Editor’s note: This text-based course is an edited transcript of the webinar, Using What We Know About How We Grow: Utilizing Development as an Assessment Tool for Early Childhood Services, presented by Alison D. Peak, MSW, LCSW, IMH-E.
Learning Outcomes
After this course, participants will be able to:
- Identify an array of developmental milestones in both the physical and social-emotional domains.
- Identify both structured and unstructured methods of assessing development.
- Consider the role of development in understanding traumatic experiences and identifying treatment interventions.
Introduction
My lens is in this place of early childhood trauma. My clinical work is with children who have experienced trauma before the age of six. That often entails working with children, either in the child welfare system or with international adoptions. While this is my lens, that often means that this is the place where my stories draw from, and my lived experience is. But so many of the things that we talk about are generalizable outside of the early childhood field. One of the things that I often talk about, when I get the opportunity to train and to teach at local universities, is this piece that makes early childhood unique is that being a child has a universality. We don't always know what it is to have had a substance abuse issue or to have been in a domestic violence situation, but we all know what it is to be three-years-old. We all have an inherent experience of what it is to try to get our needs met and for someone to not understand us or to be the smallest person in the room and not always have people understand that we have a perspective and experience at hand. Being able to recognize that universal experience and how it plays into the development of individuals as a whole, their personality formations, identity formation, ability to engage in relationships, and manage stress across the lifespan, is essential to the work that we do, as social workers. It's essential to being able to really consider the whole realm of what's occurring in a client's life and how we best meet their needs where they are.
Child Development
- Generally all Social Work programs require some level of HBSE education and childhood development training
- Few programs emphasize child development as marker for assessment and intervention
- An awareness of developmental milestones and frameworks assists social workers in understanding an individual’s strengths, areas of growth, experience as a child, and current foundation for relationships
Generally speaking, in all social work programs and social work education, there is some level of Human Behavior in the Social Environment (HBSE) education. At some point, some of us in a BSW program learned some basic information about child development from prenatal and pregnancy through death and dying. We have all had that to some extent. But, oftentimes that really is the only look at child development that we get from an educational standpoint. We are really trying to cover the entire lifespan in one semester. That can often get complicated and it also means that maybe we didn't get a super thorough dive. Very few programs really look at child development in an intensive way, and even fewer of those really talk about how that developmental knowledge and awareness translates into a place of assessment for treatment planning and intervention, and long-term conceptualization of presenting issues. I think that this is going to be an interesting conversation as we take some of those base concepts that we all know and look at what that means for us in a point of action and how we take it to a place of engagement. This also allows us to be able to identify the strengths of individuals, areas of growth, and what we in psychodynamic early childhood work refer to as an internal working model. Just as in Cognitive Behavior Therapy (CBT) it would frequently be considered your core belief, like the thought of what is it internally that I know about myself and how I am with the world and how the world is to me. These things are rooted in the place of what our experiences are that overlay, much like an old-school transparency, with our child development at that time.
Child Development Review
- Social Smile at 6 weeks
- Stranger Anxiety at 8 months
- Pointing by 12 months
- Should be increasing ability to self-soothe, move away from caregivers to engage in interesting activities by 18 months
- Walk by 1, Talk by 2
- Vocabulary by 2: 250 words, by 3: 500
- Night terrors are typical around age 3
Let's review for a bit. At some point, we all probably had a quiz on these things. Very rarely is it the thing that we pull out of our back pocket and turn into an active place of assessment. From the moment of birth, we know that all children are born with three capacities. They are born knowing the smell of their mother, knowing their mother's voice, and with some sense of fear of heights or fear of falling. That's really a survival mechanism. Babies fear falling because if they fell, more likely than not they would die. Outside of that, at the point that you're born, you can only see about six inches from your face and you can't see anything in color. Our capacities are limited. Newborns are not blank slates. They are not completely feelingless, thoughtless blobs, as has been sometimes the assumption historically. We know from T. Berry Brazelton's work that even hours after birth we can get babies to be able to regulate themselves in their own body temperature and regulate their own emotional states. They will turn their heads to follow sounds, especially the sound of their mother's voice. They will track objects and they show a keen interest in what is going on around them and how they are taking in that greater world.
By six weeks we're looking for the development of a social smile. Many parents will be very insistent that babies smile before six weeks. That happens sometimes, but it is pretty rare. By six weeks we're looking for babies to smile with the intent that there is an emotion associated with it, that they do feel happy, and that, typically, with that social smile, they have also associated that someone is going to smile back at them. This is an indication of connection and of joining.
By eight months we are also looking for babies to be able to identify clear stranger anxiety. This goes into that thought of diagnosis around separation anxiety. At eight months, we want to see some separation anxiety. We want to see that if someone a child has never seen before walks into a child care center and picks up a nine-month-old, that baby should shriek. Again, there is survival inherent in that. "I don't know this person and I don't know that they're going to keep me safe." The assumption is that this is dangerous and I need to let somebody know. We're really looking for infants to have developed this sense of seeking out their primary caregivers and wanting to maintain close proximity to them. At this point in development, we're not looking at that from a place of concern or a place in which a later diagnosis of separation anxiety would be plausible. That later diagnosis looks at a bit more age and a bit more intellectual capacity to really anticipate separation, and to fully understand object permanency in some of those pieces. We can't see really intense separation anxiety in young kids, two to three years old, but we are looking for it as a positive developmental marker by eight months.
We also want to see pointing by 12 months. I can remember years ago when the first article on the impact of pointing was published. It was such an interesting landmark piece around something that many people had often taken for granted. Children pointing by age one was indicative of so much, including the sense that adults would enjoy what children found enjoyment in and that adults would be able to identify what they were looking for. Children pointing are attempts at shared connection and at some level of communication. Pointing also is a signal in early childhood that children are aware that their thoughts are not identical to those of adults.
