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American Academy of Pediatrics
Developmental and
Behavioral Pediatrics
2ND EDITION
Section on Developmental and Behavioral Pediatrics

EDITOR
Robert G. Voigt, MD, FAAP

ASSOCIATE EDITORS
Michelle M. Macias, MD, FAAP
Scott M. Myers, MD, FAAP
Carl D. Tapia, MD, MPH, FAAP
American Academy of Pediatrics Publishing Staff
Mark Grimes, Vice President, Publishing
Eileen Glasstetter, MS, Senior Editor, Professional/Clinical Publishing
Theresa Wiener, Production Manager, Clinical and Professional Publications
Linda Diamond, Manager, Art Direction and Production
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Linda Smessaert, MSIMC, Senior Marketing Manager, Professional Resources
Mary Louise Carr, MBA, Marketing Manager, Clinical Publications
345 Park Blvd
Itasca, IL 60143
Telephone: 630/626-6000
Facsimile: 847/434-8000
www.aap.org
The American Academy of Pediatrics is an organization of 66,000 primary care pediatricians, pediatric medical
subspecialists, and pediatric surgical specialists dedicated to the health, safety, and well-being of infants, children,
adolescents, and young adults.
The recommendations in this publication do not indicate an exclusive course of treatment or serve as a standard of care.
Variations, taking into account individual circumstances, may be appropriate.
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This publication has been developed by the American Academy of Pediatrics. The authors, editors, and contributors are
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in the development of the content of this publication. Disclosures: Dr Larson disclosed an advisory board relationship
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with the most recent advice and information available from the American Academy of Pediatrics.
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© 2018 American Academy of Pediatrics
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form
or by any means—electronic, mechanical, photocopying, recording, or otherwise—without prior written permission
from the publisher (locate title at http://ebooks.aappublications.org and click on © Get Permissions; you may also
fax the permissions editor at 847/434-8000 or e-mail permissions@aap.org). First edition published 2011.
Printed in the United States of America
3-339/0418 1 2 3 4 5 6 7 8 9 10
MA0844
ISBN: 978-1-61002-134-0
eBook: 978-1-61002-135-7
EPUB: 978-1-61002-239-2
Mobi: 978-1-61002-240-8
Library of Congress Control Number: 2017935587
Section on Developmental and Behavioral Pediatrics
2017–2018
5
Executive Committee Members
Carol C. Weitzman, MD, FAAP, Chairperson
Nerissa S. Bauer, MD, MPH, FAAP
David O. Childers Jr, MD, FAAP
Jack M. Levine, MD, FAAP
Ada Myriam Peralta-Carcelen, MD, MPH, FAAP
Peter J. Smith, MD, MA, FAAP
Immediate Past Chairperson

Nathan J. Blum, MD, FAAP
Liaisons
Marilyn Augustyn, MD, FAAP
Rebecca A. Baum, MD, FAAP
Beth Ellen Davis, MD, MPH, FAAP
Alice Meng, MD, FAAP
Program Chairperson
Carolyn Bridgemohan, MD, FAAP
Newsletter Editor
Web Site Editor

Kimberlly L. Stringer, MD, FAAP
Staff
Linda B. Paul, MPH
Editors and Contributors
5
Editor in Chief
Professor of Pediatrics
Head, Section of Developmental Pediatrics
Baylor College of Medicine
Director, Meyer Center for Developmental Pediatrics and Autism Center
Texas Children’s Hospital
Houston, TX
Associate Editors
Chief, Division of Developmental-Behavioral Pediatrics
Medical University of South Carolina
Charleston, SC

Neurodevelopmental Pediatrician
Associate Professor of Pediatrics
Geisinger Autism & Developmental Medicine Institute
Lewisburg, PA

Assistant Professor, Department of Pediatrics
Houston, TX
vi
Contributors
Kruti R. Acharya, MD, FAAP
Assistant Professor of Disability and Human Development
University of Illinois at Chicago
Chicago, IL
Ch 26: Transition to Adult Medical Care
William J. Barbaresi, MD, FAAP

Director, Developmental Medicine Center
Wade Family Foundation Chair in Developmental Medicine
Boston Children’s Hospital
Harvard Medical School
Boston, MA
Ch 17: Learning Disabilities
Ch 21: Disruptive Behavior Disorders

Chief, Division of Developmental and Behavioral Pediatrics
The Children’s Hospital of Philadelphia
William H. Bennett Professor of Pediatrics
Perelman School of Medicine at the University of Pennsylvania
Philadelphia, PA
Ch 7: Basics of Child Behavior and Primary Care Management
of Common Behavioral Problems
Thomas D. Challman, MD, FAAP

Medical Director
Lewisburg, PA
Ch 19: Autism Spectrum Disorder
Ch 24: Complementary Health Approaches in Developmental and Behavioral Pediatrics
Eugenia Chan, MD, MPH, FAAP

Assistant Professor of Pediatrics
Division of Developmental Medicine
Boston, MA
Ch 23: Basics of Psychopharmacological Management
vii
Viola Cheung, DO, FAAP

Developmental Behavioral Pediatrician
TJH Medical Services
Medisys Child Development and Education Center
Flushing Hospital Medical Center
Flushing, NY
Ch 22: Anxiety and Mood Disorders

Chief, Division of Developmental Pediatrics
Chief, Division of General Academic Pediatrics
Chief, Division of Child Neurology
Director Regional Early Intervention Program
University of Florida College of Medicine–Jacksonville
Jacksonville, FL
Ch 6: Early Intervention
Peter J. Chung, MD, FAAP

Assistant Clinical Professor of Pediatrics
Division of Developmental-Behavioral Pediatrics
Center for Autism & Neurodevelopmental Disorders
University of California, Irvine
Santa Ana, CA
Stephen H. Contompasis, MD, FAAP

Emeritus Professor of Pediatrics
Larner College of Medicine
University of Vermont
Burlington, VT
Benard P. Dreyer, MD, FAAP

Director of Developmental-Behavioral Pediatrics
NYU School of Medicine and Hassenfeld Children’s Hospital at NYU Langone
Director of Pediatrics
Bellevue Hospital Center
New York, NY
Ch 3: Environmental Influences on Child Development and Behavior
viii
John C. Duby, MD, FAAP, CPE

Professor and Chair, Department of Pediatrics
Wright State University Boonshoft School of Medicine
Vice President of Academic Affairs and Community Health
Dayton Children’s Hospital
Dayton, OH
Ch 12: Social and Emotional Development
Ellen R. Elias, MD, FAAP, FACMG

Professor of Pediatrics and Genetics
University of Colorado School of Medicine
Aurora, CO
Ch 4: Biological Influences on Child Development and Behavior and Medical Evaluation
of Children With Developmental-Behavioral Disorders
Jason M. Fogler, MA, PhD

Staff Psychologist
Codirector of ADHD Services
The Division of Developmental Medicine
Instructor in Psychiatry
Boston, MA
Ch 17: Learning Disabilities
Jill J. Fussell, MD, FAAP

Professor
Developmental Behavioral Pediatrics Fellowship Director
Medical Director of the James L. Dennis Developmental Center
Section of Developmental Pediatrics and Rehabilitative Medicine
University of Arkansas for Medical Sciences
Arkansas Children’s Hospital
Little Rock, AR
Ch 15: Cognitive Development and Disorders
Dinah L. Godwin, MSW, LCSW

Meyer Center for Developmental Pediatrics
Houston, TX
Ch 25: Social and Community Services for Children With Developmental Disabilities
and/or Behavioral Disorders and Their Families
ix
Elizabeth B. Harstad, MD, MPH

Boston, MA
Ch 21: Disruptive Behavior Disorders
Pamela C. High, MD, FAAP

Director, Developmental-Behavioral Pediatrics
Hasbro Children’s Hospital
Warren Alpert Medical School, Brown University
Providence, RI
Carrie Kelly, MD, FAAP

Providence, RI
Desmond P. Kelly, MD, FAAP

University of South Carolina School of Medicine Greenville
Vice Chair for Academic Affairs, Department of Pediatrics
Greenville Health System Children’s Hospital
Greenville, SC
Ch 13: Sensory Impairments: Hearing and Vision
Mary C. Kral, PhD

Charleston, SC
Ch 20: Interpreting Psychoeducational Testing Reports, Individualized Family Service
Plans (IFSP), and Individualized Education Program (IEP) Plans
Angela C. LaRosa, MD, MSCR, FAAP

Charleston, SC
Ch 16: Speech and Language Development and Disorders
x
Austin A. Larson, MD
Instructor, Department of Pediatrics
Section on Genetics
Aurora, CO
Ch 4: Biological Influences on Child Development and Behavior and Medical Evaluation
of Children With Developmental-Behavioral Disorders
Michele L. Ledesma, MD, FAAP

