Children: Stages of Growth and Development
E Rivers, Ealing Hospital, London, UK
r 2016 Elsevier Ltd. All rights reserved.
This article is a revision of the previous edition article by H. Hayden-Wade, L.K. Leslie, volume 1, pp 325–338, © 2005, Elsevier Ltd.
Abstract
This chapter provides a brief overview of children’s (defined age 0–18 years) growth and stages of
development. In particular, it identifies general patterns of growth (including weight, height, head
circumference, brain growth, and puberty) and the acquisition of developmental milestones from childhood
through adolescence.
Normal Growth and Puberty
Normal growth follows three important phases with
peaks of rapid growth in infancy and at puberty (Sidwell
and Thomson, 2011):
1. Infantile (birth – 2 years): Rapid growth (nutrition
dependent).
2. Childhood (2 years – puberty): Constant growth rate
(5–6 cm year
1) (growth hormone dependent).
3. Pubertal: Accelerated rate of growth to a peak,
then slowing to a stop (growth and sex hormone
dependent).
Weight
After an initial period of weight loss during the imme-
diate postnatal period, birth weight is regained between
the 10th and 14th postnatal day. Between the ages of
2 weeks and 6 months, the average weight gain equals
20 g (0.71 oz) per day and decreases between 6 and 12
months to 15 g (0.53 oz) per day. Across the second
year, weight gain slows considerably, with the average
monthly weight gain at 2.5 kg (8.82 oz or 0.55 lb).
A quick rule of thumb for the first 2 years of life is that
birth weight doubles by 4 months, triples at 12 months,
and quadruples at 24 months. After age 2, average weight
gain until adolescence is 2.3 kg (5 lb) annually.
Length/Height
Rough guidelines suggest that birth length is doubled by
4 years of age and tripled by 13 years of age. By the end
of the first year, birth length increases by 50%. The
average height gain across year 2 is 12 cm (5 in.). From
age 2 to the beginning of adolescence, the average child
will grow 5 cm (2 in.) per year. Adolescence ushers in a
second growth spurt with respect to length/height. In
adolescence, a typical (average) maximum growth spurt
for a male is 10.16 cm (4 in.), whereas for female ado-
lescents, their growth spurt averages 7.52 cm (3 in.)
during its peak. By the end of the adolescent period,
Encyclopedia of Forensic and Legal Medicine, Volume 1
both males and females reach 99% of their adult
height. Linear growth is completed following epiphyseal
fusion.
Of note, length is no longer routinely measured at
birth as it is difficult to measure accurately and weight is
thought to be a more reliable indicator of growth (and
nutrition) in infancy. Height becomes a more important
marker of growth after infancy.
Head Circumference
Head circumference is routinely measured during the
first 2 years of life. During this time, the brain is growing
rapidly and the open sutures between the bones of
the skull are closing. Between birth and 2 months, the
average head growth in 1 week is 0.50 cm (0.20 in.),
and then slows to 0.25 cm (0.10 in.) between 2 and
6 months. The average total head circumference growth
from birth to 3 months is equal to 5 cm (1.97 in.), and
4 cm (1.57 in.) average from 3 to 6 months. This trend
continues to decelerate across the first year; between
6 and 9 months, head circumference increases 2 cm
(0.79 in.) and between 9 and 12 months, head circum-
ference increases only 1 cm (0.39 in.), approximately.
During the second year, a child’s head growth slows
(i.e., 2.5 cm or 1 in., for the entire year), although
attainment of 90% of adult head size occurs by the end
of that year.
Puberty
Puberty is assessed using Tanner staging (see Table 1;
Tanner, 1952). Onset of puberty in girls is said to be at
breast stage 2 and in boys is with testicular size of 4 ml
and above. Pubertal growth spurts happen at breast
stage 3 and testicular volume 10–12 ml in girls/boys
respectively.
Measurement of Growth
Because abnormalities of growth may be the first pre-
senting sign of a medical condition or environmental
doi:10.1016/B978-0-12-800034-2.00060-4 539
540 Children: Stages of Growth and Development

