❖ Principles of Growth and Development

❖ Terms
o Growth - increase in physical size (can easily be plotted in growth charts)
o Development - progression towards maturity (are they meeting milestone points) – fully
developed (are they stacking blocks? Can they tie their shoes?)
o Maturation - the point of being fully developed for their species (physically)
o Cognitive development - reaching a high level of developmental maturity (goes along with both
growth and development….more in tune to their development, not necessarily their size)

❖ Theories of Development #1

o Freud (psychosexual stages) v Erikson (development stages)

o Infant: Oral trust vs mistrust
o Toddler: Anal autonomy vs shame
o Preschooler: Phallic initiative vs guilt
o School aged: Latent industry vs inferiority
o Adolescent: Genital identify vs role confusion

Freud – talks about the psychosexual stages of a child (oral, anal, phallic, latent, and genital)

Infant – (Oral) babies put everything in their mouths pacifiers

Toddler – (Anal ) learning to potty train
Preschooler – (Phallic ) learn the difference btw girl/boy, start to assume those gender roles – if
preschooler has their hands down their pants we know it’s totally normal, but…do that when they are
alone
School aged – (Latent stage); personality development tends to be non-active or dormant
Adolescent – (genital) develop sexual maturity physically. Their bodies become sexually mature…they
enter into puberty, they are now able to reproduce

Erikson – more developmental

- Trust vs. mistrust

o Infant’s - initial bond with their primary caregivers is pretty much the basis for how they will
form every other bond with someone for the rest of their life.

o Toddler – “autonomy vs. shame

▪ Where they are taking initiative.
▪ They really want to start learning.
▪ They really want to be independent
• Is they achieve that independence (which they should in this developmental
level) then they will move on to taking initiative.
o Toddler who is potty training and has accidents and then they are shamed and punished
for those accidents even though they are developmentally doing what they are supposed
to…it can stagger their development

o Preschooler – taking that initiative; asking tons and tons and tons of questions; if they
don’t achieve it (they are people pleasers, they want to do things that are desirable).if
 they are constantly met with disapproval and being shutdown then they are going to
develop a sense of guilt.

o School-Age kids – in the developmental stage of industry vs. inferiority

o Are they able to well or are they always at the back of the class?
o Teachers pet, class clown (trying to cover up that they are not understanding their
work)

Adolescents – really just trying to assert their own independence and their own identity;
and become an adult.
• Who am I?
• What is going on?
 ❖ Theories of Development #2

Theorist: Paget’s stages of cognitive development (sensory motor focus)

Paget’s – focused on sensory motor

- 1st – reflexes
o Ex: suffeling reflex, stroke the side of their cheek they are going to go toward it bc that’s
where their food is so their rooting reflex.
▪ Infancy is broken down into 1 month to 24 months reflex stage

- 2 to 7 years – the pre-operational stage; thoughts become more symbolic (fantasize, imagine and
use their imagine to try and come up with why things are the way that they are.

- 7-12 yrs – school-age kids – more concrete thinkers; starting to understand why things are the way
they are. They can understand how a series of events creates one result.

- Adolescents – formal operational thought – they can hypothesize, start using a scientific approach
to solve problems

• Neonatal reflex (1 month)

o behavior entirely reflexive, stimulation become mental image
• Primary circular reactions (1 to 4 months)
o Hand-mouth and eye-ear coordination develop, enjoyable activities occur
• Secondary circular reaction (4 to 8 months)
o infants learn to initiate, recognize, and repeat pleasurable experiences such as pick a boo or
mirrors
• Coordination of secondary reactions (8 to 12 months)
o infants can play activities to attain goals like stacking colored boxes
• Tertiary circular reaction (12 to 18 months)
o Child can discover new properties of objects (like throwing and retrieving)
• Invention of new means through mental combinations (18 to 24 months)
o transitional period to preoperative thought; child should use toys with many uses like colored
rings
• Preoperational thought (2 to 7 years)
o thought becomes symbolic. Child can comprehend simple abstracts. Child is egocentric, has
static thinking and the concept of time is new. Centering, or focusing on a single aspect is good
for child. Using things that require imagination like clay
• Concrete operational thought (7 to 12 years)
o Concrete operations include systematic reasoning. Uses memory to learn concepts versus
subgroups (such as fruit versus apples) Classifieds objects into groupings. Child is aware of
reversibility (catch and toss) Good activity is collecting and classifying shells
• Formal operational thought (12 years and older)
o Can solve hypothetical problems with reasoning, why things are how they are, or events create
results. Good activity is “talk time“ to sort out attitudes and opinions
 ❖ Theories of Development #3

Kohlberg’s stages of moral development: (based on rules and reasoning ability)

Kohlberg – Focused on morals.

Preconventional (Level 1)
• 2-3 year olds: stage 1
o Punishment versus reward/obedience. Child does what is right because parents say so in order
to avoid punishment (NOTE: child needs help to determine what is right. Clear instructions help
avoid confusion)
• 4-7 year olds: stage 2
o Individualism. Child is a self satisfiers with no self control. Will only help others if others
help them ( NOTE: child cannot recognize situations that require actions. They’re unable to take
responsibility for self care)

Conventional (Level 2)
• 7-10 year olds: stage 3
o Orientation to interpersonal relations of mutuality. Child follows rules because they want be
good in the eyes of others (NOTE: Child helps others because it’s nice. Praise for desired
behavior is needed)
• 10-12 year olds: stage 4
o Maintenance of social order, fixed rules and authority run childs life. Child finds following
rules satisfying and follows the rules of authority to keep the systematic working (NOTE: Child
often asks what the rules are and if something is right or wrong, but may have difficulty
modifying actions if they are told its wrong one day and okay the next. Follow self-care
measures only as enforce)

Postconventinal (Level 3)
• Older than 12: stage 5
o Social contract, utilitarian lawmaking perspective, follows societies rules for the good of all
people (NOTE: adolescence can be responsible for self-care because they view this as a
standard of adult behavior)
• Older than 12: stage 6
o Universal ethical principle orientation. Follows internalize standards of conduct as they see fit
(NOTE: many adults do not reach this level of moral development)
❖ 2020 National Health Goals Related to Growth and Development #1
o Increase the proportion of children with special healthcare needs who receive their care in
family-centered, comprehensive, coordinated systems from 20.4% to a target level of
22.4%.
o Reduce the proportion of children diagnosed with a disorder through newborn blood spot
screening who experience a developmental delay requiring special education services from
15.1% to a target level of 13.6%.
o Increase the proportion of young children who are screened for an autism spectrum disorder
(ASD) and other developmental delays by 24 months of age from 19.5% to a target level of
21.5%.
o Increase the proportion of children with a developmental delay who have a first evaluation by 36
months of age.
o Reduce the proportion of children 2 to 5 years of age who are considered obese from 10.7% to a
target level of 9.6%; for children 6 to 11 years, from 17.4% to 15.7%; and for adolescents, from
17.9% to 16.1%.

❖ Nursing Process: Growth and Development

o Assessment – history (including developmental levels and progress, plot height, weight, head
circumference plotted on growth chart), head to toe physical and questions for patient + family
o Nursing diagnosis – (please see later slides – developmental delays or growth delays identified)
o Outcome identification and planning – consider EVERY health aspect (physical, social,
economic, cultural, environmental, etc) when setting appropriate goals
o Implementation – promote self-care, get activity started, encourage task achievement and
mastery in learning and achieving (the more tasks they achieve and master…the further they are
gonna go); initiative and recognize that they can and will do things.
▪ There should always be some form of PLAY and some form of ROLEMODELING
o Outcome evaluation – evaluation should be as comprehensive as goal setting was, repeat
process until all concerns are satisfied
❖ Factors Influencing Growth and Development
o Genetics – single most important element of development, can inherit many things from mom,
dad or mom and dad that cause developmental stress or inhibits proper development (autonomic
dominant genes)
o Gender – women are smaller at birth and do not get larger until 10-12 y.o., then it evens out in
high school and eventually males are larger again in adult hood; girls hit puberty sooner as
well.
o Health – if a child has health issues causing their body to use energy sources to fight things like
infection, chronic disease, etc they will not be able to use that energy and nutrients to grow (will
not meet growth and developmental mile stones at the same rate)
o Intelligence - smart children meet milestones quicker; the more intelligent this child is the faster
they will meet and achieve their skills and meet those developmental milestones.

❖ Temperament - the easy child vs the hard child

o Reaction patterns - (what we gage temperament on: 4 factors)
▪ Activity level - hyper vs docile child (both normal but which is easier to teach?)
▪ Rhythmicity – same sleep pattern or wild sleep patterns (routine); predictable
▪ Approach – open child vs shy child (will they talk to anyone or only want mom?)
▪ Adaptability – how do they react to new stimuli or situations (calm or tantrum)
▪ Intensity of reaction – how are they displaying negative emotion outwardly (tantrum or
calm and internalize it more?)
▪ Distractibility - can you redirect the child’s frustration or is it difficult
▪ Attention span and persistence - can they focus for long vs short periods; work until
mastered or give up quickly
▪ Threshold of response - level of stimulation needed to produce a reaction (smiles when
you walk in or do you have to put on a show to illicit response)
▪ Mood quality – generally happy or unhappy child overall

❖ Environment - hugely impacts growth and development (page 762)

o Socioeconomic level – may not have access to medical care, experience barriers to care or lack
good nutrition – healthy food is expensive

o Parent–child relationship - child relationship- strived relationships will cause children to thrive
less

o Ordinal position - birth order: the oldest will learn to talk, walk etc quicker than the younger
one because there are more adult examples walking and talking.

o Health - poor health will impact growth and development and cause it to be slower: location
may impact growth issues, like city vs country (pollution but access, space but lack of care)
▪ Kid living in the city may be overstimulated but will probably have better adaptability
due to their fast pace nature of their environment. Country kid is going to have room
to play and run and do things for days – life is slower pace so they may not be as
adaptable.
 o Nutrition - (info on nutritional impact), basically nutrition or lack thereof will greatly impact
growth and development – can impact everything; childhood diabetes!!!!!
➢ Diabetes from poor nutrition, growth stunting from lack of nutrition, etc
➢ Failure to thrive, weak immune system, fatigue and learning impact (cognitive
slowing)

▪ Impacts
➢ Physical growth
➢ Health maintenance
➢ Cognitive development

Possible nursing Dx for growth and development:

1. Risk for delayed growth and development related to lack of age-appropriate toys and activities (do the
kids have outlets to play, learn and grow) – they need toys!!!
2. Readiness for enhanced family coping related to parent’s seeking information about child’s growth and
development (are the parents interested and involved) – asking the right q’s?
3. Imbalanced nutrition, less than body requirements, related to parental knowledge deficit regarding
child’s protein need (are they kids getting proper intake for growth needs)

QSEN:

• Patient-Centered Care: making sure that the CHILD is at the center despite the family needs while
including family
• Teamwork & Collaboration: all sorts of providers are having input for best care
• Evidence-Based Practice: child is receiving best, proven medical care at a high quality
• Quality Improvement: education, teaching, skills improvement to make better care delivery; restore to
optimal level
• Safety: keeping children in hospital areas safe while they heal; no injury
• Informatics: know your equipment and technology/ how to use it; knowing experts on the unit and how
to use them.

