make active efforts to avoid or disregard situations that arouse

strong emotions; they move away or they distract themselves with objects. They soothe

themselves by thumb sucking, rocking, or stroking; they also engage in reassuring self-talk. In

addition, they develop substitute goals if they become thwarted in goal-directed behavior

(Shonkoff & Phillips, 2000). However, researchers who do experimental infant research note that

a number of infants must be discontinued from the research process because they cannot be

calmed enough to participate (Newman & Newman, 2015). The ability to control the intensity of

emotional states has important implications for early childhood school performance and social

relationships (Davidson & Begley, 2012).

You may not be surprised to learn that researchers have found that one of the most important

elements in how an infant learns to manage strong emotions is the assistance provided by the

caregiver for emotion management (see, for example, Lowe et al., 2012). Caregivers may offer

food or a pacifier, or they may swaddle, cuddle, hug, or rock the infant. By the time the infant is

6 months old, caregivers often provide distraction and use vocalization to soothe. One research

team found that for all levels of infant distress, the most effective methods of soothing were

holding, rocking, and vocalizing. Feeding and offering a pacifier were effective when the infant

was moderately distressed but not at times of extreme distress (Jahromi, Putnam, & Stifter,

2004). Infants who demonstrate greater emotion regulation are much more likely to have parents

who use higher levels of positive parenting behaviors, such as sensitivity, positive regard,

stimulation, and animation (Ursache, Blair, Stifter, & Voegtline, 2013). Another important

element that impacts an infant’s ability to manage emotions is whether the infant receives

adequate sleep (Kurcinka, 2006). The child’s temperament also makes a difference, as you will

see in the next section.

Finally, there are cultural differences in expectations for management of emotions in infants. For

example, Japanese parents try to shield their infants from the frustrations that would invite anger.

In other words, some emotions are regulated by protecting the child from situations that would

arouse them (Kitayama, Karasaw, & Mesquita, 2004). Cultural differences also exist in how

much independence infants and toddlers are expected to exercise in managing emotions. In one

study comparing Anglo and Puerto Rican mothers, Harwood (1992) found that Anglo mothers

expected their infants to manage their stranger anxiety and separation anxiety without clinging to

the mother. The Puerto Rican mothers, conversely, expected their infants to rely on the mother

for solace. Cultures also differ about the ways specific emotions should be managed, and babies

are socialized to respond and display specific emotions in socially acceptable ways (Gardiner,

2018). Across cultures, however, infants who receive more responsive and immediate caregiving

when they are distressed have lower rates of persistent crying, spend more time in happy and

calm states, and cry less by age 1 (see Axia & Weisner, 2002).

Temperament

Another way to look at emotional development is by evaluating temperament—the

characteristic way in which individuals approach and react to people and situations. The best-

known study of temperament in infants and young children was the New York Longitudinal

Study (NYLS), begun in 1956 (Thomas, Chess, & Birch, 1968, 1970). This study examined nine

components of temperament: activity level, rhythmicity(regularity of biological

functions), approach-withdrawal(initial reaction to any new stimulus), adaptability to new

situations and experiences, intensity of reactions, threshold of responsiveness (level of

stimulation needed to evoke a discernible response), quality of mood(happiness versus

irritability), distractibility, and attention span or persistence. From their observations, the

researchers identified three types of temperament: easy, slow to warm up, and difficult.

The easy baby is characterized by good mood, being open and adaptable to new experiences,

regular patterns of eating and sleeping, and general calmness. About 40% of study participants

fell in this category. The slow to warm up baby tends to be low in activity level, moody, and

slow to adapt to new situations and people. The researchers found that 15% of their study

participants fell in this category. The difficultbaby is active, irritable, irregular in biological

rhythms, slow to change in routine or new situations, and not easily able to adjust to new

routines. About 10% of infants fell in this category. About 35% of the NYLS sample did not fit

neatly into any of these three categories, displaying instead a mix of characteristics. There is a

tendency for recent researchers to focus on two clusters of temperamental traits, negative

emotions (irritability, fear, sadness, shyness, frustration, and discomfort) and regulatory capacity

(ability to self-regulate behavior and engage in self-soothing), as important to parent–infant

relationships as well as to future personality and behavior development (see Bridgett et al.,

2009).

For an idea of the differences in infant temperament, consider the range of reactions you might

see at a baptism service. One infant might scream when passed from one person to the other and

when water is placed on his or her forehead. The mother might have difficulty calming the infant

for the remainder of the baptism service. At the other extreme, one infant might make cooing

noises throughout the entire service and seem unbothered by the rituals. The slow-to-warm-up

infant might cautiously check out the clergy administering the baptism and begin to relax by the

time the ritual is completed.

Thomas and his colleagues believed that a child’s temperament appears shortly after birth and is

set, or remains unchanged, throughout life. Whether temperament is permanent or not is still

unresolved. Recent research suggests that temperament is less stable in infancy than at any other

time of life. Young infants’ temperaments may be shaped by sensitive caregiving. By the second

year of life, styles of responding to people and situations are more established, and in early

childhood temperament is even more stable and predictive (Goodwin, Thompson, & Winer,

2015). Neurobiologists are suggesting that infants come into the world with preexisting

temperaments or emotional styles (Davidson & Begley, 2012). They report strong evidence for a

genetic basis of emotional styles, with the genetic contribution varying from 20% to 60% for

different emotional style traits. But even traits with a strong genetic base can be modified by how

parents, teachers, and other caregivers interact with the child. After several decades of study of

the neuroscience of emotional style, Richard Davidson and colleagues (see Davidson & Begley,

2012) identify six dimensions of emotional style that have a strong neurobiological basis:

 Resilience: how quickly one recovers from adversity

 Outlook: how long one can sustain positive emotion

 Social intuition: how good one is at picking up social signals

 Self-awareness: how well one perceives bodily indications of emotions

 Sensitivity to context: how good one is at taking the context into account in regulating

emotions

 Attention: how sharply and clearly one uses focused attention

Although most of these dimensions of emotional style will not become evident in the early

months, there are early signs of a number of them.

Families like the Hicks family who have an infant with negative emotion and poor regulatory

capacity may be in special need of interventions to prevent a troubling developmental trajectory

for the infant and the relationship between the parents. Recent research provides some insight

about what could happen between Holly and Mrs. Hicks, as well as between Mr. and Mrs. Hicks,

over time. Researchers are finding that negative emotion in the first 3 months is related to

decreases in regulatory capacity from 4 to 12 months. And decreases in regulatory capacity in the

infant from 4 to 12 months predict poor parent–child relationships when the child is 18 months

old (Bridgett et al., 2009). Another research team found a relationship between infant regulatory

capacity and marital satisfaction. Following a group of infants and their families from the time

the infants were 7 months old until they were 14 months, these researchers found that marital

satisfaction increased as infants developed greater regulatory capacity and decreased when

infants failed to gain in regulatory capacity (Mehall, Spinrad, Eisenberg, & Gaertner, 2009). The

good news is that neuroscience research suggests that how easily a baby can be soothed has little

or no genetic contribution (Davidson & Begley, 2012), so the important thing is for Mrs. Hicks

to find the types of caregiving most soothing to Holly.

As parents discipline infants and toddlers to help them gain self-control, different methods of

discipline are indicated for children of different temperaments. Infants and toddlers who are

fearful and inhibited respond best to gentle, low-power discipline techniques, but these

techniques do not work well with fearless infants and toddlers who do best when positive

feelings between the caregiver and child are emphasized (Kochanska, Aksan, & Joy, 2007).

Researchers have also been interested in whether there are cultural and socioeconomic

differences in infant temperament. Several studies have found small to moderate cross-cultural

differences in infant temperament and have attributed these differences mainly to genetics (see

Gartstein, Knyazev, & Slobodskaya, 2005; Gartstein et al., 2006). To begin to examine the

contributions of the role of genetics and environment to temperament, one research team

compared three groups of Russian infants aged 3 to 12 months: infants living in Russia, infants

of parents who immigrated to Israel, and infants of parents who immigrated to the United States.

They found some differences in temperament across these three situations and concluded that the

differences in temperament between the Russian Israeli infants and the Russian American infants

probably reflect the different acculturation strategies used to adapt to different host societies

(Gartstein, Peleg, Young, & Slobodskaya, 2009). Findings about the relationship between

socioeconomic status and temperament are contradictory. Some researchers find no

socioeconomic differences (Bridgett et al., 2009) whereas other researchers find that infants in

more economically disadvantaged families have more difficult temperaments and conclude that

this difference is largely explained by family stress (Jansen et al., 2009). The difference in

findings about socioeconomic status and temperament could be caused by different samples,

with socioeconomic variations in temperament more likely to show up when the sample includes

greater income variability.

Attachment

Another key component of emotional development is attachment—the ability to form emotional

bonds with other people. Attachment is a lasting emotional bond between two people who try to

maintain closeness and ensure a continued relationship. Many child development scholars have

suggested that attachment is one of the most important issues in infant development, mainly

because attachment is the foundation for emotional development and a predictor of later

functioning. Note that this view of attachment is similar to Erikson’s first stage of psychosocial

development. This perspective is similar to the one Mrs. Hicks found on the Internet, which

raised issues of concern for her. The two most popular theories of attachment were developed by

John Bowlby (1969) and Mary Ainsworth and colleagues (Ainsworth, Blehar, Waters, & Wall,

1978).

