Life Span: Development and Infancy (Birth to Age Three)
Abstract and Keywords
Infancy and young childhood are characterized by rapid cognitive, emotional, and physical development. Each year is marked by specific developmental tasks. Infants need positive parenting, a safe environment, and attention to their basic physical needs. A strong bond with caregivers is also necessary, as this lays the foundation for trust, allowing infants to explore their world. Many of the risk factors, such as prenatal exposure to alcohol and drugs, malnutrition, and abuse and neglect, can be remedied. Interventions such as home visiting, family leave, and nutrition programs are inexpensive and effective, and should receive more attention from social work.
Infancy and young childhood are the most crucial periods in a child's development. There is a dynamic and continuous interaction between biology and experience that shapes early human development. Human relationships are the building blocks of healthy development, and children are active participants in their own development.
Several theories inform social work practice with infants and young children. Charlotte Towle's Common Human Needs (1945, rev. ed. 1987) advanced the principle that beginning at infancy, all humans have the same basic biological, psychological, social, and spiritual needs. Piaget's theory of cognitive development helps explain how infants and young children develop intelligence through four stages of adapting, assimilating, and accommodating their environment (Beillin, 1992; Smith, 1996). Attachment theory, developed primarily by Bowlby and Ainsworth, posits that children develop different styles of attachment based on their interactions with caregivers during infancy (Bretherton, 1992). Bronfenbrenner (1979) developed an ecological framework for understanding children's development, arguing that human development takes place through processes of progressively more complex reciprocal interactions over time (Bronfenbrenner & Evans, 2000; Bronfenbrenner & Morris, 1998). Social work practitioners use these theories as a framework to (a) integrate knowledge from other disciplines, such as biology, medicine, psychology, and sociology, and to transfer this knowledge to social work practice; (b) analyze how social and economic forces impact early childhood development; and (c) provide an explanation for the workers' practice decisions. Most important, these theories help social workers decide what to do (Payne, 2005).
Infants' Cognitive, Emotional, and Physical Needs
Sensitivity and responsiveness are most important for infants’ and young children's cognitive and emotional development. Sensitivity refers to how appropriate the care is to the individual child, and responsiveness has to do with how adaptive it is to changes in the child's needs (Albers, Riksen-Walraven, & de-Weerth, 2007). These are attributes both of the caregiver and of the relationship between the caregiver and child. Parents and children develop a relationship that is affected by the child's temperament, parents' own childhood experiences, the support parents receive, and the family's economic stability (Waldfogel, 2006).
Developing secure attachments is one of the major social and emotional developmental tasks for infants, as secure attachments provide a sense of basic trust. Having a sense of trust allows children to explore the world around them and form attachments with others. Children can only develop secure attachments if their caregivers are both knowledgeable about their needs and responsive to those needs (Carlson, Sampson, & Sroufe, 2003; Perry, 2003; Vasquez & Pitts, 2006; Waldfogel, 2006).
For normal development to occur, infants and young children need positive parenting, a safe environment, and attention to their basic physical needs. All children are born wired for feelings and ready to learn and early relationships are essential. Each year is marked by specific developmental tasks (Carter et al., 2005).
Birth to Age 1
The physical care that caregivers provide, especially the extent that caregivers are responsive and sensitive to children's physical needs, lays the foundation for their cognitive and emotional health. Newborns need constant attention, which can be quite challenging for infants' caregivers. The physical needs of newborns are fairly simple, in that they need to be fed and to be kept warm. However, even these simple needs can become complex. Mothers must decide whether to breastfeed, and caregivers must learn how to keep newborns warm without smothering them. From birth to age 1, infants' cognitive development sets the stage for language development, and they develop bonds of love and trust (Sohr-Preston & Scaramella, 2006; Thai & Clancy, 2001).
