2. Stages of Human Development - Kenneth Brummel-Smith and Laura Mosqueda
An understanding of the human developmental processes is a critical component of the family physician's role in continuing care. Patients often present to physicians with the superficial complaint of a medical concern when the true underlying problem relates to an adjustment to their own development or the response of the family to that adjustment. Whenever medical conditions develop in a family member, they are likely to have some impact on other members. Such conditions may have a more powerful effect when the illness occurs at the time of common stress points in the family life cycle, such as the birth of the first child or when an adolescent has been "acting up." Family physicians can be of great assistance in providing "anticipatory guidance," reassurance regarding the normality of such experiences, or assistance for those with a difficult adjustment. This chapter addresses the developmental characteristics during each stage of life and their impact on the care of the patient. Additionally, because the older population experiences a significant increase in medical problems, special attention is paid to the impact of illness on this stage of the developmental process.
There is tremendous variability in human development, but certain similarities exist in most persons.1 The notion that development ceases after adolescence is a myth. Each stage, from childhood to the end of life, is associated with specific developmental tasks (Table 2.1). Physical, psychological, and social development occur at different rates. Although the potential for maximal physical development is realized by age 30, psychological and social maturity are reached at later ages. Similarly, developmental tasks in each of these realms of our lives change as we age; the successful completion of these tasks prepares the person to move on in life, ready to meet the challenges of the next stage. Difficulty with the tasks can increase the risk of psychosocial disruption and may even lead to medical problems. Hence, understanding the patient's presenting problem, within the context of the developmental process, will enable the family physician to provide comprehensive medical care. On the other hand, it may be that the concept of a linear progression of stages is a peculiarly Western one.2 This point may be especially true when viewing the various components of the family life cycle and the development of the individual.
When dealing with a couple and the couple's first child, the family physician must be aware of the sometimes overwhelming learning experience that the parents are undergoing. Interpreting the infant's needs and dealing with the process of breast-feeding or baby foods are but two of many new experiences that must be mastered. Decisions regarding where the infant will sleep are sometimes troublesome. Some authors advocate training the child to be the master of his or her own sleep periods,3 whereas others believe that having the child sleep with the parents can provide special benefits.4 If there are other children in the family, the prospect of sibling rivalry must be addressed. When the parents take particular care to attend to the needs of the older children and involve them in the care of the new child, this adjustment usually goes smoothly.
As children reach 2 to 3 years, they begin to experiment with independent actions. This period provides trying times for parents but may also be viewed with wonder and amazement. For the parents, it is the beginning of a long stage of learning how best to set limits while promoting the child's independence. Many issues play out this theme; temper tantrums, negativity ("I'm not going to do it"), toilet training, thumb sucking, watching television, and masturbatory play are common concerns. For some children these issues are hardly problematic, whereas for others their resolution may result in the family verging on total disruption. Children require consistent standards and cues, and they need to know what is expected of them; too much control or an expectation of meeting rigid expectations usually leads to stress with little likelihood of resolution. It is especially important that the parents are in basic agreement on the approach to the child. An understanding approach that fosters the child's independent decisions, within the limits of safety and the parents' personal needs, is likely to imbue the child with a sense of accomplishment and security. Above all, children need to be respected.
Parents have a huge impact on childhood development. Important determinants of that development include (1) the inherited temperamental qualities of the child, (2) parental practices and personality, (3) the quality of the child's school, (4) relationships with peers, and (5) the historical era in which the child is raised.5 Discipline is often a difficult experience at this time. Interestingly, research has shown that verbal instructions are not effective at changing young children's problem behavior.6Explanations of future consequences related to a punishment procedure such as a time-out seem not to influence the behavior of toddlers and preschool-age children. Children at this stage of development have difficulty distinguishing causation from coincidence and fantasy from reality.7Fortunately, by age 6 children are usually developed enough to respond to reasoning and verbal instructions.
As they enter the late-childhood stage (ages 6 to 10) accidents become common. While most of these are minor, it should be recalled that death due to accidents is one of the most common causes of mortality in this age group. The family physician should proactively discuss accident prevention and safety awareness. Specific mention should be made about gun safety, as youngsters at this age explore their parent's rooms and may engage in play mimicking scenes they have seen on television.
The concept of gender socialization is important to consider. It appears that at an early age children begin to express gender-specific behaviors. Little girls may make their own dolls, and boys may fashion guns out of sticks. It is virtually impossible not to expose children to gender-identified material. Some parents may be upset that they have tried to raise their child in ways that discourage stereotyped behaviors, and yet the child still exhibits them. Still, a child should be given a wide range of opportunities for expression and exploration based on interest and aptitude rather than gender.