Bowlby’s Theory of Attachment

Bowlby, who initially studied attachment in animals, concluded that attachment is natural, a

result of the infant’s instinct for survival and consequent need to be protected. Attachment

between infant and mother ensures that the infant will be adequately nurtured and protected from

attack or, in the case of human infants, from a harsh environment. The infant is innately

programmed to emit stimuli (smiling, clinging, and so on) to which the mother responds. This

exchange between infant and mother creates an emotional bond. The infant initiates the

attachment process, but later the mother’s behavior is what strengthens the bond.

Bowlby hypothesized that attachment advances through four stages: preattachment, attachment

in the making, clear-cut attachment, and goal-corrected attachment (when the caregiver and

toddler reach a balance between the toddler’s urge for autonomy and the caregiver’s need to

protect and set limits). This process begins in the first month of life, with the infant’s ability to

discriminate the mother’s voice. Attachment becomes fully developed during the second year of

life, when the mother and toddler develop a goal-corrected partnership. During this later phase of

attachment, the child is able to manipulate the mother into desired outcomes, but the child also

has the capacity to understand the mother’s point of view. The mother and the child reach a

mutually acceptable compromise.

Bowlby contends that infants can demonstrate attachment behavior to others; however,

attachment to the mother occurs earlier than attachment to others and is stronger and more

consistent. It is thought that the earliest attachment becomes the child’s working model for

subsequent relationships (Bowlby, 1982).

Attachment explains the child’s anxiety when the parents leave. However, children eventually

learn to cope with separation. Toddlers often make use of a transitional object, or comfort

object, to help them cope with separations from parents and to handle other stressful situations.

During such times, they may cuddle with a blanket, teddy bear, or other stuffed animal. The

transitional object is seen as a symbol of the relationship with the caregiver, but toddlers also see

it as having magic powers to soothe and protect them (Davies, 2011).

Ainsworth’s Theory of Attachment

One of the most widely used methods to investigate infant attachment, known as the strange

situation procedure, was developed by Ainsworth and colleagues (Ainsworth et al., 1978). The

Ainsworth group believed that the level of infant attachment to the mother could be assessed

through the infant’s response to a series of “strange” episodes. Basically, the child is exposed

over a period of 25 minutes to eight constructed episodes involving separation and reunion with

the mother. The type of child attachment to the mother is measured by how the child responds to

the mother following the “distressing” separation.

Ainsworth and her colleagues identified three types of attachment.

1. Secure attachment. The infant uses the mother as a home base and feels comfortable leaving

this base to explore the playroom. The infant returns to the mother every so often to ensure that

she is still present. When the mother leaves the room (act of separation) and leaves the infant

with a stranger, the securely attached infant responds with separation anxiety and stranger

anxiety. The securely attached infant will cry and seek comfort from the mother when she returns

and is easily reassured and soothed by the mother’s return.

2. Insecure anxious attachment. The infant is reluctant to explore the playroom and clings to the

mother. When the mother leaves the room, the infant cries for a long time. When the mother

returns, this infant seeks solace from the mother but continues to cry and may swat at or pull

away from the mother. Ainsworth and colleagues described these infants as somewhat insecure

and doubted that their mothers would ever be able to provide the security and safety they need.

3. Insecure avoidant attachment. Some infants seem indifferent to the presence of their mother.

This infant shows little distress during the strange situation and is not enthusiastic when reunited

with the mother. Whether the mother is present or absent from the room, these infant’s responses

are the same.

More recent scholars have added a fourth response, known as the insecure

disorganized/disoriented response (Belsky, Campbell, Cohn, & Moore, 1996; Main & Hesse,

1990). These children display inconsistent, contradictory behavior: They attempt physical

closeness but retreat with acts of avoidance. These infants often have mothers who are depressed,

have a history of being abused, or continue to struggle with a traumatic experience in their own

lives. Observations of mothers of infants with disorganized attachment style reveal two patterns

of parenting. Some mothers are negative and intrusive and frighten their babies with intense

bursts of hostility. Other mothers are passive or helpless; they rarely comfort their babies and

may actually appear afraid of their babies (Lyons-Ruth & Jacobvitz, 2008). As a result, the

infants become confused in the strange situation. They fear the unknown figure and seek solace

from the mother but retreat because they are also fearful of the mother (Abrams, Rifkin, &

Hesse, 2006). Some authors have suggested that the behavior associated with the disorganized

style is actually an adaptive response to harsh caregiving (Stovall & Dozier, 1998). However,

research suggests a link between disorganized attachment and serious mental health problems in

later childhood and beyond (Lyons-Ruth & Jacobvitz, 2008; Wolke, Eryigit-Madzwamuse, &

Gutbrod, 2014).

According to Ainsworth’s attachment theory, children whose mothers are consistently present

and responsive to their needs and whose mothers exhibit a warm, caring relationship develop an

appropriate attachment. Findings from studies indicate that this is true, even when there are

negative family issues such as alcoholism by the father (Edwards, Eiden, & Leonard, 2006).

However, the implication is that only mother–infant attachment exists or is relevant to healthy

infant development. This assumption probably seemed unquestionable when these theories were

constructed. Research indicates that fathers in both Western and Eastern cultures interact with

newborns in much the same way that mothers interact with them, cradling the infant and

performing care tasks such as diaper changing, bathing, and feeding the infant when formula or

bottled breastmilk are used (Combs-Orme & Renkert, 2009; Tamis-LeMonda, Kahana-Kalman,

& Yoshikawa, 2009). As the infant develops, however, fathers and mothers develop different

play and communicative styles with infants and toddlers, a subject discussed later in this chapter

and in Chapter 4 under the heading Play as a Route to Attachment With Fathers. Today many

fathers have prominent, equal, and/or primary responsibilities in child-rearing and childcare,

sometimes by choice and other times by necessity. Sarah Johnson’s dad, for example, became

the primary caregiver for Sarah out of necessity. The gender of the parent is irrelevant in the

development of secure infant attachment. Rather, it is the behavior of the primary caregiver,

regardless of whether it is the mother or father, that has the most influence on infant attachment.

When fathers who are the primary caregivers are able to provide infants with the warmth and

affection they need, infants develop secure attachments to their fathers. In fact, under stress,

fathers become a greater source of comfort to their infants than the mothers who are the

secondary caregivers (Geiger, 1996). And, indeed, some infants and toddlers live in families with

two fathers and demonstrate secure attachment to both fathers. Perhaps the best scenario is when

infants develop secure attachments to both parents. In one study, infants with secure attachments

to both parents demonstrated fewer behavioral difficulties as toddlers, even fewer problems than

toddlers with only secure mother–infant attachment (Volling, Blandon, & Kolak, 2006).

In addition to a more prominent role by fathers over the past 20 to 30 years, more women have

entered the workforce, and many more children experience alternative forms of childcare,

including infant and toddler day care. The effect day care has on the development of attachment

in infants and toddlers continues to be hotly debated. Some argue that day care has a negative

effect on infant attachment and increases the risk of the infant developing insecure and avoidant

forms of attachment (see, e.g., Belsky, 1987; Belsky & Braungart, 1991). The risks are thought

to be especially high if the infant attends day care during the first year of life. Others argue that

day care does not have a negative effect on infant and early childhood attachment (Shonkoff &

Phillips, 2000). Friedman and Boyle (2008) reviewed 23 studies based on the National Institute

of Child Health and Human Development (NICHD) data that tracked 1,000 children from birth

through age 15. These studies found that the number of hours infants spend in nonmaternal care

is not associated with the infants’ security of attachment to the mother at age 15; they also found

that working mothers interact with their infants almost as much as mothers who are not

employed. The most robust finding was that mothers’ sensitivity to their infants during

interaction is a consistent predictor of secure attachment and positive child development. No

main effects were found between the quality and type of childcare and mother–infant attachment.

However, hours in alternative childcare was a risk factor for mother–infant attachment if

combined with other risk factors such as maternal insensitivity and poor quality of childcare.

A study in the Netherlands found that professional caregivers may be alternative attachment

figures for children when their parents are not available, but it is the professional caregivers’

group-related sensitivity, rather than the child’s individual relationship with one professional

caregiver, that promotes a sense of security and safety in children. Girls were found to be more

securely attached to their professional caregivers than boys, however (De Schipper, Tavecchio,

& Van IJzendoorn, 2008). In one study in the United States, day care was found to mitigate the

adverse effects of insecure mother–infant attachment (Spieker, Nelson, & Petras, 2003).

Recently, researchers have begun to study attachment among children in foster care. Most of

these children come into foster care without secure attachments. Once in foster care, many

children are subjected to frequent changes in their foster homes. Problems with attachment may

contribute to foster home disruptions, but foster home disruptions also contribute to attachment

problems. Two policy responses have been recommended to minimize the disruption of

attachment in foster children: (1) matching the foster care strengths and capabilities with the

needs of the child and (2) quick-as-possible family reunification. Existing research suggests that

neither of these policy responses has sufficiently minimized attachment disruptions. Research by

Tucker & MacKenzie (2012) suggests that the age of child, the nature of the circumstances

leading to foster care placement, and the nature of the foster care situations and transitions must

be understood to develop interventions to minimize attachment disruptions in specific children.

Other researchers conclude that institutional care can also have the same devastating effects on

attachment as repeated foster care disruptions (Johnson, Browne, & Hamilton-Giachritsis, 2006).

Let’s look at one other issue concerning attachment. Most studies of attachment have used the

Ainsworth group’s strange situation method. However, this measure may not yield valid results

with some groups or under certain conditions. For example, the insecure avoidant pattern of

attachment some investigators have noted among children in day care may not indicate lack of

attachment, as some have concluded. These children may be securely attached but seem

indifferent to the exit and return of the mother simply because they have become accustomed to

routine separations and reunions with their mother.