From age 1–2, children become increasingly aware of themselves and their surroundings. They develop greater independence, become more mobile, can recognize themselves in a mirror, develop the ability to imitate behavior, form simple phrases and sentences, and can follow simple directions. Children are born with much of what they need to learn language, which is one of their most important developmental tasks, and much of language learning is universal. Most children begin talking between 10 and 15 months, and their vocabularies grow rapidly from 18 months onward. The amount and quality of language children are exposed to, including singing and playing word games, enhances language learning (McMullen & Saffran, 2004; Suthers, 2001; Waldfogel, 2006).
From age 2–3, children experience huge intellectual, social, and emotional changes to help explore their world and make sense of it. Toddlers can follow two- or three-phrase commands, sort objects by color and shape, imitate actions of adults and playmates, and express a wide range of emotions. Because of children's growing desire to assert their independence, this developmental phase if often called the “terrible twos” (Keenan & Wakschlag, 2000; Ostrander, 2004).
Challenges or Dilemmas
Children's early development depends on the health and well-being of their parents. Children whose parents struggle to cope with their own emotional and environment concerns are more likely to experience developmental risk factors. Such risk factors include low birth weight; prenatal exposure to alcohol, drugs, and nicotine; abuse and neglect, which can result in infant mortality and Shaken Baby syndrome; health risk factors, such as exposure to lead and lack of immunizations; and malnutrition and overfeeding.
Low Birth Weight and Substance Abuse
Low birth weight is one of the leading causes of neonatal mortality (U.S. Department of Health and Human Services [USDHHS], Health Resources and Services Administration, & Maternal and Child Health Bureau 2006). Studies have found a relationship between drug use during pregnancy and premature birth, low birth weight and size of the infant at birth, and problems with regulation and alertness. Prenatal exposure to nicotine can increase a newborn’s sensitivity to the reinforcing effects of methamphetamine (Harrod, Lacy, & Morgan, 2012). Prenatal exposure to drugs can delay a young child's language development, affect behavior, and is a significant predictor of aggressive and delinquent conduct (National Institute on Drug Abuse [NIDA], 1999). Though prenatal exposure to cocaine and to opiates is associated with premature birth and low birth weight, such drug exposure is not associated with mental, motor, or behavioral deficits after controlling for birth weight at three years of age (Messinger et al., 2004). Fetal alcohol syndrome (FAS) results from a more persistent exposure. The consequences of FAS range from mild intellectual and behavioral issues to profound disabilities or premature death. Since evidence suggests that low birth weight and behavioral problems can be caused at average levels of exposure as low as one drink per week, no alcohol during pregnancy remains the best advice (Nugent, Greene, & Mazor, 1991).
Infant Mortality and Health Disparities
The infant mortality rate (IMR) has shown a steady decline, from 26.0 per 1,000 live births in 1960 to 6.14 per 1,000 live births in 2010 (Centers for Disease Control [CDC], 2007a; Murphy, Xu, & Kochanek, 2012). However, for decades black women have been twice as likely as white women to give birth to low birth weight babies (Reichman, 2005). In 2010, the IMR among black women was 11.61, and 5.19 among white women (Murphy et al., 2012). The United States’ IMR world ranking has steadily declined, from a ranking of 18 in 1980 to 31 in 2008. When compared to countries with lower IMRs, this ranking is due in large parts to higher rates of low birth weight and short gestational age births, or premature births, and racial and ethnic disparities (Heisler, 2012). Racial and ethnic disparities cannot be explained by socioeconomic status alone. Other contributing factors include strenuous working conditions and toxic exposures (Herdt-Losavio et al., 2009; McKinnon, 2003); neighborhood violent crime (Morenoff, 2003); and residential environmental exposures, such as air pollution (Rogers et al., 2000), substances in drinking water (Rodenbeck, Sanderson, & Rene, 2000), and industrial chemicals (Baibergenova, Kudyakov, Zdeb, & Carpenter, 2003). Paternal exposure to pesticides, solvents, and lead in the workplace before conception may affect infant health (Trasler & Doersken, 1999). Black fathers are more likely than black mothers to be exposed to toxic substances at work (McKinnon, 2003).