Table 1 Tanner staging growth abnormalities can be identified by monitoring

trends in children’s height and weight. This may be
Code Stage
difficult to obtain in the forensic setting and may require
Both girls and boys corroboration with, for example, primary care physician
P1 No pubic hair or school nurse and looking in the personal child health
P2 Small amount of downy hair record or ‘red book.’
P3 Adult type hair (coarse), starting to spread laterally There are specific growth charts for some known
P4 Like adult but smaller area
medical conditions that impact on growth such as
P5 Adult
A1 No axillary hair Down’s and Turner Syndromes. It is important that
A2 Hair present (small amount) measurements are plotted on growth charts that are
A3 Adult appropriate to underlying conditions as well as to age
group and sex of the child.
Girls
B1 Prepubertal Although the definition of a ‘normal’ distribution
B2 Breast budding means that 1% of children will have measurements that
B3 Development of breast mound plot outside the range of three standard deviations of the
B4 Areola projects at angle to breast mound mean without any underlying problems, it is generally
B5 Adult accepted that children o0.4th or 499.6th centiles
Boys should be referred for assessment. Equally, those who
G1 Prepubertal fall outside of the expected range for their parents
G2 Testicular volume Z4 ml, scrotal laxity should also be assessed. The mid-parental height can be
G3 Scrotal texture more adult, penile lengthening used as a marker for predicted growth potential and
G4 Darkening scrotum, more prominent glans, and broadening of should be taken into account. It follows that a child born
penis
of short parents is unlikely to be the tallest in the class.
G5 Adult
Mid-parental height:
Source: Adapted from Tanner, J.M., 1962. Growth at Adolescence, second ed. Oxford,
UK: Blackwell Scientific Publications. Mother’s height þ Father’s height
Girl ¼
7 cm
2

stressor, medical professionals, including forensic scien-

tists, should plot an individual child’s height, weight, Mother’s height þ Father’s height
Boy ¼ þ 7 cm
and head circumference on cross-sectional growth 2
charts. The World Health Organisation provide growth
Some causes of short stature are listed in the box below
charts for weight, height, and head circumference
(Table 2) and can be grossly divided into three patterns
measurements with centiles to compare individual re-
(Bedwani et al., 2011):
sults to the normal population (see Figures 1–4). When
measuring growth, it is important to remember that al- 1. Short and thin ¼ chronic disease or emotional
though single values can be useful in assessing whether deprivation
growth is within the normal range, monitoring the trend 2. Short and fat ¼ endocrine problem
in growth provides more useful information. 3. Short and dysmorphic ¼ syndrome.
In order to assess rate of growth, measurements need
It is important to note that in malnutrition initially
to be plotted over a 6–12 month period. Growth velocity
weight only is affected. However, with chronic mal-
can be calculated by taking two measurements 4 months
nutrition height (and head circumference in infants) is
apart and dividing by the time period to give a value in
also affected. It should also be borne in mind that
cm per year and can also be plotted on centile charts.
obesity is also a form of malnutrition and a growing
Bone age can be a useful marker when assessing
problem in the developed world.
growth. Bone age is a marker of skeletal maturity rather
Some causes of tall stature are listed in the
than growth potential. It is calculated by looking at the
table below (Table 3).
number of fused epiphyses on wrist X-ray and is used
Puberty can be abnormal by occurring too early
particularly in the assessment of short stature.
(precocious), late (delayed), or disordered.
Precocious puberty:
Abnormalities of Growth and Puberty • Girls: o8 years
• Boys: o9 years
Plotting growth is an important part of evaluating
Delayed puberty:
medical and social well-being. There are a number of
medical and social/environmental conditions that can • Girls: 413 years
impact on growth and puberty. Particular patterns of • Boys: 414 years
Children: Stages of Growth and Development 541

Figure 1 WHO growth chart boys 0–4 years.

542 Children: Stages of Growth and Development

Figure 1 Continued.
Children: Stages of Growth and Development 543

Figure 2 WHO growth chart girls 0–4 years.

544 Children: Stages of Growth and Development

Figure 2 Continued.
 Children: Stages of Growth and Development

Figure 3 (a, b) WHO growth chart boys 2–18 years.

545
546 Children: Stages of Growth and Development

Figure 3 Continued.
 Children: Stages of Growth and Development
Figure 4 (a, b) WHO growth chart girls 2–18 years.

547
548 Children: Stages of Growth and Development

Figure 4 Continued.

