Middle Childhood

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Chapter 11 Middle Childhood

Susan Feigelman

Middle childhood (6-11 yr of age), previously referred to as latency, is the period during which children increasingly separate from parents and seek acceptance from teachers, other adults, and peers. Self-esteem becomes a central issue, as children develop the cognitive ability to consider their own self-evaluations and their perception of how others see them. For the first time, they are judged according to their ability to produce socially valued outputs, such as getting good grades, playing a musical instrument, or hitting home runs. Children are under pressure to conform to the style and ideals of the peer group.

Physical Development

Growth during the period averages 3-3.5 kg (7 lb) and 6-7 cm (2.5 in) per year (see Figs. 9-1 and 9-2 on the Nelson Textbook of Pediatrics website at www.expertconsult.com image). Growth occurs discontinuously, in 3-6 irregularly timed spurts each year, but varies both within and among individuals. The head grows only 2-3 cm in circumference throughout the entire period, reflecting a slowing of brain growth. Myelinization is complete by 7 yr of age. Body habitus is more erect than previously, with long legs compared with the torso.

Growth of the midface and lower face occurs gradually. Loss of deciduous (baby) teeth is a more dramatic sign of maturation, beginning around 6 yr of age. Replacement with adult teeth occurs at a rate of about 4 per year, so that by age 9 yr, children will have 8 permanent incisors and 4 permanent molars. Premolars erupt by 11-12 yr of age (Chapter 299). Lymphoid tissues hypertrophy, often giving rise to impressive tonsils and adenoids.

Muscular strength, coordination, and stamina increase progressively, as does the ability to perform complex movements, such as dancing or shooting baskets. Such higher-order motor skills are the result of both maturation and training; the degree of accomplishment reflects wide variability in innate skill, interest, and opportunity.

There has been a general decline in physical fitness among school-aged children. Sedentary habits at this age are associated with increased lifetime risk of obesity and cardiovascular disease (Chapter 44). The number of overweight children and the degree of overweight are both increasing; although the proportion of overweight children of all ages has increased over the last half century, this rate has increased over four-fold among children ages 6-11 yr (Table 11-1). Only 8% of middle and junior high schools require daily physical education class. One quarter of youth do not engage in any free-time physical activity, whereas the recommendation is for 1 hr of physical activity per day.

Table 11-1 PERCENT OVERWEIGHT INDIVIDUALS AMONG CHILDREN AND ADOLESCENTS AGES 2-19 YR, FOR SELECTED YR 1963-1965 THROUGH 1999-2002

image

Perceptions of body image develop early during this period; children as young as 5 and 6 yr express dissatisfaction with their body image; by ages 8 and 9 yr many of these youth report trying to diet, often using ill-advised regimens. Loss of control (binge) eating occurs among approximately 6% of children of this age.

Prior to puberty, the sensitivity of the hypothalamus and the pituitary changes, leading to increased gonadotropin synthesis. For most children, the sexual organs remain physically immature, but interest in gender differences and sexual behavior remains active in many children and increases progressively until puberty. Although this is a period when sexual drives are limited, masturbation is common, and children may be interested in differences between genders. Though still somewhat controversial, there is growing consensus that breast development and menarche are occurring at an earlier age among girls in the USA. Rates of maturation differ by geography, ethnicity, and country. These differences in maturation have implications for differing expectations of others about them based on sexual maturation.

Implications for Parents and Pediatricians

Middle childhood is generally a time of excellent health. However, children have variable sizes, shapes, and abilities. Children of this age compare themselves with others, eliciting feelings about their physical attributes and abilities. Fears of being “defective” can lead to avoidance of situations in which physical differences might be revealed, such as gym class or medical examinations. Children with actual physical disabilities may face special stresses. Medical, social, and psychologic risks tend to occur together.

Children should be asked about regular physical activity. Participation in organized sports or other organized activities can foster skill, teamwork, and fitness, as well as a sense of accomplishment, but pressure to compete when the activity is no longer enjoyable has negative effects. Prepubertal children should not engage in high-stress, high-impact sports, such as power lifting or tackle football, because skeletal immaturity increases the risk of injury.

Cognitive Development

The thinking of early elementary school-aged children differs qualitatively from that of preschool children. In place of magical, egocentric, and perception-bound cognition, school-aged children increasingly apply rules based on observable phenomena, factor in multiple dimensions and points of view, and interpret their perceptions using physical laws. Piaget documented this shift from “preoperational” to “concrete logical operations.” When 5 yr olds watch a ball of clay being rolled into a snake, they might insist that the snake has “more” because it is longer. In contrast, 7 yr olds typically reply that the ball and the snake must weigh the same because nothing has been added or taken away or because the snake is both longer and thinner. This cognitive reorganization occurs at different rates in different contexts. In the context of social interactions with siblings, young children often demonstrate an ability to understand alternate points of view long before they demonstrate that ability in their thinking about the physical world. Understanding time and space constructs occurs in the later part of this period.

