Assessment of the preschooler differs from assessment with other age groups both in emphasis and method. The emphasis is on stages of development and mother-child interactions. The method makes systematic use of observation and play. This article will delineate an approach to assessment which allows a clinician to identify those children who require intervention. Anecdotal accounts are given which contrast normal and abnormal behavior patterns. These are interspersed with didactic material outlining basic aspects of child development and interview procedures.
Mary, 30 months, stood pulling at the door handle and screaming at the top of her lungs that she wanted to go out with her brothers; her mother firmly repeated that she could not and finally distracted her into a game with their dog.
Jason, 39 months, had thrown the radio and mother's bedside table decorations over the apartment balcony and was now proceeding to cut up the livingroom curtains .using the kitchen scissors. Mother caught him, slapped him across the face and screamed, "I'm leaving you!" and stormed out, slarrfming the apartment door behind her.
Mary is demonstrating self-assertion at an appropriate time in her development. Her mother seems intuitively aware of Mary's needs and helps her to refocus her demands onto an acceptable activity. Jason is demonstrating a mixture of fear and anger through covert aggression. His mother cannot handle the situation.
With each of these children a brief'period of play in the office can be diagnostically helpful. Children use play to experiment, to learn and to express their thoughts and feelings. Toys that both allow for creativity and can easily symbolize important aspects of the child's normal life (such as a dollhouse with family figures, puppets, and doctor and nurse figures), allow the child to express his or her thoughts and feelings through relatively transparent play. During the play, and while making more specific requests of the child to test specific areas of performance, the clinician can observe and record various innate and environmentally determined characteristics.
INNATE CHARACTERISTICS AND THEIR INTERACTION WITH THE ENVIRONMENT
Inborn characteristics which should be examined include: temperament, attachment behaviors, and the potential for staged development. Temperamental characteristics include: activity level, regularity, intensity of response to stimuli, the balance between tendencies to approach or withdraw, adaptability to new situations, threshold of response to stimuli, degree of distractibility attention span, and emotional tone.1 Attachment behaviors include: signals (smiling, vocalizing, crying), contacts (sucking, grasping, climbing on to mother and clinging), and movements (looking, following and approaching).2 For maximization of developmental potential, these behaviors, temperamental characteristics and other intrinsic rhythms displayed by the infant must be matched by the maternal figure. In addition to these behaviors the clinician should record characteristics of the mother infant/ child interaction including: mother's availability; appropriateness of interactions (to the developmental level of the child); frequency, quality and type of play; feeding; verbal and physical contact, the identification and expression of affect3 and her joy in parenting. If the mothering figure(s) is both qualitatively and quantitatively meeting the needs of her child the biologically normal infant will demonstrate his security through responsiveness, curiosity and exploration, interpersonal warmth and a happy affect.
The clinician should assess each of the following lines of development: motor skills, perception, speech, cognition, and emotional and interpersonal skills. This is done both to determine specific remedial programs for deficiencies and to assist those working with the child to better understand that preschooler's vulnerability to emotional and behavioral problems. These lines of development overlap and are interdependent such that delays or blocks in any one line will have some effects on all of the others. Office examination should include testing stereognosis, * copying, rapid alternating hand movements, heel-to-toe walking, hopping, riding a tricycle (age 3), copying the rhythm of a short sequence of tapping noises, copying a sequence of differently shaped objects, assembling puzzles and paper and pencil copying (for example, a 2 ½ to 3-year-old can draw circles, a 5-year-old a stick person, a 7-year-old a diamond).4
For a detailed analysis of cognitive and linguistic functioning, the clinician must rely on standardized instruments such as the Merril Palmer, the Leiter, the Stanford Binet, and the WPPSI for cognition and the Peabody and the Reynell for language. Nevertheless, an initial screening can be carried out in the clinician's office using a few reference points.
