Gross motor skills
Fine motor skills
Learns to support own head
Plays with own hands
Rolls over independently
Can grasp using whole hand
Sits up independently and may start crawling
Starts to grasp with pincer action (finger and thumb)
Able to stand unsupported and may take first steps
Grasp now includes thumb and two or more fingers
Able to walk independently
Can stack two bricks
Can run and climb stairs
Stacks multiple bricks in towers
Confident in manoeuvring and can catch a ball
Able to grasp crayon and draw a basic face
Able to balance and control a tricycle
Can manage buttons and stack large numbers of bricks
Climbs, hops and skips
Able to use pencils and colour neatly
Other developmental milestones can be less physically determined, and may be less reliable, so there are much more socially determined elements to feeding practices and independent toileting, for example, which may be culturally determined or subject to the whims of fashion.
The advantage of working in the UK system is that it is broadly supportive of the early development of children, and does have a good paediatric backup system which should mean that all children have been in contact with initially midwives, then Health Visitors who monitor up to the age of five, so parents will generally be aware of whether their children gave any cause for alarm in the early stages. Most parents, for example, will be able to tell you if their children were walking and talking at around the ‘normal’ times. The system of Community Paediatricians gives a holistic approach to dealing with young people’s physical ill health, and their expertise in physical development usually means that any early difficulties should have been addressed and that records of this will exist. Bellman et al. (2013) give a good summary of screening tools and ‘red flags’ for referral to community paediatricians. The UK system is not, of course, faultless, and there are issues of neglect and deliberate ill-treatment where children have been kept away from this system, so a CAMHS assessment needs to bear this in mind and have a safeguarding element in mind. Rare syndromes of adult mental health, such as factitious illness, where a parent or carer presents frequently with a child who has vague and undetermined physical symptoms, should also be kept in mind if there is an extensive history which seems suspicious. Formerly known as ‘Munchausen’s syndrome by proxy’ this is a difficult issue to deal with from a safeguarding perspective, but should be kept in mind as the potential for both physical and emotional harm to the child is high. In recent years, Safeguarding Children procedures have also started to monitor more closely parents who do not bring their children for hospital and community healthcare appointments as being an indicator of potential neglect (Powell and Appleton 2012).
Whilst being wary of potential safeguarding issues, it is also important to remember also that the concept of ‘diagnostic overshadowing’ can blind healthcare workers to looking for underlying physical issues as a potential cause for the presenting problems. As nurses in particular we should be conscious of a holistic approach to health. Diagnostic overshadowing is a concept developed in adult mental health and learning disabilities which suggests that an obvious learning disability or mental health history may mean that clinicians assume that this long-standing presentation is the reason for a current issue, and overlook normal investigations that they would have started if the long-standing issues weren’t present (Nash 2013). So people with learning disabilities or mental health issues can have their reports of physical pain written off as ‘hysterical’ or fabricated without a full investigation being completed. This can apply also in children and young people, so it is important to ensure that organic or physical causes for symptoms aren’t ignored. This is more obvious in young people presenting with anorexia, for example, where it is important to ask ‘Is this purely a psychological issue, or is there another reason for a change in eating patterns?’ Nash (ibid) makes the very good argument that this practice of being wary of diagnostic overshadowing is very much in the tradition of non-judgemental practice, itself an essential part of nursing practice. Yet this is in contrast with Safeguarding practices where we have to be respectful of the choices that people make and understanding of the reasons for their behaviour, but essentially we are making judgements about what needs to be acted upon in line with Safeguarding Children principles. The exercise of clinical judgement for nurses in CAMHS requires us to have enough knowledge of physical healthcare and normal physical development to make these decisions and act upon what we see, to protect vulnerable children and young people.
Box 3.1 Physical Development and Implications for CAMH Nursing
Parents will normally remember a basic physical developmental history that can help to eliminate physical causes for mental health presentations.
Young people seen on their own may question the relevance of this, and prefer to concentrate on the current presenting symptoms, in which case follow their lead, and return to this issue later.
Be aware of Safeguarding (Child Protection) issues when taking a developmental history.
Physical or organic reasons for presenting symptoms should be considered, and clinicians should be wary of ‘diagnostic overshadowing’.
3.3 Cognitive and Emotional Development
Whilst physical development of children and young people is broadly understood and agreed upon, their cognitive development is much more the subject of theorization, and there is much less consensus as to what constitutes ‘normal’ cognitive development. This, and the fact that young people develop in very individualized ways, makes it much harder to be clear about what elements are important, and often some theoretical models will fit individual circumstances better than others. For fostered and adopted children, for example, issues around attachment may be the most important part of understanding their situation, whilst for others issues around identity or personality formation may make more sense of their situation. For this reason we need to have a broad understanding of different theories in order to be able to apply them to individual needs (see Keenan et al. 2016). The theorists examined below are the principle ones, but there are many more, so we have necessarily had to be selective.
3.3.1 Piaget’s Four-Stage Theory
Assimilation—where an existing schema is used to understand a new experience.
Accommodation—where an existing schema does not fit the new experience, discovery or knowledge, and needs to be changed to make sense of this new situation.
