CLINICAL PERSPECTIVES

JOURNAL

VOLUM

Appreciating “Normal” Development: HowDid We Get Here?

Laura M. Prager, M.D.

was intrigued to learn that the Association ofAmerican Medical College (AAMC) added

I a section on the psychological, social, and

biological underpinnings of behavior to theMedical College Admission Test (MCAT).1 Suchchange adds a new dimension to undergraduatepremedical education and reflects the AAMC’sacknowledgment of the importance of the studyof human behavior through the lifecycle. Thischange is long overdue. However, I worry thatsuch instruction will be reduced to materialsuitable for machine-scored tests and requirestudents to memorize charts comparing andcontrasting developmental stages or bullet pointslisting developmental milestones. Maybe there’sanother way.

Two years ago, I began teaching a 13-weekseminar about child development to collegefreshmen entitled “How did we get here?”Freshman seminars are limited to 15 students.Incoming freshmen apply for a spot by submit-ting a brief essay explaining their interest.Applicants to my seminar reflect the diversityof the student body. Some have taken advancedplacement psychology in high school and wantto know more. Some are wondering abouta disabled sibling or a friend’s lack of resilience.Some students have already declared them-selves pre-meds. One student’s stated goal wasto be a guardian ad litem. One student plannedto be a pediatric cardiac surgeon and believedhe needed to know something about childrenand their response to chronic illness. One waswriting a novel about an experience she had hadin high school when she found herself strugglingto understand interpersonal dynamics. Anotherwanted to start a school for underprivilegedchildren in her native country. Many simplywanted a chance to figure out how they’d beenlucky enough to reach this point.

In keeping with the college’s standards, mysyllabus is dense, comprehensive, and demanding,

OF THE AMERICAN ACADEMY OF CHILD & ADOLESCENT PSYCHIATR

E 52 NUMBER 11 NOVEMBER 2013

requiring hundreds of pages of reading eachweek. First, we explore pivotal concepts andgeneral themes: attachment, temperament, moraldevelopment, language and cognition, culture,and ethnicity. Then, we switch to a chronologicperspective and examine development as asequence of stages, using our understanding ofneurobiological, physical, cultural, and psycho-logical factors to inform our assessment of howchildren change over time. I assign classic arti-cles on development, textbook chapters thatprovide overviews of specific developmentalstages, and recently published research articlesabout genetic determinants of behavior andthe anatomy and neurochemistry of braindevelopment.

Formal readings aside, how exactly shouldone teach child development to 18- or 19-year-old college freshmen? The AAMC’s goal is forfuture physicians to appreciate the “develop-mental, life span perspective” (p. 10),2 but thesestudents haven’t lived for very long and so their“perspective” is limited. Most of them are activelywrestling with identity versus role confusion,experiencing hormonal changes, discoveringand hoping they have reached Kohlberg’s fifthstage, and waiting, unknowingly, for theirprefrontal cortex to mature. In other words,they are still developing and changing, and thatvery process drives their interests and dictatestheir ability to understand the material.

I searched the extant literature but foundlittle to guide my thinking. In one article, theauthors concluded that “courses in child devel-opment do not always have optimal effectson college students’ understanding of children”and identified 3 barriers to learning: unconsciousbut tightly held beliefs, learned cultural biases,and lack of ability or willingness to distinguishbetween memorizing factual material andunderstanding concepts.3 My experience didnot support these conclusions. While munching

Y

www.jaacap.org 1121

PRAGER

on cookies and chips, my students sharedtheir individual stories and family lore andacknowledged some of their cultural biases. Earlyon, they identified which reading materialsthey found helpful and which got lost in trans-lation. They embraced the ongoing interplaybetween nature and nurture; they wantedto know how to connect developmental theoriesto their own lives.

I began to supplement the syllabus with othermaterials. The students gamely waded througha chapter about The Strange Situation and thenspent an hour reading Margaret Wise Brown’sRunaway Bunny out loud to learn more aboutattachment. One student showed us a YouTubeof “Toddlers in Tiaras” because it bothered herso much, prompting a conversation about why3-to 6-year-old girls should not be dressed uplike sexy women. Puzzling over Kohlberg, we letFaulkner’s “Barn Burning” drive our discussionof moral development in school-age children.Then, we examined and played the game ofChutes and Ladders to understand the conceptof making reparation. Reading an article abouthow babies learn language led to a vigorousargument about how many of the studentswho were born in other countries spoke accentedEnglish and why. The students squirmed througha PowerPoint presentation about the teen brainand its vulnerability to peer influences; a dis-cussion of neuronal connections quickly wassupplanted by one about hookups. By the timewe got to the last 3 sessions of the course,when we viewed selected clips from Geri Fox’sDVD charting her own daughter’s growth, thestudents were eager to apply theory to practiceand place the child on the screen in a largercontext.4

I assigned 3 papers. In the first few weeks,during our study of attachment and tempera-ment, I asked the students to write a shortresponse paper about a person who has hada major impact on their lives. In general, thestudents grasped the idea that early relationshipsare important and identified their supportingcast—people who guided, protected, nurtured,and influenced them. As one noted, “I haveinherited my mother’s eyes and temperament.I have inherited my father’s ears and soft jaw.I have inherited my grandmother’s ears. I haveinherited my grandfather’s bad habits. Butabove all, I have inherited the sacrifices and thedreams of my parents.”

