Introduction: 

The Interdisciplinary Group of Psycho-Social Studies works since 1987 in the Department of Medical Psychology of the Clinics Hospital, Faculty of Medicine, University of the Republic and it is composed of professionals from several disciplines (pedagogy, psychology, psychiatry, psycho-motor functions and sociology). 

Throughout these last years, the group has been working mainly on topics related to child development and families living in poverty. It has done research in these areas and contributed to the formation of human resources, the development prevention and promotion programs from a theoretical perspective and the evaluation of psycho-social programs.

Some of the books published by the group are: Taking Care of Future Potential (GIEP, Montevideo, 1996); Walking Through Life with Your Children (CLAP/OPS, Montevideo, 1995); Development and Family (Aula, Montevideo, 2000). In these publications, is reflected some of their research and development such as the proposal of instruments to appraise the development of the child within the family (BIPOLAR Child/Family; Instrument of Child Rearing Giep).

In this work, we try to present a synthesis of the results of the two investigations carried out in Uruguay in 1986 and 1999 as well as suggestions to be taken into account when constructing programs to promote infant development. We hope this will encourage exchange, reflection and discussions that will enrich and promote the knowledge of the topic of this seminar.

Development of the two to five year old child. Family and Poverty.

The data that will be presented were obtained from a sample investigation of the poor urban sector of Uruguay whose aim was to describe the characteristics of the development of children up to five years of age and to identify the psycho-social risk factors of this development. This was done based on the database of a collaborative study (CLAEH-UNICEF-IDRC) coordinated by Juan Pablo Terra (1986).

Based on the idea that poverty constitutes a risk factor in the comprehensive development of the child we asked ourselves which factors within the situation of poverty affected which aspects of the development,  how they affected it and what can be done to remedy this within the resources available.

We started from the hypothesis that traumatic factors have a cumulative effect in the child and the family and that they disturb a complex web of relationships that serves to support the child and assures the family balance.

Methodology

From the study of Terra and collaborators, a sample of 634 children from 2 to 5 years of age was selected. 575 of those came from what was called poor sectors (310 girls and 265 boys) and 59 from a control group. This sample was selected using the criteria of poverty of CEPAL, in a random way and stratified by groups comprising urban areas of Montevideo and the interior (capital and non-capital cities).  The following children were excluded in the study: twins, children with sensorial deficits, cerebral palsy, severe mental handicap and those whose antagonistic or shy behavior at the time of the test did not permit an adequate appraisal.

The psycho-motor development was evaluated with the test of TEPSI ( Haeussler and Marchant, rev. 1985). It is a test of description and sorting, developed and standardized in Chile for children 2 to 5 and whose consistency and validity  has been verified.  It consists of 52 items distributed in three areas of development (motor functions, language and coordination) with each one being a sub-test that permits a global assessment and provides a profile of high and low areas of development. Even though this test has not been standardized for Uruguay, the behavior of the curves in the population of reference (Chile) and the control group (Uruguay) shows that the median for Uruguay goes slightly to the right and that the difference in the median and standard deviation of both populations is not statistically significant. For the different levels of analysis we applied statistical test of Chi square and the statistical test of proportional differences.

The nutritional state was evaluated through measures of weight and height and the emotional and behavioral state was evaluated by a report of the mother's perception based on a list that explores 17 psychiatric symptoms.

The psychosocial conditions of the family were studied through an structured interview with 90 items applied to mothers. The areas explored included: socioeconomic conditions and social support, characteristics of the family, rearing practices, presence of mother and father and characteristics of the child. Double entry contingency tables were used for the descriptive and inferential analysis. The differences among the groups were examined using the tests of Chi square and the test of phi.

The analysis and identification of the risk factors for the development of the child are based on the risk approach and logistical regression.

The following are the highlights of the result of our research:

1. In relation to Psychomotor Development it has been found that:

General Sample

*   There is a greater prevalence in the alterations of the psychomotor development among children coming from the poor sector. In these sectors 67.3% of children 2-5 years of age have a normal development, 24.3% are at risk (between minus 1 and minus 2 standard deviations) and 8.4 percent show under development (more than 2 standard deviations to the right. In the control group the proportion was 85%, 13.3% and 1.7% respectively.

*  The deviations in the psychomotor development of children of poor families happens mainly in certain items in the areas of language and coordination. In the area of motor functions, the aspects evaluated seem less dependent on environmental factors and there is no significant  difference between both groups.

*  Even though this is not a longitudinal study, the analysis of the data show that the older the child the more prevalent the handicap in the psychomotor development of children coming from poor sectors. The critical point seem to be between 3 and 3 1/2 years of age for both sexes. This is a sensitive time in the development, since it is the time when they begin to consolidate, among other things, the symbolic function. These data would show the adverse effect of the environmental conditions on the potential capacities of the child. Some other works have shown the potential reversibility of this developmental delay if the environment of the child changes. If that were not possible, the possibilities of socialization and capacity to learn would have been compromised.

*  The problems in psychomotor development affect more boys that girls coming from poor sectors in a ration of 2 to 1. The greater vulnerability of boys shows up mainly in the area of coordination, specially when designing human figures or trying to copy pictures.

*  In both sexes, the items that seem more affected are those that measure the capacity for symbolic representation and social interaction. There is an inhibition in the possibilities of using the potential resources for development.

