Normal human development from birth to age 5 years is an amazing, complex period of rapid physical growth as well as neurodevelopmental growth. In a matter of a few years, humans transition from helpless infants relying entirely on their caregivers, to independent preschoolers who move about on their own, communicate their wants and needs, and share in positive and productive interactions with others.
Emotional development coincides with the development of social skills.1 From birth, parents begin to notice patterns of behavior in which their child responds to the daily routines of sleeping, eating, dressing, and diaper changes. This innate temperament influences how an individual child will respond to outside stimuli and the daily activities of living, not only as infants but as growing toddlers, preschoolers, school-aged children, adolescents, and eventually adults. How children learn to regulate their emotions also depends on interactions between the child and caregiver.1
Parents who have infants with more challenging temperaments often ask, “Will it get easier?” Pediatric professionals should reassure parents that, although the child may always be more prone to dramatic responses to changes and outside stimuli, they will develop both proactive and responsive strategies that work with their child's temperament, minimizing stress on the parent and the child. Primary care pediatricians are on the front line for guiding parents to understand their child's temperament, as well as partnering with caregivers to navigate the physical growth and cognitive, language, and social-emotional development until the child is age 18 years. This involves helping parents understand normal social-emotional behavior and quirky tendencies that may be typical of a certain stage of development as well as recognizing signs of an underlying disorder. Although a majority of preschoolers and children will display behavior that is representative of a particular developmental stage, it is estimated that 11% to 20% of children between ages 2 and 5 years can exhibit an emotional or behavior disorder at any given time.2,3 They can include anxiety and separation disorders, obsessive-compulsive disorder (OCD), oppositional defiant disorder, specific phobias, and attention-deficit/hyperactivity disorder (ADHD). Although sensory processing disorder does not fall into the category of emotional or behavior disorders, sensory difficulties can be a source of impairment in children as well as cause stress in a family. In addition, sensory sensitivities can also be a sign of autism spectrum disorder (ASD).
Perhaps one of the greatest social-emotional concerns expressed by parents at the 2- to 4-year-old well visit revolves around sensory sensitivities. This may begin with early finger food feeding and the oral aversion of certain food textures, such as with meat, crunchy foods, or “slimy” foods. Most times, that behavior is developmentally appropriate because many toddlers are not yet fully confident with the oral skill of chewing and swallowing certain foods. Parents notice that their children either like to be clean when eating and never wanting food on their hands and face, is aversive to picking up messy foods (which can limit the palate), or enjoys touching, squeezing, and smashing all foods that are presented.
These same “neat and clean” toddlers have no interest in sand at the beach and want to be held or sit on a clean blanket, whereas their peers love crawling in, digging in, and eating the sand. Some of these toddlers may display preferences for certain clothing as a preschooler, which is when parental distress regarding “sensory issues” is typically presented; they often fear that their child has an anxiety disorder or OCD.
Socks and underwear seem to represent a couple of the biggest sensory culprits. My middle child made it to 3-year-old preschool every day in a super hero costume, but never wore socks (much to my embarrassment). No sock ever “felt right” with the shoe. If a sock is “right,” then that sock must be worn daily, and if it is not available then a large meltdown ensues. Most parents initially do not understand their child's “preference” and view it as a power struggle, with their preschooler trying to take control. Developmentally, 3- and 4-year-old children are in a controlling time of their life. They have gained relative independence in their activities of daily living (sleeping, eating, toileting, and dressing) and thus begin to feel they should be fully in control. For those preschoolers in which it is simply an issue of control, often a tantrum occurs but once they realize they are not in control they can be convinced to put on the socks, coat, and shoes. For the preschooler with sensory preferences, even after the tantrum has passed this child will continue to fight the sensory sensation. This could reoccur daily, at times causing upheaval in a family's schedule resulting in late arrivals to school and work. These sensory sensitivities often carry over to the dinner table where a particular plate is required to keep food groups separate from each other or only a certain cup, fork, or spoon is used.
In addition, these children may have difficulty with change or transitions. If a routine, such as bed time or school pick up, is altered some children will display distress or express concern over the change. Pediatricians should reassure parents that it is acceptable to “pick the battle,” allowing the child to go to school without socks to ease the stress of departing the house. There are, however, some nonnegotiable rules that must be followed so the child isn't at risk of danger, such as appropriate seat belt restraints in the car or wearing a bike helmet.
