What are the early environmental and genetic influences on cognitive development?

chapter 4 Physical Development in Infancy and Toddlerhood

Infants acquire new motor skills by building on previously acquired capacities. Eager to explore her world, this baby practices the art of crawling. Once she can fully move on her own, she will make dramatic strides in understanding her surroundings.

chapter outline

·   Body Growth

·   Changes in Body Size and Muscle–Fat Makeup

·   Individual and Group Differences

·   Changes in Body Proportions

·   Brain Development

·   Development of Neurons

·   Neurobiological Methods

·   Development of the Cerebral Cortex

·   Sensitive Periods in Brain Development

·   Changing States of Arousal

· ■  BIOLOGY AND ENVIRONMENT  Brain Plasticity: Insights from Research on Brain-Damaged Children and Adults

· ■  CULTURAL INFLUENCES  Cultural Variation in Infant Sleeping Arrangements

·   Influences on Early Physical Growth

·   Heredity

·   Nutrition

·   Malnutrition

·   Learning Capacities

·   Classical Conditioning

·   Operant Conditioning

·   Habituation

·   Imitation

·   Motor Development

·   The Sequence of Motor Development

·   Motor Skills as Dynamic Systems

·   Fine-Motor Development: Reaching and Grasping

·   Perceptual Development

·   Hearing

·   Vision

·   Intermodal Perception

·   Understanding Perceptual Development

· ■  BIOLOGY AND ENVIRONMENT  “Tuning In” to Familiar Speech, Faces, and Music: A Sensitive Period for Culture-Specific Learning

On a brilliant June morning, 16-month-old Caitlin emerged from her front door, ready for the short drive to the child-care home where she spent her weekdays while her mother, Carolyn, and her father, David, worked. Clutching a teddy bear in one hand and her mother’s arm with the other, Caitlin descended the steps. “One! Two! Threeee!” Carolyn counted as she helped Caitlin down. “How much she’s changed,” Carolyn thought to herself, looking at the child who, not long ago, had been a newborn. With her first steps, Caitlin had passed from infancy to toddlerhood—a period spanning the second year of life. At first, Caitlin did, indeed, “toddle” with an awkward gait, tipping over frequently. But her face reflected the thrill of conquering a new skill.

As they walked toward the car, Carolyn and Caitlin spotted 3-year-old Eli and his father, Kevin, in the neighboring yard. Eli dashed toward them, waving a bright yellow envelope. Carolyn bent down to open the envelope and took out a card. It read, “Announcing the arrival of Grace Ann. Born: Cambodia. Age: 16 months.” Carolyn turned to Kevin and Eli. “That’s wonderful news! When can we see her?”

“Let’s wait a few days,” Kevin suggested. “Monica’s taken Grace to the doctor this morning. She’s underweight and malnourished.” Kevin described Monica’s first night with Grace in a hotel room in Phnom Penh. Grace lay on the bed, withdrawn and fearful. Eventually she fell asleep, gripping crackers in both hands.

Carolyn felt Caitlin’s impatient tug at her sleeve. Off they drove to child care, where Vanessa had just dropped off her 18-month-old son, Timmy. Within moments, Caitlin and Timmy were in the sandbox, shoveling sand into plastic cups and buckets with the help of their caregiver, Ginette.

A few weeks later, Grace joined Caitlin and Timmy at Ginette’s child-care home. Although still tiny and unable to crawl or walk, she had grown taller and heavier, and her sad, vacant gaze had given way to an alert expression, a ready smile, and an enthusiastic desire to imitate and explore. When Caitlin headed for the sandbox, Grace stretched out her arms, asking Ginette to carry her there, too. Soon Grace was pulling herself up at every opportunity. Finally, at age 18 months, she walked!

This chapter traces physical growth during the first two years—one of the most remarkable and busiest times of development. We will see how rapid changes in the infant’s body and brain support learning, motor skills, and perceptual capacities. Caitlin, Grace, and Timmy will join us along the way to illustrate individual differences and environmental influences on physical development.

image1 Body Growth

TAKE A MOMENT…  The next time you’re walking in your neighborhood park or at the mall, note the contrast between infants’ and toddlers’ physical capabilities. One reason for the vast changes in what children can do over the first two years is that their bodies change enormously—faster than at any other time after birth.

Changes in Body Size and Muscle–Fat Makeup

By the end of the first year, a typical infant’s height is about 32 inches—more than 50 percent greater than at birth. By 2 years, it is 75 percent greater (36 inches). Similarly, by 5 months of age, birth weight has doubled, to about 15 pounds. At 1 year it has tripled, to 22 pounds, and at 2 years it has quadrupled, to about 30 pounds.

FIGURE 4.1 Body growth during the first two years.

These photos depict the dramatic changes in body size and proportions during infancy and toddlerhood in two individuals—a boy, Chris, and a girl, Mai. In the first year, the head is quite large in proportion to the rest of the body, and height and weight gain are especially rapid. During the second year, the lower portion of the body catches up. Notice, also, how both children added “baby fat” in the early months of life and then slimmed down, a trend that continues into middle childhood.

Figure 4.1  illustrates this dramatic increase in body size. But rather than making steady gains, infants and toddlers grow in little spurts. In one study, children who were followed over the first 21 months of life went for periods of 7 to 63 days with no growth, then added as much as half an inch in a 24-hour period! Almost always, parents described their babies as irritable and very hungry on the day before the spurt (Lampl,  1993 ; Lampl, Veldhuis, & Johnson,  1992 ).

One of the most obvious changes in infants’ appearance is their transformation into round, plump babies by the middle of the first year. This early rise in “baby fat,” which peaks at about 9 months, helps the small infant maintain a constant body temperature. In the second year, most toddlers slim down, a trend that continues into middle childhood (Fomon & Nelson,  2002 ). In contrast, muscle tissue increases very slowly during infancy and will not reach a peak until adolescence. Babies are not very muscular; their strength and physical coordination are limited.

Individual and Group Differences

In infancy, girls are slightly shorter and lighter than boys, with a higher ratio of fat to muscle. These small sex differences persist throughout early and middle childhood and are greatly magnified at adolescence. Ethnic differences in body size are apparent as well. Grace was below the growth norms (height and weight averages for children her age). Early malnutrition contributed, but even after substantial catch-up, Grace—as is typical for Asian children—remained below North American norms. In contrast, Timmy is slightly above average, as African-American children tend to be (Bogin,  2001 ).

Children of the same age also differ in rate of physical growth; some make faster progress toward a mature body size than others. But current body size is not enough to tell us how quickly a child’s physical growth is moving along. Although Timmy is larger and heavier than Caitlin and Grace, he is not physically more mature. In a moment, you will see why.

The best estimate of a child’s physical maturity is skeletal age, a measure of bone development. It is determined by X-raying the long bones of the body to see the extent to which soft, pliable cartilage has hardened into bone, a gradual process that is completed in adolescence. When skeletal ages are examined, African-American children tend to be slightly ahead of Caucasian children at all ages, and girls are considerably ahead of boys. At birth, the sexes differ by about 4 to 6 weeks, a gap that widens over infancy and childhood (Tanner, Healy, & Cameron,  2001 ). This greater physical maturity may contribute to girls’ greater resistance to harmful environmental influences. As noted in  Chapter 2 , girls experience fewer developmental problems than boys and have lower infant and childhood mortality rates.

Changes in Body Proportions

As the child’s overall size increases, different parts of the body grow at different rates. Two growth patterns describe these changes. The first is the  cephalocaudal trend —from the Latin for “head to tail.” During the prenatal period, the head develops more rapidly than the lower part of the body. At birth, the head takes up one-fourth of total body length, the legs only one-third. Notice how, in  Figure 4.1 , the lower portion of the body catches up. By age 2, the head accounts for only one-fifth and the legs for nearly one-half of total body length.

In the second pattern, the  proximodistal trend , growth proceeds, literally, from “near to far”—from the center of the body outward. In the prenatal period, the head, chest, and trunk grow first, then the arms and legs, and finally the hands and feet. During infancy and childhood, the arms and legs continue to grow somewhat ahead of the hands and feet.

image2 Brain Development

At birth, the brain is nearer to its adult size than any other physical structure, and it continues to develop at an astounding pace throughout infancy and toddlerhood. We can best understand brain growth by looking at it from two vantage points: (1) the microscopic level of individual brain cells and (2) the larger level of the cerebral cortex, the most complex brain structure and the one responsible for the highly developed intelligence of our species.

Development of Neurons

The human brain has 100 to 200 billion  neurons , or nerve cells that store and transmit information, many of which have thousands of direct connections with other neurons. Unlike other body cells, neurons are not tightly packed together. Between them are tiny gaps, or  synapses , where fibers from different neurons come close together but do not touch (see  Figure 4.2 ). Neurons send messages to one another by releasing chemicals called  neurotransmitters , which cross the synapse.

FIGURE 4.2 Neurons and their connective fibers.

This photograph of several neurons, taken with the aid of a powerful microscope, shows the elaborate synaptic connections that form with neighboring cells.

FIGURE 4.3 Major milestones of brain development.

Formation of synapses is rapid during the first two years, especially in the auditory, visual, and language areas of the cerebral cortex. The prefrontal cortex undergoes more extended synaptic growth. In each area, overproduction of synapses is followed by synaptic pruning. The prefrontal cortex is among the last regions to attain adult levels of synaptic connections—in mid-to late adolescence. Myelination occurs at a dramatic pace during the first two years, more slowly through childhood, followed by an acceleration at adolescence and then a reduced pace in early adulthood. The multiple yellow lines indicate that the timing of myelination varies among different brain areas. For example, neural fibers myelinate over a longer period in the language areas, and especially in the prefrontal cortex, than in the visual and auditory areas.

(Adapted from Thompson & Nelson, 2001.)

The basic story of brain growth concerns how neurons develop and form this elaborate communication system.  Figure 4.3  summarizes major milestones of brain development. In the prenatal period, neurons are produced in the embryo’s primitive neural tube. From there, they migrate to form the major parts of the brain (see  Chapter 3 ,  page 82 ). Once neurons are in place, they differentiate, establishing their unique functions by extending their fibers to form synaptic connections with neighboring cells. During the first two years, neural fibers and synapses increase at an astounding pace (Huttenlocher,  2002 ; Moore, Persaud, & Torchia,  2013 ). A surprising aspect of brain growth is  programmed cell death , which makes space for these connective structures: As synapses form, many surrounding neurons die—20 to 80 percent, depending on the brain region (de Haan & Johnson,  2003 ; Stiles,  2008 ). Fortunately, during the prenatal period, the neural tube produces far more neurons than the brain will ever need.

As neurons form connections, stimulation becomes vital to their survival. Neurons that are stimulated by input from the surrounding environment continue to establish synapses, forming increasingly elaborate systems of communication that support more complex abilities. At first, stimulation results in a massive overabundance of synapses, many of which serve identical functions, thereby ensuring that the child will acquire the motor, cognitive, and social skills that our species needs to survive. Neurons that are seldom stimulated soon lose their synapses, in a process called  synaptic pruning  that returns neurons not needed at the moment to an uncommitted state so they can support future development. In all, about 40 percent of synapses are pruned during childhood and adolescence to reach the adult level (Webb, Monk, & Nelson,  2001 ). For this process to advance, appropriate stimulation of the child’s brain is vital during periods in which the formation of synapses is at its peak (Bryk & Fisher,  2012 ).

If few new neurons are produced after the prenatal period, what causes the dramatic increase in brain size during the first two years? About half the brain’s volume is made up of  glial cells , which are responsible for  myelination , the coating of neural fibers with an insulating fatty sheath (called myelin) that improves the efficiency of message transfer. Glial cells multiply rapidly from the fourth month of pregnancy through the second year of life—a process that continues at a slower pace through middle childhood and accelerates again in adolescence. Gains in neural fibers and myelination are responsible for the extraordinary gain in overall size of the brain—from nearly 30 percent of its adult weight at birth to 70 percent by age 2 (Johnson,  2011 ; Knickmeyer et al.,  2008 ).

Brain development can be compared to molding a “living sculpture.” First, neurons and synapses are overproduced. Then, cell death and synaptic pruning sculpt away excess building material to form the mature brain—a process jointly influenced by genetically programmed events and the child’s experiences. The resulting “sculpture” is a set of interconnected regions, each with specific functions—much like countries on a globe that communicate with one another (Johnston et al.,  2001 ). This “geography” of the brain permits researchers to study its developing organization and the activity of its regions using neurobiological methods.

Neurobiological Methods

Table 4.1  describes major measures of brain functioning. The first two methods detect changes in electrical activity in the cerebral cortex. In an electroencephalogram (EEG), researchers examine brain-wave patterns for stability and organization—signs of mature functioning of the cortex. And as the person processes a particular stimulus, event-related potentials (ERPs) detect the general location of brain-wave activity—a technique often used to study preverbal infants’ responsiveness to various stimuli, the impact of experience on specialization of specific brain regions, and atypical brain functioning in individuals with learning and emotional problems (DeBoer, Scott, & Nelson,  2007 ; deRegnier,  2005 ).

Neuroimaging techniques, which yield detailed, three-dimensional computerized pictures of the entire brain and its active areas, provide the most precise information about which brain regions are specialized for certain capacities and about abnormalities in brain functioning. The most promising of these methods is functional magnetic resonance imaging (fMRI). Unlike positron emission tomography (PET), fMRI does not depend on X-ray photography, which requires injection of a radioactive substance. Rather, when an individual is exposed to a stimulus, fMRI detects changes in blood flow and oxygen metabolism throughout the brain magnetically, yielding a colorful, moving picture of parts of the brain used to perform a given activity (see  Figure 4.4a ,  b , and  c ).

TABLE 4.1 Methods for Measuring Brain Functioning

METHOD DESCRIPTION
Electroencephalogram (EEG) Electrodes embedded in a head cap record electrical brain-wave activity in the brain’s outer layers—the cerebral cortex. Today, researchers use an advanced tool called a geodesic sensor net (GSN) to hold interconnected electrodes (up to 128 for infants and 256 for children and adults) in place through a cap that adjusts to each person’s head shape, yielding improved brain-wave detection.
Event-related potentials (ERPs) Using the EEG, the frequency and amplitude of brain waves in response to particular stimuli (such as a picture, music, or speech) are recorded in multiple areas of the cerebral cortex. Enables identification of general regions of stimulus-induced activity.
Functional magnetic resonance imaging (fMRI) While the person lies inside a tunnel-shaped apparatus that creates a magnetic field, a scanner magnetically detects increased blood flow and oxygen metabolism in areas of the brain as the individual processes particular stimuli. The scanner typically records images every 1 to 4 seconds; these are combined into a computerized moving picture of activity anywhere in the brain (not just its outer layers). Not appropriate for children younger than age 5 to 6, who cannot remain still during testing.
Positron emission tomography (PET) After injection or inhalation of a radioactive substance, the person lies on an apparatus with a scanner that emits fine streams of X-rays, which detect increased blood flow and oxygen metabolism in areas of the brain as the person processes particular stimuli. As with fMRI, the result is a computerized image of “online” activity anywhere in the brain. Not appropriate for children younger than age 5 to 6.
Near-infrared spectroscopy (NIRS) Using thin, flexible optical fibers attached to the scalp through a head cap, infrared (invisible) light is beamed at the brain; its absorption by areas of the cerebral cortex varies with changes in blood flow and oxygen metabolism as the individual processes particular stimuli. The result is a computerized moving picture of active areas in the cerebral cortex. Unlike fMRI and PET, NIRS is appropriate for infants and young children, who can move within limited range.

FIGURE 4.4 Functional magnetic resonance imaging (fMRI) and near-infrared spectroscopy (NIRS).

(a) This 6-year-old is part of a study that uses fMRI to find out how his brain processes light and motion. (b) The fMRI image shows which areas of the child’s brain are active while he views changing visual stimuli. (c) Here, NIRS is used to investigate a 2-month-old’s response to a visual stimulus. During testing, the baby can move freely within a limited range.