The appropriateness of using the strange situation method with certain ethnic groups has also

been questioned. An early study found Japanese infants to demonstrate more insecure anxious

attachment style than infants in other parts of the world and attributed this finding to the fact that

Japanese mothers left their infants in the care of others much less often than mothers in a number

of other cultures (Takahashi, 1990). A more recent study found that the distribution of

attachment styles of Japanese infants was consistent with worldwide norms when the researchers

controlled for the unfamiliarity of separation from the mother (Behrens, Hesse, & Main, 2007).

Conversely, in many cultures infants are cared for by a collective of mothers, older siblings,

cousins, fathers, aunts, uncles, and grandparents. The level of sense of security in these infants

depends on coordinated care of a number of caregivers. The strange situation does not capture

the fluid nature of caregiving and the degree to which it supports infants’ feelings of security and

safety (Lewis, 2005). One study found that in Israeli kibbutz-reared children, one negative

caregiving relationship could negatively affect other attachment relationships (Sagi, Koren-

Karie, Gini, Ziv, & Joels, 2002). Some researchers are using methods other than the Ainsworth

strange situation to measure attachment. For example, in a longitudinal study, a Chilean research

group used an Attachment During Stress Scale (ADS) to measure attachment and found that day

care, compared with maternal care, was not negatively associated with mother–child attachment,

maternal sensitivity, or quality of the home environment (Cácamo, Vermeer, van der Veer, &

van Ijzendoorn, 2016).

In spite of these concerns, findings from a large number of studies using the strange situation in

Europe, Africa, Asia, and the Middle East as well as North America indicate that the attachment

patterns identified by Ainsworth occur in many cultures (Gardiner, 2018). It is important to

remember that attachment theory was developed by European American theorists who

conceptualized attachment as the basis for developing subsequent independence. However, in

more collectivist cultures, attachment is seen as the basis for developing obedience and harmony

(Weisner, 2005).

Attachment and Brain Development

The attachment relationship is a major organizer of brain development and the facilitator of

anxiety and stress management as well as emotion regulation (Cozolino, 2014; Newman,

Sivaratnam, & Komiti, 2015). Attachment directly affects brain development. Gerhardt (2004)

concludes that without emotional bonding with an adult, the orbitofrontal cortex in the brain of

infants (the part of the brain that allows social relationships to develop) cannot develop well.

During the first year of life, the infant must develop the capacity to tolerate higher and higher

levels of emotional arousal. The caregiver helps the infant with this by managing the amount of

stimulation the infant receives. As the right orbitofrontal cortex develops, the infant is able to

tolerate higher levels of arousal and stimulation. However, when the caregiver is not attuned to

the needs of the infant in regard to managing stimulation during the first year of life, negative

emotions result, and growth of the right orbitofrontal cortex is inhibited (Farmer, 2009). This

process has been called the social brain.

In addition, attachment with a sensitive caregiver appears to maximize the integration of neural

circuitry in the right and left hemisphere systems, which promotes the development of emotion

regulation, empathy, and motivation, as well as cognitive skills such as attention and decision

making (Newman et al., 2015). It also helps to develop a “smart” vagus, the tenth and longest of

the cranial nerves in the autonomic nervous system. Polyvagal theory identifies two distinct

branches of the vagus: the dorsal vagus, the more evolutionary primitive branch, responds by

freezing and conserving resources in all bodily systems when threatened. The ventral vagus, the

more evolutionary advanced branch, works to regulate defensive reactions to stress by

stimulating self-soothing and communication with others. Such vagal activity augments the

ongoing interactions between the prefrontal cortex and the amygdala. It is thought that an

attachment bond with a sensitive caregiver is crucial for development of the ventral vagus.

Secure attachment relationships also stimulate growth of glucocorticoid receptors in the

amygdala, hippocampus, and components of the hypothalamus-pituitary-adrenal (HPA) axis, and

high stress during infancy and toddlerhood have been found to cause this system to be poorly

regulated (Cozolino, 2014; Newman et al., 2015).

The emotion centers of the brain are softwired and heavily influenced by early relationships

(Meyer, Wood, & Stanley, 2013). Some research has found that mild-to-moderate disruptions in

early attachment relationships can interfere with right-hemisphere processing and lead to cell

death (Newman et al., 2015). Among other things, the right hemisphere is associated with

attachment, interpersonal relationships, nonverbal communication, and emotional awareness and

memory (Meyer et al., 2013). An often-cited study is a brain imaging study that investigated

brain activation in infants reared in orphanages in Romania. The infants had little contact with an

adult, were left in their cots for most of the day, were fed with propped-up bottles, and were

never smiled at or hugged. The study found that these infants had abnormally low metabolism in

a network of areas involved in stress regulation, including the orbito-frontal cortex. Further

studies have found decreased activation in other regions of the brain involved with emotion

regulation and stress responses (Newman et al., 2015).

One concern is whether these deficiencies in brain development are permanent. Some suggest

that the brain impairments can be reversed if changes in care and attachment occur early enough

(Cozolino, 2014; Meyer et al., 2013; Newman et al., 2015). They highlight the strides in brain

development made by the Romanian orphans who were adopted into caring homes before they

were 6 months of age. Perhaps Sarah Johnson’s improvement was the result of early intervention

and moving her quickly to live with her dad. Others suggest that the brain impairments caused by

lack of attachment with a primary caregiver are permanent (Perry, 2002). Regardless, the

implication is that future brain growth is seriously jeopardized if brain development is not

adequately nurtured in the first 2 to 3 years. We have clear evidence that the human brain is

plastic and changes over time with new experiences, but we also know that it is not completely

plastic; brain vulnerabilities in early childhood predispose one to difficulties in managing social

relationships, and social relationship problems affect ongoing brain development (Farmer, 2009).

The existing literature suggests that early intervention should focus on helping the caregiver to

be reflective about the inner world of the infant (Slade, 2005). The clinician can assist with this

process by modeling such reflection—sharing with the caregiver the clinician-perceived mental

states of the infant or toddler. Newman et al. (2015) note that many caregivers who have

difficulty reflecting on the inner world of their infants had inadequate caregiving as infants and

toddlers themselves. They may not be able to engage in such reflection without resolving issues

related to their own inadequate caregiving through some form of psychotherapy. Cozolino

(2014) suggests that although early experiences are powerful brain shapers, it is never too late to

modify brain structure and functions through personal relationships, psychotherapy, and

increased self-awareness. Neuroscience research is finding that many emotions and cognitions

happen at the unconscious, automatic level and are not easily accessed for conscious exploration.

This is especially true of traumatic memories. Given our commitment to evidence-based practice,

social workers should be aware of empirical evidence of the benefits of adjunct nontalking,

somatic interventions for traumatic memories and post-traumatic stress disorder (PTSD),

including eye movement desensitization and reprocessing (EMDR) (van der Kolk, 2014),

neurofeedback (van der Kolk et al., 2016), and yoga (Mitchell et al., 2014; van der Kolk et al.,

2014). In exploratory study, music therapy has also been found to produce improvement in

PTSD symptoms (Lightstone, Bailey, & Voros, 2015). Although the study of these methods has

centered on adults with PTSD symptoms, they have also been found to be helpful to any adult

with disrupted attachments. Polyvagal theory is being used to develop both biological and

interpersonal interventions to stimulate and improve functioning in the vagus nerve,

interventions that are considered promising for symptom improvement in treatment-resistant

major depression. Such interventions include electrical stimulation of the vagus nerve (Tisi,

Franzini, Messina, Savino, & Gambini, 2014), yoga (Tyagi & Cohen, 2016), and group therapy

(Flores & Porges, 2017). Mindfulness meditation has been found to build better connections

between the amygdala and prefrontal cortex (see Davidson & Begley, 2012) and to improve

stress reactivity and anxiety symptoms associated with generalized anxiety disorder (Hoge et al.,

2013).

The Role of Play

Play is crucial to child development. Play allows infants and toddlers to enhance motor,

cognitive, language, emotional, social, and moral development. Because of their differences in

development in all areas, infants and toddlers play in different ways. Exhibit 3.10 describes four

types of infant play and three types of play observed in very young children. These later types of

play begin in toddlerhood and develop in union with cognitive and motor development. For

example, young toddlers will play with a mound of clay by hitting and perhaps squishing it.

More developed toddlers will mold the clay into a ball, and older toddlers will try to roll or throw

the molded ball.

