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INTRODUCTION

This is important information becaus e nurses are

directly responsible for assuring growth &

development.All children pass through predictable stages of

growth & development as they mature.

Parents often will ask a nurse what to expect from

their child regarding developmental progress.

NURSING PROCESS OVERVIEW

Assessment should include:
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Height & weight should be measured & plotted on a

standard growth chart for children - at all visits.

Focus history & observation on development

milestones, major markers of normal development.

24-hour recall of nutrition intake

Description of school & play behaviors

Developmental stage is assessed through

observation & listening carefully to how the child

describes self, or parents describe the child.

Nursing Diagnoses

These vary. Please consult any Nursing Diagnos is

book.

Planning

Planning should include considering all aspects of

the child's health (holist ic care) including physical,

emotional, cultural, cognitive, spiritual, nutritional &

social aspects .

Each child's progress is unique.

A child cannot be forced to achieve milestones

faster than that child's own timetable will allow.

Through anticipatory guidance a child can be

encouraged to reach his or her maximum

developmental potential.

Privacy issues must be considered with

adolescents.

Implementation to foster growth & development:

Encourage age-appropriate self-care.

Suggest age-appropriate toys or activities to

parents (most toys labeled with age can be played

with earlier than age on the package).

Role modeling by the nurse is an important

intervention for children & families (Ex: Problem

solving is more effective than acting out).

Evaluation

Evaluation for specific milestones must be ongoing


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to be accurate & us eful because many children do

not test well until school age. It also provides a

chance for early detection of various problems.

IMPORTANCE OF KNOWLEDGE TO

THE ROLE OF THE NURSE

Health Promotion & Illness Prevention

Determining a child's developmental s tage is often

the primary focus of a health interview.

Parents also need periodic anticipatory guidanceregarding their child's development.

Examples: Discussing additional home safety with a

parent when a child is approaching the age for

creeping. Cautioning the parents of a 1-year-old that

the child's appetite may decrease during the coming

year.

Anticipatory guidance must be offered at the

appropriate time or it's useless. Given too early it's

forgotten. Given too late, issues may be ignored or

addressed in a poor manner (one that is not growth-

enhancing)

Health Restoration & Maintenance: Caring for the sick

or surgical child patient.

Understanding the child's developmental stage

helps in choosing the right words to explain anillness or procedures.

Physical growth is another important factor to

cons ider. Diseas e affects children differently at

various stages of growth.

PRINCIPALS OF GROWTH ANDDEVELOPMENT


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Children do not merely grow taller & heavier.

Maturing involves growth in ability to perform

skills, to think, to relate to people, to trust, to have

confidence in oneself.

Growth- refers to increase in physical sizesuch as

weight & height (quantitative change).

Development(maturation) - refers to increase in

skill or ability to function& it is measured by

observing a child's ability to perform a specific tas k

(qualitative change).

Psychosexual development (Freud)- refers to

developing instincts or sensual pleasure.

Psychosocial development (Erikson)- refers to

personality development

Moral development (Kohlberg)refers to growing

to know right from wrong.

Cognitive development (Piaget)- refers to the abilityto learn & understand from experience, acquire &

retain knowledge, respond to new situations &

solve problems. It is measure by intelligence tes ts &

observation of the child.

Patterns

Neurologic tissues (spinal cords and brain - mature

by 2-5 years) and lymphoid tissue (spleen, thymus,

lymph nodes & tons ils) grown rapidly during

infancy & childhood.

The reproductive system shows little growth until

puberty.

There are several principals of growth &

development you must remember:

Growth and development are continuous

process es from the day we are conceived

until death.

Growth and development proceed in anorderly sequence.

Different children pass through the

predictable stages at different rates .

All body systems do not develop at the

same rate.

Development is cephalocaudal (from head to

toe).

Development proceeds from proximal to

distal body parts.

Development proceeds from gross to refined

motor skills.

There is an optimum time for initiation of

experiences or learning.


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Neonatal reflexes must be lost before

development can proceed

A great deal of skill and behavior is learned

by practice.

FACTORS INFLUENCINGGROWTH AND DEVELOPMENT

Genetics (ex: temperament) & environmental (ex:

nutrition) influences are the two primary factors in

determining a child's pattern of growth &

development.

Genetics

Can influence learning style and temperament

Gender- On average females are born weighing &

measuring less than males. Girls begin their puberty

growth spurt 6 months to a year earlier than boys.

Health- A child who inherits a genetically

transmitted d isease may not grow as rapidly or

develop as fully as the healthy child

Intelligence- Children with high intelligence tendto advance faster in skills & may fall behind in

physical skills because they spend more time with

books or such than developing motor skills.