One of the first markers that we see for children on the autism spectrum is that they did not develop the capacity to point and that when adults point, they often cannot track it. They know you're pointing, but they cannot figure out why, or where, or what you're referencing in that gesture. Pointing by 12 months is indicative of this place of positive connection, of independent thinking, and of beginning development of theory of mind. It's also a place where in situations of high levels of neglect we see that this is a milestone that often won't develop. There hasn't been shared connection, there hasn't been an experience that people see and hear me, or that someone is going to know that I want something through this gesture. That piece of social communication will often lag.
By 18 months, we're looking for an increased ability to self-soothe and to move away from caregivers and engage in other activities. We are also looking for them to come back. Often in relationships, we talk about this piece of looking for kids to make a circle. We are looking for them to start with caregivers, go out to explore, and come back to be admired, in that very classic circle of security language. They should come back, meet this reference point, and know I am safe to move out and go away and look at new things. Also, there will be a point I need to come back. I am not constantly on my own. I am not alone in the world. There are times that I'm going to need adults to meet my needs. The classic adage is walk by one and talk by two. We're looking for kids to be able to walk somewhat independently by 12 months. Some kids are more stable than others. There are definitely babies that walk by nine months. But, we start to get concerned about gross motor skills if babies are 13 months plus and still not walking.
It’s the same thing with talk by two. The standard is that by two we're looking for kids to have some level of language. Single words are sufficient. We're not looking from a developmental trajectory for words to be paired until between two and a half and three years. Even at that point we're still looking at just two to three-word sentences. Again, some kids develop quickly in that area and other kids are a little more behind. But by two, we are looking that there's some capacity for language. Generally speaking, by two, kids should have about 250 words in their vocabulary. When we add up words such as ball, milk, cookies, dog, cat, mom, dad, and grandma, it's not difficult to get to 250 words without there being a lot of linking. In linking, we are thinking about that idea of putting words together such as, "Ball go?" "Outside?" We want there to be some kind of intentionality and that the words are more complex than just naming objects.
Definitely by three years we are looking at a vocabulary of about 500 words. Again, we are really looking for those words to begin to get connected and to see some level of verbiage and some general grammatical structure.
One of the other pieces that we know is kind of a precipice for parent anxiety. In this birth to three age range is the development and existence of night terrors. Night terrors are these super intense horrific dreams that kids at about age three will have. They often wake up in the middle of the night in cold sweats, are shrieking and screaming, completely inconsolable, and totally unconscious. They don't remember it the next morning. They have no recollection of it. They are incredibly anxiety-provoking for adults who watch kids go through that process, and not at all anxiety-provoking for children themselves. Part of what causes night terrors in this classical developmental sense is that kids are not fully regulated in their sleep patterns, and so they drop into a really heavy REM sleep, but can't bring themselves out of it. That kind of REM cycle starts and is pretty heavy and they're stuck down there for a while. Whereas adults, when we get too deep we know to come back up, so our body regulates in that sleep cycle a lot easier. Kids who struggle with night terrors are really, really asleep. In that place we'll often see referrals around this age. We will often see lots of communication with pediatricians about concerns for sleep. It is much more related to their bodies beginning to process sleep cycles and less to do with actual anxiety-provoking events for the child themselves.
Child Development 3-5
- Increased vocabulary to generally appropriate grammar and 5,000 words by age 5
- “Trying on” of different roles through play and projection
- Egocentrism - I make everything in the world happen and bad things that happen are all my fault
- Beginning of friendships with peers. Lots of imaginative play. Use of play as a method of mastery
- Capacity to follow parental expectations when parents aren’t present
- Increased ability to regulate self when parents aren’t physically present
By five years we are looking at a vocabulary of about 5,000 words, and grammar should be pretty close to appropriate. We will see kids at this point misconjugate verbs from time to time. They will say things such as, "They was," or "He done gone," things that, again, are not grammatically correct, but there is this clear sense of past and present tense, of multiple sections to a sentence, and of using a verb. By five we are also looking for kids to have a clear marker around the use of "I" and "me." For example, "I went to the playground.” "They gave the ball to me." Not, "Me went to the playground." That shows a clear understanding of how to utilize those words and pronouns. Grammar is an ongoing work of art, but, by five, most kids have a pretty good grasp on it.
From ages three to five we are also seeing a lot of what we call trying on, or mastery of different roles, through play and projection onto play. Playing house and dress up, being superheroes and Power Rangers, fighting off bad guys, and working in that place of mastery through play, help children manage things that they are concerned about.
From ages three to five we also see heavy amounts of egocentrism, which is completely developmentally appropriate, and at times frustrating. One of my favorite stories is about my nephew who was probably two and a half to three and a half years old. He had an Elmo doll and when you pushed Elmo's chest it would say, "Elmo is happy to see you." He would always say, "Elmo is happy to see me" as if Elmo was programmed specifically for him and not anybody else in the entire world. At that age it really does feel, from our perspective, that the entire world revolves around us as individuals.
There is a certain level to which egocentrism hangs on throughout our lifetimes. I think, generally, one of the conditions of humanity is that we all believe we control things, way more than we probably have any impact on. We associate that things are much more quickly our fault, and being able to give grace to that. When we really are in this age of three to five years, egocentrism really does dictate that everything that happens in the world, good and bad, are as a result of something we have done. For example, I took a nap and then the dog died. It must have been because I fell asleep, not because the dog ran outside and got hit by a car. We don't have the ability to connect cause and effect in those ways. Because we feel that everything in the world is our fault, that associates to even the very big things. When we talk about this place of childhood trauma, then that also goes with the sense of I have experienced abuse because I am bad. I made those people that angry. I did something that resulted in getting punched, burned by cigarettes, or left outside on the porch for extended periods of time.