Table 2 Causes of short stature
Familial
Constitutional
Psychosocial deprivation
Chronic illness
Endocrine abnormality (e.g., growth hormone deficiency,
hypothyroidism, and Cushing’s syndrome)
Skeletal dysplasias
Chromosomal abnormalities (e.g., Down’s syndrome and Turner
syndrome)
Table 3 Causes of tall stature
Familial
Endocrine (e.g., precocious pubertya, congenital adrenal hyperplasiaa,
growth hormone secreting tumors, and hyperthyroidism)
Chromosomal abnormalities (e.g., Klinefelter’s, Marfan’s,
homocystinuria, and Beckwith–Wiedermann)
a
Note that final height will be short as condition affects timing of increased growth
velocity (growth spurt) and does not alter growth potential. Earlier increased growth
velocity results in children being taller than peers who have not yet started their
growth spurt. However, an earlier growth spurt results in earlier epiphyseal fusion
and overall reduced adult height.
The order of progression of Tanner stages (1952,
1962) (see Table 1) is just as important as timing. It
indicates whether the problem is central (hypothalamic–
pituitary axis (HPA)-dependent) or peripheral (HPA-
independent).
Early puberty happening in the right order indicates a
problem with premature activation of the central axis
(e.g., familial, brain tumors, hydrocephalus, post sepsis,
and hypothyroidism). Isolated thelarche (breast devel-
opment), menarche (onset of menstruation – usually
breast stage 4), or adrenarche (pubic and axillary hair
development) are, however, usually caused by excess sex
steroids without HPA axis activation (e.g., adrenal/
gonadal tumors).It is important to note that while cen-
tral precocious puberty in girls is usually not concerning,
in boys is nearly always pathological (Bedwani et al.,
2011). Suspected growth and puberty abnormalities
should include some of the investigations in Table 4
(under specialist advice) and treatment will depend on
the underlying condition.
Normal Development
Brain Growth
The brain, at birth, is closest to its adult size than any
other organ – in fact, it is considered close to 80% of its
adult weight. By age 6, a child’s brain is closer to 90% of
its adult weight. However, while the brain’s weight does
not change substantially, significant formation of brain
Children: Stages of Growth and Development 549
Table 4 Investigating growth abnormalities
Plot weight, height, mid-parental height, and head circumference
FBC, U and E, LFT, bone profile, TFT, and IGF1/IGFBP3a
Karyotype
Visual fieldsb
Bone age
USS pelvisc
Neuroimaging
a
Due to the pulsatile nature of growth hormone secretion, IGF1/IGFBP3 are better
markers of growth hormone deficiency than measuring growth hormone levels.
b
Pituitary tumors may press on the optic chiasm leading to visual field defects.
c
Looking for presence of ovaries/uterus.
Abbreviation: FBC, full blood count; IGF1, Insulin-like growth factor 1; IGFBP3, Insulin-
like growth factor-binding protein 3; LFT, liver function test; TFT, thyroid function test;
U and E, urea and electrolytes.
neurons and remodeling of neuronal paths is occurring
during childhood and adolescence.
The brain’s development is most rapid during the
initial 2 years of life. Prenatally, 250 000 million neu-
rons are formed per minute. Ultimately, between 100
and 200 billion neurons make up the brain, and are
responsible for storing and transmitting information as
well as providing neurological interconnection with
other neurons. Remodeling is also occurring. Neuronal
paths are being remodeled consistently through dendritic
branching (i.e., dendrites, or the thread-like extensions
of the cytoplasm of a neuron, branch into tree-like
processes, composing most of the receptive surface of a
neuron) and myelinisation (i.e., the process within which
a lipid-rich substance coils to form a protective sheath
surrounding the axon of nerve fibers to provide efficient
transmission of neuronal messages across nerve fibers).
An important developmental aspect of the brain to
consider in working with children involves the specific
order in which the various areas of the cortex develop.
The cerebral cortex, which surrounds the brain and
comprises 85% of the brain’s overall weight, provides
the intellectual capacity that differentiates human beings
from our animal counterparts. The order of develop-
ment of certain areas of control within the cerebral
cortex parallels the sequence of acquisition of different
developmental milestones and capacities as the child
matures. With respect to motor skills, cortex develop-
ment dictates a cephalocaudal progression of develop-
ment, which is marked by truncal coordination at the
outset, followed by mastery of the extremities. In the
domain of emotional, behavioral, or adaptive skills,
cortex development continues to mature through
adulthood; for example, the last section of the cortex to
develop is the frontal lobe (responsible for thought and
consciousness).
First quantified by Gesell (1932, 1935), child devel-
opment is a dynamic, orderly, and cumulative process
by which a child undergoes a series of qualitative
changes in skill levels at predictable time intervals called
developmental milestones. There are four generally
550 Children: Stages of Growth and Development
recognized domains of development for a child in the
first 6 years of life where the most rapid development
occurs:
1. gross motor
2. fine motor
3. speech/language
4. social.
Gross motor skills involve large muscle groups and
are essential for skills like running, jumping, rolling, and
balancing on one foot, whereas fine motor skills refer to
a child’s ability to manipulate items with the hands and
fingers, such as holding a spoon or turning the pages of a
book. Speech/language development reflects a child’s
ability both to understand and express language. Social
skills include abilities such as a child’s capacity to relate
to and interact with others, to self-soothe, and to self-
control.
Table 5 describes the normal timing and order of
developmental milestones for the first 6 years of life. It is
important to remember that there are wide ranges of
timings at which these skills are acquired normally.
Newborn Reflexes
Initially, all infants display a series of primitive
reflexes, which are lost as infants develop volitional
movement, generalized mass activity, and ultimately
specific responses. At birth, there are over 70 reflexes
exhibited by infants and tested, most of which are ex-
tinguished between 2 and 12 months of age.
Gross Motor Development
All children pass through similar sequences of motor
development, which progress along with the maturation
of the central nervous system in a cephalocaudal (trunk-
to-extremity ordered progression of development and
control) as well as proximal-to-distal direction. Again,
first cephalocaudal progression is marked by truncal
coordination, followed by the child’s mastery of motor
action in the extremities. The proximal-to-distal pro-
gression is seen in the coordination of upper extremities
first, followed by lower extremities. School-age children
and, later, adolescents, continue to master more com-
plicated sequential motor activities necessary for activ-
ities such as sports and driving, for example.
Fine Motor Development
The timing or acquisition of fine motor developmental
milestones involves less variability than gross motor
development.
Speech/Language Development
Although infants do not often have formal word use
until age 12 months, the first 12 months are critical to
development in terms of understanding that words are
concepts for objects. Ultimately, children will compre-
hend the meanings of various words as they continue to
develop. It is not uncommon for a child to display slow
mastery or use of new words until 18 months, followed
by a burst of language production and comprehension at
the end of the second year. Language skills continue to
be acquired, including use of prepositions, adverbs, and
adjectives (age 3 years) as well as rules of grammar (age
3–6 years). Language development from age 7 through
adolescence focuses primarily upon the social prag-
matics of the use of language.
Social Development
Normal social development is dependent largely on the
child’s environment and the number and type of inter-
actions they experience. The presence or absence of
other household members and family dynamics can
impact hugely on this area of development.
Cognitive skills refer to a child’s ability to learn new
material and solve problems and are relevant to all four
domains. Development in the early years is dominated
by acquiring motor skills, whereas latter years focus on
cognitive/language/psychosocial development.
There are a variety of psychological theories for
emotional, behavioral, and adaptive development; ex-
amples of which are discussed below.
Emotional/Behavioral/Adaptive Development
Freud and psychoanalytic theory
Although current developmental theorists view Sigmund
Freud’s psychoanalytic theory of development as too
narrow in focus, most respect and recognize his im-
portance as a pioneer in the field. Freud asserted that all
children progressed through a series of five stages. Each
stage involves crises to work through, the outcome of
which ostensibly affects adult interpersonal and emo-
tional functioning. The earliest phase (0–1.5 years or
infancy), or oral phase, revolves around feeding and oral
gratification; in order to progress to the next stage, an
infant ‘learns’ to separate itself from its mother in
learning the centrality of self (which Freud referred to as
primary narcissism). The conflict of the second stage
(anal; 1.5 –3 years) involves rebellion versus compliance
with parental demands as well as fear of loss of
parental love.
During the middle psychoanalytic stage (phallic; 3–6
years), the child’s focus involves genital exploration.
Successful transition from the phallic stage of develop-
ment necessitates identification with like-sex parent after
a period of rivalry stemming from sexual attraction to
the opposite-sex parent (termed oedipal and Electra
complexes for boys and girls, respectively).
The challenge of defining oneself within the context
of same-sex peers comes with the latency stage (ages
Table 5 Selected developmental milestones: Birth – 6 yearsa

