Monitoring a Child's Psychological Development at Child Health Clinics

General remarks

• The monitoring of a child's psychological development should include the observation of the interaction between parent and child. Both parties play a part in this interaction, and any impairment either in the child's development or the adult's parental skills will soon be evident in the interaction.
• The essential aspects to observe in the follow-up of the psychological development of a child include the recognition and regulation of emotions, social skills, executive functions and regulation of behavior.
• Early interaction with parents and other significant adults during the first few years of the child's life will form the child's developmental environment.
  • Good quality early interaction will promote the child's mental health and prevent the development of various disorders. The parents should therefore be involved, during their visits to the Child Health Clinic, in discussions regarding their role as parents and their attitude and engagement to the child. The discussion should also involve factors that may have an impact on the family life and thus affect the parents' wellbeing and ability to succeed in their parental duties.
  • How the child responds to stimuli, i.e. the child's temperament, also affects the parent-child interaction, and it may be beneficial to discuss with the parents the character of their child and how best to manage the child's care; for example, what is the best way to soothe the child. A simple, but useful, approach is to explore with the parents whether their child is oversensitive or whether the child's reactions to stimuli are normal or slow.
  • Often, listening and mapping out the parental problems is enough to help the parents work out their own solutions to family problems, thus reducing the harmful effects on the child. A good relationship and openness between the Child Health Clinic staff and the parents will make it easier for the parents to accept the input, if necessary, of social services (for example, home help when the mother is exhausted or depressed) or specialist health care services.
  • It is also important to discuss how strong the family is emotionally, particularly how much moral support is given to the parent principally in charge of looking after the child. Such support will, for example, guard a mother against postnatal depression.
    • The effect of parental mental illness on the child: see The Effect of Parental Mental Illness on the Child.

Aims of health examinations during the first year of life

• Any disturbances in early interaction should be identified, particularly postnatal depression and fatigue in the parents.
• Families who are in need of psychosocial support due to deficiencies in their own social networks or to burdening factors should be identified.
• Any deficiency in the child's ability to engage in age-appropriate interaction should be identified.
• Early interaction should be encouraged.

Health examinations during the first year of life

• The examinations should include the following:

1. Interview with the parents
   • What are the feelings of the parents?
   • Do the parents have any concerns over the child?
   • Do the parents receive support from each other/family/friends?
   • How tired are the parents?
   • What is positive about caring for the child, and what is negative?
   • Are there any difficulties/problems within the family unit?
   • How has the family solved any problems?
2. Observation of interaction
   • Does the parent look at the child and seek eye contact?
   • Do the child and the parent smile or laugh simultaneously at times as a sign of shared joy?
   • In what manner are they talking about the child?
     • Talk directed at the child should mostly have a positive tone; hostility towards the child is an indication for a closer inspection of the family's situation.
   • Does the parent talk to the child in a more high-pitched and soft voice than usual (baby talk)?
   • Does the parent hold the child naturally and hold him/her close to their own body?
   • Are the child's responses to talk and handling age-appropriate?
3. Examining the child
   • Does the child cry normally and vocalise in an age-appropriate manner?
   • Is the child able to make eye contact?
   • Does the child show interest in a human face?
   • How does the child react to handling, is he/she oversensitive or are his/her reactions normal or slow?

• Some characteristics and skills of both the child and parent, which are important as regards the monitoring and investigation of the child's psychosocial development, are listed below. These characteristics and skills are easy to observe and should be present at the time of the examination.

4-6 weeks

• The parent should look at the child and seek eye contact.
• The parent should talk and smile to the child.
• The child should be able to fix his/her gaze to the face of the parent or examiner and make eye contact.
• The child should make sounds and move during the examination corresponding to the age level and react to stimuli without delay.

4 months, extensive health examination

• In an extensive health examination, both parents are present together with the child. In this way it is possible to assess the functioning of the mutual parenting relationship, i.e. co-parenting.
• In well-functioning parenthood, both partners appreciate each other as parents and speak of each other mainly in a positive way, and conflicts are few.
• The parents and the child should be able to make eye contact and the examiner should be able to detect ”baby-talk” in the parents' communication with the child.
• Shared joy between the parent and the child, i.e. simultaneous smiles or laughs, should be observable.
• The parents should observe possible fear and need of consolation in the child e.g. when an unfamiliar examiner handles him/her and be able to console and soothe the child without any greater difficulty.
• Social smiling and reciprocal babbling are new skills that the child should be able to master at this age.
• The reason behind a failure to babble may be a disorder that affects speech production or hearing, a developmental disorder or insufficient early interaction.
• If the child does not master the above skills, further investigations into both parents' depression or mental health problems are indicated.
• If the child makes no eye contact with the examiner, does not respond to his/her smile or appears apathetic and slow in development, the possibility of depression in the child must be borne in mind and the child further examined in conjunction with child psychiatry experts.