Temperament

Refers to the usual reaction pattern of a person or

their manner of thinking, behaving or reacting to

stimuli in the environment.

Nursing Research has shown significant correlation

between infant temperament & pos tpartum

depression

Reaction Patterns- There are nine characteristics

of a reaction pattern & include the following:

Activity Level- Child may have a high or

low activity level or in between, all are

normal.

Rhythmicity- Child may have a regular

rhythm, have a predictable schedule ofdoing things or Child may have an irregular

rhythm, always changing their routines day

to day.

Approach- Child approaches new situations


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without apprehension, in an unruffled

manner or Child approaches anything new

with withdrawal and crying.

Adaptability- Refers to the ability to adapt

to s omething new over time. An example

here is that one child may cry on its first tub

bath but get use to it by the 3rdbath or

another child never seems to adapt to the

tub bath and cry's for months over the tub

bath.

Intensity of the reaction- Some children

react to s ituations crying loudly, thrashing

their arms & such while others have mild or

low-intensity reactions to stress.

Distractibility- Children who are eas ily

distracted are easier to manage, others who

cannot be distracted are consideredstubborn & willful.

Attention Span and Persistence- Refers to

ability to remain interested in a project or

activity. Some children will play alone with a

toy for hours while others will play no more

than 1-2 minutes with each toy.

Threshold of Response- Refers to how

intense the level of stimulation has to

become to receive a response. A child with a

low threshold needs little st imulation to get

a reaction & a child with a high threshold

needs intense s timulation to get a reaction.

Mood Quality- Child who is always

laughing and happy is said to have a

pos itive mood quality.

**Categories of Temperament:

The Easy child- has predictable rhythmicity,approach & adapt to new situations, mild to

moderate intensity of reaction, overall positive

mood quality. Rated by parents in 40%-50% of

children.

The Difficult Child- is irregular in habits, has a

negative mood quality, and withdraws from new

situations . Rated by parents in 10% of children.

Slow-to-Warm-Up Child- is overall fairly inactive,

responds only mildly & adapts slowly to new

situations with a general negative mood. Rated by

parents in 15% of children.

Mixed Group Child


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(Be careful with s uch 'labeling' ladies & gentlemenJ)

Nursing Implications Regarding

Temperament

Parents should be talked to about reactivity

patterns because they tend to persist. They need to

unders tand that it is their child's method of coping,

such understanding can help parent's accept &

respect the child as individual.

A child who is s low to adapt may need to have a

procedure explained several times to be able to

accept it.

Mild or intense reactivity pat terns influence how

the child will react to pain - for example the child

who has acute pain barely makes a sound versus

the child with mild pain screams & cry loudly.

Temperament can also influence breastfeeding. An

important fact for a new breastfeeding mom.

New research has found a s ignificant correlation

between infant temperature and postpartumdepression.

Environment

Can include stress (teach coping methods such as

listening to music play).

Inadequate nutrition due to low socioeconomics,

inadequate care giver skills and attention, chronicillness (resulting in decreased appetite) and

endocrine disorders which can be regulated with

diet or medications (from the external environment).

Socioeconomic Level

Food cos ts money, a child in a low-income family

may not receive proper nutrition. Health care costs

money, therefore poor health supervision could

result in no immunizations, which has many

implications.

Parent-Child Relationship

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Erikson's 8 Stages of Development

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Children who are loved thrive better than those who

are not. It is the quality of time not the amount.

Cultural norms in the family play a role in when a

child is expected to achieve particular development

milestones.

Ordinal Position of the Family

The position of a child in the family will have some

bearing on his or her growth and development.

Health

Diseas es can come from environmental sources and

influence growth and development. Treating a child

as if he or she is s ick or vulnerable to s ickness

refers to - fragile child syndrome.

Nutrition

Quality of a child's nutrition prenatally and during

the growing years influences their external health

and stature. Poor maternal nutrition can limit growth

and intelligence.

Poor nutrition limits the body's ability to

resist infection.

Lack of calcium can lead to rickets

(shortening or bowing of long bones).

And lack of vitamins can lead to vision

impairment and poor healing.

Establishing healthy eating patterns early on

life can contribute to bet ter health in the

adult years.

The tendency for being overweight may be

inherited but being overweight early in life

can also play a role.

Fat intake does not need to be restricted for

the first 2 years of life.

A percentage of fat is needed for

myelination of nerves.

Whole-grain cereals & raw fruits such as

apples provide fiber.

Olestra, a synthetic fat should not be used

by children because fat-soluble vitamins

may be excreted with this product.

Too much sugar can result in dental caries &obesity. Soft drinks, candy & chocolate are

empty calorie foods.

Salt/sodium should be moderate. Salt is an

acquired taste. If it is not introduced to a

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child or is moderate they do not develop a

desire for heavily salted foods.