Age Gross motor Fine motor: adaptive Language Personal–social: adaptive

Birth • Moves head laterally • Vocalizes • Regards face

• Responds to bell
1–3 months • Improves head control • Visually follows 901, 1801, and 3601 • Quiets to noise • Regards face and hand
• Able to support head on neck by consecutively • Coos (e.g., ‘ooh’ and ‘aah’) • Smiles responsively and
3 months • Clenches fists until 3 months • Laughs spontaneously
• Can bear weight on legs • Brings hands together • Swipes at objects • Chuckles
4–6 months • Can roll over • Can grasp rattle • Demonstrates different needs by • Regards own hand
• Can sit briefly without support • Grabs and shakes objects producing different sounds • Works for toy
• Can lift chest up using arm support • Brings hands to midline • Blows ‘raspberries’(bubbles) • Imitates speech sounds
• Turns toward sound (e.g., rattle) • Makes single-syllable
or voice consonant sounds
• Has raking grasp • Can distinguish between ‘pleasant’ and
• Can exchange objects (e.g., cube) from ‘angry’ voices
one hand to the other • Squeals
• Brings objects to mouth to feed
• Regards objects (e.g., raisin)
7–9 months • Can sit without support • Drinks from cup • Mimics noises • Can wave ‘bye-bye’
• Can crawl on floor • Responds to spoken name • Puts many objects into mouth
• Can stand while holding on to • Understands ‘no’ • Has object permanence (e.g., will look
something • Says ‘mama’ or ‘dada’ in for lost objects)
nonspecific way • Has separation anxiety
• Indicates wants by pointing

Children: Stages of Growth and Development

• Recognizes familiar words (e.g., ball
and dog)
• Combines syllabies

10–12 months • Pulls to stand • Uses pincer (i.e., thumb–finger) grasp • Says ‘mama’ or ‘dada’ in specific way • Plays repetitive verbal games (e.g., pat-
• Can stand for 2 s • Mimics reading by turning pages • Follows gesture command a-cake)
• Cruises holding on to furniture • Scribbles • Can say one specific word (by 12
• First steps months)

