To simplify analysis and discussion of the complex processes and theories related to growth and development, researchers and theorists have identified stages or age-groupings. These stages serve as reference points in describing various features of growth and development (Table 5-1). Chapters 6 through 9 discuss the physical growth and cognitive, emotional, language, and motor development specific to each stage.

The average newborn infant is approximately 20 inches (50 cm) long, with an average increase of approximately 1 inch (2.5 cm) per month for the first 6 months, followed by an increase of approximately ½ inch (1.2 cm) per month for the remainder of the first year. The child gains 3 inches (7.6 cm) per year from age 1 through 7 years and then 2 inches (5 cm) per year from age 8 through 15 years. Boys generally add more height during adolescence than do girls. Body proportion changes are shown in Figure 5-1.

Dentition, the eruption of teeth, also follows a sequential pattern. Primary dentition usually begins to emerge at approximately 6 to 8 months. Most children have 20 teeth by age 2½ years. Permanent teeth, 32 in all, erupt beginning at approximately age 6 years, accompanied by the loss of primary teeth (see Chapter 33). Although some parents place importance on eruption of the teeth as a sign of maturation, dentition is not related to the level or rate of development.

Growth and development are directional and follow predictable patterns (Boxes 5-1 and 5-2). The first direction of growth is cephalocaudal, or proceeding from head to tail (or toe). This means that structures and functions originating in the head develop before those in the lower parts of the body. At birth the head is large, a full one fourth of the entire body length, the trunk is long, and the arms are longer than the legs. As the child matures, the body proportions gradually change; by adulthood, the legs have increased in size from approximately 38% to 50% of the total body length (see Figure 5-1).

BOX 5-2

DIRECTIONAL PATTERNS OF GROWTH AND DEVELOPMENT

Cephalocaudal Pattern (Head to Toe)

Examples

Head initially grows fastest (fetus), then trunk (infant), then legs (child).

Infant can raise the head before sitting and can sit before standing.

Proximodistal Pattern (from the Center Outward)

Examples

In the respiratory system, the trachea develops first in the embryo, followed by branching and growth outward of the bronchi, bronchioles, and alveoli in the fetus and infant.

Motor control of the arms comes before control of the hands, and hand control comes before finger control.

Directional growth and development are illustrated further by myelinization of the nerves, which begins in the brain and spreads downward as the child matures (see Box 5-1). Growth of the myelin sheath and other nerve structures contributes to cephalocaudal development, which is illustrated by an infant’s ability to raise the head before being able to sit and to sit before being able to stand.

A second directional aspect of growth and development is proximodistal, which means progression from the center outward, or from the midline to the periphery. The growth and branching pattern of the respiratory tract illustrates this concept. The trachea, which is the central structure of the respiratory tree, forms in the embryo by 24 days of gestation. Branching and growth outward occur in the bronchi, bronchioles, and alveoli throughout fetal life and infancy. Alveoli, which are the most distal structures of the system, continue to grow and develop in number and function until middle childhood.

Growth and development follow patterns, one of which is general to specific. As a child matures, activities become less generalized and more focused. For example, a neonate’s response to pain is usually a whole-body response, with flailing of the arms and legs even if the pain is in the abdomen. As the child matures, the pain response becomes more localized to the stimulus. An older child with abdominal pain guards the abdomen.

Another pattern is the progression of functions from simple to complex. This pattern is easily observed in language development. A toddler’s first sentences are formed simply, using only a noun and a verb. By age 5 years, the child constructs detailed stories using many complex modifiers.

The rate of growth is not constant as the child matures. Growth spurts, alternating with periods of slow or stagnant growth, are observed throughout childhood. Spurts are frequently seen as the child prepares to master a significant developmental task, such as walking. An increase in growth around a child’s first birthday may promote the neuromuscular maturation needed for taking the first steps.

All facets of development (cognitive, motor, social/emotional, language) normally proceed according to these patterns. Knowledge of these concepts is useful when determining how a child’s development is progressing and when comparing a child’s development with normal patterns.

Mastery of developmental tasks is not static or permanent, and developmental stages do not always correlate with chronologic age. Children progress through developmental stages at varying rates within normal limits and may master developmental tasks only to regress to earlier levels when ill or stressed. Also, people can struggle repeatedly with particular developmental tasks throughout life, although they have achieved more advanced levels of development.

Jean Piaget (1896-1980), a Swiss theorist, made major contributions to the study of how children learn. His complex theory provides a framework for understanding how thinking during childhood progresses and differs from adult thinking. Like other developmental theorists, Piaget postulated that, as children develop intellectually, they pass through progressive stages (Piaget, 1962, 1967). The ages assigned to these periods are only averages. Piaget (1962, 1967) describes these stages as follows:

During the sensorimotor period of development, infant thinking seems to involve the entire body. Reflexive behavior is gradually replaced by more complex activities. The world becomes increasingly solid through the development of the concept of object permanence, which is the awareness that objects continue to exist even when they disappear from sight. By the end of this stage, the infant shows some evidence of reasoning.

