Profound changes in children's behavior belie the impression of developmental latency during the critical years of middle childhood. The onset of this dynamic period is heralded by the child's ability to separate from home and family to begin the major occupation of childhood - attending school. At its conclusion, the child is ready to assume the major tasks of adolescence, including emancipation from parents, the establishment of a unique self-identity, the development of positive social regard, and the mastery of skills that will ensure a meaningful adult role in society. In between, the child displays a myriad of behaviors characteristic of this exciting period of growth and achievement.
Behavior during the middle childhood years vividly reflects themes in affective, cognitive, and physical development (Figure).1 Major themes in affective development include the child's striving for autonomy and independence and the achievement of a sense of competence, self-confidence, and positive self-esteem; the importance of peer interactions, manifested in the child's desire to achieve social acceptance and willingness to challenge family values and beliefs in response to pressures to conform; the predictable influence of temperament or behavioral style on school performance, peer interactions, and family functioning; and the emergence of adolescent issues such as the need to challenge authority through acting-out behavior and the skepticism, or even nihilism, pervasive at this stage. From the standpoint of cognitive development, these years include the culmination of the so-called preoperational period of Piaget and the emergence of the concrete operations period, during which the mastery of language is followed by the emergence of logical thought and relative, rather than absolute, morality. Physical development is highlighted by the onset of puberty and accompanying concerns regarding body image and sexuality.
Given the dynamic developmental changes of middle childhood, the emergence of common, stagerelated behavioral issues is hardly surprising. For example, behavioral manifestations of developmental themes may include elaborate fears and fantasies; the challenging of authority through lying, swearing, or smoking; hero worship; masturbation; aggression; and self-deprecation. Alternatively, more severe and problematic clinical issues may arise that also reflect developmental themes. Examples include conduct disorder, school phobia, depression, and chronic somatic complaints such as recurrent abdominal pain.
Figure. Developmental themes influencing behavior during middle childhood.
The earliest manifestation of the drive for autonomy and independence that permeates middle childhood is the child's ability to separate from home and family with a minimum of anxiety to leave for school. A burgeoning sense of competence and self-confidence underlies the striving for autonomy, which culminates in children learning to plan and organize their own time and activities, imposing realistic self-limits, and assuming increasing responsibility for their own actions.2 Erickson's psychosocial theory identifies the central task of the school age child as being the development of a sense of industry and productivity while overcoming feelings of inferiority and dependency. * The successful mastery of skills within the school, home, and neighborhood promotes a positive self-concept and sense of competence, thereby facilitating autonomy. Children receiving positive feedback from teachers, peers, and parents develop an appreciation of their strengths and weaknesses and approach critical tasks, such as classroom learning, with enthusiasm and confidence. Children who foil to master skills, and are thus deprived of such feedback, experience a sense of inferiority that permeates their actions.
Peer interactions are of major importance during these years. By ages 7 to 8 years, social acceptance becomes a major determinant of self-confidence and self- worth. The opinions of peers may be viewed by the child as being more important than those of parents or teachers. The pressure to conform intensifies as children become segregated into "in" and "out" groups. Preoccupation with social acceptance and peer group admission poses problems when children must simultaneously deal with peer standards and adult expectations.
The stability of a child's temperament or behavioral style allows parents, teachers, and even the child to anticipate typical responses to various situations. Characteristics of temperament have important implications for school and home functioning as well as peer interactions.4 For example, children who are difficult from a temperamental standpoint may become upset or angry when confronted with challenging classroom tasks that are not easily mastered. The initial reluctance to participate and withdrawal of the shy child may be misinterpreted as anxiety or, perhaps, a limited capability for learning. Whereas the "easy" child usually does relatively well within the school setting, problems may arise when demands and expectations for behavior markedly differ between the home and classroom.
Toward the culmination of middle childhood, the onset of adolescent issues influence behavior. A critical examination of previously accepted beliefs and values contributes to the pervasive skepticism and nihilism of adolescence. The need to challenge authority coupled with pressures to gain social acceptance may encourage the child to act contrary to better judgment. The challenge to parents, teachers, and other authority figures is to maintain reasonable limits and consistent expectations while simultaneously facilitating autonomy and independence by promoting the child's sense of self-confidence and competence.