13–15 months • Can stoop and recover
• Climbs stairs using hands and knees
• Can sit down from standing
• Walks well, with wide-based gait
• Points with fingers
• Has more fine motor control (e.g.,
stacks rings and puts block in cup)
• Marks with pencil
• Able to use spoon to feed self
• Can open boxes
• Can say two specific words
• Looks for named object (e.g., ‘Where’s
the ball?’)
• Responds to name
• Obeys command: ‘Give it to me’
• Names family members
• Verbalizes jargon
• Follows one-step commands without
gesture
• Has knowledge of one or two
• Solves problems via trial-and-error
• Has second bout of separation anxiety
(first incidence occurs during 7–9
month period)
• Can indicate wants (e.g., food
preferences)
• Can engage in independent play
• Imitates household activities

551
body parts
(Continued )
Table 5 Continued

552
Age Gross motor Fine motor: adaptive Language Personal–social: adaptive

16–18 months • Can balance on one foot with support • Enjoys playing with push–pull toys • Can point to simple pictures • May demand individual attention

Children: Stages of Growth and Development

• Can walk backwards • Can take off/unzip clothing when asked
• Runs • Can build tower using two cubes • Can follow simple two-step commands
• Can point to two pictures
• Can say 3–5 specific words
• Enjoys using the word ‘no’
• Uses inventive solutions to problems
• Less mouthing of objects except
for food
• Helps in house

19–21 months • Can kick a ball forward
• Can jump up
• Can walk up steps with support
22–24 months • Walks up and down steps alone and
placing both feet on each step
2–2.5 years • Throws ball in overhand fashion
2.5–3 years • Runs well
• Alternates feet walking up stairs
• Balances on each foot for 1 s
3–3.5 years • Balances on each foot for 2 s
• Walks in straight line and backward
• Catches and kicks large ball
• Controls bowels and bladder
during day
3.5–4 years • Hops
• Can put lid on box
• Can build tower using four cubes
• Can match like objects
• Draws horizontal lines
• Can dress self
• Has adult grip on crayon
• Draws vertical lines
• Can build tower using six cubes
• Enjoys 6–12-piece puzzles
• Can copy a circle shape
• Can build tower using eight cubes
• Can copy a cross shape
• Capable of stringing beads and other
comparable activities
• Knows colors and can match objects of
similar hue
• Cuts with scissors
• Puts shoes on correct feet
• Can say 6–10 specific words
• Enjoys being read to
• Labels actions: ‘up’ ¼ pick me up
• Questions: ‘What’s that?’
• Combines words
• Uses echolalia
• Enjoys listening to stories
• Repeats rhymes
• Associates names with familiar objects
• Has up to 50 words
• Distinguishes ‘one’ from ‘many’
• Communicates feelings using words
and gestures
• Verbalizes toileting needs
• Knows six body parts
• Speech is 50% understandable
• Uses two-word sentences
• States name
• Sings parts of songs
• Learns 50 words per month
• Uses three- or five-word sentences
• Can state full name
• Understands concept of ‘one’
• Can follow three-step directions
• Has approximately 900 words
• Can repeat back three-digit numbers
• Asks ‘How? Why?’
• Understands prepositions
• Knows and uses plurals, pronouns,
and some adjectives and adverbs
• Speech is 75–100% understandable
• Can talk about remote events
• Can count to three
• Can make analogies
• May fear water
• Can put on shoes
• Washes hands
• Imaginary play, for example, ‘tea party’
• Likes small objects
• Uses spoon and fork
• Uses pronoun ‘I’
• Tests limits
• ‘Reads’ book to self
• Can be easily frustrated
• Does not understand concept of
sharing
• Engages in parallel play with peers
• Asserts independence
• May say ‘no’ often
• Brushes teeth with help
• Is able to play cooperatively
• Can wash and dry hands
• Can name friends
• Has improved attention
• Can put on t-shirt
• Enjoys board/card games
• Has memory for recent events
4–5 years • Somersaults • Can copy some letters • Understands and enjoys humor • May have imaginary friends
• Learns ‘heel-to-toe’ walking • Can copy a square when demonstrated • Makes comparisons between objects • Loves to dress up in imaginative play
• Balances on each foot for 3–5 s • Can draw a person in three parts • Speech understandable (e.g., superhero and princess)
• Has one-to-one correspondence (e.g., • Aware of gender of self and others
counts five blocks)
• Understands basic time concepts
• Names categories
5–6 years • Capable of gross motor sequenced • Distinguishes directionality (right • Speaks primary language fluently • Asserts independence
activity (e.g., skipping, swimming, and from left) • Knows home address and birth date • May fear death
biking) • Can draw a person in six parts • Sings songs and shares stories
• Balance on each foot for 6 s • Can print full name • Understands quantity concepts
• Can catch ball • Can sort various objects by • Understands sequences
common size • Can define seven words
• Begins to learn irregular plurals
• Uses words to describe inner
emotional state
• Understands opposites
a
An average age of onset is given; children vary in acquisition of these milestones.
Source: Adapted from Batshaw, M.L., 2001. When Your Child Has a Disability: The Complete Sourcebook of Daily and Medical Care. Baltimore, MD: Paul H. Brookes; Frankenburg, W.K., Dodds, J.B., 1967. The Denver developmental screening test.
Journal of Pediatrics 71 (2), 181−191. doi:10.1016/S0022-3476(67)80070-2. PMID 6029467; Frankenburg, W.K., Dodds, J., Archer, P., Shapiro, H., Bresnick, B., 1992. The Denver II: A major revision and restandardization of the Denver
developmental screening test. Pediatrics 89 (1), 91–97. Available at: http://pediatrics.aappublications.org/content/89/1/91.abstract; Psychological Corporation, 1992. The Preschool Language Scale III. Harcourt Brace Jovanovich, San Antonio, TX.