Fellow, Developmental & Behavioral Pediatrics
Department of Pediatrics
Yale School of Medicine
New Haven, CT
Mary L. O’Connor Leppert, MB, BCh, FAAP

Director, Center for Development and Learning
Kennedy Krieger Institute
Johns Hopkins University School of Medicine
Baltimore, MD
Ch 10: Developmental Evaluation
Paul H. Lipkin, MD, FAAP

Kennedy Krieger Institute
Johns Hopkins University School of Medicine
Baltimore, MD
Ch 9: Developmental and Behavioral Surveillance and Screening
Within the Medical Home

Chief, Division of Developmental-Behavioral Pediatrics
Charleston, SC
Ch 1: Child Development: The Basic Science of Pediatrics
Ch 9: Developmental and Behavioral Surveillance and Screening
Within the Medical Home
xi
Shruti Mittal, MD, FAAP

Charleston, SC
Catherine Morgan, PhD

Senior Research Fellow
Cerebral Palsy Alliance Research Institute, School of Medicine
University of Sydney
Sydney, NSW
Australia
Ch 14: Motor Development and Disorders
Michael E. Msall, MD, FAAP

Professor of Pediatrics, University of Chicago
Co-director Kennedy Research Center on Intellectual and
Neurodevelopmental Disabilities
Chief of Developmental and Behavioral Pediatrics
Comer Children’s Hospital
Chicago, Illinois
Ch 14: Motor Development and Disorders

Neurodevelopmental Pediatrician
Lewisburg, PA
Ch 19: Autism Spectrum Disorder
Ch 24: Complementary Health Approaches in Developmental and Behavioral Pediatrics
Mary E. Pipan, MD, FAAP

Clinical Director, Trisomy 21 Program
Attending Physician, Developmental Behavioral Pediatrics
The Children’s Hospital of Philadelphia
Philadelphia, PA
Ch 7: Basics of Child Behavior and Primary Care Management
of Common Behavioral Problems
xii
Jennifer K. Poon, MD, FAAP

Charleston, SC
Ch 6: Early Intervention
Michael I. Reiff, MD, FAAP

Professor, Department of Pediatrics
Division of Pediatric Clinical Neuroscience
University of Minnesota
Minneapolis, MN
Ch 18: Attention-Deficit/Hyperactivity Disorder
Marie Reilly, MD
Instructor in Pediatrics
Boston, MA
Ch 8: Development and Disorders of Feeding, Sleep, and Elimination
Ann M. Reynolds, MD, FAAP

Section of Developmental Pediatrics
Children’s Hospital Colorado
Aurora, CO
Ch 15: Cognitive Development and Disorders
Julie Ribaudo, LMSW, IMH-E(IV)

Clinical Associate Professor
University of Michigan School of Social Work
Ann Arbor, MI
Ch 5: Interviewing and Counseling Children and Families
Angelica Robles, MD, FAAP

Providence, RI
xiii
Alison Schonwald, MD, FAAP

Assistant Professor of Pediatrics, Harvard Medical School
Assistant in Medicine, Boston Children’s Hospital
Boston, MA
Ch 8: Development and Disorders of Feeding, Sleep, and Elimination
Prachi E. Shah, MD, MS

Associate Professor, Pediatrics
Division of Developmental and Behavioral Pediatrics and
Center for Human Growth and Development
University of Michigan
Ann Arbor, MI
Ch 5: Interviewing and Counseling Children and Families

Associate Professor, Pediatrics
Section of Developmental-Behavioral Pediatrics
University of Chicago
Chicago, IL
Martin T. Stein, MD, FAAP

Professor of Pediatrics Emeritus
Developmental-Behavioral Pediatrics
University of California San Diego
Rady Children’s Hospital San Diego
San Diego, CA
Ch 18: Attention-Deficit/Hyperactivity Disorder

Assistant Professor, Department of Pediatrics
Houston, TX
Stuart W. Teplin, MD, FAAP

Developmental-Behavioral Pediatrician
Associate Professor, Emeritus
Department of Pediatrics
University of North Carolina School of Medicine
Chapel Hill, NC
Ch 13: Sensory Impairments: Hearing and Vision
xiv
Bridget Thompson, DO, FAAP

Providence, RI
Katherine A. Trier, MD, FAAP

Fellow, Developmental and Behavioral Pediatrics
Boston, MA
Sherry Sellers Vinson, MD, MEd, FAAP

Neurodevelopmental Specialist
Meyer Center for Developmental Pediatrics
Houston, TX
Ch 25: Social and Community Services for Children With Developmental Disabilities
and/or Behavioral Disorders and Their Families

Head, Section of Developmental Pediatrics
Director, Meyer Center for Developmental Pediatrics and Autism Center
Houston, TX
Ch 11: Making Developmental-Behavioral Diagnoses
Paul Wang, MD, FAAP

Deputy Director, Clinical Research
Simons Foundation
New York, NY
Associate Clinical Professor of Pediatrics
Yale University School of Medicine
New Haven, CT
Ch 2: Nature, Nurture, and Their Interactions in Child Development and Behavior
xv
Lynn Mowbray Wegner, MD, FAAP

Clinical Professor, Emerita
University of North Carolina School of Medicine
Chapel Hill, NC
Ch 27: Billing and Coding for Developmental and Behavioral Problems
in Outpatient Primary Care
Carol C. Weitzman, MD, FAAP

Professor of Pediatrics and Child Study Center
Director, Developmental-Behavioral Pediatrics
Yale School of Medicine
New Haven, CT
Reviewers
5
Board of Directors Reviewer
David I. Bromberg, MD, FAAP
Committees, Councils, and Sections

Committee on Bioethics
Committee on Coding and Nomenclature
Committee on Continuing Medical Education
Committee on Drugs
Committee on Medical Liability and Risk Management
Committee on Nutrition
Committee on Psychosocial Aspects of Child and Family Health
Committee on Substance Use and Prevention
Council on Children With Disabilities
Council on Early Childhood
Council on Environmental Health
Council on Genetics
Council on School Health
Disaster Preparedness Advisory Council
Private Payer Advocacy Advisory Committee
Section on Breastfeeding
Section on Gastroenterology, Hepatology, and Nutrition
Section on Home Care
Section on Ophthalmology
Section on Oral Health
Section on Otolaryngology–Head and Neck Surgery
Section on Pediatric Pulmonology and Sleep Medicine
Section on Urology
Surgery Advisory Panel
Contents
5
CHAPTER 1
Child Development: The Basic Science of Pediatrics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
CHAPTER 2
Nature, Nurture, and Their Interactions in Child Development and Behavior. . . . . . . . . . . . . . . . . .5
Paul Wang, MD, FAAP
CHAPTER 3
Environmental Influences on Child Development and Behavior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Pamela C. High, MD, FAAP
Carrie Kelly, MD, FAAP
Angelica Robles, MD, FAAP
Bridget Thompson, DO, FAAP
Benard P. Dreyer, MD, FAAP
CHAPTER 4
Biological Influences on Child Development and Behavior and Medical
Evaluation of Children With Developmental-Behavioral Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Austin A. Larson, MD
Ellen R. Elias, MD, FAAP, FACMG
CHAPTER 5
Interviewing and Counseling Children and Families . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Prachi E. Shah, MD, MS
Julie Ribaudo, LMSW, IMH-E(IV)
CHAPTER 6
Early Intervention. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
Jennifer K. Poon, MD, FAAP
CHAPTER 7
Basics of Child Behavior and Primary Care Management of
Common Behavioral Problems. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
Mary E. Pipan, MD, FAAP
xviii
Contents
CHAPTER 8
Development and Disorders of Feeding, Sleep, and Elimination. . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
Marie Reilly, MD
Alison Schonwald, MD, FAAP
CHAPTER 9
Developmental and Behavioral Surveillance and Screening Within
the Medical Home. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135
Paul H. Lipkin, MD, FAAP
CHAPTER 10
Developmental Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
Mary L. O’Connor Leppert, MB, BCh, FAAP
CHAPTER 11
Making Developmental-Behavioral Diagnoses. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187
CHAPTER 12
Social and Emotional Development. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223
John C. Duby, MD, FAAP, CPE
CHAPTER 13
Sensory Impairments: Hearing and Vision. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 251
Desmond P. Kelly, MD, FAAP
Stuart W. Teplin, MD, FAAP
CHAPTER 14
Motor Development and Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 285
Catherine Morgan, PhD
Michael E. Msall, MD, FAAP
CHAPTER 15
Cognitive Development and Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309
Jill J. Fussell, MD, FAAP
Ann M. Reynolds, MD, FAAP
CHAPTER 16
Speech and Language Development and Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 347
Angela C. LaRosa, MD, MSCR, FAAP
Shruti Mittal, MD, FAAP
CHAPTER 17
Learning Disabilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 367
Jason M. Fogler, MA, PhD
xix
Contents
CHAPTER 18
Attention-Deficit/Hyperactivity Disorder. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 383
Michael I. Reiff, MD, FAAP
Martin T. Stein, MD, FAAP
CHAPTER 19
Autism Spectrum Disorder. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 407
CHAPTER 20
Interpreting Psychoeducational Testing Reports, Individualized Family
Service Plans (IFSP), and Individualized Education Program (IEP) Plans. . . . . . . . . . . . . . . . . . . . . 477
Mary C. Kral, PhD
CHAPTER 21
Disruptive Behavior Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 495
Elizabeth B. Harstad, MD, MPH
CHAPTER 22
Anxiety and Mood Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 505
Viola Cheung, DO, FAAP
Michele L. Ledesma, MD, FAAP
Carol C. Weitzman, MD, FAAP
CHAPTER 23
Basics of Psychopharmacological Management. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 545
Eugenia Chan, MD, MPH, FAAP
Katherine A. Trier, MD, FAAP
Peter J. Chung, MD, FAAP
CHAPTER 24
Complementary Health Approaches in Developmental
and Behavioral Pediatrics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 575
CHAPTER 25
Social and Community Services for Children With Developmental
Disabilities and/or Behavioral Disorders and Their Families. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 591
Dinah L. Godwin, MSW, LCSW
Sherry Sellers Vinson, MD, MEd, FAAP
xx
Contents
CHAPTER 26
Transition to Adult Medical Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 611
Kruti R. Acharya, MD, FAAP
Stephen H. Contompasis, MD, FAAP
CHAPTER 27
Billing and Coding for Developmental and Behavioral Problems
in Outpatient Primary Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 621
Lynn Mowbray Wegner, MD, FAAP
INDEX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 641
1
CHAPTER 1
Child Development: The Basic Science of Pediatrics

