Definition/Introduction
The concept of childhood is relatively new; in most medieval societies, childhood did not exist. At approximately 7 years of age, children were considered little adults with similar expectations for a job, marriage, and legal consequences. Charles Darwin advanced ideas about childhood development in his work on the origins of ethology (the scientific study of the evolutionary basis of behavior) and in "A Biographical Sketch of an Infant," first published in 1877. It wasn't until the 20th century that developmental theories emerged. When conceptualizing cognitive development, we cannot ignore the work of Jean Piaget. Piaget suggested that when young infants experience an event, they process new information by balancing assimilation and accommodation. Assimilation is the process of taking in new information and fitting it into previously understood mental schemas. Accommodation is the adaptation and revision of a previously understood mental schema in response to novel information. Piaget divided child development into 4 stages.
The first stage, Sensorimotor (ages 0 to 2 years of age), is the time when children master 2 phenomena: causality and object permanence. Infants and toddlers use their senses and motor abilities to manipulate their surroundings and learn about the environment. They understand cause-and-effect relationships, such as how shaking a rattle may produce a sound and how crying can make the parent(s) rush to give them attention. As the frontal lobe matures and memory develops, children in this age group can imagine what may happen without physically causing an effect; this is the emergence of thought and allows for the planning of actions. Object permanence emerges around 6 months of age. It is the concept that objects continue to exist even when they are not presently visible.
Second is the "Pre-operational" stage (ages 2 to 7 years), when a child can use mental representations such as symbolic thought and language. Children in this age group learn to imitate and pretend to play. This stage is characterized by egocentrism, i.e., the inability to perceive that others can think differently from oneself, and by the belief that everything (good or bad) is somehow linked to the self.
Third is the "Concrete Operational stage" (ages 7 to 11 years), when the child uses logical operations when solving problems, including mastery of conservation and inductive reasoning. Finally, the Formal Operational stage (age 12 years and older) suggests that an adolescent can apply logical operations and use abstractions. Adolescents can understand theories, hypothesize, and comprehend abstract ideas like love and justice. Childhood cognitive development and the Piaget stages are poorly generalizable. For example, conservation may overlap between the Pre-operational and Concrete Operational stages as the child masters conservation in 1 task and not in another. Similarly, the current understanding is that a child masters the "Theory of Mind" by 4 to 5 years, much earlier than when Piaget suggested that egocentrism resolves.[1]
Stages of Cognitive Development (Problem-Solving and Intelligence)
The word intelligence derives from the Latin "intelligere," meaning to understand or perceive. Problem-solving and cognitive development progress from establishing object permanence, causality, and symbolic thinking through concrete (hands-on) learning to abstract thinking and the embedding of implicit (unconscious) memory into explicit memory development.
- 0 to 2 months: The optical focal length is approximately 10 inches at birth. Infants actively seek stimuli, habituate to the familiar, and respond more vigorously to changing stimuli. The initial responses are more reflexive, like sucking and grasping. The infant can fixate and follow a slow horizontal arc and eventually follow past the midline. Contrasts, colors, and faces are preferred. The infant distinguishes familiar from moderately novel stimuli. As habituation to caregivers' faces occurs, preferences develop. The infant stares momentarily at the place from where an object has disappeared (lack of object permanence). At this stage, high-pitched voices are preferred.
- 2 to 6 months: Children in this age bracket engage in purposeful sensory exploration of their bodies, staring at their hands and reaching to touch their body parts; this builds concepts of cause and effect and self-understanding. Sensations and changes outside of themselves are appreciated with less regularity. As motor abilities are mastered, something that happens by chance is repeated. For example, pressing a button may light up the toy, or crying can cause the caregiver to appear. Routines are appreciated in this age group.
- 6 to 12 months: Object permanence emerges in this age group, as toddlers look for objects. A 6-month-old looks for partially hidden objects, while a nine-month-old looks for wholly hidden objects and uncovers them; this includes engaging in peek-a-boo-type games. Separation and stranger anxiety emerge as the toddler understands that out of sight is not out of mind. As motor abilities advance, sensory exploration of the environment occurs via reaching, inspecting, holding, mouthing, and dropping objects. They learn to manipulate their environment, learning cause and effect by trial and error, like banging 2 blocks together can produce a sound. Eventually, as Piaget suggested, mental schemas are built, and objects can be used functionally; for example, by intentionally pressing a button to open and reach inside a toy box.
