Play

All children play. From the infant squealing in delight during a game of peek-a-boo to the older child playing a game of basketball, children of all ages play and they play in all kinds of ways.

Play is recognized as an important part of a child's development. In fact, it is an important topic of study in many different disciplines. In the field of early childhood special education, play is valuable in assessing a child's level of development and in providing intervention. In psychology, therapists often watch children play to gain an understanding of children's problems and to help them deal with their emotions. The universal nature of play can also provide professionals working with children a basis for comparing typical and atypical development and behavior.

What Is Play?

In a preschool classroom, two four-year-old children pretend to go grocery shopping. One child methodically checks her grocery list and asks her friend what they need to buy. The other child places pretend groceries consisting of empty cans and boxes into his grocery sack. Once his sack is full, he asks his friend if she has any money in her purse to pay for the groceries. As she digs in her purse for the plastic coins and paper money, he approaches another child at the toy cash register to make his purchase.

As typical children grow and learn, they progress through stages of increasingly more complex levels of play. The above example illustrates a sophisticated level of play, where children pretend to be grocery shopping and take on the roles of shoppers, and employee. Jean Piaget, a well-known Swiss psychologist who extensively studied how children think, would have suggested that this example of play is reflective of the children's experiences and interactions with their environment. In his study of children and development, Piaget described play as a ''child's work.''

Holding views similar to Piaget's is Francis Wardle, an author and instructor at the University of Phoenix (Colorado), who defines play as ''child-centered learning.'' Play then, is a natural, child-directed way for children to learn new concepts and to develop new skills that will provide the basis for success in future settings.

The Importance of Play

Through play, children learn the skills necessary to effectively participate in their world through play. Play provides children with natural opportunities to engage in concrete and meaningful activities that enhance physical, language, social, and cognitive development. During play, children increase their knowledge and understanding of self, others, and the physical world around them.

A child's motor development becomes increasingly more refined through the physical activity that play naturally provides. Through the manipulation of toys and materials, children develop small motor skills. Large motor skills are developed as a child runs, climbs, and throws a ball.

Play is also important for the development of children's language skills. Children experiment with language during play and use words to express their thoughts and ideas. As children become more sophisticated in their play skills, their language development becomes equally sophisticated. Children use language during play to solve problems and to communicate their desires.

During play, children are provided with opportunities for social interaction with peers. Children learn the importance of social rules and how to get along with others through play. It is during this social interaction that children learn to express and control their emotions and to resolve conflicts with others.

As children are encouraged to explore and manipulate objects and materials in their environment, cognitive skills are developed and challenged. Children gain confidence as they experience fun and success in play. This increased confidence encourages children to further explore their world and to seek out even more challenging activities. Ideas and concepts expressed by children during play increase and become more complex as their play skills increase and become more complex.

Elements of Children's Play

Depending upon the materials involved in play and the level of the child's development, individual experiences, and personality, children will demonstrate a variety of play skills. Children's play skills can be described as having social and cognitive elements. The social elements are identified as solitary, parallel, or social play. The cognitive elements of play are described as being sensorimotor, pretend, constructive, mastery, or games with rules. Table 1 provides a summary of the elements of play and the typical age at which they might be noted or observed.

The social elements of play describe the amount of social interaction that the child is engaged in, whereas the cognitive elements describe the complexity of the child's play skills. Social and cognitive play elements are interrelated and will often overlap. Children may demonstrate several social and cognitive elements during one play activity.

Social Elements of Play

Solitary play is simply that—play that a child engages in alone. The child is totally absorbed in the activity and is not reliant upon the actions or words of others. Examples of solitary play include an infant shaking a rattle in her crib and a preschooler quietly looking at a book by herself. Children of all ages engage in solitary play.

Parallel play differs from solitary play in that the child is observant of others. Children are engaged in parallel play when they play side-by-side, using the

TABLE 1

Elements of Play

Social Elements

Key Descriptors

Typical Age

Solitary Play Parallel Play

Social or Group Play

Cognitive Elements

Sensorimotor Play

Pretend Play Constructive Play Mastery Play Games with Rules Play

Child plays by self

Child plays slde-by-side, observing but not Interacting with others Child plays with others and starts to develop friendships

Key Descriptors

Child engages In motor movements, reflexive and Intentional

Child acts out adult roles, familiar actions and events

Child manipulates materials and objects resulting In an end product

Child engages in motor play and pretend play simultaneously

Child engages In organized activities such as board games and sports

All ages

2-3 years

Emerges at 3-5 years

Typical Age

Birth through 2 years

Emerges at 18 months, more symbolic at

3-4 years

Emerges at 3-4 years Emerges at 4-5 years

Emerges at 5 years, pre-domlnant in middle childhood

SOURCE: Janet W. Bates.

same toys and materials, but do not engage in social interaction. A child may notice what his peers are doing, but he will not directly attempt social contact. Parallel play is a common play pattern with children ages two to three.

Social or group play is commonly first observed during the preschool years or around three to five years of age. Group play experiences provide young children with opportunities to learn social rules such as sharing, taking turns, and cooperation. Most activities provided in a nursery school or preschool setting support social or group play in young children. It is during this stage that children begin to develop friendships.

Cognitive Elements of Play

In sensorimotor play, children engage in motor movements beginning with early reflexes and moving toward more intentional actions. These early actions are initially the result of trial and error; children learn through their actions that their behavior has an effect on the environment. As children develop, their actions become more sophisticated and as a result more deliberate. For example, sensorimotor play includes the reflexive behavior of an infant grasping a rattle placed in her hand, as well as the intentional behavior of an older infant picking up and shaking a rattle to make sound. The sensorimotor stage typically occurs from infancy through age two.

