Physical influences during pregnancy, such as exposure to infectious agents and to drugs of use and abuse (see Chapter 23), can have a profound, pervasive, and persistent impact on fetal development. In the last few decades, research has shown that psychological influences can also have long-term effects on the fetus. For example, male offspring of female rats emotionally stressed during pregnancy show decreased masculine and increased feminine sexual behavior as adults. The mechanism of this effect is believed to involve a stress-related increase in maternal corticosteroid production, resulting in reduced fetal androgen secretion (Ward & Reed, 1985).

Sonographic observations indicate that human fetuses show a variety of behavior patterns that presage those they will show after birth. Facial grimacing, thumb sucking, responsiveness to taste and smell when substances are infused into the amniotic sac, and reactions to sound and light are seen prenatally. In addition to their diagnostic uses, fetal sonography and related technology have allowed parents to see their unborn child’s face (Fig. 1-1), facilitating parent/infant bonding even before birth.

The normal delivery of a healthy, full-term infant is usually a joyful event. Recent advances in childbirth analgesia and educational preparation have made vaginal birth more comfortable. The presence of the father in the delivery room, now commonplace, provides both support for the mother and the opportunity for the father to bond quickly with the new infant.

About 4 million children are born each year in the United States. In 2007, more children were born (4,317,000) than in any other year in American history. Although most deliveries are uneventful, problems related to the mother or fetus may lead to cesarean section. The number of cesarean sections decreased from 1989 to 1996, partly in response to increasing evidence that women often undergo unnecessary surgical procedures. Over the past decade, however, the rate has increased and, at 31.8%, is now higher than it has ever been. This increase reflects not only a rise in the primary cesarean rate, but also a fall in the number of women having a vaginal birth after cesarean delivery.

Unfortunately, not all infants are born full term and healthy; in 2005, approximately 12% were born prematurely (<37 completed weeks of gestation) and approximately 2% were born very prematurely (<32 completed weeks). Premature birth puts a child at risk for a variety of health problems, including physical and intellectual disability, as well as emotional, behavioral, and learning problems. The Apgar score was named for Dr. Virginia Apgar but is also useful as a mnemonic:

It quantifies physical functioning in premature and full-term newborns (Table 1-1) and can be used to predict the likelihood of immediate survival.

In part because of its high rate of premature births, the United States has a high infant mortality rate compared with rates in other developed countries. In countries such as England, Canada,
France, and Germany, prenatal care without cost is available to most women. Because the U.S. health care system does not provide free prenatal care for all women (see Chapter 27), low income in the United States is associated with premature birth and high infant mortality. Mean annual income is lower in African Americans than in white Americans (see Chapter 20), and almost twice as many non-Hispanic African American infants as non-Hispanic white infants are born prematurely. Also, when compared with other ethnic groups, a higher percentage of premature African-American infants die in the first year of life (Table 1-2). Other causes for the high rate of premature births include the trend toward delayed childbearing and increased maternal age in the United States. Older mothers are more likely to require fertility treatments that often result in multiple births, in which infants tend to be born earlier and smaller.

Women usually recover quickly from childbirth and have immediate and positive responses to their newborn infants. However, for a significant number of women who have had an uncomplicated delivery of a normal child, the postpartum period is characterized by an emotional state referred to as the postpartum blues or baby blues. This state of exaggerated emotionality and tearfulness usually lasts for a few days after birth. Although the cause of the baby blues is not always obvious, in some women it is related to physical changes, such as fatigue, and neurological events, such as changes in hormone and neurotransmitter levels, for example, oxytocin-dopamine interactions have been specifically associated with development of the maternal-infant bond (Shahrokh et al., 2010). In other women, the baby blues are more closely related to social and psychological factors, such as a perceived lack of
social support, the emotional stress of childbirth, and realistic feelings of additional responsibility. Psychological support and practical suggestions for child care from the physician are very helpful for women with postpartum blues, and most cases resolve on their own during the week or two after delivery.

A small percentage of women experience a more serious emotional reaction after childbirth. Mood disorders like major depression, characterized by feelings of hopelessness, helplessness, and even suicidal thoughts or psychotic symptoms (see Chapter 13) occur in up to 10% of new mothers within a month after childbirth. Depressed mothers typically show a general lack of pleasure and interest in their child and in their usual activities, as well as poor self-care. If left untreated, a major depressive episode can persist for 1 year or more and can interfere with the development of the maternal-child bond. Infants of depressed mothers often themselves become depressed and fail to gain weight and reach developmental milestones at the expected ages—a condition known as nonorganic failure to thrive, which can be classified in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (see Chapter 10) as reactive attachment disorder of infancy or early childhood (see below).