5
More than 50 years ago, Julius B. Richmond, MD, characterized child development as
the basic science of pediatrics.1 The processes of child development and behavior affect
all primary pediatric health care professionals* and pediatric subspecialists, and these
fundamentally differentiate pediatrics from all other areas of medicine. In addition to
being experts in childhood wellness and illness, parents expect primary pediatric health
care professionals to be experts in all aspects of childhood and adolescence, especially in
the domains of development and behavior. Thus, clinical competence in child develop-
ment and behavioral health is vital to the success of all pediatric health care encounters.
Despite child development’s role as the basic science of pediatrics, the Accreditation
Council for Graduate Medical Education unfortunately requires all pediatric residents
to receive a total of only 32 half-day sessions’ experience in developmental-behavioral
pediatrics during their residency training.2 Thus, even though most practicing primary
care general pediatricians will rarely step inside a pediatric or neonatal critical care unit
or even provide direct care for hospitalized patients after they have graduated from resi-
dency, they will rarely make it through even a half-day in their general pediatric prac-
tices without a question from a parent about a child’s development or behavior, for which,
unfortunately, they are required to receive a total of only 16 days of training. This clearly
represents a distressing mismatch between the amount of training and future demands
in daily pediatric practice.3 Given this limited experience, it is not unexpected that sur-
veys of pediatricians in practice continue to indicate that pediatricians feel ill-prepared
in this distinguishing domain of pediatric practice.4,5 In addition, family medicine resi-
dents, family and pediatric nurse practitioners, and physician assistants, who will provide
medical homes for at least one-third of all children in the United States,6 generally receive
little, if any, training in this basic science. As illustrated in Table 1.1, and even more con-
cerning in this setting of limited training, developmental disorders are the most preva-
lent chronic medical conditions encountered in primary care, and psychosocial and
behavioral issues are even more ubiquitous in day-to-day pediatric practice.7–9
* Throughout this manual, the term primary pediatric health care professionals is intended to
encompass pediatricians, family physicians, nurse practitioners, and physician assistants who
provide primary care to infants, children, and adolescents.
2
American Academy of Pediatrics Developmental and Behavioral Pediatrics
Table 1.1. Prevalence of Developmental-Behavioral Disorders and Other Chronic Medical

Conditions in Childrena
Condition Prevalence
Slower learning (IQ between 70 and 89) 23%
Asthma 8.4%
Learning disabilities 7.7%
Attention-deficit/hyperactivity disorder 6.7%
Other developmental delays/intellectual disabilities 4.4%
Autism spectrum disorder 1.5%
Epilepsy 1%
Congenital heart disease 1%
Cerebral palsy 0.4%
Inflammatory bowel disease 0.4%
Juvenile rheumatic diseases 0.4%
Diabetes 0.2%
Cancer 0.02%
Cystic fibrosis 0.04%
Chronic renal disease 0.008%
a
Data derived from Boyle CA, Boulet S, Schieve LA, et al. Trends in the prevalence of developmental disabilities in US children,
1997–2008. Pediatrics. 2011;127(6):1034–1042; Christensen DL, Baio J, Van Naarden Braun K, et al. Prevalence and characteristics
of autism spectrum disorder among children aged 8 years—Autism and Developmental Disabilities Monitoring Network,
11 sites, United States, 2012. MMWR Surveill Summ. 2016;65(3):1–23; and Centers for Disease Control and Prevention National
Center for Health Statistics. http://www.cdc.gov/nchs. Accessed January 18, 2018.
Of the 118,292 pediatricians currently certified by the American Board of Pediatrics,

only 775 are subspecialty board-certified in Developmental-Behavioral Pediatrics
and only 255 are subspecialty board-certified in Neurodevelopmental Disabilities.10
This does not represent 1,030 different subspecialists, as some individuals have both
certifications. To illustrate the critical dearth of developmental-behavioral subspecial-
ists, consider that congenital heart disease affects approximately 1% of the pediatric
population. Currently, there are 3,218 board-certified pediatric cardiologists to care
for these children.10 However, if this is the number of subspecialists required to provide
subspecialty care for this 1% of the population, then it would require nearly 80,000
board-certified developmental-behavioral pediatricians (not the current 775) to pro-
vide the same level of subspecialty care for the approximately 25% of the pediatric
population with developmental-behavioral concerns (see Table 1.1).
This combination of a very high prevalence of developmental-behavioral disorders

and an enormously critical shortage of subspecialists to whom patients may be referred
creates extremely long waiting lists at tertiary care developmental-behavioral evalua-
tion centers; this makes subspecialty referral a futile proposition for the vast majority
of children with developmental or behavioral concerns.3 Thus, most children with
developmental or behavioral concerns must be managed within their primary care
medical homes. Clinical judgment and confidence in evaluation and management of
3
Chapter 1: Child Development: The Basic Science of Pediatrics
developmental-behavioral concerns need to be considered as basic to general pediatric

practice as are evaluation and management of asthma and other common chronic
medical conditions encountered daily in pediatric practice.3
This second edition of American Academy of Pediatrics Developmental and Behavioral