One zealous mother describes joining the “toy of the month club” in which she received

developmental toys through the mail each month for the first 2 years of her child’s life. This

mother wanted to be sure that her child had every opportunity to advance in terms of motor and

cognitive skills. Although this mother’s efforts are to be applauded, she admits that these toys

were very costly and that perhaps she could have achieved the same outcome with other less

costly objects. For example, there is no evidence that a store-bought infant mobile is any more

effective than a homemade paper one hung on a clothes hanger. The objective is to provide

stimulation and opportunities for play. Fergus Hughes (2010, p. 68) makes the following

suggestions about the appropriate toys for infants and toddlers during the first 2 years of life:

 Birth to 3 months: toys for sensory stimulation, such as rattles, bells, colorful pictures and

wallpaper, crib ornaments, mobiles, music boxes, and other musical toys

 3–6 months: toys for grasping, squeezing, feeling, and mouthing, such as cloth balls, soft

blocks, and teething toys

 6–12 months: colorful picture books, stacking toys, nesting toys, sponges for water play,

mirrors, toy telephones, toys that react to the child’s activity

 12–18 months: push toys; pull toys; balls; plain and interlocking blocks; simple puzzles

with large, easy-to-handle pieces; stacking toys; riding toys with wheels close to the

ground

 18–24 months: toys for the sandbox and water play; spoons, shovels, and pails;

storybooks; blocks; dolls, stuffed animals, and puppets

Exhibit 3.10 • Types of Play in Infancy and Toddlerhood

Researchers have become interested in the impact of new technologies and the effect they have

on type of play, types of toys, and the amount of time spent in play (Bergen & Davis, 2011;

Duch, Fisher, Ensari, & Harrington, 2013). It is not uncommon for children as young as several

months old to be seen playing with technology-augmented toys or with apps on their parents’

cell phones or tablets. The impact of this technology on young children and familial relationships

is beginning to be addressed in research but needs much more attention (Lombardi, 2012). One

research team found that mothers interact less with their toddlers while engaged in play with

electronic toys than when engaged in other types of play (Woolridge & Shapka, 2012). How this

technology-based play affects moral development is another area for further exploration (Bergen

& Davis, 2011). The American Academy of Pediatrics and the government of Australia

recommend that children under the age of 2 should not watch any television or video material

(cited in Courage & Howe, 2010). Courage and Howe (2010) reviewed the empirical literature

on the effects of screen time on infant and toddler development and found the evidence was not

all bad. They found evidence for the following statements:

 Infants do not learn as readily from screen materials as do older children and adults.

 Infants learn more readily from people than from television and videos.

 Infants and toddlers are not passive when viewing television or videos; they engage more

with screen material that is interesting to them.

 Excessive screen time can interfere with time spent on physical activities and creative

play.

 Television and videos do not cause ADHD, but extremely high levels of viewing are

associated with ADHD symptoms; parents may seek relief from constant interaction with

a child with ADHD symptoms by encouraging screen time.

 Background television distracts the play of infants and toddlers.

 Infants spend more time looking at a video if a parent views it with them and talks with

them about it.

 Television can provide a route to early language development in impoverished

environments.

A later study systematically reviewed the results of 29 research reports on the correlates of

amount of screen time in children under 3 years of age published between January 1999 and

January 2013 (Duch et al., 2013). These researchers found that an average of 68% of infants and

toddlers in the reviewed studies use screen media, such as television, DVDs, and video games

daily. The demographic variables most commonly correlated with high screen time are the

child’s age (older) and race/ethnicity (minority). Child BMI, maternal distress/depression, media

time of the mother, and cognitive stimulation in the home were also correlated with screen time

of infants and times. Child BMI increased as screen time increased, screen time was greater if the

mother was distressed or depressed, screen time of the child increased as the mother’s screen

time increased, and screen time increased as cognitive stimulation in the home decreased.

Variables not associated with screen time include child sex, firstborn status, paternal education,

non–English speaking family, two-parent household, number of children in the home, and

nonparental childcare. The associations were unclear for maternal age, maternal education, and

household income.

Another important aspect of play is parent–child interaction. Parent–infant play may increase the

likelihood of secure attachment between the parent and child (Davies, 2011; Hughes, 2010). The

act of play at least provides the opportunity for infants and parents to feel good about themselves

by enjoying each other and by being enjoyed. Even before infants can speak or understand

language spoken to them, play provides a mechanism of communication between parents and

infants. Infants receive messages about themselves through play, which promotes their sense of

self (Scarlett, Naudeau, Salonius-Pasternak, & Ponte, 2005).

Many similarities exist in the way that mothers and fathers play with infants and toddlers but also

some differences. Both mothers and fathers are teachers and sensitive communicators, and both

enjoy rough-and-tumble play with their babies (Roggman, Boyce, Cook, Christiansen, & Jones,

2004). But research has also noted some differences in the ways that mothers and fathers play

with infants and toddlers. Fathers tend to be more stimulating when they play with infants and

toddlers and mothers tend to be more soothing (Feldman, 2003). Fathers engage in more rough-

and-tumble play; they are more likely to lift their babies, bounce them, and move their legs and

arms. Mothers are more likely to offer toys, play conventional games of peek-a-boo and pat-a-

cake, and engage in constructive play. However, mothers have been found to play differently

with infant sons than with infant daughters, engaging in more conversation with daughters and

making more statements about the baby’s feelings when talking with daughters; conversely, they

engage in more direction with sons and make more comments to call the baby’s attention to his

surroundings (Clearfield & Nelson, 2006). Mothers have also been found to be more likely to

follow the child’s lead, whereas fathers are more likely to steer play activity according to their

preferences. Some of these differences have been found in a number of cultures, but it is

important to note that these mother/father differences have not been found in Sweden and Israel,

both societies with more egalitarian gender roles than found in the United States (Hughes, 2010).

Play also is a vehicle for developing peer relations. A few decades ago, it was thought that babies

really weren’t interested in each other and could not form relationships with each other. Recent

research challenges this view (Hughes, 2010). The peer group becomes more important at earlier

ages as family size decreases and siblings are no longer available for daily social interaction.

Researchers have found that very young infants, as young as 2 months, get excited by the sight

of other infants; by 6 to 9 months, infants appear to try to get the attention of other infants; and

by 9 to 12 months infants imitate each other (Hughes, 2010). Although toddlers are capable of

establishing relationships, their social play is a struggle, and a toddler play session is quite a

fragile experience. Toddlers need help in structuring their play with each other. And yet

researchers have found that groups of toddlers in preschool settings develop play routines that

they return to again and again over periods of months (Corsaro, 2018). These toddler play

routines are primarily nonverbal, with a set of ritualized actions. For example, Corsaro (2018)

notes a play routine in one Italian preschool in which a group of toddlers would rearrange the

chairs in the room and work together to move them around in patterns. They returned to this

routine fairly regularly over the course of a year, modifying it slightly over time. Peer relations

are being built by “doing things together.”

Developmental Disruptions

Developmental delay is the name given to a situation in which an infant or toddler has a

significant lag in development in any of the dimensions discussed earlier (Rosenberg, Ellison,

Fast, Robinson, & Lazar, 2013). The delay may be temporary or may be a symptom of a lifelong

condition. Developmental disability is the name given when a child has a lifelong impairment

demonstrated in childhood that results in functional limitations in some dimension such as

mobility, self-care, communication, or learning (Parish, Saville, Swaine, & Igdalsky, 2016). Part

C of the Individuals with Disabilities Act (IDEA) is a nationwide program that provides services

to infants and toddlers with developmental delays in cognitive, motor, communication, and

social and emotional development, but there is no standard definition of what constitutes a

developmental delay (Rosenberg et al., 2013). Premature infants like Holly Hicks, for example,

often need time to catch up in terms of physical, cognitive, and emotional development. At what

point does Holly’s social worker decide that she is not developing fast enough and label her

developmentally delayed? At what point would it be appropriate to decide that she has a lifelong

developmental disability?

Because early interventions for infants and toddlers produce better outcomes in comparison with

interventions for school-aged children (Matson, Fodstad, & Dempsey, 2009; McMahon, 2013),

early detection and diagnosis is key. The Centers for Disease Control and Prevention (2018b),

along with the American Academy of Pediatrics, recommends screening for all types of

developmental delays and disabilities at 9, 18, and 24 or 30 months of age. Parents, grandparents,

early childhood providers, and other caregivers can contribute to developmental monitoring.

Doctors and nurses participate in developmental monitoring during well child visits. A brief

checklist of developmental milestones for infants, toddlers, and young children ages 2 months

through 5 years can be found at www.cdc.gov/ncbddd/actearly/milestones/index.html. This site

also provides brief guidelines for how caregivers can assist infants, toddlers, and young children

to achieve these developmental milestones.

In recent years, researchers have been studying the early impairments of developmental

disabilities such as cerebral palsy, Down syndrome, and seizure disorder (Hattier, Matson, Sipes,

& Turygin, 2011). A more aggressive research agenda has focused on early identification of

autism spectrum disorders (ASD), because early intervention is seen as so critical for this

developmental disability. Typical behaviors with these disorders include impairments in social

and communication development and restricted and repetitive behaviors. Barbaro and

Dissanayake (2012) investigated the early markers of ASD at the ages of 12, 18, and 24 months

to understand how infants and toddlers with ASD could be distinguished from infants and

toddlers with developmental delays that would disappear with time and early intervention. They

found that infants with the most severe symptoms at 24 months had pervasive impairment on all

social and communication items at 12 and 18 months. There was more variability in the

impairments of 12- and 18-month-old infants who would later demonstrate less severe

impairments at 24 months but were still on the autism spectrum. The infants and toddlers with

developmental delays at 12 and 18 months had typical development in every area but language at

24 months. At 12 months the markers of later ASD were deficits in pointing, waving, imitation,

eye contact, and response to name. At 18 months, the key markers were deficits in pointing, eye

contact, and showing items to a communication partner. The same markers were present at 24

months, plus an added marker of deficits in pretend play. The children with developmental delay

showed earlier deficits in pretend play but were performing at the typical level by age 24 months.

Childcare Arrangements in Infancy and Toddlerhood

Human infants start life in a remarkably dependent state, in need of constant care and protection.

On their own, they would die. Toddlers are full of life and are making great strides in

development in all areas. They are bubbling with energy and ideas that often seem improbable

from an adult perspective. They are willful and pushing for mastery in many areas. Caregiving of

toddlers has been compared to “paddling a canoe through the rapids” (Newman & Newman,

2015, p. 194). Societal health depends on finding good solutions to the question of who will care

for infants and toddlers and do so in age-appropriate ways.