Children: Stages of Growth and Development

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554 Children: Stages of Growth and Development
6–11 years). Genital exploration subsides and increased
control of sexual and aggressive drives emerges. The
child immerses him/herself in socially accepted activities
during this fourth stage. Lastly, the genital stage of
adolescence (beginning with puberty and continuing into
adulthood) involves successful separation from parents
as well as equally successful extrafamilial relationships
(e.g., with peers).
Freud’s psychoanalytic theory of development has
fueled further theorization and research in the area, in-
spiring the subsequent theories of Neo-Freudians such as
Anna Freud, Mahler, and Erikson. A forensic expert’s
knowledge of this theoretical perspective on childhood
development can certainly assist in the understanding of
a colleague or deposed expert who operates from a
Freudian or psychoanalytic viewpoint.
Erikson
Erik Erikson’s theory of emotional development stems
from Freudian theory, but with a broader, more ad-
vanced point of view. Each of the eight stages involves
one central issue, which must be resolved in order for the
individual to progress to the subsequent stage. Erikson’s
first five stages reflect the exact same age ranges as
Freud’s psychoanalytic stages. Each stage label is fairly
self-explanatory in terms of the conflict that the child
must overcome: (1) trust versus mistrust of the caregiver;
(2) autonomy versus shame and doubt regarding the
child’s own independent care-taking capabilities; (3)
initiative versus guilt in terms of accomplishment of
early age-appropriate goals (e.g., toilet training); (4) in-
dustry versus inferiority, for example, in the area of
early academic achievement; (5) identity versus role
confusion for adolescents attempting to establish au-
tonomy and sense of self; (6) intimacy versus isolation
for social connection during young adulthood; (7) gen-
erativity versus stagnation in adulthood as career paths
are established or sought; and (8) lastly, old age involves
ego integrity versus despair as the elderly individual re-
flects upon and evaluates his/her life accomplishments.
Cognitive Development
Piaget
A plethora of theoretical perspectives regarding child-
hood development exists; the most famous of which is
that of Swiss philosopher Jean Piaget (1951, 1952).
According to Piaget, children take an active role in
working within their environment to incorporate ex-
periences (which he referred to as the act of assimilation)
into their personal schema (the way they interpret their
world). As children learn and grow, they continually
modify their schema when confronted with new events.
Piaget labeled the child’s modification of schema as
accommodation. A child’s ability to modify schema
depends upon their current particular stage of
development.
Piaget’s stages include four levels. The first stage is
the sensorimotor stage, which occurs between the ages
of 0 and 2 years. During this stage, learning is facilitated
by sensory means. For example, a baby within this age
range prefers to hold and even explore a new object with
his/her mouth in order to learn about it fully through
sensory stimulation. By the end of the sensorimotor
stage, children should master object permanence (i.e.,
understand that when the mother puts a block out of
view behind her back, it is still present, just not visible)
and symbolic (representational) thought. The latter may
be seen in fantasy play, such as dress up games.
The preoperational stage (ages 2–6) involves mental
processes that are governed by the child’s own subjective
perceptions. Furthermore, the child does not make a
distinction between internal and external reality. By the
end of the preoperational stage, a child displays animism
(e.g., believing the clouds and flowers smiled at her),
egocentrism (i.e., understanding the world from his
point of view, with less, if any, empathy for others),
idiosyncratic, and transductive reasoning (i.e., linking
two usually unrelated events such as any woman wear-
ing white and receiving a shot).
Once a child attains the concrete operational stage
between ages 6 and 11 (or school age), she/he is able to
classify and sort objects using stable concepts such as
volume, mass, and number. It is during the concrete
operational stage that children learn to conserve or
understand, for example, that a given volume of water
remains the same when poured from a short, wide
container as when poured from a tall, thin container.
This is something that, Piaget proposed, children in the
preoperational stage cannot do.
Lastly, there is the stage of formal operations, which
covers the full range of adolescence. During this final
Piagetian stage, the adolescent can successfully process
abstract thought. Piaget suggested that not all human
beings reach this level of cognitive functioning. It re-
mains important for any forensic scientist to understand
the various cognitive abilities related to each stage of
child development. For example, in court questioning,
one would not expect a child of 10 to be able to process
abstract questions.
Abnormalities of Development
Clinicians stress the importance of periodic assessment
of developmental milestones in order to chart each
child’s progress in skills acquisition across the four do-
mains of development.
Tjossem’s three category classification system for
risk factors for developmental problems in children is
commonly cited and includes established, biological,
and environmental factors (Tjossem, 1976). An infant
or child is placed at established risk by a medical dis-
order, including conditions resulting from genetic and

