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CHAPTER 6
EMOTIONAL AND SOCIAL DEVELOPMENT
IN INFANCY AND TODDLERHOOD
CHAPTER-AT-A-GLANCE
Chapter Outline Instruction Ideas Supplements

Erikson’s Theory of Infant and Toddler Learning Objective 6.1 Test Bank Items 1–6
Personality p. 184
Basic Trust versus Mistrust • Autonomy versus (Please contact your Pearson sales
Shame and Doubt representative for a wide range of video
offerings available to adopters.)
Emotional Development pp. 184–190 Learning Objectives 6.2–6.3 Test Bank Items 7–49, 126
Basic Emotions • Understanding and Responding Learning Activities 6.1, 6.2
to the Emotions of Others • Emergence of Ask Yourself p. 190
Self-Conscious Emotions • Beginnings of
Emotional Self-Regulation
Temperament and Development pp. 190–195 Learning Objectives 6.4–6.5 Test Bank Items 50–74, 127–128
The Structure of Temperament • Measuring Lecture Enhancement 6.1
Temperament • Stability of Temperament • Genetic Learning Activity 6.3
and Environmental Influences • Temperament and Ask Yourself p. 195
Child Rearing: The Goodness-of-Fit Model
Development of Attachment pp. 196–206 Learning Objectives 6.6–6.8 Test Bank Items 75–118, 129–130
Bowlby’s Ethological Theory • Measuring the Lecture Enhancement 6.2
Security of Attachment • Stability of Attachment • Learning Activities 6.4–6.6
Cultural Variations • Factors That Affect Ask Yourself p. 206
Attachment Security • Multiple Attachments •
Attachment and Later Development
Self-Development pp. 206–209 Learning Objective 6.9 Test Bank Items 118–125, 131
Self-Awareness • Categorizing the Self • Learning Activity 6.7, 6.8
Self-Control Ask Yourself p. 209
BRIEF CHAPTER SUMMARY
Erik Erikson believed that the psychological conflict of the first year is basic trust versus mistrust, which is resolved on the
positive side when the balance of care is sympathetic and loving. The conflict of toddlerhood, autonomy versus shame and
doubt, is resolved favorably when parents provide suitable guidance and reasonable choices.
Emotions play powerful roles in social relationships, exploration of the environment, and discovery of the self. Basic
emotions—happiness, interest, surprise, fear, anger, sadness, and disgust—are universal in humans and other primates and have
a long evolutionary history of promoting survival.
Infants’ emotional expressions begin as global arousal states of attraction and withdrawal, which gradually become clear,
well-organized signals. Beginning at 8 to 10 months, infants engage in social referencing. During toddlerhood, self-awareness
and adult instruction provide the foundation for self-conscious emotions—guilt, shame, embarrassment, envy, and pride. The
capacity for effortful control improves rapidly as a result of development of the prefrontal cortex and support from caregivers.
Infants vary widely in temperament, including both reactivity and self-regulation. Research on temperament examines its
stability, biological roots, and interaction with child-rearing experiences. According to the goodness-of-fit model, parenting
practices that fit well with the child’s temperament help children achieve more adaptive functioning.
John Bowlby’s ethological theory of attachment recognizes the baby’s emotional tie to the caregiver as an evolved
response that promotes survival. By the end of the second year, children have formed an enduring affectionate tie to the
caregiver that serves as an internal working model, guiding future close relationships. Factors that affect attachment security
include early availability of a consistent caregiver, quality of caregiving, the fit between the baby’s temperament and parenting
Copyright © 2018 Laura E. Berk. All Rights Reserved. 67

Instructor’s Resource Manual for Berk / Development Through the Lifespan, 7e
practices, family circumstances, and parents’ internal working models. Mounting evidence indicates that continuity of
caregiving determines whether attachment security early in life is linked to later development.
Around age 2, self-recognition is well under way. Self-awareness is associated with the beginnings of empathy, the ability
to feel with another person. Self-awareness also contributes to effortful control, evident in toddlers’ strengthening capacity to
inhibit impulses, manage negative emotion, and behave in socially acceptable ways.
LEARNING OBJECTIVES
After reading this chapter, you should be able to answer the following:
6.1 What personality changes take place during Erikson’s stages of basic trust versus mistrust and autonomy versus shame
and doubt? (p. 184)
6.2 Describe the development of basic emotions over the first year, noting the adaptive function of each. (pp. 185–186)
6.3 Summarize changes during the first two years in understanding others’ emotions, expression of self-conscious emotions,
and emotional self-regulation. (pp. 188–190)
6.4 What is temperament, and how is it measured? (pp. 190–193)
6.5 Discuss the roles of heredity and environment in the stability of temperament, including the goodness-of-fit model.
(pp. 193–195)
6.6 Describe the development of attachment during the first two years. (pp. 196–197)
6.7 How do researchers measure attachment security, what factors affect it, and what are its implications for later
development? (pp. 197–203)
6.8 Describe infants’ capacity for multiple attachments. (pp. 203–205)
6.9 Describe the development of self-awareness in infancy and toddlerhood, along with the emotional and social capacities it
supports. (pp. 206–209)
LECTURE OUTLINE
I. ERIKSON’S THEORY OF INFANT AND TODDLER PERSONALITY (p. 184)

• Erik Erikson’s psychosocial theory identifies the psychological conflict of the first year as basic trust versus
mistrust. When the balance of care is sympathetic and loving, the baby will develop basic trust.
• Erikson viewed the conflict of toddlerhood as autonomy versus shame and doubt. It is resolved favorably when
parents provide young children with suitable guidance and reasonable choices.
II. EMOTIONAL DEVELOPMENT (pp. 184–190)
• Basic emotions—happiness, interest, surprise, fear, anger, sadness, and disgust—are universal in humans and other
primates and have a long evolutionary history of promoting survival.
• Babies’ earliest emotional life consists of two global arousal states—attraction and withdrawal. Emotions gradually
become clear, well-organized signals, providing more precise information about the baby’s internal state.
• Happiness binds parent and baby into a warm, supportive relationship that fosters the infant’s motor, cognitive, and
social competencies.
• Between 6 and 10 weeks, the parents’ communication evokes the social smile, followed at around 3 to 4 months by
laughter in response to active stimuli.
• From 4 to 6 months into the second year, angry expressions increase in frequency and intensity, as infants become
capable of intentional behavior and want to control their own actions and the effects they produce.
• Infant sadness is common when infant–caregiver communication is seriously disrupted—for example, in the case of
parental depression.
• Fear, most frequently expressed as stranger anxiety, rises from the second half of the first year into the second year,
keeping newly mobile babies’ enthusiasm for exploration in check.
• Once wariness develops, infants use the familiar caregiver as a secure base from which to explore the environment.
68 Copyright © 2018 Laura E. Berk. All Rights Reserved.

Chapter 6 Emotional and Social Development in Infancy and Toddlerhood
• Beginning at 8 to 10 months, babies engage in social referencing, using others’ emotional messages to evaluate the
safety and security of their surroundings, to guide their own actions, and to gather information about others’ intentions
and preferences.
• Self-conscious emotions—guilt, shame, embarrassment, envy, and pride—appear in the middle of the second year, as
18- to 24-month-olds become firmly aware of the self as a separate, unique individual.
• Emotional self-regulation—the strategies we use to adjust our emotional state to a comfortable level of intensity so
we can accomplish our goals—requires voluntary, effortful management of emotions.
• The capacity for effortful control improves gradually as more effective functioning of the prefrontal cortex increases
the baby’s tolerance for stimulation and as caregivers provide lessons in socially approved ways of expressing
feelings.
• Toward the end of the second year, toddlers rapidly develop a vocabulary for talking about feelings, but they are not
yet good at using language to manage their emotions.
III. TEMPERAMENT AND DEVELOPMENT (pp. 190–195)
• Temperament refers to early-appearing, stable individual differences in reactivity and self-regulation.
• In 1956, Alexander Thomas and Stella Chess developed a model of temperament that yielded three types of children:
the easy child, the difficult child, and the slow-to-warm-up child.
• Mary Rothbart’s influential model of temperament combines related traits to yield a list of just six dimensions,
identifying differences in reactivity and also in effortful control, which predicts favorable development and
adjustment in diverse cultures.
• Temperament is often assessed through parent interviews and questionnaires, behavior ratings by pediatricians or
teachers, and laboratory observations by researchers.
• Neurobiological measures can be used to help identify biological bases of temperament, especially for children who
fall at opposite extremes: inhibited, or shy, children, and uninhibited, or sociable, children.
• Because the overall stability of temperament is low in infancy and toddlerhood, long-term prediction from early
temperament is best achieved after age 3.
• About half of individual differences in temperament and personality have been attributed to differences in genetic
makeup, but environment is also powerful, especially in children exposed to severe malnutrition or emotional
deprivation.
• Ethnic and gender variations in infant temperament may have genetic roots, but they are supported by cultural beliefs
and practices, yielding gene–environment correlations.
• Researchers are using molecular genetic analyses to investigate gene–environment interactions—temperamental
differences in children’s susceptibility (or responsiveness) to environmental influences.
• Parents’ tendency to emphasize each child’s unique qualities affects their parenting practices, and siblings’ distinct
experiences with teachers, peers, and others also affect personality development.
• The goodness-of-fit model describes how an effective match between child-rearing practices and a child’s
temperament can produce favorable outcomes.
IV. DEVELOPMENT OF ATTACHMENT (pp. 196–206)
• Attachment is the strong affectionate tie we have with special people in our lives that leads us to feel pleasure when
we interact with them and to be comforted by their nearness in times of stress.
• Although the parent–infant bond is vitally important, later development is also influenced by the continuing quality of
the parent–child relationship.
• In John Bowlby’s ethological theory of attachment, attachment develops in four phases: (1) preattachment phase
(birth to 6 weeks), (2) “attachment-in-the-making” phase (6 weeks to 6–8 months), (3) “clear-cut” attachment phase
(6–8 months to 18 months–2 years), and (4) formation of a reciprocal relationship (18 months to 2 years and on).
• In the clear-cut attachment phase, attachment to the familiar caregiver is evident, and babies display separation
anxiety when the trusted caregiver leaves.
• Out of their early experiences, children develop an internal working model that guides all future close relationships.
• Using the Strange Situation, a laboratory procedure for assessing the quality of attachment between 1 and 2 years of
age, researchers have identified a secure attachment pattern and three patterns of insecurity: insecure–avoidant
attachment, insecure–resistant attachment, and disorganized/disoriented attachment.
• The Attachment Q-Sort uses home observation to measure attachment in children between ages 1 and 5.
• Quality of attachment is usually secure and stable for middle-SES babies experiencing favorable life conditions.
• Despite cultural variations in attachment patterns, the secure pattern is still the most common in all societies studied.