With large numbers of mothers of infants and toddlers in the paid workforce and not at home,

this question becomes a challenging one. The United States seems to be responding to this

challenge more reluctantly than other high-income capitalist countries. This difference becomes

clear in comparative analysis of two solutions for early childcare: parental leave and paid

childcare.

Parental Leave

Because of changes in the economic institution in the United States from 1975 to 1999, the

proportion of children under the age of 3 who have mothers in paid employment increased from

24% to 54% and leveled off at about 58% by 2016 (Shonkoff & Phillips, 2000; U.S. Bureau of

Labor Statistics, 2017). About one third of the employed mothers in 2016 were employed part-

time, working less than 35 hours per week at all jobs. In 2016, the employment rate of mothers

increased slightly across infancy and toddlerhood, with a 55% maternal employment rate for

infants under 1 year of age, a 58% maternal employment rate for toddlers ages 1 to 2, and a 62%

maternal employment rate for toddlers ages 2 to 3. A similar trend is occurring around the world.

In response, most wealthy industrialized countries have instituted social policies that provide for

job-protected leave for parents to allow them to take off from work to care for their infants.

Sweden was the first country to develop such a policy in 1974. The Swedish policy guaranteed

paid leave. Other high-income capitalist nations followed suit over time and now offer paid leave

on the birth or adoption of a child as part of their social care infrastructures (Rush & Seward,

2016).

By the early 1990s, the United States was the only high-income industrialized country without a

federal family leave policy (Kamerman, 1996). But in 1993, the U.S. Congress passed the

Family and Medical Leave Act (FMLA) of 1993 (Pub. L. No. 103-3). FMLA requires businesses

with 50 or more employees to provide up to 12 weeks of unpaid job-protected leave during a 12-

month period for workers to manage childbirth, adoption, or personal or family illness. Eligible

workers are entitled to continued health insurance coverage during the leave period, if such

coverage is a part of their compensation package.

Exhibit 3.11 highlights the maternal leave policies in selected wealthy countries in 2009, the last

year for which good cross-national data are available. Most of the countries listed, including the

United States, require that fathers are entitled to the same leave as mothers. That means, for

example, that mother and father could each take a 12-week leave in the United States, or 24

weeks total. In 2011, the United States and Australia were the only affluent countries of the

world that did not offer some paid parental leave at the time of birth and adoption, but Australia

provided families with a universal, flat-rate maternity grant of $5,000 for each new child to assist

with the costs of birth or adoption. In 2011, Australia initiated a paid maternal leave program of

18 weeks at the Australian minimum wage. Many Australian employers offered an additional

paid maternal leave. Four years later, on Mother’s Day 2015, the Australian government

announced that mothers could no longer “double dip” to receive more weeks of paid leave.

Mothers with no employer-provided leave will continue to receive the full Australian paid leave,

but mothers who receive more employer-paid leave than the government provides will get

nothing from the government. If the employer-provided leave is less than the government’s

benefit, the government will only make up the difference (Grose, 2015). This leaves the United

States as the only high-income country without a federal paid parental leave plan. By 2016, some

U.S. corporations had started their own programs of paid family leave, but these are typically

jobs with high pay. In addition, in 2016, 14 states plus the District of Columbia had some version

of paid family leave, and only 18 other states were complying with the federal minimum. In

addition to paid parental leave, European countries also provide birth or maternity grants and

family allowances.

Not only high-income countries provide paid family leave; many low- and middle-income

countries also provide paid parental leave. Although most countries offer more leave for mothers

than for fathers, at least 31 countries provide some leave for fathers. In most countries with paid

parental leave, a social security–type system is used to fund the paid leave. Many countries

reimburse nearly 100% of average earnings, but some only pay a portion of the missed earnings

(Livingston, 2016).

The idea of paid parental leave is a highly contested political issue in the United States, and

somewhat less so in Australia. Researchers who have studied why this policy is so controversial

in the United States compared to countries in other regions of the world have identified three

reasons: (1) a belief in American exceptionalism and hostility to the idea of following the social

policy models of other countries; (2) a greater emphasis on individualism, with each family

responsible for themselves; and (3) a more business-friendly political environment (Rush &

Seward, 2016). U.S. employer hostility to paid parental leave policies was expressed by Randel

Johnson, vice president of the U.S. Chamber of Commerce, in 2007, when he declared that the

business community would wage “all-out war” against any extension of paid parental leave in

the United States (cited in Rush & Seward, 2016, p. 4). During the 2016 U.S. presidential

campaign, Hillary Clinton released a campaign video on Mother’s Day, proposing a new paid

Family and Medical Leave Act (FMLA), with the argument that “strong mothers build strong

nations” (cited in Rush & Seward, 2016, p. 2). Clinton lost the election to Donald Trump, and

although President Trump’s daughter and adviser Ivanka Trump has supported the idea of paid

family leave, it is not on the policy agenda of the administration. In addition to the benefits of

paid parental leave for low-income families, a number of studies have underlined the public

health outcomes of parental leave. For example, a major study by Heymann and McNeill (2013)

found that 10 weeks of paid leave for new mothers was associated with a 9% to 10% drop in

infant and child mortality rates. Other research has found that paid parental leave for both

mothers and fathers improves family health and well-being and contributes to greater father

involvement in parenting and more egalitarian parent–child relationships (Seward & Rush,

2016). Given what we are learning about the important role that early attachment plays

throughout the life course, this is an area for social work advocacy in the United States.

Exhibit 3.11 • Family Leave Policies in Selected High-Income Countries in 2009

Paid Childcare

Historically in the United States, mothers were expected to provide full-time care for infants and

toddlers at home. If mothers were not available, it was expected that children would be cared for

by domestic help or a close relative but still in the home setting. Even in the 1960s, with the

development of Head Start programs, the focus was on preschool-age children; infants and

toddlers were still expected to be cared for at home. Thus, historically there was very little

provision of alternative childcare for most children younger than school age.

This phenomenon has changed dramatically, however, over the last 30 years. As noted earlier, in

2016, 58% of mothers with children under the age of 3 were employed, including 55% of

mothers with children under the age of 1 (U.S. Bureau of Labor Statistics, 2017). Therefore,

alternative childcare has become a necessity in the United States. In 2011, the last year for which

comprehensive data are available, 61% of children in the United States younger than age 5 were

involved in some type of regular childcare arrangement. About one third were not involved in

any regular childcare arrangement, mostly children with unemployed mothers. Almost one

quarter were cared for in organized facilities, 13% in day care centers and 6% in nursery or

preschools. Another 11% were in home-based care with other nonrelative childcare providers,

5% of these in family day care. Another quarter of infants, toddlers, and young children were

cared for by grandparents, 18% were cared for by the father, 7% were cared for by other

relatives, 4% were cared for by the mother while she worked, and 3% were cared for by siblings.

The numbers don’t total 100% because some children are cared for in multiple arrangements

(Laughlin, 2013).

Many advocates for early childcare and education refer to the European model as an ideal for the

United States. Countries in Europe provide “universal” childcare for all children, regardless of

the parents’ income, employment status, race, age, and so forth. These programs are supported

through national policy and funded through public funds. If they pay at all, parents pay no more

than a quarter of the monies needed. Parents in Europe thus pay far less than parents in the

United States typically pay. In 2012, only 1 in 6 eligible low-income families in the United

States received federal childcare assistance (Lombardi, 2012). This is another issue in need of

social work advocacy.

As suggested earlier, there are controversies about whether child day care centers are harmful to

infants and toddlers, but there is growing consensus that nonparental childcare is not inherently

harmful. The type of nonparental childcare must be put in ecological context and considered

along with other variables such as the quality of the childcare, the amount of time spent in

nonparental care, the sensitivity of both parental and nonparental care providers, and

characteristics of the child.

Infants and Toddlers in the Multigenerational Family

Maria, a new mom, describes the first visit her mother and father made to her home after the

birth of Maria’s new infant. “Mom and Dad walked right past me as if I was not there, even

though we had not seen each other for 6 months. I quickly realized that my status as their

‘princess’ was now replaced with a new little princess. During their visit, my husband and I had

to fight to see our own child. When she cried, they immediately ran to her. And my mother

criticized everything I did—she didn’t like the brand of diapers I used, she thought the color of

the room was too dreary for an infant—and she even scolded my husband at one point for

waking the baby when he went to check on her. I appreciated their visit, but I must admit that I

was glad when it was time for them to leave.” Maria’s description is not unique. The

involvement of grandparents and other extended family members in the care of infants and

toddlers may be experienced either as a great source of support or as interference and intrusion

(and sometimes as a little of each). And, of course, cultures of the world have different norms

about who is involved, and in what ways, in the care of infants and toddlers.

Yet the specific roles of grandparents and other extended family members are rarely discussed

within the family, which is why conflicts often occur (McGoldrick, Petkov, & Carter, 2016).

When these roles are clearly articulated and agreed on, extended family members can provide

support that enhances infant and toddler development. Family involvement as a form of social

support is further discussed as a protective factor later in this chapter.

The birth of a child, especially of a first child, brings about a major transition not only for parents

but also for the entire kin network. Partners become parents; sons and daughters become fathers

and mothers; fathers and mothers become grandfathers and grandmothers; and brothers and

sisters become aunts and uncles. The social status of the extended family serves as the basis of

the social status of the child, and the values and beliefs of the extended family will shape the way

they care for and socialize the child. In addition, many children’s names and child-rearing rituals,

decisions, and behaviors are passed from past generations to the next.

