CLINICAL PERSPECTIVES

Appreciating “Normal” Development: How Did We Get Here? Laura M. Prager,

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was intrigued to learn that the Association of American Medical College (AAMC) added a section on the psychological, social, and biological underpinnings of behavior to the Medical College Admission Test (MCAT).1 Such change adds a new dimension to undergraduate premedical education and reflects the AAMC’s acknowledgment of the importance of the study of human behavior through the lifecycle. This change is long overdue. However, I worry that such instruction will be reduced to material suitable for machine-scored tests and require students to memorize charts comparing and contrasting developmental stages or bullet points listing developmental milestones. Maybe there’s another way. Two years ago, I began teaching a 13-week seminar about child development to college freshmen entitled “How did we get here?” Freshman seminars are limited to 15 students. Incoming freshmen apply for a spot by submitting a brief essay explaining their interest. Applicants to my seminar reflect the diversity of the student body. Some have taken advanced placement psychology in high school and want to know more. Some are wondering about a disabled sibling or a friend’s lack of resilience. Some students have already declared themselves pre-meds. One student’s stated goal was to be a guardian ad litem. One student planned to be a pediatric cardiac surgeon and believed he needed to know something about children and their response to chronic illness. One was writing a novel about an experience she had had in high school when she found herself struggling to understand interpersonal dynamics. Another wanted to start a school for underprivileged children in her native country. Many simply wanted a chance to figure out how they’d been lucky enough to reach this point. In keeping with the college’s standards, my syllabus is dense, comprehensive, and demanding,

M.D.

requiring hundreds of pages of reading each week. First, we explore pivotal concepts and general themes: attachment, temperament, moral development, language and cognition, culture, and ethnicity. Then, we switch to a chronologic perspective and examine development as a sequence of stages, using our understanding of neurobiological, physical, cultural, and psychological factors to inform our assessment of how children change over time. I assign classic articles on development, textbook chapters that provide overviews of specific developmental stages, and recently published research articles about genetic determinants of behavior and the anatomy and neurochemistry of brain development. Formal readings aside, how exactly should one teach child development to 18- or 19-yearold college freshmen? The AAMC’s goal is for future physicians to appreciate the “developmental, life span perspective” (p. 10),2 but these students haven’t lived for very long and so their “perspective” is limited. Most of them are actively wrestling with identity versus role confusion, experiencing hormonal changes, discovering and hoping they have reached Kohlberg’s fifth stage, and waiting, unknowingly, for their prefrontal cortex to mature. In other words, they are still developing and changing, and that very process drives their interests and dictates their ability to understand the material. I searched the extant literature but found little to guide my thinking. In one article, the authors concluded that “courses in child development do not always have optimal effects on college students’ understanding of children” and identified 3 barriers to learning: unconscious but tightly held beliefs, learned cultural biases, and lack of ability or willingness to distinguish between memorizing factual material and understanding concepts.3 My experience did not support these conclusions. While munching

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on cookies and chips, my students shared their individual stories and family lore and acknowledged some of their cultural biases. Early on, they identified which reading materials they found helpful and which got lost in translation. They embraced the ongoing interplay between nature and nurture; they wanted to know how to connect developmental theories to their own lives. I began to supplement the syllabus with other materials. The students gamely waded through a chapter about The Strange Situation and then spent an hour reading Margaret Wise Brown’s Runaway Bunny out loud to learn more about attachment. One student showed us a YouTube of “Toddlers in Tiaras” because it bothered her so much, prompting a conversation about why 3-to 6-year-old girls should not be dressed up like sexy women. Puzzling over Kohlberg, we let Faulkner’s “Barn Burning” drive our discussion of moral development in school-age children. Then, we examined and played the game of Chutes and Ladders to understand the concept of making reparation. Reading an article about how babies learn language led to a vigorous argument about how many of the students who were born in other countries spoke accented English and why. The students squirmed through a PowerPoint presentation about the teen brain and its vulnerability to peer influences; a discussion of neuronal connections quickly was supplanted by one about hookups. By the time we got to the last 3 sessions of the course, when we viewed selected clips from Geri Fox’s DVD charting her own daughter’s growth, the students were eager to apply theory to practice and place the child on the screen in a larger context.4 I assigned 3 papers. In the first few weeks, during our study of attachment and temperament, I asked the students to write a short response paper about a person who has had a major impact on their lives. In general, the students grasped the idea that early relationships are important and identified their supporting cast—people who guided, protected, nurtured, and influenced them. As one noted, “I have inherited my mother’s eyes and temperament. I have inherited my father’s ears and soft jaw. I have inherited my grandmother’s ears. I have inherited my grandfather’s bad habits. But above all, I have inherited the sacrifices and the dreams of my parents.”