Role of the Family Physician
The family physician is often the counselor to young parents. Due to physical distance or unresolved family issues, parents may feel reluctant to discuss their parenting concerns with their own parents. The physician can explain the developmental processes that are operative, which may be especially helpful when parents are dealing with toddlers and preschool children. Reassuring the parent about the normality of such experiences and that they are doing a good job of parenting is often all that is needed. Eliciting from the parent their feelings and reactions to the child's behavior also helps to defuse the situation. As there are no "right" answers, encouraging parents to try alternative strategies is helpful. After all, doing more of what does not work, does not work. When recurrent behavioral problems are seen, the family system should be assessed for the presence of more serious discord, as the child's behavior may be a reflection of more substantial problems, such as impending divorce or abuse.
The adolescent stage of human development is also a time of individuation and is perhaps the most turbulent (see Chapter 22). The body at puberty is going through tremendous change, a true metamorphosis. Rapid growth and hormonal changes affect the young person on a daily, often variable, basis. Perhaps it is a misnomer to term this period a "stage." So much change is occurring that it is more appropriately conceived of as an explosion! Psychosocially, the tasks of this stage are clear: begin separation from the family, develop a selfidentity, develop a sexual identity, begin to depend on one's peers (rather than the family) for support, and start to formulate plans for a means of supporting ones self (Table 2.2). How these tasks are accomplished defines transition to a healthy adulthood.
The process of developing a self-identity is often one of the most stressful aspects of this stage for the adolescent's parents. It is interesting that exactly when adolescents are trying to be more independent from their parents, they become more dependent on their peers. In many cases, the adolescent chooses an adversarial path to this end. Whatever the parents believe, the opposite must be true! In reality, such dissension is usually a test, and if the groundwork of love and respect has been laid, deep inside the teen still looks to the parents for safety and guidance.
Sexual issues play a major role during this period. The majority of teens in the United States will have had intercourse by the time they graduate from high school. While sex is talked about more than in the past, there still is a great need for open, honest communication. Teens have a high pregnancy rate and frequently do not use barrier protection methods. Risk for human immunodeficiency virus (HIV) disease may also be increased due to teenagers' belief in their own indestructibility. Nonthreatening discussion of sexual issues by parents, sometimes aided by discussions with the family physician, is crucial to adolescents' acquisition of skills in coping with their newly developed sexuality.
By this age most gay and lesbian persons have become aware of their sexual orientation. It is also a time when open discussions about these discoveries can be extremely difficult. When all teenagers are dealing with trying to establish what is "normal," it is no surprise that in a society that generally discriminates against nonheterosexual orientations, these teens may experience special stresses. Although earlier work suggested that despite these stresses homosexual adolescents had an incidence of mental health problems that was no higher than that of the heterosexual population, recent research indicates that gay and lesbian adolescents are at high risk for depression and suicide.8 Parents often have strong feelings and reactions to a child who is homosexual, and the family physician may play a critical role in helping the family find their way to acceptance and understanding.
As with younger children, teens need clear limits and standards. The difference is that they must also be involved and invested in the establishment of these limits. As the teenager moves through the continuum of change, increasing amounts of independent action should be not only allowed but also fostered. During this tumultuous time of change, the parents can assist the young person by proactively addressing issues like sex, drugs, and alcohol. Although young people may not respond with open discussion at that time, the message that there is safety in asking questions is established.
Role of the Family Physician
If approached sensitively, the family physician has the opportunity to truly serve the adolescent. Many issues at this stage may be perceived as "off limits" in the family. The physician, however, can address questions that teens may feel embarrassed to discuss with their parents, such as drug use, sex, or risk-taking.
Interviewing teenagers requires special skill, but the motivated physician can master this skill. The physician must address privacy issues. It is best to first discuss with the parents and child together your philosophy regarding confidentiality. If all interactions between the physician and the teen are to be privileged, it should be made clear and the commitment then maintained. The physician should advise teens that only in the rarest of circumstances (e.g., suicidal ideation) is anything divulged without their consent. Besides providing a great service, the elicitation of an adolescent's worries about sexual matters or feelings of depression can leave the physician feeling accomplished and satisfied, and it is well worth the effort.