Cognitive development during middle childhood is discussed elsewhere in this issue. The brief mention of aspects of such development in this article merely highlights the cognitive basis for typical behaviors characteristic of this age. For example, elaborate fears and fantasies, including the child's identification with real and imaginary heroes and characters, so prominent during the early years of middle childhood, reflect the child's abilities during Piaget's preoperational period to transcend reality and partake of fantasy.5 From ages 7 to 11 years, during the so-called concrete operations period, the child develops abilities to use logic, see the viewpoints of others, focus on multiple aspects of a problem simultaneously, and solve problems using mental transformation in place of physically manipulating objects. As a consequence of cognitive and social development, rules are no longer viewed as absolute. Rather, they are considered a mechanism for maintaining order and facilitating interactions. Their interpretation therefore depends on context and it changes under certain circumstances. This relative moralism, as opposed to absolute moralism, allows children to consider intent in interpreting the consequences of another's actions and promotes the acceptance of rules among peer groups and at school that may differ from those at home.
At the outset of middle childhood, as gender identity becomes firmly established, children develop a normal curiosity regarding the bodies of others. During ensuing years they develop an increasing interest in their own bodies. This self-interest and related concerns may be reflected in somatic complaints such as recurrent abdominal pain and "growing pains." The subsequent onset of puberty has obvious implications for children's behavior. Concerns with body image may be reflected in a sense of modesty as well as fears that the child's body may in some way be defective.
As previously suggested, a variety of behaviors during middle childhood may be regarded as manifestations of the child's striving for autonomy and independence. Fantasy, through imaginary play and role modeling, enables the child to experiment with various behaviors while exploring new territories such as the classroom, neighborhood, or homes of friends. Assuming the identity of a sports figure or video hero may serve as a safe means to express aggressive feelings. "Macho" behaviors such as boasting and being aggressive or overly demanding of peers may be an attempt to combat a myriad of underlying fears (eg, monsters, ghosts, or snakes) characteristic of this age. Alternatively, such behaviors may reflect efforts to compensate for self-doubt, a lack of confidence, or even embarrassment due to an inability to master certain skills. Self-deprecating comments (Tm stupid!" "I'm so ugly!") and a questioning of self-worth may reflect normal fluctuations in self-esteem that occur throughout middle childhood. The challenging of parents and testing of limits that escalate during early adolescence have their roots in middle childhood, as the child must increasingly view parents, teachers, and other authority figures as "ordinary" people to successfully achieve autonomy. This challenging of authority and limits is typically reflected in such acting-out behaviors as lying, swearing, and aggression.
The major importance of peer interactions influences numerous stage-related behaviors. Within the home setting, parents may be exasperated by the child's desire to dress, speak, and eat like peers. Disputes may erupt when family rules and expectations conflict with those of peers who are afforded more independence, a larger allowance, or greater freedom in activities such as television viewing. Within the classroom, a child may feel pressured to undermine academic performance intentionally to conform with peers and avoid the trappings of school success, such as being labeled a "nerd." Children may ostracize, ridicule, or even bully others who are perceived as different out of fear that they themselves may not be considered to belong to the "in" group. Scapegoating among school age children is common. Cliques are formed as children segregate themselves according to criteria such as sex, cultural background, academic and athletic abilities, and health status. Sibling rivalry may be intensified as the need to succeed at home to sustain self-esteem may result in an escalation of normal competitiveness.
With the approach of adolescence, an increase in acting-out behavior may signify ill-advised attempts to gain peer approval and act independently while challenging authority figures. Despite impressive cognitive gains, limitations in children's abilities to use hypothetical or abstract reasoning may adversely influence judgment. Common acting-out behaviors such as lying, swearing, or bullying may escalate to more serious acts such as petty theft or destructive behavior at home.