(Photo (c) from G. Taga, K. Asakawa, A. Maki, Y. Konishi, & H. Koisumi, 2003, “Brain Imaging in Awake Infants by Near-Infrared Optical Topography,” Proceedings of the National Academy of Sciences, 100, p. 10723. Reprinted by permission.)

Because PET and fMRI require that the participant lie as motionless as possible for an extended time, they are not suitable for infants and young children (Nelson, Thomas, & de Haan,  2006 ). A neuroimaging technique that works well in infancy and early childhood is near-infrared spectroscopy (NIRS), in which infrared (invisible) light is beamed at regions of the cerebral cortex to measure blood flow and oxygen metabolism while the child attends to a stimulus (refer again to  Table 4.1 ). Because the apparatus consists only of thin, flexible optical fibers attached to the scalp using a head cap, a baby can sit on the parent’s lap and move during testing—as  Figure 4.4c  illustrates (Hespos et al.,  2010 ). But unlike PET and fMRI, which map activity changes throughout the brain, NIRS examines only the functioning of the cerebral cortex.

Development of the Cerebral Cortex

The  cerebral cortex  surrounds the rest of the brain, resembling half of a shelled walnut. It is the largest brain structure, accounting for 85 percent of the brain’s weight and containing the greatest number of neurons and synapses. Because the cerebral cortex is the last part of the brain to stop growing, it is sensitive to environmental influences for a much longer period than any other part of the brain.

Regions of the Cerebral Cortex.

Figure 4.5  shows specific functions of regions of the cerebral cortex, such as receiving information from the senses, instructing the body to move, and thinking. The order in which cortical regions develop corresponds to the order in which various capacities emerge in the infant and growing child. For example, a burst of activity occurs in the auditory and visual cortexes and in areas responsible for body movement over the first year—a period of dramatic gains in auditory and visual perception and mastery of motor skills (Johnson,  2011 ). Language areas are especially active from late infancy through the preschool years, when language development flourishes (Pujol et al.,  2006 ; Thompson,  2000 ).

The cortical regions with the most extended period of development are the frontal lobes. The  prefrontal cortex , lying in front of areas controlling body movement, is responsible for thought—in particular, consciousness, inhibition of impulses, integration of information, and use of memory, reasoning, planning, and problem-solving strategies. From age 2 months on, the prefrontal cortex functions more effectively. But it undergoes especially rapid myelination and formation and pruning of synapses during the preschool and school years, followed by another period of accelerated growth in adolescence, when it reaches an adult level of synaptic connections (Nelson,  2002 ; Nelson, Thomas, & de Haan,  2006 ; Sowell et al.,  2002 ).

FIGURE 4.5 The left side of the human brain, showing the cerebral cortex.

The cortex is divided into different lobes, each containing a variety of regions with specific functions. Some major regions are labeled here.

Lateralization and Plasticity of the Cortex.

The cerebral cortex has two hemispheres, or sides, that differ in their functions. Some tasks are done mostly by the left hemisphere, others by the right. For example, each hemisphere receives sensory information from the side of the body opposite to it and controls only that side. *  For most of us, the left hemisphere is largely responsible for verbal abilities (such as spoken and written language) and positive emotion (such as joy). The right hemisphere handles spatial abilities (judging distances, reading maps, and recognizing geometric shapes) and negative emotion (such as distress) (Banish & Heller,  1998 ; Nelson & Bosquet,  2000 ). In left-handed people, this pattern may be reversed or, more commonly, the cerebral cortex may be less clearly specialized than in right-handers.

Why does this specialization of the two hemispheres, called  lateralization , occur? Studies using fMRI reveal that the left hemisphere is better at processing information in a sequential, analytic (piece-by-piece) way, a good approach for dealing with communicative information—both verbal (language) and emotional (a joyful smile). In contrast, the right hemisphere is specialized for processing information in a holistic, integrative manner, ideal for making sense of spatial information and regulating negative emotion. A lateralized brain may have evolved because it enabled humans to cope more successfully with changing environmental demands (Falk,  2005 ). It permits a wider array of functions to be carried out effectively than if both sides processed information exactly the same way.

*The eyes are an exception. Messages from the right half of each retina go to the right hemisphere; messages from the left half of each retina go to the left hemisphere. Thus, visual information from botheyes is received by both hemispheres.

Researchers study the timing of brain lateralization to learn more about  brain plasticity . A highly plastic cerebral cortex, in which many areas are not yet committed to specific functions, has a high capacity for learning. And if a part of the cortex is damaged, other parts can take over tasks it would have handled.But once the hemispheres lateralize, damage to a specific region means that the abilities it controls cannot be recovered to the same extent or as easily as earlier.

At birth, the hemispheres have already begun to specialize. Most newborns show greater activation (detected with either ERP or NIRS) in the left hemisphere while listening to speech sounds or displaying a positive state of arousal. In contrast, the right hemisphere reacts more strongly to nonspeech sounds and to stimuli (such as a sour-tasting fluid) that evoke negative emotion (Davidson,  1994 ; Fox & Davidson,  1986 ; Hespos et al.,  2010 ).

Nevertheless, research on brain-damaged children and adults offers dramatic evidence for substantial plasticity in the young brain, summarized in the  Biology and Environment  box on  page 126 . Furthermore, early experience greatly influences the organization of the cerebral cortex. For example, deaf adults who, as infants and children, learned sign language (a spatial skill) depend more than hearing individuals on the right hemisphere for language processing (Neville & Bavelier,  2002 ). And toddlers who are advanced in language development show greater left-hemispheric specialization for language than their more slowly developing agemates (Luna et al.,  2001 ; Mills et al.,  2005 ). Apparently, the very process of acquiring language and other skills promotes lateralization.

In sum, the brain is more plastic during the first few years than it will ever be again. An overabundance of synaptic connections supports brain plasticity, ensuring that young children will acquire certain capacities even if some areas are damaged. And although the cortex is programmed from the start for hemispheric specialization, experience greatly influences the rate and success of its advancing organization.

Sensitive Periods in Brain Development

Both animal and human studies reveal that early, extreme sensory deprivation results in permanent brain damage and loss of functions—findings that verify the existence of sensitive periods in brain development. For example, early, varied visual experiences must occur for the brain’s visual centers to develop normally. If a 1-month-old kitten is deprived of light for just three or four days, these areas of the brain degenerate. If the kitten is kept in the dark during the fourth week of life and beyond, the damage is severe and permanent (Crair, Gillespie, & Stryker,  1998 ). And the general quality of the early environment affects overall brain growth. When animals reared from birth in physically and socially stimulating surroundings are compared with those reared under depleted conditions, the brains of the stimulated animals are larger and heavier and show much denser synaptic connections (Sale, Berardi, & Maffei,  2009 ).

Human Evidence: Victims of Deprived Early Environments.

For ethical reasons, we cannot deliberately deprive some infants of normal rearing experiences and observe the impact on their brains and competencies. Instead, we must turn to natural experiments, in which children were victims of deprived early environments that were later rectified. Such studies have revealed some parallels with the animal evidence just described.

For example, when babies are born with cataracts (clouded lenses, preventing clear visual images) in both eyes, those who have corrective surgery within four to six months show rapid improvement in vision, except for subtle aspects of face perception, which require early visual input to the right hemisphere to develop (Le Grand et al.,  2003 ; Maurer, Mondloch, & Lewis,  2007 ). The longer cataract surgery is postponed beyond infancy, the less complete the recovery in visual skills. And if surgery is delayed until adulthood, vision is severely and permanently impaired (Lewis & Maurer,  2005 ).

Studies of infants placed in orphanages who were later exposed to ordinary family rearing confirm the importance of a generally stimulating physical and social environment for psychological development. In one investigation, researchers followed the progress of a large sample of children transferred between birth and 3½ years from extremely deprived Romanian orphanages to adoptive families in Great Britain (Beckett et al.,  2006 ; O’Connor et al.,  2000 ; Rutter et al.,  1998 ,  2004 ,  2010 ). On arrival, most were impaired in all domains of development. Cognitive catch-up was impressive for children adopted before 6 months, who attained average mental test scores in childhood and adolescence, performing as well as a comparison group of early-adopted British-born children.

These children in an orphanage in Romania receive little adult contact or stimulation. The longer they remain in this barren environment, the more likely they are to display profound impairments in all domains of development.

But Romanian children who had been institutionalized for more than the first six months showed serious intellectual deficits (see  Figure 4.6 ). Although they improved in test scores during middle childhood and adolescence, they remained substantially below average. And most displayed at least three serious mental health problems, such as inattention, overactivity, unruly behavior, and autistic-like symptoms (social disinterest, stereotyped behavior) (Kreppner et al.,  2007 ,  2010 ).

Biology and Environment Brain Plasticity: Insights from Research on Brain-Damaged Children and Adults

This preschooler, who experienced brain damage in infancy, has been spared massive impairments because of early, high brain plasticity. A teacher guides his hand in drawing shapes to strengthen spatial skills, which are more impaired than language.

In the first few years of life, the brain is highly plastic. It can reorganize areas committed to specific functions in ways that the mature brain cannot. Consistently, adults who suffered brain injuries in infancy and early childhood show fewer cognitive impairments than adults with later-occurring injuries (Holland,  2004 ; Huttenlocher,  2002 ). Nevertheless, the young brain is not totally plastic. When it is injured, its functioning is compromised. The extent of plasticity depends on several factors, including age at time of injury, site of damage, and skill area. Furthermore, plasticity is not restricted to childhood. Some reorganization after injury also occurs in the mature brain.

Brain Plasticity in Infancy and Early Childhood

In a large study of children with injuries to the cerebral cortex that occurred before birth or in the first six months of life, language and spatial skills were assessed repeatedly into adolescence (Akshoomoff et al.,  2002 ; Stiles,  2001a ; Stiles et al.,  2005 ,  2008 ). All the children had experienced early brain seizures or hemorrhages. Brain-imaging techniques (fMRI and PET) revealed the precise site of damage.

Regardless of whether injury occurred in the left or right cerebral hemisphere, the children showed delays in language development that persisted until about 3½ years of age. That damage to either hemisphere affected early language competence indicates that at first, language functioning is broadly distributed in the brain. But by age 5, the children caught up in vocabulary and grammatical skills. Undamaged areas—in either the left or the right hemisphere—had taken over these language functions.

Compared with language, spatial skills were more impaired after early brain injury. When preschool through adolescent-age youngsters were asked to copy designs, those with early right-hemispheric damage had trouble with holistic processing—accurately representing the overall shape. In contrast, children with left-hemispheric damage captured the basic shape but omitted fine-grained details. Nevertheless, the children improved in drawing skills with age—gains that do not occur in brain-injured adults (Akshoomoff et al.,  2002 ; Stiles et al.,  2003 ,  2008 ).

Clearly, recovery after early brain injury is greater for language than for spatial skills. Why is this so? Researchers speculate that spatial processing is the older of the two capacities in our evolutionary history and, therefore, more lateralized at birth (Stiles,  2001b ; Stiles et al.,  2002 ,  2008 ). But early brain injury has far less impact than later injury on both language and spatial skills. In sum, the young brain is remarkably plastic.

The Price of High Plasticity in the Young Brain

Despite impressive recovery of language and (to a lesser extent) spatial skills, children with early brain injuries show deficits in a wide range of complex mental abilities during the school years. For example, their reading and math progress is slow. And in telling stories, they produce simpler narratives than agemates without early brain injuries (although many catch up in narrative skills by early adolescence) (Reilly, Bates, & Marchman,  1998 ; Reilly et al.,  2004 ). Furthermore, the more brain tissue destroyed in infancy or early childhood, the poorer children score on intelligence tests (Anderson et al.,  2006 ).

High brain plasticity, researchers explain, comes at a price. When healthy brain regions take over the functions of damaged areas, a “crowding effect” occurs: Multiple tasks must be done by a smaller-than-usual volume of brain tissue (Stiles,  2012 ). Consequently, the brain processes information less quickly and accurately than it would if it were intact. Complex mental abilities of all kinds suffer into middle childhood, and often longer, because performing them well requires considerable space in the cerebral cortex.

Brain Plasticity in Adulthood

Brain plasticity is not restricted to early childhood. Though far more limited, reorganization in the brain can occur later, even in adulthood. For example, adult stroke victims often display considerable recovery, especially in response to stimulation of language and motor skills. Brain-imaging techniques reveal that structures adjacent to the permanently damaged area or in the opposite cerebral hemisphere reorganize to support the impaired ability (Kalra & Ratan,  2007 ; Murphy & Corbett,  2009 ).

In infancy and childhood, the goal of brain growth is to form neural connections that ensure mastery of essential skills. Animal research reveals that plasticity is greatest while the brain is forming many new synapses; it declines during synaptic pruning (Murphy & Corbett,  2009 ). At older ages, specialized brain structures are in place, but after injury they can still reorganize to some degree. The adult brain can produce a small number of new neurons. And when an individual practices relevant tasks, the brain strengthens existing synapses and generates new ones (Nelson, Thomas, & de Haan,  2006 ).

Plasticity seems to be a basic property of the nervous system. Researchers hope to discover how experience and brain plasticity work together throughout life, so they can help people of all ages—with and without brain injuries—develop at their best.

FIGURE 4.6 Relationship of age at adoption to mental test scores at ages 6 and 11 among British and Romanian adoptees.

Children transferred from Romanian orphanages to British adoptive homes in the first six months of life attained average scores and fared as well as British early-adopted children, suggesting that they had fully recovered from extreme early deprivation. Romanian children adopted after 6 months of age performed well below average. And although those adopted after age 2 improved between ages 6 and 11, they continued to show serious intellectual deficits.

(Adapted from Beckett et al., 2006.)

Neurobiological findings indicate that early, prolonged institutionalization leads to a generalized decrease in activity in the cerebral cortex, especially the prefrontal cortex, which governs complex cognition and impulse control. Neural fibers connecting the prefrontal cortex with other brain structures involved in control of emotion are also reduced (Eluvathingal et al.,  2006 ; Nelson,  2007b ). And activation of the left cerebral hemisphere, governing positive emotion, is diminished relative to right cerebral activation, governing negative emotion (McLaughlin et al.,  2011 ).

Additional evidence confirms that the chronic stress of early, deprived orphanage rearing disrupts the brain’s capacity to manage stress, with long-term physical and psychological consequences. In another investigation, researchers followed the development of children who had spent their first eight months or more in Romanian institutions and were then adopted into Canadian homes (Gunnar et al.,  2001 ; Gunnar & Cheatham,  2003 ). Compared with agemates adopted shortly after birth, these children showed extreme stress reactivity, as indicated by high concentrations of the stress hormone cortisol in their saliva—a physiological response linked to persistent illness, retarded physical growth, and learning and behavior problems, including deficits in attention and control of anger and other impulses. The longer the children spent in orphanage care, the higher their cortisol levels—even 6½ years after adoption. In other investigations, orphanage children displayed abnormally low cortisol—a blunted physiological stress response that may be the central nervous system’s adaptation to earlier, frequent cortisol elevations (Loman & Gunnar,  2010 ).

Appropriate Stimulation.

Unlike the orphanage children just described, Grace, whom Monica and Kevin had adopted in Cambodia at 16 months of age, showed favorable progress. Two years earlier, they had adopted Grace’s older brother, Eli. When Eli was 2 years old, Monica and Kevin sent a letter and a photo of Eli to his biological mother, describing a bright, happy child. The next day, the Cambodian mother tearfully asked an adoption agency to send her baby daughter to join Eli and his American family. Although Grace’s early environment was very depleted, her biological mother’s loving care—holding gently, speaking softly, playfully stimulating, and breastfeeding—may have prevented irreversible damage to her brain.

In the Bucharest Early Intervention Project, about 200 institutionalized Romanian babies were randomized into conditions of either care as usual or transfer to high-quality foster families between ages 5 and 30 months. Specially trained social workers provided foster parents with counseling and support. Follow-ups between 2½ and 4 years revealed that the foster-care group exceeded the institutional-care group in intelligence test scores, language skills, emotional responsiveness, and EEG and ERP assessments of brain activity (Nelson et al.,  2007 ; Smyke et al.,  2009 ). On all measures, the earlier the foster placement, the better the outcome. But consistent with an early sensitive period, the foster-care group remained behind never-institutionalized agemates living with Bucharest families.

