Chapter 1: The Beginning of Life: Pregnancy through Preschool

Intro

Introduction

A newborn child is transformed in only 1 year from a self-involved infant who can barely lift her head to an interactive, mobile human being with specific desires and strong preferences. An impatient and insecure adolescent, anxious about what he will do and where he belongs in the world, becomes a confident adult, comfortable with himself and with what he is accomplishing in life. These examples illustrate an essential concept of human development; people confront and master physical and social milestones not only during childhood, but also into and throughout adult life. The milestones of childhood are achieved at a rapid speed. Milestones achieved later are mastered more slowly but can be just as profound.

Another important concept of development is that “normal” behavior at one age may be “abnormal” at another. A 3-year-old who puts the cat in the clothes dryer is considered “naughty” but not abnormal. A 10-year-old who does the same thing is likely to be given the diagnosis of conduct disorder (see Chapter 2). A 2-year-old who refuses to stay with a baby sitter is showing normal separation anxiety. A 9-year-old who will not go to school because he fears leaving his mother shows signs of separation anxiety disorder (see Chapter 2).

At all stages of development, a person has tasks to accomplish. The ability to carry out these tasks indicates that development is proceeding normally. Difficulty with these responsibilities suggests a developmental delay or even psychopathology. For example, a teen should be able to function academically and socially in a high-school setting. The possibility of depression or drug abuse arises if he is failing his classes or has no friends. Similarly, while a normal elderly person can live successfully on her own with little help from others, an illness that causes significant cognitive impairment will leave her unable to function safely and independently.

Physicians need to be aware of the physical, social, and cognitive changes that occur during all phases of normal development. Only then can they identify problems and provide treatment and direction to patients when things go wrong.

Prenatal Life, Birth, and the Postpartum Period

In some cultural groups, the prenatal period is included in the calculation of an individual’s age. Biological and environmental factors present during the prenatal period, birth, and just after birth significantly influence physical and mental development.

Prenatal life

Physical influences during pregnancy, such as exposure to infectious agents and to drugs of use and abuse (see Chapter 23), can have a profound, pervasive, and persistent impact on fetal development. In the last few decades, research has shown that psychological influences can also have long-term effects on the fetus. For example, male offspring of female rats emotionally stressed during pregnancy show decreased masculine and increased feminine sexual behavior as adults. The mechanism of this effect is believed to involve a stress-related increase in maternal corticosteroid production, resulting in reduced fetal androgen secretion [Ward ; Reed, 1985].

Sonographic observations indicate that human fetuses show a variety of behavior patterns that presage those they will show after birth. Facial grimacing, thumb sucking, responsiveness to taste and smell when substances are infused into the amniotic sac, and reactions to sound and light are seen prenatally. In addition to their diagnostic uses, fetal sonography and related technology have allowed parents to see their unborn child’s face (Fig. 1-1), facilitating parent/infant bonding even before birth.

Figure 1-1.

Figure 1-1

Photograph of an 8-month-old child along with the ultrasound sonography record taken 4 months into the infant’s prenatal development.
(Courtesy of Robyn Alvarez.)

Birth

The normal delivery of a healthy, full-term infant is usually a joyful event. Recent advances in childbirth analgesia and educational preparation have made vaginal birth more comfortable. The presence of the father in the delivery room, now commonplace, provides both support for the mother and the opportunity for the father to bond quickly with the new infant.
About 4 million children are born each year in the United States. In 2007, more children were born (4,317,000) than in any other year in American history. Although most deliveries are uneventful, problems related to the mother or fetus may lead to cesarean section. The number of cesarean sections decreased from 1989 to 1996, partly in response to increasing evidence that women often undergo unnecessary surgical procedures. Over the past decade, however, the rate has increased and, at 31.8%, is now higher than it has ever been. This increase reflects not only a rise in the primary cesarean rate, but also a fall in the number of women having a vaginal birth after cesarean delivery.

Premature birth and infant mortality

Unfortunately, not all infants are born full term and healthy; in 2005, approximately 12% were born prematurely (;37 completed weeks of gestation) and approximately 2% were born very prematurely (;32 completed weeks). Premature birth puts a child at risk for a variety of health problems, including physical and intellectual disability, as well as emotional, behavioral, and learning problems. The Apgar score was named for Dr. Virginia Apgar but is also useful as a mnemonic:

A—appearance (color)
P—pulse (heartbeat)
G—grimace (reflex irritability)
A—activity (muscle tone)
R—respiration

It quantifies physical functioning in premature and full-term newborns (Table 1-1) and can be used to predict the likelihood of immediate survival.