• Factors that affect attachment security include early availability of a consistent caregiver and quality of caregiving.
• Sensitive caregiving is moderately related to attachment security; highly inadequate caregiving is a powerful predictor
of disruptions in attachment.
• In Western societies, interactional synchrony separates the experiences of secure from insecure babies. However,
studies of non-Western communities and Asian cultures suggest that security depends on attentive caregiving, not
necessarily contingent interaction.
• Babies with genotypes associated with emotional reactivity are more susceptible than others to the effects of both
negative and positive parenting.
• Family stressors and parents’ internal working models also play a role in attachment security.
• Bowlby’s theory allows for multiple attachments, including attachment to fathers and to siblings.
• Mounting evidence exists that continuity of caregiving is the factor that determines whether attachment security is
linked to later development.
V. SELF-DEVELOPMENT (pp. 206–209)
• Newborns’ capacity for intermodal perception supports the beginnings of self-awareness, as babies experience
intermodal matches that differentiate their own body from surrounding bodies and objects.
• Over the first few months, infants distinguish their own visual image from other stimuli, but their self-awareness is
limited.
• Implicit self-awareness serves as the foundation for development of explicit self-awareness—understanding that the
self is a unique object.
• During the second year, toddlers become consciously aware of the self’s physical features. Around age 2, self-
recognition is well under way, although toddlers still make scale errors.
• Cultural variations in early self-development may reflect a society’s emphasis on autonomous versus relational child-
rearing goals.
• As self-awareness becomes a central part of children’s emotional and social lives, older toddlers who have
experienced sensitive caregiving express the first signs of empathy.
• Between 18 and 30 months, children develop a categorical self, based on age, sex, physical characteristics, and
goodness versus badness, which they use to organize their own behavior.
• As effortful control—the ability to inhibit impulses, manage negative emotion, and behave in socially acceptable
ways—emerges between 12 and 18 months, toddlers first become capable of compliance.
• To study self-control, researchers often give children tasks that require delay of gratification—a capacity that is
influenced by both temperament and quality of caregiving.

LECTURE ENHANCEMENTS
LECTURE ENHANCEMENT 6.1

Temperament Research: A Review of Major Findings of the Past Quarter Century (pp. 190–195)
Objective: To review the most significant advances in research on temperament over the past quarter century and consider the
major questions that remain to be addressed.
“What Is Temperament Now?” by Shiner et al. (2012) presents an overview of major advances in temperament research since
the publication twenty-five years earlier of Goldsmith et al.’s (1987) “What Is Temperament? Four Approaches.” That paper,
now viewed as classic, brought together the originators of four prominent temperament models—Goldsmith, Thomas and
Chess, Rothbart, and Buss and Plomin—to address fundamental questions about the nature of temperament.
The current authors note that Goldsmith et al. were prescient in identifying issues that would remain central to the field—
for example, the relationship between temperament and later life outcomes. Today’s researchers, however, have a more
complex understanding of interactions between biological factors and experience. For example, Shiner et al. describe how
recent research has led to an expanded view of Thomas and Chess’s concept of goodness of fit. Whereas Thomas and Chess
encouraged parents to modify the environment so as to achieve a better fit with their child’s temperament, more recent studies
suggest an alternative approach using temperament-based strategies to help children modify their capacity for self-regulation.
Shiner et al. pose several key questions that remain to be investigated. These include relationships between temperament
and personality traits, how temperament interacts with context and with the environment, and how changes in temperament are
related to biological and psychological processes. In connection with class discussion of temperament and development (pp.
190–195), this paper provides a valuable historical perspective on what researchers have learned since 1987 and what questions
are still to be explored.
Shiner, R. L., et al. (2012). What is temperament now? Assessing progress in temperament research on the twenty-fifth
anniversary of Goldsmith et al. Child Development Perspectives, 6, 436-444. doi: 10.1111/j.1750-8606.2012.00254.x
LECTURE ENHANCEMENT 6.2

Young Children in Foster Care: Promoting the Capacity for Secure Attachment (pp. 199–203)
Objective: To consider the developmental needs of young children in foster care and the effectiveness of interventions
designed for these children and their caregivers.
Because “fully normal emotional development,” as described in the text (p. 200), “depends on establishing a close tie with a
caregiver early in life,” it is not surprising that infants and toddlers in foster care, who have experienced maltreatment and
disruptions in relationships with their primary caregivers, are at risk for attachment difficulties and for persisting emotional and
social problems.
In this paper, Dozier et al. (2013) identify key caregiving variables for these vulnerable children on four dimensions:
synchrony, nurturance, stability of care, and commitment. They present two approaches to intervention—Attachment and
Biobehavioral Catch-up (ABC) and the New Orleans Intervention—that are designed to address children’s needs on these four
dimensions and thereby promote the development of secure attachment. The authors cite positive outcomes for children in both
interventions as evidence that such programs “can protect children at a critical time during development.”
Dozier et al. also consider ways of enhancing the foster care system to better meet children’s developmental needs. They
conclude that foster parents ideally must be able to “commit to the child as if he or she were their own child” while still
supporting the child’s relationship with birth parents and valuing efforts to reunite the child with the birth family. Their
findings and recommendations provide the basis for class discussion of the policy implications of research into the key factors
that affect attachment security.
Dozier, M., Zeanah, C. H., & Bernard, K. (2013). Infants and toddlers in foster care. Child Development Perspectives, 7,
166–171. doi: 10.1111/cdep.12033

LEARNING ACTIVITIES
LEARNING ACTIVITY 6.1

Classroom Demonstration: Development of Emotional Expression (pp. 185–186, 188–189)
Arrange for a group of babies, ranging in age from several weeks to 18 months, to visit your classroom for a demonstration of
emotional expression during infancy. You can see if any students have babies of their own in that age range, or you may have
friends or colleagues who are willing to participate. Include some or all of the following activities:
(1) Ask students to carefully observe the infants’ facial, body, and vocal expressions and to record any examples of basic
emotions, noting the events that may have elicited each emotion. For example, if a baby smiles, is it in response to the
parent’s facial expression or voice?
(2) Ask students to interview parents about their babies’ expression of the basic emotions (happiness, interest, surprise,
fear, anger, sadness, and disgust). Are their answers consistent with research presented in the text, which suggests that
infants’ precise emotions are difficult to detect in the early months but, with age, gradually develop into clear, well-
organized signals?
(3) If the group includes a baby between 2 and 4 months of age, try to evoke the social smile by nodding, smiling, and
talking softly to the infant. To underscore the adaptive role of the smile in promoting positive parent–child
interactions, ask students to observe the baby’s response to this stimulation and to note how the parents, in turn,
respond to the infant’s smile,
(4) For babies 3 months of age and older, ask parents to describe and, if possible, demonstrate stimuli that elicit laughter.
Ask students to note the dynamic quality of these stimuli—for example, kissing the baby’s tummy.
(5) If the group includes any infants over 7 months of age, investigate the rise in fear reactions by approaching the baby
and asking students to note the infant’s response. Does the baby show wariness of a strange adult?
(6) If there are any babies over 10 months of age, ask students to look for instances of social referencing and to note
whether the baby uses the parent as a secure base.
For each activity, ask students to compare their observations with research presented in the text.