The leading causes of infant death include congenital abnormalities, pre-term/low birth weight, sudden infant death syndrome (SIDS), and newborns affected by maternal complications of pregnancy (Murphy et al., 2012). Infant mortality among African Americans in 2008 was twice the national average. The SIDS death rate among American Indian and Alaska Natives is nearly two times the rate of non-Hispanic white mothers (CDC, 2007a). Research suggests that infants who sleep on their backs are less likely to die from SIDS than infants who sleep in a prone position, or on their stomachs. However, women in lower social classes may be less likely to receive this public health information than other women. When they do, they may be less likely to heed this public health information, placing their infants on their stomachs for sleeping, rather than on their backs.
Thus, more needs to be done to understand the cultural barriers to adapting this preventive health measure to prevent SIDS (Pickett, Luo, & Lauderdale, 2005). Low birth weight is associated with increased risk in adulthood for cardiovascular disease, hypertension, and diabetes, all of which occur at disproportionate rates among African Americans, and contribute to lower life expectancies. The association between birth weight and adult morbidity remains even when accounting for lifestyle factors (Barker, 2000).
Maternal tobacco smoking is the primary risk factor associated with SIDS (Campos, Bravo, & Eugenín, 2009). Prenatal exposure to nicotine contributes to lifelong alterations in respiratory health (Wongtrakool, Wang, Hyde, Roman, & Spindel, 2012), increased substance use (Harrod et al., 2012), and increased smoking (Abreu-Villaça, Seidler, & Slotkin, 2004; Buka, Shenassa, & Niaura,2003).
Within the African American community, maternal education and marital status may ultimately influence infant mortality, mediated by biological and demographic factors, health care, and infant health status at birth (Jackson, Rowley, & Curry Owens, 2012; Sharma, 1998). Despite relatively low incomes, low formal education, and lack of access to medical care, everyday pregnancy care may explain why Mexican immigrant women have positive birth outcomes (Sherraden & Barrera, 1997). African American women have a disproportionately high rate of low birth weight infants when compared with Euro-American women (Hoyert, Freedman, Strobino, & Guyer, 2001). Although socioeconomic and behavioral factors contribute to adverse birth outcomes, such factors as income, education, prenatal care, marital status, and substance abuse do not fully account for these ethnic disparities. There is now emerging evidence that the disproportionate rates of infant mortality, low birth weight, and pre-term delivery in African Americans may result from group differences in exposure or susceptibility to prenatal stress, including stress related to racism and discrimination as well as physiological differences in physiological responses to stress (Giscombé & Lobel, 2005).
Infant Abuse and Neglect
More children die from maltreatment between the ages of 0 and 3 than during any other time (USDHHS, 2012). Four-fifths (81.6%) of all child fatalities were younger than 4 years old. Examining this percentage by single year age reveals that 42.4% of child fatalities were younger than 1 year, 18.2% were 1 year old, 18.2% were 2 years old, and 7.8% were 3 years old. In 2011, children younger than 1 year had the highest rate of victimization at 16.8 per 1,000. Victims aged 1, 2, or 3 years had victimization rates of 7.25, 2.25, and 3.0 victims, respectively, per 1,000 children of those respective ages in the population (USDHHS, 2012). The consequences of maltreatment for infants and young children can affect a child's development in ways that may not be recoverable with age (Scannapieco & Connell-Carrick, 2005). Relationship trauma in early life can lead to progressive impairment of the ability to adjust and to take action on one’s behalf, and difficulties in developing the ability to register affect and pain (Baradon, 2010). Infants and toddlers who have been physically abused may exhibit signs of posttraumatic stress disorder (PTSD) that may be manifested in both cognitive and behavioral changes, including problems achieving autonomy, lack of empathic understanding, and a tendency to engage in more concrete, rather than imaginary play (MacDonald et al., 2008; Perry, 1997, 1999). Though there is a dearth of research on PTSD among young children, life-threatening trauma, such as abuse, during the early childhood years may impact the child's long-term development (Scheeringa, 2004). Physically, children who are abused may exhibit a failure to thrive. In more severe cases, physical abuse can cause developmental delays, retardation, paralysis, and mental health concerns in later life (Perry & Azad, 1999; Raineki, Cortés, Belnoue, & Sullivan, 2012). Unpredictable and prolonged stress negatively affects infants’ developing brains. In toddlerhood, such children may become aggressive to control the predictability of the abuse rather than wait for it to happen (Perry, 1997). Shaken baby syndrome results from vigorously shaking a baby, and these infants present with seizures, vomiting, lethargy, drowsiness, and death. Such infants often show retinal damage and brain injury, and the brain injury can also result in spinal cord injury, leading to paralysis (Scannapieco et al., 2005).