Table 1.1 The Apgar Scoring System

Measure Score
0 1 2
Heartbeat Absent Slow (;100/min) Rapid (;100/min)
Respiration Absent Irregular, slow Good, crying
Muscle tone Flaccid, limp Weak, inactive Strong, active
Color of body and extremities Both body and extremities pale or blue Pink body, blue extremities Pink body, pink extremities
Reflexes, for example heel prick or nasal tickle No response Grimace Foot withdrawal, cry, sneeze, cough

In part because of its high rate of premature births, the United States has a high infant mortality rate compared with rates in other developed countries. In countries such as England, Canada, France, and Germany, prenatal care without cost is available to most women. Because the U.S. health care system does not provide free prenatal care for all women (see Chapter 27), low income in the United States is associated with premature birth and high infant mortality. Mean annual income is lower in African Americans than in white Americans (see Chapter 20), and almost twice as many non-Hispanic African American infants as non-Hispanic white infants are born prematurely. Also, when compared with other ethnic groups, a higher percentage of premature African-American infants die in the first year of life (Table 1-2). Other causes for the high rate of premature births include the trend toward delayed childbearing and increased maternal age in the United States. Older mothers are more likely to require fertility treatments that often result in multiple births, in which infants tend to be born earlier and smaller.

Table 1.2 Ethnicity and Infant Mortality in the United States (2005)

Ethnic Group Total Infant Deaths Per 1,000 Live Births Preterm-Related Infant Deaths Per 1,000 Live Births
All ethnic groups 6.9 2.5
Asian or Pacific Islander 4.9 1.7
Mexican 5.6 1.9
White 5.8 1.8
Native American 8.0 1.9
Puerto Rican 8.3 3.4
Non-Hispanic black (African American) 13.9 6.3

Postpartum reactions

Women usually recover quickly from childbirth and have immediate and positive responses to their newborn infants. However, for a significant number of women who have had an uncomplicated delivery of a normal child, the postpartum period is characterized by an emotional state referred to as the postpartum blues or baby blues. This state of exaggerated emotionality and tearfulness usually lasts for a few days after birth. Although the cause of the baby blues is not always obvious, in some women it is related to physical changes, such as fatigue, and neurological events, such as changes in hormone and neurotransmitter levels, for example, oxytocin–dopamine interactions have been specifically associated with development of the maternal–infant bond [Shahrokh et al., 2010]. In other women, the baby blues are more closely related to social and psychological factors, such as a perceived lack of social support, the emotional stress of childbirth, and realistic feelings of additional responsibility. Psychological support and practical suggestions for child care from the physician are very helpful for women with postpartum blues, and most cases resolve on their own during the week or two after delivery.

Case 1.1

The Patient

The day after giving birth to a healthy, 7 lb 6 oz (3.34 kg) male infant, a 28-year-old woman reports that she feels “low” and has been crying intermittently throughout the day. She expresses distress at her reaction to this much-desired child and is surprised by her sad feelings. She denies thoughts of harming herself or the infant and expresses the desire to hold and cuddle him. Her pregnancy was uncomplicated and her medical history is unremarkable. Her social history reveals that she is married, and there is no record of marital problems or previous psychiatric illness. At discharge the next day, the patient reports that she is feeling better but still has episodes of crying during the daytime.

Comment

This patient is probably showing the baby blues. In this normal state, the woman is emotional and tearful for a few days after the birth. Baby blues are believed to be related to factors like hormonal changes and the stress of childbirth.

Treatment

There is no specific treatment for the baby blues. Most cases resolve on their own by the end of the first week after the birth. The patient should be monitored carefully over the next few weeks by phone calls and regular visits to the physician to be sure she is free of early signs of the more serious and potentially dangerous reactions of postpartum depression and postpartum psychosis.

A small percentage of women experience a more serious emotional reaction after childbirth. Mood disorders like major depression, characterized by feelings of hopelessness, helplessness, and even suicidal thoughts or psychotic symptoms (see Chapter 13) occur in up to 10% of new mothers within a month after childbirth. Depressed mothers typically show a general lack of pleasure and interest in their child and in their usual activities, as well as poor self-care. If left untreated, a major depressive episode can persist for 1 year or more and can interfere with the development of the maternal–child bond. Infants of depressed mothers often themselves become depressed and fail to gain weight and reach developmental milestones at the expected ages—a condition known as nonorganic failure to thrive, which can be classified in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (see Chapter 10) as reactive attachment disorder of infancy or early childhood (see below).

Mood disorders such as depression can include psychotic features such as hallucinations (i.e., false perceptions such as hearing voices) or delusions (i.e., false beliefs such as being spied upon) (see Chapter 12). Postpartum women who have mood disorder with psychotic features may experience a particular type of hallucination, command hallucinations, where voices instruct the mother to harm or actually kill her infant. Tragically, in some cases, the affected mother carries out these commands before the danger of her condition is recognized and treated.
A less common but also serious reaction to childbirth is postpartum psychosis, which occurs in 0.1% to 0.2% of postpartum mothers. Described in the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5) as brief psychotic disorder with postpartum onset (see Chapter 12), this condition is characterized by hallucinations, delusions, or other psychotic symptoms that occur in the absence of mood symptoms and are not better accounted for by mood disorder with psychotic features. Postpartum psychosis also begins in the postpartum month and lasts for up to 1 month.