In this three to five range we also see the beginning of friendships with peers. Between three and five lots of kids are in some kind of child care setting, whether that’s voluntary pre-K, preschool, or something else. With that, there is the beginning of deeper friend relationships. Prior to about three years old, we see opportunistic play. "I wanna play with the blocks, Joey's also in the blocks. Joey and I are friends as long as we're in the blocks.” But, in 15 minutes when I wanna play outside, then “Brandon's outside and now I'm gonna play with Brandon." But, from three to five years, we see kids seeking out other peers out of preference, really preferring to engage in activities because of who is engaging in the activity, less than the activity itself. We start to see them really engaging in imaginative play with peers, whether that is playing house where everybody has a role, or everyone is playing Power Rangers and gets their own spot. Think about how those concepts then kind of build on top of each other.
Three to five is also the place where we see the beginning of kids’ capacity to follow parental expectations when parents aren't present. "You stand right here. I'm going to walk around the corner and I'll be right back." The kids can hold on to the expectation that they are supposed to stay in one place. Think about Kohlberg's moral development and the idea of the marshmallow test, when the child is given the marshmallow and told, “If you don't eat it then I'll give you two when I come back.” Then adults can exit the room. Not all kids, but a fair number, are able to hold that expectation internally in anticipation of what's to come.
Also, kids at this age are at an increased capacity to regulate themselves when parents are not present. When we think about infants, they really have to have an adult to be able to self-soothe. They have got to have somebody who will pick them up, who will hold them, who will rub their back, who will give them food, and blankets, and bottles, and pacifiers, and all of the myriad of things. By three to five, kids are spending lots of time out of their day without their primary caregiver. They can begin to engage in self-soothing by saying, "I am sad and I need some time alone” or, "I really need to go find my teddy bear” or, "I want to call my mama." They can ask for what it is that they are after, and much more clearly be able to regulate their own emotions without having that caregiver right by their side.
Child Development 5-10
- General slowing of developmental milestones, by deepening of foundational capacities - fine motor skills improve, grammar and syntax expand, friendships are more stable and consistent
- Formulation of individual hobbies, routines (dance, basketball)
- Ability to predict patterns of behavior
- Resolution of fantastical thinking by age 8
- Beginning to identify perspectives of others
In that five to 10 range, what we see is a general slowing of developmental milestones. Between birth to five, the brain’s capacity for development and learning and increases through synapses are pretty intense. Then we see that narrow down between five and 10 as kids are not growing as rapidly. The percentage of growth between when kids are born and when they are five is exponential. While kids do continue to grow between five and 10, it is not on the same scale. What we do see is rather than this rapid development of new milestones, a fine-tuning, and a deepening of the milestones that do exist. We've learned to walk, we've learned to run and now we spend lots of time practicing how to be the fastest. We have learned to begin to draw and write, so now we spend time practicing handwriting. We are taking milestones we've already hit and fine-tuning them to a place where they're much more adult-like in their capacities and able to get a deeper learning from those.
We also see, between five and 10, that kids really do develop their own hobbies and routines and that they have an activity that they really prefer to engage in. They are beginning to set their own typical routines. "Every Saturday morning I have Cheerios, and then I watch this on TV, and after that, I play outside." They have rhythms to their daily process that are pretty consistent and stable.
Kids in this age range are also able to predict patterns of behavior. "I spilled my juice on the carpet and I know that's gonna make Mama mad. And when Mama gets mad, then sometimes she sings, and that means I should go play in my room." They can clearly connect cause and effect and have a really good idea of what is to come. For example, "I know that if I get in trouble at school because I hit somebody on the playground, then Dad's gonna be upset when he picks me up." We're looking in that same place of being able to predict patterns of behavior, that kids are also beginning to be able to identify perspectives of others who are engaged in that behavior. "I kicked somebody on the playground, and then Sarah cried because it hurt and her feelings were sad." They may not be able to fully realize all of the layers of how now Sarah doesn't want to be your friend because this is the third time you kicked her this week. But they can begin to associate with what that perspective is, and what the feelings may have been for the other child or adult, or whoever in question in this situation.
By age eight kids usually have a pretty clear resolution to fantastical thinking. Fantastical thinking is the line between what is real and what is fantasy. By age eight, they should know that unicorns don't exist and should have some real doubt and conversation about doubt around things like Santa and the Tooth Fairy. One of my kids is six right now and is super fascinated with this. He will watch TV and say, "Mom, Paw Patrol's not real, right? Like, they're not down the street, right? Like, we can't go meet them." He has this idea that these are characters that he knows and things that he understands about them, and they have feelings and likes and dislikes, but yet they don't exist.
There's a real play at this six to eight age around understanding what is real and what is make-believe. When we see fantastical thinking extend beyond age eight, it is definitely a place for assessment of what is motivating that. There are some real reasons why kids would hang on to fantastical thinking beyond that, and some of them do include developmental delays and some kind of cognitive difficulty. There are others, but those are generally primary.
Neurological Development
- Synaptic connections develop rapidly in the first 3 years of life
- Generally the idea of “if you don’t use it you lose it” but also “what fires together wires together.”
- Oxytocin and Cortisol are used by the brain from birth to regulate emotions and to send clear signals about activities and relationships that are un/safe.
- Increased levels of oxytocin and cortisol act as reinforcers within the neurological system that result in increased number of oxytocin/cortisol receptors for life.