Pretend play usually begins around eighteen months of age. Children at the pretend play level are able to act out adult roles, actions, and events that are familiar to them. At about the age of three or four, pretend play skills become more symbolic. This means that children are able to substitute one object for another. The younger child "feeds" a baby doll with a toy bottle, whereas the older child is able to "feed" the baby with a wooden block, pretending that the block is the baby bottle. It is during this level of play that the child's own experiences directly influence and provide a foundation for their play.

It is at about the age of three to four that children develop an interest in constructive play. Children at the constructive level manipulate objects and materials in their world resulting in an end product, such as a chalk picture, a block tower, or a sand mountain. Here children draw designs on a piece of paper, build with blocks, play and dig in the sand, and so forth. As children become skilled in manipulating objects and materials in their environment, they also become more skilled in expressing thoughts, ideas, and concepts.

The child at the mastery play level is able to demonstrate skilled motor movements and engage in forms of imaginative or pretend play simultaneously. Children at this level move about their environment with ease, confident in their actions. A child at the mastery level would be able to run and jump over obstacles on a playground while pretending to be a cartoon superhero. Mastery play typically emerges around four to five years of age and continues to develop as the child encounters new play experiences and challenges.

By the age of five, children become interested in formal games that have rules and, at times, have two or more sides. Games with rules play is predominant during the middle childhood years, a time during which children's thinking becomes more logical. It is at this level of play that children begin to realize that activities such as Red Rover, Simon Says, and card games will not work unless everyone follows the same set of rules. This level of cognitive play is much more organized than the earlier levels described and may involve competition and defining criteria that establishes a "winner."

Play is important to all aspects of a child's development. Children learn ideas and concepts and enhance language, social, and motor skills through play. As Piaget so simply stated it: Play is a child's work.

See also: FRIENDSHIP; PARALLEL PLAY; SOCIAL

DEVELOPMENT

Bibliography

Bredekamp, Sue, and Carol Copple. Developmentally Appropriate Practice in Early Childhood Programs. Washington, DC: National Association for the Education of Young Children, 1997.

Bronson, Martha R. The Right Stuff for Children Birth to Eight: Selecting Play Materials to Support Development. Washington, DC: National Association for the Education of Young Children, 1995.

Fernie, David. ''The Nature of Children's Play.'' In the ERIC Clearinghouse on Elementary and Early Childhood Education [web site]. Champaign, Illinois, 1988. Available from http:// npin.org/library/pre1998/n00373/n00373.html; INTERNET.

The Nemours Foundation. ''The Power of Play: How Play Helps Your Child's Development." In the Kids Health for Parents [web site]. 1999. Available from http://www.kidshealth.org/ parent/emotions/behavior/power_play.html; INTERNET.

Janet W. Bates

POSTPARTUM DEPRESSION

The postpartum period is a time of unrivaled demands and unique stresses, and is a developmentally challenging time for new parents even in the best of circumstances. During a normal postpartum experience, it is not unusual for new parents to experience heightened family and family-of-origin issues associated with the transition to parenthood. For example, adjustments usually need to be made in areas such as sleep schedules, employment, and role allocation. And, even for seasoned parents, there is the adventure of understanding the particular infant's unique temperament, needs, vulnerabilities, and strengths. The experience of depression in the mother during the postpartum period transforms an already challenging adventure into a potentially overwhelming one.

What Is Postpartum Depression?

There are three forms of postpartum depression, which vary greatly in terms of severity, duration, and impairment. The least severe (and most common) type is known as the ''baby blues.'' This is a mild syndrome occurring in up to 80 percent of new mothers. It usually starts within the first few days following childbirth and may last from a few hours to several days. Although distressing, the symptoms (which generally include episodes of crying, mood swings, and worry) do not cause significant impairment for the mother. On the other hand, ''postpartum psychosis'' is a rare yet very severe psychiatric illness. In such cases, the symptoms, which include mood disturbances along with hallucinations or delusions, cause major impairment in the new mother's ability to function. This illness usually requires that the mother be hospitalized.

The third type of depression, known as ''postpar-tum depression,'' occurs in approximately 15 to 20

percent of women following childbirth. It is a psychiatric syndrome, defined by the Diagnostic and Statistical Manual of Mental Disorders: DSM-IV as dysphoric mood (or loss of pleasure or interest in usual activities), coupled with symptoms such as sleep and appetite changes, cognitive disturbances, loss of energy, and/or recurrent thoughts of death, which co-occur for at least a two-week period. These symptoms cause significant distress and/or impairment in the new mother's functioning. It is important to note that these are the same symptoms used to diagnose a major depression at anytime during a person's life. The depressive syndrome is labeled a postpartum depression if the symptoms begin within the first three months following childbirth. On average, postpartum depression lasts for about four months, although it can vary considerably in length.

What Causes Postpartum Depression?

Depression during the postpartum period can best be considered an accident of timing; research has suggested that the rates, antecedents, course, and quality of depression during the postpartum period are similar to episodes experienced at other times in a woman's life. Although some research has suggested that negative life events during pregnancy and following delivery (such as financial difficulties, unemployment, and poor marital adjustment) may be associated with the onset of postpartum depression in new mothers, research in the late 1990s identified a previous instance of major depression as the most salient risk factor for postpartum depression.

What Are the Consequences of Postpartum Depression?

There has been an abundance of research on the influence of maternal depression in general on child outcome. This is for good reason—such research generally supports the notion that parental psychological distress (such as depression) is related to the development of negative parent-child interaction and family relationship patterns, which are associated with poor child outcomes. Depressed mothers as a group provide more negative self-reports regarding various aspects of family life, including dissatisfaction in relationships with their spouses and children, as well as stress and uncertainty regarding their own role as parents. Maternal depression has also been associated with disruptions in family unit functioning.