❖ Nursing Care Implications of Stages of Growth and Development #1

o Predictable – can predict when a child will recognize their privates, and they will play with it
around a certain age (Ex: little boy finds his genitals and plays with them in public – gonna
happen)
o Measurable (objective) - you can write down factors that are “growing”: height, weight,
stages, etc ; span across their physical, emotional and cognitive levels
o Physical; emotional; cognitive – the growth must be seen in all areas or the child may need
special adaptation to a care plan.
o Impact patient teaching – based on the child’s growth stage, how we decide to teach them best
is based on where they are as a kid
o Impact nursing care strategies - their age and development decide our strategy ; interventions
that we choose.
 ❖ Nursing Care Implications of Stages of Growth and Development:
o Nursing care plan based on family teaching:

The family asks, “are there principles of growth and development I should know to be better as a parent?”

Aspects of growth and development are well studied. Generally, they include:

• Growth and development are continuous process from conception to death: we all meet lifetime
milestone at some point: my children going to lose their parents, I'm going to lose my parents and I
potentially could lose my spouse and job. Those are all development appropriate milestones and it
doesn’t just end in childhood but also adults meet them as well. You get married and have children,
graduate with your education and start the career. these are things that almost everyone is going to do
roughly around the same time frame. This is where producibility and that measurability comes in
place.
• Growth and development proceed in an orderly sequence: height only progresses in one direction,
similarly development proceeds in a predictable order as children learn to sit before, they crawl and
crawl before they stand
• Children pass through the predictable stages at different rates: : two children may pass through the
motor sequence in different rates where one begins walking at nine months and another doesn’t walk
until 14 months. Although they are different, they’re both developing normally and in a predictable
sequence- it is predictable but different kids do it at different rate.
• All body systems do not development the same rate: some body tissues mature more rapidly than
others. Neurological tissue experiences peak growth during the first year whereas genital tissues do not
grow until puberty. EX- lungs is last things that mature because they don’t have to take breath until
they come out but their skin is fully intact
• Development is cephalocaudal (head to tail): newborns can only lift their head off the bed as babies,
but as they get older, they can lift their entire bodies and control them; development start
o cephalocaudal – means developmental occurs head to toe and proximal to distal (it moves
centrally to out
• Development proceeds from proximal to distal body parts: a newborn does not use their hands or
arms very much, but by 10 months infants can coordinate arms and thumb to pick up objects
o EX: kid or infant: will find mouth sooner than their hand and hand sooner than their feet
• Development proceeds from gross to refined motor skills: three-year old’s color best with large
crayons while 12-year-old can write with fine pens because their fine motor skills are refined
o It proceeds from gross mastery of skill than fine mastery of skill EX- you will learn how to use
pencil and you will actually learn how to write than learn how to write neatly.
• There’s an optimal time for initiation of experiences or learning: children cannot learn tasks until
their nervous system matures to that particular stage of learning. This means no matter how much you
may have a child practice, until the body is ready an infant will not be able to sit and control their own
head.
o EX- We don’t need to teach 3-year-old how to drive car because they are not just ready yet
• Neonatal reflexes must be lost before development can proceed: infants cannot grasp items with skill
until the grasp reflexes fade, infants cannot stand until the walking reflex has faded, etc.
o EX: Sucks reflex – tong thrust outward – born with reflex to draw milk out from something
that has pressure against it BUT that thrust reflex from suckling inhibit from taking in solid
food – They spit out food because of the thrust relax not because they don’t like it
• A great deal of skill and behavior is learned by practice: if children fall behind the growth and
development “curves” because of illness, they are very capable of catch-up as long as they practice
o They have to learn how pull food in and chew it enough to swallow it- eating solid food is
different than milk from breast – musculature need to develop and thrust reflex need to be lost
before they can eat solid food

❖ Nursing Care Implications of Stages of Growth and Development #3

 Nursing care to empower family:
- Care is different depending on the child. Reassure mom and dad that sometimes kids have different
temperaments, and that this may be normal for their child. If parents struggle to bond due to facial deformities
or illness, this may be more difficult. Empower families and parents:
• The easy child: most children fall into this category. Child is positive, adaptive, have a predictable
rhythm, are easy to care for, and overall positive mood quality
• The intermediate child: some characteristics of a easy and difficult children
• The difficult child: Child has irregular mood quality, irregular habits, and withdraws in new situations.
Comprises 10% of children
• The slow to warm up child: children who are fairly inactive responds mildly and adapt slowly and
have a negative mood, comprises a 15% of children

Nursing Care Implications of Diet and Nutrition:

Components of healthy diet (same for adults)

• Protein- building blocks of tissues, essential for children who are rapidly growing. Need complete
proteins (meats) and incomplete proteins (plants)

o May be difficult for children to be vegetarian during the growing phases, must combine proteins
in this case
• Carbohydrates- main energy source for child’s body
• Fat- secondary energy source, essential for brain growth in infants (forms myelin sheath in infants
during their growth, more myelin helps to create motor refinement) - ) – “FAT “ BABY GROW UP
SMART KID
• Vitamins- necessary for metabolic action and function, kids need fat soluble (A K E D) and water
soluble (B complex’s and C)
• Minerals- helps to build new cells and regulates body processes

Adequate nutrition in vegetarian diets

• Types- 5 main types (strict to lax)

o Protein: milk, eggs, beans, wheats, corn
o Calcium: dairy
o Iron: (RED MEAT – best sources for iron) legumes, whole grains, dried fruits, dark green
veggies

• Vitamins and minerals: b12 only present in meat, must supplement

o Total calories: may need to eat more to meet their daily caloric requirement

❖ Nutrition guidelines for a healthy diet

o Variety of foods - healthy plates are colorful, full of texture, have all the food groups and are in
good portions; get experimental
o Balance; portion size; physical activity - incorporate activity as just eating can lead to
overweight kid; controlling portion size; including daily physical activities as daily routine. And
all food groups are represented:
▪ Grain products, fruits, and vegetables
▪ CHOOSE a Diet low in fats, stay away saturated fat, and good to lower cholesterol.
o Moderate: sugars, salt/sodium, NO alcohol
 STAY AWAY FROM THE CHOLESTEROL AND SATURATED FAT