In addition to impoverished environments, ones that overwhelm children with expectations beyond their current capacities interfere with the brain’s potential. In recent years, expensive early learning centers have sprung up, in which infants are trained with letter and number flash cards and slightly older toddlers are given a full curriculum of reading, math, science, art, gym, and more. There is no evidence that these programs yield smarter “superbabies” (Hirsh-Pasek & Golinkoff,  2003 ). To the contrary, trying to prime infants with stimulation for which they are not ready can cause them to withdraw, thereby threatening their interest in learning and creating conditions much like stimulus deprivation!

How, then, can we characterize appropriate stimulation during the early years? To answer this question, researchers distinguish between two types of brain development. The first,  experience-expectant brain growth , refers to the young brain’s rapidly developing organization, which depends on ordinary experiences—opportunities to explore the environment, interact with people, and hear language and other sounds. As a result of millions of years of evolution, the brains of all infants, toddlers, and young children expect to encounter these experiences and, if they do, grow normally. The second type of brain development,  experience-dependent brain growth , occurs throughout our lives. It consists of additional growth and refinement of established brain structures as a result of specific learning experiences that vary widely across individuals and cultures (Greenough & Black,  1992 ). Reading and writing, playing computer games, weaving an intricate rug, and practicing the violin are examples. The brain of a violinist differs in certain ways from the brain of a poet because each has exercised different brain regions for a long time.

Experience-expectant brain growth occurs early and naturally, as caregivers offer babies and preschoolers age-appropriate play materials and engage them in enjoyable daily routines—a shared meal, a game of peekaboo, a bath before bed, a picture book to talk about, or a song to sing. The resulting growth provides the foundation for later-occurring, experience-dependent development (Huttenlocher,  2002 ; Shonkoff & Phillips,  2001 ). No evidence exists for a sensitive period in the first five or six years for mastering skills that depend on extensive training, such as reading, musical performance, or gymnastics. To the contrary, rushing early learning harms the brain by overwhelming its neural circuits, thereby reducing the brain’s sensitivity to the everyday experiences it needs for a healthy start in life.

Experience-expectant brain growth occurs naturally, through ordinary, stimulating experiences. This toddler exploring a mossy log enjoys the type of activity that best promotes brain development in the early years.

Changing States of Arousal

Rapid brain growth means that the organization of sleep and wakefulness changes substantially between birth and 2 years, and fussiness and crying also decline. The newborn baby takes round-the-clock naps that total about 16 to 18 hours (Davis, Parker & Montgomery,  2004 ). Total sleep time declines slowly; the average 2-year-old still needs 12 to 13 hours. But periods of sleep and wakefulness become fewer and longer, and the sleep–wake pattern increasingly conforms to a night–day schedule. Most 6- to 9-month-olds take two daytime naps; by about 18 months, children generally need only one nap. Finally, between ages 3 and 5, napping subsides (Iglowstein et al.,  2003 ).

These changing arousal patterns are due to brain development, but they are also affected by cultural beliefs and practices and individual parents’ needs (Super & Harkness,  2002 ). Dutch parents, for example, view sleep regularity as far more important than the U.S. parents do. And whereas U.S. parents regard a predictable sleep schedule as emerging naturally from within the child, Dutch parents believe that a schedule must be imposed, or the baby’s development might suffer (Super et al.,  1996 ; Super & Harkness,  2010 ). At age 6 months, Dutch babies are put to bed earlier and sleep, on average, 2 hours more per day than their U.S. agemates.

Motivated by demanding work schedules and other needs, many Western parents try to get their babies to sleep through the night as early as 3 to 4 months by offering an evening feeding—a practice that may be at odds with young infants’ neurological capacities. Not until the middle of the first year is the secretion of melatonin, a hormone within the brain that promotes drowsiness, much greater at night than during the day (Sadeh,  1997 ).

Furthermore, as the Cultural Influences box on the following page reveals, isolating infants to promote sleep is rare elsewhere in the world. When babies sleep with their parents, their average sleep period remains constant at three hours from 1 to 8 months of age. Only at the end of the first year, as REM sleep (the state that usually prompts waking) declines, do infants move in the direction of an adultlike sleep–waking schedule (Ficca et al.,  1999 ).

Even after infants sleep through the night, they continue to wake occasionally. In studies carried out in Australia, Israel, and the United States, night wakings increased around 6 months and again between 1½ and 2 years and then declined (Armstrong, Quinn, & Dadds,  1994 ; Scher, Epstein, & Tirosh,  2004 ; Scher et al.,  1995 ). As  Chapter 6  will reveal, around the middle of the first year, infants are forming a clear-cut attachment to their familiar caregiver and begin protesting when he or she leaves. And the challenges of toddlerhood—the ability to range farther from the caregiver and increased awareness of the self as separate from others—often prompt anxiety, evident in disturbed sleep and clinginess. When parents offer comfort, these behaviors subside.

LOOK AND LISTEN

Interview a parent of a baby about sleep challenges. What strategies has the parent tried to ease these difficulties? Are the techniques likely to be effective, in view of evidence on infant sleep development?

Cultural Influences Cultural Variation in Infant Sleeping Arrangements

This Vietnamese mother and child sleep together—a practice common in their culture and around the globe. Hard wooden sleeping surfaces protect cosleeping children from entrapment in soft bedding.

Western child-rearing advice from experts strongly encourages nighttime separation of baby from parent. For example, the most recent edition of Benjamin Spock’s Baby and Child Care recommends that babies sleep in their own room by 3 months of age, explaining, “By 6 months, a child who regularly sleeps in her parents’ room may feel uneasy sleeping anywhere else” (Spock & Needlman,  2012 , p. 62). And the American Academy of Pediatrics ( 2012 ) has issued a controversial warning that parent–infant bedsharing may increase the risk of sudden infant death syndrome (SIDS).

Yet parent–infant “cosleeping” is the norm for approximately 90 percent of the world’s population, in cultures as diverse as the Japanese, the rural Guatemalan Maya, the Inuit of northwestern Canada, and the !Kung of Botswana. Japanese and Korean children usually lie next to their mothers in infancy and early childhood, and many continue to sleep with a parent or other family member until adolescence (Takahashi,  1990 ; Yang & Hahn,  2002 ). Among the Maya, mother–infant bed-sharing is interrupted only by the birth of a new baby, when the older child is moved next to the father or to another bed in the same room (Morelli et al.,  1992 ). Bedsharing is also common in U.S. ethnic minority families (McKenna & Volpe,  2007 ). African-American children, for example, frequently fall asleep with their parents and remain with them for part or all of the night (Buswell & Spatz,  2007 ).

Cultural values—specifically, collectivism versus individualism (see  Chapter 2 )—strongly influence infant sleeping arrangements. In one study, researchers interviewed Guatemalan Mayan mothers and American middle-SES mothers about their sleeping practices. Mayan mothers stressed the importance of promoting an interdependent self, explaining that cosleeping builds a close parent–child bond, which is necessary for children to learn the ways of people around them. In contrast, American mothers emphasized an independent self, mentioning their desire to instill early autonomy, prevent bad habits, and protect their own privacy (Morelli et al.,  1992 ).

Over the past two decades, cosleeping has increased in Western nations. An estimated 13 percent of U.S. infants routinely bedshare, and an additional 30 to 35 percent some-times do (Buswell & Spatz,  2007 ; Willinger et al.,  2003 ). Proponents of the practice say that it helps infants sleep, makes breastfeeding more convenient, and provides valuable bonding time (McKenna & Volpe,  2007 ).

During the night, cosleeping babies breastfeed three times longer than infants who sleep alone. Because infants arouse to nurse more often when sleeping next to their mothers, some researchers believe that cosleeping may actually help safeguard babies at risk for SIDS (see  page 110  in  Chapter 3 ). Consistent with this view, SIDS is rare in Asian cultures where cosleeping is widespread, including Cambodia, China, Japan, Korea, Thailand, and Vietnam (McKenna,  2002 ; McKenna & McDade,  2005 ). And contrary to popular belief, cosleeping does not reduce mothers’ total sleep time, although they experience more brief awakenings, which permit them to check on their baby (Mao et al.,  2004 ).

Infant sleeping practices affect other aspects of family life. For example, Mayan babies doze off in the midst of ongoing family activities and are carried to bed by their mothers. In contrast, for many American parents, bedtime often involves a lengthy, elaborate ritual. Perhaps bedtime struggles, so common in Western homes but rare elsewhere in the world, are related to the stress young children feel when they must fall asleep without assistance (Latz, Wolf, & Lozoff,  1999 ).

Critics warn that bedsharing will promote emotional problems, especially excessive dependency. Yet a study following children from the end of pregnancy through age 18 showed that young people who had bedshared in the early years were no different from others in any aspect of adjustment (Okami, Weisner, & Olmstead,  2002 ). Another concern is that infants might become trapped under the parent’s body or in soft bedding and suffocate. Parents who are obese or who use alcohol, tobacco, or illegal drugs do pose a serious risk to their sleeping babies, as does the use of quilts and comforters or an overly soft mattress (American Academy of Pediatrics,  2012 ; Willinger et al.,  2003 ).

But with appropriate precautions, parents and infants can cosleep safely (McKenna & Volpe,  2007 ). In cultures where cosleeping is widespread, parents and infants usually sleep with light covering on hard surfaces, such as firm mattresses, floor mats, and wooden planks, or infants sleep in a cradle or hammock next to the parents’ bed (McKenna,  2001 ,  2002 ). And when sharing the same bed, infants typically lie on their back or side facing the mother—positions that promote frequent, easy communication between parent and baby and arousal if breathing is threatened.

Finally, breastfeeding mothers usually assume a distinctive sleeping posture: They face the infant, with knees drawn up under the baby’s feet and arm above the baby’s head. Besides facilitating feeding, the position prevents the infant from sliding down under covers or up under pillows (Ball,  2006 ). Because this posture is also seen in female great apes while sharing sleeping nests with their infants, researchers believe it may have evolved to enhance infant safety.

ASK YOURSELF

REVIEW How do overproduction of synapses and synaptic pruning support infants’ and children’s ability to learn?

CONNECT Explain how inappropriate stimulation—either too little or too much—can impair cognitive and emotional development in the early years.

APPLY Which infant enrichment program would you choose: one that emphasizes gentle talking and touching and social games, or one that includes reading and number drills and classical music lessons? Explain.

REFLECT What is your attitude toward parent–infant cosleeping? Is it influenced by your cultural background? Explain.

image3 Influences on Early Physical Growth

Physical growth, like other aspects of development, results from a complex interplay between genetic and environmental factors. Heredity, nutrition, and emotional well-being all affect early physical growth.

Heredity

Because identical twins are much more alike in body size than fraternal twins, we know that heredity is important in physical growth (Estourgie-van Burk et al.,  2006 ; Touwslager et al.,  2011 ). When diet and health are adequate, height and rate of physical growth are largely influenced by heredity. In fact, as long as negative environmental influences such as poor nutrition and illness are not severe, children and adolescents typically show catch-up growth—a return to a genetically influenced growth path once conditions improve. Still, the brain, the heart, the digestive system, and many other internal organs may be permanently compromised (Hales & Ozanne,  2003 ). (Recall the consequences of inadequate prenatal nutrition for long-term health, discussed on  page 92  in  Chapter 3 .)

Genetic makeup also affects body weight: The weights of adopted children correlate more strongly with those of their biological than of their adoptive parents (Kinnunen, Pietilainen, & Rissanen,  2006 ). At the same time, environment—in particular, nutrition—plays an especially important role.

Nutrition

Nutrition is especially crucial for development in the first two years because the baby’s brain and body are growing so rapidly. Pound for pound, an infant’s energy needs are twice those of an adult. Twenty-five percent of babies’ total caloric intake is devoted to growth, and infants need extra calories to keep rapidly developing organs functioning properly (Meyer,  2009 ).

Midwives in India support a mother as she learns to breastfeed her infant. Breastfeeding is especially important in developing countries, where it helps protect babies against life-threatening infections and early death.

Breastfeeding versus Bottle-Feeding.

Babies need not only enough food but also the right kind of food. In early infancy, breastfeeding is ideally suited to their needs, and bottled formulas try to imitate it. Applying What We Know on the following page summarizes major nutritional and health advantages of breastfeeding.

Because of these benefits, breastfed babies in poverty-stricken regions are much less likely to be malnourished and 6 to 14 times more likely to survive the first year of life. The World Health Organization recommends breastfeeding until age 2 years, with solid foods added at 6 months. These practices, if widely followed, would save the lives of more than a million infants annually (World Health Organization,  2012b ). Even breastfeeding for just a few weeks offers some protection against respiratory and intestinal infections, which are devastating to young children in developing countries. Also, because a nursing mother is less likely to get pregnant, breastfeeding helps increase spacing between siblings, a major factor in reducing infant and childhood deaths in nations with widespread poverty. (Note, however, that breastfeeding is not a reliable method of birth control.)

Yet many mothers in the developing world do not know about these benefits. In Africa, the Middle East, and Latin America, most babies get some breastfeeding, but fewer than 40 percent are exclusively breastfed for the first six months, and one-third are fully weaned from the breast before 1 year (UNICEF,  2009 ). In place of breast milk, mothers give their babies commercial formula or low-grade nutrients, such as rice water or highly diluted cow or goat milk. Contamination of these foods as a result of poor sanitation is common and often leads to illness and infant death. The United Nations has encouraged all hospitals and maternity units in developing countries to promote breastfeeding as long as mothers do not have viral or bacterial infections (such as HIV or tuberculosis) that can be transmitted to the baby. Today, most developing countries have banned the practice of giving free or subsidized formula to new mothers.

Partly as a result of the natural childbirth movement, breastfeeding has become more common in industrialized nations, especially among well-educated women. Today, 74 percent of American mothers breastfeed, but more than half stop by 6 months (Centers for Disease Control and Prevention,  2011a ). Not surprisingly, mothers who return to work sooner wean their babies from the breast earlier (Kimbro,  2006 ). But mothers who cannot be with their infants all the time can still combine breast- and bottle-feeding. The U.S. Department of Health and Human Services ( 2010a ) advises exclusive breastfeeding for the first 6 months and inclusion of breast milk in the baby’s diet until at least 1 year.

Women who do not breastfeed sometimes worry that they are depriving their baby of an experience essential for healthy psychological development. Yet breastfed and bottle-fed infants in industrialized nations do not differ in quality of the mother–infant relationship or in later emotional adjustment (Fergusson & Woodward,  1999 ; Jansen, de Weerth, & Riksen-Walraven,  2008 ). Some studies report a slight advantage in intelligence test performance for children and adolescents who were breastfed, after controlling for many factors. Most, however, find no cognitive benefits (Der, Batty, & Deary,  2006 ).

Applying What We Know Reasons to Breastfeed

Nutritional and Health Advantages Explanation
Provides the correct balance of fat and protein Compared with the milk of other mammals, human milk is higher in fat and lower in protein. This balance, as well as the unique proteins and fats contained in human milk, is ideal for a rapidly myelinating nervous system.
Ensures nutritional completeness A mother who breastfeeds need not add other foods to her infant’s diet until the baby is 6 months old. The milks of all mammals are low in iron, but the iron contained in breast milk is much more easily absorbed by the baby’s system. Consequently, bottle-fed infants need iron-fortified formula.
Helps ensure healthy physical growth One-year-old breastfed babies are leaner (have a higher percentage of muscle to fat), a growth pattern that persists through the preschool years and that may help prevent later overweight and obesity.
Protects against many diseases Breastfeeding transfers antibodies and other infection-fighting agents from mother to child and enhances functioning of the immune system. Compared with bottle-fed infants, breastfed babies have far fewer allergic reactions and respiratory and intestinal illnesses. Breast milk also has anti-inflammatory effects, which reduce the severity of illness symptoms. Breastfeeding in the first four months is linked to lower blood cholesterol levels in adulthood and, thereby, may help prevent cardiovascular disease.
Protects against faulty jaw development and tooth decay Sucking the mother’s nipple instead of an artificial nipple helps avoid malocclusion, a condition in which the upper and lower jaws do not meet properly. It also protects against tooth decay due to sweet liquid remaining in the mouths of infants who fall asleep while sucking on a bottle.
Ensures digestibility Because breastfed babies have a different kind of bacteria growing in their intestines than do bottle-fed infants, they rarely suffer from constipation or other gastrointestinal problems.
Smooths the transition to solid foods Breastfed infants accept new solid foods more easily than bottle-fed infants, perhaps because of their greater experience with a variety of flavors, which pass from the maternal diet into the mother’s milk.