Not only are mothers affected by postpartum depression, the children of depressed mothers also exhibit a variety of impairments in social, psychological, and emotional functioning. More specifically, maternal depression during the postpartum period has

The least severe and most common type of postpartum depression is known as the "baby blues," a mild syndrome occurring in up to 80 percent of new mothers that usually starts within the first few days following childbirth and may last from a few hours to several days. (Karen Huntt Mason/Corbis)

The least severe and most common type of postpartum depression is known as the "baby blues," a mild syndrome occurring in up to 80 percent of new mothers that usually starts within the first few days following childbirth and may last from a few hours to several days. (Karen Huntt Mason/Corbis)

been associated with problems for infants such as increased levels of distress/irritability, protest, withdrawal, and avoidance of social interaction. Maternal postpartum depression has been related to insecure parent-infant attachment in some studies but not others. Researchers need to provide a better understanding of how the timing, chronicity, and intensity of the mother's depression are related to the infant's development. In general, even though maternal depression in the postpartum period has been found to be problematic for mothers and infants, it is important to keep in mind that depressed mothers ''don't always look as bad as they feel'' (according to researchers Karen Frankel and Robert Harmon) and that they likely have the ability in most cases to provide ''good enough'' parenting to their young children.

Are Interventions Effective in Treating Postpartum Depression?

There have been two main approaches for treating postpartum depression, neither of which has had much empirical testing. The first strategy is to focus directly on the individual woman, with the main goal of reducing her depressive symptoms. As discussed above, postpartum depression is by definition a major depression that occurs during the postpartum period. There is ample evidence to suggest that major depression can effectively be treated with psychophar-macological intervention (i.e., antidepressant medication). Mothers (and physicians) are generally reluctant, however, to use medication during the postpartum period given potential complications associated with breast-feeding. Alternatively, individual psychotherapy has been used to help improve the moods of depressed women. For example, Michael O'Hara and his colleagues reported in 2000 that interpersonal psychotherapy (IPT) was an effective treatment for reducing depressive symptoms, and improving social adjustment, in women with postpartum depression. Initially, IPT involves identifying depression as a medical disorder that occurs within an interpersonal context. The next stage of treatment focuses on current interpersonal challenges identified by the patient (i.e., difficulties with a partner or extended family, role transitions, and/or losses related to the birth). The final stage of treatment consists of reinforcing the patient's competence related to symptom reduction, as well as future-oriented problem solving related to the potential recurrence of depressive symptoms.

The second general strategy for treatment is to focus on maladaptive relationship patterns or parenting practices that are often associated with maternal postpartum depression, in order to improve and enhance parent-infant interactions. There are a number of techniques that have been examined, including relationship-based intervention conducted in the family's home, interaction guidance, and touch or massage therapy for infants. Although these approaches vary in technique, all are generally designed to enhance maternal sensitivity, responsivity to infant cues, and positive parent-infant interaction. Primary outcomes are examined in terms of improvement in factors such as infant regulatory capacities, social-emotional development, and parent-infant attachment. In addition, reduction in maternal depressive symptoms is usually reported, although this is not the direct focus of the intervention. Overall, improvements are noted, although minimal information is available to determine the duration or the specific effects.

Summary

There are several important points to consider in regard to postpartum depression. First, postpartum depression has been linked to adverse infant and family outcomes. Postpartum depression has been associated with problematic infant development, poor parent-child interactions, and unhealthy family functioning. Recent research has suggested that it is the quality of family functioning that is the key to promoting positive child outcomes.

Second, the best intervention for postpartum depression is early identification. Women at risk for postpartum depression can be identified early (even during pregnancy) by determining whether the woman has a history of depression. Past history of depression is one of the most consistent findings for the prediction of postpartum depression.

Third, once the risk for maternal depression has been identified, steps can begin immediately to prevent adverse outcomes for mother and child. Early identification of depression is most critical—that is, before the baby is born. Even prior to the onset of fullblown disorder, services can be put in place to facilitate parenting competence, enhance parent-child relationship quality, and/or reduce intensity of depressive symptoms by connecting mothers with appropriate community services.

Finally, interventions are effective in ameliorating symptoms of postpartum depression. Much research has focused on the treatment of mothers' depressive symptoms. Treatment strategies for post-partum depression also need to include family development plans that account for each family's unique strengths and needs, an emphasis on strengthening family relationships by highlighting the role of fathers and other important caregivers, and the promotion of positive parenting and parental competence. Without question, giving support to families who are experiencing significant risks such as maternal depression is ultimately in the best interest of children.

See also: BIRTH; PARENTING; PREGNANCY

Bibliography

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: DSM-IV. Washington, DC: American Psychiatric Association, 1994.

Campbell, Susan B., and Jeffrey F. Cohn. "Prevalence and Correlates of Postpartum Depression in First-Time Mothers.'' Journal of Abnormal Psychology 100 (1991):594-599.

Campbell, Susan B., and Jeffrey F. Cohn. "The Timing and Chro-nicity of Postpartum Depression: Implications for Infant Development.'' In Lynne Murray and Peter J. Cooper eds., Postpartum Depression and Child Development. New York: Guil-ford Press, 1997.

Campbell, Susan B., Jeffrey F. Cohn, C. Flanagan, S. Popper, and Meyers. "Course and Correlates of Postpartum Depression during the Transition to Parenthood.'' Development and Psy-chopathology 4 (1992):29-47.

Cooper, Peter J., and Lynne Murray, eds. "The Impact of Psychological Treatments of Postpartum Depression on Maternal Mood and Infant Development.'' In Postpartum Depression and Child Development. New York: Guilford Press, 1997.

Cowan, Carolyn P., and Phillip A. Cowan. When Partners Become Parents. New York: Basic, 1992.

Cummings, E. Mark, and P. T. Davies. "Maternal Depression and Child Development.'' Journal of Child Psychology and Psychiatry 35 (1994):73-112.

DeMulder, Elizabeth K., and Marian Radke-Yarrow. ''Attachment with Affectively Ill and Well Mothers: Concurrent Correlates." Development and Psychopathology 3 (1991):227-242.

Dickstein, Susan, and Ronald Seifer. ''Longitudinal Course of Depression in Women from Pregnancy to Postpartum.'' Paper presented at the biennial meeting of the Marce Society, Iowa City, IA, 1998.