Protein - is essential for growth with its

amino acids.

Carbohydrates - provide the main fuel,

especially for the neurological system (i. e.

your brain) and the actively growing brain

cells of infants and toddlers.

Fats - are needed for myelination of nerve

fibers in infants. Also provide energy and

insulation.

Vitamins - do not produce energy but that

help the cells to do so. ADE & K can only

be absorbed in the presence of fat

molecules. Thus another need for some fat

in the diet. Water-soluble vitamins (B

complex & C) cannot be s tored in the bodyand must be taken daily.

Minerals - are needed to build new cells and

regulate body processes i.e. calcium.

Macronutrient - is a (major) mineral

that you need more than 100mg of

daily.

Micronutrient - is a (minor) mineral

that you need less than 100mg of

daily.

Trace minerals - are only needed in

small amounts.

Careful asses sment and family education are

needed for families who practice vegetarian

diets to ensure adequate nutrition for

growth during childhood. May review

details in a dietary book.

SELECTED THEORIES

OF DEVELOPMENT

A developmental task is a skill or a growthresponsibility arising at a particular time in an

individual's life.

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Freud's Psychoanalytic Theory

Describes child development as ps ychos exual

stages in which interests become focused on a

particular body site.

Infant - Oral phase- Infant s ucks for enjoyment or

relief of tension, as well as for nourishment.

Toddler - Anal phase- Children find pleasure inboth the retention and defecation of feces; Part of

self-discovery and a way of exerting independence.

Preschooler - Phallic phase- Children may show

exhibitionism; Leads to increased knowledge of the

two sexes.

School-Age Child- Latent phase - Libido (energy)

appears to be diverted into concrete thinking.

Adolescent - Genital phase- Establish of new

sexual aims and finding of new love objects.Criticisms of Freud - Based theory on observations

of the mentally ill or what people should do to avoid

mental illness. This theory looks at illness rather

than wellness, which limits its applicability to the

promotion of health.

Erikson's Theory of Psychosocial

Development

Stresses the importance of culture and society on

personality development.

Where Freud looked at ways that mental illness

develops, Erikson looked at actions that lead to

mental health and describes eight stages across a

life span. At each s tage there is conflict between

two opposing forces.

Infant - Trust vs. mistrust- or learning confidenceor learning to love. Infants whose needs are met i.e.

discomforts quickly removed, who are cuddled,

fondled, played with, and talked to view the world

as s afe & people as helpful & dependable. Those

with unmet needs develop distrust and become

fearful and suspicious of the world and people.

Trust vs . mistrust arises again at each successive

stage of development.

Toddler - Autonomy vs. shame- autonomy meaningself-governance or independence builds on

children's new motor & mental abilities. Children

take pride in new accomplishments and want to do

things independently. Toddlers need to do what


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they are capable of doing & will develop a sense of

being able to control muscle & impulses. Toddlers

are independent people. Caregivers who are

impatient and do everything for them enforce a

sense of shame and doubt. If they aren't allowed to

do they doubt their ability to do .

Preschooler - Initiative vs. guilt- Learning initiative

is learning how to do things. Children can initiate

motor activities of various sorts on their own.

Giving freedom & opportunity to initiate motor play

i.e. running, bike riding, s liding, wrestling, or play

with materials such as finger paints , sand, water &

modeling clay; Parent's answering questions; Not

inhibiting creative or fantasy play, all enforce their

sense of initiative. If they are made to feel their

motor activity is bad, ques tions are bothersome,

play is silly or stupid they may develop guiltinstead.

School -Age Child- Industry vs. inferiority- Here

children are interested in doing things well. They

want to know if they are doing a good job or doing

it right. Children who are encouraged, praised and

rewarded develop a sense of accomplishment and

thus a sense of industry. Parents who view

activities as mischief or don't show appreciation for

their child's work may develop a feeling of

inferiority. Children whose sense of industry has

been des troyed at home may be revitalized by a

committed teacher or nurse.

Adolescent - Identity vs. role confusion- At this

time adolescent must integrate all the different

images of themselves i.e. son, daughter, friend,

student, scout and so on into a whole that makes

sense. If they are unable to do this they experience

role confus ion & are unsure of the kind of person

they are. They may seek a negative identity

preferable to no identity at all.

The Young adult - Needs to achieve a sense of

intimacy as opposed to isolation - Intimacy means

they can relate well with other people and form

long-lasting relationships. The Nursing

implications: Women without a sense of intimacy

may have more difficulty accepting a pregnancy &

beginning to love a newborn child.