Supporting Emotional Self-Regulation in Infants and Toddlers (pp. 189–190)
Ask students to imagine they have been asked to speak to a group of parents on the importance of helping young children
manage their emotional experiences. Using research presented in the text as a guide, have students list the points they would
include in their presentation—for example:
(1) Why is emotional self-regulation important?
(2) What infant and toddler behaviors reflect the beginnings of effortful control and emotional self-regulation?
(3) How can parents help their infants and toddlers regulate emotion?
(4) What are some cultural differences in the emphasis placed on socially appropriate emotional behavior?
(5) What caregiving behaviors are likely to foster self-regulation? What caregiving behaviors should parents avoid. Why?


Matching: The Rothbart Model of Temperament (pp. 190–191)
Present the following exercise as an in-class activity or quiz.
Directions: Match each of the following terms with its correct description.
_____ 1. Activity level
_____ 2. Attention span/persistence
_____ 3. Fearful distress
_____ 4. Irritable distress
_____ 5. Positive affect
_____ 6. Effortful control
Descriptions:
A. Wariness and distress in response to intense or novel stimuli, including time to adjust to new situations
B. Extent of fussing, crying, and distress when desires are frustrated
C. Frequency of expression of happiness and pleasure
D. Level of gross-motor activity
E. Capacity to voluntarily suppress a dominant, reactive response in order to plan and execute a more adaptive response
F. Duration of orienting or interest
Answers:
1. D 4. B
2. F 5. C
3. A 6. E

Temperament: Improving Goodness of Fit (p. 195)
Goodness of fit involves creating child-rearing environments that recognize each child’s temperament while simultaneously
encouraging more adaptive functioning. Ask students to consider the following scenarios:
(1) A difficult 2-year-old whose parents both work long hours for low pay and do not have reliable child-care
arrangements. They sometimes use angry, punitive discipline, and their child reacts with defiance and disobedience.
(2) A shy child who was born in a rural village in China, but whose family has recently moved to a large city. Although
this child was considered well-adjusted in her native village, her shyness is not regarded positively in her urban
preschool.
For each scenario, ask students to identify some changes that might improve goodness of fit for these parents and children.


Observing the Attachment Relationship During the First Two Years (pp. 196–198)
This activity can be included as an extension of Learning Activity 6.1. Arrange for several babies and their parents (students,
colleagues, or friends) to visit your class. If possible, one child should be a baby 6 weeks of age or younger, one should be
between 6 weeks and 6 to 8 months old, one between 8 and 18 months, and one between 18 and 24 months of age.
(1) Ask students to observe the youngest baby and to describe the built-in signals of the preattachment phase—grasping,
smiling, crying, and gazing into the adult’s eyes.
(2) Ask students to observe how the infant between 6 weeks and 6 to 8 months of age responds to a familiar caregiver and
then to a stranger. Does the baby smile, laugh, and babble more freely with the familiar caregiver? Does he or she
quiet more readily when picked up?
(3) To demonstrate the development of “clear-cut” attachment, ask the parent of a baby between 8 and 18 months old to
leave the room briefly, as in Ainsworth’s Strange Situation.* Does the baby become distressed at the parent’s
departure? Is he or she quickly comforted by physical proximity when the parent returns?
(4) After the babies have had sufficient time to become comfortable in the classroom, ask the parent of the 18- to 24-
month-old to explain to the child that he or she is going to leave the room for a moment but will be back shortly. Then
ask students to note the child’s reaction. How does it compare to the reactions of the younger children?
For each example, ask students to compare their observations with research on development of attachment that is presented in
the text.
*Make sure the parent is able to return immediately if the child becomes distressed.

Attachment, Parental Employment, and Child Care (pp. 202–203)
In small groups, ask students to respond to the following scenario:
Paul and Ava are parents to 3-month-old Kevin. After giving birth, Ava decided to spend several months at home caring
for Kevin, but she plans to return to her full-time job as soon as her 12-week maternity leave ends. Some of Ava’s friends
have expressed concerns about her returning to work so soon, and Paul’s parents are worried that Kevin may experience
learning and behavioral problems if he begins attending child care at such a young age. Ava enjoys being a stay-at-home
mother, but she and Paul could really use the income Ava’s job will provide.
Using research in the text as a guide, what advice would you give Paul and Ava? Do their friends and family have valid
concerns? Why or why not? What types of support can Paul provide after Ava returns to work? When qualities should Paul and
Ava look for when choosing a child-care center?
*To supplement the activity, direct students to MyDevelopmentLab and the Playful Learning in Early Childhood video, which
illustrates characteristics of high-quality child care.


True or False: Self-Development During the First Two Years (pp. 206–209)
Present the following exercise as an in-class activity or quiz.
Directions: Read each of the following statements and determine if it is True (T) or False (F).
_____ 1. Not until the second half of the first year do infants sense that they are physically distinct from their
surroundings.
_____ 2. Around age 2, children refer to themselves by name or with a personal pronoun.
_____ 3. Toddlers who are frequently punished for misbehavior tend to demonstrate high levels of empathy.
_____ 4. Contrary to popular belief, language skills have little influence on self-development.
_____ 5. Toddlers use their understanding of the categorical self to organize their own behavior.
_____ 6. To behave in a self-controlled fashion, children must think of themselves as separate, autonomous beings who
can direct their own actions.
_____ 7. For most toddlers, opposition is far more common than compliance.
_____ 8. Overall, girls tend to exhibit more self-control than boys.
_____ 9. Toddlers can obey simple commands from an adult but do not yet show any signs of consciencelike
understanding.
_____ 10. Strict parenting with little tolerance for misbehavior is especially effective for helping toddlers develop
compliance and self-control.
Answers:
1. F 6. T
2. T 7. F
3. F 8. T
4. F 9. F
5. T 10. F

Observing Toddlers for Compliance and Self-Control (pp. 208–209)
Invite two or three parents to bring their toddlers (ranging in age from 12 months to 2 years) to your classroom for a
demonstration of compliance and self-control. Prior to the demonstration, gather several age-appropriate toys and several boxes
of raisins, or you can ask parents to bring toys and/or raisins from home. Present the following activities:
(1) Ask the child (or have the parent ask the child) not to touch an interesting toy that is within arm’s reach.
(2) Hide some raisins under cups and instruct the child to wait until you (or the parent) say it is all right to pick up a cup
and eat a raisin.
(3) Give the children several directions—for example, to bring you an object or to put away a toy.
In each case, note how well children follow the instructions. Do older children exhibit more compliance and self-control than
younger children? How do parents respond to their child’s behavior?

ASK YOURSELF . . .
CONNECT: Why do children of depressed parents have difficulty regulating emotion (see page 187)? What
implications do their weak self-regulatory skills have for their response to cognitive and social challenges? (pp. 187, 189)
Depressed parents rarely smile at, comfort, or talk to their babies, who respond to the parent’s sad, vacant gaze by turning
away, crying, and often looking sad or angry themselves. Depressed parents also view their infants negatively, which
contributes to their inept caregiving. As their children get older, these parents’ lack of warmth and involvement is often
accompanied by inconsistent discipline—sometimes lax, at other times too forceful.
In the early months, infants have only a limited capacity to regulate their emotional states. When their feelings get too
intense, they are easily overwhelmed and depend on the soothing interventions of caregivers for distraction and reorienting of
attention. But when parents are depressed, they are less likely to provide these interventions. Children who experience these
maladaptive parenting practices often have serious adjustment problems. To avoid their parents’ insensitivity, some withdraw
into a depressed mood themselves; others become impulsive and aggressive. Over time, children subjected to parental
negativity develop a pessimistic world view—one in which they lack self-confidence and perceive their parents and other
people as threatening. Children who constantly feel in danger are likely to become overly aroused in stressful situations, easily
losing control in the face of cognitive and social challenges.
APPLY: At age 14 months, Reggie built a block tower and gleefully knocked it down. At age 2, he called to his mother
and pointed proudly at his tall block tower. What explains this change in Reggie’s emotional behavior? (pp. 188–189)
As 18- to 24-month-olds become firmly aware of the self as a separate, unique individual, self-conscious emotions appear.
These emotions, which involve injury to or enhancement of our sense of self, include guilt, shame, embarrassment, envy, and
pride. At 14 months, Reggie had not yet developed a clear sense of himself as a separate person, so he simply enjoyed the
experience of building the block tower and then knocking it down. But by the time he was 2, he experienced pride in his
achievement at stacking the blocks into a tower, and wanted to share his accomplishment with his mother.
Besides self-awareness, self-conscious emotions require an additional ingredient: adult instruction in when to feel proud,
ashamed, or guilty. The situations in which adults encourage these feelings vary from culture to culture. In Western nations,
most children are taught to feel pride in personal achievement, as Reggie is expressing.
REFLECT: Describe several recent instances illustrating how you typically manage negative emotion. How might your
early experiences, gender, and cultural background have influenced your style of emotional self-regulation?
(pp. 189–190)
This is an open-ended question with no right or wrong answer.
CONNECT: Explain how findings on ethnic and gender differences in temperament illustrate gene–environment
correlation, discussed on pages 68–69 in Chapter 2. (pp. 193–194)
According to the concept of gene–environment correlation, our genes influence the environments to which we are exposed.
This helps to explain ethnic and gender differences in temperament, because children of different sexes and different ethnic
groups will be exposed to different experiences. For instance, Japanese mothers tend to view their infants as independent beings
who must learn to rely on their parents through close physical contact. European-American mothers, in contrast, typically
believe that they must wean the baby away from dependency toward autonomy. Consistent with these beliefs, Asian mothers
interact gently, soothingly, and gesturally with their babies, whereas European-American mothers use a more active,
stimulating, verbal approach. Also, Chinese and Japanese adults discourage babies from expressing strong emotion, which
contributes further to their infants’ tranquility. These differences in parenting practices help explain why Chinese and Japanese
babies tend to be less active, irritable, and vocal; more easily soothed when upset; and better at quieting themselves.
Similarly, gender differences in temperament are evident as early as infancy, suggesting a genetic foundation. Boys tend to
be more active and daring, less fearful, more irritable when frustrated, more likely to express high-intensity pleasure in play,
and more impulsive than girls. And girls’ large advantage in effortful control undoubtedly contributes to their greater
compliance and cooperativeness, better school performance, and lower incidence of behavior problems. At the same time,
parents more often encourage their young sons to be physically active and their daughters to seek help and physical closeness—
through the activities they encourage and through more positive reactions when their child exhibits temperamental traits
consistent with gender stereotypes.