Dickstein, Susan, Ronald Seifer, Lisa C. Hayden, Masha Schiller, Arnold J. Sameroff, Gabor Keitner, Ivan Miller, Steven Ras-mussen, Marilyn Matzko, and Karin Dodge-Magee. ''Levels of Family Assessment II: Impact of Maternal Psychopathology on Family Functioning.'' Journal of Family Psychology 12 (1998):23-40.

Downey, Geraldine, and J. C. Coyne. ''Children of Depressed Parents: An Integrative Review." Psychological Bulletin 108 (1990):50-76.

Field, Tiffany, N. Grizzle, F. Scafidi, and S. Abrams. ''Massage Therapy for Infants of Depressed Mothers.'' Infant Behavior and Development 19 (1996):107-112.

Field, Tiffany M., Nathan A. Fox, J. Pickens, and T. Nawrocki. ''Relative Right Frontal EEG Activation in Three- to Six-Month-Old Infants of 'Depressed' Mothers.'' Developmental Psychology 31 (1995):358-363.

Frankel, Karen A., and Robert J. Harmon. ''Depressed Mothers: They Don't Always Look as Bad as They Feel.'' Journal of the American Academy of Child and Adolescent Psychiatry 35 (1996):289-298.

Heinicke, Christoph M., N. R. Fineman, G. Ruth, S. L. Recchia, D. Guthrie, and C. Rodning. ''Relationship-Based Intervention with At-Risk Mothers: Outcome in the First Year of Life." Infant Mental Health Journal 20 (1999):349-374.

McDonough, Susan. ''Interaction Guidance: Understanding and Treating Early Caregiver-Infant Relationship Disturbances.'' In Charles Zeanah ed., Handbook of Infant Mental Health. New York: Guilford Press, 1993.

McGrath, Ellen, Gwendolyn P. Keita, Bonnie R. Strickland, and Nancy F. Russo. Women and Depression: Risk Factors and Treatment Issues. Washington, DC: American Psychological Association, 1990.

Milgrom, J., P. R. Martin, and L. M. Negri. Treating Postnatal Depression. Chichester, Eng.: Wiley, 1999.

Murray, Lynne, and Peter J. Cooper, eds. "The Role of Infant and Maternal Factors in Postpartum Depression, Mother-Infant Interactions, and Infant Outcomes.'' In Postpartum Depression and Child Development. New York: Guilford Press, 1997.

O'Hara, Michael W. "Interpersonal Psychotherapy for Postpartum Depression.'' Paper presented at the biennial meeting of the Marce Society, Iowa City, IA, 1998.

O'Hara, Michael W., J. A. Schlechte, D. A. Lewis, and E. J. Wright. "Prospective Study of Postpartum Blues.'' Archives of General Psychiatry 48 (1991):801-806.

O'Hara, Michael W., S. Stuart, L. L. Gorman, and A. Wenzel. "Efficacy of Interpersonal Psychotherapy for Postpartum Depression.'' Archives of General Psychiatry 57 (2000):1039-1045.

O'Hara, Michael W., Ellen M. Zekoski, Laurie H. Philipps, and Ellen J. Wright. ''Controlled Prospective Study of Postpartum Mood Disorders: Comparison of Childbearing and Nonchild-bearing Women.'' Journal of Abnormal Psychology 99 (1990):3-15.

Parke, Ross D., and Barbara R. Tinsley. ''Family Interaction in Infancy.'' In Joy D. Osofsky ed., Handbook of Infant Development, 2nd edition. New York: Wiley, 1987.

Weissman, Myrna M., G. D. Gammon, K. John, K. R. Merikangas, V. Warner, B. A. Prusoff, and D. Sholomskas. ''Children of Depressed Parents.'' Archives of General Psychiatry 44

Weissman, Myrna M., and J. C. Markowitz. ''Interpersonal Psychotherapy: Current Status.'' Archives of General Psychiatry 51 (1994):599-606.

Susan Dickstein

POVERTY

One of every five children in the United States lives in a family with income below the official poverty level, despite general agreement that this poverty threshold ($14,630 in 2001 for a family of three) is out of date and too low when considering current housing costs and other family expenditures (e.g., child care, health care). Arloc Sherman of the Children's Defense Fund reports that one in three children in this country will experience at least one year of poverty before they reach age sixteen. Minority children are disproportionately represented, especially among those who experience persistent poverty. As summarized by Suniya Luthar of Columbia University, one in four African-American children experiences ten to fifteen years of poverty; this is a rare phenomenon for Anglo children.

When addressing the incidence of childhood poverty, it is also important to consider what Daniel Hernandez of the National Academy of Sciences and Institute of Medicine defines as relative poverty. This is the minimum income required to purchase those items that society considers essential to decent and respectable living, the minimum level required to avoid the stigma of living in inhumane conditions. Her nandez defined relative poverty as 50 percent of the median income for a given year, adjusted for family size. Given this definition, about one in three children in the United States lives in relative poverty.

Causes of Poverty

What are the causes of childhood poverty or low family income? The most obvious answer is that the parents make low wages for their work. Full-time work at or near the minimum wage is insufficient to move even a small family above the poverty level. What characteristics are associated with low income for families? Parents in poor families tend to be younger and less educated than parents in nonpoor families; they are also more likely to be single or divorced. The rise in childhood poverty since the 1970s is associated with an increase in single-parent families. It would be a mistake, however, to view single parenthood as a major cause of child poverty independent of economic factors. Custodial parents experience significant declines in family income following divorce or separation. Also, single parents often have difficulty balancing the demands of parenting (e.g., picking up a sick child from child care) and the demands of job advancement or promotion. Finally, family stress and conflict caused by poverty can be responsible for divorce or separation; Sherman reports that poor parents separate twice as frequently as do nonpoor parents.