The Middle Age person - Needs to develop a senseof generatively in which they extend their concerns

to the community and outs ide world. Those whose

develop th is are able to juggle their various lives

and are self-confident. Those without this sense


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become stagnated or self-absorbed. The nursing

implications: Women without a sense of

generatively may have more difficulty accepting a

pregnancy & a new role of childbearing &

childrearing.

Criticisms of Erikson's Theory

Is that life does not occur in easily divided

stages.

Piaget's Theory of Cognitive

Development

Include the Sensorimotor Stage, Preoperational

Thought, Concrete Operational Thought & Formal

Operational Thought.

Piaget defines s tages of cognitive development

Sensorimotor Stage

Infant- Babies relate to the world through

the senses, us ing only reflex behavior.

As infants progress they learn the concept

that people are entities separate from their

environment. Learn that objects in the

environment are permanent & continue to

exist even though they are out of sight or

changed in some way (infants know their

parents exist and will return to them).

Eight-month anxiety - is when the infant

continues to cry for their parents because

they know their parents still exist even when

out of sight

As infants further progress they

demonstrate goal-directed behavior andactively seek new experiences. It is

important to have enough stimulating

objects around for exploring so that

experimenting & learning can proceed in this

way.

Preoperational Thought

Toddler- Toddlers begin to develop some

cognitive skills s uch as symbolic thought

and egocentric thinking. During

preoperational thought children are able to

use symbols to represent objects.

Preschooler- Develop intuitive-thought, a

tendency to look at an object and see only


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one of its characterist ics (referred to as

centering). An example of centeringis a

child observes that their medicine tas tes bad

but does not understand it will also help

them. Preschool thinking is also influenced

by role fantasy, or how children would like

something to turn out. They also use

assimilation,taking information and

changing it to fit their existing ideas. They

believe wishes are as real as facts, that

dreams are as real as daytime happenings

and perceive animals & even inanimate

objects as being capable of thought &

feeling. Later they learn accommodation

(they change their ideas to fit reality rather

than the reverse). Egocentrismis also

strong during this period (perceiving theirown thoughts & needs as better or more

important than those of others).

Concrete Operational Thought

School-Age Children- are able to discover

concrete solutions to everyday problems

and recognize caus e-and-effect

relationships. Reasoning during school age

tends to be inductive, proceeding from

specific to general.

Formal Operational Thought

Adolescents - Are capable of thinking in

terms of poss ibility, such as what could be,

rather than limited to what already is. This

makes it poss ible for adolescents to use

scientific reasoning.

Criticisms of Piaget's Theory

He only used a small sample of subjects, his

own children.

Kohlberg's Theory of Moral

Development

Is a theory on moral reasoning or the way that

children gain knowledge of right and wrong.

Recognizing these stages can help identify how a

child may feel about their illness & whether the

child can be depended on to carry out self-care

activities such as self-administered medicine.


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Preconventional (Level I)About 2-7 years old

Infants- have little concept but they do

learn that when they do certain actions,

parents g ive affection and approval. To

support this caregivers should give praise

when infants do what they are asked to do.

The average infant is trying hard to please

but probably falls short due to immaturity.

Infants who have developed a s ense of trust

are better able to develop a spiritual

orientation in future years & thus be bound

by a moral conscience.

Toddlers - reason for doing the 'right thing'

is centered most s trongly in mother or father

'saying so', rather than spiritual or societal

motivation. However, they may not obey

requests from people other than theirparents as they do not view their authority

at the same level (may be necessary for

parents to reinforce ins tructions).

Preschoolers - tend to 'do good' out of self-

interest rather than out of true intent to do

good or because of a s trong spiritual

motivation. Children at this age imitate what

they see, so if they see less-than-perfect role

modeling, they may copy these wrong

actions & assume those actions are correct.

Because of egocentrism, a preschooler will

do things for others only in return for things

done for him or her. Ex: Lie still while I

change your dressing and then we'll play in

the playroom when I'm through.

Conventional (Level II)About 7-12 years old

School-age Child- enters the conventional

development s tage, the level at which many

adults function. Young school-age children

may lie about their actions to disguise that

they have been involved in an action that is

not 'nice.' This age group may have trouble

following self-care measures reliably when

out of a nurses or parent's s ight, because

they feel it is necessary to obey rules only

when the rules can be clearly enforced.

Postconventional (Level III)Greater than 12 years

oldAdolescents - are capable of internalizing

standards of conduct (they do what they

think is right regardless of whether they

have s ocial rules). They are capable of


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carrying out self-care measures even when

someone else is not present & are capable of

understanding the importance of measures

to themselves & that certain things should

simply be done because they are right.

Criticisms of Kohlberg's Theory

Challenged as being male-oriented research

because original research was done entirely

on boys. (See Susan Gilligans In a

Different Voice. Additionally see Susan

Hoff Sommers The War on Boys)

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