Sexually oriented behaviors during middle childhood often concern parents. Around ages 5 to 6 years, curiosity regarding other children's bodies may lead to innocent experimenting and "playing doctor." Around 8 to 9 years, some exploratory play and even manipulation of genitals among children of the same sex is common, typically reflecting the culmination of gender identity and the realization that one's sex is fixed and final, as opposed to homosexual preferences. As interest in a child's own body heightens with the approach of puberty, self-exploration and masturbation are common.
CLINICAL ISSUES AND PROBLEMS
Conduct disorder is among the most prevalent and worrisome psychiatric diagnoses during middle childhood. According to the Diagnostic and Statistical Manual of Mental Disorders, conduct disorder refers to a persistent pattern of conduct in which the basic rights of others and major age-appropriate societal rules or norms are violated.6 Both the frequency and severity of behaviors distinguish conduct disorder from stagerelated acting out. In contrast to the latter, children with conduct disorder show no concern for the feelings, wishes, or well-being of others, nor do they display guilt or remorse for their actions.
Community-based surveys have suggested that up to 10% of boys and 2% of girls less than 18 years of age may be considered to have a conduct disorder. Behavioral manifestations may emerge during middle childhood, especially for boys, and are typically evident in all settings - home, school, and community. Examples of typical aggressive behaviors include physical fighting and bullying, cruelty to people and animals, destruction of property, fire setting, purse snatching, and breaking and entering. Nonaggressive behavior patterns during middle childhood may include truancy, running away from home, frequent lying, cheating, and covert stealing. Substance abuse and precocious sexual activity may emerge prior to adolescence.
The course of conduct disorder is variable, with one third to one half of children experiencing psychiatric disorders, antisocial personality, social adjustment problems, alcoholism and substance abuse, and criminality as adults. Despite varied intervention strategies (eg, psychotherapy, behavior modification, pharmacotherapy, and environmental manipulation including detention in correctional institutions), effective treatment has been elusive. Early identification and intervention during middle childhood before the emergence of full-blown criminal activity, juvenile delinquency, and substance abuse may prove more helpful. Addressing coexisting and possibly contributing disorders such as depression, attention deficits, and learning disorders may also favorably influence outcome.
School phobia is a vivid manifestation of a child's unsuccessful achievement of autonomy and independence during middle childhood. It may be defined as poor school attendance due to either an unwarranted fear of school or inappropriate anxiety about leaving home. The incidence of school phobia is estimated at about 2% of schoolchildren per year, with girls and boys being equally affected throughout the middle childhood years. The behavior of such children is characterized by a remarkable discrepancy between marked anxiety and panic when separation from home is threatened and relative normalcy under most other circumstances. Children typically complain of feeling ill in an attempt to convince parents of the need to remain at home. Although symptoms may involve virtually any organ system, the most common complaint is abdominal pain. These somatic complaints are remarkable for their vagueness and nonspecificity as well as their tendency to disappear after school begins, on weekends, and during school vacations. In contrast to truants, school-phobic children remain at or near home, with parents being aware of school absences. Despite their absenteeism, these children tend to be good students.
A variety of etiologic possibilities for school phobia have been proposed. The prevailing psychoanalytically oriented interpretation emphasizes the importance of separation anxiety and an unresolved dependency relationship between mother and child, with the child's fear being more of leaving mother than of attending school. The child's striving for independence leads to maternal feelings of rejection and hostility, thereby resulting in guilt and overprotection. Other proposed etiologies relate to traumatic incidents that occur in school, the child's poor self-image and low self-esteem, and childhood depression. No single theory is sufficient to explain all cases of school phobia and such school avoidance behavior may be the consequence of a variety of possible factors.
Pediatric assessment of school phobia should include confirmation of the child's absence pattern with school authorities; alleviation of medical concerns through history, physical examination, and a minimum of ancillary studies; investigation of possible school-related stresses; differentiation from truancy; and identification of any contributing factors related to the child, parent, or family interactions.7 The prognosis for this behavior problem is generally favorable. Insistence on the child's immediate return to school is stressed by most experts, with additional approaches to intervention including desensitizanon, home tutoring, psychotherapy, and medications to allay excessive anxiety.