Consequences of Poverty

Children who grow up in families with low incomes are significantly more likely to experience a wide range of problems and poor developmental outcomes than children from wealthier families. Greg Duncan from Northwestern University and Jeanne Brooks-Gunn from Columbia University have summarized extensive research findings that substantiate significant associations between poverty and children's health, cognitive development, behavior problems, emotional well being, and problems with school achievement. For example, children from poor families are 1.7 times more likely to be born with low birthweight, 2 times more likely to repeat a grade in school, 2 times more likely to drop out of school, and 3.1 times more likely to have an out-of-wedlock birth than children from nonpoor families. The specific aspects of poverty that are most destructive, as well as the specific outcomes of poverty, vary across different ages and developmental levels. For example, inadequate nutrition is associated with low birthweight, an important measure of well-being for infants that is predictive of later behavior problems and poor school achievement. As another example, the effects of in

One of every five children in the United States lives in a family with income below the official poverty level. Children who grow up in families with low incomes are significantly more likely to experience a wide range of problems and poor developmental outcomes. (Library of Congress)

come on children's intelligence are most apparent for children who experience poverty in early childhood (two to five years of age).

When examining the consequences of poverty, it is important to recognize several patterns. First, the effects of poverty are usually nonlinear, meaning that the consequences of income differences below or near poverty levels are substantially greater than comparable differences at higher income levels. Differences in outcomes between children from families living at 50 percent of the poverty level versus 100 percent of the poverty level are large and significant. In contrast, income differences among middle or upper class families make little or no difference for children. Second, persistent poverty can be particularly destructive for children, compared to short-term poverty. For example, Brooks-Gunn and Duncan reported that children who experienced poverty during four to five of their first five years experienced a full nine-point decline in intelligence test scores compared to children who experienced no poverty; fewer years of poverty resulted in a four-point decline in test scores. Third, it is important to recognize that different risk factors (e.g., poverty, father absence, maternal depression, low parental education) are cumulative in their effects. Poor children experience more risks than do nonpoor children. Luthar argued that the effects of poverty are qualitatively different and worse for contemporary children (compared to earlier generations) because of the accumulation of multiple risks in poor families. Finally, it is important to recognize that the effects of poverty can be interactive as well as cumulative. That is, research indicates that poor children are more vulnerable to further negative influences than are children from families with higher incomes. For example, Pamela Klebanov, of Columbia University, and her colleagues found that family risk factors had greater negative effects on infant intelligence for poor children than for nonpoor children.

Poverty influences aspects of children's lives that child development experts have long recognized as essential to normal development. For example, economic stress interferes with positive, high-quality parent-child interactions. As another example, children living in poor families are often socially isolated and/or painfully aware of the shame and stigma associated with poverty. In a research study, the author found that children who most frequently went hungry were also most likely to report that adults criticized or disapproved of them. Child development experts recognize the importance of positive self-esteem to healthy development. Of course, living in a poor family also increases the chances of living in a poor neighborhood with more exposure to violence and less social support for families than in other neighborhoods. Klebanov and her colleagues found that neighborhood poverty had significant effects on children's developmental test scores as early as age three (beyond the effects of family risks and family income). Stressful parent-child relationships, social isolation and shame, and poor neighborhoods are examples of potential mediators or pathways through which poverty produces negative outcomes for children. Researchers have identified a number of other mediators of the effects of poverty on children, including low-quality child care, inadequate health care, the inability to provide a rich and stimulating learning environment in the home, chronic exposure to violence, and poor parental mental health.

Some of the most impressive research findings on childhood poverty come from statistical analyses of large data sets in which pure effects of family income have been isolated from the effects of other factors often associated with poverty (e.g., single parenthood, low parental education). Duncan and Brooks-Gunn and their colleagues demonstrated that family income significantly predicted children's academic achievement and ability, even after removing any predictive power associated with family risk factors that often go along with poverty. Such findings are particularly important in invalidating arguments that poor outcomes for poor children result from other factors besides income level (e.g., character flaws in families, negative effects of welfare, low education levels, single parenting). On the other hand, such an approach to statistical analyses may also represent an unfair or overly rigorous test of whether poverty matters for children. As also noted by Luthar, one will necessarily underestimate the consequences of poverty if one eliminates or ignores any influences of poverty that are also associated with common causes of that poverty (e.g., low parental education, single parenthood). In the real world, poverty naturally coexists with other important family risk factors.

Programs for Children Living in Poverty

This review suggests a number of policies and programs that should be helpful to children living in poverty. For example, research identifying pathways for the influences of poverty reinforces the need for programs designed to provide stimulating learning environments (e.g., Head Start), to strengthen poor neighborhoods, to improve the quality of child care available to low-income families, and to provide mental health services for parents. Robert St. Pierre and Jean Layzer, researchers with Abt Associates, have summarized the successes and failures of various programs designed to improve the ''life chances of children in poverty.'' They conclude that intensive early childhood programs, with follow-up as children enter school, can have significant positive effects. In con trast, research has failed to demonstrate that parenting education yields positive outcomes for children. St. Pierre and Layzer suggested that most comprehensive two-generation programs (focusing on both parents and children) have failed because of their erroneous focus on coordinating existing services instead of adding intensive programs needed by vulnerable children. These researchers concluded that ''without the societal will to make direct and dramatic changes in the economic circumstances of low-income families, policymakers will have to continue to rely on programs such as the ones reviewed in this article as a second-best solution to helping low-income families.'' (St. Pierre and Layzer 1998, p. 19). Overall, the research on children and poverty indicates that the most successful programs for producing positive child outcomes will be those that reduce family poverty.

See also: HEAD START; HEALTH INSURANCE Bibliography

Brooks-Gunn, Jeanne, Greg Duncan, and Nancy Maritato. ''Poor Families, Poor Outcomes: The Well-Being of Children and Youth.'' In Greg Duncan and Jeanne Brooks-Gunn eds., Consequences of Growing Up Poor. New York: Russell Sage Foundation, 1997.