Parents should understand that preparing in advance, such as informing the child about changes and planning an outfit at night, helps to decrease distress in the child. In many cases, these sensitivities diminish over time or the child learns to tolerate them as they become more involved with peers and activities. Additionally, parents also learn their child's nuances, which enable better management of any sensory sensitivities.
Developmental Red Flags
Occasionally, these nuances do not diminish over time and the child's difficulty with leaving for school on time and interacting productively in school and with other children shifts to another level. The behaviors become disruptive at home and at school and prevent the child from developing age-appropriate peer relationships as well as participating in activities.
It is important for physicians to observe for red flags in social-emotional development at every visit. Clinicians should evaluate for early signs and symptoms of ASD, ADHD, generalized anxiety disorder, separation disorder, OCD, and phobias.4 Anxiety disorders can have an age of onset as early as the preschool years but may not cause significant impairment until school-aged years.
At age 5 years, parents are excited for their child to attend kindergarten and begin to develop academically, grow socially, and acquire their own individual interests. This marks a new stage in both the child's and parent's life. Most often, because of the excitement of attending school, the new colorful shoes, book bags, and character lunchboxes, the child happily releases his or her parent's hand and heads into the classroom. However, for some children, much to the dismay of their parents, there are tears, refusals to walk in, and occasionally all-out tantrums at home, the bus stop, or the school yard. This most often occurs in the first several days of school and resolves, but it could occur suddenly several weeks into the school year when the child is probably exhausted from the daily grind. This adaptive anxiety is expected and occurs after a substantial transition in the child's life.4
This behavior may also be a form of separation anxiety, which is the most common anxiety disorder in school-aged children.4 Although it is considered to be a normal stage of development in the first few months of starting school, it is considered a disorder if it continues beyond this stage of school and causes significant distress and interferes with the child's normal functional development.
In some children, as early as preschool, everyday life occurrences provoke anxiety, causing a multitude of somatic symptoms such as stomachaches, fatigue, and muscle aches. These symptoms, which can sometimes include inappropriate outbursts, often occur on school days, but dissipate on days off. If a pattern of evolving complaints occurs over several months with no organic causation, then it is important for clinicians to explore the social-emotional health of the child. Although the symptoms may start with anxiety related to separation on school days, it can evolve to affect other aspects of the child's life including difficulties falling asleep alone and fear of being left with a babysitter. Additionally, children may become increasingly dependent on the parent, seeking constant reassurance and help to manage their anxiety and fear of separation that it causes significant impairment to the entire family.4
OCD is characterized by obsessions that are associated with anxiety or emotionally distressing and intrusive thoughts such as guilt, worry, or dread related to a feared or catastrophic outcome. The compulsions (ritualistic activity) are performed to negate the obsessive thoughts and prevent the feared outcome.4,5 Children who have OCD are often secretive about their symptoms; thus, childhood OCD may go unrecognized for long periods.5 Parents may notice unusual habits or patterns of pointless repetitive behaviors such as walking through doors a precise number of times, touching an object equally with both hands, or compulsions such as excessive handwashing. However, in many cases, the only symptoms are nonspecific functional impairment that may include a decrease in school performance or a loss of interest in school and peer activities. Older children and adolescents often recognize the behavior as irrational; hence, their need to be secretive. Younger children are less insightful and do not recognize the behavior as irrational.5 Either way, in the child's mind, the obsessive thoughts and associated compulsive behavior is necessary.
In most cases, children who have challenging childhood temperaments and quirky preschool behavior develop into strong willed, well-adjusted productive adolescents and adults. However, it is important that primary care pediatricians recognize the signs and symptoms of any behavioral disorders.5 Based on clinical judgment alone, many primary care physicians are not able to identify behavioral and emotional problems in their patients;3 therefore, using a standard general mental health screening instrument such as the Pediatric Symptom Checklist can assist in detecting signs of distress and functional impairment.5 Implementing more regular screening for behavior and emotional disorders is much needed and may benefit the total health of children and adolescences.