APPLY: Mandy and Jeff are parents of 2-year-old inhibited Sam and 3-year-old difficult Maria. Explain the
importance of effortful control to Mandy and Jeff, and suggest ways they can strengthen it in each of their children.
(pp. 191, 192, 195)
The self-regulatory dimension of temperament, effortful control, is the capacity to voluntarily suppress a dominant
response in order to plan and execute a more adaptive response. The capacity for effortful control in early childhood predicts
favorable development and adjustment in diverse cultures. Mandy and Jeff should be aware that if a child’s disposition
interferes with learning or getting along with others, adults must gently but consistently counteract the child’s maladaptive
style. The concept of goodness of fit describes how Mandy and Jeff can create a child-rearing environment that recognizes each
child’s distinct temperament while simultaneously encouraging more adaptive functioning. Mandy and Jeff can help Sam
develop strategies for regulating fear by offering warm, supportive parenting while also making appropriate demands for him to
approach new experiences. With Maria, they should remain positive and sensitive and should be careful not to resort to angry,
punitive discipline, which will undermine the development of effortful control.
REFLECT: How would you describe your temperament as a young child? Do you think your temperament has
remained stable, or has it changed? What factors might be involved? (pp. 190–195)
CONNECT: Review research on emotional self-regulation on page 189. How do the caregiving experiences of securely
attached infants promote emotional self-regulation? (pp. 199–200)
Sensitive caregiving—responding promptly, consistently, and appropriately to infants and holding them tenderly and
carefully—is moderately related to attachment security and also helps infants regulate emotion. In Western cultures, a special
form of communication called interactional synchrony, in which infant and adult match emotional states, especially positive
ones, characterizes the experiences of securely attached babies. Sensitive face-to-face play, in which interactional synchrony
occurs, increases babies’ responsiveness to others’ emotional messages and also helps them regulate emotion. Infants whose
parents “read” and respond contingently and sympathetically to their emotional cues tend to be less fussy, to express more
pleasurable emotion, to be more interested in exploration, and to be easier to soothe.
APPLY: What attachment pattern did Timmy display when Vanessa arrived home from work, and what factors
probably contributed to it? (pp. 198, 201–203)
When Vanessa came to pick him up from child care, Timmy ignored her—behavior typical of an insecure–avoidant
attachment. After going through a divorce, Vanessa was anxious and distracted. Because she needed to work long hours to
make ends meet, she placed 2-month-old Timmy in child care and often had a babysitter pick him up at the end of the day, give
him dinner, and put him to bed. Timmy’s response to Vanessa reflects a repeated finding—that serious stressors such as job
loss, a failing marriage, financial difficulties, or parental psychological problems (such as anxiety or depression) can undermine
attachment. These stressors can affect babies’ sense of security directly, by exposing children to angry adult interactions or
disrupting familiar daily routines. Or, as in the case of Vanessa and Timmy, they may undermine attachment security indirectly
by interfering with parental sensitivity.
REFLECT: How would you characterize your internal working model? What factors, in addition to your relationship
with your parents, might have influenced it? (pp. 197, 202–203)
CONNECT: What type of early parenting fosters the development of emotional self-regulation, secure attachment, and
self-control? Why, in each instance, is it effective? (pp. 189–190, 200–201, 209)
Between 2 and 4 months, caregivers can build on the baby’s increasing tolerance for stimulation by initiating face-to-face
play and attention to objects, arousing pleasure in the baby while adjusting the pace of their behavior so the infant does not
become overwhelmed and distressed. As a result, the baby’s tolerance for stimulation increases further.
From 3 months on, the ability to shift attention away from unpleasant events or engage in self-soothing helps infants
control emotion. Infants whose parents “read” and respond contingently and sympathetically to their emotional cues tend to be
less fussy and fearful, to express more pleasurable emotion, to be more interested in exploration, and to be easier to soothe.
Similarly, sensitive caregiving is moderately related to attachment security in diverse cultures and SES groups. Mothers of
securely attached babies tend to exhibit maternal mind-mindedness, frequently referring to their infants’ mental states and
motives. This tendency to treat the baby as a person with inner thoughts and feelings seems to promote sensitive caregiving.

In studies of Western babies, a special form of communication called interactional synchrony, in which the caregiver
responds to infant signals in a well-timed, rhythmic, appropriate fashion and both partners match emotional states, separates the
experiences of secure from insecure babies. Interactional synchrony occurs during sensitive face-to-face play, which increases
babies’ responsiveness to others’ emotional messages and also helps infants regular emotion.
Between 12 and 18 months, as the capacities necessary for self-control begins to emerge, toddlers first become capable of
compliance. They show clear awareness of caregivers’ wishes and expectations and can obey simple requests and commands.
They can also decide to do just the opposite, but for most, assertiveness and opposition occur alongside compliance with an
eager, willing spirit, suggesting that the child is beginning to adopt the adult’s directives as his own.
APPLY: Len, a caregiver of 1- and 2-year-olds, wonders whether toddlers recognize themselves. List signs of
self-recognition in the second year that Len can observe. (p. 207)
1. Toddlers older than 18 to 20 months, when placed in front of a mirror, respond to unique features of their mirror
image. For example, if red dye is rubbed on the child’s nose or forehead, toddlers will touch or rub their own nose or
forehead, indicating awareness of their unique appearance.
2. Around age 2, children show self-recognition when they point to themselves in photos and refer to themselves by
name or with a personal pronoun (“I” or “me”).
3. Around age 2½, most children reach for a sticker surreptitiously placed on top of their heads when shown themselves
in a live video.
4. Around age 3, most children recognize their own shadow.
REFLECT: In view of research on toddlers’ compliance, active resistance, and budding capacity to delay gratification,
do you think that the expression “the terrible twos”—commonly used to characterize toddler behavior—is an apt
description? Explain. (pp. 208–209)

MEDIA MATERIALS
For details on individual video segments that accompany the DVD for Development Through the Lifespan, Seventh Edition,
please see the DVD Guide for Explorations in Lifespan Development. The DVD and DVD Guide are available through your
Pearson sales representative.
Additional DVDs and streaming videos that may be useful in your class are listed below. They are not available through
your Pearson sales representative, but you can order them directly from the distributors. (See contact information at the end of
this manual.)
Attachment Relationships: Nurturing Healthy Bonds (2010, Insight Media, 28 min.). The development of attachment from birth
to toddlerhood.
Attachment Theory (2013, Films Media Group, 27 min.). Current and historical models of attachment, including the work of
Bowlby and others. A viewable/printable worksheet is available online.
Fathering: What It Means to Be a Dad (2009, Films Media Group, 21 min.). Fathering expert Steve Onell and young fathers
discuss the importance of a father in a child’s life.
Flesh and Blood: Sibling Rivalry (2006, Films Media Group/BBC–Open University, 60 min.).The significance of sibling
rivalry and bonding. Part of the series Child of Our Time.
History of Parenting Practices: Child Development Theories (2006, Films Media Group, 19 min.). The events, policies, and
theories that shaped child rearing in the twentieth century. Online resources are available.
Infants: Social & Emotional Development (2010, Learning Seed, 26 min.). The range of emotions that infants express in the
first year of life, the stages of emotional development, and how children form attachments.
John Bowlby: Attachment Theory Across Generations (2007, Insight Media, 35 min.). The impact of attachment relationships
on adult behavior, including the findings of recent neuroscientific research.
Mary Ainsworth: Attachment and the Growth of Love (2005, Davidson Films, 38 min.). Mary Ainsworth’s research on human
attachment, including footage of the Strange Situation. Narrated by Robert Marvin, PhD.
Toddlers: Social and Emotional Development (2009, Insight Media, 26 min.). Emotional expression among toddlers, including
the roles of gender and temperament.