Duncan, Greg, and Jeanne Brooks-Gunn. ''Family Poverty, Welfare Reform, and Child Development.'' Child Development 71 (2000):188-196.

Hernandez, Daniel. ''Poverty Trends.'' In Greg Duncan and Jeanne Brooks-Gunn eds., Consequences of Growing Up Poor. New York: Russell Sage Foundation, 1997. Klebanov, Pamela, Jeanne Brooks-Gunn, Cecilia McCarton, and Marie McCormick. ''The Contribution of Neighborhood and Family Income to Developmental Test Scores over the First Three Years of Life.'' Child Development 69 (1998):1420-1436. Luthar, Suniya. Poverty and Children's Adjustment. Thousand Oaks, CA: Sage, 1999.

Sherman, Arloc. Poverty Matters: The Cost of Child Poverty in America.

Washington, DC: Children's Defense Fund, 1997. St. Pierre, Robert G., and Jean I. Layzer. ''Improving the Life Chances of Children in Poverty: Assumptions and What We Have Learned.'' Social Policy Report: Society for Research in Child Development 12, no. 4 (1998):1-27.

Linda J. Anooshian

PREGNANCY

Pregnancy is one of the most important watershed events in a woman's life. Some regard the nine-month gestation as one of the happiest times in their lives, others as the most arduous test of patience that they have ever experienced. It is certain, however, that from both a physical and personal perspective, a woman is undeniably changed by this event. What follows is basic information regarding the developmental changes that the woman and fetus undergo during the course of a gestation.

Maternal Development

A woman's physical state begins to change from as early as the implantation of the fertilized egg and continues to change throughout gestation. The ability of a woman to alter herself to support and nurture the development of another being within her own body is one of nature's most impressive feats. From a physiologic standpoint, the maternal body remodels almost all of its organ systems, from heart to hormones, to prepare for the upcoming nine-month gestation. These changes result in the various signs and symptoms characteristic of pregnancy.

In general, a typical gestation, or pregnancy, lasts nine months or three trimesters of three months. Trimesters are used to mark significant milestones in a pregnancy. For example, most spontaneous miscarriages occur prior to the end of the first trimester. The end of the second trimester usually is a good time to recheck maternal lab values, such as the blood count, and to screen for diabetes in pregnancy. From an obstetrician's standpoint, a gestation is measured in weeks. Because different women have different tendencies toward ovulation (some ovulate earlier in their menstrual cycles, some later), it is difficult to establish a gestational age from the time of fertilization. Instead doctors and midwives calculate the gestation-al age from a more reliable indicator: the first day of the woman's last normal menstrual period. This starting time is usually about two weeks prior to ovulation. The due date can be quickly calculated using a simple formula: adding seven days to the date of the start of the last normal menstrual period, then subtracting three months. The resulting month and day represent the expected delivery date of a full-term gestation.

One of the most obvious signals of pregnancy is the interruption of a woman's menstrual cycle. This sign is most reliable in women who have regular, consistent menses (menstrual flows). A period that is ten days late or more in a woman with regular menses can be considered a strong indicator of pregnancy. This suspicion is strengthened if a woman goes on to skip her next period altogether. This qualification changes for women who have a history of skipping periods or have erratic cycles that are affected by environmental or physical stressors. For these women, a pregnancy test is the best way to ascertain pregnancy.

What is the most reliable way to determine whether a woman is pregnant? There are dozens of home pregnancy tests available. These are good initial measures to use. Although some companies state that their tests are greater than 97 percent accurate, some individuals fail to use these tests properly, which can result in a lower than expected accuracy rate. Studies done in the early 1980s and 1990s showed that the accuracy rates of home pregnancy tests ranged from 70 percent to 83 percent for women who were actually pregnant. The best way to obtain a diagnosis is to undergo a blood test ordered by a doctor and performed by trained technicians. These tests use chemical analysis to measure the presence of a hormone called human chorionic gonadotropin (HCG). HCG is produced by placental cells and is expressed in maternal blood and urine almost immediately from the day the embryo implants in the uterus. These biochemical tests determine the level of hormone in a woman's blood sample. Increasing levels of HCG, along with the other symptoms and signs of pregnancy, provide the most reliable, consistent, and reproducible results for determining pregnancy.

Other symptoms of pregnancy that are commonly seen include nausea, fatigue, changes in urinary habits, and ultimately the perception of fetal movement. Episodes of nausea and occasional vomiting, also known as ''morning sickness,'' occur around six weeks from the start of a woman's last menstrual period. Typically, the woman experiences a few episodes of nausea and vomiting, most commonly for a few hours during the morning. These episodes usually pass by the end of the first trimester. Occasionally, women will have more serious episodes of vomiting marked by increased frequency and intolerance of any food or liquid intake. This condition, known as hyperemesis gravidarum, can persist throughout pregnancy. Treatment entails the use of antinausea medications, and if cases are severe enough, hospital-ization for intravenous rehydration.

Changes in urinary habits are noted during the first trimester. At that time, the growing uterus begins to exert more force on the bladder, producing the sensation of fullness and increasing the number of trips to the bathroom. As pregnancy continues, the uterus expands out of the pelvis, relieving some pressure on the bladder and decreasing urinary frequency. As the time of labor approaches, however, the fetus ''drops'' into the pelvis and reexerts pressure on the bladder, resulting in a return of frequent urination.

The first sensation of fetal movement, also known as the ''quickening,'' is reported by most women to occur between sixteen and twenty weeks. These movements are described as ''fluttering'' or ''tickles'' in the abdomen. First-time mothers usually report that the quickening occurs later than women who have previously gone through pregnancy. Although this event is not fully diagnostic of pregnancy by itself, it is a milestone that is noted by many obstetricians and is a good way to roughly judge the gestational age of the pregnancy.