For some time development was thought to cease with the adolescent years. It is now clear, however, that the later stages of life are filled with important developmental tasks. Erik Erikson9characterized young adulthood as being concerned with intimacy and the ability to form a meaningful and lasting relationship. Finding a partner, adjusting to the partner's lifestyle and expectations, and deciding on whether or when to have children are important aspects of this stage. It is also a time when the newly created family must adapt to the families of origin of each member (Table 2.3).
Young adults are usually quite concerned with mastery over their life. The full entry into adult life is often associated not only with marriage but also with establishing a career. The norm today is that both men and women must develop a method for meeting economic responsibilities, so most women work outside of the home. Women are often torn between desires to spend more time with children and their career demands. Decisions about child care are often troublesome to young families.
There is great variation during this period. For those who choose to marry, it is important to understand that a "perfect union" is not without discord. In fact, it appears that a strong affective bond requires more than just reciprocal gratification. It appears that discord and repair are necessary components of a lasting relationship. Successful repair turns despair into positive emotions.10 A successful marriage has these characteristics: (1) power is shared by the partners, (2) there is a high level of mutual respect, (3) a level of self-disclosure that is satisfying to one another exists, (4) with greater selfdisclosure there is increased opportunity to appreciate both similarities and differences, and (5) appreciation of similarities and differences leads to increased closeness and augmented individuation.
Though it is still perceived as being the norm by many people, the traditional "nuclear family" accounts for fewer than 25% of all families. Some individuals forsake marriage to pursue professional careers. Those who are gay or lesbian may only become fully aware of their orientation at this time. Single parents must struggle with significant financial concerns while trying to accomplish career development, and perhaps search for a mate. Persons who do follow a less traditional path must frequently cope with negative reactions of their families and the society and can use the support and understanding of a health care professional.
Financial concerns often affect families at this stage. Only 15% of American households are now supported solely by a male breadwinner, compared to 42% in 1960.11 Some believe that a major threat to the family today is the broad-based cultural shift away from respect for activities that cannot be justified in terms of market dollar value.12 Family functions are increasingly being "outsourced," as parents take on more roles outside of the home. This change affects both mothers and fathers as many more men are choosing to become stay-at-home dads.
Role of the Family Physician
Contacts with the physician during this stage are often made by women and are related to birth control, pregnancy, or well-child visits. Many opportunities are available for anticipatory guidance and counseling. The physician should assess the stress level of the woman, and facilitate discussing her concerns about child rearing, her relationship with her partner, and her career. A frequent visit to the doctor by someone who is physically healthy is often an indicator of underlying psychosocial concerns.
Men in this age group see physicians much less often, making health-promotion-oriented interventions more sporadic and difficult. An ideal opportunity arises in the pregnant couple to encourage the father to attend prenatal or well-child visits.
Erikson9 spoke of middle age as the time in life characterized by a conflict between generativity and stagnation. Generativity refers to the concern in establishing and guiding the next generation. It has been shown to be a strong predictor of subjective well-being, greater life satisfaction, and even greater work satisfaction.13 This stage is often attended by consolidation of one's social and occupational roles. The uncertainty and testing of the young adult stage has passed. Many are firmly fixed in their careers, sometimes disproportionately so. Children are growing up and leaving home. For many, it is a time of relative economic stability and intellectual accomplishments. The question often arises concerning the appropriate goals in life. This is often termed the "mid-life crisis."
An important adaptation response to this stage is the development of new challenges to replace those already accomplished (Table 2.4). For some, this means changing jobs or duties within a job. Some take on added responsibilities or managerial roles. Others may increase their involvement in church and community affairs or exercise programs. Whatever the method, such endeavors are probably preferable to gaining all of one's sense of accomplishment through other people's activities, such as from one's spouse or children.
Much has been written about the "empty-nest" syndrome. Traditionally, this referred to a sense of loss and emptiness, especially in women, after the children left home. Research has been unable to document such a negative experience. Rather, it seems that the prime determinate of the parent's response to the children leaving is their own feelings of self-worth.
Daniel Levinson et al14 described three overlapping stages in men's lives during this period: early (17-45 years), middle (40-65 years), and late (>60 years). The stages are separated by a transition period of 4 to 5 years. Within the stages there are specific patterns and developmental experiences. Levinson et al found remarkable similarities in the experiences of men from varied backgrounds and occupations. This type of research lends further evidence to the continual process of growth and development throughout the life span.
Women during this stage have special transitions as well.15 Traditionally, menopause was viewed as something fraught with problems: hot flashes, depression, and loss of femininity. Research has failed to bear out these ominous outcomes. Sexual activity may even increase when the couple is freed from the concerns of childbearing. Women may begin to fill the very useful role of a grandmother, assisting their children in raising and teaching grandchildren. Some women embark on new careers or educational endeavors.