Sources: American Academy of Pediatrics, 2005; Buescher, 2001; Michels et al., 2007; Owen et al., 2008; Rosetta & Baldi, 2008; Weyermann, Rothenbacher, & Brenner, 2006.

Are Chubby Babies at Risk for Later Overweight and Obesity?

From early infancy, Timmy was an enthusiastic eater who nursed vigorously and gained weight quickly. By 5 months, he began reaching for food on his mother’s plate. Vanessa wondered: Was she overfeeding Timmy and increasing his chances of becoming overweight?

Most chubby babies thin out during toddlerhood and early childhood, as weight gain slows and they become more active. Infants and toddlers can eat nutritious foods freely without risk of becoming overweight. But recent evidence does indicate a strengthening relationship between rapid weight gain in infancy and later obesity (Botton et al.,  2008 ; Chomtho et al.,  2008 ). The trend may be due to the rise in overweight and obesity among adults, who promote unhealthy eating habits in their young children. Interviews with 1,500 U.S. parents of 4- to 24-month-olds revealed that many routinely served older infants and toddlers french fries, pizza, candy, sugary fruit drinks, and soda. On average, infants consumed 20 percent and toddlers 30 percent more calories than they needed. At the same time, as many as one-fourth ate no fruits and one-third no vegetables (Siega-Riz et al.,  2010 ).

How can concerned parents prevent their infants from becoming overweight children and adults? One way is to breastfeed for the first six months, which is associated with slower early weight gain (Gunnarsdottir et al.,  2010 ). Another is to avoid giving them foods loaded with sugar, salt, and saturated fats. Once toddlers learn to walk, climb, and run, parents can also provide plenty of opportunities for energetic play. Finally, because research shows a correlation between excessive television viewing and overweight in older children, parents should limit the time very young children spend in front of the TV.

Malnutrition

Osita is an Ethiopian 2-year-old whose mother has never had to worry about his gaining too much weight. When she weaned him at 1 year, there was little for him to eat besides starchy rice-flour cakes. Soon his belly enlarged, his feet swelled, his hair fell out, and a rash appeared on his skin. His bright-eyed curiosity vanished, and he became irritable and listless.

In developing countries and war-torn areas where food resources are limited, malnutrition is widespread. Recent evidence indicates that about 27 percent of the world’s children suffer from malnutrition before age 5 (World Health Organization,  2010 ). The 10 percent who are severely affected suffer from two dietary diseases.

Marasmus  is a wasted condition of the body caused by a diet low in all essential nutrients. It usually appears in the first year of life when a baby’s mother is too malnourished to produce enough breast milk and bottle-feeding is also inadequate. Her starving baby becomes painfully thin and is in danger of dying.

Osita has  kwashiorkor , caused by an unbalanced diet very low in protein. The disease usually strikes after weaning, between 1 and 3 years of age. It is common in regions where children get just enough calories from starchy foods but little protein. The child’s body responds by breaking down its own protein reserves, which causes the swelling and other symptoms that Osita experienced.

Children who survive these extreme forms of malnutrition grow to be smaller in all body dimensions and suffer from lasting damage to the brain, heart, liver, or other organs (Müller & Krawinkel,  2005 ). When their diets do improve, they tend to gain excessive weight (Uauy et al.,  2008 ). A malnourished body protects itself by establishing a low basal metabolism rate, which may endure after nutrition improves. Also, malnutrition may disrupt appetite control centers in the brain, causing the child to overeat when food becomes plentiful.

Learning and behavior are also seriously affected. In one long-term study of marasmic children, an improved diet led to some catch-up growth in height, but not in head size (Stoch et al.,  1982 ). The malnutrition probably interfered with growth of neural fibers and myelination, causing a permanent loss in brain weight. And animal evidence reveals that a deficient diet alters the production of neurotransmitters in the brain—an effect that can disrupt all aspects of development (Haller,  2005 ). These children score low on intelligence tests, show poor fine-motor coordination, and have difficulty paying attention (Galler et al.,  1990 ; Liu et al.,  2003 ). They also display a more intense stress response to fear-arousing situations, perhaps caused by the constant, gnawing pain of hunger (Fernald & Grantham-McGregor,  1998 ).

Inadequate nutrition is not confined to developing countries. Because government-supported supplementary food programs do not reach all families in need, an estimated 21 percent of U.S. children suffer from food insecurity—uncertain access to enough food for a healthy, active life. Food insecurity is especially high among single-parent families (35 percent) and low-income ethnic minority families—for example, Hispanics and African Americans (25 and 27 percent, respectively) (U.S. Department of Agriculture,  2011a ). Although few of these children have marasmus or kwashiorkor, their physical growth and ability to learn are still affected.

Left photo: This baby of Niger, Africa, has marasmus, a wasted condition caused by a diet low in all essential nutrients. Right photo: The swollen abdomen of this toddler, also of Niger, is a symptom of kwashiorkor, which results from a diet very low in protein. If these children survive, they are likely to be growth stunted and to suffer from lasting organ damage and serious cognitive and emotional impairments.

ASK YOURSELF

REVIEW Explain why breastfeeding can have lifelong consequences for the development of babies born in poverty-stricken regions of the world.

CONNECT How are bidirectional influences between parent and child involved in the impact of malnutrition on psychological development?

APPLY Eight-month-old Shaun is well below average in height and painfully thin. What serious growth disorder does he likely have, and what type of intervention, in addition to dietary enrichment, will help restore his development? (Hint: See  page 92  in  Chapter 3 .)

REFLECT Imagine that you are the parent of a newborn baby. Describe feeding practices you would use, and ones you would avoid, to prevent overweight and obesity.

image4 Learning Capacities

Learning refers to changes in behavior as the result of experience. Babies come into the world with built-in learning capacities that permit them to profit from experience immediately. Infants are capable of two basic forms of learning, which were introduced in  Chapter 1 : classical and operant conditioning. They also learn through their natural preference for novel stimulation. Finally, shortly after birth, babies learn by observing others; they can imitate the facial expressions and gestures of adults.

FIGURE 4.7 The steps of classical conditioning.

This example shows how a mother classically conditioned her baby to make sucking movements by stroking the baby’s forehead at the beginning of feedings.

Classical Conditioning

Newborn reflexes, discussed in  Chapter 3 , make  classical conditioning  possible in the young infant. In this form of learning, a neutral stimulus is paired with a stimulus that leads to a reflexive response. Once the baby’s nervous system makes the connection between the two stimuli, the neutral stimulus produces the behavior by itself. Classical conditioning helps infants recognize which events usually occur together in the everyday world, so they can anticipate what is about to happen next. As a result, the environment becomes more orderly and predictable. Let’s take a closer look at the steps of classical conditioning.

As Carolyn settled down in the rocking chair to nurse Caitlin, she often stroked Caitlin’s forehead. Soon Carolyn noticed that each time she did this, Caitlin made sucking movements. Caitlin had been classically conditioned.  Figure 4.7  shows how it happened:

· 1. Before learning takes place, an  unconditioned stimulus (UCS)  must consistently produce a reflexive, or  unconditioned, response (UCR) . In Caitlin’s case, sweet breast milk (UCS) resulted in sucking (UCR).

· 2. To produce learning, a neutral stimulus that does not lead to the reflex is presented just before, or at about the same time as, the UCS. Carolyn stroked Caitlin’s forehead as each nursing period began. The stroking (neutral stimulus) was paired with the taste of milk (UCS).

· 3. If learning has occurred, the neutral stimulus by itself produces a response similar to the reflexive response. The neutral stimulus is then called a  conditioned stimulus (CS) , and the response it elicits is called a  conditioned response (CR) . We know that Caitlin has been classically conditioned because stroking her forehead outside the feeding situation (CS) results in sucking (CR).

If the CS is presented alone enough times, without being paired with the UCS, the CR will no longer occur, an outcome called extinction. In other words, if Carolyn repeatedly strokes Caitlin’s forehead without feeding her, Caitlin will gradually stop sucking in response to stroking.

Young infants can be classically conditioned most easily when the association between two stimuli has survival value. In the example just described, learning which stimuli regularly accompany feeding improves the infant’s ability to get food and survive (Blass, Ganchrow, & Steiner,  1984 ).

In contrast, some responses, such as fear, are very difficult to classically condition in young babies. Until infants have the motor skills to escape unpleasant events, they have no biological need to form these associations. After age 6 months, however, fear is easy to condition. In  Chapter 6 , we will discuss the development of fear and other emotional reactions.

Operant Conditioning

In classical conditioning, babies build expectations about stimulus events in the environment, but their behavior does not influence the stimuli that occur. In  operant conditioning , infants act, or operate, on the environment, and stimuli that follow their behavior change the probability that the behavior will occur again. A stimulus that increases the occurrence of a response is called a  reinforcer . For example, sweet liquid reinforces the sucking response in newborns. Removing a desirable stimulus or presenting an unpleasant one to decrease the occurrence of a response is called  punishment . A sour-tasting fluid punishes newborns’ sucking response, causing them to purse their lips and stop sucking entirely.

Many stimuli besides food can serve as reinforcers of infant behavior. For example, newborns will suck faster on a nipple when their rate of sucking produces interesting sights and sounds, including visual designs, music, or human voices (Floccia, Christophe, & Bertoncini,  1997 ). As these findings suggest, operant conditioning is a powerful tool for finding out what stimuli babies can perceive and which ones they prefer.

As infants get older, operant conditioning includes a wider range of responses and stimuli. For example, researchers have hung mobiles over the cribs of 2- to 6-month-olds. When the baby’s foot is attached to the mobile with a long cord, the infant can, by kicking, make the mobile turn. Under these conditions, it takes only a few minutes for infants to start kicking vigorously (Rovee-Collier,  1999 ; Rovee-Collier & Barr,  2001 ). As you will see in  Chapter 5 , operant conditioning with mobiles is frequently used to study infants’ memory and their ability to group similar stimuli into categories. Once babies learn the kicking response, researchers see how long and under what conditions they retain it when exposed again to the original mobile or to mobiles with varying features.

Operant conditioning also plays a vital role in the formation of social relationships. As the baby gazes into the adult’s eyes, the adult looks and smiles back, and then the infant looks and smiles again. As the behavior of each partner reinforces the other, both continue their pleasurable interaction. In  Chapter 6 , we will see that this contingent responsiveness contributes to the development of infant–caregiver attachment.

Habituation

At birth, the human brain is set up to be attracted to novelty. Infants tend to respond more strongly to a new element that has entered their environment, an inclination that ensures that they will continually add to their knowledge base.  Habituation  refers to a gradual reduction in the strength of a response due to repetitive stimulation. Looking, heart rate, and respiration rate may all decline, indicating a loss of interest. Once this has occurred, a new stimulus—a change in the environment—causes responsiveness to return to a high level, an increase called  recovery . For example, when you walk through a familiar space, you notice things that are new and different—a recently hung picture on the wall or a piece of furniture that has been moved. Habituation and recovery make learning more efficient by focusing our attention on those aspects of the environment we know least about.

Researchers investigating infants’ understanding of the world rely on habituation and recovery more than any other learning capacity. For example, a baby who first habituates to a visual pattern (a photo of a baby) and then recovers to a new one (a photo of a bald man) appears to remember the first stimulus and perceive the second one as new and different from it. This method of studying infant perception and cognition, illustrated in  Figure 4.8 , can be used with newborns, including preterm infants (Kavšek & Bornstein,  2010 ). It has even been used to study the fetus’s sensitivity to external stimuli—for example, by measuring changes in fetal heart rate when various repeated sounds are presented (see  page 85  in  Chapter 3 ).

Recovery to a new stimulus, or novelty preference, assesses infants’ recent memory TAKE A MOMENT… Think about what happens when you return to a place you have not seen for a long time. Instead of attending to novelty, you are likely to focus on aspects that are familiar: “I recognize that—I’ve been here before!” Like adults, infants shift from a novelty preference to a familiarity preference as more time intervenes between habituation and test phases in research. That is, babies recover to the familiar stimulus rather than to a novel stimulus (see  Figure 4.8 ) (Bahrick, Hernandez-Reif, & Pickens,  1997 ; Courage & Howe,  1998 ; Flom & Bahrick,  2010 ; Richmond, Colombo, & Hayne,  2007 ). By focusing on that shift, researchers can also use habituation to assess remote memory, or memory for stimuli to which infants were exposed weeks or months earlier.

As  Chapter 5  will reveal, habituation research has greatly enriched our understanding of how long babies remember a wide range of stimuli. And by varying stimulus features, researchers can use habituation and recovery to study babies’ ability to categorize stimuli as well.

FIGURE 4.8 Using habituation to study infant perception and cognition.

In the habituation phase, infants view a photo of a baby until their looking declines. In the test phase, infants are again shown the baby photo, but this time it appears alongside a photo of a bald-headed man. (a) When the test phase occurs soon after the habituation phase (within minutes, hours, or days, depending on the age of the infants), participants who remember the baby face and distinguish it from the man’s face show a novelty preference; they recover to (spend more time looking at) the new stimulus. (b) When the test phase is delayed for weeks or months, infants who continue to remember the baby face shift to a familiarity preference; they recover to the familiar baby face rather than to the novel man’s face.

Imitation

Babies come into the world with a primitive ability to learn through  imitation —by copying the behavior of another person. For example,  Figure 4.9  shows a human newborn imitating two adult facial expressions (Meltzoff & Moore,  1977 ). The newborn’s capacity to imitate extends to certain gestures, such as head and index-finger movements, and has been demonstrated in many ethnic groups and cultures (Meltzoff & Kuhl,  1994 ; Nagy et al.,  2005 ). As the figure illustrates, even newborn primates, including chimpanzees (our closest evolutionary relatives), imitate some behaviors (Ferrari et al.,  2006 ; Myowa-Yamakoshi et al.,  2004 ).

FIGURE 4.9 Imitation by human and chimpanzee newborns.

The human infants in the middle row imitating (left) tongue protrusion and (right) mouth opening are 2 to 3 weeks old. The chimpanzee imitating both facial expressions is 2 weeks old.

(From A. N. Meltzoff & M. K. Moore, 1977, “Imitation of Facial and Manual Gestures by Human Neonates,” Science, 198, p. 75. Copyright © 1977 by AAAS. Reprinted with permission of the AAAS and A. N. Meltzoff. And from M. Myowa-Yamakoshi et al., 2004, “Imitation in Neonatal Chimpanzees [Pan Troglodytes].” Developmental Science, 7, p. 440. Copyright 2004 by Blackwell Publishing. Reproduced with permission of John Wiley & Sons Ltd.)

Although newborns’ capacity to imitate is widely accepted, a few studies have failed to reproduce the human findings (see, for example, Anisfeld et al.,  2001 ). And because newborn mouth and tongue movements occur with increased frequency to almost any arousing change in stimulation (such as lively music or flashing lights), some researchers argue that certain newborn “imitative” responses are actually mouthing—a common early exploratory response to interesting stimuli (Jones,  2009 ). Furthermore, imitation is harder to induce in babies 2 to 3 months old than just after birth. Therefore, skeptics believe that the newborn imitative capacity is little more than an automatic response that declines with age, much like a reflex (Heyes,  2005 ).