The concept of “school readiness” is controversial. There is no consensus on whether there is a defined set of skills needed for success on school entry, and whether certain skills predict later achievement. By age 5 yr, most children have the ability to learn in a school setting, as long as the setting is sufficiently flexible to support children with a variety of developmental achievements. Rather than delaying school entry, high quality early education programs may be the key to ultimate school success. Separation anxiety, or school refusal, is common in the early school years.

School makes increasing cognitive demands on the child. Mastery of the elementary curriculum requires that a large number of perceptual, cognitive, and language processes work efficiently (Table 11-2), and children are expected to attend to many inputs at once. The first 2 to 3 yr of elementary school is devoted to acquiring the fundamentals: reading, writing, and basic mathematics skills. By 3rd grade, children need to be able to sustain attention through a 45 min period and the curriculum requires more complex tasks. The goal of reading a paragraph is no longer to decode the words, but to understand the content; the goal of writing is no longer spelling or penmanship, but composition. The volume of work increases along with the complexity.

Table 11-2 SELECTED PERCEPTUAL, COGNITIVE, AND LANGUAGE PROCESSES REQUIRED FOR ELEMENTARY SCHOOL SUCCESS

PROCESS DESCRIPTION ASSOCIATED PROBLEMS
PERCEPTUAL
Visual analysis Ability to break a complex figure into components and understand their spatial relationships Persistent letter confusion (e.g., between b, d, and g); difficulty with basic reading and writing and limited “sight” vocabulary
Proprioception and motor control Ability to obtain information about body position by feel and unconsciously program complex movements Poor handwriting, requiring inordinate effort, often with overly tight pencil grasp; special difficulty with timed tasks
Phonologic processing Ability to perceive differences between similar sounding words and to break down words into constituent sounds Delayed receptive language skill; attention and behavior problems secondary to not understanding directions; delayed acquisition of letter-sound correlations (phonetics)
COGNITIVE
Long-term memory, both storage and recall Ability to acquire skills that are “automatic” (i.e., accessible without conscious thought) Delayed mastery of the alphabet (reading and writing letters); slow handwriting; inability to progress beyond basic mathematics
Selective attention Ability to attend to important stimuli and ignore distractions Difficulty following multistep instructions, completing assignments, and behaving well; problems with peer interaction
Sequencing Ability to remember things in order; facility with time concepts Difficulty organizing assignments, planning, spelling, and telling time
LANGUAGE
Receptive language Ability to comprehend complex constructions, function words (e.g., if, when, only, except), nuances of speech, and extended blocks of language (e.g., paragraphs) Difficulty following directions; wandering attention during lessons and stories; problems with reading comprehension; problems with peer relationships
Expressive language Ability to recall required words effortlessly (word finding), control meanings by varying position and word endings, and construct meaningful paragraphs and stories Difficulty expressing feelings and using words for self-defense, with resulting frustration and physical acting out; struggling during “circle time” and in language-based subjects (e.g., English)

Cognitive abilities interact with a wide array of attitudinal and emotional factors in determining classroom performance. These factors include external rewards (eagerness to please adults and approval from peers) and internal rewards (competitiveness, willingness to work for a delayed reward, belief in one’s abilities, and ability to risk trying when success is not ensured). Success predisposes to success, whereas failure impacts self-esteem and reduces self-efficacy, diminishing a child’s ability to take future risks.

Children’s intellectual activity extends beyond the classroom. Beginning in the 3rd or 4th grade, children increasingly enjoy strategy games and wordplay (puns and insults) that exercise their growing cognitive and linguistic mastery. Many become experts on subjects of their own choosing, such as sports trivia, or develop hobbies, such as special card collections. Others become avid readers or take on artistic pursuits. Whereas board and card games were once the usual leisure time activity of youth, video and computer games currently fill this need.

Implications for Parents and Pediatricians

Concrete operations allow children to understand simple explanations for illnesses and necessary treatments, although they may revert to prelogical thinking when under stress. A child with pneumonia may be able to explain about white cells fighting the “germs” in the lungs, but still secretly harbors the belief that the sickness is a punishment for disobedience.

As children are faced with more abstract concepts, academic and classroom behavior problems emerge and come to the pediatrician’s attention. Referrals may be made to the school for remediation or to community resources (medical or psychologic) when appropriate. The causes may be one or more of the following: deficits in perception (vision and hearing); specific learning disabilities; global cognitive delay (mental retardation); primary attention deficit; and attention deficits secondary to family dysfunction, depression, anxiety, or chronic illness (Chapters 14 and 29). Children whose learning style does not fit the classroom culture may have academic difficulties and need assessment before failure sets in. Simply having a child repeat a failed grade rarely has any beneficial effect and often seriously undercuts the child’s self-esteem. In addition to finding the problem areas, identifying each child’s strengths is important. Educational approaches that value a wide range of talents (“multiple intelligences”) beyond the traditional ones of reading, writing, and mathematics may allow more children to succeed.