Pediatrics continues to represent a cooperative effort of the American Academy of
Pediatrics Section on Developmental and Behavioral Pediatrics and Council on Chil-
dren With Disabilities. While it certainly cannot provide the experiential learning that
an expansion of required subspecialty exposure to developmental-behavioral pediatrics
during pediatric or family medicine residency training or in the training of future
primary care nurse practitioners or physician assistants would provide, given the crucial
need to enhance the education of all primary pediatric health care professionals in this
basic science of pediatrics, this manual attempts to blend the overlapping perspectives
of both Neurodevelopmental Disabilities and Developmental-Behavioral Pediatrics
with the goal of improving care for all children.
Finally, this manual is intended to be neither an exhaustive reference geared for the
subspecialist nor a cursory introductory list of developmental and behavioral pediatric
topics. Instead, this expanded second edition aims to be a resource that provides the
essentials of what all primary pediatric health care professionals need to know to
successfully care for children with developmental and behavioral concerns in their
practices and to identify those who truly require subspecialty referral. It is hoped that
with the assistance of this manual, primary pediatric health care professionals will
gain more confidence in evaluating and managing children with developmental and
behavioral concerns and provide evidence-based developmental-behavioral pediatric
care within the medical home.
References
1. Richmond JB. Child development: a basic science for pediatrics. Pediatrics. 1967;39(5):649–658
2. Accreditation Council for Graduate Medical Education Program Requirements for Graduate
Medical Education in Pediatrics. http://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/
320_pediatrics_2017-07-01.pdf?ver=2017-06-30-083432-507. Accessed January 18, 2018
3. Voigt RG, Accardo PJ. Formal speech-language screening not shown to help children. Pediatrics.
2015;136(2):e494–e495
4. Sices L, Feudtner C, McLaughlin J, Drotar D, Williams M. How do primary care physicians identify young
children with developmental delays? A national survey. J Dev Behav Pediatr. 2003;24(6):409–417
5. Halfon N, Regalado M, Sareen H, et al. Assessing development in the pediatric office. Pediatrics.
2004;113(6)(suppl 5):1926–1933
6. Phillips RL, Bazemore AW, Dodoo MS, Shipman SA, Green LA. Family physicians in the child health
care workforce: opportunities for collaboration in improving the health of children. Pediatrics.
2006;118(3):1200–1206
7. Boyle CA, Boulet S, Schieve LA, et al. Trends in the prevalence of developmental disabilities in US children,
1997–2008. Pediatrics. 2011;127(6):1034–1042
8. Christensen DL, Baio J, Van Naarden Braun K, et al. Prevalence and characteristics of autism spectrum
disorder among children aged 8 years—Autism and Developmental Disabilities Monitoring Network,
11 sites, United States, 2012. MMWR Surveill Summ. 2016;65(3):1–23
9. Centers for Disease Control and Prevention National Center for Health Statistics. http://www.cdc.gov/nchs.
Accessed January 18, 2018
10. American Board of Pediatrics, Inc. Pediatric Physicians Workforce Data Book 2015-2016. Chapel Hill, NC:
American Board of Pediatrics, Inc; 2016
5
CHAPTER 2
Nature, Nurture, and Their Interactions in

Child Development and Behavior
Paul Wang, MD, FAAP
5
Nature and nurture have long been regarded as rival influences on child development
and behavior. One school of thought has contended that a child’s behaviors and devel-
opmental outcome are determined by nature—that is, by innate biology—while a rival
school has argued that nurture—a child’s environment and experiences—is dominant in
determining the child’s developmental outcome. While the nature-nurture debate raged
among academics, intuitive parents and primary pediatric health care professionals have
long known that both sets of factors—the innate and the experiential—are important in
the complex processes of child development and behavior. Over the last several decades,
science has amassed substantial evidence to document the importance of both nature
and nurture.1 Moreover, current research is elucidating the complex ways in which
nature and nurture interact throughout the childhood years.
This chapter attempts to provide a framework in which to consider how nature, nurture,
and their interactions shape children’s lives. Many examples are provided of both innate
and experiential factors that influence children’s development and behavior, and of the
mechanisms through which those factors are believed to act. Throughout the chapter, the
reader is asked to hold 2 overarching concepts in mind: individual variability and devel-
opmental plasticity. Because of individual variability, children differ in how any factor
may shape their development and behavior regardless of whether that factor is innate
or environmental. As research is beginning to show, much of this variability may be
rooted in the interaction of nature and nurture, also known as gene by environment
interaction or GxE. Because of developmental plasticity, the effects of both innate and
experiential factors can be either augmented or ameliorated by other factors over time.
No developmental influence, whether innate or environmental, should be regarded as
deterministic, strictly consigning a child to a certain fate. Rather, the processes of devel-
opment continue throughout childhood, adolescence, and even adulthood, allowing
biological and behavioral interventions to shape later outcomes.
6
Innate Factors in Child Development and Behavior

Nature can be variably construed in either a narrow or a broad manner. From the
narrow perspective, a child’s nature is defined as the child’s innate biological endow-
ment and heredity and, thus, consists primarily of genetics. From the broader perspec-
tive, all factors that are believed to operate through a direct biological mechanism are
construed as being within the category of nature.
Genetics
Research on the influence of nature on children’s behavior and development started in
earnest with twin studies, which examine the resemblance of monozygotic (identical)
twins to each other and the resemblance of dizygotic (fraternal) twins to each other.
Data from these twin studies are commonly summarized in a numerical parameter
known as heritability, which can range from 0 to 1.00 and is symbolized as h2. For
example, studies of attention-deficit/hyperactivity disorder (ADHD) estimate its
heritability to be between 0.60 and 0.90, while IQ studies estimate the heritability
of intelligence 0.50 to 0.85 with values tending higher with increasing age (ie, genetic
factors have a larger influence in older ages).2 It should be understood that heritability
is an abstract mathematical parameter that does not translate easily to tangible inter-
pretation. That is, if the heritability of reading disability is 0.75, it does not imply that
75% of all cases of dyslexia have an exclusively genetic etiology, or that the child of a
person with dyslexia has a 75% chance of having dyslexia, or any such implication.
Heritability merely describes the proportion of the statistical variance in a trait that
was attributable to genetics in a particular research study.
Behavioral genetic studies commonly yield estimates of heritability that are greater
than 0.50 for many developmental-behavioral diagnoses and traits,3 leading some
commentators to claim that biology is more important than environment. Such a claim
is misleading at best. First, the word more is confusing in this context. Even when the
estimate of heritability is high, it cannot be concluded that any particular case of a
disease is “more” caused by genetic or environmental factors or that more cases of that
disease are caused by genetics than environment. Since no study of any trait has shown
complete genetic heritability (ie, heritability has always been found to be <1.00), and
since even identical twins do not show 100% concordance for any diagnosis or trait
(eg, autism, schizophrenia, reading skills; Figure 2.1), it implies that environmental
factors can make a clinically significant difference even when 2 individuals are geneti-
cally identical. It seems much more likely that all or almost all cases of a disease have
both genetic and environmental influences in their pathogenesis. Robert Plomin, one
of the most prominent researchers in the field, has commented that behavioral genetic
studies can be regarded as providing some of the best evidence of the importance of
environmental factors in shaping health and disease.4
A further argument against the overinterpretation of heritability parameters is that they

are dependent on the amounts of genetic and environmental variation in the popula-
tions under study. For example, if all the subjects in a study had identical environments,
7
Chapter 2: Nature, Nurture, and Their Interactions in Child Development and Behavior
90
MZ
80
DZ
70
Twin Concordance
60
50
40
30
20
10
0
Reading Language Maths Schizophrenia Depression Alcoholism
Learning Difficulties Psychiatric Disorders
Figure 2.1. Twin concordances for learning disabilities and for psychiatric disorders.
Abbreviations: MZ, monozygotic; DZ, dizygotic.
Reproduced from Haworth C, Plomin R. Quantitative genetics in the era of molecular genetics: learning abilities and
disabilities as an example. J Am Acad Child Adolesc Psychiatry. 2010;49(8):783–793, with permission from Elsevier.
the study would show misleadingly high estimates of genetic heritability and low esti-
mates of environmental influence. In fact, it is well known that extreme environmental
manipulation can have enormous effects on behavior and development. Common, real-
life variability in the environment also affects estimates of heritability, as Turkheimer
and colleagues5 demonstrated. They found that estimates of the heritability of IQ are
higher in populations with higher socioeconomic status (SES), while heritability is near
zero in populations of lower SES. Explanations for this finding are only speculative, but
it seems possible that families with higher SES provide a more consistently beneficial
environment to their children, thus minimizing the environmental differences between
them and thereby making genetics a larger source of variance. In populations with
lower SES, on the other hand, some children may encounter more beneficial environ-
ments (eg, a particularly nurturing teacher) while others do not, which results in
higher estimates of environmental variance in IQ and minimal genetic heritability.
With the advent of molecular genetic methods, twin studies have been supplanted by
research that examines specific genes and their effects on child behavior and develop-
ment. Genome-wide association studies (GWASs) provide one example of this new
approach. In these studies, single nucleotide polymorphisms, which are commonly
found in the general population, are studied in relation to phenotypic traits. In general,
GWASs are suited to finding genetic differences that are relatively common but have
relatively weak effects on the risk of having a medical condition, whether that disease is
emphysema or a reading disability. More recently, next-generation genetic sequencing
methods have been applied to the task of finding the genetic roots of behavior and
development. These methods include whole exome sequencing and whole genome
sequencing, in which every base pair in a person’s genome is sequenced, whether it
8
is found in an exon, in an intron, or in the intervening segments that comprise 98% of