To illustrate this point, there is an old joke about a mother who prepared a roast beef for most

Sunday family dinners. She would always cut the roast in half and place it in two pans before

cooking it in the oven. Observing this behavior, her young daughter asked her why she cut the

roast in half. After some thought she told her daughter that she did not know for sure; she

remembered that her mother had always cut her roast in half. Later the mother asked her mother

why she had cut her roast in half before cooking it. The senior mother explained that she did not

have a pan large enough for the size roast she needed to feed her family. Thus, she would cut the

roast in half to fit it into the two pans that she did own.

Here is another example. One mother reports giving her infant daughter herb tea in addition to an

ointment provided by her physician for a skin rash. It seems that this skin rash was common

among infant girls in each generation in this family. A specific herb tea was traditionally used to

treat the rash. This mother confesses that she did not tell her mother or grandmother that she used

the ointment prescribed by her doctor. It is interesting for us to note that although the mother did

not have complete faith in the tea, she also did not have complete faith in the ointment. The

mother states that she is not sure which one actually cured the rash.

Violation of family and cultural rituals and norms can be a source of conflict between new

parents and other family members (McGoldrick et al., 2016). For example, differences of

opinion about baptism, male circumcision, and even childcare arrangements can create family

disharmony. There are many ways to grandparent, and grandparents often jump into the new role

without prior planning or discussion with their children about expectations about the grandparent

role. Complaints can arise about intrusive or indifferent grandparents or, on the other hand, about

demanding or neglectful adult children. New parents inherit any unresolved family issues that

should be dealt with at this time to avoid engulfing the new family in lasting emotional

problems. McGoldrick et al. (2016) suggest that this is a good time to engage new parents in

family-of-origin work. It is also a good time for the grandparent generation to make renewed

efforts to give up old grievances and accept their adult children and their partners as the adults

that they are. They further suggest that grandparents may need reminding that in a society with

high divorce rates, it is wise to keep good relationships with their in-laws to ensure ongoing

access to grandchildren in the case of divorce.

Risks to Healthy Infant and Toddler Development

Unfortunately, not all infants and toddlers get the start they need in life. Millions of infants and

toddlers around the world are impoverished, abandoned, neglected, and endangered.

Collectively, the adults of the world have not ensured that every child has the opportunity for a

good start in life. Not only do these adversities have consequences for the infant’s or toddler’s

immediate development, but research indicates that adversities experienced in childhood can also

have negative consequences throughout the individual’s life span. In a large, well-known study

referred to as the adverse childhood experience (ACE), study investigators examined the

consequences of adverse childhood experiences—including abuse; family violence; and parental

substance abuse, mental illness, or imprisonment—on the infant’s later adult physical and mental

health outcomes (Felitti et al., 1998). Not only did they find a relationship between the two, but

they also concluded that exposure to adversities during childhood, especially abuse and

household dysfunction, increased the likelihood of developing a potentially fatal disease in

adulthood. As the number of adverse childhood experiences increased so did the likelihood of

risky health behaviors, chronic physical and mental health conditions, and early death. You have

probably already surmised what some of the environmental factors are that inhibit healthy

growth and development in infants and toddlers. This section addresses a few of those factors

that social workers are especially likely to encounter: poverty, inadequate care giving, and child

maltreatment.

Poverty

Examining the social science evidence about the effects of family life on physical and mental

health, Repetti, Taylor, and Seeman (2002, p. 359) made the following observation: “The

adverse effects of low SES [socioeconomic status] on mental and physical health outcomes are

as close to a universal truth as social science has offered.” When a family is impoverished, the

youngest are the most vulnerable, and, indeed, children birth to age 3 have the highest rates of

impoverishment around the world (Koball & Jiang, 2018; UNICEF, 2012). Although there are

many ways of measuring poverty, it is generally agreed that 1 billion children across the world

live in poverty, representing 1 in 2 children (Global Issues, 2013). Although children living in

the poorest countries are much more likely than children living in wealthy countries to be poor,

the proportion of children living in poverty has been rising in many of the wealthiest nations

(UNICEF, 2012). Using a relative measure of poverty as income below 50% of the national

median income, the UNICEF researchers found that the percentage of children living in poverty

in 35 economically advanced countries ranged from 4.7% in Iceland to 25.5% in Romania. The

United States had the second highest rate, 23.1%. Fourteen countries, including most European

countries, had child poverty rates of less than 10%.

In the United States, the National Center for Children in Poverty (NCCP) (Koball & Jiang, 2018)

estimates that families need an income about 2 times the U.S. federal poverty level to meet basic

needs, and they refer to families below this level as low income. NCCP (Koball & Jiang, 2018)

reports that, in 2016, 5.0 million (44%) infants and toddlers lived in low-income families, 3.4

million (21%) lived in families below the poverty level, and 1.1 million (10%) lived in deep

poverty. This is a slight improvement over the economic situation of infants and toddlers in

2010, when the country was still recovering from the deep recession of 2008, and is very similar

to the prerecession rates. There are racial and ethnic differences in the rates of children under the

age of 18 living in poverty: 61% of Black children live in low-income families, compared with

60% of American Indian children, 59% of Hispanic children, and 28% of White and Asian

children. When looking at these overall rates for children under the age of 18, it is important to

remember that low-income status is slightly more prevalent in the families of infants and toddlers

than in families with older children. Children with immigrant parents are more likely than

children with native-born parents to live in low-income families, 51% compared with 38%.

Geographical differences also exist in the rates of children in low-income families in the United

States, with children in the South and West being more likely to live in low-income families than

children in the Northeast. About half (53.5%) of low-income children under the age of 18 and

32% of children living under the poverty line live with at least one parent employed full time,

year-round (Koball & Jiang, 2018).

Although some young children who live in poverty flourish, poverty presents considerable risks

to children’s growth and development. (That risk continues from infancy and toddlerhood into

early and middle childhood, as Chapters 4 and 5 explain.) Children living in poverty often suffer

the consequences of poor nutrition and inadequate health care. Undernutrition in infancy and

toddlerhood is a major risk factor for serious health problems at later stages of life, especially if

it is combined with prenatal undernutrition (Barker & Thornburg, 2013).

Negative associations between family poverty and children’s cognitive development begin to

emerge by the end of the second year of life. By age 2, poor toddlers score 4.4 points lower on

IQ tests than nonpoor toddlers. In addition, poor infants and toddlers are more likely to

demonstrate emotional and behavioral problems than nonpoor infants and toddlers. Three-year-

olds who live in deep poverty have been found to display more internalizing behavior symptoms,

such as anxiety, withdrawal, and depression, than other children of the same age (Barajas et al.,

2008). Children are affected not only by the direct consequences of poverty but also by indirect

factors such as family stress, parental depression, and inadequate or nonsupportive parenting

(Davies, 2011). Irma Velasquez’s depression and anxiety will affect her relationship with Henry.

Poor children are also more likely to be exposed to environmental toxins (Hetherington &

Boddy, 2013).

Most disturbing is the link between poverty and infant mortality—the death of a child before

his or her first birthday. In general, infant mortality rates are highest in the poorest countries

(Hug, Sharrow, & You, 2017). Infant mortality rates have been falling around the world, but

there are huge regional disparities, and the infant mortality rate is not falling as rapidly as the

mortality rate for older children. The infant mortality rate in the United States is high compared

with other high-income nations, but Bosnia and Herzegovina, a country with less than one tenth

of the average income of the United States, has achieved a slightly better infant mortality rate

than the United States (Hug et al., 2017). Within the United States, mortality rates for infants are

higher among those living in poor families and for infants in some racial and ethnic groups; the

rate among non-Hispanic Black infants was 11.3 per 1,000 births in 2015, compared with 8.3 per

1,000 births among American Indian/Alaska Natives, 5.0 per 1,000 births among Hispanics, 4.9

per 1,000 births among non-Hispanic Whites, and 4.2 per 1,000 births among Asian/Pacific

Islanders. As you can see, the infant mortality rate among non-Hispanic Blacks is more than

twice the rate among Hispanic, non-Hispanic White, and Asian/Pacific Islander infants; the rates

for American Indian/Alaska Native infants fall in the middle (Centers for Disease Control and

Prevention, 2018c).

Inadequate Caregiving

Because they are so dependent on caregiver assistance in all areas of their lives, infants and

toddlers’ developmental risk is heightened when parents fail to carry out caregiving functions.

There are many reasons why infants and toddlers may receive inadequate care. The care of some

infants is compromised when their mothers suffer from depression. Research indicates that about

8% to 19% of women experience clinical depression following childbirth (Ko, Farr, Dietz, &

Robbins, 2012; O’Hara & McCabe, 2013). Similar rates have been found around the world

(Pearlstein, Howard, Salisbury, & Zlotnick, 2009; Wisner, Chambers, & Sit, 2006). Mothers are

at greater risk of postpartum depression if they face chronic stressors during pregnancy (Liu &

Tronick, 2013), and it is generally accepted that the precipitous hormonal changes at birth, to

which some women seem especially sensitive, play a large role. Mothers who are depressed have

been found to interact differently with their infants than nondepressed mothers. They are more

likely to show negative emotions and behaviors such as withdrawal, hostility, intrusiveness,

coerciveness, and insensitivity (Jennings et al., 2008). They are more likely to be less responsive

to their babies, show less affection, and to touch their infants in more negative ways. They may

fail to protect their infants from harm, and they rate their infants’ behavior more negatively

(Zajicek-Farber, 2009). Infants of depressed mothers have been found to show some negative

outcomes, including overall distress, withdrawn behavior, deficits in social engagement,

problems with sleep and feedings, and difficulty regulating emotions (Leventon & Bauer, 2013;

Muscat, Obst, Cockshaw, & Thorpe, 2014). They are also more likely to show deficits in

cognitive development, language development, and insecure attachment at 1 year and 18 months

(Quevedo et al., 2012).