❖ Nursing Care Implications of Diet and Nutrition #4

Infancy growth (age 1 month-1year) - infant typically triples in weight & increases length by 50%
Assessment for healthy development of infant
-Important areas to discuss include nutrition, elimination, growth patterns, development
-height, weight, and head circumference should be measured & plotted on standard growth charts
Appearance of the average infant
-eyes follow across midline at 3 months
-RR slows to 20-30 by 1 yr
-Liver remains immature
-Legs may appear short & bowed
-Social smile @ 2 months
-1st tooth @ 6 months
-HR slows to 100-120 by 1 yr
-abdomen protuberant
Possible outcome identification
-Mother states she feels fatigued but able to cope with sleep disturbance from night waking
-Parents state five actions they are taking daily to encourage bonding
-Father states both he and spouse are adjusting to new role as parents
-Parents verbalize appropriate techniques they use to stimulate infant
-Infant demonstrates age-appropriate growth and development
Standard schedule for infant health care visits
-2 weeks
-2 months
-4 months
-6 months
-9 months
-12 months
Health maintenance schedule
-development, growth, vision, hearing, nutrition, parent-child relationship, & sleep positioning assessed at every
doctors visit
-dental health assessed at every visit after teeth erupt
-newborn screening done at 2 week visit
-anemia & lead screening done at 12 month visit
When immunizations for the child are given
-2, 4, 6, & 12 month visit: Haemophilus Influenzae type B, Pneumococcal, diptheria/tetanus/pertussis (Dtap)
-Polio: 2, 4, & 6 month visit
-Hepatitis B: birth, 2, & 6 or 12 months
-Rotavirus: 2, 4, & possibly 6 months
-Influenza: 6 months & then yearly
-Varicella: 1 year
-12 or 15 months: measles/mumps/rubella, Hepatitis A
Weight of the infant
-most infants double birth weight by 4-6 months & triple it by 1 year
-typically gain 2lbs each month for first 6 months, and then 1lb for next 6 months
-average 1 yr old weighs 21-22 lbs
Infant height
-height increases by 50% in first year from around 20 in to 30 in
-measure infant lying supine on a measuring board (even if they can stand)
Head circumference
-rapid brain growth in this time period
-Some infant's heads appear asymmetric until the second half of the first year, especially if they are placed on
their back to sleep (suggest tummy time during the day to help)
Body proportion
-lower jaw becomes more prominent
-chest circumference is even with head circumference by 12 months
-abdomen remains protuberant until infant starts walking for a while
-Cervical, thoracic, and lumbar vertebral curves develop as infants hold up their head, sit, and walk
Cardiovascular system
-heart continues to occupy a little over half the width of the chest
-slightly elevated blood pressure (average of 100/60 mmHg)
-Infants prone to physiologic anemia at 2-3 months bc life of a RBC is 4 months, so the cells the child had at
birth begin to disintegrate at that time & new cells are not yet being produced in adequate numbers
-Adult Hgb created at 5-6 months
-serum iron levels decrease at 6-9 months as last of iron stores established in utero are used
Respiratory System
-Because the lumens of the resp. tract remain small & mucus production by the tract to invading
microorganisms is still inefficient, upper respiratory infections occur readily and tend to be more severe than in
adults
GI tract
-Immature in its ability to digest food & mechanically move it along
-amylase (necessary to digest complex carbs) is deficient until 3rd month
-Lipase (necessary to digest saturated fat) is decreased for whole 1st year
Liver of the infant
-remains immature
-inadequate conjugation of drugs
-inefficient formation of carbs, protein, & vitamins for storage
Extrusion reflex
-present until 3-4 months
-Can independently drink from a cup at 8-10 months
Kidney of the infant
-remain immature
-not as efficient as adult kidney in eliminating waste
Endocrine system
-remains immature in response to pituitary stimulation (adrenaline)
-may not be able to respond to stress as effectively as an adult
Infant's immune system
-becomes functional by 2 months
-Can actively produce IgG & IgM by 1 year
-IgA, IgE, & IgD are not plentiful until preschool age
Adjusting to cold
-not mature until 6 months
-can now shiver & has additional adipose tissue
-brown fat decreases as subcutaneous fat increases
Fluid volume of the infant
-extracellular fluid accounts for 35% of body weight w/ intracellular as 40% (adult levels: 20% & 40%)
-this increases an infant's susceptibility to dehydration from illnesses (like diarrhea) because loss of
extracellular fluid could result in loss of over 1/3 of an infant's body fluid
Teeth
-1st tooth (typically central incisor) usually erupts at 6 months & then one each month from then on
-Neonatal teeth: teeth that form in the 1st 4 months
-Deciduous teeth (baby teeth) are essential for allowing proper growth of dental arch (if injured, need immediate
attention)
Motor development of the infant
-development occurs in cephalocaudal (head to toe) & gross-to-fine
-Control proceeds from head to trunk to lower extremities
-gross motor development: ability to accomplish large body movements
-Fine motor movements: measured by observing prehensile ability (ability to coordinate hand movements)
Assessing gross motor development involves 4 positions
1. ventral suspension position
2. Prone position
3. Sitting position
4. Standing position
Ventral suspension position
-an infant's appearance when held in midair on a horizontal plane and supported by a hand under the abdomen
-Newborn: allows head to hang down
-1 month old: lift head momentarily
-2 month old: hold head in same plane as rest of body
-3 months & on: lift & maintain head well above
-6-9 months: parachute reaction present, when infants are suddenly lowered toward an examining table, the
arms extend as if to protect themselves from falling
Prone position
-newborns can turn their head to move it out of a position where breathing is impaired, but they cannot hold
their head raised for an extended time
-1 month: lift head & turn easily to the side
-2 month old: raise head & maintain position but can not raise chest high enough to look around
-3 month old: lifts head & shoulders well off table & looks around
-4 month old: lifts chest off bed & look around actively while turning head side to side, can turn from front to
back (neck-righting reflex occurs, causes babies to lose balance & roll sideways when lifting head)
-5 month old: can put weight on forearms when prone
-9 month old: can creep (has abdomen off floor & moves one leg w one arm & then the other leg w the other
arm)
Infant rolling
-most babies turn front to back 1st when rolling over, and then turn back to front 1 month later
Sitting position
-newborn: when placed on back and then pulled to a sitting position, has extreme head lag (present until about
1 month), In sitting position back appears rounded & infant demonstrates only momentary head control
-2 months: can hold head fairly steady when sitting up, but head tends to bob & still shows a head lag
-4 month old: no longer has a head lag
-5 month old: straightens back when sitting
-6 months: can sit momentarily w/o support
-7 month old: can sit alone only when hands are held forward for balance
-8 month old: sits alone w/o support
-9 months: can lean forward & regain balance
Standing position
-newborn: stepping reflex present until 1 month
-3 months: try to support part of weight on feet
-4 months: able to support weight on legs because stepping reflex has faded
-5 months: tonic neck reflex gone & moro reflex fading
-6 months: can almost support full weight
-7 month old: bounces in place
-9 month old: can stand when holding on to something
-10 months: can pull themselves into standing position, but can not let themselves down
-11 months: can move around when holding on
-12 months: can stand alone for a moment
When should the infant start walking?
-child has until 22 months to walk & will still be within normal limits
Fine motor development
-1 month old baby holds fists very tightly
-2 months: begin to grasp objects for a few min b4 dropping it
-3 months: reach for objects
-4 months: bring hands together & pull at clothes, thumb opposition (bringing thumb & fingers together) begins
-5 months: accept objects handed to them w hands (fisting beyond 5 months suggests delayed motor
development)
-6 months: can hold objects in both hands, can hold a spoon to feed themselves
-7 months: can transfer toys from 1 hand to another
-10 months: pincer grasp (ability to bring thumb & 1st finger together) develops, allows them to pick up small
objects, point w 1 finger
-12 months: can hold a crayon to draw a line, can hold a cup, can take off socks & put hands into sleeves
Language development
-make small, cooing sounds by end of 1st month
-parents can differentiate their cry by 2 months (hungry vs tired cry)
-3 months: will squeal or laugh out loud
-4 months: very talkative, cooing, babbling, gurgling when spoken to
-5 months: say simple vowel sounds ("goo goo gah gah")
-6 months: learn to imitate (can imitate parents cough)
-9 months: usually speaks first words ("da-da", "ba-ba")
-10 months: master words such as "bye-bye" or "no"
-12 months: generally say 2 words
Play
-1 month: enjoy a mobile over their crib or playpen, enjoy watching parent's faces (tell parents holding infant for
long periods of time is not bad)
-Hearing: enjoy sound of a rattle or music box
-4 month olds roll over
-5 month olds can handle blocks, squeeze toys, etc
-can introduce bath toys when infant can sit up at 6 months
-7 month old need toys that are easy to transfer b/w each hand
-8 month old: sensitive to textures (enjoy toys w different feelings)
-9 months: needs experience of creeping (time out of crib or playpen), enjoy toys that go inside each other
-10 months: enjoy peek-a-boo, patty cake
-11 months: spend most of the time walking
-12 months: enjoy nursery rhymes, music, taking things out of containers, pull toys
-should not be watching TV