our DNA (formerly referred to as “junk DNA”). These “next-gen” studies are finding
variations that are rare in the population as a whole but that may carry much stronger
disease risk.6 (It is reasoned that if a genetic difference carried a high risk for a serious
medical condition, then it could not be common in the population, as it would decrease
the fitness of individuals who have it.) Even when differences in genotype are found,
science is faced with the daunting task of understanding how these differences in
genetic sequence give rise to seemingly dramatic phenotypic differences. Genes and
their protein products interact in enormously complex networks, regulating the
expression and effect of other genes and proteins, and scientists will be busy for
many decades unraveling this complexity.
Genetic factors can have either large or subtle influences on child development and
behavior. Examples of the former include genetic diagnoses that are associated with
intellectual disability or severe behavioral abnormalities. These disorders can result
from single gene mutations (eg, in the FMR1, HPRT1, or MECP2 genes associated with
fragile X syndrome, Lesch-Nyhan syndrome, and Rett syndrome, respectively) or from
genetic conditions that affect multiple genes (eg, contiguous gene deletion syndromes
such as Williams syndrome or velocardiofacial syndrome, chromosomal aneuploidies
such as Down syndrome and segmental chromosomal deletions or duplications). In some
of these disorders, the exact pathogenic mechanism is not fully understood. For example,
it is still not conclusively known which genes on the triploid chromosome 21 have signif-
icant roles in causing the neurobiological differences associated with Down syndrome.
In other disorders, including fragile X syndrome and many metabolic conditions, such
as Lesch-Nyhan syndrome, the pathogenesis is understood to a greater extent.
In contrast to the large effects of mutations in genes such as FMR1, HPRT1, and MECP2,
mutations and variants in other genes are believed to have more subtle effects on the
risk for conditions such as reading disability, ADHD, and other learning disabilities.
For some conditions, such as autism spectrum disorder (ASD), research suggests that
there are both large-effect and small-effect genes. Mutations in the SHANK3 and CHD8
genes, for example, are associated with a large risk for autism, but mutations in large-
effect genes such as these are estimated to account for only 30% to 40% of all cases of
ASD, at most, while most cases of ASD are believed to be associated with small-effect
mutations or common variants in other genes.7 These genetic differences may not give
rise to autism on their own but may work with other genetic risk factors or with yet-
unspecified environmental factors to cause autism. Because of the smaller effects of
these genes, however, and their complex interactions with other factors, they have
been difficult to identify and to confirm.
Individual variability in clinical manifestations is present both for small-effect common

variant genetic differences but also for the large-effect genes. For instance, only 25% to
30% of individuals with fragile X syndrome, associated with the FMR1 gene, meet full
diagnostic criteria for autism. Even the level of intellectual disability seen in fragile
X syndrome varies widely among those with the full mutation. Similarly, mutations in
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"Guess again," said Harty; and she did guess all the aunts, cousins, and
friends that had ever been to make them a visit, but in vain. When Harty
had enjoyed her curiosity long enough, he said, "Well, Miss Mouse" (a
name he often called her), "sister Rosa is coming home to live, and she is to
tell us what to do, and be like a little mother for us! That's what father told
me."
Lucy did not know whether to be glad or sorry at this news; she had not
seen her sister for many years, and perhaps she might be afraid of her, and
perhaps Rosa might not care for such a little girl as herself, even younger
than Harty.
The excited boy was in a state of great delight, and he talked to Lucy
until she quite entered into his feelings. "Won't it be nice," he said, "to have
Rosa at home? I shall offer her my arm when she goes to church, and lead
you with the other hand. I shall lend her my 'Swiss Family Robinson;' I
mean to put it in her room, that she may read it whenever she pleases. But
she need not attempt to make me mind her, for I sha'n't do it; I am not going
to have any girl set over me!"
"Oh, fie! Harty!" said Lucy, "to speak so of sister Rosa before you have
seen her."
"Before I have seen her!" repeated Harty; "I remember her perfectly; I
have not forgotten how I used to play—she was my horse—and drive her
round the house; you were only a little baby then."
"Not so very little," answered Lucy, pettishly, for her brother had made
her feel as if it were a disgrace to be young.
While they were talking, Julia Staples called to walk with her to school.
Lucy soon told her all about her sister's expected return.
"I should not think you would like it!" said Julia; "she'll want the nicest
of everything for herself, and make you wait on her, as if you were her
servant."
Before they reached the school-house, Lucy was quite sure that Rosa's
coming would make her unhappy. Julia Staples had been talking with little
thought, but she had roused evil feelings in Lucy's mind which were
strangers there. She was not naturally envious, but now her heart burned at
the idea that her sister would always be praised, and go out with her father,
while she would be left at home with no one to care for her. Children do not
think enough of the harm they may do each other by idle conversation. Julia
might have encouraged Lucy in feeling kindly towards her expected sister,
and have made her look forward to the meeting with pleasure; but she filled
her mind with wicked, envious thoughts.
Do my young friends ever think whether they have roused wrong