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The second assignment was adapted from an exercise used at the university’s medical school. We visited a local museum and the students searched for artwork that, for example, reflects a recent transition or evokes a memory of childhood. One student, on viewing a bronze sculpture in which Daphne, pursued by Apollo, is transformed into a young tree, made the connection: “The sculpture seems to capture the essence of my own experience: for me, there really was not one distinct moment at which the transition from one stage of life to the next began, nor was there a moment when I knew the process was finished.” For their final assignment, I asked the students to pick a book or books from their childhood that made an impression on them. Using our readings and discussion as a foundation, they had to explain why this particular book mattered so much. Did the story capture a developmental stage, assuage developmentally appropriate fears, create a moral imperative, or pose a challenge to age and stage? Was it important because the student read it to himself or because someone read it to him? Justifying his choice of several children’s books initially published in Spanish, one student commented: “Through these books I began to read and to mold the language that represented my culture and my family. I began to create a moral structure that created feelings and attachment to my parents and grandparents, as well to the people around me.. In these books, there are symbols of the creation of me, and of the beauty that is the molding of the child’s mind.” My students arrived at college with lofty goals and the ambition and self-discipline to achieve them. As they wrote in their course evaluations, they left my class with the loftiest goal of all: “Now I want to be a parent.” “I was afraid of being a mother but you have helped me to see that I can be one.” “I know I’m going to be a great father.” I will be thrilled if most choose to be parents when they are ready, but the world also needs thoughtful, informed, self-reflective, inquiring people, and many of these students are well on their way. I will be delighted if a few go on to become practicing physicians of any specialty, but I will be satisfied if, regardless of career choice, they manage to remember that development is uneven and unpredictable, and that despite all their accomplishments to date,

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maturation takes time. I want them to move forward knowing that they will find the answer to the question “how did we get here?” by using their newfound familiarity with the multiple domains of development to reflect on where they came from. Not every college can or will support seminars of the type that I teach, but colleges will be increasingly interested in offering courses that will help undergraduates fulfill these new prerequisites and do well on the MCAT. I applaud the AAMC’s goal, but I suspect that many early efforts to instruct students about development will probably not prepare them to be more thoughtful or self-reflective doctors. Child and adolescent psychiatrists should seize this new opportunity to influence future physicians by creating innovative and stimulating ways to teach students about development. (Some already have; I know of at least one course for undergraduates at a different college in which a child and adolescent psychiatrist uses contemporary films to illustrate developmental theories.) We are uniquely suited to this task. &

Accepted September 6, 2013. Dr. Prager is with Massachusetts General Hospital. The author thanks the students of Freshman Seminar 24u, Harvard College 2012 and 2013, for their enthusiasm and guidance. Disclosure: Dr. Prager reports no biomedical financial interests or potential conflicts of interest. Correspondence to Laura M. Prager, M.D., Massachusetts General Hospital, Yawkey 6956, 55 Fruit Street, Boston, MA 02114; e-mail: [email protected]

0890-8567/$36.00/ª2013 American Academy of Child and Adolescent Psychiatry http://dx.doi.org/10.1016/j.jaac.2013.08.021

REFERENCES 1. Stuber ML. New developments in medical student education: opportunities for child and adolescent psychiatrists. J Am Acad Child Adolesc Psychiatry. 2012;51:753-755. 2. Association of American Medical Colleges. Behavioral and social science foundations for future physicians. November 2011. https://www.aamc.org/download/271020/data/behavioralands ocialsciencefoundationsforfuturephysicians.pdf. Accessed August 15, 2013. 3. McDevitt TM, Ormrod JE. Fostering conceptual change about child development in prospective teachers and other college students. Child Dev Perspect. 2008;2:85-91. 4. Fox G. Normal Development DVD Series: A Longitudinal Stimulus Video Resource for Educators [DVD]. Van Nuys, CA: Child Development Media; 2010.

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Appreciating "normal" development: how did we get here?

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