- Neurological developments occur from the brain stem forward, resulting in greater development in complex areas of through as we age.
When we think about neurological development, as I said a few minutes ago, one of the things that we think about often is the time between birth and 36 months because the number of neural connections that are made is about a million a minute. Those synaptic connections are rapid and constantly firing. We know that if you don't use it, you lose it. If we are not developing capacities in a wide range in early childhood, then it's a lot harder, later on, to make your brain do those things. One of the things in my background is that I speak fluent Spanish, which I learned to do later in life during college. It was really hard. Often, we see kids in this birth to three range that when they have grown up in bilingual households, gone to bilingual schools, and engaged in TV that's in English and Spanish both, it just comes second nature to speak both languages. They didn't spend money on a degree and several years practicing to be able to limp their way through a good conversation. There is this piece of if you don't use it, you lose it.
There is also the saying, “What wires together fires together.” Within the brain, there are groupings of synapses that go together. Certain muscle movements are associated with emotional release. Our feelings and our stress center also impact our development in gross motor functioning. If those things are wiring together and there is a delay in one of them, then there will also be a delay in the other piece that is wiring side-by-side.
Thinking about the neurological aspect, if there has been a developmental delay in one area, there will also be side effects in others. The other thing about understanding child development in relation to child trauma is that oxytocin and cortisol are essential hormones in looking at danger and proximity in early childhood. From the moment of birth, the brain emits both of these hormones to say what is safe and what is dangerous. I often talk about this being almost the Applied Behavior Analysis (ABA) of neurology, that if we are in a place where people are kind to us and they meet our needs and we feel comfortable, our brain will elicit oxytocin that says, "This is a positive thing you want to repeat." When we are in situations of danger, or when people are angry at us or don't meet our needs, then our brain will elicit cortisol that essentially says, "This is a behavior you do not want to repeat." There are really clear signals about activities and relationships that are safe and unsafe. It’s important to establish that neurological reinforcer.
Those developments really do occur from the bottom up. Thinking through brainstem up to the frontal cortex, which is also associated with greater complexity and development, the frontal cortex piece of our brain is the last to develop because it is the most complex. When our brain is able to feel safe and calm, then it will speed through this process of development in the back part of the brain and spend more time developing that frontal cortex. In situations where we have felt high stress and threat, then the opposite is true. Our brain spends more time in the back and base of our brain and not nearly as much time building this frontal cortex. If we don't use it, we lose it.
Trauma and Development
- Trauma in early childhood “arrests” development at the age in which it occurs.
- Trauma in early childhood frequently results in delays in both social-emotional and gross motor development
- Social-Emotional Development (The developmental milestones around relationships, self-regulation, social skills)
- Gross Motor (Physical development such as ability to speak, run, skip, etc.)
We often think about that trauma in early childhood essentially arrests development at the stage in which it occurs. We talked about how development occurs in waves and through milestones, and that there is the concept of both social-emotional and gross motor development. Trauma essentially sticks wherever that development is. If we have a kid where there's been a major increase in chronic trauma, or one really large trauma at age four, then we're going to see that development maintain there until the trauma is addressed, even if our chronological development continues. We look older, we're taller, we have more weight, and we're in the fourth grade, but we still function in this place from the moment when the trauma occurred. It really does delay, pretty frequently, both social-emotional and gross motor development.
The area of social-emotional encompasses developmental milestones around relationships, self-regulatory capacity, and social skills. Gross motor is the physical development side, such as the ability to speak, or run, or skip. We do see delays in both domains for children who have experienced trauma, and especially for children who have experienced multiple ongoing trauma. That can look like poor development of personal relationships with peers. It may also look like difficulty in regulating when big emotions arise. It can also show up as speech delays.
A lot of kids from early histories of trauma are quite clumsy. Their fine motor and gross motor skills are just not fully up to par. Their vestibular internal sense of balance is not where we would think of it to be for their typically developing peers. For children with early histories of trauma, it is observable that interactions with the world feel much younger than those of our same-aged peers and are often times lagging.
Trauma and Child Development
- Interpersonally, early childhood trauma frequently results in dynamics that are reflective of the age of trauma.
- Problem-solving and self-regulation capacities that are much younger than the client’s age
- Difficulties in understanding perspective of others
- Prolonged belief in fantastical figures
- Interpersonal relationships reflective of younger dynamics
When we think about child development, not only does trauma delay further child development, but it also delays development in general. Early childhood trauma frequently results in dynamics that are reflective of that age of trauma. The example I gave was of trauma at age four that impacts a fourth-grader, but it goes beyond that. It often shows up in our work with adults or in marriage and couples counseling. You might see this if there was a trauma at age 13, and at 35 continue to expect that social relationships are going to mimic that of our relationships at 13, or that we continue to regulate our own senses of stress and find identity in the same ways that we typically would if we were still 13.
There is a persistent theme similar to the idea of Erikson's Stages of Development. I had a professor who would refer to it as the idea of packing a bag in that you pack your bag with what you have at that stage of development and then you move on. When we haven't packed the bag with what we need for the next stage, we just stay for a while until we figure out what that need is, and then are able to meet that need and move forward.
Those problem-solving skills reflect the age where trauma occurred and the regulation capacity of the person. Again, throughout not only adolescence, but into adulthood, it will come up that adults who have experienced chronic trauma as children often are much more impulsive, have a lot of difficulty engaging in really healthy relationships, and are in that place of constant fight or flight. Part of that is because that's the way that children function. We remain there neurologically because we haven't yet gone through that stage.