Infants who are neglected may be delayed in their cognitive development, and may exhibit a failure to thrive (Barnett, Miller-Perrin, & Perrin, 2005). Such infants are usually below the 5th percentile of relative growth (Kerr, Black, & Krishnakumar, 2000). Chronic neglect can have a devastating effect on the developing brain, since infants and young children require a stimulating environment to foster the development of neural pathways (De Bellis, 2005; Streeck-Fischer & van der Kolk, 2000). Such children may also fail to develop gross and fine motor skills. Neglected toddlers tend to be easily frustrated, impulsive, and be uninterested in play (Erickson & Egeland, 2002). It should be noted that an infant well cared for in a dirty home would not exhibit these developmental delays. While the cognitive deficits of neglected infants seem to be cumulative, their developmental delays may be recoverable if identified early enough (Oliván, 2003).
Sexual abuse of infants can be equally devastating, since children who experience sexual abuse earlier in life are at greater risk for poor psychological functioning in adulthood than those maltreated later in life (Kaplow & Widom, 2007; Markese, 2007). Because major brain development occurs over the first 2–3 years of life, the developing brain is especially vulnerable to the harmful effects of stress and trauma, such as sexual abuse (Nelson & Carver, 1998; van der Kolk, 1996). This may affect all their future relationships, and they may use disassociation as a primary coping mechanism. (Diseth, 2005; Sar, Akyüz, & Doğan, 2007).
Childhood Diseases or Lack of Immunizations
School vaccination requirements have been a key factor in the prevention and control of vaccine-preventable diseases in the United States (Buttenheim, Jones, & Baras, 2012; CDC, 2013). There are many vaccine-preventable diseases, which, not long ago, disabled and killed millions of children. These diseases are now uncommon as a result of the high childhood immunization coverage levels. Since many of the viruses and bacteria that cause these diseases are still circulating in the United States, or are only a plane ride away, it is important that infants and young children receive recommended immunizations on time. If a child is not vaccinated and is exposed to a disease germ, the child's body may not be strong enough to fight the disease. Before vaccines, many children died from diseases that vaccines now prevent, such as whooping cough, measles, and polio. The same germs exist today (CDC, 2013). Many new immigrants and refugees, including women and young children, are susceptible to measles, mumps, or rubella and may benefit from targeted vaccination programs (Greenaway et al., 2007). In 2009, the CDC issued new guidelines requiring immigrants to have age-appropriate vaccinations (CDC, 2009). Programs to vaccinate new immigrants may reduce the number of young children who are exposed to infectious diseases (CDC, 2007a). Children under the age of 1 are too young to receive a vaccination and are among those who would benefit from vaccination programs that target new immigrants and refugees (CDC, 2007b).
Malnutrition and Overfeeding
Ironically, both malnutrition and overfeeding can be observed among infants in the United States, both of which have long-term health consequences. There is no universally accepted definition of malnutrition, However, the World Health Organization defines malnutrition as the cellular imbalance between supply of nutrients and energy and the body's demand for them to ensure growth, maintenance, and specific functions (Alberda, Graf, & McCarger, 2006).