Vision
-1 month: able to regard object in midline of vision as close as 18in.
-2 months: focus well & can follow moving objects, indicates binocular vision (ability to fuse 2 images into 1)
-3 months: follow objects across midline, develop hand regard (study hands in front of their face)
-4 months: recognize familiar objects, follow parents w eyes
-6 months: develop depth perception which helps when they reach for objects
-7 months: depth perception increases, pat their own image in a mirror
-10 months: begins object permanence
-can be overstimulated (too many mobiles or colors) or under-stimulated (bland hospital walls)
Hearing
-2 months: will stop an activity at the sound of spoken words
-many 3 month olds turn their heads to locate a sound
-4 months: when infants hear a distinct sound, they turn & look in that direction
-5 months: demonstrate they can localize sounds downward and to the side by turning their head and looking
down
-6 months: can locate sounds made above them
-10 months: recognize their name & listen acutely when spoken to
-12 months: can easily locate sounds in any direction
-all throughout 1st year, enjoy soft music/cooing, startled by harsh sounds, parents reading to them
Touch
-need to be touched to experience skin-to-skin contact
-Teach parents to handle infants with assurance yet gentleness
Taste
-turn away from or spit out a taste they don't like
-when they try solid foods at 6 months, urge parents to make mealtime a time for fostering trust as well as
supplying nutrition by being certain feedings are done at an infant's pace and the amount offered fits the child's
needs
Smell
-can smell in 1-2 hrs after birth
-respond to an irritating smell by turning their head away from it
-identify smell of breastmilk
-teach parents to be alert to substances that cause sneezing when sprayed in air
Emotional development
-1 month: show they can differentiate b/w faces & other objects by studying these things longer than other
objects
-Social smile: reflects growing maturity, infant smiles at a person as early as 6 weeks
-3 months: demonstrate increased social awareness by readily smiling at the sight of a parent's face, laugh at
sight of a funny face
-4 months: when a person who has been playing w/ baby leaves, likely to cry or show that interaction was
enjoyable, prefer primary caregiver over anyone else
-5 months: may show displeasure when an object is taken away from them
-6 months: aware of difference b/w people who regularly care for them & strangers
-7 months: show obvious fear of strangers, may cry when taken from parent
-8 months: fear of strangers reaches its height (often termed 8th month anxiety)
-9 months: aware of changes in tone of voice
-12 months: most have overcome fear of strangers, enjoy joining in family activities
Cognitive development: primary & secondary circular reaction
-3rd month: child enters primary circular reaction (explores objects by grasping them or mouthing them, do not
realize that their actions cause things to happen like a toy rattling)
-6 months: enters secondary circular reaction (realize that their actions cause things to happen, like hitting the
mobile causes it to move)
-10 months: discover object permanence
-1 year: capable of reproducing events (realize hitting a mobile moves it & then hit again, drop objects off high-
chair repeatedly)
How can parents establish trust in the infant?
-arises primarily from a sense of confidence that one can predict what is coming next
-parents should study their infant's reaction to activities and then establish a workable schedule based on that
(e.g., breakfast, bath, playtime, nap, lunch, walk outside, quiet playtime, dinner, story, and bedtime)
-important that care is mainly given by 1 person
Ways for nurses to help an ill infant develop a sense of trust
-encourage mothers to breastfeed
-if parent is not present, hold infant for feeding
-try to avoid tape if possible (painful to remove)
-only restrain body parts when necessary (parents should not restrain, but should comfort child after)
-prevent being cold
-describe what you're doing in friendly voice to child
-flavor oral medicine
-never add medicine to formula
-comfort after injections
-encourage parents to rock infant to sleep or do it yourself if parents not present
-awake infant gently
-hold & comfort when in pain
-provide a mobile or mirror in crib
Promoting infant safety
-Unintentional injuries are a leading cause of death in children from 1 month through 24 months
-most injuries occur because parents under or over-estimate child's ability
Aspiration prevention
-chief injury threat in 1st year
-round objects more dangerous than square ones
-carrots & hotdogs dangerous
-do not prop bottles (overestimates infants ability to push the bottle away, sit up, turn the head to the side,
cough, and clear the airway)
-Newborn's grasp and sucking reflexes automatically cause them to grasp and pull the object into their mouth
-to test if a toy can be dangerous for baby: if it fits inside a toilet paper roll, then it can be aspirated
-kids <5 y/o should not eat popcorn or peanuts
-assess toys for loose pieces
Fall prevention
-2nd major cause of infant injuries
-no infant should be left unattended on a raised surface
-can turn over by 2 months, so from then on be especially cautious
-crib rails shouldn't be >2 & 3/8in apart
-should not sleep in a bassinet past 2 months
Car safety
-backwards facing car seat until 2 y/o or until child reaches the highest weight or height allowed by the car
safety seat's manufacturer
Safety with siblings
-infants become more fun to play with at about 3 months
-children <5 y/o are not knowledgeable enough to be left unattended w infant
-Some preschoolers may be so jealous of a new baby they will physically harm an infant if left alone
Bathing & swimming safety
-As babies begin to develop good back support, many parents begin to bathe them in adult tub
-never leave them alone in tub
-swim lessons offered as young as 6 months
-swim lessons do not allow infant to be trusted more in water than other infants of the same age
-swim programs can cause hypothermia & spread of microorganisms (infants are not toilet trained)
-Exposure to chlorinated water might damage lung epithelium, which then has the possibility to become a
precursor to childhood asthma
Childproofing
-at 5-6 months when infant begins teething, will chew on any object in reach
-look for lead paint: painted cribs, playpen rails, or windowsills
-Paints safe for baby furniture should be marked "Safe for use on surfaces that might be chewed by children."
-move furniture in front of electrical fixtures
-safety gates before baby crawls
-potentially poisonous substances should be moved to high up cupboards
-as soon as they walk, are able to get to a road or swimming pool if not supervised
Dietary allowance for infants
-1st year includes rapid growth: high-protein & high calorie intake needed
-calories needed dec in 1st year from 120 cal/kg to 100 cal/kg at end of year
Introduction of solid foods
-delayed until 6 months
-this delays overwhelming kidneys w heavy solute load & may delay development of food allergies
-parents can tell infants are ready when they are nursing vigorously every 3-4hrs and do not seem satisfied or
are taking >32 oz (960 ml) of formula a day and do not seem satisfied
-chewing doesn't begin until 7-9 months so should not give foods that require chewing until then
-extrusion reflex must be gone b4 (3-4 months)
Introduction of specific solid foods
-Iron-fortified infant cereal mixed with breast milk, orange juice, or formula: aids in preventing iron-
deficiency anemia, least allergenic type of food, & is the most easily digested so it is usually the first food
offered
-Veggies are a good source of vit A & add new texture and flavors to diet
-Fruit; best sources of vit C and a good source of vit A
-Meat: good source of protein, iron, and B vitamins
-By 6 months, egg yolk, a good source of iron, can be added
Techniques for feeding solid food
-omit wheat, tomatoes, oranges, fish, and egg whites if there are allergies in the family
-offer new foods 1 at a time for 3-7 days (allows them to detect a food allergy)
-at 1 year, stomach can hold no more than 1 cup (so may not take more than 2 tablespoons in beginning)
-if they do not accept solid foods readily, try again in a few days
-avoid preparing spinach, carrots, beets, green beans, and squash because these can contain excessive amounts
of nitrates that are not processed well by infants (baby food filters out nitrates)
Cereal
-infant cereal fortified w vitamin B & iron (remind parents to buy this kind)
-mixed w breast milk, formula, or juice
-once child has taken rice cereal for 1 week, can try another kind (like wheat)
-Do not give in a bottle
-should eat this cereal until 3-4 y/o bc rich in nutrients
Fruits & veggies
-cook veggies & blend it so it doesn't need to be chewed
-if using commercial baby foods, should begin with level 1 types (single ingredient and pureed) and feed from a
dish rather than directly from the jar bc saliva can mix in jar
-shouldn't use jar of baby food 48 hrs after it was opened
Meat & eggs
-grind meat so it is tender, or use commercial baby food
-only egg yolk used because protein in egg white can lead to allergy or be difficult for baby to digest
-egg can be hard boiled or bought as commercial baby food
Table food
-encourage parents to establish a 3-meal-a-day pattern if that is what they do
-encourage parents to use homemade foods rather than commercially prepared junior or toddler foods as much
as possible so they'll have less difficulty switching to parent's cooking when older
-high chairs are dangerous: fasten the restraint & never leave them unattended
Establishing healthy eating patterns
-there are not hard set rules, do whatever works for your infant
-if infant refuse to eat, ask parents for a 24-hr recall- baby may be eating too much & parents have high
expectations
-if infants are fatigued or overstimulated, they may not eat well
-do not force infant to eat
Weaning from breastfeeding/bottlefeeding
-drink from a cup at 9 months
-sucking reflex diminishes at 6-9 months (consider weaning from a bottle)
-parents should choose 1 feeding a day & begin offering fluid by the new method
-after 3 days-1 week when infant is acclimated to this small change, then change a second feeding & so on
Self-feeding
-can start at 6 months (w fingers), will be messy
-if infant becomes fatigued or frustrated w self feeding, parent can help w/o making a big deal of it
-when baby plays w food (squishes in fingers or puts it in hair), it is time to end the meal
Vegetarian diet
-foods to try: peas, potatoes, carrots, apples, prunes (which are high in iron), bananas, infant cereal (fortified),
tofu, wheat germ, legumes, brewer's yeast, and vitamin D
-vegetarian diets are high in fiber, so may have more frequent & looser stool
Bathing
-do not need a bath every day
-if parent is too tired that day, can just wash face/hands/diaper area
-some may need scalp washed every day to prevent seborrhea (scaly scalp often called cradle cap)
-treat seborrhea w oiling the scalp w mineral oil or petroleum jelly overnight
-child enjoys poking at soap bubbles or playing with bath toys
-bath toys help infant learn different textures
Diaper area care
-change diapers every 2-4 hours
-do not interrupt sleep to change diapers
-if a rash develops: air dry or try sleeping w/o diaper
-Routinely using an ointment (zinc oxide or petroleum ointment) to keep urine & feces away from skin is good
prophylaxis
-shouldn't use baby powder- risk for aspiration

Dental care
-fluoride use (in water, supplement, or fluoride drops) at 6 months
-toothbrushing can begin before teeth erupt: rubbing a soft washcloth over the gum pads eliminates plaque and
reduces the presence of bacteria
-once 1st tooth erupts, should be brushed w soft brush or washcloth once or twice a day (toothpaste not
necessary)
Dressing
-when they begin to creep, need long pants to protect knees
-only need soft soled shoes or socks until they begin walking
-when they start walking, only need soles that protect against floor surface
Sleep
-most need 10-12hrs/night & 1 or several naps during the day
Exercise
-benefit from outings in carriage or stroller because sunlight provides vit D
-only expose child to small amounts of sun (3-5 min on 1st day & work up until 15-20min at a time)
-sunscreen use not recommended until 6 months old
-going for leisurely walks while pointing out the sights of the world (trees, birds, dogs, houses, neighbors) helps
children develop language
Teething
-gums are sore & tender before teeth erupt
-as soon as tooth is through, tenderness ends
-can be cranky from not eating as much as normal
-rub gum line w finger or soft cloth can help tooth erupt
-place teething rings in fridge or freezer
-any OTC meds for teething are discouraged (can numb throat)
-may use tylenol if prover approves it
Thumb sucking
-peaks at about 18 months
-normal, does not deform jaw, does not cause "baby talk" or any speech concerns
-should not continue into school age
-making an issue of it makes it worse, try to ignore it
Use of pacifiers
-benefits: comforting, may aid in pain relief, decreases risk of SIDS
-risks: inc incidence of otitis media (ear infection), possible negative effect on breastfeeding, dental
malocclusion
-colic babies crave sucking because have stomach pain & interpret this as hunger
-child whose sucking needs are met in infancy will not crave as much oral stimulation later in life (less likely to
become a pencil chewer, cigarette smoker, nail biter, etc)
-can come apart & be aspirated & fall on ground often
-should wean b/w 3-9 months
Evaluating pain in the infant
-sharp pain manifested as fussiness or crying
-arm & leg pain manifested by limpness
-ear pain manifested as brushing or tugging ear
-stomach pain manifested by pulling legs against abdomen
Head banging
-some infants bang head against bars of crib for period of time before they fall asleep
-can be a normal behavior
-used to relax and fall asleep
-investigate stressors in house (eliminating stress may help)
-parents should pad rails so infants don't injure themselves
-not normal if continues past preschool period or is associated w other symptoms
Sleep concerns
-breastfed babies tend to awake more often than formula fed (breast milk is more easily digested & so become
hungry earlier)
-to cope with night waking, delay bed time by 1 hr, shorten afternoon naps, don't respond to infant immediately
to give them time to fall back asleep
Constipation
-inc fluid intake
-Some parents misinterpret the normal pushing with BM as constipation
-as long as stools are not hard & do not contain blood, grunting & face turning red is normal
-Infants w true constipation should be examined for anal fissure or tight anal sphincter
-may have Hirschsprung disease (lack of innervation to portion of colon) or hypothyroidism
Loose stools
-many new parents are unaware of normal stool & falsely report loose stool
-if mother takes laxative while breastfeeding, may affect child's stool
-loose stool may occur w introduction of fruits & veggies
-formula fed infant may have loose stools if formula is not diluted properly
-may have celiac disease
-ask parents if there is mucus or blood in stools, fever, vomiting
Colic
-abdominal pain that generally occurs in <3 months & is marked by loud, intense crying
-infants pull their legs up against their abdomen, faces become red & flushed, fists clench, & abdomen becomes
tense
-formula fed babies may vigorously suck bottle then stop suddenly when stomach pain occurs
-unknown cause (formula fed babies have more symptoms)
-abdominal pain tends to last 3 hrs a day & occur 3 days a week
Helping colic
-formula fed: ask about type of formula used, if parents hold baby upright while feeding & burp often
-breast feeding: ask if mom avoids gassy foods such as cabbage
-small, frequent feedings
-reduce stimuli, take car rides, or play music that stimulates sound of a heartbeat
-as infant cries, parents become tense, baby senses this tension & colic becomes worse
Spitting up
-formula fed babies appear to do it more
-should not contain blood or bile
-spitting up a mouthful of milk 2-3x a day is normal
-it is not normal for milk to be projected 3-4 ft away
-burping limits spit up
-may try sitting baby up for 30 min after feeding
Diaper dermatitis
-aka diaper rash
-feces left in contact w skin can be a cause
-Urine that is left in diapers too long breaks down into ammonia, a chemical that is irritating
-Frequent diaper changing, applying an ointment, and exposing diaper area to air may help
-may have an allergy to diaper material or laundry products if cloth diapers are used
Miliaria
-prickly heat rash
-occurs most often in warm weather or when babies are overdressed or sleep in overheated rooms
-clusters of reddened papules w occasional vesicles & pustules surrounded by erythema usually appear on neck
1st & spread
-bathing 2x a day during hot weather (possibly w baking soda in water) may improve rash