8 months

• Observing of the interaction between the parent and the child as well as of parenting as above.
• Shared joy between the parent and the child, i.e. simultaneous smiles or laughs, should be observable.
• The child should be able to interact through playing (for example, the ”give and take” game and peek-a-boo).
• The examiner should note signs of the so-called social referencing, i.e. the child quickly glancing at the parent's face to check whether a new situation or person is safe.
• Social referencing and shyness with strangers, i.e. clearly preferring the usual carer to strangers, are signs of advancing psychosocial development.
• The child should be able to grasp another person's intention (i.e. the child will look at an object pointed at by the parent and not at the pointing finger).
• The reason behind a failure to master the above skills may be insufficient interaction between parent and child or some other developmental disorder which should be investigated.
• If the child shows no interest in people, a developmental delay or an autistic disorder should be suspected and the child referred for further investigations.

18 months, extensive health examination

• The child should master some purposeful communication with the aid of expressions and gestures.
• The child should understand the meaning of some words.
• The child may say a few words, copies adults.
• The child understands the permanence of objects (for example, after watching a toy being hidden under a piece of paper the child will be able to uncover it).
• The development of the symbolic function is observable in the child's play: he/she plays pretend plays, e.g. a building block can act as a telephone, the child offers the parent imaginary food, etc.
• Social referencing and shyness with strangers should be evident by the age of 18 months.
• Sharing and attunement of emotions should be present between parent and child, for example, the parent joins in the fun with the child during play or comforts the child in a sympathetic voice after a vaccination.
• Shared joy between the parent and the child, i.e. simultaneous smiles or laughs, should be observable.
• There should be situations in the parent-child interaction where the parent guides and, if necessary, limits the child both verbally and, if necessary, with non-verbal measures (e.g. prevents the child from grabbing an object that was not to be taken).
• The lack of these skills will warrant further investigations.

Examinations at preschool age

• Important signs of developing psychosocial skills to be noted at preschool health examinations are a gradually increasing capacity for self-regulation, empathy and social skills. The development of these skills requires parental regulation of the child's behaviour through showing empathy towards the child's feelings (attunement) and setting the child limits.
• Further investigations are indicated if the parental skills are for some reason inadequate or if the child's skill levels are not age-appropriate. The child's health records should include information about the family's daily routine and child upbringing principles; such information will help to understand the situation as regards the role of the parents. The observation of the parent-child interaction during the health examinations will give information about the child's skill levels as well as about the parent's attitude towards the child and his/her ability to regulate the child. The aim is to identify problems early and offer help either through local services offered by the Child Health Clinic and family counselling or through social, child psychiatry and child protection services.
• At preschool age, majority of children attend day care or nursery school outside of home. The overall adaptation to and possible problems (e.g. bullying) in these settings should be assessed by inquiring the parents and, if feasible, the child him-/herself as well as the day care centre staff.

2 years

• The child should be able to
  • use words and short sentences for communication (for example, ”give me” or ”no”)
  • show initiative during interaction
  • stop doing something when told to do so and obey short, clear instructions (self-regulation)
  • console and seek consolation from a parent (empathy skills between parent and child).
• The parent should be able to give the child clear instructions and set limits, and ensure that they are followed without resorting to force.
• The parent should feel empathy towards the child and regulate the child's feelings by understanding and sharing them (attunement).
• Shared joy between the parent and the child, i.e. simultaneous smiles or laughs, should be observable.
• The child should have regular daily routines that help in developing sense of time and self-regulation in the child.

3 years

• The child should be able to
  • talk about, for example, the happenings of the day (”narrative self”)
  • show interest in other children
  • wait for a short time
  • tolerate a parent's short absence
  • differentiate between reality and imagination
  • differentiate between the sexes.
• Parental skills as above

4 years, extensive health examination

• In addition to the previous skills the child should be able to
  • make friendships
  • partake in interactive play with others.

5 years

• In addition to the previous skills the child should be able to
  • concentrate on one thing for about 10-15 minutes at a time
  • work together with others
  • take part in role playing
  • follow rules, for example, in games
  • have friends and name his/her best friend.