Postpartum depression often goes undiagnosed and untreated across cultural groups (Dennis &

Chung-Lee, 2006), but it is more likely to receive attention in societies that have regular

postpartum visits from midwives or nurses. Early intervention can help to improve the parent–

child relationship and promote the health of both the mother and the infant. Antidepressive

medications are often prescribed for the mother, and the entire family may benefit from

psychotherapy, parent education, and parent support groups (Bobo & Yawn, 2014). Family

dynamics are often altered when mothers are depressed following childbirth, and research

indicates that infant relationships with fathers and other caregivers can buffer the negative effects

of poor interactions with a depressed mother (Cabrera, Fitzgerald, Bradley, & Roggman, 2014).

Very little research exists on psychosocial and mental health issues for new fathers, but the

Australian First Time Fathers Study attempted to address this gap in knowledge (Condon, 2006).

This study found no evidence of male postnatal depression but did find that male partners of

women with postpartum depression are at risk of depression, anxiety, and abusing alcohol. At

first, most men are confused by their wives’ depression but supportive. If the depression lasts for

months, which it often does, support is usually gradually withdrawn. Men report that they find

their wives’ irritability and lack of physical affection more troubling than the sadness and

tearfulness. This study also found that male partners and other family members of depressed

mothers often take on more and more of the care of the infant over time, which reinforces the

mother’s sense of incompetence. Communication breakdowns are very common in these

situations.

The most pervasive response to inadequate caregiving is nonorganic failure to thrive (NOFTT), a

condition in which infants and toddlers have poor feeding habits and fail to make weight gains

while having no underlying medical condition. Feeding disorders usually show up as food refusal

or low food intake in relation to the infant or toddler age. Feeding problems have been found to

be a concern of 10% to 25% of parents of healthy children under the age of 3, but only 1% to 5%

of infants and toddlers suffer from the severe feeding problems that result in failure to thrive

(Rybak, 2015). Infants and toddlers with feeding difficulties are a heterogeneous group that are

challenging for both parents and health care providers. A basic medical evaluation involving a

multidisciplinary team of dietician, speech pathologist, psychologist, and pediatrician is essential

to rule out organic causes of the feeding problem. Feeding problems occur in 30% of preterm

infants and in up to 80% of infants with neurological impairments or inborn metabolic

dysfunctions (Rybak, 2015). When organic causes are ruled out, psychosocial deprivation and

parental pathologies are often found to be involved. One recent longitudinal study produced

findings consistent with an international scientific literature that infants and toddlers with feeding

problems without organic origin tend to have mothers who are depressed or have a feeding

disorder themselves (Cerniglia & Cimino, 2015). Cerniglia and Cimino (2015) also found that

the fathers of infants and toddlers with nonorganic feeding problems are more likely than other

fathers to have obsessive/compulsive behaviors and anxiety. Another research team has found

that sensory processing problems involving an aversion or negative reaction to certain types of

sensory stimuli are more common among toddlers with NOFFT (Yi, Joung, Choe, Kim, &

Kwon, 2015). Research also indicates that around 18 months of age, many toddlers demonstrate

a period of neophobiaand begin to reduce the number and variety of accepted foods, with the

consumption of meat, vegetables, and fruits being dramatically reduced (Rybak, 2015). With

repeated exposure, this phase usually passes. As you can see, feeding problems and failure to

make weight milestones can be tricky in infancy and toddlerhood. A thorough evaluation by a

multidisciplinary team is critical, and parents must be approached with sensitivity and without

prejudgement (Sipotz, 2015). A social worker can be an invaluable member of the diagnostic and

treatment team.

Ongoing parental conflict, harsh parenting, and parental mental illness and substance abuse are

also risk factors for infant and toddler development. When there is a high level of parental anger

and conflict, parents typically become less available to the infant or toddler, creating an insecure

home environment (Struge-Apple, Davies, & Cummings, 2006). Research indicates that infants

and toddlers raised with high parental conflict have more active stress response systems. Parents

who react to a toddler’s assertive and limit-testing behavior with harsh discipline provide a

model of aggression for solving relationship issues (Bayer et al., 2011). Serious parental mental

illness, including chronic depression, bipolar disorder, post-traumatic stress disorder (PTSD),

and schizophrenia, often compromise the ability of parents to meet the needs of infants and

toddlers (Goodman & Brand, 2009; Natsuaki et al., 2010). Severe and chronic maternal

depression has been associated with insecure attachment (Goodman & Brand, 2009).

Parents whose lives are organized around accessing and abusing legal and illegal substances are

4 times more likely than other parents to neglect their infants and toddlers (Street, Whitlingum,

Gibson, Cairns, & Ellis, 2008). For example, opioid use during pregnancy increased in the

United States from 1.19 per 1,000 births in 2000 to 5.63 per 1,000 births in 2009 (Patrick et al.,

2012). Given these recent trends, it is not surprising that the incidence of neonatal abstinence

syndrome (NAS) has increased by 300% since the 1980s (Sublett, 2013). NAS develops in

infants exposed to opiates during pregnancy and often leads to infant withdrawal, with symptoms

typically appearing 48 to 72 hours after birth. NAS often requires lengthy hospital stays, and

symptoms can last up to 6 months after birth (Sublett, 2013). There is little rigorous research

concerning outcomes for infants with NAS. The limited research available suggests that in

general, opioid-exposed infants are more likely to have attention deficit disorders, disruptive

behavior, and the need for psychiatric referrals (Ornoy & Yacobi, 2012). Also of concern is the

effect of withdrawal on the infant’s growth and development and the impact it has on maternal

bonding. Infants with NAS often demonstrate excessive crying, irritability, poor sleep, rigid

muscle tone, tremors, hyperthermia, excessive sucking with poor feeding, loose stools, yawning,

sweating, nasal stuffiness, and sneezing, all of which can affect mother–child bonding and

attachment. Social workers provide support to pregnant women and mothers attempting to

remain free of opiates. Here is an example. Kim had been receiving treatment at a methadone

clinic for 5 months for long-term heroin addiction when she found out she was pregnant. The

staff at the clinic referred her to a substance abuse support program for pregnant women and new

mothers staffed with social workers. Through individual and group counseling, along with case

management, Kim was able to reduce the amount of methadone needed to remain heroin-free.

She had difficulty finding prenatal care because many physicians in her area were reluctant to

take patients who are on methadone during pregnancy. With some arm twisting from the social

worker, the doctor agreed to provide prenatal care, and Kim had a successful delivery. About 4

or 5 days after the birth, Kim’s infant demonstrated only mild symptoms of NAS. The hospital

made a referral to child protective services who investigated but did not take custody of Kim’s

infant after learning from the social worker the consistent work Kim had demonstrated in

remaining drug-free. Kim continued in the substance abuse support program and continued to

remain drug-free and provide quality care for her new daughter.

Child Maltreatment and Trauma

National data indicate that in 2015, 683,000 children in the United States were assessed to be

victims of abuse or neglect. (It is important to note that it is generally assumed that many abused

and neglected children never come to the attention of government authorities.) Infants from birth

to 1 year of age have the highest rate of victimization, at 24.2 per 1,000 (Child Welfare

Information Gateway, 2017). The youngest children are the most vulnerable to child

maltreatment. For all age groups, 75.3% of confirmed cases of child maltreatment involved

neglect, 17.2% involved physical abuse, 8.4% involved sexual abuse, and 6.2% involved

psychological abuse.

The effect of child maltreatment and other trauma on the brain during the first 3 years of life has

been the subject of considerable study in recent years (Farmer, 2009; Fawley-King & Merz,

2014). Remember that neuroscientific research has clearly demonstrated that the brain is plastic

throughout life, which means it is shaped by experiences across the life course. Research

indicates that several brain parts involved in responses to stress are especially disrupted and

changed by traumatic events during the first 3 years of life. They include the brain parts that

regulate homeostasis (brain stem and locus coeruleus); form memory systems and regulate

emotion (hippocampus, amygdala, and frontal cortex); and regulate the executive functions of

planning, working memory, and impulse control (orbito-frontal cortex, cingulate and dorsolateral

prefrontal cortex). In addition, the major neuroendocrine stress response system, the

hypothalamic-pituitary-adrenal (HPA) axis, is also impacted by trauma. Research indicates that

early life stress, such as child maltreatment, can lead to disruptions in HPA axis functioning and

result in anxiety disorders and depression in adulthood (see Fawley-King & Merz, 2014).

The child who experiences maltreatment or other trauma at the age of 2, 3, or 4 is at risk of

developing memory problems, difficulty regulating emotions, and problems integrating sensory

experiences. Research shows that people who experience childhood trauma are more likely to

develop decreased volume in the hippocampus, a brain characteristic also found with adults

experiencing PTSD. Injuries to the hippocampus have been found to be associated with cognitive

impairments, memory deficits, poor coping responses, and dissociation (Farmer, 2009). When a

child is exposed to extreme stress or trauma, the autonomic nervous system is activated, resulting

in increased heart rate, respiration, and blood pressure. The child may freeze in place before

beginning to fight. In the case of child sexual abuse, the child may dissociate, or detach from

what is happening, becoming compliant and emotionally numb (Fawley-King & Merz, 2014).