- 12 to 18 months: Around this time, motor skills make it easier for the child to walk, reach, grasp, and release. Toys can be explored, made to work, and novel play skills emerge. Gestures and sounds can be imitated. Egocentric pretend play emerges. As object permanence and memory advance, objects can be found after witnessing a series of displacements, and moving objects can be tracked.
- 18 months to 2 years: As memory and processing skills advance and frontal lobes mature, outcomes are imagined without so much physical manipulation, and new problem-solving strategies emerge without rehearsal. Thought arises, and there is the ability to plan actions. Object permanence is wholly established, and objects can be searched for by anticipating where they may be without witnessing their displacement. At 18 months, symbolic play expands beyond the self; the child may attempt to feed a toy as if it were themselves, and may imitate housework.
- 2 to 5 years: During this stage, the preschool years, magical and wishful thinking emerges; for example, the sun went home because it was tired. This ability may also give rise to apprehensions about monsters, and logical solutions may not be enough for reassurance. Perception dominates over logic, and giving them an imaginary tool, like a monster spray, to help relieve that anxiety may be more helpful. Similarly, the concepts of conservation and volume are lacking, and what appears larger is considered more. For example, one cookie split into 5 equal parts may equal 2 cookies.
- Children in the preschool stage have a poor concept of cause and may think sickness is due to misbehavior. They are egocentric in their approach and may look at situations only from their own point of view, offering a favorite stuffed toy for comfort to an upset loved one. At 36 months, a child can understand simple time concepts, identify shapes, compare 2 items, and count to 3. Play becomes more comprehensive. At 48 months, children can count to 4, identify 4 colors, and understand opposites.
- At 5 years of age, pre-literacy and numeracy skills continue to develop; 5-year-old children can count to 10 accurately, recite the alphabet by rote, and recognize a few letters. A child also develops hand preference at this age. Play stories become even more detailed between 4 and 5 years and may include imaginary scenarios, including imaginary friends. Playing with game rules and obeying them are also established during the preschool years. Rules can be absolute.
- 6 to 12 years: During early school years, scientific reasoning and understanding of physical laws of conservation, including weight and volume, develop. A child can understand multiple points of view and can understand one perspective of a situation. They realize the rules of the game can change with mutual agreement. Basic literacy skills in reading and numbers are initially mastered. Eventually, around third to fourth grade, the emphasis shifts from learning to read to reading to learn, and from spelling to composition. All these stages need mastery of sustained attention and processing skills, receptive and expressive language, and memory development and recall. The limitations of this stage are an inability to comprehend abstract ideas and a reliance on logical answers.
- 12 years and older: During this age, adolescents can exercise logic systematically and scientifically. They can simultaneously apply abstract thinking to solve algebraic problems and multiple logics to reach a scientific solution. It is easier to use these concepts for schoolwork. Later in adolescence and early adulthood, these concepts can also apply to emotional and personal life problems. Magical thinking or following ideals guides decisions more than wisdom. Some may be more influenced by religious or moral rules and absolute concepts of right and wrong. Questioning the prevalent code of conduct may cause anxiety or rebellion and eventually lead to the development of personal ethics. Side by side, social cognition, apart from self, is also developing, and concepts of justice, patriarchy, and politics are being established. During late teens and early adulthood, thinking about the future, including ideas such as love, commitment, and career goals, becomes important.[2]
Issues of Concern
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Issues of Concern
Pediatric and primary care practitioners are in a prime position to monitor children's growth and development, particularly cognitive development. A lag in cognitive development may alert the provider to attention-deficit/hyperactivity disorder, learning disability, global developmental delay, developmental language disorder, developmental coordination disorder, mild intellectual disability, autism spectrum disorders, moderate-severe intellectual disability, cerebral palsy, fetal alcohol syndrome (FASD), or vision and auditory disorders.