Baby-bottle tooth decay syndrome

-putting infant to bed w a bottle can cause this
-Decay occurs because, while an infant sleeps, liquid from the propped bottle continuously soaks the upper
front teeth & lower back teeth
-sugars in solution demineralize tooth enamel until it decays
-if parents insist bottle is necessary to put infant to bed, suggest they use water & use bottle w small hole in
nipple
Obesity in infants
-weight greater than the 90-95th percentile
-caused by excess calorie intake
-difficult to reverse
-most often occurs w formula fed infants when parents make them finish bottle or cereal
-occurs if parents feed child every time they cry rather than investigating reason
-infant should take no more than 32 oz of formula daily and shouldn't be breastfeeding more often than every 2
hours
Concerns of the family with an infant with unique needs
-baby born w disability may need to be hospitalized: inhibits bonding, parents should visit often
-may not reach developmental milestones (cant use arms for tasks, etc)
-point out positive things about child to parents
-child may have difficulty developing trust
-parents may be so focused on child's disabilities that they don't recognize other issues such as colic (investigate
this)
Nutrition for the infant with unique needs
-ill infants may tire too easily to suck long enough
-neurologic disability: may not have sucking & swallowing reflex
-may need NG tube or gastrostomy feedings or TPN
-provide infant a pacifier if necessary to still fulfill sucking needs
-parents still need to hold infants
Autonomy - independence

Lordosis - abnormal anterior curvature of the lumbar spine (sway-back condition)

Parallel play - activity in which children play side by side without interacting
Deferred imitation - the ability to remember and copy the behavior of models who are not present
Preoperational thought - Piaget's second stage of cognitive development, occuring from ages 2 through 7, as the
child learns language, symbolic play, and symbolic drawing, but does not grasp abstract concepts.
Assimilation - taking in information and changing it to fit their existing ideas
Discipline - the set of strategies and behaviors parents use to teach children how to behave appropriately
Punishment - is a consequence that result from breakdown in discipline
5 to 6 lb (2.5kg) - weight gain during the toddler period
5 in. (12cm) - height gained during the toddler period
2cm - the head circumference only increases during the second year compared to about 12 cm during the
first year
6 month to 1 year - head circumference equals to chest circumference

110 to 90 beats/min - toddler's HR

99/64 mmHg - toddler's BP

more acrid - stomach secretions becomes that prevents GI infections

8 new teeth (canines and first molars) - erupts during the second year
15 months (fine motor) - drinks from a cup well; rotates spoon; scribbles
15 months (gross motor) - walks well alone, creeps up steps
15 months (language) - 4-6 words
15 months (play) - can stack two blocks, enjoys being read to, drops tous for adult to recover
18 months (fine motor) - no longer rotates spoon to bring it to mouth
18 months (gross motor) - Walks up/down stairs with help; Throws a ball overhand; Jumps in place
18 months language - 7-20 words, uses jargons, naming one body part
18 month (play) - imitates household chores, begins parallel play
24 month (fine motor) - Can open doors and doorknobs, unscrew lids
24 month (gross motor) - walks up stairs alone still using both feet at a time
24 month (language) - 50 words; two-word sentences such as "Daddy go"
24 month play - parallel play is evident
30 month (fine motor) - makes simple lines or strokes for with a pencil
30 month (gross motor) - can jump down from stairs

30 month (language) - verbal language increasing steadily; knows full name

30 month (play) - spend time playing house, imitating parent's actions; play is "roughhousing" or active
Autonomy vs. Shame and Doubt
Erikson's stage in which a toddler learns to exercise will and to do things independently; failure to do so
causes shame and doubt

Developmental milestone 18
Fine motor
- No longer rotates a spoon to bring it to mouth

Gross motor
- Can run and jump in place
- Can walk up and down stairs holding on to a person's hand or railing
- Typically places both feet on one step before advancing
Animism - the belief that inanimate objects (such as toys and teddy bears) have human feelings and intentions.
Assimilation - uses toys in the wrong way
toy hammer = instead of pounding with it, she may shake it to see if it rattles
Centration - the tendency to focus on only one aspect of a situation at one time
Deferred imitation - Toddlers are able to remember an action and imitate it later
Egocentrism - child's inability to see a situation from another person's point of view.
Lordosis - forward curve of the spine at the sacral area seen in toddlers
Parallel play - When children play beside other children, not with them or side by-side play
Separation Anxiety - child becomes fearful and nervous when away from home or separated from a loved one,
usually a parent or other caregiver, to whom the child is attached.
Sibling Rivalry - feeling of jealousy of a toddler every time a new baby enters into his domain.
Symbolic Representation - ability to make one thing - a word or an object - stand for something other than itself
Weight and Height
- gains only about 5 to 6 lb (2.5 kg) and 5 in. (12 cm) a year
- baby fat, begins to disappear toward the end of the second year
- changes from a plump baby into a leaner, more muscular
- appetite decreases accordingly, yet adequate intake of all nutrients is still essential to meet energy needs.
Head Circumference
- increases only about 2 cm during the second year compared to about 12 cm during the first year.
- equals chest circumference at 6 months to 1 year of age.
- By 2 years, chest circumference should have grown greater than that of the head.
Body Proportion
- prominent abdomen
- lordosis
 Preschool period
-years 3,4,5
-most children of this age want to do things for themselves
-typically have 6-12 respiratory infections per year
Growth during the preschool period
-is more cognitive and emotional(personality) than physcial
Assessment
-health history and performing both a physical and developmental evaluation
-child's weight, height, and body mass index (BMI) according to standard growth charts
-general appearance
Appearance of the average preschooler
-vocab inc markedly
-tonsils appear enlarged
-no new teeth develop
-growth is only 2 to 3.5in per year
-HR dec to about 85bpm
-body contour changes to be more child like than baby like
-genu valgus(knock-knees) may be evident
-inc coordination--> bicycle riding, running, kicking
Changes in body contour in the preschooler
-wide-legged gait, prominent lordosis, and protuberant abdomen of the toddler-->slimmer, taller, and much
more childlike proportions
-ectomorphic body build(slim)or endomorphic(large) body build become apparent
Lymphatic tissue
-inc in size, particularly the tonsils; levels of immune globulin (Ig)G and IgA antibodies inc--> these changes
tend to make illnesses more localized

Physiologic splitting of heart sounds

-may be present for the first time on auscultation
Innocent heart murmurs
-may be heard for the first time
-occurs bc the changing size of the heart in reference to the thorax--> anteroposterior and transverse diameters of
the chest have not yet reached adult proportions
Blood pressure
-100/60 mmHg
Bladder
-easily palpable above the symphysis pubis
-voiding is frequent enough (9 or 10 times a day) that play must be interrupted
-voiding accidents may occur if a child becomes absorbed in an activity
A child who earlier in life had an indeterminate longitudinal arch in the foot generally demonstrates: a
well-formed arch now

Genu valgum
-knock knees
-disappears with increased skeletal growth at the end of the preschool period
Weight gain
-average child gains only about 4.5 lb (2 kg) a year
-appetite remains the same as it was during the toddler years
Height gain
-only 2 to 3.5 in. (6 to 8 cm) a year on average
Teeth
-generally have all 20 of their deciduous teeth by 3 years of age
-permanent teeth don't replace these until school age
-Preserving these teeth is important--> they hold the position for the permanent teeth as the child's jaw grows
larger
-deciduous tooth removed--> need conscientious follow-up to be certain a space for a permanent tooth remains
Language development
-extent of a 3-year-old child's vocabulary--> varies depending on how much the child has been encouraged to
ask questions or participate in conversations
-vocabulary of about 900 words --> uses it to ask questions constantly(up to 400 a day)
Egocentrism
-perceiving that one's thoughts and needs are better or more important than those of others
-strong during the preschool period
-preschoolers define objects mainly in relation to themselves(spoon is "what I eat with," not a curved metal
object)
Four- and 5-year-old children
-enjoy participating in mealtime conversation and can describe an incident from their day in great detail
Preschoolers
-do not need many toys bc with an imagination keener than it will be at any other time in life, they enjoy
games that use imitation such as pretending they are a teacher, cowboy or cowgirl, firefighter, or store clerk
-many have imaginary friends
Play in Four- and 5-year-olds
-divide their time between roughhousing and imitative play
Play in Five-year-olds
-become interested in group games or reciting songs they have learned in kindergarten or preschool
Age 3
-fine motor skills: Undresses self; stacks tower of blocks; draws a cross
-gross motor skills: Runs; alternates feet on stairs; rides tricycle; stands on one foot
-language: Vocabulary of 900 words
-play: Able to take turns; very imaginative