We will also see continuing difficulties in understanding perspective of others. We talked about the capacity to understand alternative perspectives developed between ages of six and eight. Even at that point, the understanding of another's perspective is really rudimentary. We can get to the place of like, "I kicked somebody on the playground and they were sad," but often we don't get to understanding that that person had also had a hard morning and their other friend had been mad at them, and so they were extra sad because it felt like everybody was mad at them. We'll see that carry through often in adolescents when they're questioned such as, "Why did you do a thing?” or, "How did we decide that this was our best course of action?" They will respond with a shoulder shrug and “I don’t know.” They know there had to be a reason, but cannot give words to it in that space. The same thing happens as those individuals get older. We still see this very flat understanding in the perspective of others. They can say, "I'm sure she was sad," but they really can't step outside of themselves to alternate perspective and think about what the full experience might have been like for somebody else.
We do see prolonged belief in fantastical figures when children have had experiences of trauma early on. Again, a lot of that is delayed development. It's also due to delayed object permanence where they think, "I'm not 100% sure what exists when I'm not around. And where people go or what happens from there." Kids will often hang on to these fantastical figures as a comfort for all of the really rough things that they have been through. The idea that there is something magical and that there is someone out there in the world who's really good can be highly comforting. We will see those 12 or 13-year-old kids continuing to believe in Santa Clause and the Easter Bunny. This furthers some of what we have talked about with delayed social skills because the other kids in their classroom, who are typically developing same-aged peers, are really going to have a hard time with that. They will often think, "What is this kid in my seventh-grade class who still believes that Santa's a real thing?" That creates secondary opportunities for there to be strife in peer relationships and potentially for other traumatizing events. Our mismatch in development now creates a space where there's going to be a response, and a potentially negative response from greater society.
We have talked about how relationships, interpersonally, are also going to be reflective of younger dynamics, that there are expectations that people are going to respond the way they did when we were in seventh grade, and that we can engage impulsively in relationships and that people easily forgive and forget, much like early high school. There's still a lot of that implied juvenile formations of relationships, because we are still operating from this is the place where time stopped. The developmental assessment is a piece that can be really helpful in gaining a clear picture of what all is going on for the child in question.
This can also be helpful when looking at transitional 18 to 25-year-old adults, and even older adults. Think through with them and reflect individually as practitioners on what are some of those things that we are seeing, interpersonally, cluster with this client. What are the things that we see that they're doing really well in? What are the things that seem to be a consistent struggle? What might that help us understand about their early experience?
Developmental Assessment
Structured Developmental Assessments
- Provide clear questions/answers to milestone achievement
- Are often set up to be self-report by parents
- Are easily used by clinicians who are newer to work with children or who don’t see children on a regular basis
- MCHAT (Assessment given at age 2 to identify symptoms of global developmental delays)
- ASQ & ASQ-SE (Self-report screeners that identify delays in gross motor development and in social-emotional functioning
- PSC-17 (Self-report that identify symptoms of attention difficulties, anxiety, depression, and interpersonal struggles)
The assessment piece can be done in a couple of different ways. Structured developmental assessments are helpful if you're in something other than a clinical kind of practice. This can include if you are in a situation where you're doing integrated care or providing services, like an addendum to some kind of medical setting, or if you are providing some level of case management or case consultation and don't have time to sit and do a super thorough assessment.
Structured developmental assessments will give you pretty clear questions and answers to whether or not milestones have been achieved, and are generally pretty quick to complete. Most of them are also set up to be self-report by parents. Thinking through if you're in a medical model, these can be included in typical intake packet paperwork. They are just checked off, somebody reviews them, and in three to five minutes you've got a pretty good idea of what's going on with this child and family and in their world. They are also much more easily accessible for clinicians who don't see children on a really regular basis, or who are newer to the use of development as an assessment point.
There are a variety of structured developmental assessments that are available. A few to consider are listed below. Some of those structured developmental assessments, like the MCHAT, and the PSC-17 are public domain and are free to access.
Pediatric Symptom Checklist (PSC-17)
The Pediatric Symptom Checklist (PSC-17) has 17 questions. They always sound official, but they are not nearly that intimidating. It is a self-report and identifies a pretty broad range of symptoms that might be present in younger kids. It looks at everything, from attention difficulties and anxiety and depression, to interpersonal struggles and academic achievement, the whole nine yards.
Modified Checklist for Autism in Toddlers (M-CHAT)
The MCHAT is an assessment that is generally given to kids between about 12 months and four years of age. It looks much more into global developmental delays and ruling in or out the possibility of an autism spectrum disorder. Again, it's going to give you a pretty clear cluster of symptoms around object permanency, theory of mind, ability to take perspectives of others, speech and language development, and use of reciprocal language. It’s much less from a perspective of I want and I need, but in questions and looking for conversational response.
Ages and Stages Questionnaires (ASQ & ASQ-SE)
The Ages and Stages Questionnaires required a paid subscription. The ASQ-SE is the social-emotional version of the screener. The ASQ looks much more at fine and gross motor skills, asking questions such as, "Can they crawl? Are they cruising? Do they walk? Can they throw a ball overhanded?" The SE version looks much more at the social-emotional development of the child. Both the ASQ and the ASQ-SE are self-report and are to be completed by whoever the primary caregiver is. They both give a thorough perspective among multiple domains. The ASQ and ASQ-SE both also shift by six-month age ranges, so that the questions, and what they're looking for in regards to what children can do, are going to consistently shift. That says this child should now be at a different level. We should have different responses now than we would have a year ago. Not the same set of questions, not the same set of answers. Those are really good places to begin some foundational assessment around development, and to also begin to expand understanding for us, as providers, of what we're looking at, and how to utilize that as a point of intervention.