2.      Risk factors associated with child development

The statistical analysis of the data allowed to establish an association between alterations in the psychomotor and emotional development of the child and certain characteristics of the family situation. In the following chart we present a selection of the psychosocial variables associated with developmental disorders and which are part of the group of areas studied (socioeconomic conditions, social support, family environment, maternal availability, beliefs and rearing practices):

The levels of poverty when measured by income, show little association with the psychomotor development except in cases of extreme poverty or indigence.

The work of the mother, when physically demanding and with little gratification - such as domestic work - interferes with the availability of the mother to satisfy the needs of the child. On the other hand, a kind of work that stimulates the mother may augment her self esteem and enrich the mother/child relationship.

The phenomenon of promiscuity (1.5 persons per bed), associated with the child sleeping with the parents or with the mother and the phenomenon of crowding in the house, involve not only lack of space but produce interference in the possibility of children developing the experience of their own body with probable consequences in the process of becoming autonomous, in psychosexual development and in the development of mental representations.

Poor communication among members of the family is another risk factor, specially distortion in the communication and exclusion of the child in verbal exchanges. The crucial aspects of a distorted family communication deal with confusing and contradictory messages, frequent violent discussions, inability to use the language to solve problems and hiding from the child information that is key for his/her development.

The perception of a violent interaction within the family is associated with behavioral problems in the child. In the situation of poverty, a tense and hostile atmosphere in the family does not create the proper conditions for development and provides models of aggressive family behavior.

Depression makes it difficult for the mother to recuperate both for herself and for the family, affects the availability of the mother to the child and disturbs the mother/child adjustment. The mother, due to her emotional difficulties, could provoke untimely frustrations, show intolerance towards dependency, not be able to understand the child and interfere with the adequate organization in the child of his/her corporal and mental functions. In this segment of the population, maternal depression has been associated with lack of expectations of satisfaction from the man and the perception that the man does not provide adequate help and has little participation in the rearing of the child. Other factors are poor relations as a couple, a violent family climate, consumption of antidepressants and more use of alcohol.

Even though the frequency of depression is about the same among poor and non poor groups, the impact that it has in the development of the child is not the same. Among the middle class depression has not been associated with problems in child development. This shows the importance of other alternative sources of support as lessening the effects of maternal depression in the child (being a couple, a substitute for the mother, access to treatment, programs, etc.)

The paternal influence is an aspect being studied more frequently lately as a factor in child development. For many decades the studies centered in the mother/child relationship as matrix of human  development and the base for personality building and future social relationships. But it is known today that the father plays an important role in the development of the child. His function goes beyond the support of the mother and her availability to the child. It has specific liaisons and characteristics that enrich in their own right the experiences of the child. The father/child relationship is different than the mother/child relationship. The impact of the absence of a father is widely recognized and this becomes amplified in conditions of poverty, specially if the image of the absent father transmitted by the mother is a negative one.

The predominant characteristics of the harm done depends on the sex of the child. This is a point that has not been sufficiently studied. The use of techniques of factorial analysis and multiple regression have led to the conclusion that, in the case of a boy, the psychomotor delay depends on aspects that interfere with the capacity of the mother to provide psycho-emotional support to the child due to disadvantaged labor conditions, absence from home, not being valued as a woman/mother and the absence of a positive masculine figure for the child to identify with. The boys of single mothers working as domestics seem to constitute a high risk group.

In girls, the psychomotor delay is associated with aspects related to the mechanisms of identification of the girl with her mother, specially family conflicts and difficulties in family communication that do not allow the active participation of the child. In the area of emotional development, the risk factors identified have been punitive practices, poor family relations, violence and maternal depression.

According to our data, the psychosocial profile of those families would be characterized by:

*  a depressed or demoralized mother due to daily deprivation, unable to find satisfaction with her partner and without hope of finding it within herself, that seeks a  tight relationship with her male child in order to regain her self esteem. This kind of relationship leaves little room for the understanding and promotion of the child's characteristics and potential.

*  a father who is absent in three ways: for his own inability to fulfill his paternal function, for the lack of expectations that the mother shows about him as a couple and for the devaluated vision of him that she portrays to the child.

*  a family relationship that provides no support, with both parents fragile and at the same time rigid, with the predominance of hostile and violent ties within an environment lacking physical emotional space. To this we have to add the inability to use words as a vehicle of communication, negotiation and conflict resolution.

*  a relationship within a context where social supports (health centers, education centers, etc.) are not operative as resources to provide support and appreciation.

These difficulties emerging from the family profile that we have described become compounded when the socioeconomic shortages are extreme and there is no hope for a better future.

Rearing practices, beliefs, availability, family organization and psychomotor development in families with children 0 to 2 years of age.

This descriptive study took place as part of a research to evaluate the impact of a program to promote early development being implemented since September 1999, in the CAIF Centers in Uruguay.

From the sample of children, analyzed by age and sex, those with visible or diagnosed pathologies were excluded.

The population studied was composed of 339 adults and 350 children who were 0-2 years old before they joined the program "A place to grow and learn through play" of Plan CAIF. 77% of the participants belongs to 11 Centers in the interior of the country and the rest to 3 Centers in Montevideo.  The distribution of the child population is homogeneous in relation to sex, with a small predominance of girls (54% to 46% of boys). The age distribution was 49.8% of children 0 to 12 months old and 50.2% of children 13 to 24 months old.

In relation to who were the rearing adults who responded to the questionnaires, 92% were mothers, 1.1 % fathers, 4.4% both parents, 0.3% grandmothers and 2.2% aunts. Since the mothers represent by far the largest majority of respondents, we will refer to them throughout this work as the person interviewed.