Table 6 Red flags for developmental delay
Gross motor Fine motor
• Excessive head lag beyond • Fixed squint (any age)
6 weeks • Not fixing/following at 6 weeks
• Persisting primitive reflexes at • Hand preference before
6 months 18 months
• Not sitting at 12 months • Immature grip at 18 months
• Not standing at 18 months
Source: Adapted from Bedwani, S.J., Anderson, C., Beattie, M., 2011. MRCPCH Clinical: Short Cases, History Taking and Communication Skills, third ed. London: PasTest.
chromosomal abnormalities. An infant or child is at
biological risk due to prenatal, perinatal, neonatal, or
early developmental insults. Examples include poor
maternal nutrition, infectious diseases, or toxins passing
through the placenta during pregnancy, and trauma
sustained during delivery. An infant or child is placed at
environmental risk by life experiences such as onset of a
chronic medical condition, poverty, malnutrition, and
child abuse and neglect.
It is important to remember that there is huge vari-
ation in when milestones are achieved in normal chil-
dren. ‘Red flags’ (see Table 6) can be used as a guide
to when concerns should be raised. When assessing
development, it is much more important to look at
the progression of skill acquisition and whether the
skills are congruent between all domains. Loss of skills
is always abnormal and should trigger referral for
investigation.
Abnormalities of development are common in about
10% of children and can be global, in which a child
shows delayed acquisition of skills across all four do-
mains, or specific to one or more domains (see below
under individual headings). The pattern of delay gives
clues as to the underlying problem. Global delay is
usually seen in chronic disease or when the environment
is non-nurturing.
Gross Motor Delay
Isolated gross motor delay may indicate underlying
neurological or musculoskeletal problems such as cere-
bral palsy, congenital hip dysplasia, or muscular
dystrophy.
Fine Motor Delay
Visual problems are likely to give rise to problems with
fine motor skills. It is important to ask parents if they
have any concerns about their child’s vision.
Children: Stages of Growth and Development 555
Speech Social
• Failure to respond to sound • Not smiling at 6 weeks
• Inability to understand simple
commands at 18 months
• Not babbling at 12 months
• No spontaneous vocalization
at 18 months
• Unable to speak in short
sentences at 2.5 years
• Parents unable to understand
speech at 2.5 years
• Poor articulation making
speech difficult at 4 years
Language Delay
Children display wider variability in speech and lan-
guage development than any other area due to the var-
iety of individual and environmental factors (e.g., the
verbal environment of the child’s home or child care
facility). For example, children born to large families
may exhibit delays in language production given the
lowered frequency of attention and opportunities for
verbal interaction when compared to single-child famil-
ies. Older siblings understand the needs of their younger
siblings without the need for verbal communication, for
example, if the younger child wants a toy, they may
indicate this need by pointing. If the older child fetches it
rather than waiting for the younger to try to verbalize
their wishes, it reduces the need for the younger child to
learn how to communicate this need verbally.
Bilingual children may also experience temporary
(i.e., ameliorates by age 2–3 years) delays in language
acquisition, often combining the two languages into a
mutant language of their own.
Furthermore, poverty can deleteriously affect infants’
language development. Although being from a low-
income home does not necessarily automatically yield
language delay, it is a high-risk factor.
It is important to ask parents if they have any con-
cerns about hearing. Congenital hearing loss will impact
on speech and language development and is now
screened for at birth as early intervention can allow
normal development.
Social Delay
Delayed social development may indicate presence of
autistic spectrum disorders and is often in combination
with delayed speech/language skills (Table 7).
Assessing Growth and Development
Given the fact that each child’s individual variability
in development is related to a number of factors, any
556 Children: Stages of Growth and Development
Table 7 Investigating developmental delay
Hearing
Vision
FBC, U and E, LFT, CK, Celiac screen, and TFT
Metabolic screen
Genetic testing (including karyotype and Fragile X)
X-rays of hips/spine
Neuroimaging
Abbreviations: FBC, full blood count; CK, creatine kinase; LFT, liver function test; TFT,
thyroid function test; U and E, urea and creatinine.
developmental assessment must include a thorough
medical history (including pregnancy and birth, in-
fections, hospitalizations, surgeries, and medications),
family history, and social history. When taking the so-
cial history, it is important to ascertain presence of other
children at home, who may be at risk if safeguarding
concerns have been raised. Interviews with primary
caregivers regarding the history of that child’s acqui-
sition of specific developmental skills (including emo-
tional/behavioral/adaptive skills) may be necessary as it
is sometimes not possible to get the child to demonstrate
all the achieved skills during any given consultation.
Thorough physical examination should take place, in-
cluding measuring weight and height (and head cir-
cumference in infants) and plotting on a growth chart