Age 4
-fine motor skills: can do simple buttons
-gross motor skills: Constantly in motion; jumps; skips
-language: Vocabulary of 1,500 words
-play: Pretending is major activity
Age 5
-fine motor skills: Can draw a six-part figure; can lace shoes
-gross motor skills: Throws overhand
-language: Vocabulary of 2,100 words
-play: Likes games with numbers or letters
Developmental task for the preschool-age child
-achieve a sense of initiative versus guilt(Erikson)
Children with a well-developed sense of initiative
-like to explore because they have discovered that learning new things is fun
If children are criticized or punished for attempts at initiative, they can develop a sense of:
guilt for wanting to try new activities or to have new experiences
Those who leave the preschool period with a sense of guilt
-can carry it with them into school situations
-may even have difficulty later in life making decisions about everything from changing jobs to choosing an
apartment

Gaining a sense of initiative

-preschoolers need exposure to a wide variety of experiences and play materials so they can learn as much
about how things work as possible
-Urge parents to provide play materials that encourage creative play(finger paints, soapy water to splash or
blow into bubbles, sand to build castles, and modeling clay or homemade dough to mold into figures or make
into pretend cookies)
Imitation
-peaks during preschool age
-generally imitate those activities best that they see their parents performing at home
Fantasy
-Toddlers cannot differentiate between fantasy and reality--> they believe cartoon characters they see on
television are real
-preschoolers--> begin to make this differentiation
Freud
-development of Oedipus and Electra complexes
Oedipus complex
-strong emotional attachment a preschool boy demonstrates toward his mother
-other parent may become jealous, needs to be reassured that this is a normal part of maturing
Electra complex
-the attachment of a preschool girl to her father
-might prefer to always sit beside her father at the table, or she may ask for her father to tuck her in at night
-other parent may become jealous, needs to be reassured that this is a normal part of maturing
Gender roles
-preschoolers begin to be aware of the difference between sexes and so need to be introduced to both gender
roles
-Encourage single parents to plan opportunities for their children to spend some time with adults other than
themselves(grandparent, a friend, or a relative of the opposite sex)
Socialization in 3 year olds
-capable of sharing, play with other children their age much more agreeably than do toddlers--> makes the
preschool period a sensitive and critical time for socialization
Socialization in 4 year olds
-continue to enjoy play groups, may become involved in arguments more than they did at 3 years of age,
especially as they become more certain of their role in the group
Socialization in 5 year olds
-begin to develop "best" friendships, perhaps on the basis of who they walk to school with or who lives closest
to them
-rule that generally pertains to 5 year olds--> two or four will play, but three or five will quarrel
According to Piaget
-cognitive development--> still preoperational by 3 years of age but also enter second phase called intuitional
thought
During this second phase of development(intuitional thought)
-children learn by asking questions such as "How come?" and "Why?"
-piaget believed children tend to be so certain of their knowledge and understanding that they are unaware of
how they gained this knowledge initially
-may shift from using only magical beliefs to using rational beliefs to explain situations or events that they had
not experienced previously
Intuitive children
-show a style of thinking he called "centration"
-focused on the characteristic of an object or person, and they base their decisions or judgment on that one
characteristic
-ex: 4-year-old who was asked to put toys into groups might focus his or her attention on the color of the toy
instead of the shape or the material from which they are constructed
-preschoolers cannot make mental substitutions and often feel they are always right
Conservation
-preschoolers are not aware of this property
-if they have two balls of clay of equal size, but one is squashed flatter and wider than the other, they will insist
the flatter one is bigger (because it is wider) or the intact one is bigger (because it is taller)--> cannot see that
only the form, not the amount, has changed
Inability to appreciate conservation has implications for nursing care
-preschoolers are not able to comprehend that a procedure performed two separate ways is the same procedure
Children of preschool age determine right from wrong based on their:
parents' rules because they have little understanding of the rationale for these rules or even whether the rules are
consistent
Preschoolers begin to have an elemental concept of spirituality: if they have
been provided some form of religious training preschoolers tend to do good
out of:
self-interest rather than because of strong spiritual motivation(Kohlberg)
Keeping children safe, strong, and free
-Cautioning a child never to talk with or accept a ride from a stranger
-Teaching a child how to call for help in an emergency (yelling or running to a designated neighbor's house if
outside, or dialing 911 if near a phone)
-Describing what police officers look like and explaining that police can help in an emergency situation
-Explaining that if children or adults ask them to keep secrets about anything that has made them
uncomfortable, they should tell their parents or another trusted adult, even if they have promised to keep the
secret
-Explaining that bullying behavior from other children is not to be tolerated and should be reported so they can
receive help managing it
Preschoolers outgrow carseats
-when they reach about 40lbs, will graduate to a booster-type seat--> remind parents to check the position of
the shoulder harness in both types of seat so the belt doesn't cross a child's face or throat
Motor vehicles
-Teach safety with tricycles (e.g., look before crossing driveways, do not cross streets)
-Teach the child to always hold hands with an adult before crossing a street
-Teach parking lot safety (e.g., hold hands with an adult, do not run behind cars that could be backing up)
-Teach children to consistently wear helmets when beginning bicycle riding.
Falls
-Always supervise a preschooler at a playground
-Remove drawstrings from hooded clothing
-Help the child to judge safe distances for jumping or safe heights for climbing
Drowning
-teach beginning swimming
Animal bites
-Do not allow the child to approach strange dogs
-Supervise the child's play with family pets
Poisoning
-Never present medication as a candy
-Never take medication in front of a child
-Never store food or substances in containers other than their own
-Post the telephone number of the poison control center by the telephone or as a cell phone contact number (1-
800-222-1222)
-Teach the child that medications are a serious substance and not for play
Burns
-Store matches in closed containers
-Do not allow the preschooler to help light birthday candles or fireplaces; fire is not fun or a treat.
Community Safety
-Teach the preschooler that not all people are friends (e.g., "Do not talk to strangers or take candy from
strangers")
-Define a stranger as someone the child does not know, not someone odd looking
-Teach the child to say "no" to people whose touching he or she does not enjoy, including family members.
(When a child is sexually maltreated, the offender is usually a family member or close family friend.)
General Safety
-Know the whereabouts of the preschooler at all times
-Be aware the frequency of unintentional injuries increases when parents are under stress. Special precautions
must be taken at these times
-Some children are more active, curious, and impulsive and therefore more vulnerable to unintentional injuries
than others.
Preschoolers may not eat a great deal of meat
-it can be hard to chew
As long as a child is eating foods from all five food groups and meets the criteria for a healthy child such
as being alert and active with height and weight within normal averages:
additional vitamins are probably unnecessary
Caution parents not to give more vitamins than the recommended daily amount
-poisoning from high doses of fat-soluble vitamins or iron can result
Common deficits in a vegetarian diet
-calcium, vitamin B12, and vitamin D
Dressing
-Many 3-year-olds and most 4-year-olds can dress themselves except for difficult buttons
-conflict may occur over what the child will wear
-prefer bright colors or prints--> select items that are appealing rather than matching
-solving the problem of mismatching--> fold together matching shirts and slacks so a child sees them as a set
rather than individual pieces
Sleep
-more aware of their needs than toddlers; when they are tired, they often curl up on a couch or soft chair and fall
asleep
-many give up afternoon naps
-may refuse to go to sleep because of fear of the dark and may wake at night terrified by a bad dream
-may need a nightlight
Exercise
-preschool period is an active phase
-play tends to be vigorous
-Roughhousing helps relieve tension and should be allowed as long as it does not become destructive
-love time-honored games such as ring-around-the-rosy, London Bridge, or other more structured games they
were not ready for as toddlers
-can help develop motor skills
Hygiene
-can wash and dry hands adequately if the faucet is regulated for them(not too hot)
-should not be left unsupervised in the bathtub
-girls--> may develop vulvar irritation and bladder infections from exposure to bubble bath products-->
should not add products to the water
-cranberry juice may help prevent tub infections(not well studied)
-do not clean their ears of fingernails well--> need touching up my parents or siblings
Care of teeth
-Although many preschoolers do well brushing their own teeth, parents must check that all tooth surfaces
have been cleaned
-parents should floss--> beyond motor ability
-should continue to drink fluoridated water or receive a prescribed oral fluoride supplement
-eat apples, carrots, chicken, or cheese for snacks rather than candy or sweets--> prevent tooth decay
-allowed to chew gum--> should be sugar free
-dental visit should be arranged no later than 2yo
-dental services can begin at 3yo
Bruxism
-teeth grinding
-may begin at this age as a way of "letting go," similar to body rocking, which children do for a short time each
night before falling asleep
-excessive--> may have above average anxiety
-cerebral palsy--> may do this bc of spasticity of jaw muscles
-crowns of teeth can become abraded
-can advance to such an extent that tooth nerves become exposed and painful
Time out
-a useful technique for parents to correct behavior throughout the preschool years
-allows parents to discipline without using physical punishment and allows a child to learn a new way of
behavior without extreme stress
-should be as many minutes long as the child is old--> 3-5 min is appropriate for a preschooler
Death of a preschooler
-major cause is automobile accidents followed by poisonings and falls
Even though the number of major illnesses is few in this age group, the number of minor illnesses, such
as: common colds and ear infections, are high

Children who live in homes in which parents smoke

-higher incidence of ear (otitis media) and respiratory infections
Children who attend child care or preschool programs
-inc incidence of gastrointestinal disturbances (vomiting and diarrhea) and upper respiratory infections
Children may demonstrate frequent whining or clinging behavior
-because of parade of constant minor infections
Fear of the dark
-example of a fear heightened by a child's vivid imagination
-children awaken screaming bc of nightmares--> may be reluctant to go to bed or go back to sleep by
themselves unless a light is left turned on or a parent sits nearby
-parents need to monitor what their children are exposed to--> television, adult discussions, and frightening
stories
-need reassurance that they are safe and that whatever was chasing them was a dream and is not in their room

Evaluating seriousness of illness or condition

-Preschoolers are eager to please and tend to answer all questions such as "Does your stomach hurt?" with a yes
-Observing the child for signs of illness (e.g., refusing to eat, holding an arm stifly, having to go to the
bathroom frequently) is often more productive as an evaluation technique.