The most well-known causes of intellectual disability are FASD, Down syndrome, Fragile X syndrome, other genetic or chromosomal problems, lead or other toxicities, and environmental influences such as poverty, malnutrition, abuse, and neglect. Prenatal causes of intellectual disability include infection, toxins and teratogens, congenital hypothyroidism, inborn errors of metabolism, and genetic abnormalities. Fetal alcohol syndrome is the most common preventable cause of intellectual disability. Down syndrome is the most common genetic cause, and Fragile X syndrome is the most common inherited cause. First-tier tests recommended for intellectual disability are chromosomal microarray and Fragile X testing.
Clinical concerns can arise in areas of visual analysis, proprioception, motor control, memory storage and recall, attention span and sequencing, and deficits in receptive or expressive language. Early recognition of intellectual disability leads to earlier diagnosis and intervention, showing promising results in improved cognition. Besides what is best for children and families, early intervention saves overall economic expenditure on disabilities. Thus, surveillance alone is inadequate; active screening for developmental delay should be an integral part of medical practice.[3] Commonly used screening measures include the Ages and Stages Questionnaire and the Survey of Well-being of Young Children. If the results of surveillance and screening are concerning, watchful waiting is inadequate, and a referral is necessary for early intervention.
Intellectual disability is defined as a concern for intellectual and adaptive functioning. Usually, on standardized measures, this means a score less than 2 standard deviations below the mean, which is 100 for most measures. Standardized tests used to measure intellectual function include the Wechsler Intelligence Scale for Children (WISC), the Wechsler Preschool and Primary Scale of Intelligence (WPPSI), and the Stanford-Binet test. One standardized test for adaptive functioning is the Vineland Adaptive Behavior Scale. A learning disability should be suspected when the intelligence score is within the average range, but a significant discrepancy in achievement scores exists, or a child does not respond to evidence-based interventions. Evidence-based interventions include increasing instruction time and specialized instruction by trained personnel in deficit areas.
Clinical Significance
Early intervention during the "critical period" in development has shown promising results.[4] Thus, clinicians must take the lead in diagnosing, treating, and establishing resources for early intervention to provide optimal health opportunities for our children. Early intervention services should be provided in 2 areas: biological risk/disabilities and environmental risk. Pediatric and primary care practitioners should understand the Individuals with Disabilities Act (IDEA) and other federal policies. Early intervention laws give entitlement to services from birth through early intervention home-based service, the Individualized Family Service Plan (IFSP) from birth to 3 years of age, and individualized education plans for ages 3 to 21 years. The goal is to minimize or prevent disability by accommodating children with intellectual disabilities or changing the curriculum to meet the individualized needs of the child. This plan should be based on an interprofessional assessment to understand the child's needs. Thus, clinicians should partner with social workers, psychologists, or psychiatrists for thorough evaluations; lawyers to explore legal support and advocacy for services; therapists; early intervention providers; and schools to plan individualized goals and monitor progress.
References
Newcombe NS. Cognitive development: changing views of cognitive change. Wiley interdisciplinary reviews. Cognitive science. 2013 Sep:4(5):479-491. doi: 10.1002/wcs.1245. Epub 2013 Jun 25 [PubMed PMID: 26304241]
Wilks T, Gerber RJ, Erdie-Lalena C. Developmental milestones: cognitive development. Pediatrics in review. 2010 Sep:31(9):364-7. doi: 10.1542/pir.31-9-364. Epub [PubMed PMID: 20810700]
Council on Children With Disabilities, Section on Developmental Behavioral Pediatrics, Bright Futures Steering Committee, Medical Home Initiatives for Children With Special Needs Project Advisory Committee. Identifying infants and young children with developmental disorders in the medical home: an algorithm for developmental surveillance and screening. Pediatrics. 2006 Jul:118(1):405-20 [PubMed PMID: 16818591]
Bundy DAP, Silva ND, Horton S, Jamison DT, Patton GC, Alderman H, Behrman JR, Glewwe P, Fernald L, Walker S. Evidence of Impact of Interventions on Growth and Development during Early and Middle Childhood. Child and Adolescent Health and Development. 2017 Nov 20:(): [PubMed PMID: 30212122]