At 8 to 12 months the infant can search behind a cloth for the ball that he just saw placed there. At 18 to 24 months a toddler begins to think out mentally the effect of an action before doing it and he becomes able to alternate his attention between two objects to produce a coordinated effect (eg, he retrieves a ball using a stick). Between the age of Wi and 4'/2, children progressively acquire the ability to coordinate 1, 2, 3, and 4 symbolically encoded relations into an overall pattern or structure: for example, by Wi associate a spoken word (eg, ball) and the object; by 2 obey, "pat the doll", where they must pick out the doll from 5 pattable objects; by 3, choose a picture from a set of distrae - tors, "give me the picture of: the baby sitting on the table"; and by 4, a fourth relation, "give me the picture of: the baby sitting on the table with a ball".5 The same four age groups can also be tested by checking the child's ability to copy increasingly difficult block designs (a 2 -block tower, a 3 -block pyramid, a bridge with 3 blocks, and a 6-block pyramid with spaces between each block) or by a "Simon Says" game.
For language development the clinician should record the child's verbal reception (comprehension) and expression. The content of sentences should be appropriate to the situation, used interactively for communication and be appropriate to the age level of the child. By 2 years most children can produce 2-word phrases, by 2 to 3, 3-word sentences in a subject- verb-object pattern and use 50 words and understand from 100 to 300 words, name a few parts of the body and 6 or 7 common objects. At 3 years most can give their first and last names, use plurals and begin to use adjectives, then pronouns, then adverbs and at 4, give some opposite analogies such as long and short, define a few words, use 5-word sentences, count 3 objects. At 5 most use compound/complex sentences and can state the days of the week.
From 4 to 7 the child becomes less egocentric and relates experience less exclusively to his own point of view or perception. He can recognize sequences and routines but true concepts related to time develop slowly (age 5 to 7) and events are related not because of cause and effect but because of a spacial or temporal relationship.
In the foregoing examination the clinician must ensure that parental expectations are in line with the child's actual developmental (not chronological) level. Otherwise frustration for both the child and the parent may result in either acting out behavior or anxiety and withdrawal.
LEARNED FACTORS IN CHILD DEVELOPMENT
Starting in the first year of life messages are received by a naive, dependent and uncritical organism and thus are incorporated as essential truths about self and the world. These "messages" include statements of facts; eg, the world is safe (or dangerous), you are good (or bad); and statements of conditions for acceptance: stay close to me and do only what I say, don't ask for help, etc. The pattern of messages may be well-defined and consistent or chaotic and unpredictable. Whatever the specific verbal and nonverbal messages and the pattern with which they are given, the child will gradually establish a concept of how he should be (ideal self), who he actually is (self concept) and an expectation of how others will react to him. From this emerges a characterological style of coping with others. This coping style has the effect of forcing the environment into reaffirming the child's own basic concept of himself.
Mary helped Mom clear the table. Mommy praised her and Mary felt very good about herself.
When Mommy screamed at Jason and slammed the door he felt frightened. He knew that he was bad and nobody liked him. He wanted his mother but he could not trust her. The only time her behavior was predictable was when he was really bad.
Between 7 and 16 months the autonomous strivings of the child steadily increase and the child explores the environment. The degree to which these natural strivings will be exhibited depends upon the degree of trust and confidence that the infant has in mother's approval and faith that she will be there upon his return. This rather granthose narcissistic stage of development is thought to be essential for the proper evolution of healthy self-esteem and independence. At around 16 to 20 months the child develops a different cognitive sense of himself in relationship to others. It is as if he recognizes for the first time that others act quite independently of his wishes and may not be there when he requires their presence. The child appears anxious when mother leaves the room and checks back frequently to see that she is there. This stage is called rapproachment. It gives way in the toddler to a new resurgence of autonomous strivings, curiosity and exploration.