Equilibration—this is the process of coping when new information cannot be easily accommodated into the existing schemas. An unsettling period of re-examining existing ways of thinking and making sense of the new information. This explains why development may not be a smooth process, as these episodes call for a big leap in understanding.
Sensorimotor stage (Birth–2 years)
Infants use their motor skills to explore the world and learn from it. They learn ‘Object Permanence’, that an object still exists even if they can no longer see it, which requires the ability to make a mental representation of an object.
Pre-operational stage (2–7 years)
During this stage there is less reliance on physical senses, but they remain ‘illogical’ thinkers in many ways. Thinking becomes more symbolic, understanding that a word or object can stand for something other than itself. At this stage, children are still egocentric and struggle to see the world from anything other than their own perspective.
Concrete operational stage (7–11 years)
The development of ‘logical’ (or operational) thought, which includes working things out internally, though with a concrete representation to help, and a better understanding of abstract concepts like conservation (that quantity may be constant even if appearance changes).
Formal operational stage (11 years and older)
This stage lasts for the rest of our lives, as we become capable of more abstract thought, and can, for example, test hypotheses to make sense of the world, and make decisions based on the information presented to us.
Box 3.2 Some Implications of Piaget’s Theories for Assessment and Understanding
Piaget thought that children cannot understand the permanence of death until the concrete operational stage, so helping children who have suffered bereavements will be different depending on their age.
Likewise if they cannot understand the permanence of death, expressing a wish to die themselves (however distressing this is to those around them) is different in younger children than it is for young people who DO understand what it is they are wishing for.
Younger children who talk about ‘hearing voices’, but have not yet developed a fuller understanding of external points of view are more likely to reflecting their own internal thinking processes.
3.3.2 Vygotsky’s Social Development Theory
Whilst Piaget largely saw development as individual, Lev Vygotsky’s (1978) emphasis is much more on the influence of a child’s surroundings. He put much more emphasis on culture, surroundings and in particular the role of the adults around the child in development. He also gave more weight to the development of language as an indicator of understanding, saying that whilst thought and language develop initially separately they merge at around the age of three and become intertwined at that point.
The cultural and societal influences in Vygotsky’s thought are essential for fostering and guiding cognitive development. This is illustrated in his concept of the Zone of Proximal Development which puts the individual child at the centre, effectively what a child can learn on their own, but then has the surrounding zone expanding the potential for learning through the influence of ‘knowledgeable others’ (parents, family, neighbours, teachers and peers) and technology and tools. These provide the scaffolding that guides learning, though inevitably this will have a cultural bias and be limited by the interests and bias of the knowledgeable others. Beyond this zone is an area which is initially out of reach, but which the individual can access as they become more independent, and potentially less constricted by their immediate surroundings. This obviously has implications for educational theory and guided learning as well as peer-based collaborative learning.
Primitive speech, from birth to around 2 years, consisting of single words or phrases, largely imitative or expressing basic emotions.
Social speech, or a naïve psychological stage, from around 2 to 4 years, when we use communicate with each other, and the fascination with the names of objects illustrates an understanding of symbolism.
Private speech, generally from age 4 to 7 years, essentially saying out loud what you are thinking as you think it, which serves an intellectual processing and self-regulating function.
Inner speech, from age 8 when the private speech becomes internal thought with no need for vocalization.
Box 3.3 Vygotsky’s Social Development Theory Applied
Vygotsky illustrates well the link between how people think and what they say. By tuning into how children and young people phrase their thoughts we have a good chance to see how those ideas have developed, and how we can help them to overcome hurdles in their cognitive processing. CBT and systemic therapies both put a lot of emphasis on how language is linked to thought and use this as a way of challenging unhelpful thinking, and looking for alternative ways of understanding feelings and emotions.
Although Vygotsky emphasizes the positives of social and cultural influences, these can also be limiting, and presenting alternative ways of thinking about the world beyond that to which some children and young people have been acclimatized by virtue of their upbringing can lead to some challenging discussions.
3.3.3 Bronfenbrenner’s Ecological Systems Theory
Vygotsky was not the only theorist who put emphasis on social aspects of learning and child development, another important figure was Urie Bronfenbrenner (1979) who took a more balanced view of the ‘nature versus nurture’ debate to develop his systems theory. In broader terms, systemic theory also underpins what used to be called ‘Family Therapy’ but is now usually referred to as systemic psychotherapy.
Microsystem is the most immediate surroundings to the individual, usually family initially, but also including local school, local faith group, healthcare workers and peers.
Mesosystem includes the complex interactions between different elements of the microsystem, focused on the quality of those interactions and the influence they have on the individual.
Exosystem widens out to those elements of society which influence those around the individual, including healthcare and social care systems, parental workplaces, politics and media influence on the beliefs of those immediately involved.
Macrosystem includes the broadest influences acting on the individual, ethnicity, socio-economic status, common cultural values, identity and heritage.
Chronosystem is a final influence which doesn’t fit easily with the two-dimensional concentric circle model but recognizes the way that these factors will change over the lifespan, and particularly will become disrupted at times of transition.