What was evaluated were the rearing practices, family organization and emotional state of the adult group as well as the psychomotor development of the children sorted by age, sex and location.

To analyze the rearing practices, the instrument used was the IPCG (Instrument of Rearing Practices GIEP, 1998). This instrument consists of an interview that sorts out a series of situations related to rearing practices, beliefs and values that families play in their daily relations. For that, a semi-structured questionnaire was presented with 40 questions, most of them closed, divided in 9 areas: communication, language, play, limits, autonomy, parental functions, parental availability and perception and knowledge of the child. In its development it avoided the utilization of judgments that would imply a positive or negative appraisal of the aspects investigated. Its analysis may be quantitative or qualitative, based on criteria related to behaviors and practices that foster development according to national and international research.

The evaluation of the emotional state was based on the Mental Health Scale SF-36. This scale is part of the shortened instrument to measure the quality of life with respect to health M.O.S. SF-36 (Medical Outcome Study Short Form). The version used was translated by Alonso and team (Spain) and validated for our environment by Schwartzmann and team. It consists of a multidimensional evaluation designed to measure the general state of health using 8 indicators that evaluate physical and mental aspects. It has been used in many international and national studies to evaluate the result of treatment or psychosocial interventions. It has been demonstrated that in spite of being a brief instrument it is psychometrically reliable. It has also been demonstrated that the Mental Health Scale is useful in the detection of depressive disorders and in evaluating the outcome of treatments.

The scale used includes an evaluation of mental health and vitality. It consists in 9 questions with 5 options of intensity (from never to always). It measures in its lower level the presence of almost permanent feelings of nervousness and depression and in its upper level the prevalence of feelings of wellbeing and calmness. The index of mental health has a maximum score of 30 and a minimum of 5 and the vitality index has a maximum of 20 and a minimum of 4. This instrument can be self administered unless the person cannot read. In this study, the average values for the population are calculated.

To evaluate the Psychomotor Development of the child the E.E.D.P. was used (Scale of Evaluation of the Psychomotor Development of Rodríguez, Arancibia and Undurraga, 1976). It is a filtering test designed to evaluate children 0 to 24 months old. It is composed of 75 items, 5 for each level of age, grouped in four areas of functioning:

-     Motor area: includes gross motor functions, general and specific body coordination, posture and locomotion reactions.

-     Area of language: refers to both verbal and no-verbal language, including reactions to sounds, vocalizations, comprehension and verbal emissions.

-     Social area: refers to the ability of the child to enter into relationships with other people and his/her capacity of learning by imitation.

-     Area of coordination: includes the reaction of the child that requires coordination of functions and social or sensorial-motor interests.

This test is administered individually in about 20 minutes, based on direct observation of the child in performing tasks proposed to him/her and some questions to the mother. The results are registered in a standard protocol. A standard coefficient is obtained of development based on three categories: normal, at risk and developmentally delayed. It is backed by studies of internal validity and power to predict.

The results are expressed in terms of relative frequency. To study the degree of association between variables and their level of meaning the methods of Phi and Cramer (strength of association) and Chi square (level of meaning) were used.

For the analysis of the rearing practices, a different age sorting was used other than the one employed for the rest of the variables. Two groups were created: under 10 months old (40%) and over 10 months old (60%). The reason for this age grouping is based on the fact that starting at 10 months the children show important changes in the resources they use to express and put into practice their needs (at the motor, cognitive, instrumental and emotional levels)

From the results of the descriptive analysis the following can be highlighted:

1.  In relation to Psychomotor Development

Global psychomotor development of the Centers C.A.I.F. Comparison with other studies.

*0 to 24 months

The results of the test on psychomotor development obtained before the beginning of the program through the evaluation of 272 children 0 to 24 months old, show that 30% of the population are in the category of at risk or developmentally delayed. The frequency of developmental delay is three times greater that the one expected in a curve of normal population and in the at risk group it is almost double.

Event though there are different samples, we consider of interest to mention the results of the national representative study of poor urban sector (Terra and team, 1989). Both the children evaluated by CAIF before the beginning of the Program and the children of poor sectors investigated by Terra show a similar distribution in the three categories of normal, at risk and developmentally delayed. In both samples the same measuring instrument (EEDP) was used. In both studies, the frequency of retardation is three and a half times higher than in the non-poor population and also three and a half times higher than the one expected in a normal curve of population.

Terra and team remarked: "It cannot be said that situations of risk or developmental delay evaluate the present and future intellectual potential of the child. The information available only indicates that if the environmental conditions of the child are not modified, he/she will be at a great disadvantage to face the future stages of the socialization process. At least in a society such as the Uruguayan one, we have to presuppose that psychomotor delay predisposes the child to marginalization in areas as diverse and important as schooling, insertion into the labor force, economic conditions and social and cultural integration with society at large. If these presuppositions are correct, psychomotor delay becomes one of the social mechanisms in the perpetuation of poverty. Just this makes of psychomotor delay in development a serious problem both in the area of social and human destiny of the children affected and in the area of the perverse mechanisms that lead to a society distorted for democratic life.

All these data become more relevant with the information produced by research on the predictive power of the E.E.D.P.. One of the investigations compared the coefficients of development obtained by E.E.D.P. in two years old children with the ones obtained in the same children by the age of six through the Terman test. The comparison of those coefficients show a high level of correlation between them. It can also be stated that breast-fed babies of poor families that show developmental delays in the area of coordination have a high probability of showing alterations in the sight-motor development by age 6 according to the test of Bender (Bocaz and Seguel, 1978).