Unstructured Developmental Assessments
- Allow for observation to be the primary method of data collection
- Allow for observation of parent-child interactions
- Require the clinician to be well versed in the administration of the assessment
- Marshack Interaction Method
- What to Look for In Relationships? Assessment
- General observation of the child or child & parent
There are also unstructured developmental assessments. These provide their own set of strengths and areas of awareness. Unstructured developmental assessment means that these are not a screening tool. They don't have a series of questions that can be completed in the self-report format and they take much longer than about five to 10 minutes to complete. These do allow for observation of parent-child interactions. It is much more that the clinician is looking at some kind of observation with a specific lens, looking to see certain markers, positive or negative, and the awareness comes from the clinician’s perspective and is not so much symptomology presented by the parent themselves. Again, with screeners, parents are going to be the ones who raise the red flags around whatever is being asked. With unstructured developmental assessments it does require that the clinician in question be well versed in the administration of that assessment. They really need to know what it is that they're going to layout for this family, and they also really need to know what they're looking for and looking at. For example, when children or parents engage in a certain way or when there is a response in a certain manner, there should be an awareness by the clinician that this is an area of concern, or this is a real strength within this place of attachment relationship.
There are a variety of these unstructured developmental assessments. Some of them are almost observation of free play among a family. The What to Look for in Relationships? Assessment is a guide for some of those free-play interactions to have a list and say, "Okay, these are the things I saw. These are the things that I'm looking for."
There's still some level of structure in the idea of having a containment, or some type of activity that has the possibility of creating good observable material, as is the case with the Marshack Interaction Method, or with the Krol Assessment. Both of those have a series of identified activities that are to be completed by the parent and child together which allows a clinician to look at specific things. Those include a parent’s capacity to understand a child's developmental perspective, a child's capacity to follow directions, a parent's capacity to set expectations appropriately and follow-through, and being able to give and receive nurture among a dyad. Those are structured in the sense that they're not just a general observation of free play, but they are not structured in, again, the actual clinical material comes from the clinician's assessment and not from parent or child report. Oftentimes when we look at these unstructured assessments on the front end it can make you wonder, “What could we possibly see in such a short amount of time?” or, “How could such a question elicit any real kind of information?”
Marshack Interaction Method (MIM)
The Marshack Interaction Method is the one that I use most frequently. When using the MIM, you select five activities from a variety of domains. Then you allow the parent and child to work through them untimed. It is up to them how long it takes, what they do with it, and where they are headed. One of the cards that I frequently pull is that a parent will show a child something that they don't know. That's all it says. The card says, "Parent will teach a child something they don't know." This is always a very curious thing to observe. Sometimes we get parents who decide they're going to teach kids how to play hopscotch or that they'll teach kids how to draw a circle. One time I had a father who taught his three-year-old son how to tie his shoes for 45 minutes. We don't generally have the fine motor skills to be able to tie shoes until we're right around five. The expectation for the activity was a little off to begin with. Then, consistently maintaining the activity for 45 minutes was far beyond what was developmentally appropriate for a three-year-old. This simple prompt allowed me to see clearly that Dad's expectations of what this little boy could do on a daily basis created a lot of frustration for this kiddo, and resulted in further conflict between he and Dad.
They do require that the clinician know what you're looking for and have a good history of using development as a place of assessment. It’s also important for the clinician to feel really comfortable in that role of observing and making inferences from the material that is seen. They can be really rich, in that there's a depth to them that you don't get out of structured assessments.
Developmental Assessment in Intervention
- Using developmental tools can assist in identifying areas to target for intervention in clinical work.
- These assessments can also be reflective of the age in which development slowed as a result of trauma.
- Many early childhood trauma intervention models assert that optimal functioning is gained by scaling back expectations and clinical focus to target the social-emotional age of the child vs. the chronological age.
- Use of structured and unstructured assessments can assist in identifying the social-emotional age of the client.
- Dialectical Developmental Psychotherapy leverages that adjusting expectations/interactions to the social-emotional age allow children to “catch up” to age-appropriate expectations more quickly.
- ost parents can quickly and accurately identify level of functioning through the exercise of “Stop acting like a ____-year-old.”
- Assisting families in identifying appropriate expectations for the identified social-emotional age
- Bruce Perry’s Neurosequential Model utilizes a formalized assessment to identify the areas of the brain where development is “stuck”
- Promotes use of a variety of interventions from a developmentally appropriate approach
- Emphasizes the idea of “regulate, relate, respond”
- Encourages interventions that “wire together”-such as engaging in sensory activities while engaging in talk therapy
- A variety of other trauma interventions can be well utilized when combined with developmental assessment
All of those things then allow us to identify where the areas are that might need intervention in clinical work. Again, back to that example that I gave about the dad and the little boy. It was quite clear that one of the places we were going to start was some general psychoeducation around child development. It was important to talk through with Dad and say, "What is it that you're hoping for him? He worked really hard and you worked really hard. You both got really frustrated. What is it that you want him to learn in these places? What are you hoping for him in the future?" It does help in goal setting, being able to identify those points for intervention, but also, again, with when we think about adults and adolescents.
When we are looking at the developmental perspective, if we are seeing consistently that this child cannot hang up their clothes, has bleached three loads of laundry, and has been in fights with peers at school six out of the last seven school days, then we are going to look back and say, "What things are we doing well?" For example, what age are we really functioning at? It’s the idea of identifying kids from their place of social-emotional maturity, rather than their chronological age and looking at where their birth certificate says they should be. When we are able to pull back and recognize that this is where we're functioning and use that as a point of intervention, then we will really see shift in developmental change pretty quickly in that area.
These assessments can also be reflective of the age in which development was slowed due to trauma. Many times, we will have this piece with developmental assessment where everything feels like this 30-year-old is still 16 and still functioning in this place as though we're in high school. Sometimes there may be a red flag in the back of our head that helps us go back and ask questions such as:
- Tell me about what high school was like for you.