Although there is little doubt that depression is an important mental health problem during middle childhood, estimates of its incidence have varied widely, ranging from 2% to 15%. An incidence up to 60% has been observed among children experiencing major problems with school functioning. In part, such discrepancies reflect difficulties with diagnosis due to the varied presentation of depression during the middie childhood years. The classic "vegetative" signs seen in adults, such as eating and sleeping disorders, are less frequent in children. Behavioral manifestations may include difficulty in concentrating, indecision, easy distractability, memory problems, withdrawal, inattention, passivity, somatic complaints, sleep disorders, aggression, anxiety, and school avoidance. A change in school performance may be a major symptom of depression.
Given its varied manifestations during the school age years, depression should always be considered when children are experiencing behavioral or learning problems. If parents are depressed there is a greater likelihood that their children are similarly affected. Other factors that may contribute to depression include chronic illness, learning problems, loss of relatives or close friends, and family stresses such as poverty, frequent moves, and divorce or separation.8
Disorders of Continence
Several aspects of continence disorders deserve emphasis because of their influence on behavior during middle childhood. The peak incidences of both enuresis and encopresis occur during these years. Because of wide variations in the ages of bowel and bladder control among normal children, these diagnoses are generally reserved for children beyond the preschool years. Enuresis refers to bed-wetting occurring several times per month in children at least 5 to 6 years of age. The incidence of enuresis declines steadily from a peak of 25% to 30% at age 6 years to 5% to 15% at age 12 years, with affected males exceeding females at each age.9 Similarly, encopresis is generally defined as the passage of formed or semiformed stools in the child's underwear, occurring regularly after ages 4 to 5 years. Although the incidence among school age children is lower than for enuresis (1.5% of second grade children), a similar male preponderance is found.10
Behavioral manifestations of enuresis and encopresis during middle childhood reflect the importance of such developmental themes as autonomy and independence and peer interactions. Diminished selfesteem and a poor self-image may result in social withdrawal, depression, excessive dependency and difficulty separating from parents, anxiety, and somatic complaints such as recurrent abdominal pain. Fear of discovery by peers and public humiliation and ridicule may lead to social withdrawal and a reluctance to participate in age-appropriate activities (eg, gym class, sleeping overnight at friends' homes, and summer camp). A curtailment of activities may lead to conflict at home and disputes among family members. There is some evidence to suggest a higher incidence of difficulty with school adjustment among children with enuresis.
In addition to medical regimens of varying efficacy, treatment of enuresis and encopresis must also promote a more positive self-image and encourage the child's sense of control over symptoms. Initial counseling should demystify the problem by explaining non judgmen tally the biological basis for incontinence. Discussion of such factors as immaturity, small bladder capacity, or weakened bowel musculature is helpful in alleviating guilt on the part of both child and family. Asking the child to chart progress on a calendar or assume responsibility for certain aspects of treatment promotes a sense of control and achievement.
Recurrent Somatic Complaints
Complaints of recurrent pain are quite common during the middle childhood years. According to various surveys, 10% to 20% of school age children may complain of recurrent abdominal pain, limb pain or "growing pains," or headache. An identifiable organic etiology is rarely found, accounting for only approximately 5% of cases. The course of such pains is typically one of exacerbations and remissions, with the child able to function normally between episodes.
The increased incidence of recurrent pain during middle childhood defies simple explanation. Children's reactions to painful stimuli appear to be influenced by their level of cognitive and affective development. It is uncertain as to which the extent a child's concern that his or her body may be defective contributes to recurrent somatic complaints. Nonetheless, the frequency and characteristic appearance of such pains during middle childhood certainly suggest that aspects of development may serve as predisposing factors.