Psychomotor development by age  

As age advances, the "normal" category goes down due to the influence of the categories of at risk and developmentally delayed in groups of children 13 to 24 months old. In older children the category of at risk is one and a half times greater and the category of developmentally delayed is three times greater than that of children 0 to 12 months old. These differences, from the statistical point of view, show a low co-relation. (Cr. 20 - P .007).

That tendency coincides with the findings of investigations on this topic done in the '70's. These investigations show that it is at the age of 15 to 18 months that the coefficient of deficit in psychomotor development among the poor sectors doubles the coefficient registered before that age, unless there are changes in the environment of the child (Rodríguez and Lira, 1976; Lira and Rodriguez, 1979); (Lira and Galvez, 1985); (Bralic and team., 1989); (Lira, 1992).

Also the international research previously mentioned, as well as other follow up studies on older children (Silva, 1980; Frankebourg, 1990) show that the prevalence of deficits in the development of the child grows with age.

These results coincide with the findings of the investigation CLAEH-GIEP of 1989 (Terra and team, 1989; GIEP-CLAEH, 1997). It is relevant to note that in spite of the 10 year gap between both studies, the same problems have been detected. On this point it is important to remark that if the population of 0-2 years old children evaluated before the CAIF Program, showed similar patterns than the sample of Terra and team, it indicates that these children, unless there are changes in their environment, have a high probability that their psychomotor development will keep deteriorating with age.

This confirms the need to implement focused programs promoting early development, specially when taking into account what has been said about the predictive value of the E.E.D.P.  According to Rutter (1980), children have the capacity to compensate for the most vulnerable aspects of their development, specially in the early years. According to Pringle, the sychosocial factors must be persistent and continuous to alter development.

Psychomotor development by sex

The results of the psychomotor development by sex show, as was the case in the previous study of children 2 to 4, the tendency (Cr. 15-P.06) to a certain difference in favor of girls since the percentage of developmental delay in boys is almost four times that of the developmental delay in girls. This shows that the more serious situations are predominant among boys.

There is a vulnerability in the development of boys biologically determined in part by the slower maturation processes of the nervous system (Fejerman, 1976). Research on the process of developing has shown that maturation between boys and girls differs from birth on. Boys are behind girls in walking, talking, growing teeth (Hutt, 1966). Boys show more disorganization and less emotional stability than girls during their first months of life and take longer time to regulate their rhythms  (Haviland and Malatesta, 1981). It is obvious that maturational factors in each baby influence their own experience and their relationship with their mothers, affecting the emotional and socio-cultural ties to her. Even in cases of similar support given by the mother, behavioral differences have been noticed between both sexes (Olesker, 1998).

In the case of boys, poor environment added to a situation of greater biological vulnerability will augment the probability of stunting their development. The environment would reinforce and amplify biological factors and limit the unfolding of potentialities.

International and national research has shown statistically significant differences in psychomotor development favoring girls when babies are continually exposed to psychosocial factors of risk. Girls are two to one in better shape than boys. These differences become statistically significant by the time they are 2 years of age (Bralic and team, 1989), (Silva, 1988), (Moore, 1990), mainly in the area of language. The national study of GIEP (1997) shows that by the age of 2, the psychomotor development of boys of poor families is negatively affected in a ratio of 2 to 1 compared to the development of girls. Boys show lower scores in the representation of the human figure, the ability to create and aspects related to language. This study also show that the more important psychosocial variables affecting negatively the development of boys are:

-     the absence of a father or a father who does not participate in bringing up the child or who only assumes a punitive role.

-     working mother (physical demands and many hours away from home) without gratification as a woman, in her relationship as a couple, in her role as mother, and holding a negative image of her family and male chauvinist beliefs. 

2. In relation to rearing practices, beliefs, parental availability and family organization.

Communication

60% of mothers respond actively to the attempts of the child to communicate verbally or non verbally but the other adults show little interest in establishing an interaction with the child in spite of the attempts of the child to communicate. With the increase in the age of the child there is also an increase in the active communication of mothers. Probably, with the increasing ability of the child to send signals he is able to stimulate his mother and even reverse the attitude of adults who underestimate his/her early communication.

A high percentage of mothers (80%) acknowledge the positive role that interaction with peers play in child development.

All adults agree on the importance of verbal communication with young children, because it helps the child to "learn to talk" (29%); develops understanding and thought (24%) and allows communication (18%). Only 5% consider the importance of verbal communication is strictly normative "for the child to learn to behave". From these data it can be inferred that the majority of parents see verbal communication as a uni-directional function of learning rather than as a vehicle for exchange.

On what is considered the right time to talk to children about topics such as birth, 70% responded that the best is "to answer when the child asks". This kind of answer is different than the one received in the previous study (CLAEH - GIEP) in which only 24% of responded gave a similar answer. It is impossible to know if this openness to talk about sexuality relates to more access to information, a reduction to prejudices or if it is just the socially accepted response today.

On the topic of death, 53% opts for the answer "he went to heaven", 5% prefers no to touch the subject and say that "he went on a trip", 14% say that you have to explain if the child asks and 26% opt for saying that "he did not die". The first answer seems to be the most common one relating death to children within a religious context of strong cultural support.

Songs

Songs represent customs and habits that are part of the culture and family history and are a vehicle for the family to introduce the child to cultural aspects that will foster the development of the child and his feeling of social belonging. In the stage of 0 to 2 years of age, adults usually use different musical forms to relate to the children. Among them we can mention psalmodies of a single vowel, lullabies, musical short verses and popular songs played by the media.