- Tell me about what you did on a day-to-day basis.
- Who were your peers?
- How did you engage?
- Where were you in the social system that existed at that point?
- What were your goals?
- Who did 16-year-old you think that 30-year-old you would be?
Those assessments also help us to open up potentially where trauma might be that people aren't readily recognizing. That happens frequently and we will get individuals who say, "Yeah that happened, but it wasn't a big deal." Or, "I thought that happened to everybody." These assessments really can open up and create conversation where it didn't previously exist. In that place, many early childhood trauma intervention models assert that the optimal functioning for a child will be attained when we scale back the expectations to meet that place of social-emotional age versus the chronological age.
Dan Hughes' work with Developmental Dyadic Psychotherapy looks at that. Bruce Perry's work under the Neurosequential Model talks about identifying where within the brain and where within the social construct children who have had chronic exposures to pretty intense trauma really do engage. For example, what's the level they're functioning well at? What is the point when we pull back the expectations to where they have been successful and then build scaffolding, or supports around them to move forward? At that point kids will make success quite rapidly. However, I'm sure if you've ever been in a room with an eight-year-old and the expectations are beyond what are within the capacity to be accomplished by that child, frustration ensues. Then everybody gets frustrated. The kid's frustrated because they can't do it and the caregiver's frustrated because they won't do it, and now everybody's in a standoff.
Being able to recognize that the internal part of this child, or adolescent, or a 30-year-old is functioning very differently than the external body of this individual can make a considerable difference in the way we approach a case, but also in the long-term outcome for that individual participating in services. Again, this shows how the use of structured and unstructured assessments can really help us in identifying that social-emotional age of the client.
As I previously said, the ASQ and the ASQ-SE are really good at that. If you can find the place within those ASQs we're really starting to fall behind developmentally, then you can go back to the earlier editions. For example, if we didn't do well at the 60-month assessment, what do we look like if we scale back to the 36-month? Are we successful at that point or do we need to go back to the 30-month? Where is the point in those structured assessments that says, "Oh, here's where we were successful." In unstructured assessments we can often see frustration in kids faster than the caregiver because we are not in it in that moment. We are not talking, we are not playing, and we are not juggling multiple conversations. Our sole goal in is to watch and to see what there is that maybe hasn't been seen so far.
We talked about Dan Hughes and the Dialectical Developmental Psychotherapy, but Bruce Perry's Neurosequential Model has a similar approach, that adjusting the expectations really allows for kids to catch up. I always tell families that if we're functioning like we're 18 months old and we're four, it's not going to take the same amount of time to catch up, as if we were actually 18 months old and have to get to being four. We go back to that analogy from earlier about packing suitcases in Erikson's Developmental Stages. Sometimes there's some stuff already in that suitcase. We missed a couple of really big pieces. Maybe somebody managed to forget a left shoe. That's going to be hard. You can't go hiking without both of your shoes, but we're not going back looking for both of them. We're not going back looking for everything. We're going back to scale back expectations to create an environment where we can then pull together the things we did pick up along the way and catch up much faster.
One of the ways that I'm able to get a preliminary sense of this is to ask parents and caregivers, "How often do you find yourself fussing at this child and saying, ‘Stop acting like a ___ year old’?" Most caregivers can fill in that blank pretty rapidly. "Oh, I swear he's two” or “I'm telling you, there are times that he is five and I don't know how we have gone from 14 to five in three minutes." Then they will tell you that there is something within them that resounds to the idea that this child's social-emotional development is stuck at a certain place. They know that there is a place where they are successful, where they are continuing to engage from a specific perspective over and over and to the point of lots of frustration. It’s important to work to help families and caregivers and support relationships to identify what's appropriate in thinking through scaling back to the child’s social-emotional age. This is hard. Clinically, I get a lot of pushback around it. To say, "Yes, I know this child is nine, but he acts three and so I'm going to ask that we scale back expectations to as though he were three."
Parents get really wary. I use the term parents loosely here. Sometimes it's biological parents, sometimes it's a kinship placement, it could be foster parents, or it might be a caregiver that they've lived with forever. Whoever that primary person is often says, "My frustration is that they're not mature enough and you want me to treat them like they're younger?" We have to talk through and hold this frustration and conflict that they're experiencing and discuss how we get to a place where decreased frustration and decreased conflict results in decreases in cortisol and better capacity for our neurology to learn. We want parents to have this goal. The goal may be for them to be independent and have friends and go on a playdate. For some of my kids a win would just be getting an invitation to a birthday party.
It's also the clinical hat use of negotiation around helping families identify what they are willing to scale back. Some families will also say, "I'm not doing that." So, how do we say, "Okay, I hear you. You are not willing to reset expectations on that, but where can we do that?" We ask and hope for a really broad range answer.
I had a 14-year-old who was adopted from a country internationally when he was 12. That was a really big shock for him, not only from a developmental perspective, but also from a cultural lens of going from a place and a country that English was not his predominant language and things were dealt with much differently, to being placed in a home in a rural community where everybody spoke English and everybody looked alike. There was an assumption that everybody did things the way that this community did. One example is this 14-year old, who acts like he's three, and needs a bedtime routine. If he were three, he'd have a bedtime routine. Another example is my 11-year-old who has a history of cancer. He had lots of time in hospitals and exposure to chemo and radiation. If you just hand him a toothbrush and toothpaste he's going to brush his teeth for about 30 seconds, and he might actually brush three of them. We have to stand there and make sure he brushes, spits, rinses, and does his mouthwash, as though he were five, because that's where we're at.