Another random document with
no related content on Scribd:
It is fair, however, to assume that there must be a capacity for
serious results in the vibratory jar, as the discoverable lesions in
many well-examined cases have been in themselves insufficient to
kill. The rapidity of recovery of those who get well also bears weight
on this point.
Of nineteen cases of recovery from concussion of the brain of which

I have record, the average stay in hospital was eight days. The
range of stay was from one to twenty-five days. Many of these were
at first profoundly shocked, some of them apparently hopelessly so
when we compared their symptoms with those who died. As they
recovered, however, in so short a time, there surely could not have
been any gross lesion to account for their symptoms. What else,
then, can account for them than vibratory jar? and if this can produce
such severe results within the line of recovery, why cannot the
degree of it be so extended as to involve, for example, the
respiratory centres, and so kill without leaving perceptible sign?
The SYMPTOMS of concussion of the brain range from a mere daze or

stunning to those of deep unconsciousness. There is no paralysis of
the extremities in pure cases. Often the patient is very restless, and
throws his limbs about in all directions. When these are quiet there is
response to irritation and electricity. Loud speaking to him may elicit
some attention, but the answers are mostly incoherent. There is
pallor, often extreme, coldness of surface, and sweating. Vomiting is
usual, and may come on immediately or later, and it continues as
long as there is anything to discharge; sometimes there is retching.
In favorable cases the cessation of vomiting is accompanied by a
slow return to consciousness, which may be preceded by delirium.
This return is never sudden, and the method of it serves to
distinguish the case from that of some forms of epilepsy. The pulse
is generally frequent and feeble, often irregular; in extreme cases it
may be slow and feeble, very rarely, if ever, strong or bounding. After
reaction it becomes more natural, and if recovery follows it will not
show much variation. The temperature is depressed at first. In one
characteristic case it was 98° on the first day, reached 101° on the
third day, and receded to 98½° on the eighth day, when the brain
symptoms disappeared.
There may be retention of urine and sluggishness of the bowels, but

in bad cases coincident with the vomiting there is sometimes
involuntary discharge both of feces and urine. The respiration is
irregular, sometimes almost ceasing, and then returning with great
rapidity.
Much has been said and written about the condition of the pupils in
concussion of the brain. I have made this matter a subject of
observation, and am convinced that the state of the pupils is of no
diagnostic value whatever as to determining the existence of
concussion or compression. Their state is of great value in telling us
that the functions of certain brain-centres are partially or wholly
impaired. The progress of the case will tell us whether the
impairment is due to clot or effusion, congestion or jar.
It is wrong, therefore, to say that the pupils are one way in

compression and another in concussion. It is right to say that in
either case they are sluggish or wholly irresponsive to light. In one
person they may be dilated, in another contracted, and in the same
person the eyes may present marked contrasts.
In the light of modern physiology this is what might be expected. The

condition of the pupils is dependent on that part of their nerve-
connections which is involved in the injury, and also upon the
method of that involvement. Clinical experience, I think, amply
sustains this view.
The reaction from what may be called pure concussion is generally

slow. The patient is apt to be dazed for some time, although the
pulse and temperature may be normal. When there is a rebound with
fever, and florid complexion, and suddenly or gradually another but
deeper unconsciousness supervenes, it is almost certain that
positive lesion took place at the time of injury, and that the reaction
has brought with it great congestion if not extravasation.
Now, really, compression to be followed by inflammation is the
condition demanding attention.
DIAGNOSIS.—The history of the case and the symptoms as detailed

will enable us to reach a conclusion in most cases as to the
existence of concussion of the brain. There are some conditions,
however, from which it is to be carefully distinguished. These are
simple fracture, with or without depression, compression from any
cause, drunkenness, and epilepsy.
There may be such profound shock with fracture that at first

concussion symptoms mask those of the lesion, or even keep them
for a time completely in abeyance. The head bruises are often very
deceptive to the touch in the search for fracture.
I am in the habit of directing students to feel their own scalps, in

order that they may appreciate the fact that the touch gives no
sensation whatever of the natural thickness of the cranial covering. It
seems as though something like a piece of thin parchment only
intervenes between the fingers and the bone. The fact is, the scalp
varies from an eighth to a quarter of an inch thick, differing in
different places, and where muscles, as the temporal, for example,
are beneath it, the bone is much deeper. The importance of this
observation lies in the fact that a pulpefied bruised mass of scalp will
cause the edges of its healthy surrounding part to feel almost
precisely like bone around the borders of a depressed fracture. The
accompanying general symptoms will mostly not be in accord with
this condition, but in some cases the deception is so complete that it
is very difficult to persuade those not familiar with the fact that a
fracture does not exist, and to induce them to refrain from rash
proceedings.
One case I can call to mind where the opinion of the attending
physician was only changed by the ultimate favorable result, which
left no sign of permanent injury of any kind. These cases are
particularly apt to occur with children.
I remember also another source of deception. A boy was severely
injured by a blow upon the forehead. Concussion was marked. There
was a lacerated wound reaching to the edge of the orbit; fractured
bone could be felt, and at first sight what appeared to be brain-
matter was oozing from the wound. A hasty unfavorable prognosis
was given to the parents. On closer examination it was found that
the fracture was of the external wall of the frontal sinus, and the
supposed brain-matter was the delicate fat-lobules of the orbit. The
patient recovered rapidly.
There is a marked distinction between the ordinary symptoms of

concussion and those of compression, whether from depressed
fracture or effusion, as of blood in apoplexy. Here there are flushed,
often swollen, countenance, stertorous breathing, slow and it may be
strong pulse, deep or absolute insensibility, and fixed pupils. The
injury, if there is one, is mostly palpable and explanatory. If it is
concealed, the other symptoms point to the true nature of the case.
The diagnosis from drunkenness is not always easy, although deep

intoxication is more apt to be accompanied with compression than
with concussion signs. Drunkards often have bruises on their heads
caused by falls, and some of them are pale and sick after debauch.
The smell of liquor is not always reliable, for it is so common after
accident for friends to administer stimulants before the patient is
seen by a medical man that he might be easily misled into too hasty
a judgment. The general appearance of the old stager is well known,
but in cases where there is the least doubt the patient, whether in
hospital or in private, should be kept a sufficient time under
observation for the effects of drink to pass off. Then it will be seen
whether this has masked a more serious condition. Too hasty
conclusions in this matter have led to most unpleasant occurrences.
These are well known in police administration and to hospital men.
The convulsions of the epileptic, the foaming mouth, and the quick
return to partial or complete consciousness will generally serve to
distinguish the case from one of concussion, but at times there are
those who require also to be kept under observation for some hours,
and even a day or more, in order to come to a correct conclusion.
The PROGNOSIS in concussion is generally favorable, but if complete

unconsciousness is present it is doubtful as to the individual so long
as this lasts, for, as before intimated, the cases which recover may
present as marked symptoms at first as those which prove fatal.
Recovery is mostly complete, but not suddenly so. The after-effects

in any case may prove serious.
There is, however, an unwarranted tendency to attribute any defect

in character, and even criminal lapses, to a blow upon the head,
especially should the history or marks of one be discovered as
having occurred at any time, no matter how long, previous to the
inquiry.
The blow may be the cause of subsequent epilepsy, chronic

inflammations, and insanity or imbecility. These cases have,
however, an almost continuous history of trouble from the date of the
injury, the manifestations varying in severity from time to time as
pathological changes go on or as exciting causes develop them.
TREATMENT.—Absolute simple rest in bed is all that is necessary in

mild cases of concussion. The patient should be well watched for
any symptoms which might supervene and show that the injury was
more severe than at first supposed. On the other hand, serious
symptoms may be present without indicating any great gravity in the
case. Children, for example, often have convulsions from the
slightest cause. I have attended them when these set in immediately
after the injury, but in a day or two there was entire recovery.
The more serious cases equally require rest, but also something
more. To bring about reaction from shock, sinapisms to the
extremities, to the nape of the neck, and over the stomach should be
used. Hot-water bags should be placed along the sides of the body
and limbs. Alcoholic stimulants must be sparingly used, if at all: they
are rarely necessary. The stomach will often reject them unless in
minute doses. If too much is absorbed, unpleasant consequences to
the brain may follow. In extreme cases hypodermic injections of
brandy or ether may be administered. Ammonia, camphor, and other
diffusible stimulants may be useful, either externally or internally.
If the reaction is regular, with gradual restoration to consciousness