According to our data, 85% of mothers use one or the other of those musical forms of communication with their children and this kind of communication increases with the age of the child. Of all the forms previously described, the only one that does not show in our data are psalmodies. Perhaps this is due to the fact that the questionnaire mentions "favorite songs" and perhaps mothers do not conceive this melodic form based on sound and movement as a real song.

According to the mothers in our sample, children prefers lullabies (32%) specially before the age of 10 months. Reasons for using songs: one third (34.7%) sings to make the child sleep, almost one fifth (23.9%) to entertain the child and 11% to sooth his pain. In relation to the number of children, the frequency of mothers who sing is inverse to the number of children. The more children the less songs.

Lullabies are playful activities of great value in the mother-baby relationship since they put into play simultaneously many aspects of both mother and child. On the part of the child, cognitive and emotional aspects of his/her development are at play and on the part of the mother they evoke the sensitivity, empathy, creativity and wealth of the representational world through language. A new liaison of words, gestures and songs is created between mother and child. When singing a lullaby, the tone of voice creates a musical wrapping that enhances the other elements of the relationship. Lullabies are millenary practices whose positive role both for the body and the soul of the child was already recognized by Plato (Cerutti S, 1998)

28% of mothers who sing identify popular songs (transmitted by the media) as the favorites to their children. This predominates, according to them, in children over 10 months old.

Parental creativity, such as inventing songs, is less frequent (8%) and this practice diminishes when the child's age is over 10 month. 16% of respondents identified as favorites, songs transmitted through educational institutions.

Stories

Stories are one of the creative expressions of man. They develop imagination, creativity, capacity for amazement, for concentration, for order and sequence of thought. "In a world dominated by zapping and fragmentation, to listen to a story becomes a highly pleasurable and educational activity… listening to a story implies to stop the accelerated pace and leave behind the tiredness and routine of daily life" (Padovani, Ana,  1999)

Only 40% of mothers tell stories to their children. Telling stories is not as frequent as singing songs. Of the total of adults who tell stories, 44% invent the story themselves and 49% use known stories. Of the latest, 7% use fairy tales and 7% do not identify any favorite story.

"The importance of listening to stories is that through this experience, the child begins to discover the symbolic potential of language and its ability to create possible or imaginary worlds through symbols that are independent of the objects, happenings and relations symbolized. These symbols can be interpreted in other contexts, different than the ones in which the original experience took place, if it really took place" (Colomer and Camps, 1996)

What is curious is the absence of the so called "formula stories", traditional, popular and anonymous stories that deal with absurd and extravagant forms representing pure play and pure pleasure. It is probable that some of the invented stories of the sample represent this genre.

It seems that our data lead to the conclusion that the means of communication based essentially in language (that are the bases for the structuring of thought in the sense that they introduce order and temporal and spatial sequence) are less accessible to the child than those based on the body, objects or actions. This would show, on one side, the limitation of parents, who themselves might not have had access to symbolic thought that would lead to verbal narration. On the other hand, the findings show that in poor sectors, the limitations of the environment itself make it difficult for the child to develop symbolic thought and use metaphors that would represent the world and find meaning linking facts, experiences and emotions.

Games and Toys

Playing is a universal, healthy process through which, from the beginning, the baby explores his abilities within the limits set by the mother or other relatives. To define play is not easy. According to Winnicott, it is an activity that happens in the space between the internal and the external world, between the real and the fantasy world. As stated by Paulina Kernberg, " play develops creativity and sublimation."

Play, at any age, depending on the stage of development, the personality of the child and cultural factors,  has the characteristic of being a very absorbent and gratifying activity, done with a positive attitude and started spontaneously. 

On the other hand, playing has a great value in the transmission of norms and customs. When studying play, we need to include not only the capacity of the child to play but also all the cultural aspects influencing this capacity.  The way we play show new ideas and the objects with which we play reflect the economic and social conditions of our cultures and their values and attitudes. The possibilities and the form of playing influence among other things the relations we establish between work and rest, the materials available to play with, the local idea of children, the history and memories that each adult has of his childhood, the value of play and the way to rear children. 

In the population studied, 56% of mothers claim to frequently teach games to their children, 24% do so occasionally and 20% rarely.

In relation to the meaning that adults assign to play, 60% assign it a pleasure value, with or without a learning component, and 33% assign it a cognitive function without associating it with the main characteristic of this activity that is the pleasurable experience. Without pleasure, play is not play.

Half of adults (51%) are worried that children might get hurt while playing. 38% do not see the playing of their children as an activity that involves them but as an activity that entertains so "the child does not disturb them". 2% see the child's play as disturbing the order of the household.

Looking at the age of the child population in which this study is based, the number of mothers that apparently do not feel involved in their children's play,  seems to be quite high.

57% of adults can identify the favorite game or toy of their children and 43% cannot. Among the preferences, 53% of games correspond to the ones called "rearing games". We also find games imitating daily life (12%) and activities done with an object. The favorite objects are: a ball (14%), little cars (8%), rattles (4%). Also registered are games of filling and emptying (3%) and games using natural elements such as earth or sand (3%).

Analyzing the options that adults offer to children to play, almost half of the children of the population evaluated have access to their toys and to objects of the house. 34% have limits imposed in relation to the use of objects around them, specially children under 10 months old. This would relate to the need for protection and the impossibility of the child to reach them by himself/herself. The other 14% have restrictions not only in relation to the objects around them but also in relation with their own toys. This would limit the possibility of the child to chose his toys with possible developmental consequences.  On the other hand, two thirds of the mothers are able to identify their child's favorite toy.