Malnutrition has been described with increasing frequency in hospitalized and chronically ill children in the United States, and occurs in as many as 10% of children in rural areas (Shashidhar & Grigsby, 2006). Rapid infant weight gain has been associated with increased risk of being overweight at 4 years of age (Dennison, Edmunds, Stratton, & Pruzek, 2006). Overfeeding in infancy could explain in part why childhood obesity is on the rise (Ong & Loos, 2006; Plagemann, 2006; Rising & Lifshitz, 2005).
Lead Poisoning or Environmental Risk Factors
Exposure to lead can lead to intellectual and behavioral deficits in children and hypertension and kidney disease in adults. The CDC Healthy People 2010 report established the goal of eliminating lead poisoning among children in 10 years (CDC, 2009). In the United States, exposure to lead among children is so widespread that it may be causing a general reduction in the overall IQ of children. In spite of well-intended programs to help children exposed to lead, it is uncertain whether the effects can be reversed (CDC, 2012b). There are approximately half a million U.S. children aged 1-5 with blood leads levels at which the CDC recommends public health actions be initiated (CDC, 2009). Though the percentage of children aged 1–5 with unsatisfactory blood levels has declined sharply, blood lead levels remain higher for minority populations, children from low-income families, and children who live in older homes (CDC, 2005). Researchers have shown that high-risk neighborhoods, characterized by poverty, high percentages of residents on public assistance, and multiple or subdivided housing units, are also neighborhoods with significant sources of lead toxicity. Children from these neighborhoods are also more likely to be diagnosed with a learning disability (Margai & Henry, 2003; McLoyd, 1998). Young children who have either immigrated to the United States with their families or been adopted may be at increased risk as a result of either pre- or post-immigration exposure. Children who may be exposed to lead-containing folk remedies may also be at risk (Bernard, 2003). While efforts to reduce lead exposure have resulted in the decline in blood lead levels (CDC, 2005), other sources of lead exposure such as drinking water contaminated during delivery and exposure to aging buildings remain (Bernard, 2003).
Working Mothers and Infant Bonding
Children who are securely attached to their parents are more socially competent and get along better with peers (Allen, Porter, McFarland, McElhaney, & Marsh, 2007; Lucas-Thompson & Clarke-Stewart, 2007). According to research, there is a network of behavioral, physiological, and neural processes that underlie the psychological constructs of attachment theory that is especially relevant for the mother–infant bond (Hofer, 2006). As a result, attachment theory was taken to suggest that working mothers posed a risk to their children's mental health. However, research has shown that children with working mothers (or fathers) can develop secure attachments to them (Tizard, 1991; Waldfogel, 2006). Further, research suggests that there are no significant differences between infants of mothers who worked full-time and mothers who worked part-time or not at all in the infant’s first year of life nor were there any differences in behavioral outcomes at 3 years of age (Brooks-Gunn, Han, & Waldfogel, 2010). Marked changes in the nature, schedule, and amount of work engaged in by parents of young children make it increasingly difficult to balance workplace and family responsibilities (National Research Council & Institute of Medicine, 2004). Mothers who work full-time during an infant's first year of life may find it difficult to breastfeed, which can have adverse effects on a child's health. Mothers' full-time work after the first year has neutral or positive effects (Russell, 1999; Tizard, 1991). Ultimately, adequate caregiving is based on caregivers' ability to integrate life experiences into the caregiving relationship (Waldfogel, 2006).
Fathers and Infants
Fathers play a critical role in early child development (Freeman, Newland, & Coyl, 2010). With the exception of lactation, there is no evidence that women are biologically predisposed to be better parents than fathers (Lamb, 2002), and fathers experience similar changes in hormonal levels around the time of their infants' birth (Storey, Walsh, Quinton, & Wynne-Edwards 2000). Some researchers have found little difference between levels of maternal and paternal sensitivity, though fathers' responsiveness appears to vary according to the degree that they assume responsibility for infant care (Gervais, 1997; Ninio & Rinott 1988). Warm and stimulating parenting from fathers in the child’s first years of life is predictive of enhanced reading and math skills in early childhood (Coley, Lewin-Bizan, & Carrano, 2011). Though there is considerable cultural variability in how much time fathers spend with infants (Lamb, 1987; Quinlan & Quinlan 2007), further research is needed to understand parenting styles of fathers, especially among African American and Latino families (Campos, 2008).