Others claim that newborns—both primates and humans—imitate a variety of facial expressions and head movements with effort and determination, even after short delays—when the adult is no longer demonstrating the behavior (Meltzoff & Moore,  1999 ; Paukner, Ferrari, & Suomi,  2011 ). Furthermore, these investigators argue that imitation—unlike reflexes—does not decline. Human babies several months old often do not imitate an adult’s behavior right away because they first try to play familiar social games—mutual gazing, cooing, smiling, and waving their arms. But when an adult models a gesture repeatedly, older human infants soon get down to business and imitate (Meltzoff & Moore,  1994 ). Similarly, imitation declines in baby chimps around 9 weeks of age, when mother–baby mutual gazing and other face-to-face exchanges increase.

According to Andrew Meltzoff, newborns imitate much as older children and adults do—by actively trying to match body movements they see with ones they feel themselves make (Meltzoff,  2007 ). Later we will encounter evidence that young infants are remarkably adept at coordinating information across sensory systems.

Indeed, scientists have identified specialized cells in motor areas of the cerebral cortex in primates—called  mirror neurons —that underlie these capacities (Ferrari & Coudé,  2011 ). Mirror neurons fire identically when a primate hears or sees an action and when it carries out that action on its own(Rizzolatti & Craighero,  2004 ). Human adults have especially elaborate systems of mirror neurons, which enable us to observe another’s behavior (such as smiling or throwing a ball) while simulating the behavior in our own brain. Mirror neurons are believed to be the biological basis of a variety of interrelated, complex social abilities, including imitation, empathic sharing of emotions, and understanding others’ intentions (Iacoboni,  2009 ; Schulte-Ruther et al.,  2007 ).

Brain-imaging findings support a functioning mirror-neuron system as early as 6 months of age. Using NIRS, researchers found that the same motor areas of the cerebral cortex were activated in 6-month-olds and in adults when they observed a model engage in a behavior that could be imitated (tapping a box to make a toy pop out) as when they themselves engaged in the motor action (Shimada & Hiraki,  2006 ). In contrast, when infants and adults observed an object that appeared to move on its own, without human intervention (a ball hanging from the ceiling on a string, swinging like a pendulum), motor areas were not activated.

Still, Meltzoff’s view of newborn imitation as a flexible, voluntary capacity remains controversial. Mirror neurons, though possibly functional at birth, undergo an extended period of development (Bertenthal & Longo,  2007 ; Lepage & Théoret,  2007 ). Similarly, as we will see in  Chapter 5 , the capacity to imitate expands greatly over the first two years. But however limited it is at birth, imitation is a powerful means of learning. Using imitation, infants explore their social world, not only learning from other people but getting to know them by matching their behavioral states. As babies notice similarities between their own actions and those of others, they experience other people as “like me” and, thus, learn about themselves (Meltzoff,  2007 ). In this way, infant imitation may serve as the foundation for understanding others’ thoughts and feelings, which we take up in  Chapter 6 . Finally, caregivers take great pleasure in a baby who imitates their facial gestures and actions, which helps get the infant’s relationship with parents off to a good start.

ASK YOURSELF

REVIEW Provide an example of classical conditioning, of operant conditioning, and of habituation/recovery in young infants. Why is each type of learning useful?

CONNECT Which learning capacities contribute to an infant’s first social relationships? Explain, providing examples.

APPLY Nine-month-old Byron has a toy with large, colored push buttons on it. Each time he pushes a button, he hears a nursery tune. Which learning capacity is the manufacturer of this toy taking advantage of? What can Byron’s play with the toy reveal about his perception of sound patterns?

image5 Motor Development

Carolyn, Monica, and Vanessa each kept a baby book, filled with proud notations about when their children first held up their heads, reached for objects, sat by themselves, and walked alone. Parents are understandably excited about these new motor skills, which allow babies to master their bodies and the environment in new ways. For example, sitting upright gives infants a new perspective on the world. Reaching permits babies to find out about objects by acting on them. And when infants can move on their own, their opportunities for exploration multiply.

Babies’ motor achievements have a powerful effect on their social relationships. When Caitlin crawled at 7½ months, Carolyn and David began to restrict her movements by saying no and expressing mild impatience. When she walked three days after her first birthday, the first “testing of wills” occurred (Biringen et al.,  1995 ). Despite her mother’s warnings, she sometimes pulled items from shelves that were off limits. “I said, ‘Don’t do that!’” Carolyn would say firmly, taking Caitlin’s hand and redirecting her attention.

At the same time, newly walking babies more actively attend to and initiate social interaction (Clearfield, Osborn, & Mullen,  2008 ; Karasik et al.,  2011 ). Caitlin frequently toddled over to her parents to express a greeting, give a hug, or show them objects of interest. Carolyn and David, in turn, increased their expressions of affection and playful activities. And when Caitlin encountered risky situations, such as a sloping walkway or a dangerous object, Carolyn and David intervened, combining emotional warnings with rich verbal and gestural information that helped Caitlin notice critical features of her surroundings, regulate her motor actions, and acquire language (Campos et al.,  2000 ; Karasik et al.,  2008 ). Caitlin’s delight as she worked on new motor skills triggered pleasurable reactions in others, which encouraged her efforts further. Motor, social, cognitive, and language competencies developed together and supported one another.

The Sequence of Motor Development

Gross-motor development refers to control over actions that help infants get around in the environment, such as crawling, standing, and walking. Fine-motor development has to do with smaller movements, such as reaching and grasping.  Table 4.2  shows the average age at which U.S. infants and toddlers achieve a variety of gross- and fine-motor skills. It also presents the age ranges during which most babies accomplish each skill, indicating large individual differences in rate of motor progress. Also, a baby who is a late reacher will not necessarily be a late crawler or walker. We would be concerned about a child’s development only if many motor skills were seriously delayed.

Historically, researchers assumed that motor skills were separate, innate abilities that emerged in a fixed sequence governed by a built-in maturational timetable. This view has long been discredited. Rather, motor skills are interrelated. Each is a product of earlier motor attainments and a contributor to new ones. And children acquire motor skills in highly individual ways. For example, before her adoption, Grace spent most of her days lying in a hammock. Because she was rarely placed on her tummy and on firm surfaces that enabled her to move on her own, she did not try to crawl. As a result, she pulled to a stand and walked before she crawled! Babies display such skills as rolling, sitting, crawling, and walking in diverse orders rather than in the sequence implied by motor norms (Adolph, Karasik, & Tamis-LeMonda,  2010 ).

TABLE 4.2 Gross- and Fine-Motor Development in the First Two Years

MOTOR SKILL AVERAGE AGE ACHIEVED AGE RANGE IN WHICH 90 PERCENT OF INFANTS ACHIEVE THE SKILL  
When held upright, holds head erect and steady 6 weeks 3 weeks–4 months    

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When prone, lifts self by arms 2 months 3 weeks–4 months    
Rolls from side to back 2 months 3 weeks–5 months    
Grasps cube 3 months, 3 weeks 2–7 months    
Rolls from back to side 4½ months 2–7 months    
Sits alone 7 months 5–9 months  

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Crawls 7 months 5–11 months    
Pulls to stand 8 months 5–12 months    
Plays pat-a-cake 9 months, 3 weeks 7–15 months    

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Stands alone 11 months 9–16 months    
Walks alone 11 months, 3 weeks 9–17 months    
Builds tower of two cubes 11 months, 3 weeks 10–19 months    
Scribbles vigorously 14 months 10–21 months    
Walks up stairs with help 16 months 12–23 months    
Jumps in place 23 months, 2 weeks 17–30 months    
Walks on tiptoe 25 months 16–30 months    

Note: These milestones represent overall age trends. Individual differences exist in the precise age at which each milestone is attained.

Sources: Bayley, 1969, 1993, 2005.

Photos: (top) © Laura Dwight Photography; (middle) © Laura Dwight Photography; (bottom) © Elizabeth Crews/The Image Works

Motor Skills as Dynamic Systems

According to  dynamic systems theory of motor development , mastery of motor skills involves acquiring increasingly complex systems of action. When motor skills work as a system, separate abilities blend together, each cooperating with others to produce more effective ways of exploring and controlling the environment. For example, control of the head and upper chest combine into sitting with support. Kicking, rocking on all fours, and reaching combine to become crawling. Then crawling, standing, and stepping are united into walking (Adolph & Berger,  2006 ; Thelen & Smith,  1998 ).

Each new skill is a joint product of four factors: (1) central nervous system development, (2) the body’s movement capacities, (3) the goals the child has in mind, and (4) environmental supports for the skill. Change in any element makes the system less stable, and the child starts to explore and select new, more effective motor patterns.

The broader physical environment also profoundly influences motor skills. Infants with stairs in their home learn to crawl up stairs at an earlier age and also more readily master a back-descent strategy—the safest but also the most challenging position because the baby must turn around at the top, give up visual guidance of her goal, and crawl backward (Berger, Theuring, & Adolph,  2007 ). And if children were reared on the moon, with its reduced gravity, they would prefer jumping to walking or running!

LOOK AND LISTEN

Spend an hour observing a newly crawling or walking baby. Note the goals that motivate the baby to move, along with the baby’s effort and motor experimentation. Describe parenting behaviors and features of the environment that promote mastery of the skill.

When a skill is first acquired, infants must refine it. For example, in trying to crawl, Caitlin often collapsed on her tummy and moved backward. Soon she figured out how to propel herself forward by alternately pulling with her arms and pushing with her feet, “belly-crawling” in various ways for several weeks (Vereijken & Adolph,  1999 ). As babies attempt a new skill, related, previously mastered skills often become less secure. As the novice walker experiments with balancing the body vertically over two small moving feet, balance during sitting may become temporarily less stable (Chen et al.,  2007 ). In learning to walk, toddlers practice six or more hours a day, traveling the length of 29 football fields! Gradually their small, unsteady steps change to a longer stride, their feet move closer together, their toes point to the front, and their legs become symmetrically coordinated (Adolph, Vereijken, & Shrout,  2003 ). As movements are repeated thousands of times, they promote new synaptic connections in the brain that govern motor patterns.

Dynamic systems theory shows us why motor development cannot be genetically determined. Because it is motivated by exploration and the desire to master new tasks, heredity can map it out only at a general level. Rather than being hardwired into the nervous system, behaviors are softly assembled, allowing for different paths to the same motor skill (Adolph,  2008 ; Thelen & Smith,  2006 ).

FIGURE 4.10 Reaching “feet first.”

When sounding toys were held in front of babies’ hands and feet, they reached with their feet as early as 8 weeks of age, a month or more before they reached with their hands. This 2½-month-old skillfully explores an object with her foot.

Dynamic Motor Systems in Action.

To find out how babies acquire motor capacities, some studies have tracked their first attempts at a skill until it became smooth and effortless. In one investigation, researchers held sounding toys alternately in front of infants’ hands and feet, from the time they showed interest until they engaged in well-coordinated reaching and grasping (Galloway & Thelen,  2004 ). As  Figure 4.10  shows, the infants violated the normative sequence of arm and hand control preceding leg and foot control, shown in  Table 4.2 . They first reached for the toys with their feet—as early as 8 weeks of age, at least a month before reaching with their hands!

Why did babies reach “feet first”? Because the hip joint constrains the legs to move less freely than the shoulder constrains the arms, infants could more easily control their leg movements. When they first tried reaching with their hands, their arms actually moved away from the object! Consequently, foot reaching required far less practice than hand reaching. As these findings confirm, rather than following a strict, predetermined pattern, the order in which motor skills develop depends on the anatomy of the body part being used, the surrounding environment, and the baby’s efforts.

Cultural Variations in Motor Development.

Cross-cultural research further illustrates how early movement opportunities and a stimulating environment contribute to motor development. Over half a century ago, Wayne Dennis ( 1960 ) observed infants in Iranian orphanages who were deprived of the tantalizing surroundings that induce infants to acquire motor skills. These babies spent their days lying on their backs in cribs, without toys to play with. As a result, most did not move on their own until after 2 years of age. When they finally did move, the constant experience of lying on their backs led them to scoot in a sitting position rather than crawl on their hands and knees. Because babies who scoot come up against furniture with their feet, not their hands, they are far less likely to pull themselves to a standing position in preparation for walking. Indeed, by 3 to 4 years of age, only 15 percent of the Iranian orphans were walking alone.

Cultural variations in infant-rearing practices affect motor development.  TAKE A MOMENT…  Take a quick survey of several parents you know: Should sitting, crawling, and walking be deliberately encouraged? Answers vary widely from culture to culture. Japanese mothers, for example, believe such efforts are unnecessary (Seymour,  1999 ). Among the Zinacanteco Indians of southern Mexico and the Gusii of Kenya, rapid motor progress is actively discouraged. Babies who walk before they know enough to keep away from cooking fires and weaving looms are viewed as dangerous to themselves and disruptive to others (Greenfield,  1992 ).

American TV Show “Shameless” And Psychology

Running head: Case Summary 1

Case Summary 7

 

 

 

 

 

 

Case summary of Fiona

Joslynn McNeish-Edgerton

Liberty University

 

 

 

 

 

 

 

 

 

 

Client History

Fiona Gallagher is the eldest child to a low-class family residing within the Southside of Chicago. Fiona is currently 24 years old. Her parents, Monica and Frank Gallagher, are both alcoholics struggling with their own mental health illness. The mother of the family is mentally ill thus abandoning her children leaving the father who consequentially neglects his fatherly role. Monica has been clinically diagnosed with Bipolar Disorder; she spent most of Fiona’s childhood in mental hospitalized and refuses to take her medication. Frank, who has been involved in the legal system several times for fraud, continues to drink, even after obtaining a new liver. Monica and Frank had six children: Fiona, Lip, Ian, Debbie, Carl, and Liam. The relationships between the children and the parents are estranged due to the long history of substance abuse. The family is poor and believes it’s only through alcohol that their pressure can be relieved. All the member of the family has their individual flaws all presumably, as a result of large quantity alcohol consumption.

At the age of 6, Fiona was left in a car for several days with her siblings; Fiona is typically left with most of the responsibilities. This caused her to become a foster child. Throughout her childhood, Fiona and her siblings were removed from the home several times. She has to quit school and do manual jobs to ensure that her brothers and sister do not lack food on the table. Fiona’s family has survived with both parents and six siblings.

In a closer reference to Fiona, following her father’s drunkard nature, Fiona is left in position of child-rearing for her younger siblings. Frank Gallagher doesn’t have any responsible over the family, rendering Fiona the guardian role. Fiona struggling to make ends meet for herself and the family through her jobs. This is due to Fiona’s lack of education. By assuming the parental role, she makes sure everyone has eaten; the siblings attend schools and are out of the troubles in their upbringing. She shifted from job to job in an attempt to raise adequate money for herself and the family.

Later on, Fiona is depicted as making out with her high school friend, Craig, who married to Lucy. She slept with Craig and hen Lucy learnt of it, she is angered and chases Fiona through the streets while carrying her baby in a basket. Fiona is however an unapologetic most so on an occasion when Lucy threw a chocolate at her when she was with Debbie shopping.

She is again depicted as a family lady who moves in to rescue her siblings who were at the social services office even though her boss was only willing to let her a day off in exchange for sex. She maneuvers out a way and later on listens to the tape at the offices just to realize it was her father ,Frank, who had made the call. She decided to take a legal action against her father for his deeds

Fiona later on met Mike, her boss, but again ruins their relationship despite cautious talks by Mike as being against likes that comes in relationships. Fiona jeopardizes this agreement when she repeatedly sleeps with Robbie, Mike’s brother. Robbie against all odds informed Mike of the secret affair between him and his wife, Fiona. Fiona is angered and doesn’t accept Robbie’s gift of cocaine when Fiona as celebrating her birthday. Fiona however left the coffee on the table leading to its consumption by Liam who is hospitalized. This led to Fiona’s arrest and a bail of cash set to let her free. It’s Mike who settled the fine to rescue Fiona.

After several months outside relationship, Fiona is getting her ups together and leading a happy life, she however messes up again. She decided to date Gus, ho as a friend to the real guy, the musician that Fiona had set out to meet after realizing the guy as actually having a girlfriend. The to, Fiona and Gus, decided to wed within one week of meeting a subject that makes Fiona keep the marriage a secret for the first few days.