When we can shift those expectations, as controversial as it often is, we'll see parents’ frustration drop and kids’ frustrations drop. When the relationship has an opportunity for connection and positive mutual regard, then people are suddenly willing to do things for each other. Kids will say, "All right mom, I'll go take care of that" or, "Okay, Grandma, I got that for you." Now we can start to make progress in some of those areas where we've expressed frustration about lack of responsibility, lack of maturity, and lack of follow-through.
Bruce Perry's Neurosequential Model is a much more formalized assessment on identifying chronological age than those examples that I gave earlier. They do a pretty thorough assessment around obtaining medical records, academic records, and looking at EEGs. It's like a full medical workup where they create a thorough brain map and can pinpoint exactly where development got stuck and what areas are doing really well and what areas are lagging behind. It's a pretty impressive model in being able to quickly conceptualize that level of information and provide it to clinicians to really look at how does this impact intervention? How do we make those shifts in our clinical decision making? Then we are able, generally, to catch up and make progress more quickly, because we are targeting both the pieces where the brain is strong and the pieces where there is weakness. This is a model you have to be trained on independently and you have to pay for it. It's not really a thing you can just read a book and do.
While it identifies that the brain is stuck, one of the pieces about the Neurosequential Model is that they promote, from a clinical lens, a pretty wide variety of clinical approaches. They may say, "We're going to have to tweak this to meet the developmental needs in this section of the brain." But you can use Trauma-Focused Cognitive Behavioral Therapy (TF-CBT), Eye Movement Desensitization and Reprocessing (EMDR), child-parent psychotherapy, whatever it may be, we're just going to make some adjustments and accommodations.
They really are complimentary to multiple kind of approaches to trauma and trauma treatment. In that place, the Neurosequential Model also emphasizes the idea of regulate, relate, and respond. Throughout all trauma approaches hold this idea that we don't do trauma work until we are calm. We don't do trauma work when we're in the middle of trauma. From that, the adage within the Neurosequential Model is we have to be able to teach kids how to regulate themselves, we have to have them in a regulated place, and then we build the connection, we engage in that place of relationship, we engage in relating between caregiver and that child, or partner and the other partner, clinician and that identified client. Once that person is regulated and we have engaged in relationship building, then we can respond. Then we can say, "We are going to take some deep breaths. I know that you are so sad and I see your tears. You know that I care about you. You cannot go swimming outside. It is 50 degrees." We can give that hard information that is the piece that kind of pushes boundaries with that child, or family, or individual in this process of regulate and relate and respond. These are the other pieces we talked earlier about that neurologically things that wire together fire together.
The Neurosequential Model pulls a lot on that concept and tries to pair interventions that wire together. Remember, we talked about the map where they look at places where the brain is really strong and places where muscularly it's really weak. They will say, "Use this thing that's strong. We know that the part that really is attracted to music in this brain is a big deal so let's play some music and talk about feelings at the same time." We are going to use what's strong and what's really weak and be able to pair those two together, because when they can wire together, then they'll fire together. From my perspective, this really allows for the creation of some pretty creative intervention models. I think that it is also really fun to be able to just look at those places and be able to pair things together.
You can really use a variety of whatever your preferred clinical approach is and consistently hold in the back of your mind overlaying this piece of what does development tell me about what may be going on? What does developmental assessment tell me about where I might best make my move, make a commitment, or shift my intervention just slightly, in hopes for kind of a better grasp from that client and improved long term outcomes?
References
Bruce, D. P. (2009). Examining child maltreatment through a neurodevelopmental lens: Clinical applications of the neurosequential model of therapeutics. Journal of Loss and Trauma, 14(4), 240-255, DOI: 10.1080/15325020903004350
Campbell, C., Roberts, Y., Snyder, F., Papp, J., Strambler, M., & Crusto, C. (2016). The assessment of early trauma exposure on social-emotional health of young children. Children and Youth Services Review, 71, 308-314.
Choi, K.R., & Graham-Bermann, S. A. (2018). Developmental considerations for assessment of trauma symptoms in preschoolers: A review of measures and diagnoses. Journal of Child and Family Studies, 27, 3427-3439.
Davies, D. (2011). Child development: A practitioner’s guide. New York: The Guilford Press.
Denton, R., Frogley, C., Jackson, S., Jphn, M., & Querstret, D. (2017). The assessment of developmental trauma in children and adolescents: A systemic review. Clinical Child Psychology and Psychiatry, 22(2), 260-287.
Frankel, K. A., Harrison, J. N., & Njoroge, W. (2019). Clinical guide to psychiatric assessment of infants and young children. New York: Springer International.
Harel-Gadassi, A., Friedlander, E., Yaari, M., Bar-Oz, B., Eventov-Friedman, S., Mankuta, D., & Yirmiya, N. (2018). Developmental assessment of preterm infants: Chronological or corrected age? Research in Developmental Disabilities, 80, 35-43.
Hughes, D. A. (2000). Facilitating developmental attachment: The road to emotional recovery and behavioral change in foster and adopted children. Maryland: Rowan & Littlefield.
Kisiel, C. L., Fehrenbach, T., Torgersen, E., Stolbach, B., McClelland, G., Griffin, G., & Burkman, K. (2014). Constellations of interpersonal trauma and symptoms in child welfare: Implications for a developmental trauma framework. Journal of Family Violence, 29(1), 1-14. https://doi.org/10.1007/s10896-013-9559-0
Phua, D., Kee, M., & Meaney, M. (2020). Positive maternal mental health, parenting, and child development. Biological Psychiatry, 87(4), 328-337.
Weitzman, C. (2003). Developmental assessment of the internationally adopted child: Challenges and rewards.