appropriate for age and sex. Careful inspection for
dysmorphic features should be carried out in order to
aid identification of underlying genetic syndromes.
Nutritional status should be commented on; in par-
ticular the condition of skin, nails, dentition, and mu-
cous membranes. Temperature, heart rate, and blood
pressure can also give clues to underlying medical
problems such as thyroid abnormalities as well as eating
disorders such as anorexia nervosa.
In infants with head injuries, it is particularly im-
portant to document the head circumference as this
trend can then be monitored over the subsequent days,
which may give indication of more significant injury
with intracranial bleeding. In children whose cranial
sutures have not yet fused, the head will expand when
subject to raised intracranial pressure. This means that
the symptoms of raised intracranial pressure may not be
apparent and so head circumference may be an earlier
indication of problem.
Developmental status can be measured through two
types of play-based tests: screening tests and evaluation
tests. A developmental screening test is a quick and
broad assessment of skills; its purpose is to identify a
subpopulation of children who are in need of further,
more in-depth evaluation. Screening tests can either rely
on a caregiver report of developmental milestones via a
questionnaire or involve the standardized administration
of items by a professional or paraprofessional. Devel-
opmental evaluation instruments are standardized meas-
ures that are administered by highly trained professionals
such as a psychologist. These tests, more labor-intensive
and prolonged (lasting 1–3 h), are used to create a
profile of a child’s strengths and weaknesses in a variety
of developmental domains (Aylward, 1994, 1997). The
administrator then determines how these strengths and
weaknesses will impact a child’s interactions within
multiple environments (family, school, and larger com-
munity). A discussion of specific screening and evalu-
ation tools used to assess developmental progression is
beyond the scope of this chapter; see references below
for further reading regarding these types of tools.
Table 7 gives a guide as to some investigations which
may be necessary to evaluate the cause of developmental
delay.
Children should be referred for assessment if ‘red
flags’ are noted or if there are significant parental or
other health professional concerns.
Conclusions
Assessing children’s growth and development can pro-
vide important clues as to the presence of underlying
medical conditions or social concerns, but it is important
to remember that the normal variation is extensive.
Monitoring progress of growth and development is
more informative than one isolated assessment. Since
it is often difficult to demonstrate the relevant skills
in one assessment, it is also important to listen to
parental concerns and corroborate with other health
professionals wherever appropriate. Children falling
well outside the normal range or where ‘red flags’ are
present should be referred for formal assessment.
See also: Anthropology: Bone Pathology and Antemortem Trauma.
Anthropology: Forensic Anthropology and Childhood. Anthropology:
Morphological Age Estimation. Autopsy: Pediatric. Children:
Noninflicted Causes of Childhood Death. Children: Physical Abuse.
Children: Sexual Abuse − Epidemiology. Odontology: Overview
References
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Aylward, G.P., 1997. Infant and Early Childhood Neuropsychology: Clinical Child
Psychology Library. New York, NY: Plenum Press.
Bedwani, S.J., Anderson, C., Beattie, M., 2011. MRCPCH Clinical: Short Cases,
History Taking and Communication Skills, third ed. London: PasTest.
Gesell, A., 1932. The developmental morphology of infant behavior pattern.
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America A18 (2), 139–143.
Gesell, A., 1935. Behavior pattern and behavior morphology. Science 81 (2088),
15–18.
Piaget, J., 1951. Play, Dreams and Imitation in Childhood. New York, NY: WW
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Piaget, J., 1952. The Origins of Intelligence in Children (M. Cook, Trans.). New
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Sidwell, R., Thomson, M., 2011. Concise Paediatrics, second ed. London: Hodder
Arnold.
Tanner, J.M., 1952. The assessment of growth and development in children.
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Tanner, J.M., 1962. Growth at Adolescence, second ed. Oxford, UK: Blackwell
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Tjossem, 1976. Intervention Strategies for High Risk Infants and Young Children.
Baltimore, MD: University Park Press.
Further Reading
Dixon, S.D., Stein, M.T. (Eds.), 1991. Encounters with Children: Pediatric Behavior
and Development. Chicago, IL: Year Book.
Illingworth, R.S., 1992. The Development of the Infant and Young Child: Normal and
Abnormal, ninth ed. Singapore: Longman.
Children: Stages of Growth and Development 557
Levine, M.D., Carey, W.B., Crocker, A.C. (Eds.), 1992. Developmental-Behavioral
Pediatrics, second ed. Philadelphia, PA: WB Saunders.
Rudolph, A.M., Kamei, R.K. (Eds.), 1994. Rudolph’s Fundamentals of Pediatrics.
Norwalk, CT: Appelton & Lange.
Shelov, S.P., 1991. The American Academy of Pediatrics: Caring For Your Baby and
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Trawick-Smith, J., 2000. Early Childhood Development: A Multicultural Perspective,
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