Evaluating bowel and bladder problems

-Preschoolers are independent in toilet habits for the first time, so parents do not have diaper contents to
evaluate
-Frequent trips to the bathroom, rubbing the abdomen, and holding genitals are the usual signs of bowel or
bladder dysfunction.
Evaluating nutritional intake
-Preschoolers begin to eat away from home at friends' houses or at child care, or stay overnight with
grandparents for the first time--> parents have less opportunities to observe daily food intake as accurately as
before
- Observing whether a child is growing and is active is better than monitoring any one day's intake.
Evaluating bed-wetting
-Many preschoolers continue to have occasional enuresis at night until school age
-If other signs are present (e.g., pain, low-grade fever, listlessness), a child should have a urine culture bc
persistent bed-wetting can indicate a low-grade urinary tract infection

Evaluating activity versus hyperactivity

-Parents wonder whether their active child could be hyperactive
-As a rule of thumb, if a child can sit through a meal (when he is hungry), watch a half-hour television show
(that is his favorite), or sit still while his favorite story is read to him--> not hyperactive.
Age-specific diseases to be aware of
-Preschool age is a time for vision and hearing assessment because, for the first time, a child is able to be
tested by a standard chart or by audiometry tests
-UTIs tend to occur with a high frequency in preschool-age girls
-language assessment should be done if a child is not able to make wants known by complete, articulated
sentences by age 3 years (exceptions are transposing w for r and broken fluency: "I want-want-want to go")
Fear of mutilation
-significant during the preschool age
-arises bc preschoolers do not know which body parts are essential and which ones(like an inch of scraped skin,
can be easily replaced)
-can be worried that if some blood is taken out of their bodies, all of their blood will leak out
According to Freud
-boys develop a fear of castration, they are more in tune with their body parts and are starting to identify with
the same-sex parent as they go through the Oedipal phase
Fear of separation
-major concern for preschoolers
-sense of time is distorted--> they cannot be comforted by assurances such as "Mommy will pick you up from
preschool at noon"--> more effective to say "Mommy will pick you up from preschool after you have had
your snack"
Telling tall tales
-Parents may be concerned that tall tales can lead to chronic lying if supported
-Caution them not to encourage this kind of storytelling but instead help the child separate fact from fiction-->
"That's a good story, but now, tell me what really happened."
imaginary friends
-normal, creative part of the preschool years and can be invented by children who are surrounded by real
playmates as well as by those who have few friends, parents may find them disconcerting
-Parents can help their preschooler separate fact from fantasy about their imaginary friend by saying--> "I
know Eric isn't real, but if you want to pretend, I'll set a place for him."
Around 3yo
-sharing is understood
-children begin to understand some things are theirs, some belong to others, and some can belong to both
-children who are ill or under stress--> greater difficulty with sharing
Regression
-Some preschoolers, generally in relation to stress, revert to behavior they previously outgrew(thumb-
sucking, negativism, loss of bladder control, and inability to separate from their parents)--> help parents
understand that regression in these circumstances is normal
Sibling rivalry
-may first become evident during the preschool period--> the first time children have enough vocabulary to
express how they feel
If children are to start preschool or child care:
it's also best if they can do so either before the new baby is born or 2 or 3 months afterward--> children can
perceive starting school as a result of maturity and not of being pushed out of the house by the new child
If the mother will be hospitalized for the birth:
-parents should be certain their child is prepared for this separation
Anticipatory guidance to help minimize sibling rivalry
-After returning home from the hospital with the baby, devote attention to your preschooler and spend some
special time together after the baby has gone to bed.
-When friends and family visit, encourage them to spend time with the preschooler as well as the baby
-If they bring gifts for the baby, it is often wise for them to bring a small present for the preschooler as well.
-So your preschooler doesn't come to expect gifts (promoting sibling rivalry), teach her to help open the
baby's gifts. Explain it is the baby's birthday and on her birthday she will receive gifts, too.
-Don't ask your preschooler a question such as "Do you like your new sister?" It is better to express feelings
of empathy such as "New babies cry a lot. It's hard to get used to that, isn't it?"
-Provide special time for your preschooler during each day, so when you say, "Mommy and Daddy love
you just the same," it seems real. This might be a quiet time for talking or reading.
-While feeding the baby, read or tell a story to your preschooler. Some children enjoy feeding a doll while a
parent feeds the baby or giving a doll a bath while the baby has one.
Masturbation
-common for preschoolers to engage in while watching TV or before they fall asleep at night
-frequency may inc during times of stress
-If observing a child doing this bothers parents--> suggest they explain certain things are done in some places
but not in others
"Where do babies come from?"
-parents usually find a simple, factual answer to this type of question is best, such as "Babies grow in a special
place in a mother's body called a uterus."--> saying "uterus" rather than "tummy" prevents children from
envisioning babies and food all mixed together in their mother's stomach
-natural for preschoolers to ask where babies come from
A school or child care experience
-helpful for preschoolers bc peer exposure seems to have a positive effect on social development
"child care center" and "preschool"
-often used interchangeably, so parents cannot depend on the name of a school to define its structure
Child care center
-provide child care while parents work or are otherwise occupied
Preschool
-dedicated to stimulating children's sense of creativity and initiative and introducing them to new experiences
and social contacts that they would not ordinarily receive at home
Head Start programs and many modern child care centers
-fulfill functions of both a preschool and child care centers
To continue to evaluate their child's school experience:
urge parents to make a habit of asking children what happened at school, what they learned, and the names
of any new friends
Evaluating child care centers: Management
-Length of operation does not necessarily indicate quality, but it allows you to locate other parents who have
used the center to ask about their experience there
-Ask in your local community what agency has the responsibility for licensing child care centers. If not
licensed, its quality is suspect.
-If staff members are teachers, more learning activities will be provided; staff should be qualified to
perform cardiopulmonary resuscitation.
-A fast turnover rate means little continuity of care will be provided (and probably suggests dissatisfaction with
center administration).
-ratio of three or four children to one staff member provides time for quality interaction.
-Parents should be able to drop in at any time. Be wary of facilities that restrict parental visiting in any way.
Evaluating child care centers: physical environment
-There should be opportunities for rough-and-tumble and imaginative play in addition to naptime areas and
table activities.
-Stairways should be fenced. No paint should be peeling.
-A first-floor plan is safest. Fire exits should be well marked. An evacuation plan should be practiced.
-Find out how often children are taken outside: once or twice a day, or only occasionally for "outings"?
-Ask if a child can nap if tired or has to wait until a set naptime.
-Both potty chairs and small toilet seats should be available.
-Food should be preschool friendly and healthy, not just high-fat snacks.
-Food poisoning is a concern without refrigeration.
Evaluating child care centers: staff philosophy
-Watch how they greet children. They should ask questions and listen to answers.
-It is best if the cleaning staff are separate from the care staff.
-Ask caregivers to describe their care pattern; if this is not planned, little continuity of care results.
-Imaginative items, such as a puppet theater, finger paint, and water play, should be included.
-The method should reflect the parents' philosophy. Staff should be able to talk to children calmly without
raising their voices in anger.
-There should be specific goals the caregivers hope to accomplish.
-Play or learning activities should be individualized.
Evaluating child care centers: healthcare protocols
-There should be access to a nurse.
-Staff should be able to evaluate for illness. They should know actions to take in an emergency.
-The counter where diapers are changed should be wiped with a disinfectant; tissues and hand- washing
facilities should be present.
-Be sure the center requires waterproof disposable diapers to minimize contamination of the environment and
other children and separates diaper-changing areas from other activities, especially anything related to food
handling. Observe caregivers changing diapers. Do they wash hands after each change? Are children
encouraged to wash their hands before eating?
-A center should have a very specific policy on what illness symptoms require a child to be kept home, and
they should enforce this policy strictly. For instance, a runny nose may be acceptable, but a fever is not, and
children with chickenpox should be kept at home until the lesions are covered with scabs. Children with
special needs should be integrated into usual activities.
Evaluating child care centers: children's behavior
-Observe for at least one morning.
-rushing to greet visitors--> could be a sign of boredom with their center's activities and a strong need for adult
attention.
Parents may wonder if their child is ready for kindergarten
-urge parents to discuss their concern with school officials to determine whether their child should be
registered for kindergarten or delayed for a year

Broken fluency
-repetition and prolongation of sounds, syllables, and words
-often referred to as secondary stuttering-->bc the child began to speak without this problem and then, during
the preschool years, develops it
-ex: "I-I-I want a n-n-new spoon-spoon-spoon."
-remind parents this is a part of normal development and will pass
Broken fluency is resolved most quickly if:
-Do not discuss in the child's presence that he or she is having difficulty with speech because this can make the
child conscious of speech patterns and compound the problem.
-Listen with patience rather than interrupt or ask the child to speak more slowly or to start over. These actions
make the child aware speech is repetitious, and broken fluency increases.
-Always talk to the child in a calm, simple way to role model slow speech. If adults talk quickly, the child
imitates this pattern and has difficulty speaking clearly.
-Protect space for the child to talk if there are other children in the family. Rushing to say something before a
second child interrupts is the same as rushing to conform to adult speech.
-Do not force a child to speak if he or she does not want to. Do not ask preschoolers to recite or sing for
strangers.
-Do not reward a child for fluent speech or punish for nonfluent speech. Broken fluency is a developmental
stage in language formation, not an indication of regression or a chronic speech pattern.
nocturnal emission - ejaculation during sleep

Accommodation - the ability to adapt through processes to fit what is perceived such as understanding that there
can be one reason for other people's actions.