and no noticeable rise in temperature, nothing further is required but
a continuance of the rest and the use of cooling drinks and spare
diet. The bowels and bladder must be attended to; the catheter may
have to be used.
Restlessness, with or without delirium, is not unusual, but it generally

subsides under full doses of bromide of potassium.
When reaction is followed by high fever, and especially when there is

with it a passing on into secondary unconsciousness independent of
true sleep, we have almost surely internal compression from
congestion, effusion of serum, or hemorrhage to deal with. Now,
blood may be taken generally or locally with great benefit. Cups,
both dry and wet, to the temples and back of the neck are very
useful. Leeching also is an efficient method of depletion. Ice in bags
or towels, or cold water, should be applied to the head. Hot water,
say about 120° to 130°, to the head is often of great service and very
soothing.
The choice between cold and hot water is to be determined by the

effects produced. Sometimes surprisingly good results come from
alternating their use. Hot mustard foot-baths may be given in bed
while the patient is kept lying on his back with the limbs flexed.
The result only in these severe cases will determine whether the
symptoms were due to great congestion or to extravasation, possibly
with brain lesion. Complete recovery takes place in the first
condition. In the latter a fatal termination is much more probable, and
if there is recovery it is apt to be only partial, and the patient may be
the victim of nervous troubles more or less pronounced throughout a
long life.
Concussion of the Spine.
John G. Johnson of New York is authority for the statement that

English railways paid in five years two million two hundred thousand
pounds, or eleven million of dollars, as damages awarded by juries
in cases of concussion of the spine. The statement appears almost
incredible, but the facts are ample to sustain it.
It also illustrates the powerful influence of one great authority

(Erichsen) better than anything I know of in the history of the medical
profession. After this celebrated surgeon's lectures and work on
concussion of the spine, etc. were published, dating back to 1866,
the great body of medical men received them as the standard and
guide in all such cases. They were a godsend to plaintiffs and
prosecuting attorneys, and the defendant had a poor chance with
juries when the possible miseries of any one who claimed
compensation for injury to the spine was pathetically pictured to
them.
That the defendants have suffered injustice in a great number of

cases I think there can be no doubt. Is it any wonder, therefore, that
a reaction has occurred of late, and that the views formerly held by
professional men have been subjected to sharp criticism founded
upon a much more scientific and practical knowledge of the subject
at issue?
As in all reactions, extreme views have been reached by certain

observers, and there are those who seem to hold that concussion of
the spine cannot occur. By spine here is meant the spinal cord or
marrow.
It has been well remarked, I think by Page, that we do not speak of

concussion of the skull. We always say concussion of the brain. The
use of the term spine has given rise to much confusion, but the
professional man will understand what is meant when so-called
concussion of the spine is under discussion.
The advocates of the rarity or even impossibility of the injury call

attention with much force to the anatomical facts. First, to the
immense strength, pliability, and cushioning of the bony and
ligamentous encasement or column; then to the ample calibre of the
canal in which the nervous cord is suspended, and to the pliant
structures intervening between its inner walls and the cord itself.
From without inward, in the canal, we have fat, watery connective
tissue, and the plexus of spinal vessels; then comes the dura mater,
loosely investing the cord and unattached to the bone, not forming
here, as in the skull, the internal periosteum. Within the dura mater is
the arachnoid, its visceral layer separated by a wide interval from the
viscus or cord, which interval contains the cerebro-spinal fluid; then
the pia mater or vascular membrane, which closely invests the cord.
Besides these structures there is the ligamentum denticulatum

passing from the dense pia mater to the parietes of the canal and
supporting the cord and roots of the nerves in the most efficient way
—pliable enough to yield and break the force of vibrations, and
strong enough to sustain.
Thus we see that the cord is much more securely protected from the
effects of external violence than the brain, and we can understand
that there is reason for the doubt of the sceptics as to the frequency
of the injury described as concussion of the spine.
Clinical observation is, I think, of far greater value in determining

questions of the kind than any theory, however strongly supported by
anatomical facts. Does transient concussion of the spine occur as
transient concussion of the brain occurs? Page, if I understand him,
says not. In his work on Injuries of the Spine and Spinal Cord
(London, 1883), in criticising a well-known case as to the claim of
persistent paraplegia without discoverable lesion, he says: “We
italicize the word persistent, for simple concussion of the brain may
give rise to a transient unconsciousness, and, if the analogy holds
good, concussion of the spine should per se produce a transient
paraplegia. We know of no case, nor can we discover the history of
any case, where this has happened.”
I italicise the last sentence. In 1881 a boy came under my care who
was shot in the back three inches to the right of the third or fourth
dorsal vertebra. He at once had characteristic symptoms in the legs
of being wounded in the spine in such a way as to affect the cord
somehow. There was partial paraplegia, with pains in both limbs.
Under rest these symptoms soon disappeared. In a few days I made
a deep incision and removed some clothing and fragments of bone,
and then from the depths of the spinal gutter I took a large conical
ball which was resting against the bony bridge of a vertebra. The boy
recovered rapidly. I saw him some months afterward perfectly well.
Surely, this was a case of spinal shock or concussion with transient

paraplegia, and the cause of it could have been nothing else than
the impact of the ball against the column, producing vibratory jar
sufficient to affect the cord. The immediate symptoms and the rapid
and complete recovery are, in my opinion, inconsistent with any
theory of congestion or pronounced lesion of the medulla.
Here is another case of transient paraplegia also occurring in 1881,

and, to my mind, still more significant: A man fell from a height of
about twenty feet and landed directly on his feet. He was
immediately paraplegic. On examination no injury to the spinal
column could be detected, but there was fracture of both calcanea.
The spinal symptoms were thoroughly marked. Besides the paralysis
of the limbs there was loss of control of the bladder and bowels, and
the other accessories in such cases. But all went on to recovery. Pari
passu with the fractures the spinal symptoms improved. It is not
necessary here to give further details, but simply to state that in four
months, the time required being chiefly due to the fractures, the
patient was discharged able to walk and well in every other respect.
If this is not a case of transient paraplegia owing to spinal shock or

concussion, I am willing to admit that I do not know the requirements
of the critics when they ask for such cases. I think that it is no matter
how the blow or shock to the column is received, whether direct or
indirect, so that it is shown that the medulla is influenced within the
line of recovery, without having suffered fairly presumable lesion.
President Garfield surely suffered from transient spinal shock

produced immediately by impact of the bullet upon the column. The
symptoms soon passed off, and at the post-mortem the cord was
healthy in every respect. The differences between his case and the
others I have mentioned were those of degree only, his concussion
not being severe enough to cause paraplegia.
Spinal concussion or shock from railway collisions does not differ

from forms of the same injury received in other ways. It is absurd,
therefore, to give a peculiar pathological history to so-called railway
spine. That the injury occurs, I have no doubt; that the medulla is
seriously affected in the vast majority of cases, I have very great
doubt.
I cannot now, after thirty years of hospital and private practice, call to
mind a single case of concussion of the spine arising from other
accidents than on railways which has had the terrible after-history
that is so often attributed to them; and I have seen in that time many
cases of spinal injuries of all kinds.
There is another fact of personal experience. I have examined many

cases of claimed irreparable or serious injury to the spine in private,
both for plaintiff and defendant, in impending suits, but I cannot
remember a single application of a patient for admission to the
hospital to be treated for the after-effects of concussion of the spine,
the original injury having been received in a railway collision.
As all sorts of people ride on railways, it is strange that the numerous

recipients of concussions of the spine are pecuniarily independent of
hospitals. One old fraud I do remember who fell from a street-car
and claimed lasting injury to the upper part of the spine and the
head, and adequate compensation for it in court. I was not called as
a witness at the trial, and the plaintiff recovered very heavy
damages. These were afterward reduced to a much smaller amount
when it was discovered what I knew about the case.
Other structures of the spine besides the medulla are much more
subjected to injury than it is, and their consequences often mislead
both patient and doctor, especially the former.
The ligaments and muscles are exposed to contusions, strains,

ruptures, and twists which are wrongly attributed to concussion.
From these injuries and from so-called concussions the patient
recovers rapidly or slowly according to their extent. If damages are
looked for from a corporation, he is in a state of what may be called
expectant pecuniosity, and shows no amendment until the question
is settled. Otherwise, he gets well, as those do who are injured but
have no expectations.
There is a striking want of confirmation by post-mortem examination

of the terrible effects which are said to follow concussion of the
spine.
In fact, the records of such examinations are so few, notwithstanding

the immense number of those who have claimed to have the injury
that the sceptics are somewhat justified in attributing the few cases
which have shown great pathological changes in the cord and its
membranes to the coincidence of disease, as myelitis or syphilis, or
to much graver injuries than concussion.
I have reported a case in full in the Medical News and Abstract