As noted, 75.3% of all confirmed cases of child maltreatment involve neglect. Child neglect is

thought to occur when caregivers are ignorant of child development, overwhelmed by life

stresses, or struggling with mental health or substance abuse problems. Children who experience

neglect in the early years of life often do not thrive. Much of the early human research on child

neglect focused on Romanian children who were placed in state-run institutions with few staff

(staff–child ratio of 1:60) and very little sensory and emotional stimulation. At 3 years of age,

these children were found to have delays in physical growth as well as in motor, cognitive, and

language skills; they also had poor social skills. Preliminary research suggests that neglect leads

to deficits in prefrontal cortex functioning (attention and social deficits) and executive

functioning (planning, working memory, and impulse control). Working memory is key to

learning. Early evidence suggests that these changes in brain functioning are related to

difficulties in managing emotions, problem solving, and social relationships. Most troubling is

the finding that children who are neglected early in life have smaller brains than other children;

they have fewer neurons and fewer connections between neurons. Social workers need to keep

abreast of the developing neuroscience research on the effects of child maltreatment and other

forms of trauma on brain development, but we must also remember to put the brain in context.

We must advocate for policies that ensure parents have the best available resources to provide

the type of parenting infants and toddlers need. We must also encourage research that examines

how to heal the disrupted brain.

An association has also been found between infant temperament and abuse (Grogan-Kaylor &

Otis, 2007). Infants who have “difficult” temperament are more likely to be abused and

neglected. The combination of difficult temperament and environmental stress increases the risk

of child abuse. Infants and toddlers with mental, physical, or behavioral abnormalities are also at

a higher risk for abuse (Guterman & Embry, 2004). Regardless, interventions with infants and

toddlers who have experienced abuse and neglect should be administered as soon as possible

with the infant and caregiver, and focus on the infant–caregiver relationship (Osofsky, Stepka, &

King, 2017).

Protective Factors in Infancy and Toddlerhood

Many young children experience typical growth and development despite the presence of risk

factors. They are said to have resilience. Several factors have been identified as mediating

between the risks children experience and their growth and development. These factors are

“protective” in the sense that they shield the child from the consequences of potential hazards.

Following are some protective factors that help diminish the potential risks to infants and

toddlers.

Maternal Education

International research indicates that the education of the mother directly affects the outcome for

infants and toddlers. This effect has been found in very poor populations in low-income

countries. Longitudinal research of families in the poorest parts of Ecuador found that maternal

education was a strong predictor of children’s cognitive development at 36 months (Schady,

2011). Longitudinal research of a birth cohort from one Brazilian city measured the social,

motor, communication, and cognitive development of infants and toddlers at 3, 12, and 24

months of age and found the level of maternal schooling to be associated with developmental

outcomes at all three ages (Barros, Matijasevich, Santos, & Halpern, 2010). Another research

team investigated the risk and protective factors for child health in 42 developing countries and

found that maternal education has a substantial influence on child health (Boyle et al., 2006).

Given these findings, it is not surprising that all the researchers cited in this paragraph

recommend education of girls and women as a protective factor for children.

Similar results have been found for another group of high-risk infants and toddlers—those born

at very low birth weight (VLBW). One research team followed a group of VLBW infants in

Taiwan during the first 2 years of life and found that maternal education and 6-month

neurological status were the most significant predictors of the developmental trajectory from

birth to age 2 (Wang, Wang, & Huang, 2008).

Social Support

Social support is often found in informal networks, such as friends and extended family

members, or in formal support systems, such as the church, community agencies, day care

centers, social workers, and other professionals. The availability of social support seems to

buffer many risk factors, such as stress experienced by parents (Werner & Smith, 2001). For

example, Mrs. Hicks could truly benefit from having the opportunity to take a break from the

stresses of caring for Holly. Both formal and informal social support can fill this gap for her. One

research team found that a combination of formal and informal social support, including both

instrumental and emotional support, enhanced the ability of homeless mothers to provide

consistent parenting (Marra et al., 2009).

Extended family members often serve as alternative caregivers when parents cannot provide care

because of physical or mental illness or job demands. Reliance on an extended family is

particularly important in some cultural and socioeconomic groups. In cultures where families

live in multigenerational households, shared caregiving has been found to serve as a protective

factor in situations where risk factors are involved (Feldman & Masalha, 2007). Sarah’s dad,

Chris Johnson, probably would not have been able to care for her without the support of his

family. And it is through the support of his family that he has been able to continue his

education.

Easy Temperament

There is evidence that infants with an easy temperament are less likely to be affected by risk

factors. In a study of resilience in children exposed to domestic violence, one research team

(Martinez-Torteya, Bogat, von Eye, & Levendosky, 2009) found that easy temperament was a

significant predictor of resilience in 2-, 3-, and 4-year-old children. Another research team

(Derauf et al., 2011) found that easy infant temperament was associated with better behavioral

outcomes in 3-year-old toddlers who had been exposed prenatally to methamphetamine. The

association between easy temperament and “protection” is both direct and indirect. Infants with a

positive temperament may simply perceive their world more positively. Infants with a positive

temperament may also induce more constructive and affirming responses from those in their

environment. Researchers have found that mothers of infants with easy temperament are less

likely than mothers of infants with difficult temperament to become depressed (Montirosso et al.,

2012; Solmeyer & Feinberg, 2011).

National and State Policy

Many social workers and others advocate for better national and state policies that will enhance

good health among infants and toddlers, build and support strong families, promote positive

early learning experiences, and create systems that advance the development and well-being of

infants and toddlers. This includes legislation and financial support to ensure things such as

adequate health coverage for infants and toddlers, paid parental leave and childcare, improved

policies and programs that prevent child abuse, and development of programs and policies that

promote parental and infant mental health. Also, continued support of national programs like the

Women, Infants, & Children (WIC) program and the Child and Adult Care Food Program

(CACFP) are considered crucial to promoting healthy physical development in infants and

toddlers. Other advocates promote improving existing social and educational programs. Knitzer

(2007), for example, identifies what she wittingly refers to as legislation to improve the odds for

young children. She suggests investing more federal and state financial resources to extend

programs such as Early Head Start to incorporate home visiting, center-based instruction, and

family support for all low-income babies and toddlers through (instead of up to) age 3. There is

strong evidence that the tax and social welfare policies of other economically advanced countries

are doing a better job of alleviating child poverty than the policies in the United States (UNICEF

& World Bank Group, 2016). This has long-term consequences for the health of a society.

Implications for Social Work Practice

Knowledge about infants and toddlers has several implications for social work practice.

 Become well acquainted with theories and empirical research about growth and

development among infants and toddlers.

 Assess infants and toddlers in the context of their environment, culture included.

 Promote continued use of formal and informal social support networks for parents with

infants and toddlers.

 Continue to promote the elimination of poverty and the advancement of social justice.

 Advocate for compulsory health insurance and quality health care.

 Advocate for more affordable, quality childcare.

 Collaborate with news media and other organizations to educate the public about the

impact of poverty and inequality on early child development.

 Learn intervention methods to prevent and reduce substance abuse.

 Help parents understand the potential effects of inadequate caregiving on their infants,

including the effects on brain development.

 Help parents and others understand the association between child development and

consequential outcomes during adulthood.

 Provide support and appropriate intervention to parents to facilitate effective caregiving

for infants and toddlers.

Key Terms

 attachment 96

 brain plasticity 87

 cognition 88

 concrete operations stage 88

 developmental delay 103

 developmental disability 103

 developmental niche 77

 formal operations stage 89

 infant 77

 infant mortality 108

 information processing theory 90

 motor skills 85

 myelination 87

 neurogenesis 86

 neurons 86

 object permanence 89

 preoperational stage 88

 reflex 84

 sensorimotor stage 88

 sensory system 83

 separation anxiety 89

 stranger anxiety 89

 symbolic functioning 88

 synapses 86

 synaptic blooming 87

 synaptic pruning 87

 synaptogenesis 87

 temperament 95

 toddler 77

 transitional object 97

 working model 97

Discussion

The parents of Jesus, Mary, and Joseph did not have room to spend the night, and they

ended up in an animal send. Mary went into labor and gave birth to a baby boy who was named

Jesus. Due to motherly love, Mary wrapped her son with cloths and placed him onto a manger to

protect him from cold. Just like any parent would be protective of their child Mary wanted to

make sure her son was safe regardless of the situation she had given birth. Mary and Joseph

protected the baby Jesus because it was their duty as parents to make sure the child gets the best

care. Jesus may not have been born in a healthy environment, which was a risk to his health, but

Mary protected him with clothes.

Mary and Joseph spent their time taking care of baby Jesus and creating a bond with him

at an early age. Interaction with infants and toddlers has an influence on the baby’s body and

brain development. Parents should learn to interact with infants as soon as they are born because

it is a way of shaping their life, and infant development will have a role to play in future growth.

Infants need to feel loved and protected to avoid developing emotional and mental issues as they

grow up.

Environmental safety and nutrition also influence an infant’s body and brain

development. It is the duty of the parents to make sure a safe environment surrounds their

infants. In the case of Jesus, he was swaddled with clothes by Mary after birth and placed in a

manger where he could remain warn and safe from external harm. For effective toddler

development, parents should ensure a healthy environment surrounds their infants (Dulcan,

2015).

References

Dulcan, M. K. (Ed.). (2015). Dulcan's textbook of child and adolescent psychiatry. American

Psychiatric Pub.

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