Recurrent abdominal pain is a prototype for recurrent somatic complaints in middle childhood. As suggested, a specific etiology (whether organic or psychogenic) is rarely identified, although there may be some overlap of features with those characteristic of either organic disease or psychiatric conditions such as depression, conversion reaction, school phobia, reaction anxiety, or hypochondriasis. The child affected by the typical syndrome of so-called "nonspecific dysfunctional pain" is usually between 5 and 10 years of age and complains of periumbilical pain severe enough to limit activity. Characteristics such as frequency, duration, severity, and nature of the pain are typically vague and inconstant. Despite the obscurity of such pain, a high prevalence of autonomic correlates have been described including pallor, nausea, vomiting, headache, prolonged transit time, and perspiration.11
When an appropriate, focused evaluation results in a clinical impression of nonspecific recurrent abdominal pain, pediatric counseling is indicated. Discussion with the child and family should dispel concerns of an underlying illness while stressing that the pain perceived by the child is real - not imagined or evidence of malingering. Encouraging the child to keep a diary of painful episodes may promote a sense of control over symptoms while providing additional helpful diag' nostic information during return visits. Encouraging the child's normal functioning, with full participation in appropriate activities, including school, may result in a decreased frequency of painful episodes.
IMPLICATIONS FOR ANTICIPATORY GUIDANCE
Behavioral development in middle childhood has important implications for the process and content of counseling during preventive child health care. The child's emerging autonomy suggests the importance of dealing with the child as an increasingly independent individual. The child's striving for a sense of competence and responsibility should extend to health' related behaviors. By the beginning of middle childhood, part of each health visit should be spent talking directly with the child (usually with a parent present) about topics of the child's interest. Because children may feel performance anxiety when attention is focused on them, questions should be simple, direct, and involve non threatening topics such as hobbies or recent activities. The interest of the pediatrician in the child's answers may serve to support the child's selfesteem. By the end of middle childhood, the child may be seen alone and encouraged to participate in discussions and to make independent decisions concerning such health-related issues as diet and exercise. By the time of adolescence, it is hoped the child will be ready to participate in substantive discussions concerning the emotionally laden topics of sexuality and substance abuse.12
The content of anticipatory guidance for parents should reflect developmental themes and stage-related behaviors. Parents should be encouraged to help promote the child's autonomy and sense of mastery by, for example, delegating appropriate responsibilities, granting the child an allowance, and promoting activities outside the home such as scouting or summer camp. Specific topics for discussion may include safety and injury prevention, common fears of school age children, school performance, outside activities, physical fitness, healthy dietary practices, the importance of monitoring television viewing, and the physical changes of puberty. The general goal of anticipatory guidance during middle childhood is the same as during other childhood periods: to promote children's optimal growth and development. However, the unique challenge to parents and pediatricians is to facilitate the child's achievement of independence and sense of confidence and competence in preparation for adolescence.
The Figure was modified from Telzrow.1
1. Telzrow RW: Anticipatory guidance in pediatric practice. ] Coni Educ Pedían 1978; 20:14-27.
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4. Thomas A, Chess S: Tempérament and Development. New York, Brunner-Mazel, 1977.
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6. American Psychiatric Association: Diagnostic and Statistical Manual of Menial Disorders, Third Edition-Revised. Washington, DC, American Psychiatric Association, 1987.
7. Dworkin PH: Learnmg and Behavior Problems of School Children. Philadelphia. WB Saunders Co, 1985.
8. Schowalter JE: Depression in children and adolescents, Pediatr Rev 1981; 5:51-55.
9. Gross RT. Dornbusch SM: Enuresis, in Levine MD, Carey WB. Crocker AC, et al (eds): Development-Behavioral ftdiatricj. Philadelphia. WB Saunders Co. 1983.
10. Levine ML>. Encopresis, in Levine MD, Carey WB, Crocker AC et al ledsV Developrnerual-Behovioral ftdiotiics. Philadelphia, WB Saunders Co. 1983.
11 . Barr RG: Abdominal pain, in Hoekelman RA (ed): Primor» ftdioiric Core. St Louis, CV Mosby Co, 1987.
12. Committee on Psychosocial Aspects of Child and Family Health, American Academy of Pediatrics: Guidelines for Health Supervision II. Elk Grove ViIIaKe. IL. American Academy of Pediatrics. 1988.