feelings in their companions? Two children can hardly talk together for half
an hour without having some influence over each other, for good or for evil.
The wrong thought that you have planted in the heart of a child may
strengthen, and lead her to do some very wicked thing when you have
forgotten the conversation.
A traveller once took some seeds of a very valuable plant with him on a
journey. From time to time he cast them in the fields as he passed, and when
he was far away they sprang up and were a great blessing to the people who
owned the fields. A wicked traveller might have scattered the seeds of
poisonous plants, which would have grown up to bring sickness and death
to all who partook of them. Our life is like a journey, and whenever we talk
with the people around us, we cast some seeds in their hearts, those which
may spring up to bless them, or those which may cause them sin and
sorrow.
CHAPTER V.
THE ARRIVAL.
"Your sister is to be here at ten o'clock, and you must be ready to receive
her," said Mrs. Maxwell to Lucy, a few days after the occurrences related in
the last chapter.
"Shall I put on my white frock?" asked Lucy.
"Nonsense! child," was the reply; "isn't your sister to see you every day,
from morning to night, in whatever you happen to have on? Go, get a clean
apron, and make your hair smooth, that is all the dressing that little girls
need."
This idea did not suit Lucy, for she was very anxious that her sister
should love her, and she thought if she were prettily dressed at first, she
would be more likely to do so. As she looked in the glass while arranging
her hair, she thought she never had seemed quite so ugly. The fact was, she
was beginning to have a fretful expression, which was spoiling her face.
Lucy had never heard that scowls must in time become wrinkles. She was
not at all pleased with her simple appearance, but there seemed no way for
her to wear any ornament, not even a hair ribbon, for her soft light curls
were cut so closely, that they could only lie like her waxen doll's, in golden
rings about her head.
Lucy was fond of dress, and she would have liked to wear jewellery to
school, as many of the scholars did, but Mrs. Maxwell never allowed it. The
little girl had a bracelet of her mother's hair, and this she, one morning,
clasped on her arm under her apron, to be worn on the outside after she
reached school, where Mrs. Maxwell could not see it. As she stopped on the
road to change it, there came a sudden pang into her heart—she was
deceiving, and with the gift of her dead mother; perhaps that dear mother
could see her now, she thought; and hastily putting down her sleeve, she
hurried to school.
Though the bracelet was not displayed, and no one around her knew that
she wore it, she felt guilty and unhappy until it was restored to the box in
which it was usually kept. The remembrance of that day checked her this
morning, as she was about to place on her slender finger a ring which had
been her mother's, and in her child-like dress, she went down to wait for her
sister.
She found Harty at the front window, but by no means in a fit condition
to give Rosa a welcome, for his face had not been washed since breakfast,
and his dark curls were, as usual, in wild confusion.
"Here comes Miss Prim!" he shouted, as Lucy entered, "as neat as a new
pin. For my part, I don't intend to dress up for Rosa; she'll have to see me
this way, and she may as well get used to it at once. I do wish she'd come, I
am tired of waiting; the clock struck ten five minutes ago. Hurrah! there's
the carriage!" he cried, and was out of the room in an instant.
Lucy longed to follow, but she seemed fastened to her chair; there she
sat, looking anxiously out of the window, as the carriage entered the yard
and drove up to the door.
Her father got out first, and then gave his hand to a tall, slender girl, who
sprang with one leap to the stops, and was locked in Harty's rough embrace.
"But where is little Lucy?" she asked, when Harty had ceased to smother
her with kisses.
The voice was kind and cheerful, and Lucy stepped forward, hanging her
head, and timidly putting out her hand.
Rosa overlooked the little hand, and clasped the bashful child tenderly in
her arms.
Tears came in Lucy's eyes, she could not tell why—not because she was
unhappy, for she felt sure she should love her sister.
"God bless you, my children!" said Dr. Vale, "may you be happy
together. Rosa, you must be a second mother to our little one. Lucy, show
your sister her room; I must leave you now; I must not neglect my patients,
even to enjoy seeing my children once more together." So saying, he drove
from the door.
Rosa's room had no gloomy associations to her, for she had not been at
home at the time of her mother's death, and she only remembered it as the
spot where she had enjoyed much sweet conversation with that dear mother,
now, she trusted, a saint in heaven.
As her eyes fell on the truthful picture of that lost friend, they were
dimmed by natural tears, which were soon wiped away, for why should she
weep for one whose pure spirit was at rest?
Rosa was a Christian; not that she never did wrong, but it was her chief
wish to do right. She had just been confirmed, and felt most anxious to do
something to serve the Saviour, whose follower she had professed herself to
be. When she received her father's letter recalling her home, she found it
hard to obey, for she had been so long at her uncle's, that it was a severe
trial to leave his family circle, and to lose his advice, which she knew she
should so much need, to keep her true to the promises which she had now
taken upon herself. Mr. Gillette, with gentle firmness, pointed out to his
niece that it was her plain duty to return unhesitatingly to her father's house.
"You wish, dear Rosa," he said, "to be a true follower of the Saviour, and
to do something for His cause. Go home to your brother and sister, strive by
example and kind advice to lead their young hearts to Him who will repay
all their love. But be careful, my child, while you are striving for the good
of others, not to neglect your own character. Be yourself all that you wish to
make them!"
Rosa had returned with a true desire to be of service to Lucy and Harty,
and she had many plans for their welfare. Just now she longed to be alone
for a few moments, that she might thank her Heavenly Father for His
protecting care during the journey, and ask His blessing on her new home.
Her first impulse was to send the children away, but she checked it, and
made them quite happy by allowing them to assist her in unpacking. Lucy
handled everything very carefully, but Harty made Rosa tremble, by his
way of tumbling over her collars and ribbons.
At last, all was unpacked but the little box of books, which Harty
insisted on opening himself. "Run, get my hatchet," he said to Lucy, who
willingly brought it.
"This is too small to work with," said the eager boy, after a few
moments' exertion, "get me the large hatchet, Lucy."
Lucy again obeyed; but her brother spoke not a word of thanks when she
came back, breathless with running. This rudeness did not escape Rosa,
although she hoped it was only occasioned by her brother's anxiety to
oblige her, and was not his usual manner.
The obstinate nails at last came out, and all the party sat down on the
floor, and began taking out the books. Harty looked at the titles one after the
other, and threw them aside with disappointment; at length he said,
impatiently, "Are they all as sober as sermons? I should think you were
going to be a parson, Rosa."
"Not exactly!" said she, with a merry laugh, "but you must not be
surprised if I preach a little sometimes. Then you don't like my books; I am
sorry for that, but I hope we shall have a great deal of pleasure in reading
them together, by-and-by."
"Not I," answered Harty; "I like stories about shipwrecks and great
soldiers, and strange and wonderful things."
"Then here is a book which ought to please you," said Rosa, laying her
hands on the beautiful Bible which had been Mr. Gillette's parting gift. "Do
you not love to read it?"
Harty hung his head, and answered, "There are no nice stories in the
Bible."
"No nice stories in the Bible!" said Rosa. She turned the leaves rapidly,
and began to read the story of Gideon. At first, Harty looked very
indifferent; but she read in a clear voice, and animated manner, and by
degrees he dropped the books which lay on his lap, and leaned his head on
his hands, in rapt attention. When she came to the attack on the camp of the
Midianites, he was ready to join the shout, "The sword of the Lord and of
Gideon!"
"Where is it? where is it?" asked Harty, when Rosa had finished, "I want
to look at it myself."
She pointed to the place, and promised to find him many more
interesting stories, that they could read together.
Lucy meanwhile had crept close to Rosa's side, and laid her hand upon
her lap. "And there is something to interest you, too, Lucy," said Rosa:
"here is the Prodigal Son, let me read it to you."
"Do! do! sister Rosa," said both of the children. She needed no urging,
and read the short and beautiful parable with real feeling.
Harty felt touched, he knew not why, but with an effort to look
unconcerned, he asked, abruptly, "What does it mean, Rosa?"
"It teaches us many sweet lessons, dear Harty," answered Rosa; "I cannot
well explain them all to you, but I know that it is to make us understand that
God loves us as the father loved his wandering son. Did you notice that he
knew the Prodigal when he was afar off, and ran to meet him? So God sees
when we wish to do right, though nobody about us may guess it, and He is
ready to welcome us to His love. Is it not strange that the Holy God should
love us so tenderly?"
Harty looked wearied, and did not reply. Lucy tried to speak, but she was
almost weeping, and her lips would not move.
"Come, we must not talk any more," said Rosa, cheerfully. "See how the
things are all lying about. Harty, can you take the box away for me?"
He started off, with a sense of relief, and Rosa was left alone with her
little sister. She kissed the child gently, and said, "You must tell me, some
time, why those tears come so quickly; I want to know all that troubles you,
and be your friend."
Lucy only replied by placing her hand in that of her sister. Harty now
returned, and they all went to work busily, and soon arranged the books on
the shelves of the bookcase.
"Come, Rosa," said Harty, "I want to show you my room, and to take
you down in the orchard;" and he seized her rather forcibly by the hand.
The room was still in confusion, and Rosa would have preferred to stay
and see her things nicely put away, but she contented herself with closing
one or two of the drawers, and then followed her eager brother. Lucy
silently went with them, keeping close to her sister's side, now and then
looking half-lovingly, half-wistfully, into Rosa's cheerful face.
Harty's room was a curiosity shop, filled with all kinds of odd things that
he had gathered together. Mrs. Maxwell and he had been for a long time at
war about the birds' nests, nuts, shells, stones, &c., that he was constantly
bringing to the house, and leaving about to her great annoyance. On several
occasions she threw away his carefully collected treasures, and at last, the
young gentleman, in great displeasure, went to his father and asked, "if he
might not be allowed, at least in his own room, to keep anything valuable
that he found in his walks." His father consented, and after that his room
became a perfect museum. Stuffed birds, squirrel-skins, and crooked sticks
were ranged on his mantel-piece, in a kind of order, and the chest of
drawers was covered with similar specimens.
From time to time, Mrs. Maxwell came herself to dust among them,
though Harty was sure to complain after such visits that his treasures had
been greatly injured. On this particular morning Mrs. Maxwell had been
thoroughly dusting, on account of the expected arrival, and as Harty entered
the room he darted from Rosa, and carefully taking from the shelf some
twigs, with bits of spiders' web attached to thorn, he angrily exclaimed,
"Old Maxwell has been here, I know! I wish she would let my things alone!
the hateful thing! See here, Rosa, this was a beautiful web, as perfect as it
could be; I brought it only yesterday morning, when it was all strung with
dew-drops, and now look at it! Isn't it enough to make any one angry?"
Rosa looked sorrowfully at her brother, and made no reply for a moment;
at length she answered: "Dear Harty, you can find another spider's web; but
angry words once spoken can never be taken back. Won't you show me
what you have here, and forget your trouble?"
The hasty boy was soon engaged in explaining what all the queer-
looking things were, and why he valued them. In some of them Rosa was
much interested: she had never seen a titmouse's nest before, and as she
took the curious home in her hand, she thought of the kind Heavenly Father
who had taught those little creatures to build it with such skill, and had
watched the nestlings from the time they left the shell, until they flew
lightly away on their fluttering wings.
"What can you be thinking about?" said Harty, as she looked earnestly at
the pretty thing.
"Pleasant thoughts," said Rosa, smiling, as she took from his hand a
huge beetle.
Lucy wondered to see her sister take what seemed to her such a frightful
thing so calmly in her hand. "There now! I like that!" shouted Harty, "she
handles it like a boy. There's Lucy, she screams if I put such a thing near
her, if it has been dead a month. Isn't she a goose?"
Lucy looked anxiously at Rosa, fearing she would say something