It is hypothesized that extremes of engulfment and indulgence or a lack of empathy and unresponsiveness in the principal mothering figure during the first few years of life may predictably induce partial blocks at one or more of these stages of psychosocial development.6 For example, the child who is faced with an emotionally shallow and depriving environment during rapproachment may defend against the recognition that significant others have emotionally abandoned him by externalizing frustration through uncontrolled aggression and impulsiveness combined with an almost insatiable need to have the attention and admiration of others. The child of a dominant and overprotective parent may, on the other hand, have his autonomous strivings stifled as a condition of his acceptance by the parenting figure. His frustrations are internalized and he appears unable to invest healthy narcissism in himself, feeling incompetent, afraid to explore, and dependent upon his parent. He is an anxious and conforming child and may as the years go by display generalized anxiety or a range of anxietybased symptoms such as: phobias, compulsions, and psychosomatic symptoms. These children demonstrate symptomatically their "catch 22" situation in that they have natural autonomous strivings yet their environment makes the negation of these a condition for acceptance.
Both the foregoing behavioral extremes, overt aggression (externalizing) or anxiety and withdrawal (internalizing), or combinations of them such as are seen in passive aggressive (dawdling, messing, forgetting, lying, cheating, stealing) or depressed yet directly confronting and overtly aggressive children should all be noted in the initial interview with the parents and child. For criteria for each of the behavioral disorders that may be observed the reader is referred to the Diagnostic and Statistical Manual of Mental Disorders, third edition.
The clinician will see each of these patterns of behavior in different children and sometimes overlapping in the same child. The preschooler shows considerable plasticity and he may well show one set of behaviors in one environment and a different pattern in another. Extremes in the environment, particularly when combined with an organic vulnerability in the form of a difficult temperament or a cognitive/linguistic or other developmental delay, are believed to result in the emergence of psychopathology and deviant behavior patterns in the young child. The behaviors are not always pathological per se but may be examples of normal developmental attitudes, feelings and behaviors which are "pathological" in the sense that they are chronologically inappropriate, exaggerated, and embellished later in the child's development by more complex psychic processes. Our observation has been that if a more stable and constructively reinforcing environment is introduced, the preschool child who demonstrates the aforementioned pathological coping styles may begin to advance developmentally. Instead of a straightforward disappearance of undesirable symptoms, he may move through each of a series of behavior patterns or pathological coping styles in a definable sequence. For example, the anxious and conforming child or the anxious but egocentric child may move through a covertly aggressive behavioral style followed by more overt aggression with obvious underlying depressive feeling before emerging with healthy functioning.7
The normal child, in contrast to the foregoing, is helpful, flexible, and predictable. He displays an appropriate level of self-esteem, has many stable friendships and gets pleasure from helping others.
Mary (age 4) is attending Junior Kindergarten.
Jason (age 4 ½) has been expelled from three different daycares and Junior Kindergarten. He was referred to a treatment center where he receives speech therapy, play therapy, a (cognitive) stimulation program, anda therapeutic gym program. His mother is attending a supportive psychotherapy and child management group from which home visits are made.
1. Thomas A, Chess S: Temperament and Development. New York, Brunner/ Mazel, 1977.
2. Lewis M: Clinical Aspects of Child Development: An Introductory Syndesis of Developmental Concepts and Clinical Experience, ed 2. Philadelphia, Lea ?? Febiger, 1982.
3. Ainsworth MDS: The development of in/ant- mother attachment, in Caldwell BM, Rkciutic HN (eds): Review of Child Development Research. Chicago, University of Chicago Press, 1973. vol }. pp 1-94.
4. Miller LJ : Milier Assessment for Preschoolers. Colorado, The Foundation for Knowledge in Development. 1982.
5. Case R. Khanna F: The missing links: stages in children's progression from sensorimotor to logical thought. Neu> Directions for Child Development. 1981; 12:21-32.
6. Thompson MGC, Patterson PGR: Predicting the ewlutimi of childhood psychopathnlogy: A developmental approach, (unpublished data, 1982).
7. Thompson MGG: Children and Adolescents, in Merskey H (ed): Psychiatric Illness: Diagnosis, Management and Treatment for General Practitioners and Students ed 3. London. Bailliere Tindall. 1980, pp 182-239.