On the other hand, divorce at this stage of life can be particularly troublesome for women. Income falls precipitously, and if children are still home, the demands of parenting are usually carried out alone. Women tend to remarry less often than men (three quarters of divorced men and two thirds of divorced women remarry)12 and may not have had a viable source of independent income before the divorce.
As one enters the forties and fifties, there is a growing awareness of the inevitable changes in one's body in response to aging. Aging becomes a physical reality, rather than just an intellectual concern. Weight gain is commonly seen and many report difficulty in reducing even with increased exercise. Illnesses, particularly in men, begin to rise in prevalence. Often there is a newfound desire to exercise to recover one's "lost youth."
In spite of all these potential changes, it may be surprising that life events have been shown to have very little influence on the levels of personality traits in individuals. However, in a longitudinal study of over 2000 subjects it does appear that the perception that one's family or social life were getting worse was associated with increased levels of anxiety, depression, and stress.16
Role of the Family Physician
One of the most important interventions by the family physician is to communicate the normality of these experiences. Some persons may be particularly upset that they are feeling unsatisfied with their lives at a time when they have accomplished so much. Health maintenance and disease screening interventions become more important. The patient needs to be taught that it is never too late to make positive changes in health status.
Retirement, as a social phenomenon, is a relatively recent human experience. Much is still being learned about the positive and negative effects of retirement. In general, retirement that is freely chosen and well planned is strongly correlated with positive health outcomes (Table 2.5). Time for exercise, both physical and psychosocial, may increase. Many elders become involved in educational pursuits or advocacy programs. For some, the chance to travel is gratifying.
Opportunities for contact with grandchildren usually increase. While both child and grandparent usually appreciate increased contact, sometimes it can be stressful. Between 1980 and 1997, the number of children being raised by their grandparents rose by 33%.12
For most, retirement income is sufficient for their needs.17 However, because of the shrinkage in real wages in the 1970s and 1980s, Levy and Michel18 noted that "the entire cohort of baby boomers will reach retirement (ages 55-64) with less than 50% of the net worth of their parents' cohort at a similar age: $143,000 versus $293,000."
Even when the retirement is planned, there are a number of developmental issues that the person must confront. Historically, men have viewed much of their self-worth in terms of their ability to produce on the job. This stage demands that the person reassess his sense of worth and come to some positive measures of worth outside of work. At present, over 45% of adult women are employed in jobs outside of the home.19 Hence, these reactions may also be expected in women as this cohort ages. Retirement counselors are now available through the American Association of Retired Persons (AARP) or many large corporations to provide both economic and emotional planning to pre-retirees. They can assist with advance planning for retirement by offering advice on financial considerations or other activities.20
Retirement seems to take a negative toll when it is mandated based on age or comes unexpectedly. In these cases, it should be viewed as a risk factor for the development or exacerbation of health problems. Another risky situation is when the spouse's work outside of the home has enabled the couple to long avoid underlying problems. With retirement, much more time is spent by the couple together. They may find that for the first time in their lives together they have differences that need to be addressed directly.
Role of the Family Physician
The family physician can assist by broaching the subject of retirement with all patients. Education about the positive benefits of retirement can be provided. Encouragement of meeting with a retirement counselor may be useful. Scheduling an extra visit around the retirement for health maintenance purposes can also serve to emphasize healthy behaviors at this important transition period. Interviewing the spouse of the retiring partner is also advisable to assess how the spouse is adjusting. One should be particularly concerned when there is a sudden increase or a new onset of health problems. This may indicate a difficult adjustment situation.
To some people, the concept that development occurs even in old age is an oxymoron. Much literature exists describing the tasks of this stage in primarily negative terms, such as "disengagement," "adjustment to losses," "and preparation for dying," and illness and significant changes in one's body and family are common during this stage. In contrast, little has been written until recently about the positive aspects of aging. In fact, one's ability to adjust to the changes of life often determines whether the last years are viewed in a positive light.