unkind.
"Oh! yes, she is a little goose," was the reply, "but such a dear little
goose, that I am sure I shall love her very much. We must teach her not to
be afraid of trifles."
The timid child clasped Rosa's hand more closely, and inwardly resolved
to try to please her sister in everything. She even touched with the tip of her
finger a snake-skin from which she had always shrunk before, as she heard
Harty and Rosa admiring it, while they handled it freely.
Some of the specimens which Harty seemed to think very precious were
uninteresting to Rosa, and some were even disgusting; but she looked at all,
and tried to discover the beauties which Harty so eagerly pointed out.
Her uncle had taught her that politeness is a Christian duty, and to be
always shown, even to nearest relatives, and to those younger than
ourselves.
Harty was delighted, and slapped Rosa on the back in token of his
pleasure. "You are a glorious girl!" said Harty; "why, if that had been Lucy,
she would have cried, and said I always hurt her."
"You forget," said Rosa, "that Lucy is a delicate little girl; you cannot
play with her as you would with a boy. You must take care of her, as the
knights of old guarded their ladye-love, and handle her as carefully as you
would a bird's nest."
At this Harty laughed, and Lucy smiled.
"Now for the orchard," cried Harty; and away he ran, pulling the girls so
rapidly along that they could hardly keep from falling down stairs.
A pleasant place was that orchard; the grass was fresh and short, and
some of the branches of the old trees bent almost to the ground. Under these
Harty had placed wooden seats, and there it was his delight to study. Very
little studying he accomplished, though, for his eye wandered at one
moment to a ripe apple on the topmost bough, and the next to a curious
insect that was creeping on the trunk near him.
Rosa placed herself on the rustic seat, and looked upward through the
waving branches to the clear blue sky above, and a half smile came over her
face, that Harty did not understand. He did not guess that the sweet scene
was filling the heart of his sister with love to the great Creator. Nor did
Lucy understand her any better; but the expression on her sister's
countenance made her warm with love towards her.
Harty soon grew restless, and engaged his companions for a race. Away
they flew over the soft grass, and Rosa was the first to reach the fence,
which had been agreed upon as the goal; Lucy came next, while Harty,
puffing and panting, brought up the rear.
"I declare that was not fair," he began; "we did not start together."
"Never mind," said Rosa; "we girls ought to be the fastest runners, for
that is all we can do in danger. Girls run, while boys must stand and defend
themselves and their sisters."
This view of the case suited Harty, and reconciled him to his defeat; and
they continued chatting amicably in the orchard and piazza until the bell
rang for them to prepare for dinner. As they entered the house, Mrs.
Maxwell met them, and looking sternly at Rosa, she said, "I hoped you
were going to set a good example, Miss Rosa, to these careless children, but
there I found your room all in confusion, while you were out running races.
Your father has reckoned without his host, if he looks to you to make them
particular."
Rosa knew that it had cost her an effort to leave the room in that
condition, and that she had done so to please her brother. She did not defend
herself, however, for she now saw that it would have been better to make
him wait a few moments. Hastening up stairs, she soon found a place for
everything, and put everything in its place, and as she did so, she resolved
not to let her anxiety to win the affection of her brother and sister lead her
astray.
Dr. Vale looked very happy, when he sat down to dinner with his family
about him. He was pleased with Rosa's easy, cheerful manner, and delighted
to see Lucy's face lighted with smiles, and Harty doing his best to act the
gentleman. And acting it was, for anything like politeness was far from
being habitual with him.
When they rose from the table, Dr. Vale led his eldest daughter to her
room, and entering it, closed the door. The doctor walked towards the
portrait, and gazed at it a few moments in silence, then, turning to Rosa, he
said, with some emotion, "You do not, I fear, remember your mother
distinctly, my child. I have had this life-like image of your mother placed
where it will be ever near you, that it may remind you of the part that you
must act to the dear children. May God bless and assist you in your task:
pray earnestly to Him to watch over you and guide you, and you cannot fail.
And now, dearest, never think me cold nor stern, when I am silent. My
professional cares often weigh so heavily upon me that I notice but little
what is passing around me; but nothing can so absorb my mind as to make
me indifferent to the welfare of my children. Come to me with all that
troubles you, and you shall find a father's heart, though perhaps a faltering
tongue."
The doctor pressed his daughter to his bosom, kissed her forehead, and
left the room. As soon as he had gone, Rosa fell on her knees to implore the
God of all good to strengthen her for the great task that was before her, and
to enable her to make herself such an example as the children might safely
follow.
CHAPTER VI.
AN ACCIDENT.
In about half an hour there was a gentle tap at Rosa's door. It was Lucy,
who entered timidly, and going towards Rosa, said, blushing, "Don't mind
Mrs. Maxwell, dear; she often speaks in that way to me, when she don't
mean anything."
"Mind her! No and yes: she will not worry me; but I shall be glad to
have some one to make me remember to be neat at all times. Where's
Harty?" said Rosa.
"He's getting ready to go to the woods: he wants you to go with him."
"With all my heart," answered Rosa. "Are we to go now?"
"Yes, as soon as we can put on our bonnets," said Lucy, as she went to
her room, to get her things. She put on a pair of thin slippers, although she
knew they were to cross a damp meadow, for she could not make up her
mind to wear the thick boots that were so much more suitable. Lucy had
certain articles of dress which it gave her great pleasure to wear, and these
shoes were among the favourites. Many a cold and sore-throat they had cost
her, but her vanity was not overcome even by such consequences.
Hand in hand the three children walked merrily along, chatting as

pleasantly as if they had not been parted for years.
Rosa and Harty declared that they liked to step on the soft meadow, that
it was like a rich carpet that yielded to their feet. Their shoes were so thick
that they did not feel the dampness, and they had no idea how
uncomfortable Lucy was, in her thin slippers, thoroughly soaked with the
moisture. They soon entered the woods, where the tall trees grew so close
together that they almost shut out the pleasant sunlight. Here Rosa found so
much to admire that she was constantly exclaiming with delight. She had
not lived in the country since her childhood, and there was a charm in
everything that met her eyes. Sometimes she was struck with new beauties,
and sometimes she was reminded of by-gone days.
"Do you remember, Harty," she said, "how we came here together, when
you were a little bit of a boy, and made a house under that tree for my doll
to lie in? And have you forgotten, when we where gathering chestnuts just
here, and I found I had lost my shawl, and how we hunted, and found it at
last hanging on the fence by the meadow?"
Harty remembered these and many other occasions when he had enjoyed
rambles with his sister; and they continued calling the past to mind, until
poor Lucy felt quite sad that she knew nothing of what caused them so
much pleasure. She grew silent, and at last withdrew her hand from Rosa,
as she thought, "Yes, it will be as Julia Staples said, Harty and Rosa will go
together, and not care for me."
The sun was just setting when they drew near home on their return. They
had taken a long walk, but Lucy had not recovered her spirits, although
Rosa, perceiving that she was not happy, had done all in her power to
amuse her. Lucy felt half inclined to laugh and enjoy herself occasionally,
but then the wicked, jealous thought would come up in her mind, and she
grew sober again, and coldly answered her sister's cheerful remarks.
They had walked through the woods quite round to the back of the
house, and were almost to the pleasant orchard, when they came to a wide
brook, which they must cross to reach the by-path that led to the house. A
single plank was placed across the stream. Harty ran gaily over, and went
up the hill on the other side without looking behind him.
"Let me lead you over," said Rosa, kindly offering her hand to her little
sister.
"I had rather go by myself," answered Lucy, sullenly, and placed her foot
on the plank. She walked tremblingly on until she was half over, then the
plank shook a little, and she grew frightened, swayed from side to side, lost
her balance, and fell into the brook.
Lucy's shriek attracted the attention of Harty, who was by this time some
distance up the hill, and he hastened towards her; but she had scarcely sunk
in the water before Rosa had leaped from the bank and caught her in her
arms.
The stream was rapid, and the fearless girl could hardly have kept her
footing had she not caught hold of the plank above with one hand, while
with the other she carried the half-fainting Lucy.
They reached the opposite side in safety, and Harty was there to assist
them in climbing the bank. Great tears stood in his eyes, not from fright for
Lucy, but from admiration of Rosa's courage.
"You are a sister worth having!" were his first words. "How I wish you
were a boy!"
Poor Lucy, what pain these words gave her! Although she had been in
such danger, Harty only thought of Rosa!
The true-hearted sister, meanwhile, was lifting her thoughts in