During the period of preoperational thought, language becomes increasingly useful. Judgments are dominated by perception and are illogical, and thinking is characterized, especially during the early part of this stage, by egocentrism. In other words, children are unable to think about another person’s viewpoint and believe that everyone perceives situations as they do. Magical thinking (the belief that events occur because of wishing) and animism (the perception that all objects have life and feeling) characterize this period.

At the end of the preoperational stage, the child shifts from egocentric thinking and begins to be able to look at the world from another person’s view. This shifting enables the child to move into the period of concrete operations, where the child is no longer bound by perceptions and can distinguish fact from fantasy. The concept of time becomes increasingly clear during this stage, although far past and far future events remain obscure. Although reasoning powers increase rapidly during this stage, the child cannot deal with abstractions or with socialized thinking.

Normally, adolescents progress to the period of formal operations. In this period the adolescent proceeds from concrete to abstract and symbolic and from self-centered to other centered. Adolescents can develop hypotheses and then systematically deduce the best strategies for solving a particular problem because they use a formal operations cognitive style. Not all adolescents, however, reach this landmark at a consistent age, and at any given time, an adolescent may or may not exhibit characteristics of formal operations (Kuhn, 2008).

Sigmund Freud (1856-1939) developed theories to explain psychosexual development. His theories were in vogue for many years and provided a basis for other theories. Freud postulated that early childhood experiences provide unconscious motivation for actions later in life (Freud, 1960). According to Freudian theory, certain parts of the body assume psychological significance as foci of sexual energy. These areas shift from one part of the body to another as the child moves through different stages of development. Freud’s work may help to explain normal behavior that parents may confuse with abnormal behavior, and it also may provide a good foundation for sex education.

Freud believed that during infancy sexual behavior seems to focus around the mouth, the most erogenous area of the infant body (oral stage). Infants derive pleasure from sucking and exploring objects by placing them in their mouths. During early childhood, when toilet training becomes a major developmental task, sensations seem to shift away from the mouth and toward the anus (anal stage). Psychoanalysts see this period as a time of holding on and letting go. A sense of control or autonomy develops as the child masters body functions.

During the preschool years, interest in the genitalia begins (phallic stage). Children are curious about anatomic differences, childbirth, and sexuality. Children at this age often ask many questions, freely exhibit their own sexual organs, and want to peek at those of others. Children often masturbate, sometimes causing parents great concern. Although it is not universal, a phenomenon described by Freud as the Oedipus complex in boys and the Electra complex in girls is seen in preschool children. This possessiveness of the child for the opposite-sex parent, marked by aggressiveness toward the same-sex parent, is considered normal behavior, as is a heightened interest in sex. To resolve these disturbing sexual feelings, the preschooler identifies with or becomes more like the same-sex parent. The superego (an inner voice that reprimands and evokes guilt) also develops. The superego is similar to a conscience (Freud, 1960).

Freud describes the school-age period as the latency stage, when sexuality plays a less prominent role in the everyday life of the child. Best friends and same-sex peer groups are influential in the school-age child’s life. Younger school-age children often refuse to play with children of the opposite sex, whereas prepubertal children begin to desire the companionship of opposite-sex friends.

During adolescence, interest in sex again flourishes as children search for identity (genital stage). Under the influence of fluctuating hormone levels, dramatic physical changes, and shifting social relationships, the adolescent develops a more adult view of sexuality. Cognitive skills, particularly in young adolescents, are not fully developed, however, and decisions are made often based on the adolescent’s emotional state, rather than on critical reasoning (Cromer, 2011). This can lead to questionable judgments about sexual matters and questions or confusion about sexual feelings and behaviors (A. Freud, 1974).

Erik H. Erikson (1902-1994), inspired by the work of Sigmund Freud, proposed a popular theory about child development. He viewed development as a lifelong series of conflicts affected by social and cultural factors. Each conflict must be resolved for the child and adult to progress emotionally. How individuals address the conflicts varies widely. According to Erikson, however, unsuccessful resolution leaves the individual emotionally disabled (Erikson, 1963).

Each of eight stages of development has a specific central conflict or developmental task. These eight tasks are described in terms of a positive or negative resolution. The actual resolution of a specific conflict lies somewhere along a continuum between a perfect positive and a perfect negative.