(Philada., Nov., 1881) which illustrates how coincidence might easily
play its part in a supposed concussion. This feature of it is not
alluded to in that paper. A gentleman began to complain of pain
posteriorly at the root of the neck. Paralytic symptoms gradually
developed. It is unnecessary to repeat the details here, but the
history was a most dreadful one, and precisely that of the few
serious ones described in the works on concussion. Within a year
the patient died. The autopsy revealed a meningitis and softening
and destruction of the cord to the extent of two and a half inches of
its brachial enlargement. There was no other disease. Now, this
patient frequently travelled on railways, and if he had been subjected
to the slightest accidental shock it would have been received on all
sides as the cause of the disease. There was, however, no such
history, nor was anything ever known to account for the fact that a
man in otherwise perfect health should have two and a half inches of
his spinal cord as it were spontaneously destroyed.
I will state in passing that this case did not confirm the views of
Johnson and others as to there not being any severe pain on
pressure in myelitis. It showed also that clinical observation is not
always in accord with plausible anatomical facts or reasoning.
Thus, Johnson says: “It is a mistake to suppose that meningitis or

myelitis is accompanied by pain on pressure: the spinal cord is
surrounded by a bony wall thicker than the bones of the skull, and
you might as well press on the head to see if the brain is diseased.”
Now, in this case the pain was simply atrocious and greatly
increased by pressure. To relieve both it and the disease the actual
cautery was applied on both sides of the spinous processes; and
some estimate may be made of the sufferings of the patient, who
would not take ether, when he exclaimed as the hot irons were
burning through his tissues, “Oh, that is better than the pain.”
To sum up, then, I think I have shown that concussion of the spinal
cord proper occurs. I also believe it may occur in a railway collision
just as it occurred in the man who fell twenty feet. Why should not a
traveller sitting in a peculiar position—with his feet, for example,
firmly against a partition or wall of the car—suffer it in a collision.
On the other hand, the great majority of those who after accidents
claim injury to the spinal cord as the cause of their disabilities are
wholly mistaken. The question is of great importance, for upon it
depends the testimony as to whether the patient has sustained
temporary or permanent injury.
Each case must be studied on its own merits. There is no class of

injuries so full of opportunity for the exaggerator or malingerer. The
history of many of them is by no means complimentary to human
honesty. Those interested can study the special works on the
subject: space is not given to detail them in this paper.
The SYMPTOMS and PROGNOSIS of concussion of the spine may be
almost inferred from what has been written above. There are
tinglings, pain, and sometimes cramps in the limbs; there may be
partial or complete paraplegia which is transient in character.
Complete paraplegia is very rare, and when it exists it almost always
indicates a more serious injury than concussion. The case I have
cited is an exceptional one.
The bladder is almost always affected; there is either suppression or

incontinence. The bowels are sluggish for a time. The pulse is mostly
quickened; the temperature does not vary much from the normal.
Priapism, which is so frequently present in wounds involving the
spinal column and cord, is not present in concussion.
I have in the Medical News (Nov., 1881) given my reasons for

believing this symptom to be due to a coincident impression or
laceration of the sympathetic nerve when there is a fracture or other
injury of the vertebra. This view I have been able to sustain by a
case reported in the Medical News (Philada., Feb. 25, 1882).
The PROGNOSIS of concussion of the spine is generally favorable. The

recovery is slow in pronounced cases. Where such terrible
consequences follow as are described in some of the cases which
have been caused by railway collision, there is reason to believe that
the original injury was either too severe to come under the head of
concussion, or that some coincident deterioration was present at the
time of the accident.
The DIAGNOSIS from fractures and dislocations is mostly easy. In

these cases the local and general symptoms are nearly always so
definite as to give no trouble in coming to a conclusion as to their
nature. In obscure cases time will develop the truth.
In the TREATMENT of concussion of the spine the great remedy is rest.

Under this alone the slight cases will rapidly recover. The more
severe ones will require other aids, such as cupping, both wet and
dry, to the spine over and about the chief seat of complaint.
Sinapisms, blisters, and iodine are useful in the order named. Opium
will be borne much better for the relief of pain and restlessness than
in like injuries of the head. The natural functions must be looked
after. Both the catheter and enemata may be required. Great care
must be taken to provide against chafing of the skin and bed-sores.
For this I know of nothing better than repeated sponging with
alcohol, and drying the surface at once by a good rubbing. The
points of pressure should be frequently changed by shifting the
patient.
As soon as the acute symptoms pass away the patient should be

encouraged to rise and use moderate exertion. This, if well borne,
should be increased day by day, for it will be soon found whether the
efforts are injurious or not. All the requirements are present in these
cases to produce chronic hysterical invalids, both male and female. It
is therefore incumbent upon the medical attendant to protect his
patient from discouraging surroundings of any kind. It is also his duty
to so act that while he will be careful to work no injustice, he will at
the same time be on the watch for malingering, for this will often be
practised, especially by those who are among the expectants
already mentioned in this article.
INTRACRANIAL HEMORRHAGE AND

OCCLUSION OF THE CEREBRAL VESSELS,
APOPLEXY, SOFTENING OF THE BRAIN,
CEREBRAL PARALYSIS.
BY ROBERT T. EDES, M.D.
The various subjects embraced in this article are so closely united to

each other, both in a clinical and in a pathological point of view, that
they must be considered to a certain extent in common. It is of
course more systematic to group them entirely according to the
obvious and final lesion, as hemorrhage, thrombosis, or embolism;
but when it is considered how very closely the symptoms of one
affection may counterfeit those of another—so closely, in fact, that a
diagnosis with absolute certainty is not only difficult, but often
impossible—and also that similar conditions of the vessels may give
rise either to rupture or occlusion, so that not infrequently two sets of
lesions may be found in the same brain, and, finally, that the basis of
prognosis and of the later treatment is not unlike in different lesions,
—we are surely justified in bringing them, at least in the beginning,
under a common head.
Intracranial hemorrhage, and especially cerebral hemorrhage, is the

lesion which more frequently than any other gives rise to the group
of symptoms known as apoplexy, and from this fact has arisen the
frequent incorrect application of the word apoplexy, in a pathological
as well as a clinical sense, to indicate an extravasation of blood, as
in the so-called pulmonary apoplexy, where the anatomical lesion,
being an extensive effusion of blood into the tissues of the lung,
bears an apparent resemblance to the state of the brain often found
in apoplexy primarily and properly so called, the symptoms, however,
being entirely different. This error receives additional support from
the fact that in some injuries to the brain, especially to the base,
pulmonary hemorrhage may secondarily take place. Apoplexy,
however, is not always the result of hemorrhage, but occurs with
many cases of embolism and of thrombosis, and is sometimes, so
far as we can tell, dependent upon neither of these conditions,
recovery in one set of cases taking place so rapidly as to preclude
the supposition of a considerable organic lesion, and in others, which
are fatal, nothing being found beyond an excess of serum or of
vascularity, and sometimes not even that. The first of these
conditions has been called simple apoplexy, but with our present
knowledge its simplicity seems to border closely on ignorance, or at
any rate is not of a character to satisfy the inquiring mind. It is
therefore better to retain the term apoplexy strictly as a convenient
term for a certain set of symptoms, but, whenever possible to
substitute for it an anatomical description of the lesion found post-
mortem or diagnosticated with reasonable probability during life.
The practitioner may very properly, and without laying himself open
to criticism of his diagnostic accuracy, return the cause of death in a
case of sudden death, or where his opportunity for observation has
been limited, or where no post-mortem examination has been held,
as being apoplexy; but in others, where the symptoms were decisive
or a post-mortem has disclosed the exact lesion, the condition of the
cranial contents should be stated. It is also a not uncommon mistake
—or rather piece of carelessness—to speak of small hemorrhages in
the brain as small apoplexies. A small extravasation may give rise to
slight symptoms or next to none, but a real apoplexy can hardly be
small, although it may be short.
The root from which the word apoplexy is derived seems to have
been used by the classic writers in something like its present clinical
signification (Απορληκτος, seized with (apoplexy or) stupor—
Aristophanes; mad—Demosthenes; Αποπλησσομαι, to be struck with
amazement—Sophocles). Morbus attonitus, another of its names,
expresses a somewhat similar idea.
Morgagni was familiar with cerebral hemorrhage, and Bonetus in the