When Jimmy returns, again Fiona sleeps with him though she confesses to Gus; their relationship is not okay further weakening it. At this point, her flirting nature with the boss is growing into love and she actually can’t make up her mind on the three guys.

Fiona’s youngest brother, Carl, who had started selling cocaine realized that most of his friends died from using it and another one is shot in the neighborhood. He decided to quit. He stopped peddling the cocaine from the leader of the cartel and started attending school. He needed to get away from the drugs and substance abuse.

Debbie, younger sister, who was now pregnant from his school boyfriend learns to be responsible. She realizes that life is not easy with an extra mouth to feed. She looks for a job and this is supposed to distract her from abusing drugs. The drug abuse subsides and she comfortably takes care of the child. Though young, she gets married to ensure she does not do any ill.

Fiona bought a Laundromat with a loan and later sold it making numerous profits. Her mother, Monica, died and Fiona is resistant to shed a tear for her mother abandoned them at an early age.

Ian, second oldest brother, realized that he is gay after having an encounter with one of the friends and starts sleeping with other men too. He becomes a stripper in order to earn money. Due to his erractic behavior, kidnapping a neighbor’s child, and being hospitalized, he was eventually diagnosed with Bipolar Disorder, like his mother. Fiona is often in charge of making sure Ian takes his medication and stays out of trouble.

Presenting Problems

With reference to the TV series, Shameless, the society is faced with the challenge of addiction and alcoholism both the parents and children. Major causes of these ills are genetic inheritance, family history, the environment, sociocultural beliefs and behavior, among other factors. The family is faced with poverty and they all believe drug abuse is the only way out of the mess.

The society, particularly the family, has been implicated as being faced by several social vices. These vices, to some extent, have consequentially resulted into family break ups and largely disintegration of the society. Among the major social ills that pose threat to the family and the society at large are drug and substance abuse, prostitution, theft, and burglary.

Fiona is depicted as a lady who enjoys dancing and drinking with her friend, Veronica her neighbor. She was at one time busted by her younger sibling in possession of cocaine. This lifestyle of drinking was adopted by Fiona following the pressure mounted on her from the responsibilities and her personal relationship life. Being jarred into in possession of cocaine resulted into her house arrest.

Despite the struggles Fiona makes to provide for the family, she is also a drug addict. This is probably due to too much pressure she is undergoing after assuming the fatherly role of their siblings as well as battling with her personal relationship. Her younger brother bumped into her stash of cocaine leading to her house arrest.

Fiona in order to quit drinking and immoral sexual behavior she starts a washing machine business which she bought from an old woman. She is doing the job together with waiting in a hotel in the same street. This keeps her busy and the drinking and the sleeping around subside. She asks everyone in the family to be more responsible and get some money every morning which they have to use for their daily need and savings.

Lip goes to rehab where he is supposed to change his drinking and drug taking habits. He goes there with the help one of his professors who he helped in class work with students. He goes to rehab and comes back a changed man. He applies for a job at the University where he had earlier been dismissed. He does not get the position but does not give up. He goes and asks Fiona to employ him since she is now the manager of the hotel where was waiting.

The siblings begin to do the right things and the drinking and drug abuse subsides. Each of them gets a stable partner. Where Fiona starts dating one man and this stops her from sleeping around which is caused by the drugs that she takes. She quits smoking for some time, now that she has a responsible man who she planned to marry. Lip on the other hand quit alcohol too. He is occupied with helping the sister in the hotel. They start a normal life free of drugs all over again. But for how long?

Alcohol has kept the society in a situation that the elder could not mold the younger siblings into sensible behavior. Drug abuse has blindfolded the Gallaghers into believing that it’s the only way out of their poverty. They have reached a point that they can’t resort to other ways of rectifying their poverty states. They are presented as having no thoughts of other people who are poorer than they are. To them, alcoholism is the only way out.

In conclusion, alcoholism as a vice has brought about disentanglement in the Gallagher family with each member of the family leading a destructive life. This ranges from neglect of the primary responsibilities of the parents, siblings’ personal lives most so affairs. This scenario leads to a poorly raised society with people who cannot perfectly perform simple tasks as required. Some members of the family are portrayed as engaging in prostitution which is entirely a consequence of the drug abuse.

 

 

 

 

 

 

 

 

 

 

References

Cristiana, F. (2014). Offensive Epithets. Shameless, 7-16.

 

Cristiana, F. (2014). Prologue. Shameless, 1-6. doi:10.1525/california/9780520273405.003.0001

Application Of Attachment Theory To A Case Study

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Theory Into Practice: Four Social Work Case Studies In this course, you select one of the following four case studies and use it throughout the entire course. By doing this, you will have the opportunity to see how different theories guide your view of a client and that client’s presenting problem. Each time you return to the same case, you use a different theory, and your perspective of the problem changes—which then changes how you ask assessment questions and how you intervene. These case studies are based on the video- and web-based case studies you encounter in the MSW program.

Table of Contents Tiffani Bradley ………………………………………………………………………………………………….. 2 Paula Cortez ……………………………………………………………………………………………………. 9 Jake Levey …………………………………………………………………………………………………….. 10 Helen Petrakis ………………………………………………………………………………………………… 13

 

 

 

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Tiffani Bradley Identifying Data: Tiffani Bradley is a 16-year-old Caucasian female. She was raised in

a Christian family in Philadelphia, PA. She is of German descent. Tiffani’s family consists of her father, Robert, 38 years old; her mother, Shondra, 33 years old, and her sister, Diana, 13 years old. Tiffani currently resides in a group home, Teens First, a brand new, court-mandated teen counseling program for adolescent victims of sexual exploitation and human trafficking. Tiffani has been provided room and board in the residential treatment facility for the past 3 months. Tiffani describes herself as heterosexual.

Presenting Problem: Tiffani has a history of running away. She has been arrested on

three occasions for prostitution in the last 2 years. Tiffani has recently been court ordered to reside in a group home with counseling. She has a continued desire to be reunited with her pimp, Donald. After 3 months at Teens First, Tiffani said that she had a strong desire to see her sister and her mother. She had not seen either of them in over 2 years and missed them very much. Tiffani is confused about the path to follow. She is not sure if she wants to return to her family and sibling or go back to Donald.

Family Dynamics: Tiffani indicates that her family worked well together until 8 years

ago. She reports that around the age of 8, she remembered being awakened by music and laughter in the early hours of the morning. When she went downstairs to investigate, she saw her parents and her Uncle Nate passing a pipe back and forth between them. She remembered asking them what they were doing and her mother saying, “adult things” and putting her back in bed. Tiffani remembers this happening on several occasions. Tiffani also recalls significant changes in the home’s appearance. The home, which was never fancy, was always neat and tidy. During this time, however, dust would gather around the house, dishes would pile up in the sink, dirt would remain on the floor, and clothes would go for long periods of time without being washed. Tiffani began cleaning her own clothes and making meals for herself and her sister. Often there was not enough food to feed everyone, and Tiffani and her sister would go to bed hungry. Tiffani believed she was responsible for helping her mom so that her mom did not get so overwhelmed. She thought that if she took care of the home and her sister, maybe that would help mom return to the person she was before.

Sometimes Tiffani and her sister would come downstairs in the morning to find empty beer cans and liquor bottles on the kitchen table along with a crack pipe. Her parents would be in the bedroom, and Tiffani and her sister would leave the house and go to school by themselves. The music and noise downstairs continued for the next 6 years, which escalated to screams and shouting and sounds of people fighting. Tiffani remembers her mom one morning yelling at her dad to “get up and go to work.” Tiffani and Diana saw their dad come out of the bedroom and slap their mom so hard she was knocked down. Dad then went back into the bedroom. Tiffani

 

 

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remembers thinking that her mom was not doing what she was supposed to do in the house, which is what probably angered her dad.

Shondra and Robert have been separated for a little over a year and have started dating other people. Diana currently resides with her mother and Anthony, 31 years old, who is her mother’s new boyfriend.

Educational History: Tiffani attends school at the group home, taking general education classes for her general education development (GED) credential. Diana attends Town Middle School and is in the 8th grade.

Employment History: Tiffani reports that her father was employed as a welding

apprentice and was waiting for the opportunity to join the union. Eight years ago, he was laid off due to financial constraints at the company. He would pick up odd jobs for the next 8 years but never had steady work after that. Her mother works as a home health aide. Her work is part-time, and she has been unable to secure full-time work.

Social History: Over the past 2 years, Tiffani has had limited contact with her family

members and has not been attending school. Tiffani did contact her sister Diana a few times over the 2-year period and stated that she missed her very much. Tiffani views Donald as her “husband” (although they were never married) and her only friend. Previously, Donald sold Tiffani to a pimp, “John T.” Tiffani reports that she was very upset Donald did this and that she wants to be reunited with him, missing him very much. Tiffani indicates that she knows she can be a better “wife” to him. She has tried to make contact with him by sending messages through other people, as John T. did not allow her access to a phone. It appears that over the last 2 years, Tiffani has had neither outside support nor interactions with anyone beyond Donald, John T., and some other young women who were prostituting.

Mental Health History: On many occasions Tiffani recalls that when her mother was

not around, Uncle Nate would ask her to sit on his lap. Her father would sometimes ask her to show them the dance that she had learned at school. When she danced, her father and Nate would laugh and offer her pocket change. Sometimes, their friend Jimmy joined them. One night, Tiffani was awakened by her uncle Nate and his friend Jimmy. Her parents were apparently out, and they were the only adults in the home. They asked her if she wanted to come downstairs and show them the new dances she learned at school. Once downstairs Nate and Jimmy put some music on and started to dance. They asked Tiffani to start dancing with them, which she did. While they were dancing, Jimmy spilled some beer on her. Nate said she had to go to the bathroom to clean up. Nate, Jimmy, and Tiffani all went to the bathroom. Nate asked Tiffani to take her clothes off and get in the bath. Tiffani hesitated to do this, but Nate insisted it was OK since he and Jimmy were family. Tiffani eventually relented and began to wash up. Nate would tell her that she missed a spot and would scrub the area with his hands. Incidents like this continued to occur with increasing levels of molestation each time.

 

 

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The last time it happened, when Tiffani was 14, she pretended to be willing to dance

for them, but when she got downstairs, she ran out the front door of the house. Tiffani vividly remembers the fear she felt the nights Nate and Jimmy touched her, and she was convinced they would have raped her if she stayed in the house.

About halfway down the block, a car stopped. The man introduced himself as Donald,

and he indicated that he would take care of her and keep her safe when these things happened. He then offered to be her boyfriend and took Tiffani to his apartment. Donald insisted Tiffani drink beer. When Tiffani was drunk, Donald began kissing her, and they had sex. Tiffani was also afraid that if she did not have sex, Donald would not let her stay— she had nowhere else to go. For the next 3 days, Donald brought her food and beer and had sex with her several more times. Donald told Tiffani that she was not allowed to do anything without his permission. This included watching TV, going to the bathroom, taking a shower, and eating and drinking. A few weeks later, Donald bought Tiffani a dress, explaining to her that she was going to “find a date” and get men to pay her to have sex. When Tiffani said she did not want to do that, Donald hit her several times. Donald explained that if she didn’t do it, he would get her sister Diana and make her do it instead. Out of fear for her sister, Tiffani relented and did what Donald told her to do. She thought at this point her only purpose in life was to be a sex object, listen, and obey—and then she would be able to keep the relationships and love she so desired.

Legal History: Tiffani has been arrested three times for prostitution. Right before the

most recent charge, a new state policy was enacted to protect youth 16 years and younger from prosecution and jail time for prostitution. The Safe Harbor for Exploited Children Act allows the state to define Tiffani as a sexually exploited youth, and therefore the state will not imprison her for prostitution. She was mandated to services at the Teens First agency, unlike her prior arrests when she had been sent to detention.

Alcohol and Drug Use History: Tiffani’s parents were social drinkers until about 8

years ago. At that time Uncle Nate introduced them to crack cocaine. Tiffani reports using alcohol when Donald wanted her to since she wanted to please him, and she thought this was the way she would be a good “wife.” She denies any other drug use.

Medical History: During intake, it was noted that Tiffani had multiple bruises and burn

marks on her legs and arms. She reported that Donald had slapped her when he felt she did not behave and that John T. burned her with cigarettes. She had realized that she did some things that would make them mad, and she tried her hardest to keep them pleased even though she did not want to be with John T. Tiffani has been treated for several sexually transmitted infections (STIs) at local clinics and is currently on an antibiotic for a kidney infection. Although she was given condoms by Donald and John T. for her “dates,” there were several “Johns” who refused to use them.

 

 

 

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Strengths: Tiffani is resilient in learning how to survive the negative relationships she has been involved with. She has as sense of protection for her sister and will sacrifice herself to keep her sister safe.

Robert Bradley: father, 38 years old Shondra Bradley: mother, 33 years old Nate Bradley: uncle, 36 years old Tiffani Bradley: daughter, 16 years old Diana Bradley: daughter, 13 years old Donald: Tiffani’s self-described husband and her former pimp Anthony: Shondra’s live-in partner, 31 years old John T.: Tiffani’s most recent pimp

 

 

 

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Paula Cortez

Identifying Data: Paula Cortez is a 43-year-old Catholic Hispanic female residing in New York City, NY. Paula was born in Colombia. When she was 17 years old, Paula left Colombia and moved to New York where she met David, who later became her husband. Paula and David have one son, Miguel, 20 years old. They divorced after 5 years of marriage. Paula has a five-year-old daughter, Maria, from a different relationship.

Presenting Problem: Paula has multiple medical issues, and there is concern about

whether she will be able to continue to care for her youngest child, Maria. Paula has been overwhelmed, especially since she again stopped taking her medication. Paula is also concerned about the wellness of Maria.

Family Dynamics: Paula comes from a moderately well-to-do family. Paula reports

suffering physical and emotional abuse at the hands of both her parents, eventually fleeing to New York to get away from the abuse. Paula comes from an authoritarian family where her role was to be “seen and not heard.” Paula states that she did not feel valued by any of her family members and reports never receiving the attention she needed. As a teenager, she realized she felt “not good enough” in her family system, which led to her leaving for New York and looking for “someone to love me.” Her parents still reside in Colombia with Paula’s two siblings.

Paula met David when she sought to purchase drugs. They married when Paula was 18 years old. The couple divorced after 5 years of marriage. Paula raised Miguel, mostly by herself, until he was 8 years old, at which time she was forced to relinquish custody due to her medical condition. Paula maintains a relationship with her son, Miguel, and her ex-husband, David. Miguel takes part in caring for his half-sister, Maria.

Paula does believe her job as a mother is to take care of Maria but is finding that more and more challenging with her physical illnesses.

Employment History: Paula worked for a clothing designer, but she realized that her true

passion was painting. She has a collection of more than 100 drawings and paintings, many of which track the course of her personal and emotional journey. Paula held a full- time job for a number of years before her health prevented her from working. She is now unemployed and receives Supplemental Security Disability Insurance (SSD) and Medicaid. Miguel does his best to help his mom but only works part time at a local supermarket delivering groceries.

Paula currently uses federal and state services. Paula successfully applied for WIC, the

federal Supplemental Nutrition Program for Women, Infants, and Children. Given Paula’s low income, health, and Medicaid status, Paula is able to receive in-home childcare assistance through New York’s public assistance program.

 

 

 

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Social History: Paula is bilingual, fluent in both Spanish and English. Although Paula identifies as Catholic, she does not consider religion to be a big part of her life. Paula lives with her daughter in an apartment in Queens, NY. Paula is socially isolated as she has limited contact with her family in Colombia and lacks a peer network of any kind in her neighborhood.