JOURN

1122 www.jaacap.org

The second assignment was adapted from anexercise used at the university’s medical school.We visited a local museum and the studentssearched for artwork that, for example, reflectsa recent transition or evokes a memory ofchildhood. One student, on viewing a bronzesculpture in which Daphne, pursued by Apollo,is transformed into a young tree, made theconnection: “The sculpture seems to capturethe essence of my own experience: for me, therereally was not one distinct moment at whichthe transition from one stage of life to the nextbegan, nor was there a moment when I knewthe process was finished.”

For their final assignment, I asked thestudents to pick a book or books from theirchildhood that made an impression on them.Using our readings and discussion as a founda-tion, they had to explain why this particularbook mattered so much. Did the story capturea developmental stage, assuage developmen-tally appropriate fears, create a moral impera-tive, or pose a challenge to age and stage? Wasit important because the student read it tohimself or because someone read it to him?Justifying his choice of several children’s booksinitially published in Spanish, one studentcommented: “Through these books I began toread and to mold the language that representedmy culture and my family. I began to createa moral structure that created feelings andattachment to my parents and grandparents, aswell to the people around me.. In these books,there are symbols of the creation of me, andof the beauty that is the molding of thechild’s mind.”

My students arrived at college with lofty goalsand the ambition and self-discipline to achievethem. 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 ofbeing a mother but you have helped me to seethat I can be one.” “I know I’m going to be a greatfather.” I will be thrilled if most choose to beparents when they are ready, but the worldalso needs thoughtful, informed, self-reflective,inquiring people, and many of these studentsare well on their way. I will be delighted if a fewgo on to become practicing physicians of anyspecialty, but I will be satisfied if, regardless ofcareer choice, they manage to remember thatdevelopment is uneven and unpredictable, andthat despite all their accomplishments to date,

AL OF THE AMERICAN ACADEMY OF CHILD & ADOLESCENT PSYCHIATRY

VOLUME 52 NUMBER 11 NOVEMBER 2013

CLINICAL PERSPECTIVES

maturation takes time. I want them to moveforward knowing that they will find the answerto the question “how did we get here?” by usingtheir newfound familiarity with the multipledomains of development to reflect on where theycame from.

Not every college can or will support semi-nars of the type that I teach, but colleges will beincreasingly interested in offering courses thatwill help undergraduates fulfill these newprerequisites and do well on the MCAT. Iapplaud the AAMC’s goal, but I suspect thatmany early efforts to instruct students aboutdevelopment will probably not prepare them tobe more thoughtful or self-reflective doctors.Child and adolescent psychiatrists should seizethis new opportunity to influence future physi-cians by creating innovative and stimulatingways to teach students about development.(Some already have; I know of at least onecourse for undergraduates at a different collegein which a child and adolescent psychiatristuses contemporary films to illustrate develop-mental theories.) We are uniquely suited tothis task. &

JOURNAL OF THE AMERICAN ACADEMY OF CHILD & ADOLESCENT PSYCHIATR

VOLUME 52 NUMBER 11 NOVEMBER 2013

Accepted September 6, 2013.

Dr. Prager is with Massachusetts General Hospital.

The author thanks the students of Freshman Seminar 24u, HarvardCollege 2012 and 2013, for their enthusiasm and guidance.

Disclosure: Dr. Prager reports no biomedical financial interests orpotential conflicts of interest.

Correspondence to Laura M. Prager, M.D., Massachusetts GeneralHospital, Yawkey 6956, 55 Fruit Street, Boston, MA 02114; e-mail:lmprager@partners.org

0890-8567/$36.00/ª2013 American Academy of Child andAdolescent Psychiatry

http://dx.doi.org/10.1016/j.jaac.2013.08.021

REFERENCES1. Stuber ML. New developments in medical student education:

opportunities for child and adolescent psychiatrists. J Am AcadChild Adolesc Psychiatry. 2012;51:753-755.

2. Association of American Medical Colleges. Behavioral andsocial science foundations for future physicians. November 2011.https://www.aamc.org/download/271020/data/behavioralandsocialsciencefoundationsforfuturephysicians.pdf. Accessed August15, 2013.

3. McDevitt TM, Ormrod JE. Fostering conceptual change about childdevelopment in prospective teachers and other college students.Child Dev Perspect. 2008;2:85-91.

4. Fox G. Normal Development DVD Series: A Longitudinal StimulusVideo Resource for Educators [DVD]. Van Nuys, CA: ChildDevelopment Media; 2010.

Y

www.jaacap.org 1123