Implications for Social Work
Interventions that address infants' developmental risk factors are effective and inexpensive and should receive more attention from social workers. Research shows that short-term interventions with a clear focus appear to be more effective than long-term, broad-based interventions (van IJzendoorn, Juffer, & Duyvesteyn, 1995). For example, early intervention to improve mother-infant transactions among pre-term infants can improve cognitive outcomes for children at age 5 (Nordhov et al., 2010). Screening low-income pregnant women in a community setting may be an effective intervention to prevent FAS, low birth weight, and related conditions (O'Connor & Whaley, 2003). As discussed, infants are most vulnerable to child abuse and neglect when compared to older children. Home visiting is a beneficial and cost-effective strategy to prevent abuse and neglect of infants (Howard & Brooks-Gunn, 2009). When it does occur, practitioners need to take a long-term, developmental view when assessing, understanding and supporting children who have sustained injury or maltreatment during these critical early years (Ashton, 2010).
Despite the benefits of the Supplemental Nutrition Program for Women, Infants, and Children (WIC), many eligible households do not participate (Gundersen, 2005; Jacknowitz & Tiehen, 2009; Lee & Mackey-Bilaver, 2007). Social workers should advocate for the following interventions to be universally accessible to infants and their families: prenatal health care, WIC and other nutrition programs, pre- and perinatal home visitation, early intervention, and drug and alcohol treatment and tobacco cessation programs for women who are pregnant. The Family and Medical Leave Act should be expanded to include all working parents, and welfare reform's work requirements for parents of infants should be curtailed (Scharlach & Grosswald, 1997). Studies have shown that extending paid job-protected maternity leave by 10 weeks reduced postneonatal mortality, suggesting that infants fare better when mothers can stay home to care for them during their first weeks of life (Waldfogel, 2006). In spite of initial concerns regarding the effect of work requirements as a result of the passage of the Personal Responsibility and Work Act of 1996, research suggests that children whose mothers make the transition from welfare to work were no healthier than children with welfare-dependent caregivers (Slack et al., 2007). Furthermore, requiring women to work while pregnant may negatively affect birth weight, especially for African American mothers. The effect of job strain on low birth weight of women who were working during early and late pregnancy was significantly greater for African Americans than for European Americans (Oths, Dunn, & Palmer, 2001). While social workers at the program level may not be able to affect whether mothers receive maternity leave and other economic supports, they can provide social support and encourage mothers to enroll in programs that provide social support, health services, parenting education, and other services. Such programs have been demonstrated to be effective in reducing low birth weight and enhancing the well-being of infants and young children (Rodriguez, Dumont, Mitchell-Herzfeld, Walden, & Greene, 2010; Olds, 2002).
Trends or Directions
As of 2013, there was little indication of greater public support for families with infants and young children, in spite of the research that indicates positive outcomes for targeted early intervention, in part due to the economic climate. For example, despite the benefits associated with the WIC, more than one in four eligible infants do not receive WIC (Gundersen, 2005). However, once implemented, the Affordable Health Care for America Act provides for well-baby visits, developmental assessments, and counseling from physicians for parents of infants and children. These preventive programs will be available in new health plans for children with no cost sharing. The law also makes sure that more mothers have access to needed services to ensure a healthy pregnancy (USDHHS, 2012). Such preventive programs can improve long-term developmental outcomes for children, especially for children who live in poverty. Since the late 1980s, young children have become more likely to be poor, which imposes significant burdens on their well-being and increases the odds for adverse developmental outcomes. Ethnically diverse families face unique challenges as a result of social, political, and cultural realities that limit families' access to resources and create additional stressors to families that already are vulnerable at this critical stage of development. Clearly more can be done to support families of young children, as research suggests that such support can promote positive trends in infants' development.
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