November 1998, VOLUME102 /ISSUE Supplement E1

Facilitating and Encouraging Healthy Emotional Development

  1. John G. Warhol, PhD

The faculty of the 1998 Johnson & Johnson Pediatric Round Table: New Perspectives in Early Emotional Development are among the world's leaders in the field of infant development. Each brought to the table years of experience from a variety of disciplines. The salient points of their discussions are summarized in the following article.


Emotional development in infants and children has lifelong effects, and everyone caring for them—pediatricians, child health professionals, families, and caregivers—has an important role in the growth and development of unique and healthy human individuals. A common theme to facilitate optimal infant development, advanced by all participants in this Pediatric Round Table, is the need for excellent communication and cooperation among all individuals who influence young lives.

On one level, improved communication between researchers and clinicians will get meaningful new information into practice where it can be used effectively. This process will be even more effective if professionals from both disciplines, in the interests of cross-fertilization, exchange ideas and observations early and frequently. In many ways, round table meetings such as this break new ground and establish the foundation of productive alliances.

On another level, communication between professionals and parents, grandparents, and day-to-day caregivers must have an appropriate tone and content to actually deliver meaningful effective messages. It often is important to step back from years of professional training to think in parent terms. What do parents have to know to have the greatest positive effect on their infant? What do I have to avoid saying so that I don't add to their uncertainty, anxiety, or frustration? One often-repeated example of the latter dealt with explaining why the first years of life were important in the child's later health and well-being. All too often this knowledge made parents worry that even the tiniest mistake would destroy their infant's opportunity for a happy, healthy, and productive life.

The answer to this dilemma is that there is no simple answer. Every infant, every family, every environment is unique. Each is the product of a diverse genetic, cultural, and religious heritage. The pediatrician must embrace this complexity, yet communicate with simplicity.


But what is new, valid, and meaningful to professionals and parents?

Emotional Development Is Important

A basic tenet is that early emotional development is as important as early physical development. Talking about physical development is always somewhat easier, because well-established milestones for growth and physical skills have been known for years. Discussing emotional and behavioral milestones is more complex because they are less well-defined, and there may be a danger in proscribing clear-cut “emotional milestones” because each infant is unique and develops at his or her own pace.

Early Life Is a Crucial Time in a Person's Development

At a young age, the brain is growing, developing, and open in special ways to visual, tactile, olfactory, and auditory stimulation. The combination of these stimuli, the way people interact with infants, and the total environment in which infants live all influence long-term behavior and intellectual development. For example, development of emotional attachment between a mother and her new infant is important within hours and days of birth. In cultures where mother and infant are kept apart, the rates of infant abandonment and abuse are high; these rates plummet when mother and infant are provided maximum contact with each other. In this case, by allowing emotional development to occur fully and naturally, a healthy mother–infant dyad is formed, a baby is cared for by his mother, and society benefits on all fronts.

Discussing and Evaluating Emotional Development

Addressing emotional development requires professionals who are sensitive and emotionally available. Helping parents and infants through emotional or behavioral problems is not the same as treating otitis media. Practitioners need to “be there” for their patients, not just physically, but emotionally. This involves using your own emotions to appreciate the uniqueness and individuality of those you care for. Your emotions help you understand your patients' feelings of interest and surprise, struggle and suffering, or anxiety and depression. Your emotions are a window into your patients' lives and antennae for receiving their behavioral cues and concerns.

Considering this new dimension of clinical practice prompted a discussion that focused on the role pediatricians and pediatric nurses play in emotional and behavioral development. In the current environment of managed health care, what exactly are pediatric specialists and what should they do? A concern was that emotional issues, although important, are generally not considered billable items within managed health systems. Therefore, there is little incentive to devote time and resources to them. Bringing a developmental specialist into a group practice has certain advantages, but the issue of funding once again is a problem. But perhaps more important was the observation that when parents come to a pediatrician, they want to see a pediatrician. There are, for better or worse, expectations and privileged relations that exist only between physicians and nurses and their patients. Although other trained health professionals contribute immensely, the pediatric specialists often are the first point of contact and should take the lead in emotional assessment.

Because this is often not the case, there is a need to motivate, influence, and educate medical professionals in the skills of emotional and behavioral assessment. Quite naturally, these skills need to be applied in clinical practice. Once again, communication among peers is important in making others aware of early emotional development. Continuing Medical Education programs, journal articles, symposia, conferences, and just talking to colleagues are all valid methods to increase awareness of development. For medical students and pediatric residents, more training should be available in infant development and behavior.

The Role of Family and Environment

Infants exist in complex settings involving parents, relatives, caregivers, religious beliefs, and ethnic practices, as well as the physical environment. These create a tapestry within which the infant's life is woven; each thread leads to and from the infant in ways that professionals should understand. With that understanding, opportunities are created to form therapeutic alliances for the benefit of the infant.

The infant's overall environment was cited as crucial—the number of risk factors correlates inversely with later success. Infants with multiple risk factors are more likely to be developmentally and intellectually compromised compared with those with few or no risk factors. The pervading role of the environment complicates interventions or research that address only one or two variables when many risk factors may be present. Therefore, it may be beneficial for professionals to take a step back and examine the entire picture before diagnosing or intervening in developmental problems.

Yet within this tapestry, the birth of an infant provides an entry point for positively affecting with development in a familial context. Because birth is a time of reorganization and redefinition for the mother and family, professionals have an unmatched opportunity to become involved. At or around birth, there is an openness that enables you to learn about parental expectations, ghosts, or potential problems in the caregiving environment. Learning of these situations makes it possible to reassure parents and, when needed, to embark on more extensive interventions.

It also is important to remember that mothers are not the only caregivers involved intimately with newborns and children. Fathers make important, tangible contributions to infant development. Professionals are encouraged to include the role of fathers in their own context of infant development and, consequently, encourage fathers themselves to participate actively in their infants' lives.

Similarly, nonparental caregivers can have considerable impact on infant development. An emerging concern for this group is how to provide them with appropriate developmental information. In light of the focus first on mothers, then on fathers, caregivers (who may be with the infant as much or more than the parents) could certainly benefit from additional consideration. In the absence of more concrete plans, communication once again is important—professionals need to talk with parents, and parents with caregivers, to ensure that infants are getting all they need to develop optimally.


Early emotional development is a field rich in opportunities to advance the understanding of fundamental processes that shape the lives of infants and families. At the biological level, much still can be learned about the chemical, physiologic, and structural relations between the developing human brain and behavior. This exploration should include expanded study of normal baseline behavior, as well as examples of abnormal development, pathology, and trauma.

In examining behavior itself, better descriptions are needed for a variety of clinical syndromes and emotions; any such description then would be subject to empiric verification. Also worth studying is the possible identification of hierarchical emotional milestones in development; on the other hand, such milestones may be absent, and research will reveal the importance of individual variability in emotional development.

The richest areas for research will flow from the collaboration of professionals with different, yet complementary, skills and experience. Cooperation among neurologists, psychologists, developmental biologists, pediatricians, and nurses can lead to improved study design and more definitive data for virtually all issues in early development. Working together will help everyone appreciate the complexity and contextualized nature of emotions and help create new tools to capture and understand that complexity.

And, finally, research is needed to discover the best ways to deliver information about early emotional and behavioral development to parents and caregivers. Although it can be anticipated that optimal communication will involve a variety of techniques and approaches, helping parents understand their infants and themselves is at the heart of many intervention strategies. By sharing our new perspectives in early emotional development in the most effective ways, we can make a lasting positive impact on the healthy development of infants and their families throughout the world.