Sleep

At the beginning of life, sleeping responds to a mainly physical and maturating need. In the growing child, the relational aspects of this function acquire more relevance.

We could say that in the first year of life, while the maturing phenomenon influences the architecture of sleep, environment and relationships play a role in the rhythm and faces of sleep. Based on physical and mental compensation, the temperature, nutritional satisfaction (both emotional and food), physical well being, stimuli from the environment, are all determinants that would allow the child to sleep or to feel comfortable when awake. At this age, as acknowledged by many researchers, the sequence suction/breast feeding or bottle/satiety/sleep is the predominant mechanism of sleeping. This is coherent with the developmental phase of the child which is the oral phase.

In this period, as recognized by many mothers, children sleep by sucking on something: breast, bottle, thumb or soother since this provides a sensation of safety, like having with them part of their mother. 40% of the children evaluated use a soother as prelude to sleep. If we add this to those who fall sleep after breast feeding, 53% of children suck on something while falling sleep.

According to the adults interviewed, almost a quarter of children (24%) do not use any soothing object to sleep.

As the child grows, and as part of the process of personality development, two important phenomena associated with sleep appear. The first one is a fear of separation from familiar people and places while sleeping. This happens not only to children but also to parents who are also living a separation.

The other phenomenon, occurring a bit later, that generates anxiety, is the nightmare. In order to be able to separate himself and overcome the anxieties, fears and ambivalence that are part of that period of growth, the child requires a feeling of security and trust that allows him to surrender to the separation knowing that nothing will happen. This basic feeling of trust, transmitted in part by the parents during the day and also part of the child's temperament, allows the child to face that separation. Parents discover, either spontaneously or by external guides, that the child needs certain mechanisms to deal with the separation. It is what authors such as Winnicot call "transitional space". The child might turn to his body, to objects, to rituals or activities with parents such as singing, story telling or simply cuddling as a ways to learn to control his feelings of solitude. At the time of going to bed, the attachment to these objects can be so strong that the child may feel hopeless without them.

In relation to this progressive building of transitional spaces that facilitates the surrender of the child to sleep it should be said that for 50% of children there is no real physical separation since 26% fall sleep while breastfeeding, 22% "in arms" and 6% with adults in bed.

Only one fifth of the population (18%) mentions ritual practices preceding sleep or simply put the child to bed. These behaviors show the absence of practices that precede sleep and facilitate the separation mother-child.

The task of putting the child to sleep is predominantly a mother's function (70%). Only 7% of fathers share this task. Studies show that there are many benefits for the child if both parents carry on this task. On one hand, this sharing of family functions alleviates the mother's extra burden. On the other hand it favors the direct relationship father/child. Finally, in the act of going to sleep, it facilitates the mechanisms of separation from the maternal figure.

About the place where the child sleeps, 70% sleep in his/her own bed, but it is of interest to note that 30% sleep with their parents even though only 9% explain that this is due to the fact that there is no other bed.

Practices related to autonomy

The capacity of parents to recognize, accept and value the original characteristics of their children and at the same time perceive their progress and their evolution in relation to their emotions, resources and needs, has a clear influence on the development and in the autonomy of the child. This capacity of the parents is so important that it has been selected as an indicator of the way parents relate to their children and as a predictor of the type of attachment that the child will create and on which the child will build future relationships.

To recognize the child as an active being with his/her own mind and desires and to interact with the child within this framework, permits the child to build an autonomous identity with the capacity to decide, to value his/her own achievements and projects and therefore to develop the feeling of social competence.

We are getting to know more and more the repertoire of capacities that the child brings to the world and with which he actively interacts with his surroundings. The idea of a passive baby, of a tabula rasa, goes very much contrary to the evidence. Parents should be helped to develop the ability to discover, foster and interact with the capacities inherent to their children beyond simple projections or transference.

Based on the former concepts, it is notable the fact that only 50% of mothers evaluated think that children have, from birth, their own unique desires and thoughts. The rest of the population consider that those capacities are only acquired at pre-school and school age. This makes it difficult for them to recognize what the child from birth is able to do by himself.

Rearing practices and limits

Another essential aspect of the relationship of parental figures with the child - closely related to the development of basic trust and at the same time necessary for family functioning - is the way conflicts between the needs of children and the needs of adults are resolved and the way solutions are negotiated respecting individual and collective limits as well as family norms. The literature on the topic shows that setting limits has a negative effect on children when those limits are imposed in a violent way or through physical punishment or when they are imposed in incoherent ways (depending on changing moods) or in incongruent ways (without an explanation to justify them). At the same time, it is just as harmful to the child not to put any limits to him/her or to adopt an extremely permissive attitude out of fear of curtailing natural development or freedom of expression.

The word "no" is probably essential for the child in his quest to build and identity and develop his/her own ideas. Therefore he needs the balance of a reasonable degree of freedom to explore and test his surroundings which will make it easier to accept rules and limits that he must follow.

This does not mean that the topic of limits is a difficult one for the majority of parents, specially after the child is 10 month old. Still problems related to feeding and sleeping often create conflicts between the needs of the child and the needs of adults and test the capacity of parents to come up with solutions that imply mutual respect and proper family functioning.

About feeding, we can say that the importance of eating  implies both the need for nutrients to grow and the pleasure and satisfaction of the oral stage that satisfies hunger. This has an important role in the psychosexual development of the child and in the building of attachment since, from the moment of birth, the relationship mother/child  centers around feeding. This continues during the first year of life.