Sepulchretum gives several cases. The allusions of Galen and
Hippocrates supposed to refer to this lesion are not unequivocal,
although the Father of medicine could hardly have helped being
familiar with the symptoms of so striking a form of disease.
Cerebral softening has been recognized since the early part of the
present century, and in some of the cases thirty years ago an
efficient cause, in the form of arterial disease, assigned to it; but the
complete theory of its causation forms a part of the general doctrine
of embolism and thrombosis which was so largely developed and
systematized by Virchow. Andral and Durand-Fardel had apparently
no idea of the exact mechanism of its origin, the latter supposing it to
depend upon inflammation, while Todd mentions a case where
softening giving rise to paralysis depended upon a dissecting
aneurism of the carotid. He seems to have generalized so far as to
say that white softening is atrophic, but the precise way in which this
localized atrophy was usually brought about evidently escaped him.
According to him, the suddenness of the attack was owing to a
gradual disorganization of the brain-substance with few or no
symptoms, and then a sudden rupture of diseased fibres by some
accidental cause or by their having reached the extreme limit of
cohesion.
Intracranial hemorrhage may be situated outside of the dura mater,

separating this membrane from the bones of the skull and producing
more or less compression of the brain. It is usually the result of a
blow, but not necessarily of a fracture of the skull. When a fracture is
present, blood may pass through it from the interior and give rise to
an external extravasation in addition to that which is likely to be the
direct result of the blow upon the skin and subjacent soft parts. The
middle meningeal artery is a frequent source of this hemorrhage.
Hemorrhage in this position will naturally give rise to symptoms of
compression, and, if the fact of the blow be not known or the fracture
manifest, may be mistaken for some of the deeper-seated forms.
Blood may be effused upon the surface of the brain in the so-called
cavity of the arachnoid—that is, outside of the pia mater—or in the
meshes of this membrane, following its course along the sulci. This
also is not infrequently the result of violence either with or without
fracture of the bone. Its source is likely to be found in the veins which
empty into the longitudinal sinus from the surface of the brain.
Rupture of a lateral sinus from a not very severe blow has been the
source of large and fatal hemorrhage.1 Blows upon the head, with or
without fracture of the cranial bones, are likely to cause rupture of
the cerebral substance with hemorrhage, and this may find its way to
the outside and cover more or less of the surface. Such injuries to
the brain, it is important to note, do not necessarily correspond
immediately to the place of the blow or to the external ecchymoses.
Meningeal hemorrhage in this region may, however, be observed
when no injury has been received, or at least when there is neither
history nor external traces of any.
1 Cincinnati Clinic, p. 135, 1874.
The conditions under which it occurs may not vary greatly from those
of the more ordinary intracerebral effusion. In two instances under
the observation of the writer the source of hemorrhage has been a
vessel of small, but not the smallest, calibre (artery), situated near
the fissure of Sylvius, in the lower parietal or temporo-occipital lobe.
In children meningeal hemorrhage is, with only a few exceptions, the
usual lesion of apoplexy. The blood is usually dark and coagulated in
recent cases. Blood found under the membranes where no fracture
has taken place is, however, more likely to have been derived from
the brain-substance and to form part of a cerebral hemorrhage.
Hemorrhagic pachymeningitis, indicated by a layer of fibrin included

between the dura on the one hand and a false membrane on the
other, is met with in connection with meningeal and cerebral
hemorrhages. It is supposed to depend on a small and thin
hemorrhage upon the surface of the brain, which forms, by its irritant
action, a false membrane about itself. It is found usually over the
vertex.
Hemorrhage into the ventricles is nearly always the consequence of

a hemorrhage in the brain-substance breaking through, although it
may in rare cases originate in the vessels of the choroid plexus,
velum interpositum, or meninges. Its source, however, is sometimes
so near the surface as to cause but little laceration of the cerebral
tissue. The blood breaking into any one of the ventricles may be
found in one or all of them (except the fifth), and form quite an
accurate cast of their shape.
The most common form of intracranial hemorrhage, however, which
most nearly concerns us here, and which is generally meant when
sanguineous apoplexy is spoken of, has its principal seat in the brain
itself, which is, of course, more or less lacerated. Such hemorrhages
may vary greatly in size, from a mere red point (punctate or
capillary), of which many may be present at once, to one of many
ounces, filling a large cavity of nearly the length of one hemisphere,
and pushing the torn and compressed brain-substance before it in
every direction. The amount of laceration produced of course varies
greatly; sometimes it seems as if nothing more than a pushing aside
of fibres without rupture had taken place, while at others large
masses of tissue are torn away and mixed up with the blood into a
pulp.
In a recent hemorrhage the clot itself, speaking of those of a size

above the capillary, is usually homogeneous, the brain-substance
surrounding it ragged, œdematous, yellowish or red, and frequently
containing many minute secondary hemorrhages. The rest of the
brain is frequently found anæmic from pressure, the convolutions
flattened, the surface dry, and the section exhibiting a diminished
quantity of blood. In older cases, however, and probably also in
some where atrophy, senile or otherwise, has preceded the
hemorrhage, this condition is not found, and we may have the
convolutions shrunken and the meshes of the pia containing an
excess of serum.
If death does not take place speedily, the clot undergoes

degenerative changes. Its color becomes somewhat lighter,
chocolate color, reddish-yellow, or yellowish-red. A portion is
absorbed, and after a time the cerebral substance in the
neighborhood forms about it a wall of some density, so that finally
nothing is left but a cyst with fluid or semifluid contents, and often
remains of connective tissue. Sometimes the absorption of a clot of
moderate size is so complete that only a firm mass of a reddish or
yellowish-brown color marks the seat of an old hemorrhage. The
brain-substance in the neighborhood may be more or less atrophied,
and a distinct depression may be noted over the position. The
microscope shows in a fresh hemorrhage only broken-down nerve-
tissue and blood and vessels more or less degenerated. In an older
one the blood-corpuscles have disappeared, but masses of pigment
of a dark yellow or a brownish-red remain to show the former
presence of blood. This pigment occurs in the form of rounded
granules or of small rhombic crystals, and has received the name of
hæmatoidin. The light-yellow masses often found along the course of
the cerebral vessels are not evidence of hemorrhage, but of
congestion merely. The so-called inflammation or granulation
corpuscles, which are simply the fattily degenerated cells of the
organ in which they are found, and which usually possess no
distinctive form, being simply round masses of fat-drops, are often
met with in the brain in hemorrhage or softening. It is sometimes
perfectly evident, however, from their form, triangular or pyramidal,
that they are degenerated nerve-cells. The blood-vessels, those just
above the size of capillaries, are usually in a condition of fatty
degeneration, masses of dark granules occupying more or less
densely the line of their walls. A mere deposit of fatty granules inside
the perivascular sheath, but outside of and not involving the walls of
the arteries, may present the appearance of a degeneration of the
walls themselves. This condition may be a consequence of any
lesion involving degeneration of brain-tissue, and in no way a cause.
The intermediate stages of transformation in a hemorrhage are less

frequently found than the recent or old ones, since the patient, if he
does not die within a few days, is likely to live for some weeks or
months.
The changes taking place in the clot itself within the first few days
are not very marked, but the walls of the cavity may become softer
and more deeply colored, at first red and afterward yellow. Blood-
crystals have been detected on the seventeenth day (Virchow). The
following descriptions have been given of clots of different ages:
Eleven days—reddish-yellow softening clot, with brain-tissue stained
for half an inch in depth, and brain rather hard in vicinity. Eighteen
days—cavity with its edges anteriorly and superiorly sharply defined,
with the edges posteriorly ragged and yellowish, filled with a

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I. ERIKSON’S THEORY OF INFANT AND TODDLER PERSONALITY (p. 184)

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Of nineteen cases of recovery from concussion of the brain of which

The SYMPTOMS of concussion of the brain range from a mere daze or

There may be retention of urine and sluggishness of the bowels, but

It is wrong, therefore, to say that the pupils are one way in

In the light of modern physiology this is what might be expected. The

The reaction from what may be called pure concussion is generally

DIAGNOSIS.—The history of the case and the symptoms as detailed

There may be such profound shock with fracture that at first

I am in the habit of directing students to feel their own scalps, in

There is a marked distinction between the ordinary symptoms of

The diagnosis from drunkenness is not always easy, although deep

The PROGNOSIS in concussion is generally favorable, but if complete

Recovery is mostly complete, but not suddenly so. The after-effects

There is, however, an unwarranted tendency to attribute any defect

The blow may be the cause of subsequent epilepsy, chronic

TREATMENT.—Absolute simple rest in bed is all that is necessary in

If the reaction is regular, with gradual restoration to consciousness

Restlessness, with or without delirium, is not unusual, but it generally

When reaction is followed by high fever, and especially when there is

The choice between cold and hot water is to be determined by the

John G. Johnson of New York is authority for the statement that

It also illustrates the powerful influence of one great authority

That the defendants have suffered injustice in a great number of

As in all reactions, extreme views have been reached by certain

It has been well remarked, I think by Page, that we do not speak of

The advocates of the rarity or even impossibility of the injury call

Besides these structures there is the ligamentum denticulatum

Clinical observation is, I think, of far greater value in determining