In addition to these self-reported symptoms of pregnancy, an obstetrician can use ultrasonography to definitively identify an early gestation. Using transvaginal ultrasound techniques, an obstetrician can identify a gestational sac as early as two weeks, although four to five weeks is the norm. A yolk sac can be seen as early as three weeks but should be clearly seen by six weeks. At seven weeks, the earliest picture of the developing fetus, known as the fetal pole, can be detected. By eight weeks, the fetal heart can be seen contracting. From this gestational age to about twelve weeks, the size of the fetus, measured from the top of the head to the hips (the crown-rump length), can be compared with the gestational age based on a woman's last menstrual period. These two measures are used to determine the gestational age of the pregnancy and to predict the pregnancy's due date.

As the pregnancy progresses, the uterus continues to enlarge. By twelve weeks of gestation, the uterus becomes perceptible through the abdominal wall. This is usually noticed as a small lump that protrudes from the lower abdomen, slightly above the pelvic bone (pubic symphysis) at the level of the start of pubic hair growth. Starting at twenty weeks, a measurement is regularly taken from the pubis to the top, or fundus, of the uterus during an obstetrical visit. The bladder must be empty to produce an accurate measurement. The resulting measurement in centimeters should roughly equal the number of weeks of pregnancy, with an error of plus or minus two centimeters. This measurement, called the fundal height, may indicate that the fetus is not growing properly (i.e., is too small or too big). If an abnormal result is obtained, an ultrasound can usually be done to check fetal growth and the level of amniotic fluid in the womb. This general principle is applicable to single fetal gestations only, because twins and other multiple pregnancies necessarily produce a larger fundal height.

In addition to these changes in physical stature, the pregnant woman goes through a series of amazing physiologic changes that affect all aspects of the maternal body. From a metabolic perspective, pregnancy necessitates an increased maternal need for nutrients, water, and energy (calories). The fetus is dependent on the expectant mother for all nutritional needs and oxygenation, and it extracts what it needs at the woman's expense. Thus, the woman herself needs to gain weight and increase her caloric consumption to meet her own needs and those of the fetus. The National Research Council's dietary guidelines recommend that pregnant women increase their caloric intake by approximately 300 kilocalories per day. Specifically, a nonpregnant woman requires approximately 2,200 kilocalories per day. A pregnant woman should thus consume 2,500 kilocalories per day.

The demand for iron also increases during pregnancy. The body uses iron to carry oxygen in the blood, which is ultimately transported to the fetus. Thus, it is recommended that women increase their iron intake, especially during the second and third trimesters, when the fetus does the bulk of its growing to reach its physical size. Usually, adequate amounts of iron can be obtained through ingestion of iron rich foods, such as liver, and dark leafy vegetables, such as spinach. Some sources have found, however, that the amount of iron provided by both normal dietary intake and maternal storage is insufficient to meet pregnancy demands. In fact, the National Academy of Sciences and the American College of Obstetrics and Gynecology recommend that pregnant women receive a supplement of 30 milligrams of iron per day. Most obstetricians recommend that a woman stay on her prenatal vitamin, which should supply enough iron to cover the recommended amount. It is also common practice to check the level of blood (via the hematocrit and hemoglobin tests) both at the start and in the third trimester of pregnancy. If the expectant mother is found to be anemic, she is started on additional iron supplements (ferrous sulfate tablets).

In addition to the increased demand for nutrients, increasing the intake of water is vital to the maintenance of pregnancy. Higher levels of total body water are required to provide the increased fluid volume needed to meet the demands of increased blood flow and circulation to the developing baby. Thus, the pregnant woman's kidney system begins to retain water. Maintaining adequate amounts of fluid intake is also important, as it is easier for pregnant women to become dehydrated, which can lead to pre-term contractions.

The summation of all these dietary and metabolic changes can be seen in the recommendations for weight gain in pregnancy. In a normal nonobese woman, a twenty-five to thirty-five pound weight gain is recommended. This value fluctuates depending on the prepregnancy weight of a woman; specifically, an underweight woman may gain up to forty pounds, while it is recommended that overweight women limit their weight gain to fifteen to twenty pounds. Usually, three to six pounds are gained in the first trimester, with a subsequent gain of one-half to one pound per week thereafter until term. Weight should be measured at every obstetrical visit. If a woman does not show a ten-pound weight gain by the mid-second trimester, her nutritional status should be reviewed. A woman with below average weight gain is at higher risk of producing a low-birthweight and intrauterine growth-restricted infant. Likewise, obese women

Amniocentesis is a prenatal test in which fluid is extracted from the amniotic sac via the uterus of a pregnant woman. The results of the test can indicate whether or not the infant will have a chromosomal problem, such as a genetic disease. (Pete Saloutos/The Stock Market)

should be careful about their weight gain as they have an increased risk of producing a large for age (macro-somic) baby, with its associated higher risk of difficult delivery and cesarean delivery.

As each week of the pregnancy passes, the woman will be able to gauge the progression of her pregnancy only through the increasing size of her belly and the amount of activity felt in her uterus. She may not be fully aware of the extent of change occurring with the fetus. Hidden within the woman is a process that is no less fascinating than the changes the woman is undergoing.

Fetal Development

The first trimester is the most critical period for fetal development. It is at this point that the fertilized egg begins to develop from a mass of disparate cells into an organized whole that is truly the sum of its individual specialized parts. The start of the third week after fertilization marks the beginning of the embryonic period. At this point, the fertilized egg begins to differentiate its cells into the beginnings of the placenta and the body of the future fetus. By the end of the fourth week after ovulation, the embryo is roughly four to five millimeters (0.16 to 0.2 inches) long, and heart activity can be seen on ultrasound. By the end of the sixth week, the embryo is roughly two centimeters (three-quarters of an inch) long and has a definitive head separate from the body. A vast amount of organ development occurs before many women realize that they are indeed pregnant, highlighting the importance of attention to the health of women as they anticipate pregnancy.