Five (5) years ago Paula met a man (Jesus) at a flower shop. They spoke several times. He would visit her at her apartment to have sex. Since they had an active sex life, Paula thought he was a “stand-up guy” and really liked him. She believed he would take care of her. Soon everything changed. Paula began to suspect that he was using drugs, because he had started to become controlling and demanding. He showed up at her apartment at all times of the night demanding to be let in. He called her relentlessly, and when she did not pick up the phone, he left her mean and threatening messages. Paula was fearful for her safety and thought her past behavior with drugs and sex brought on bad relationships with men and that she did not deserve better. After a couple of months, Paula realized she was pregnant. Jesus stated he did not want anything to do with the “kid” and stopped coming over, but he continued to contact and threaten Paula by phone. Paula has no contact with Jesus at this point in time due to a restraining order.

Mental Health History: Paula was diagnosed with bipolar disorder. She experiences

periods of mania lasting for a couple of weeks then goes into a depressive state for months when not properly medicated. Paula has a tendency toward paranoia. Paula has a history of not complying with her psychiatric medication treatment because she does not like the way it makes her feel. She often discontinues it without telling her psychiatrist. Paula has had multiple psychiatric hospitalizations but has remained out of the hospital for the past 5 years. Paula accepts her bipolar diagnosis but demonstrates limited insight into the relationship between her symptoms and her medication.

Paula reports that when she was pregnant, she was fearful for her safety due to the baby’s father’s anger about the pregnancy. Jesus’ relentless phone calls and voicemails rattled Paula. She believed she had nowhere to turn. At that time, she became scared, slept poorly, and her paranoia increased significantly. After completing a suicide assessment 5 years ago, it was noted that Paula was decompensating quickly and was at risk of harming herself and/or her baby. Paula was involuntarily admitted to the psychiatric unit of the hospital. Paula remained on the unit for 2 weeks.

Educational History: Paula completed high school in Colombia. Paula had hoped to

attend the Fashion Institute of Technology (FIT) in New York City, but getting divorced, then raising Miguel on her own interfered with her plans. Miguel attends college full time in New York City.

Medical History: Paula was diagnosed as HIV positive 15 years ago. Paula acquired

AIDS three years later when she was diagnosed with a severe brain infection and a T- cell count of less than 200. Paula’s brain infection left her completely paralyzed on the right side. She lost function in her right arm and hand as well as the ability to walk. After

 

 

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a long stay in an acute care hospital in New York City, Paula was transferred to a skilled nursing facility (SNF) where she thought she would die. After being in the skilled nursing facility for more than a year, Paula regained the ability to walk, although she does so with a severe limp. She also regained some function in her right arm. Her right hand (her dominant hand) remains semi-paralyzed and limp. Over the course of several years, Paula taught herself to paint with her left hand and was able to return to her beloved art.

Paula began treatment for her HIV/AIDS with highly active antiretroviral therapy (HAART). Since she ran away from the family home, married and divorced a drug user, then was in an abusive relationship, Paula thought she deserved what she got in life. She responded well to HAART and her HIV/AIDS was well controlled. In addition to her HIV/AIDS disease, Paula is diagnosed with Hepatitis C (Hep C). While this condition was controlled, it has reached a point where Paula’s doctor is recommending she begin a new treatment. Paula also has significant circulatory problems, which cause her severe pain in her lower extremities. She uses prescribed narcotic pain medication to control her symptoms. Paula’s circulatory problems have also led to chronic ulcers on her feet that will not heal. Treatment for her foot ulcers demands frequent visits to a wound care clinic. Paula’s pain paired with the foot ulcers make it difficult for her to ambulate and leave her home. Paula has a tendency not to comply with her medical treatment. She often disregards instructions from her doctors and resorts to holistic treatments like treating her ulcers with chamomile tea. When she stops her treatment, she deteriorates quickly.

Maria was born HIV negative and received the appropriate HAART treatment after birth. She spent a week in the neonatal intensive care unit as she had to detox from the effects of the pain medication Paula took throughout her pregnancy.

Legal History: Previously, Paula used the AIDS Law Project, a not-for-profit organization

that helps individuals with HIV address legal issues, such as those related to the child’s father . At that time, Paula filed a police report in response to Jesus’ escalating threats and successfully got a restraining order. Once the order was served, the phone calls and visits stopped, and Paula regained a temporary sense of control over her life.

Paula completed the appropriate permanency planning paperwork with the assistance of the organization The Family Center. She named Miguel as her daughter’s guardian should something happen to her.

Alcohol and Drug Use History: Paula became an intravenous drug user (IVDU), using

cocaine and heroin, at age 17. David was one of Paula’s “drug buddies” and suppliers. Paula continued to use drugs in the United States for several years; however, she stopped when she got pregnant with Miguel. David continued to use drugs, which led to the failure of their marriage.

Strengths: Paula has shown her resilience over the years. She has artistic skills and has

found a way to utilize them. Paula has the foresight to seek social services to help her

 

 

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and her children survive. Paula has no legal involvement. She has the ability to bounce back from her many physical and health challenges to continue to care for her child and maintain her household. David Cortez: father, 46 years old Paula Cortez: mother, 43 years old Miguel Cortez: son, 20 years old Jesus (unknown): Maria’s father, 44 years old Maria Cortez: daughter, 5 years old

 

 

 

 

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Jake Levy Identifying Data: Jake Levy is a 31-year-old, married, Jewish Caucasian male. Jake’s

wife, Sheri, is 28 years old. They have two sons, Myles (10) and Levi (8). The family resides in a two-bedroom condominium in a middle-class neighborhood in Rockville, MD. They have been married for 10 years.

Presenting Problem: Jake, an Iraq War veteran, came to the Veterans Affairs Health

Care Center (VA) for services because his wife has threatened to leave him if he does not get help. She is particularly concerned about his drinking and lack of involvement in their sons’ lives. She told him his drinking has gotten out of control and is making him mean and distant. Jake reports that he and his wife have been fighting a lot and that he drinks to take the edge off and to help him sleep. Jake expresses fear of losing his job and his family if he does not get help. Jake identifies as the primary provider for his family and believes that this is his responsibility as a husband and father. Jake realizes he may be putting that in jeopardy because of his drinking. He says he has never seen Sheri so angry before, and he saw she was at her limit with him and his behaviors.

Family Dynamics: Jake was born in Alabama to a Caucasian, Eurocentric family

system. He reports his time growing up to have been within a “normal” family system. However, he states that he was never emotionally close to either parent and viewed himself as fairly independent from a young age. His dad had previously been in the military and was raised with the understanding that his duty is to support his country. His family displayed traditional roles, with his dad supporting the family after he was discharged from military service. Jake was raised to believe that real men do not show weakness and must be the head of the household.

Jake’s parents are deceased, and he has a sister who lives outside London. He and his sister are not very close but do talk twice a year. Sheri is an only child, and although her mother lives in the area, she offers little support. Her mother never approved of Sheri marrying Jake and thinks Sheri needs to deal with their problems on her own. Jake reports that he has not been engaged with his sons at all since his return from Iraq, and he keeps to himself when he is at home.

Employment History: Jake is employed as a human resources assistant for the

military. Jake works in an office with civilians and military personnel and mostly gets along with people in the office. Jake is having difficulty getting up in the morning to go to work, which increases the stress between Sheri and himself. Shari is a special education teacher in a local elementary school. Jake thinks it is his responsibility to provide for his family and is having stress over what is happening to him at home and work. He thinks he is failing as a provider.

Social History: Jake and Sheri identify as Jewish and attend a local synagogue on

major holidays. Jake tends to keep to himself and says he sometimes feels pressured to be more communicative and social. Jake believes he is socially inept

 

 

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and not able to develop friendships. The couple has some friends, since Shari gets involved with the parents in their sons’ school. However, because of Jake’s recent behaviors, they have become socially isolated. He is very worried that Sheri will leave him due to the isolation.

Mental Health History: Jake reports that since his return to civilian life 10 months ago,

he has difficulty sleeping, frequent heart palpitations, and moodiness. Jake had seen Dr. Zoe, a psychiatrist at the VA, who diagnosed him with post-traumatic stress disorder (PTSD). Dr. Zoe prescribed Paxil to help reduce his symptoms of anxiety and depression and suggested that he also begin counseling. Jake says that he does not really understand what PTSD is but thought it meant that a person who had it was “going crazy,” which at times he thought was happening to him. He expresses concern that he will never feel “normal” again and says that when he drinks alcohol, his symptoms and the intensity of his emotions ease. Jake describes that he sometimes thinks he is back in Iraq, which makes him feel uneasy and watchful. He hates the experience and tries to numb it. He has difficulty sleeping and is irritable, so he isolates himself and soothes this with drinking. He talks about always feeling “ready to go.” He says he is exhausted from being always alert and looking for potential problems around him. Every sound seems to startle him. He shares that he often thinks about what happened “over there” but tries to push it out of his mind. Nighttime is the worst, as he has terrible recurring nightmares of one particular event. He says he wakes up shaking and sweating most nights. He adds that drinking is the one thing that seems to give him a little relief.

Educational History: Sheri has a bachelor’s degree in special education from a local

college. Jake has a high school diploma but wanted to attend college upon his return from the military.

Military History: Jake is an Iraqi War veteran. He enlisted in the Marines at 21 years

old when he and Shari got married due to Sheri being pregnant. The family was stationed in several states prior to Jake being deployed to Iraq. Jake left the service 10 months ago. Sheri and Jake had used military housing since his marriage, making it easier to support the family. On military bases, there was a lot of social support and both Jake and Sheri took full advantage of the social systems available to them during that time.

Medical History: Jake is physically fit, but an injury he sustained in combat sometimes

limits his ability to use his left hand. Jake reports sometimes feeling inadequate because of the reduction in the use of his hand and tries to push through because he worries how the injury will impact his responsibilities as a provider, husband, and father. Jake considers himself resilient enough to overcome this disadvantage and “be able to do the things I need to do.” Sheri is in good physical condition and has recently found out that she is pregnant with their third child.

Legal History: Jake and Sheri deny having criminal histories.

 

 

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Alcohol and Drug Use History: As teenagers, Jake and Sheri used marijuana and drank. Both deny current use of marijuana but report they still drink. Sheri drinks socially and has one or two drinks over the weekend. Jake reports that he has four to five drinks in the evenings during the week and eight to ten drinks on Saturdays and Sundays. Jake spends his evenings on the couch drinking beer and watching TV or playing video games. Shari reports that Jake drinks more than he realizes, doubling what Jake has reported.

Strengths: Jake is cognizant of his limitations and has worked on overcoming his

physical challenges. Jake is resilient. Jake did not have any disciplinary actions taken against him in the military. He is dedicated to his wife and family.

Jake Levy: father, 31 years old Sheri Levy: mother, 28 years old Myles Levy: son, 10 years old Levi Levy: son, 8 years old

 

 

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Helen Petrakis Identifying Data: Helen Petrakis is a 52-year-old, Caucasian female of Greek descent

living in a four-bedroom house in Tarpon Springs, FL. Her family consists of her husband, John (60), son, Alec (27), daughter, Dmitra (23), and daughter Althima (18). John and Helen have been married for 30 years. They married in the Greek Orthodox Church and attend services weekly.

Presenting Problem: Helen reports feeling overwhelmed and “blue.” She was referred

by a close friend who thought Helen would benefit from having a person who would listen. Although she is uncomfortable talking about her life with a stranger, Helen says that she decided to come for therapy because she worries about burdening friends with her troubles. John has been expressing his displeasure with meals at home, as Helen has been cooking less often and brings home takeout. Helen thinks she is inadequate as a wife. She states that she feels defeated; she describes an incident in which her son, Alec, expressed disappointment in her because she could not provide him with clean laundry. Helen reports feeling overwhelmed by her responsibilities and believes she can’t handle being a wife, mother, and caretaker any longer.

Family Dynamics: Helen describes her marriage as typical of a traditional Greek

family. John, the breadwinner in the family, is successful in the souvenir shop in town. Helen voices a great deal of pride in her children. Dmitra is described as smart, beautiful, and hardworking. Althima is described as adorable and reliable. Helen shops, cooks, and cleans for the family, and John sees to yard care and maintaining the family’s cars. Helen believes the children are too busy to be expected to help around the house, knowing that is her role as wife and mother. John and Helen choose not to take money from their children for any room or board. The Petrakis family holds strong family bonds within a large and supportive Greek community.

Helen is the primary caretaker for Magda (John’s 81-year-old widowed mother), who lives in an apartment 30 minutes away. Until recently, Magda was self-sufficient, coming for weekly family dinners and driving herself shopping and to church. Six months ago, she fell and broke her hip and was also recently diagnosed with early signs of dementia. Helen and John hired a reliable and trusted woman temporarily to check in on Magda a couple of days each week. Helen would go and see Magda on the other days, sometimes twice in one day, depending on Magda’s needs. Helen would go food shopping for Magda, clean her home, pay her bills, and keep track of Magda’s medications. Since Helen thought she was unable to continue caretaking for both Magda and her husband and kids, she wanted the helper to come in more often, but John said they could not afford it. The money they now pay to the helper is coming out of the couple’s vacation savings. Caring for Magda makes Helen think she is failing as a wife and mother because she no longer has time to spend with her husband and children.

 

 

 

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Helen spoke to her husband, John (the family decision maker), and they agreed to have Alec (their son) move in with Magda (his grandmother) to help relieve Helen’s burden and stress. John decided to pay Alec the money typically given to Magda’s helper. This has not decreased the burden on Helen since she had to be at the apartment at least once daily to intervene with emergencies that Alec is unable to manage independently. Helen’s anxiety has increased since she noted some of Magda’s medications were missing, the cash box was empty, Magda’s checkbook had missing checks, and jewelry from Greece, which had been in the family for generations, was also gone.

Helen comes from a close-knit Greek Orthodox family where women are responsible for maintaining the family system and making life easier for their husbands and children. She was raised in the community where she currently resides. Both her parents were born in Greece and came to the United States after their marriage to start a family and give them a better life. Helen has a younger brother and a younger sister. She was responsible for raising her siblings since both her parents worked in a fishery they owned. Helen feared her parents’ disappointment if she did not help raise her siblings. Helen was very attached to her parents and still mourns their loss. She idolized her mother and empathized with the struggles her mother endured raising her own family. Helen reports having that same fear of disappointment with her husband and children.

Employment History: Helen has worked part time at a hospital in the billing

department since graduating from high school. John Petrakis owns a Greek souvenir shop in town and earns the larger portion of the family income. Alec is currently unemployed, which Helen attributes to the poor economy. Dmitra works as a sales consultant for a major department store in the mall. Althima is an honors student at a local college and earns spending money as a hostess in a family friend’s restaurant. During town events, Dmitra and Althima help in the souvenir shop when they can.

Social History: The Petrakis family live in a community centered on the activities of the

Greek Orthodox Church. Helen has used her faith to help her through the more difficult challenges of not believing she is performing her “job” as a wife and mother. Helen reports that her children are religious but do not regularly go to church because they are very busy. Helen has stopped going shopping and out to eat with friends because she can no longer find the time since she became a caretaker for Magda.

Mental Health History: Helen consistently appears well groomed. She speaks clearly

and in moderate tones and seems to have linear thought progression—her memory seems intact. She claims no history of drug or alcohol abuse, and she does not identify a history of trauma. More recently, Helen is overwhelmed by thinking she is inadequate. She stopped socializing and finds no activity enjoyable. In some situations in her life, she is feeling powerless.

 

 

 

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Educational History: Helen and John both have high school diplomas. Helen is proud of her children knowing she was the one responsible in helping them with their homework. Alec graduated high school and chose not to attend college. Dmitra attempted college but decided that was not the direction she wanted. Althima is an honors student at a local college.

Medical History: Helen has chronic back pain from an old injury, which she manages

with acetaminophen as needed. Helen reports having periods of tightness in her chest and a feeling that her heart was racing along with trouble breathing and thinking that she might pass out. One time, John brought her to the emergency room. The hospital ran tests but found no conclusive organic reason to explain Helen’s symptoms. She continues to experience shortness of breath, usually in the morning when she is getting ready to begin her day. She says she has trouble staying asleep, waking two to four times each night, and she feels tired during the day. Working is hard because she is more forgetful than she has ever been. Helen says that she feels like her body is one big tired knot.