The change in cognition allows the child to understand “if/when” clauses. Increased responsibilities and expectations accompany increased rights and privileges. Discipline strategies should move toward negotiation and a clear understanding of consequences, including removal of privileges for infringements.

Social, Emotional, and Moral Development

Social and Emotional Development

In this period energy is directed toward creativity and productivity. The central Ericksonian psychosocial issue, the crisis between industry and inferiority, guides social and emotional development. Changes occur in three spheres: the home, the school, and the neighborhood. Of these, the home and family remain the most influential. Increasing independence is marked by the 1st sleepover at a friend’s house and the 1st time at overnight camp. Parents should make demands for effort in school and extracurricular activities, celebrate successes, and offer unconditional acceptance when failures occur. Regular chores, associated with an allowance, provide an opportunity for children to contribute to family functioning and learn the value of money. These responsibilities may be a testing ground for psychologic separation, leading to conflict. Siblings have critical roles as competitors, loyal supporters, and role models.

The beginning of school coincides with a child’s further separation from the family and the increasing importance of teacher and peer relationships. Social groups tend to be same-sex, with frequent changing of membership, contributing to a child’s growing social development and competence. Popularity, a central ingredient of self-esteem, may be won through possessions (having the latest electronic gadgets or the right clothes) as well as through personal attractiveness, accomplishments, and actual social skills. Children are aware of racial differences and are beginning to form opinions about racial groups that impact their relationships.

Some children conform readily to the peer norms and enjoy easy social success. Those who adopt individualistic styles or have visible differences may be teased. Such children may be painfully aware that they are different, or they may be puzzled by their lack of popularity. Children with deficits in social skills may go to extreme lengths to win acceptance, only to meet with repeated failure. Attributions conferred by peers, such as funny, stupid, bad, or fat, may become incorporated into a child’s self-image and affect the child’s personality, as well as school performance. Parents may have their greatest effect indirectly, through actions that change the peer group (moving to a new community or insisting on involvement in structured after-school activities).

In the neighborhood, real dangers, such as busy streets, bullies, and strangers, tax school-aged children’s common sense and resourcefulness. Interactions with peers without close adult supervision call on increasing conflict resolution or pugilistic skills. Media exposure to adult materialism, sexuality, and violence may be frightening, reinforcing children’s feeling of powerlessness in the larger world. Compensatory fantasies of being powerful may fuel the fascination with heroes and superheroes. A balance between fantasy and an appropriate ability to negotiate real-world challenges indicates healthy emotional development.

Moral Development

By the age of 5 or 6 yr, the child has developed a conscience, meaning that he or she has internalized the rules of the society. She or he can distinguish right from wrong, but may take context and motivation into account. Children will adopt family and community values, seeking approval of peers, parents, and other adult role models. Social conventions are important, even though the reason behind some rules may not be understood. Initially, children have a rigid sense of morality, relying on clear rules for themselves and others. By age 10 yr, most children understand fairness as reciprocity (treat others as you wish to be treated).

Implications for Parents and Pediatricians

Children need unconditional support as well as realistic demands as they venture into a world that is often frightening. A daily query from parents over the dinner table or at bedtime about the good and bad things that happened during the child’s day may uncover problems early. Parents may have difficulty allowing the child independence or may exert excessive pressure on their children to achieve academic or competitive success. Children who struggle to meet such expectations may have behavior problems or psychosomatic complaints.

Many children face stressors that exceed the normal challenges of separation and success in school and the neighborhood. Divorce affects nearly 50% of children. Domestic violence, parental substance abuse, and other mental health problems may also impair a child’s ability to use home as a secure base for refueling emotional energies. In many neighborhoods, random violence makes the normal development of independence extremely dangerous. Older children may join gangs as a means of self-protection and a way to attain recognition and belong to a cohesive group. Children who bully others, and/or are victims of bullying, should be evaluated, since this behavior is associated with mood disorders, family problems, and school adjustment problems. Parents should reduce exposure to hazards where possible. Due to the risk of unintentional firearm injuries to children, parents should be encouraged to ask parents of playmates whether a gun is kept in their home and, if so, how it is secured. The high prevalence of adjustment disorders among school-aged children attests to the effects of such overwhelming stressors on development.

Pediatrician visits are infrequent in this period; therefore, each visit is an opportunity to assess children’s functioning in all contexts (home, school, neighborhood). Maladaptive behaviors, both internalizing and externalizing, occur when stress in any of these environments overwhelms the child’s coping responses. Due to continuous exposure and the strong influence of media (programming and advertisements) on children’s beliefs and attitudes, parents must be alert to exposures from the television and Internet. An average American youth spends over 6 hr/day with a variety of media, and image of these children have a television in their bedrooms. Parents should be advised to remove the television from their children’s rooms, limit viewing to 2 hr/day, and monitor what programs children watch. The Draw-a-Person (for ages 3-10 yr, with instructions to “draw a complete person”) and Kinetic Family Drawing (beginning at age 5 yr, with instructions to “draw a picture of everyone in your family doing something”) are useful office tools to assess a child’s functioning.

Bibliography

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