thankfulness to Him who had enabled her to save the life of the child.
Lucy was too weak to walk home, and Rosa and Harty formed a lady-
chair with their arms, and carried her safely up the hill, Rosa laughing at
their ridiculous appearance in their wet clothing, for she had plunged into
the stream up to her neck.
"Here we are! all safe and sound!" shouted Harty, as Mrs. Maxwell came
out to meet the strange-looking party.
"A pretty-looking set you are! Do not come into the house in that
condition!" was Mrs. Maxwell's reply. "Pray where have you been?" she
continued: "I wonder if we are to have such doings all the time."
Rosa gently but firmly replied, that Lucy had been in great danger, and
she thought she ought to be undressed immediately, and placed in a warm
bed.
There was something in Rosa's quiet, dignified manner that awed Mrs.
Maxwell: she came forward and took Lucy from their arms without another
word, while Rosa hastened to her room to put herself in order to wait upon
her sister. In a few moments she was neatly dressed, and standing by Lucy's
bedside.
Dr. Vale had returned, and having heard from Harty an account of the
matter, was soon with his little daughter. He ordered a warm draught to be
administered, and said he did not think she needed any other medicine, as
she seemed not to be really injured, only much agitated by the fright.
He kissed the little girl tenderly as he thought how near he had been to
losing his pet, and greatly praised Rosa's promptness and courage in saving
her from the death with which she was threatened.
Lucy could not thank her sister, for she felt guilty, as she remembered
the unkind, suspicious thoughts that were in her mind when the accident
happened. She shuddered at the idea that she might have died while her
spirit was so unfit to go into the presence of the holy God. She felt that she
had been very wicked, and she could not believe that God would pardon
her.
"I know I shall be very ill," she said to herself, "because I was so
naughty, and perhaps I shall die, and then nobody would care, and Harty
and Rosa would be just as happy."
This last thought checked her half-formed resolution to tell her sister of
her wrong feelings; and she turned away from the kind face that was
bending down to her, and said, "I wish you would go away, I had rather be
alone."
Rosa did go, but only to the door of her own room that was opposite:
there she placed her chair, that she might be near, if Lucy should be lonely
or want anything, little thinking what was in her sister's heart.
Lucy lay very still all the evening. Rosa thought she was sleeping, and
did not disturb her. During those long, dark hours, Rosa was not sad. She
had many pleasant thoughts. She liked to be alone, sometimes, for then she
could more fully realize that God was with her.
Nine o'clock came, yet Rosa did not like to leave her sister: often during
the evening she had stolen to her side to see if she were still sleeping. Once
she stooped and kissed her; then Lucy longed to throw her arms around the
neck of the kind watcher, and say that she had not been asleep; but
something kept her silent.
At ten, the doctor came in. Rosa stole softly down stairs and told him
how quiet the little girl had been during the evening. "But, dear father," she
said, "I do not like to leave her alone to-night. May I not lay her in my bed,
where I shall be sure to know if she wakes, and wants anything?"
"Certainly, dear," was the father's reply, "and I will carry her myself,
carefully, that she may not wake. She is too heavy for you to lift, though
you did take her so nobly through the water, my darling."
The doctor took the little girl gently in his arms; she did not seem to be
awake, but oh! how guilty she felt all the time, to think that she had
cherished harsh feelings towards one who wished to be so kind to her; and
ashamed she felt that she was even then deceiving; but she had not the
courage to open her eyes and say that it was all pretence. Rosa covered her
very carefully, and placed her head comfortably on the pillow, and then
began to move about noiselessly, preparing for the night.
Lucy was just closing her eyes, thinking her bed-fellow was about to lie
down beside her, when Rosa threw her wrapper round her, and taking her
small Bible, sat down to read. She did not once raise her eyes or move,
while she was reading, yet Lucy could see that her expression changed from
time to time, as if she was very much interested. There was a sweet
peacefulness on her countenance as she closed the book, and Lucy resolved
to open at the mark the next morning, that she might read herself what had
had so pleasant an effect.
She then looked up and saw that Rosa was kneeling, with her eyes
raised, and praying earnestly in a low voice. Lucy was almost startled, Rosa
seemed so really to be speaking to some one, and she involuntarily looked
about to see if there were any one in the room.
She had been so long accustomed to merely prayers herself, that she had
almost forgotten that prayer is always speaking to God.
By degrees she rose in the bed and leaned eagerly forward to catch the
words, which were scarcely audible as she lay on the pillow.
She heard her sister earnestly ask pardon for the sins she had just been
confessing, while she thanked her Heavenly Father with the confidence of a
child for His free forgiveness; and then she prayed, oh, how earnestly! that
God would enable her to watch over her brother and sister, and lead them to
the dear Saviour, the only source of real happiness, and for whose sake she
knew all her petitions would be granted. Before she rose, she begged to be
enabled to remember that the Saviour was beside her, through the dark night
to preserve her from all harm.
As Rosa finished her prayer, Lucy sank down in the bed, overcome with
awe. God was really in the room; Rosa had spoken to Him, and seemed to
know that He had heard her. What must His pure eye have seen in her own
heart! how much that was wrong! Could He forgive? In a few moments the
light was extinguished, and Rosa was at her sister's side. She lay very still at
first, that she might not waken the sleeper, but very soon a little hand was
laid in hers, and Lucy gently whispered, "Dear Rosa, do you really think the
Saviour is near us?"
Rosa was startled to find her companion awake; but she took the little
hand instantly, and said, "Yes, dear Lucy, He is with us always."
"Doesn't it make you afraid," said Lucy, "to think so?"

"Afraid to think He is near us, dearest! Why, He is our best friend! Do
not you love Him, Lucy?"
Lucy began to sob, and said, at last, that it always frightened her to think
about such things, and she never did, unless something reminded her that
she must die.
"My dear little sister," said Rosa, "God loves you: you need not be afraid
of Him, if you really wish to please Him."
"But I can't please Him, I can't do right," sobbed Lucy.
"I know you cannot," Rosa replied, "but He will forgive you for Jesus'
sake, and help you, if you ask Him."
"But I forget all about it," said Lucy.
"It is very hard to remember at first, that God is always with you, and
you are trying to be His child. I know, dear Lucy, that you must wish to love
and serve the kind Heavenly Father who has done so much for you: begin
to-night; ask Him to make you His child, and to take care of you."
Lucy made no answer, but in silence she did as her sister had advised,
and God who seeth all hearts received and answered her simple petition.
The few words that Rosa had said, dwelt in her mind. "God loves you,"
she thought, again and again, as she lay in her quiet bed; and when her eyes
closed in sleep, it was with the remembrance that the God who loved her
was near to watch over her.
CHAPTER VII.
SUNDAY MORNING.
Sunday morning came, and the sun was fairly risen before either of the
little girls was awake. Rosa was the first to open her eyes: she would
willingly have taken another nap, but the first stanza of a morning hymn
occurred to her mind, and she remembered her resolution to overcome her
laziness.
As she repeated—
"Awake, my soul, and with the sun

Thy daily course of duty run,
Shake off dull sloth, and early rise
To pay thy morning sacrifice,"
she got up very carefully that she might not rouse her sister. "I will let the
child sleep a little longer," she said to herself, "for she is so pale, I don't
believe she is quite well."
It was a beautiful morning: the fields and orchards were bright with the
sunshine, and the birds seemed singing even more happily than usual. As
soon as Rosa had dressed herself, and finished her usual devotions, she
went down stairs to enjoy the fresh air. As she walked in the garden, the
conversation she had had with Lucy the evening before passed through her
mind. What her uncle had said to her about being useful to her own family
seemed about to be realized. "Poor little Lucy," she thought: "may God help
me to lead the dear child in the right path."
Harty heard Rosa's footsteps in the garden, and was soon at her side.
"Here, brother, is something for your museum," was her greeting, and she
pointed to a chrysalis which hung on a low rose-twig by the path. "Is it not
beautiful? Just look at the silver spots!"
"It is a capital specimen," answered Harty, as he carefully broke the little

branch to which it was fastened: "I wonder what kind of a butterfly it will
be. Rosa!" he added, "I did not think you would like such things as these."
"Not like the beautiful things God has made!" exclaimed Rosa. "Why, I
love to look at every little object in nature, and think that our Heavenly
Father planned it and made it so perfect. It seems easy to believe that He
notices all our little joys and troubles, when wo see that even the smallest
insect is made with such care."
As Rosa spoke, her eyes sparkled and she looked around her, as if every
object which was in sight was a proof to her of the love of the kind Creator.
Harty made no answer, but looked thoughtfully at the chrysalis as they
entered the house together.
The breakfast-bell was ringing, and they met Lucy in the hall. She
glanced slyly towards her sister, remembering the conversation of the
evening before. Rosa kissed her cordially, and, hand in hand, they went to
the table.
"Perhaps Miss Rosa had bettor pour out coffee," said Mrs. Maxwell
stiffly to the doctor, as the children came in.
"Would you like it, Rosa?" asked her father.
Rosa saw that Mrs. Maxwell looked displeased, and, in a moment, it

passed through her mind, that perhaps she would not like to give up the
place she had held so long to one so young as herself, and she quickly said,
—
"May I put that off a little longer, father? I am afraid I could not suit you
as well as Mrs. Maxwell does; she has made tea for you a great while."
"A long time, dear child," said the doctor; and his thoughts went back to
the days when his delicate wife sat opposite him, her sweet face growing
paler each morning, until at last her weak hands could no longer do their
office, and Mrs. Maxwell took her place.
Rosa knew of what her father must be thinking, and she did not speak for
several minutes. At length she said, "Is old Mr. Packard any better to-day,
father?"
"I have not seen him yet," was the reply. "I shall have to make a round of
visits this morning," continued the doctor, "so I shall not have the pleasure
of taking my tall daughter to church to-day: I leave that to Harty."
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