Eating time is also for the child a time of communication with his immediate surroundings, of encounter and exchange with the family and an occasion to express his/her feelings (love, anger) and get acquainted with the family rituals.

Nourishment is one of the most important factors in children. 70% of breastfeeding babies have some symptoms related to nourishment and 70% of psychosocial consultations with pediatricians are related to this topic. Given the high frequency of consultations on this topic by the general population, it is interesting to list a synthesis of factors that have influence on nourishment:

      a)     personal psychical dispositions of mothers and their capacity to promote the baby.  
b)     The stage of evolution of the child  
c)      Social factors with their rites and preconceived ideas transmitted within families from generation to
         generation  
d)     Advances in pediatric knowledge that modify previous assumptions and recommendations in child     
        rearing
e)     Food intolerance and diseases that generate nourishment problems that perpetuate themselves even
        after remission.
f)      Capacity to manage limits with flexibility, coherence and constancy.

With respect to feeding, 35% of mothers try to distract the child so he/she will eat even after initial refusal. 28% allow the child to eat as much or as little as he/she wants. In relation to the age of children, it is curious to note that 40% of mothers of children under 10 months old claim that their child never refused food. This percentage diminishes with age and only 23% of mothers of children over 10 months old report the same situation. At this age over half of the mothers report that they distract their children when they refuse to eat, 30% let the children eat what they want and only 2% turn to punitive practices.

From the earliest stages of life the child shows an active participation by opposition or by whims related to food and by losing his appetite when feeling sad. When the child eats with gusto, the mother feels happy and thinks that she is a good mother. On the contrary, when the child refuses food, the mother feels anguished not only because the child is not eating but because she feels internally rejected. It is usually difficult for the mother to accept that the child rejects food that has been prepared with so much dedication and often responds with feelings of impotence, resentment and anger.

In line with the previous findings, punishment for disobedience is more frequent than punishment for refusal to eat. Adults tolerate much less the challenge to their orders than any other challenge that the child might present.

70% of parents or tutors show flexibility in their negotiations with the child and mention that sometimes the child "gets what he wanted". The other 30% show either extreme permissiveness or extreme rigidity (the child "always or never gets what he wanted")

Decision making

It is very important for the child to get from the parents a clear understanding on rearing practices, limits, flexibility and openness to negotiation. This is done through consistent decisions taken by parents. To this we must add the need for a regular and consistent routine that will give the child a sense of order, of knowing what to expect, and the calmness of knowing that things happen with order and are not forgotten.

Decisions related to health, education, limits and friendships are taken by both parents in over half of the families interviewed. In one third of the cases is the mother the one dealing with those areas.

In relation to practices related to the acquisition of habits (sleep, feeding, hygiene) 57% of mothers have the decisive role while 37% of fathers share those responsibilities. This difference could be attributed to culturally accepted forms of distribution of family functions that award women the task of dealing with daily aspects of rearing and reserves the participation of men to broader decisions. 

On the other hand, assigning a hyper value to the mother's function - a frequent phenomenon in poor sectors -  could also provide additional explanations to the differences in the decision making role of each parent in relation to acquiring habits and other rearing areas.

Male chauvinist beliefs  

The majority of mothers deny having discriminatory beliefs with respect to rearing practices related to the sex of their children. The percentage of mothers who admit male chauvinist beliefs in this portion of the population is quite lower than the one in the findings of the previous investigation. The exception is the number of mothers who think that the boys should have more freedom which remains pretty much the same.

3. Emotional state of family references

32% of mothers claim to feel nervous frequently, 13% feel usually dejected and sad and 27% are usually exhausted. On the other hand, 68% of mothers claim to feel vigorous, 58% claim to be calm and in peace and the same percentage claim to be usually energetic.

FEELS BADLY	68%	NERVOUS	32%
DISCOURAGED	13%	CALM	58%
ENERGETIC	65%	TIRED	27%
SAD, DISCOURAGED	17%	EXHAUSTED	27%

4.  Influence of the emotional state on rearing practices and beliefs

When studying the relationship between the emotional state of the people responsible for the child, (usually the mothers), and rearing practices, the negative effects that emotional problems create in the mental availability and the capacity of parents to interact with the child is confirmed.

Only 50% of separated mothers who claim to have vitality (93%) consider that the visits of the father have a positive effect in the child compared with the ones who claim not to have vitality. (Cramer: .66 P= .01)

When the mothers feel nervous they tend to play less with their children. Only 38% of those who claim to be nervous play frequently with their children as opposed to 61%  of those who claim not to be nervous. (Cramer: 23 P= .01)

The mothers who feel discouraged (45%) play less with their children than those who do not feel that way. (Cramer: .23 P= .01)

When the mother is discouraged, she tends to give passive answers to communication t attempts of the child. In general it is higher the incidence of mothers who do not communicate either because of the absence of an answer or because they only give a passive answer (Cramer: .23 P= .02)

Also it can be said that when mothers feel discouraged they take longer to recognize the capacity for autonomy in their children. 36% of depressed mothers think that their children will acquire this capacity only as young adults. (Cramer: .38 P= .0003)

In the area of talking to their children about death, depressed mothers have more difficulty to do it.  Only 13% can tell their children that "he died" as opposed to 33% who do not discuss the topic. The most frequent answer provided by both non-depressed mothers (73%) and depressed mothers (51%) is the reference to the popular belief "he went to heaven" when trying to explain death. (Cramer: .25 P= .06)