The fetal period is usually considered to start by the eighth week after fertilization. By this time, the period most crucial to organ and structural development has passed. Development from this period consists of the growth and maturation of structures that were formed during the embryonic period. According to Williams Obstetrics, a primary textbook in the obstetrical field, the milestones in fetal development can be marked every four weeks of the fetus's menstrual/ gestational age.

At twelve weeks from the last menstrual period, the fetus is clearly visible by transvaginal ultrasound and may be visualized by abdominal technique depending on the quality of the equipment and the size of the expectant mother. Fingers and toes are differentiated from each other, and fingernails are present. The external genitalia are starting to develop, but it is difficult to determine gender at this point.

By sixteen weeks, the fetus can be seen by abdominal ultrasound. The fetus now weighs approximately 110 grams (four ounces) and has well-developed lower limbs. Intestines, stomach, and bladder should be visible. The sex of the baby can be reliably determined at this point, with fetal cooperation, of course. At this time, most pregnant women undergo screening tests of their blood to check for possible problems with Down syndrome or spina bifida. An ultrasound to assess anatomy and to look for any signs of structural defects is usually done at this age.

The end of the twentieth week represents the midpoint of pregnancy. The average fetus weighs approximately 320 grams (eleven ounces) and is approximately sixteen centimeters (six and one-quarter inches) long. At this point, some scalp hair may be seen in ultrasound images, and the body is covered with a fine, downy hair called lanugo.

The twenty-fourth week represents a major milestone as hospitals with high-tech (level 3) neonatal intensive care nurseries and neonatal specialists consider fetuses at this age to be viable. Unfortunately, fetuses born at this age are extremely premature. The skin is wrinkled, with small amounts of subcutaneous (below the skin) fat present; thus, they have tremendous problems maintaining body temperature. They weigh only 630 grams (twenty-two ounces) and have poorly developed lungs, which necessitates the use of ventilators to assist breathing.

At twenty-eight weeks, the fetus is now roughly twenty-five centimeters (nine and three-quarter inches) long and can weigh approximately 1,100 grams (two pounds, six ounces). By this point, the fetus that is delivered will have eyes partially open, limbs that can move energetically, and may be able to cry. Most fetuses born at this point will survive under the care of a high-tech, level 3 neonatal intensive care unit.

By thirty-two weeks, the average fetus weighs roughly 1,800 grams (three pounds, fifteen ounces), and measures approximately 28 centimeters. The skin is wrinkled and red, but the body begins to fill out with more deposition of subcutaneous fat. This represents another major milestone as the chances of the other problems of prematurity, such as hemorrhages in the brain or the eye and problems with the intestines, drop considerably. The biggest problems facing babies born at this age involve lung development and function.

The thirty-sixth week represents another important milestone. At this point, the baby measures approximately thirty-two centimeters (twelve and one-half inches) and weighs approximately 2,500 grams (five pounds, eight ounces). The body is filled out with subcutaneous fat. Although babies born at this age are still technically ''preterm'' (infants are considered term at thirty-seven to forty weeks), most women who go into labor at this age would not be stopped with medications. Babies born at this age have an excellent chance of survival.

Finally, at forty weeks, the goal of gestation is reached. At this age, the average baby measures thirty-six centimeters (fourteen inches) and weighs approximately 3,400 grams (seven pounds, seven ounces). The skin is smooth and pink, the body is plump, and the lungs generally function well. It should be noted that these stages of development represent general characteristics only. There is always a large degree of variability in fetal development, much of which is influenced by variable factors such as genetic makeup (e.g., chromosomal defects), characteristics of the parents (e.g., size, weight, race) and characteristics of the pregnancy (e.g., toxemia, maternal smoking, bleeding during the pregnancy). At times, the gestation may go past forty weeks. This occurrence is not uncommon. In fact, very few deliveries occur at exactly forty weeks. In cases where pregnancies go ''post-term,'' the women should be followed normally. Most obstetricians will institute measures to induce delivery if the woman does not go into labor on her own past forty-two weeks. At this point, there is concern that the fetus will grow too big and an increased chance of cesarean delivery. Furthermore, the placenta has a finite ''lifespan,'' and gestations that continue too long past the due date have a higher risk for placental failure, which could harm the safety of the fetus.

Although the gestation itself represents a relatively short period in a woman's life, the physical and personal changes that pregnancy brings about in a woman last throughout her lifetime. Clearly, pregnancy is a task that should not be met without preparation and assistance.

See also: BIRTH; CONTRACEPTION; PRENATAL CARE;

PRENATAL DEVELOPMENT; REPRODUCTIVE

TECHNOLOGIES

Bibliography

Cunningham, F. Gary, Paul C. MacDonald, Norman F. Gant, Kenneth J. Leveno, Larry C. Gilstrap, Gary D. Hankins, and Steven L. Clark, eds. Williams Obstetrics. Stamford, CT: Simon and Schuster, 1997.

Doshi, M. L. ''Accuracy of Consumer Performed In-Home Tests for Early Pregnancy Detection.'' American Journal of Public Health 76 (1986):512-514.

Gabbe, Steven G., Jennifer R. Niebyl, and Joseph L. Simpson, eds. Obstetrics: Normal and Problem Pregnancies. New York: Churchill and Livingstone, 1997.

Jeng, L. L., R. M. Moore, R. G. Kaczmarek, P. J. Placek, and R. A. Bright. ''How Frequently Are Home Pregnancy Tests Used? Results from the 1988 National Maternal and Infant Health Survey.'' Birth 18 (1991):11-13.

National Research Council. Recommended Dietary Allowances, 10th edition. Washington, DC: National Academy Press, 1989.

Valanis, B. G., and C. S. Perlman. ''Home Pregnancy Testing Kits: Prevalence of Use, False-Negative Rates, and Compliance with Instructions.'' American Journal of Public Health 72 (1982):1034-1036.

Garrett Lam

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