According to Erikson (1963), the first developmental task is the establishment of trust. The basic quality of trust provides a foundation for the personality. If an infant’s physical and emotional needs are met in a timely manner through warm and nurturing interactions with a consistent caregiver, the infant begins to sense that the world is trustworthy. The infant begins to develop trust in others and a sense of being worthy of love. Through successful achievement of a sense of trust, the infant can move on to subsequent developmental stages.

According to Erikson, unsuccessful resolution of this first developmental task results in a sense of mistrust. If needs are consistently unmet, acute tension begins to appear in children. During infancy, signs of unmet needs include restlessness, fretfulness, whining, crying, clinging, physical tenseness, and physical dysfunctions such as vomiting, diarrhea, and sleep disturbances. All children exhibit these signs at times. If these behaviors become personality characteristics, however, unsuccessful resolution of this stage is suspected.

The toddler’s developmental task is to acquire a sense of autonomy rather than a sense of shame and doubt. A positive resolution of this task is accomplished by the ability to control the body and body functions, especially elimination. Success at this stage does not mean that the toddler, even as an adult, will exhibit autonomous behavior in all life situations. In certain circumstances, feelings of shame and self-doubt are normal and may be adaptive.

Erikson’s theory describes each developmental stage, with crises related to individual stages emerging at specific times and in a particular order. Likewise, each stage is built on the resolution of previous developmental tasks. During each conflict, however, the child spends some energy and time resolving earlier conflicts (Erikson, 1963).

Lawrence Kohlberg (1927-1987), a psychologist and philosopher, described a stage theory of moral development that closely parallels Piaget’s stages of cognitive development. He discussed moral development as a complicated process involving the acceptance of the values and rules of society in a way that shapes behavior. This cognitive-developmental theory postulates that, although knowing what behaviors are right and wrong is important, it is much less important than understanding and appreciating why the behaviors should or should not be exhibited (Kohlberg, 1964).

Guilt, an internal expression of self-criticism and a feeling of remorse, is an emotion closely tied to moral reasoning. Most children 12 years old or older react to misbehavior with guilt. Guilt helps them realize when their moral judgment fails.

Building on Piaget’s work, Kohlberg studied boys and girls from middle- and lower-class families in the United States and other countries. He interviewed them by presenting scenarios with moral dilemmas and asking them to make a judgment. His focus was not on the answer but on the reasoning behind the judgment (Kohlberg, 1964). He then classified the responses into a series of levels and stages.

During the Premorality (preconventional morality) level, which has three substages (see Table 5-2), the child demonstrates acceptable behavior because of fear of punishment from a superior force, such as a parent. At this stage of cognitive and moral development, children cannot reason as mature members of society. They view the world in a selfish, egocentric way, with no real understanding of right or wrong. They view morality as external to themselves, and their behavior reflects what others tell them to do, rather than an internal drive to do what is right. In other words, they have an external locus of control. A child who thinks “I will not steal money from my sister because my mother will spank me” illustrates premorality.

During the Morality of Conventional Role Conformity (conventional morality) level, which is primarily during the school-age years, the child conforms to rules to please others. The child still has an external locus of control, but a concern for social order begins to emerge and replace the more egocentric thinking of the earlier stage. The child has an increased awareness of others’ feelings. In the child’s view, good behavior is that which those in authority will approve. If behavior is not acceptable, the child feels guilty.

Two stages, stage 3 and stage 4, characterize this level (see Table 5-2). This level of moral reasoning develops as the child shifts the focus of living from the family to peer groups and society as a whole. As the child’s cognitive capacities increase, an internal sense of right and wrong emerges, and the individual is said to have developed an internal locus of control. Along with this internal locus of control comes the ability to consider circumstances when judging behavior.

Level 3, Morality of Self-Accepted Moral Principles (postconventional morality), begins in adolescence, when abstract thinking abilities develop. The person focuses on individual rights and principles of conscience during this stage. There is an internal locus of control. Concern about what is best for all is uppermost, and persons step back from their own viewpoint to consider what rights and values must be upheld for the good of all. Some individuals never reach this point. Within this level is stage 5, in which conformity occurs because individuals have basic rights and society needs to be improved. The adolescent in this stage gives as well as takes and does not expect to get something without paying for it. In stage 6, conformity is based on universal principles of justice and occurs to avoid self-condemnation (Colby, Kohlberg, & Kauffman, 1987; Kohlberg, 1964).

Only a few morally mature individuals achieve stage 6. These people, committed to a moral ideal, live and die for their principles.

Kohlberg believes that children proceed from one stage to the next in a sequence that does not vary, although some people may never reach the highest levels. Even though children are raised in different cultures and with different experiences, he believes that all children progress according to his description.

The DDST-II, designed to be used with children between birth and 6 years of age, assesses development on the basis of performance of a series of age-appropriate tasks. There are 125 tasks or items arranged in four functional areas (Frankenburg & Dodds, 1992):

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