Depressed mothers have the feeling that they cannot control the child since almost half of them feel that the child "always gets his/her way" as opposed to 20% of mothers who do not share this opinion. (Cramer: .23 P= .01)

In the area of decisions taken by parents on topics such as education, if the mother is depressed those decisions are less likely to be taken together by both parents (40% vs. 60%). This also happens in relation to health, since the mother alone makes those decisions or she delegates them to others. (Cramer =.27 p= .04)

In relation to decisions on friends of the child, the same patterns shows up. This leads us to realize the great measure in which the depression of the mother interferes with the couple's relation. Depression could also be interpreted as a symptom of a conjugal conflict. (Cramer =. 31;p= .04)

Again in the area of decisions about setting limits for the child, when the mother is depressed she tends to delegate this to others, showing how difficult it is for her to take charge of the rearing of the child. (Cramer= .40 ; p= .0004)

Mothers who claim to be usually calm (46% vs.59%) are less worried about their children getting hurt while playing (43% vs. 28%) since they are entertained and do not disturb anyone. (Cramer:= 22 ; p= .04).

Depressed mothers are less prone to organize games for their children (Cramer = .20 p= .07) and have difficulty in making decisions about their children (health C: .29 p=.01) (limits C: .37 ; p= .001), (friendships C: .38; p= .0002) and delegate this responsibility to the father, relatives or others. Also when the parents are separated, depression on the mother's part is associated with a lower frequency of visits by fathers. (Phi: .40 ; p= .0008)

For the relation between depression and lack of personal expectations (low self esteem) we can refer to the findings of the previous investigation.

CONCLUSIONS:

The mechanisms by which poverty affects the development of children is much more complex and goes far beyond the obvious limitations of food, lodging or hygiene. In the first place we can mention the accumulation of situations of deficiency or trauma which perhaps compound the problem of dysfunction in the family life and in the rearing practices.  Each one of those factors has a larger effect than if it was acting alone. The accumulation and mass of those factors, that surpasses the person's capacity to respond, brings results that in other circumstances would not happen. Even though today there is great emphasis in the concept of resilience (the capacity to overcome adverse circumstances), it is necessary to emphasize that there is no resilience possible once you go beyond a certain threshold.

Therefore the need is not for a patch to help remedy simple shortages but to restore the whole network of disturbed situations by modifying all those risk factors.

Among the poor sectors we have to add the symbolic negative weight carried by their situation of marginality  in society. In this sense it is possible that social policies to help the poor are valuable not only as a concrete help but also as a symbolic gesture of integration.

Another important aspect of the data of our investigation is that they try to contribute towards the elaboration of social policies that deal with the specific reality of our country and are tailored towards understanding and acting within the specific mechanisms of our society in generating and reproducing marginality.

It is necessary to save two potentialities: the children's, whose capacity for resistance must be supported, and the family's, caught  between progressive and regressive dynamics.  It is more useful to help the family so that the family can help the child than to try to substitute the family. This bipolar strategy requires a precise diagnostic of the critical points that influence the development of the pairing child-family as well as the best forms of intervention based on supporting this double potential.

The challenge then is to locate and find a way to support the spontaneous organized movements coming up from the poor sectors that tend to counter the damage created by the condition of poverty. We believe that our findings provide hope for the future since, side by side with the difficult and hard to modify factors created by poverty, there exist other positive dynamics and factors that can be supported and enhanced  by society.

For many team members working with the poor, this information confirms their daily experiences in the field. The hope is that this material, properly ordered and clarified, will become a source of operational knowledge for the future and at the same time will open new questions and problems to be dealt by future investigations.

The importance of the problems identified and the complexity of dealing with them, show the pressing need for educational and health institutions counting on interdisciplinary teams that are well trained and supported.

Often people working with the poor feel discouraged and condemned to failure in view of the complexity of the situation with so many difficulties faced by parents and children. For those people, the perspective of working with supporting teams will bring new hope to their work and provide them with an opportunity for analysis, exchange, dialog and negotiations with other experts. This will support the integration of families to institutions and vice-versa.

In other words, the weight of the problems and the lack of resources of people working in institutions for the poor, added to the isolation and lack of recognition, leads to misunderstandings, discouragement, poor communication, lack of flexibility, demoralization, which in its turn produces weariness, tiredness, lack of creativity that precludes the very possibility of change.

We need well formed and well informed human resources to appraise the adequacy of the measures adopted. If the measures are not adequate and opportune, they endanger the future potential of the country since it is among the poor sectors that the demographic growth is more pronounced.

The resources available are there but they are not used properly. The lack of coordination and the dispersion of organizations working with children, the lack of proper instruments to detect the most vulnerable groups, failures in providing proper training and support for people and for community resources are some of the shortcomings in social policies that, in our view, render the resources ineffective.

To finish, we offer here a series of proposals to be taken into account when implementing policies and programs directed to child development in poor sectors.

    - Implement a bipolar approach directed to help both the child and the family.

    - Help to raise or to reinforce self-esteem in women so they can find gratification

• As mothers  

• In their personal achievements

• As a couple.

   -  Support the function of men within the family, rescuing their place as father and as couple, trying not to reinforce their exclusion. Reintegrate men to the home as a place of exchange and enjoyment.

  -   Stimulate the use of active communication among all members of the family as a vehicle of negotiation and conflict resolution offering model programs of respectful communication.

  -   Change interventions into forms of emotional social support that promote integration, recognition, respect and the feeling of being valued and accepted.

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