Regression of Milestones
Clinical Background of Milestones:
Developmental Milestones in a child is like turning the pages of one life in a very standardized and predictable manner. Any delayed or aberrant growth curve in achievement of milestones may signify a constitutional problem or a response to stress. The childs developmental level of functioning is determined by combining observations made during the interview with the standardized developmental measures.
The clinician assesses areas of functioning that include motor development, activity level, verbal communication, ability to engage in play, problem-solving skills, adaptation to daily routines, relationships, and social responsiveness. The parents ability to provide a nurturing, safe, and stimulating environment for the child is assessed through observation and discussion with them.
Case Scenario A 2-1/2 year-old African male, John (will name him John, for confidentiality reasons) who had achieved some mastery over his bowel and bladder with no daytime accidents. John was promoted to a higher grade but it was soon apparent that to the staff of his Daycare center that he started to have accidents in school. He refused to go to the bathroom by himself as if he was asking for reassurance and validation of his desire to be held close and nurtured as a child. He was sent back to the previous class within 4 weeks because he was no longer completely potty-trained. His mother would report that he would do OK at home and no accidents were reported. The teacher tried to attend to his biological, developmental needs in an age appropriate and independent manner.
Consultation with schoolteacher revealed that John would become aggressive and throw tamper tantrums when redirected. He was provoked for no apparent reason. He would have spells of agitation, drooling, teeth grinding, eye rolling, aimless thrashing of his extremties, kicking and hitting staff and making loud sounds. He would appear" spacy" and had to be calmed downed by holding him tight and talking to him gently. He would make up stories to get out of trouble in class, and would blames others for his behavioral problems. He would respond poorly to limit setting by the teachers. He would say, "I will kill you" to other kids when angry but never verbalized any suicidal intentions. He would say, "my mother hates me" because his mother would make such comments when she was mad at him. He seemed to have issues with low self-esteem and always wanted things that belongs to other kids in the class.
Consultation with Johns mother was
requested but never happened. Teacher tried to engage Johns mother in some
meaningful dialogue to see what should be done about his problems with potty training. The
mother reacted to inquiry in a very superficial and least concerned manner. She would
laugh about the concerns shown by the school staff about Johns behavior and gave no
insight or suggestion. She would only say, "I dont know what to do with him at
home, so I dont know what to tell you". His father at home has been in and out
of the family over the years. John would react fearfully when any body would suggest that
his father would be informed about his behavioral problems. His father has spanked him for
his behavioral problems. Mother claimed that he wears pull-ups at home.
Observation of Johns behavior and interaction in class showed that John was very aggressive with his peers. He liked to lead and appeared to be a class leader. His speech and motor control seemed to be developmentally age appropriate. He was attentive during class activities when given attention and praise by the teacher. During attention seeking behavior, teacher used manipulation techniques to obtain compliance form him. Teacher seemed to have difficulty in managing the John and students due to 1:9 student teacher ratio. John was overtly interactive and quite verbal about his needs when engaged directly. He seemed to be a happy kid who loves attention, but wants to control the outcome of interaction.
Discussion: Johns achievement of some mastery over his bowel/bladder control led John to be promoted to a class with higher functioning kids. Within few months he started to have accidents at school and struggled with staff over control issues. His regression regarding milestones lead us to think about environmental factors which effected him. The normal development and its deviation were carefully observed in Johns case.
It seemed apparent form clinical observation, and discussion with staff and parents that Johns obvious regression with daytime accidents may reflect a response to a situation at home. His mothers inability to set limits and inconsistency about helping him toilet train at home added significantly to Johns presentation. His mother may have taken an easy route and make school staff do all the hard work of reinforcing and limit setting. Johns attention seeking behavior at school may also be part of his need to be loved and may reflect a psychological defense mechanism against feelings or fears of being overlooked or neglected. His mother and father may be overindulged in their adult relationship so that there was no time for John. Johns acting out and physical aggression may also be part of his unresolved anger issues because of his struggle with control issues at home. It may be that daycare staff overcompensated with lots of attention and emphatic interaction, which kept him, regressed so that John dont have to grow up and give up regressed behaviors. With gentle suggestions to day care staff and Johns mother an attempt was done to look at Johns regression as a constant need of love and guidance. The teacher was reinforced that she are doing a good job because there was a sense of frustration with his class teacher. The mother was educated about the need to set limits and provide a more consistent and predictable environment at home. Mother was also educated about the impact of parental sense of involvement and commitment to the successful resolution of a developmental arrest. With consultation and close meaningful involvement of primary care taker of John we hope he will be able to facilitate his normal development, in term of motor, cognitive, and social skills.
Zaigham Ansari, M.D.