Early studies in gerontology often characterized these years as with the term "disengagement".21More recent writers have rejected this notion in favor of recognizing that as we age we become more diverse, making such generalizations impossible. As a population, the older age group is more physiologically and socially diverse than perhaps any other age group. Such diversity is most likely due primarily to social factors and differential experiences of the meaning of old age. Income and education play a significant role in the maintenance of health through the later years. In this stage of life, approximately 7 years is added to healthy life expectancy when comparing the richest income group to the poorest.22
Persons in this stage usually take stock of their life. Most accomplishments in life have been made, although many of the world's greatest leaders have made their most significant contributions to society when they were well past their seventieth birthday. A positive adjustment to aging is found in those who can feel that, on balance, their life has been worthwhile and in those who willingly and consciously adapt to change. For some, a sense of legacy is felt through children and grandchildren. For others, it is measured in terms of accolades, writings, or other external measures. While in the earlier years people are often oriented toward happiness (a positive affective state), in the later years older people are more likely to be satisfied, a perception that one's personal goals have been achieved17 (Table 2.6).
Regardless of income, the majority of older people perceive themselves as being in good health. This viewpoint is interesting considering that over 50% of those over age 75 are unable to perform at least one activity of daily living (e.g., bathing, dressing). This dichotomy probably can be explained by two perceptions: (1) that older people are remarkably adaptable and tend to view disability in a positive light, and (2) that some older people may be accepting of medically related changes that could potentially be reversed by better care. Older people are able to view changes in physical function with more equanimity than younger people faced with the same degree of impairment.23However, there is also a prevalent myth in our society that "old equals sick." Sickness is common, but it should not be considered normal.
A major theme in an older person's life may be that of loss: the loss of physical capabilities, functional reserves, income, and, perhaps most importantly, the loss of friends and family members. These losses can sometimes take a devastating toll on older persons (Table 2.7). It is not uncommon to have older patients go through a period in life when they experience the loss of a friend or family member to death on a monthly basis. It is a testament to the strength of older persons that this experience is so common yet so few become clinically depressed because of it.
On the other hand, older people do have a high incidence of depression and suicide. Older single white males have the highest rate of suicide of all age groups. Depression may affect as many as 30% of the population yet is often missed by primary care physicians.24 Family physicians must develop skills in the detection and treatment of depressive disorders.
One area where there is a great deal of similarity among older persons is the almost universal fear of dependency. This fear far outweighs the fear of death in most geriatric patients. Many will make medical decisions based on the risk of becoming dependent or having to go to a nursing home. Some will decide to refuse treatment rather than burden their families with the high financial and emotional costs of long-term care (also see Chapters 23 and 24).
Role of the Family Physician
The older person uses the family physician for more than just medical care. People in this age group may be reticent to see a counselor but willing to discuss their innermost fears with their doctor. In most settings there are social workers available who are happy to assist the physician with initiation and coordination of referrals to social service agencies. Some physicians who have a high percentage of geriatric patients in their practice find that having a social worker in the office is invaluable. Unfortunately, many physicians spend too little time in the office with older persons.25
Dying today is very different from dying in the early 1900s, when most of today's geriatric patients were born. At the turn of the century, most deaths occurred at home and the death rate in childhood was particularly high.26 Most deaths currently affect people over the age of 65, and over 70% of Americans die in institutions, either hospitals or nursing homes.27 Deaths in hospitals are often traumatic for surviving family members. The risk of an adverse health event may also be greater during times of bereavement, especially when the survivor is quite elderly.28
There is a strong presumption for prolonging life, almost at any cost, among many physicians. Older persons, and even some younger ones with terminal illness, may not share this value. Instead, the goals of relief of suffering, enhancement of function, and increasing the quality of life become predominant. But how should "quality of life" be defined? One person's perception of quality may be at odds with another's. Physicians are poor predictors of what older persons will consider to be low quality of life.29 Older persons need open, honest appraisals from their physicians as to the interventions that may provide benefits and the limitations of medical care.
In the last 20 years, the hospice movement has helped people who are dying maintain a higher quality of life. Almost two thirds of hospice patients are over age 65.30 By emphasizing patient-directed approaches to symptom control, even in those with no prospect for medical improvement, people can live more satisfying lives. The major objectives of care are pain control; prevention of constipation, depression, or other symptoms; involvement of families; and care at home or a home-like environment. Medicare has recognized the benefits of this approach by funding hospice care since 1982. The family physician will need to be skillful in assessing the presence of suffering and providing appropriate interventions. Unfortunately, recent research indicates that as many as 46% of patients die in pain that could have been better controlled31 (also see Chapter 62).
Understanding the stages of life can help the family physician anticipate and explain common stresses experienced by patients. It is important to remember the great variability seen in individuals and the wide range of types of families that will be encountered in family practice. Because the burden of illness is increases with old age, particular attention should be paid to viewing the experience of aging from the patient's perspective. After all, becoming old is the one "condition" we all hope to acquire, especially when one considers the alternative.
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