5.04.2010

Reassuring news, paranoid parents!

One of the deeply humbling things about having the Critter around is realizing how incredibly ignorant I have been when it comes to the actual business of parenting. You'd think with all the fancy book-larnin' and Board certification and such, I'd stride through the experience of child-rearing with the wind in my hair and a smile on my lips.

No.

When Critter was brand spanking new, he made (in the manner of all newborns) a variety of horrible strangulating, squeaking or gurgling noises while he slept. Even worse was when I couldn't hear him breathing, and would stand over his bassinet fighting the urge to poke him to make sure his lungs were working. While I had attempted to be reassuring during nights on call when panicked parents would call with similar worries, it was an entirely different experience to live through when it's your own kid.

In that vein, friends with young children (you know who you are) have done far more for my sanity than any pediatric text ever could. More recently, Critter has been a little bit slow to crawl. While I was deeply proud of his early development when it came to certain skills (he was transferring objects from hand to hand like a champ a couple of months early, and currently delights in his new-found page-turning skill to confound my attempts to read to him), I was convinced that his lack of crawling by nine months meant something dire about his long-term cognitive prospects. He would reach toward objects, get annoyed, and commence self-soothing thumb sucking. (Now that he is crawling tentatively, I can move on to other areas of paranoid craziness.)

But at least all of this monitoring is useful, right? It gives me a glimpse of his general intelligence and overall developmental potention, yes?

No. So says Nicholas Day in Slate:
[B]ut when parents today worry about their child not meeting developmental norms, especially for motor skills, they're too often worrying needlessly. The typical child, it turns out, is a myth. But someone forgot to tell the parents.

Arnold Gesell, a pioneering developmental scientist at Yale, came up with the theory of developmental norms—the idea that there is a normal way for humans to develop—a little less than a century ago. Gesell believed that motor development was a question of neuromuscular maturation: Motor skills developed as the brain matured. It followed that all infants had to pass through the same series of developmental steps, in the same order, at the same times. Gesell just had to map what those steps were and when exactly they occurred.

He did so in astonishing, migraine-inducing detail. Using cameras to record the tiniest details of infant behavior, Gesell described the appearance of 40 different motor skills and the developmental stages of each of those skills: 23 stages of crawling, 58 stages of grasping, 53 stages of rattling. His work was rigorous, seemingly authoritative, and the basis for the first charts depicting how infants should develop. These showed babies as they moved in a strict, perfectly timed procession from lying to rolling over to sitting to crawling, and so on. Gesell's work was hugely influential: It cemented the concept of developmental norms, and the separation of normal and abnormal, into the popular consciousness. Gesell's books and the movies of infants produced by his laboratory made him famous, an early child-rearing expert. This video offers a sense of his patient, painstaking style and the quiet grandeur of his pursuit.

Yet Gesell himself knew that his norms weren't set in stone. As Ann Hulbert writes in Raising America, her magisterial history of modern American childrearing advice, he warned that norms " 'are readily misued if too much absolutist status is ascribed to them,' as he knew from having arrived at them by observing countless deviations."


The article goes on to describe how pervasive the idea of developmental milestones has become in pediatric training and care. The certification exam of the American Board of Pediatrics is full of questions about subtle differences in milestones between, say, month 3 and month 4. You're expected to know them backward and forward. Delays of any kind are meant to be monitored closely, and intervening early is frequently recommended to shore up skills that seem to be lagging.

I think Day overstates things when he dismisses developmental monitoring out of hand. Keeping track of general progression is useful, and patients who show delays in numerous domains really do warrant further investigation. However, the attention we pay to every single milestone is excessive, and only leads to anxiety and frustration.

The funny thing is that this is my philosophy as a pediatrician. As often as seems prudent, I reassure worried parents that their kid who isn't babbling quite on time or who still hasn't taken that first step is almost certainly normal. (I take as non-alarmist an approach as I can, generally speaking.) Unless something is clearly wrong, I tend to avoid over-investigating and take a "wait and see" stance. So far, this has worked out quite well.

But when it's my own kid? OHMYGOD HE'S NOT CRAWLING YET??!?! It's depressing how human a parent I remain. But, in the long run, I know he's going to be just fine.

6 comments:

  1. Frustrating, I think. Maybe scary, too. But I personally know of two individuals who did not walk until about 18 months, but they grew up without difficulty, and, when they did decide to walk, just got up and walked - well. Two more examples of "not by the rule book," I think.

    ReplyDelete
  2. I, too, think the author of that Slate article is a bit hand-wavy. Language delays, especially, benefit from early detection and intervention. Then again, my son, who is quite verbal now, spoke about 5 words eighteen months, which is a bit of a red flag.

    But waaaaay too many kids I know were "delayed" and turned out fine. Parents were worried for no reason. In fact, I don't know a single kid of my acquaintance who was not delayed in something or other. Some did things in the wrong order (my son crawled for two months before he could sit up). And there are huge cultural differences. Also one *can*, say, toilet train an eighteen-month-old (as is done in other cultures), it's just an enormous amount of effort for something that becomes much easier later on.

    ReplyDelete
  3. Yeah, but sometimes you do get delays, my 20 month old still ain't talking (he just babbles) so our pediatrician has referred him to a specialist. In every other respect he is like a 20 month old, and in some ways he is advanced (he understands and can perform complex tasks in order, like picking up a ball and putting it on the chair, then putting his shoes away, etc), but lord knows if this ONE thing ain't worrisome.

    And my 7 year old has early onset puberty, he is literally head and shoulders above his classmates and weighs 80 pounds. He looks like an 11 year old. Otoh, no classmate dares mess with him or bully him, otoh, he is self conscious already, which stinks for a 7 year old.

    In one sense it makes my 5 year olds bed wetting seem like nothing. He is average height, weight, intellect, you name it (but way above average in looks, then again all 3 of my sons are gorgeous)

    charo

    ReplyDelete
  4. To wit:
    http://wondermark.com/616/

    ReplyDelete
  5. And people ask me, "Why don't you want to have children?"

    ReplyDelete
  6. Dan, it's somehow very reassuring to find that a pediatrician has many of the same (usually unfounded) worries as the rest of us parents.

    Agree with Elizabeth that facile dismissal of developmental milestones is problematic especially with regard to language.

    Anecdotally, our first developmental clue about our son's autism was a mild delay of expressive language, for which he received therapy at age 3, and which proved to be the easiest challenge to solve (within a year he was at age norms.) Not sure if that would have been the case had it not been diagnosed as early.

    As it turned out, he is much more significantly impaired with motor function, which was not diagnosed until age 5 (and for which OT has made a huge difference, but will likely remain to some degree for his lifetime.) He met all his early milestones for motor skills, so his problems didn't become apparent until later.

    And an anecdote to reassure you about the Critter: My sister didn't stand unsupported until 22 months!!! She's 34, and totally "normal"--in fact, an excellent athlete.

    ReplyDelete