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Normal Childhood Development and Symptoms of Bigger Issues. Pupus with the Principal Facilitated By Victor L. Ruterbusch, MD LCDR/MC/USN La Jardin Academy, Lower School 03NOV2010. DISCLAIMER.

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Normal childhood development and symptoms of bigger issues

Normal Childhood Development and Symptoms of Bigger Issues

Pupus with the Principal

Facilitated By

Victor L. Ruterbusch, MD


La Jardin Academy, Lower School 03NOV2010


  • The views expressed by this presenter are not necessarily those of the military or of Tripler Army Medical Center.

  • Dr. Ruterbusch is a Child and Adolescent Psychiatry Fellow, not yet board eligible.

  • I have no financial interests to disclose.

  • My daughter attends 2nd grade at LJA.


  • Children are all different…

  • Good parenting is about being creative, yet consistent and providing the “best fit”.

  • Children are NOT a diagnosis, but rather a “moving target” that you need to really focus on…

  • Spring Metaphor

  • Your hard work at this stage will make your whole life better….

Stage theory for normal development

Put forth by Piaget, Kohlberg, Erikson, Freud and others

Based upon assumption that development takes place in stages that follow the same basic criteria:

Describe Qualitatively different behaviors

Refer to general issues

Unfold in an invariant sequence

Are culturally universal

Stage Theoryfor Normal Development

Cognitive development 80 piaget

Sensorimotor: (0-2) Intentional behavior, “trial and error”, beginning of mental pictures

Pre-Operational: (2-6) imaginative play, categorize, weights and numbers

Concrete Operations: (6-11) “black and white” conservation of mass, beginning of logic.

Formal Operations (11-20) capable of Abstract Thought “If /then propositions” comparisons and deductions made from information NOT concretely presented, “scientific thought”.

Cognitive Development (80%)Piaget

Piaget concrete operations 6 11
PiagetConcrete Operations: (6-11)

  • Seriation—the ability to sort objects according to size, shape, or any other characteristic.

  • Transitivity- If A is taller than B, and B is taller than C, then A must be taller than C).

  • Classification—ability to name and identify sets of objects according to appearance, size or other characteristic

  • Decentering—the child takes into account multiple aspects of a problem to solve it.

  • Reversibility—the child understands that numbers or objects can be changed, then returned to their original state.

  • Conservation—understanding that quantity, length or number of items is unrelated to the arrangement or appearance of the object or items.

  • Elimination of Egocentrism—the ability to view things from another's perspective (the “mountain experiment”)

Eriksonian tasks

Erikson viewed the whole life span as a series of “tasks” that have to be successfully “mastered”.

Their success is measured as a ratio.

Individuals who master a task gain a “virtue”

Individuals who fail to master these tasks along the same time course as their peers suffer the “opposite” consequence, or maladaption.

Eriksonian Tasks

Eriksonian tasks1

“Basic Trust vs. Mistrust” birth to 1 year: If child’s primary caregiver consistently meets the child’s needs, the child masters basic trust with virtue of Hope and Drive, or suffers the consequence of proceeding through life “mistrusting” people.

“Autonomy vs. Shame and Doubt” (18 mo. to 3) Child learns to walk and talk, “I am what I will” (Self Control vs. Impulsivity)

“Initiative vs. Guilt” (3 to 6) Child builds sentences, parental ideals, toileting, and a superego, (Purpose and direction vs. Inhibition)

Eriksonian Tasks

Eriksonian tasks continued

“Industry vs. Inferiority” (6 to 11) Child searches for achievement in academics, sports, clubs, especially in comparison with their peers. (Competence and Method vs. Inertia)

“Ego Identity vs. Role Confusion” (11 to 20) , peers become more important than parents, “I know WHO I am”. (Fidelity vs. Fanaticism)

“Intimacy vs. Isolation” (20 to 40)

“Generativity vs. Self-absorption” Adulthood

“Integrity vs. Disgust and Despair” Old age.

Eriksonian Tasks (continued)

Kohlberg s morality

Posed as a series of “dilemmas”.

Answering yes or no to the dilemma did not matter. The moral development is revealed in the reasoning behind the answer. Hans und das medicine...

Kohlberg stages 1 and 2 (pre-conventional, might is right)

Kohlberg stages 3 and 4 (conventional, moral relativism)

Kohlberg stages 5 and 6 (universal principles)

Kohlberg’s Morality

Bigger issues clinical differential diagnosis comorbidity
Bigger IssuesClinical/Differential Diagnosis/Comorbidity


Oppositional Defiant Disorder

Conduct Disorder

Anxiety Disorder

Depressive Disorder

Bipolar Disorder

Learning Disability

Medical Problem (hyperthyroid, lead poisoning, hearing or vision problem)

Epidemiology of adhd
Epidemiology of ADHD

General Population:- 3-12% in 6-12yo school age children- 2-4% in adults- Inattentive > Hyperactive > Combined

Clinically referred population:-2-10% in pediatric primary care-40-60% in Child/Adolescent Psychiatry-Combined > Inattentive > Hyperactive

Etiology of adhd
Etiology of ADHD

Disorder of catecholamine UNDERACTIVITY (epinephrine, norepinephrine, dopamine)

Behavioral disinhibition + impaired executive function (FRONTAL LOBES)

Neuroimaging shows involvement in frontal cortex, striatum, and cerebellum (usually smaller volumes, decreased blood flow PET scan)

May be predisposed if there are early neuro-developmental problems (esp. 2nd trimester)

Adhd inattentive
ADHD - Inattentive

Six or more of the following symptoms have been present for at least 6 monthsto a point that is disruptive and inappropriate for developmental level:


1) Has poor attention to details or makes careless mistakes in schoolwork, work, or other activities.

2) Has trouble keeping attention on tasks or play activities.

3) Does not seem to listen when spoken to directly.

4) Does not follow instructions, fails to finish schoolwork, chores, etc (not oppositional behavior or failure to understand)

5) Has trouble organizing activities.

6) Avoids, dislikes or doesn't want to do things that take a lot of mental effort7) Loses things needed for tasks and activities (e.g. pencils, books, tools)

8) Easily distracted.

9) Forgetful in daily activities.

Adhd hyperactive impulsive
ADHD - Hyperactive & Impulsive

Six or more of the following symptoms have been present for at least 6 monthsto a point that is disruptive and inappropriate for developmental level:

OFTEN… 1) Fidgets with hands or feet or squirms in seat.

2) Gets up from seat when remaining in seat is expected.

3) Runs about or climbs when and where it is not appropriate (adolescents or adults may feel very restless).

4) Has trouble playing or enjoying leisure activities quietly.

5) “On the go" or often acts as if "driven by a motor".

6) Talks excessively.

7) Blurts out answers before questions have been finished.

8) Has trouble waiting one's turn.

9) Interrupts or intrudes on others (e.g., butts into conversations or games).


COLLATERAL INFORMATION!!! (need symptoms in 2 settings)


Other assessment tools include Connors scales, Continuous Performance Test, Vanderbilt scales….

…But should not be used solely for diagnostic purposes (most helpful with charting progress over time)


  • Theories of Development, William Crain.

  • Childhood and Society, Erik H. Erikson.

  • Textbook of Child and Adolescent Psychiatry, Dulcan and Wiener.

Recommended reading
Recommended Reading

  • Theories of Development, William Crain.

  • Between Parent and Child, Ginott.