Legal History: The only member of the Petrakis family that has legal involvement is

Alec. He was arrested about 2 years ago for possession of marijuana. He was required to attend an inpatient rehabilitation program (which he completed) and was sentenced to 2 years’ probation. Helen was devastated, believing John would be disappointed in her for not raising Alec properly.

Alcohol and Drug Use History: Helen has no history of drug use and only drinks at

community celebrations. Alec has struggled with drugs and alcohol since he was a teen. Helen wants to believe Alec is maintaining his sobriety and gives him the benefit of the doubt. Alec is currently on 2 years’ probation for possession and has recently completed an inpatient rehabilitation program. Helen feels responsible for his addiction and wonders what she did wrong as a mother.

Strengths: Helen has a high school diploma and has been successful at raising her

family. She has developed a social support system, not only in the community but also within her faith at the Greek Orthodox Church. Helen is committed to her family system and their success. Helen does have the ability to multitask, taking care of her immediate family as well as fulfilling her obligation to her mother-in-law. Even under the current stressful circumstances, Helen is assuming and carrying out her responsibilities.

John Petrakis: father, 60 years old Helen Petrakis: mother, 52 years old Alec Petrakis: son, 27 years old Dmitra Petrakis: daughter, 23 years old Althima Petrakis: daughter, 18 years old Magda Petrakis: John’s mother, 81 years old

Counseling Paper “Case Conceptualization: Interventions And Evaluation”

In this assignment, you will continue to discuss your work with the client you presented in your Unit 5 Case Conceptualization paper.

Complete this assignment by addressing the following topics in a four-part format.

Part 1: Interventions

List the three goals you formulated for this client and presented in your Unit 5 paper. (If your instructor provided feedback or comments about your goals on that assignment, you can include revised goals here.)

For each goal, list one specific counseling intervention you used during your work with this client to help him or her make progress toward that goal. Each intervention must be evidence based; you will need to support your choice of intervention with reference to the current professional literature and research showing its effectiveness.

For each intervention you list, include the following:

  • Discuss how you introduced this intervention into the counseling session and how the client responded.
  • Describe how the intervention is reflective of your specific theoretical approach, drawing from the key concepts and assumptions of that theory.
  • Discuss your rationale for selecting the intervention, in terms of its appropriateness for your specific client and his or her presenting issues. Address all sociocultural issues that you considered when introducing this intervention into your work with the client.
  • Include at least one reference to a current article in the professional literature that supports the use of the intervention as being effective with this type of client and/or presenting issues.

Part 2: Ethical and Legal Issues

Discuss any ethical or legal issues that emerged during your work with this client. (If no such issues arose, then discuss the types of ethical or legal issues that might emerge when working with this type of client and/or these presenting issues.)

Discuss the steps you took to address the ethical or legal issues. Refer to the specific standard from the ACA Code of Ethics that relates to any ethical issue that you describe. Include reference to specific laws or regulations that apply to these types of situations.

Part 3: Client Progress and Counseling Outcome

For each of the goals you developed, describe the ways in which the client demonstrated progress during the time you worked with him or her. Include specific changes that the client reported to you, changes that you observed during sessions, and/or information that you gathered from other sources (such as self-report measures or assessments or reports from third parties that you gathered with the client’s written consent).

  • If the client showed progress toward a goal, what do you believe led to this change? For example, was a specific intervention particularly effective? Did the relationship you formed with the client, or some interaction between you and the client during a session, have an impact on how the client changed?
  • If the client did not show the progress you anticipated for the goal, what is your understanding of this? Would you consider a different theoretical approach, or different types of interventions, based on your review of the work you have done with the client?

What is your overall evaluation of the work you did with this client? If you were going to make recommendations to the next therapist who works with this client (or with a client similar to this one), what would you suggest, in terms of the main approach, goals, and interventions that the therapist might consider?

Support your ideas with reference to the current professional literature.

Part 4: Future Development

Discuss the progress you have made as a counselor during your fieldwork experience.

  • What are your main strengths?
  • What specific areas of knowledge and self-awareness have you developed?
  • What has been particularly challenging for you?

Thinking ahead to the work you will be doing in gaining your post-degree hours towards licensure, what are three specific skills or areas of knowledge that you would like to focus on?

  • How will you select an internship or clinical experience that will assist you in meeting these goals?
  • How do you plan to maximize your supervision experience in your post-degree internship, based on what you have experienced during supervision so far?
  • What specific license, certification, and/or credentials will you be seeking after graduation?

As you move forward in your career, how will you align your continued professional development and your clinical practice with the standards we have for mental health counselors?

  • Refer to specific standards from the ACA Code of Ethics, as well as to other national and state standards that guide the work counselors do.
  • Include a description of the professional organizations to which you’ll belong and how this membership will be important to your professional and career development.
  • List three specific areas of professional development that you will be exploring in the future.

    Running head: INITIAL CASE CONCEPTUALIZATION: PTSD 1

    May 11, 2019

    Initial Case Conceptualization: PTSD

    Client Information

     

     

    INITIAL CASE CONCEPTUALIZATION: PTSD !2

    Maria is a 25 year old African American female, with four children under the age of six

    years old. To ensure her protection of her identity, I will refer to her as Maria. Maria states that

    she is a christian and does not attend church often. Maria reports that she would like to become

    more active in church again. Maria says that she is currently in an abusive relationship with her

    spouse of seven years. While she is not physically disabled, she mentioned that she is facing var-

    ious psychological challenges that have made her live in an inpatient psychological hospital.

    Maria says that she identifies as a female who is attracted to the opposite sex. She is currently

    working two jobs to sustain her life and the lives of her four children aged six, three, one, and

    two months (1boy and 3 girls). Therefore, she is financially and economically challenged; but

    she has been doing the best she could to make ends meet despite her circumstances.

    Maria has managed to secure a 2-bedroom apartment that she shares with her four chil-

    dren. Besides her two jobs, she also seeks welfare support to help her with daycare, medical and

    food assistance. Maria also mentioned that her older brother sends her checks from time to time

    to help her with the children. Additionally, she makes use of food stamps that have been availed

    to her to cut the cost of food. Some non-governmental organization has also volunteered to take

    care of educational needs of her two older children. While her emotional and psychological state

    seems a bit unstable, Maria is physically healthy, and reports that she takes care of her physical

    wellbeing, by walking 3 miles per day, to catch a bus to work.

    Maria presenting issues is PTSD, she has been sexually assaulted numerous of times

    throughout her childhood. She seems to be trying to forget some issues of her past that bring

    back bad memories regarding her sexual abuse. She seems traumatized by her sexual past, which

     

     

    INITIAL CASE CONCEPTUALIZATION: PTSD !3

    is apparent in how she disregards any questions about her sexual abusive past. The relevant his-

    tory behind her traumatic response to sexual-related questions stems from her experiences as a

    young girl. At the time of the abuse, she was living with her grandmother, cousins, uncles, broth-

    ers, and aunts. From the ages of four to nine, she was sexually abused by her family members.

    The trauma from those incidents has seemingly remained with her in her adult life. It is affecting

    her relationship with males.

    Theoretical Approach

    The theoretical approach I used for Maria was Trauma-Focused Cognitive Behavioral

    Therapy (TF-CBT). This is an evidence-based theoretical approach to treatment of traumatized

    children, caregivers, adolescents, and their parents. According to research, TF-CBT has a high

    success rate of resolving a broad array of behavioral and emotional difficulties that are associated

    with complex traumatic experiences. This theoretical approach works by reducing the negative

    behavioral and emotional responses following trauma, including child sexual abuse, and other

    forms of ill-treatment like domestic violence, mass disasters, loss, and other related traumatic

    events (North et al., 2015).

    Cohen et al. (2006) conducted a pilot study for modified cognitive behavioral therapy for

    childhood traumatic grief (CBT-CTG). The purpose of this study was to evaluate the outcomes of

    a modified 12-session protocol on cognitive behavioral therapy for CBT-CTG and was conduct-

    ed between March 2004 and October 2005. The findings of the research suggested that the short-

    ened CBT-CTG protocol, which is similar to what most child bereavement programs offer, is

    widely acceptable and has a high level of efficacy for the population selected. As such, the CBT-

     

     

    INITIAL CASE CONCEPTUALIZATION: PTSD !4

    CTG approach led to the healing of CBT and post-traumatic stress disorder symptoms, which led

    to decreased anxiety, child depression, and behavioral improvement. In another study conducted

    by Cohen et al. (2012) titled “Trauma-focused CBT for youth with complex trauma”, the authors

    identified that many youths develop complex trauma which includes regulation issues in the do-

    mains of affect, behavior, attachment, cognition, biology, and perception. Their research seeks to

    describe the practical strategies for applying TF-CBT for youth who are positively diagnosed

    with trauma. The results indicate that data from youth suffering from complex trauma supports

    the use of TF-CBT strategies for successful treatment. In their article, “Trauma-focused cognitive

    behavioral therapy for children: impact of the trauma narrative and the treatment length”, De-

    blinger et al. (2011) reported that mixed model analyses demonstrated that significant post-

    treatment improvement has occurred in regard to the outcomes of the conditions identified prior.

    Using the TF-CBT was instrumental in helping to select the kind of information I was

    looking for in Mrs. X. After reviewing the most common treatments using the TF-CBT approach,

    I was able to pursue my information collection approach by inquiring about any traumatic events

    that my client had undergone during her upbringing. When she mentioned the sexual abuse case

    at a tender age of four years, the symptoms that she was manifesting were proven. The treatment

    of post-traumatic stress disorder focuses on the correction of upsetting or distorted attributions

    and beliefs related to the traumas. As such, it provides a supportive environment in which the

    victim is encouraged to talk about their traumatic experiences as well as learn skills that will help

    them to cope with ordinary stressors originating from the incident (North et al., 2016). This was

    applicable to the case of my client because she confessed that she was afraid of contact with me,

    which is why she had avoided dating as much as she could. TF-CBT additionally helps parents

     

     

    INITIAL CASE CONCEPTUALIZATION: PTSD !5

    who have not been abusive to cope with their children’s emotional distress and develop skills to

    help their children (Pai, Suris, & North, 2017). This is the treatment that Mrs. X needed; this the-

    oretical approach was very helpful in ensuring we worked towards that direction together.

    Assessment and Diagnosis

    The following is the initial DSM-5 and ICD Code 10 criteria that Maria was diagnosis

    with: Post traumatic Stress Disorder 309.81 (F43.10), after collaborating with other profession-

    als the F43.12 post-traumatic stress disorder chronic level best fit this client.

    Criterion A: Stressor, Maria was exposed to sexual violence directly.

    Criterion B: Intrusion symptoms. The sexual abuse Maria experienced persistently across

    a period of five years led to unwanted upsetting memories, flashbacks, emotional distress, and

    physical reactivity whereby she hates the physical touch of men.

    Criterion C: Avoidance. Maria avoids any sexual-related stimuli as she mentions that she

    is very wary of dating due to the mere memory of her sexual abuse earlier. Due to these trauma-

    related thoughts and feelings, men are actually trauma-related external reminders.

    Criterion D: Negative alterations in cognitions and mood. Maria recounted that she has

    negative thoughts and feelings about her own girls that began after she gave birth to them. This is

    demonstrated in her inability to remember some features of the trauma, overly negative assump-

    tions, depressive thoughts about herself and the world, an exaggerated blame on herself for not

    moving on with her life, decreased interest in dating, and difficulty in experiencing life positively

    due to a feeling of constant isolation.

     

     

    INITIAL CASE CONCEPTUALIZATION: PTSD !6

    Criterion E: Alterations in reactivity and arousal. Maria has trauma-related arousal that

    began and worsened with her sexual abuse. She is irritable when asked about dating; she is hy-

    pervigilant; she has difficulty concentrating, and sometimes she has cases of sleeplessness.

    Criterion F: Duration. The symptoms have been prevalent for a long time since the inci-

    dent happened and are still going on.

    Criterion G: Functional significance. Maria symptoms have caused her distress. She dis-

    closed that she has been fired from some of her previous jobs due to functional impairment relat-

    ing to her poor social interactions at the job.

    Criterion H: Exclusion. Maria loves solitude and enjoys her solitude which are symptoms

    not related to any substance use or other illnesses.

    Based on the DSM-5 criterion results, and for billing purpose the ICD code 10 that

    would be used for billing for this case is F43.12 post-traumatic stress disorder chronic level,

    because she had still been experiencing the post-effects of her traumas (Pai, Suris, & North,

    2017).

    To reach a diagnosis, I compiled the information from each session with the information

    from the previous sessions while looking for patterns. Within my assessments, I made use of

    such instruments as checklists for anxiety, depression, trauma, and other related checklists. I,

    however, did consult with other professionals about Maria. I depended entirely on my abilities to

    decipher information and research. I also put into consideration the sociocultural factors relating

    to the stereotypes towards African Americans when presenting this paper. All the information

    collected from the diagnosis process was very instrumental in my choice of the theoretical ap-

     

     

    INITIAL CASE CONCEPTUALIZATION: PTSD !7

    proach (CF-CBT) because the conclusion reached from the diagnosis was that this was a case of

    posttraumatic stress disorder. I, therefore, had to match the theoretical approach to the condition

    that Maria was suffering from, and the result was fully supported by the CF-CBT theoretical

    framework.

    Counseling Goals

    The first goal was to reduce irritability when discussing her sexual abuse incident. Maria

    stated that this was standing in the way of her social life, and romantic relationships . The objec-

    tive is to help her to increase her comfort with social situations; the progress should be measured

    through a self-assessment report given to Maria. This process will take up to 6 months.

    The second goal is to increase Maria’s ability to make sense of traumatic experiences and

    come to emotional terms with them. This goal will ensure that Maria does not have intense emo-

    tional and physical reactions when reminded of the sexual abuse. The process will take roughly 6

    months.

    The third goal is to increase Maria’s participation in activities she previously avoided, for

    instance, dating. This will ensure that Maria gets the emotional support she needs from a sexual

    partner. This is projected to take 8 months.

    Maria’s assessment information and diagnosis were critical in formulating the counselling

    goals because it highlighted the various areas she needed help with most. When selecting these

    goals, I considered that since Maria is a single mother, she would require more time to adjust

     

     

    INITIAL CASE CONCEPTUALIZATION: PTSD !8

    than a regular person would. The three goals highlighted are reflective of the CF-CBT approach

    because they underline the focus to reduce the impact of the trauma that Maria endured.

    References

     

     

    INITIAL CASE CONCEPTUALIZATION: PTSD !9

    Cohen, J. A., Mannarino, A. P., & Staron, V. R. (2006). A Pilot Study of Modified Cognitive-Be-

    havioral Therapy for Childhood Traumatic Grief (CBT-CTG). Journal of the American

    Academy of Child & Adolescent Psychiatry, 45(12), 1465-1473. Doi:10.1097/01.chi.

    0000237705.43260.2c

    Cohen, J. A., Mannarino, A. P., Kliethermes, M., & Murray, L. A. (2012). Trauma-focused CBT

    for youth with complex trauma. Child Abuse & Neglect, 36(6), 528-541. Doi:10.1016/

    j.chiabu.2012.03.007

    Deblinger, E., Anthony P., Judith A., Melissa K., & Robert A. (2012). Trauma-Focused Cognitive

    Behavioral Therapy for Children Affected by Sexual Abuse or Trauma. PsycEXTRA

    Dataset. Doi:10.1037/e552572013-001

    North C.S., Surís A.M. Smith R.P., & King R.V. (2016). The evolution of PTSD criteria across

    editions of DSM. Annual Clinical Journal of Psychiatry, 28:197–208.

    North C.S., Suris A.M., Davis M., & Smith R.P. (2015). Toward Validation of the Diagnosis of

    Posttraumatic Stress Disorder. American Journal of Psychiatry, 166:34–41.

    Pai, A., Suris, A., & North, C. (2017). Posttraumatic Stress Disorder in the DSM-5: Controversy,

    Change, and Conceptual Considerations. Behavioral Sciences, 7(4), 7. Doi: 10.3390/

    bs7010007