Mood disorders such as depression can include psychotic features such as hallucinations (i.e., false perceptions such as hearing voices) or delusions (i.e., false beliefs such as being spied upon) (see Chapter 12). Postpartum women who have mood disorder with psychotic features may experience a particular type of hallucination, command hallucinations, where voices instruct the mother to harm or actually kill her infant. Tragically, in some cases, the affected mother carries out these commands before the danger of her condition is recognized and treated.

A less common but also serious reaction to childbirth is postpartum psychosis, which occurs in 0.1% to 0.2% of postpartum mothers. Described in the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5) as brief psychotic disorder with postpartum onset (see Chapter 12), this condition is characterized by hallucinations, delusions, or other psychotic symptoms that occur in the absence of mood symptoms and are not better accounted for by mood disorder with psychotic features. Postpartum psychosis also begins in the postpartum month and lasts for up to 1 month.

Development of children proceeds in many different areas and in a predictable pattern. These areas can be divided for convenience into motor, social, and verbal/cognitive spheres. Motor development occurs in a cephalad to caudad and central to peripheral fashion. For example, the child gains control of his head before he can control his legs, and he can control his arms before he can control his fingers. Social development proceeds from self to others, from total self-involvement to interactions with people in the outside world.
Cognitive/verbal development progresses from understanding to expressing. A young child typically can understand more words than he can speak.

Most children achieve developmental milestones within a range of time at a similar pace in all spheres, although some show delays in one or more areas. For example, a 4-year-old child may be intellectually advanced but socially immature. Sometimes, social stress can delay the acquisition of new skills or cause regression (a defense mechanism [see Chapter 8] in which the child behaves in a “babyish” way) in already acquired skills. For example, after the family moves to a new home, a toilet-trained child may begin to wet his bed again. It is important to identify developmental delays and address them as soon as possible because their persistence can become a source of social and educational impairment.

Theorists who have studied the biological and sociological forces that affect the development of children have derived several impressions and schemes. Although an exhaustive discussion of these theories is beyond the scope of this book, knowledge of the most important concepts helps one understand how children acquire their behavior and skills.

It was once believed that all newborn children were blank slates, ready to be written on and shaped by life events. The important longitudinal work of Chess and Thomas (1986) showed instead that infants possess at birth endogenous differences in temperament, innate traits shown in response to the environment, and that these characteristics remain quite stable for at least the first 25 years of life. These traits include activity level, reactivity to stimuli, cyclic behavior patterns like sleeping, reactions to people, mood, distractibility, and attention span. Chess and Thomas further showed that children tend to fall into one of three temperament categories:

As their studies progressed and their subjects approached adolescence, Chess and Thomas observed that, with respect to psychological problems, easy children were at low risk; slow-to-warm-up children were at some increased risk; and difficult children were at high risk.

Erik Erikson described development in terms of critical periods for the achievement of social goals. One implication of his theories is that if a specific goal is not achieved at a specific age, the individual will have difficulty achieving the goal in the future. For example, in Erikson’s stage of basic trust versus mistrust, either the child learns to trust others during the first year of her life or she will have feelings of vulnerability in future social interactions.

Jean Piaget described development in terms of cognitive or learning capabilities of the child at each age. His research suggested that these capabilities were more closely related to neurological maturity than to a child’s innate potential to learn.

Margaret Mahler described early development as a sequential process of separation of the child from the mother or primary caregiver. Her findings indicated that the ease with which a child negotiated this process of separation-individuation influenced his or her ability to enjoy trusting and emotionally fulfilling relationships in adult life.

Sigmund Freud described child development in terms of the parts of the body from which the most pleasure is derived at each stage. For example, the first year of life is the oral stage, a period when pleasure is derived primarily from sucking at the breast or bottle. Freud’s theories, scrutinized more closely and discounted by some in recent years, are described in more detail in Chapter 8.

One of the first tasks facing an infant is to form the most important social relationship of its life—an attachment to the person who has primary responsibility for its care. Although the father or other relative may assume this role, the primary caregiver is usually the mother. Attachment of the infant to its mother is a gradual process that takes place over the first few months of life.

In the first postnatal month, children are in what Margaret Mahler called the normal autistic phase. This term describes a state of self-involvement and lack of interest in others that, in older children, signifies psychopathology (see “autism spectrum disorder” later in the chapter). At some
time between the first and second months of life, children normally begin to respond to other people. Although a reflexive smile is present at birth, the social smile

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