Conservation - the ability to appreciate that a change in shape does not necessarily mean a change in size.
Class inclusion - the ability to understand that objects can belong to more than one classification
Caries - "cavities", are progressive, destructive lesions or decalcification of the tooth enamel and dentin.
Malocclusion - any deviation of the tooth position from the normal
weight gain - 3 to 5 lb (1.3-2.2 kg.)
height gain - 1-2 inch (2.5-5cm)
pulse rate - decreases to 70 to 80 beats/min
blood pressure - 112/60 mmHg

10 years of Age
-Brain growth is complete, fine motor coordination is refined.
9 years of age
-IgG & IgA each reach adult levels and lymphatic tissues continue to grow
6 years of Age
-Frontal Sinuses develop
sexual maturation
girls: 12-18 years
boys: 14-20 years
promoting development of a school age child n daily activities
-dress
-sleep
-exercise
-hygiene
-care of teeth
common health problems on the school-age period
-dental caries malocclusion
common fears & anxieties of a school aged child
-anxiety related to beginning school school refusal or phobia homeschooling
-children who spent time independently sex education
-stealing
-violence or terrorism
school age
-children between ages 6 to 12 years
although these years represent a time of slow physical growth,
-school-age child's cognitive growth and development continue to proceed at rapid rates
-initiation of independent decision making
demonstrate contradictory responses
-child enjoys on one occasion may change over time
-become increasingly more influenced by attitudes of their friends
nurses can help the nation achieve these goals by
-urging children to begin and maintain a consistent exercise program
-to brush teeth and go for dental checkups regularly
-to follow safety rules for bicycles and automobiles
assessment
-assess growth and development
-history question: school progress and extracurricular activities
-able to express their own opinions and belief, may be interviewed with their parents or separately depend on
situation
-need privacy when undressed
-parents often mention behavioral issues or conflicts
outcome identification and planning
-tend to enjoy small or short term project
-behavior problems need to be well defined (often, parents need to accept the problem as one consistent with
normal growth and development)
implementation
-interested in learning adult roles (watch your behaviors)
-feel more comfortable if they know "hows" and "whys" of action
physical growth: weight and height
-avg annual weight gain: 3-5 lb (1.3-2.2 kg)
-avg increase in height: 1-2 in. (2.5- 5 cm)
frontal sinuses develop at about
-6 years, so sinus headaches become a possibility
until about age 9
-IgG, IgA (adult levels)
-lymphatic tissues continue to grow in size (often mistaken for disease, can result in temporary conduction
deafness)
-appendix (line w/ lymphatic tissue)- swells, trapped fecal material and inflammation occurs

by age 10
-brain growth and fine motor coordination is complete
-adult vision level is achieved
-If the eruption of permanent teeth and growth of the jaw do not correlate with final head growth, malocclusion
with teeth malalignment may be present
cardiovascular system
-left ventricle of heart enlarges to be strong enough to pump blood to the growing body
-innocent heart murmurs (extra blood crossing heart valves)
-pulses (dec to 70-80 bpm)
-BP (rises to abt 112/60 mmHg)
respiratory system
-increased oxygen-carbon dioxide exchange, which increases exertion ability and stamina
musculoskeletal system
-scoliosis may become apparent for first time in late childhood
-older than 8 years should be screened
at a set point in brain maturity
-hypothalamus transmits an enzyme to the anterior pituitary gland to begin production of gonadotropic
hormones, which then activate changes in the testes and ovaries to cause puberty
timing of the onset of puberty varies widely,
-between 8-14 years of age, partly due to genetic and cultural differences and is rated according to Tanner
stages
-sexual maturation (girl/ 12-18, boy/14-20)
-sex education
-precocious puberty (abnormal onset of puberty)
boy: 9-11 years old
-prepubertal weight gain occurs
boy: 11-12 years old
-Sparse growth of straight, downy, slightly pigmented hair at base of penis.
-Scrotum becomes textured; growth of penis and testes begins.
-Sebaceous gland secretion increases.
-Perspiration increases.
boy: 12-13 years old
-Pubic hair present across pubis.
-Penis lengthens.
-Dramatic linear growth spurt.
-Breast enlargement may occur.
girl: 9-11 years old
-Breasts: elevation of papilla with breast bud formation; areolar diameter enlarges.
girl: 11-12 years old
-Straight hair along the labia; vaginal epithelium becomes cornified.
pH of vaginal secretions becomes acidic; slight mucous vaginal discharge is present.
-Sebaceous gland secretion increases.
-Perspiration increases.
-Dramatic growth spurt.
girl: 12-13 years old
-Pubic hair grows darker; spreads over entire pubis.
-Breasts enlarge, still no protrusion of nipples.
-Axillary hair present.
-Menarche occurs.
sexual and physical concerns
-time for parents to discuss w/children the physical changes that will occur and the sexual responsibility these
changes dictate
-teach that their body is their own
-changes in sebaceous gland (acne), vasomotor instability (blushing), perspiration increases
concerns of girls
-prepubertal girls are usually taller by 2 in (5 cm) or more than preadolescent boys
-notices the change in pelvic contour, broader
-conscious of breast development, asymmetrical breast size (normal), supernumerary (additional nipples) may
darken or increase in size (d/t hormones)
early preparation of menstruation
-important preparation for future childbearing and for a girl's concept of herself as a woman
-teach how menstruation is a normal function, proper hygiene, and reassurance they can bathe, shower, and
swim during their periods
-teach abt either sanitary napkins or tampons, if choose tampons (caution- toxic shock syndrome)
vaginal secretions
-will begin to be present
-if this not explained, may fear needlessly she has contacted an infection
-teach any secretion that cause vulvar irritation should be evaluated by a healthcare provider (infection)

menstrual irregularity
-some during the 1 or 2 years after menarche
-occurs d/t cycles are at first anovulatory
-with added maturity and onset of ovulation, cycles become more regular
-fear that it might indicate hormone imbalance, future ability to conceive, possible pregnancy
other risk factors of menstrual irregularity
-malnourishment and obesity
-emotions
-continues beyond the first year, a careful history of the girl's nutrition; overall health; school, social and home
adjustment
-dysmenorrhea or painful menstruation
concerns of boys
-become aware of increasing genital size
-if they do not know testicular development precedes penis growth, they can worry about their growth will be
inadequate
-gynecomastia can occur in prepubescent boys (most often in those who are obese, may concern about breast
tumor, embarrassment)
-pubic hair (cannot yet grow)
increased seminal fluid begins to be produced
-boys begin to notice ejaculation during sleep (nocturnal emissions)
concerns for transgender children
-depression and anxiety (need family support)
-gender preferences are often identified in early childhood
-important not to ridiculed or isolated secondary to their gender preference
teeth
-deciduous teeth are lost and permanent teeth erupt during the school age period
-average child gains 28 teeth b/w 6-12 years; central and lateral incisors; first, second, and third cuspids; first and
second molars
physical development: age 6
-year of constant motion; skipping is a new skill; first molars erupt
-first-grade teacher becomes authority figure; adjustment to all-day school may be difficult and may lead to
nervous manifestations of fingernail biting, etc
-defines words by their use (e.g., a key is to unlock a door, not a metal object).
social age development: age 7
-central incisors erupt; difference between sexes becomes apparent in play (e.g., video games vs. dolls);
spends time in quiet play
-quiet year; striving for perfection leads to this year being called an eraser year
-learns conservation (e.g., water poured from tall container to a wide, flat one is the same amount of water); can
tell time; can make simple change.

social age development: age 8

-coordination definitely improved; eyesight fully develops; playing with friends becomes important.
-"Best friends" develop; whispering and giggling begin; can write in cursive as well as print; understands
concepts of past, present, and future.
social age development: age 9
-all activities done with friends
-friend or club age; a 9-year-old club is formed to spite someone, has secret codes, is all boy or all girl; clubs
disband and reform quickly.
school age development: age 10
-coordination improves.
-ready for camp away from home; collecting age; likes rules; ready for competitive games.
school age development: age 11
-active, but awkward and ungainly
-insecure with members of opposite sex; repeats off-color jokes.
social age development: age 12
-coordination improves
-sense of humor is present; is social and cooperative.
gross motor development
6: endlessly jump, tumble, skip, hop, enough coordination to walk a straight line 7: quiet,
gender differences manifest during play
8: appear awkward in their play and eating habits, ride bicycle well, and enjoy sports
9: on the go constantly, enough eye-hand coordination to enjoy baseball, basketball, volleyball
10: more interested in perfecting their athletic skills than they were previously
11: awkward, growth spurt and drop out of sports activities rather than look ungainly attempting them, energy
into constant motion
12: activities w/ intensity and concentration, enjoy participating in sports events for charities (walkathons),
cooperative around house, responsibility and complete given tasks
fine motor development
6: tie shoelaces, cut and paste well, draw, print
7: "eraser year", never quite content w/ what they have done, set high a standard
8: children's eyes are developed enough (regular sized type), write script in addition to print, enjoy showing off
this new skill in cards, letters, etc
9: writing begins to look mature and less awkward
play
6: reading, increasingly challenging video games
7: require more props, imaginative play, collecting items, helping in the kitchen, simple science projects
8: table games, but hate to lose, change rules in the middle of a game to keep from losing 9: play hard
(rough), difficulty going to bed at night, not interested in perfecting their skills, music or art, social media
10: playing screen games, interest in opposite sex is apparent, rules/fairness, club activities 11/12: dancing and
table game, rules can be modified to their advantage, time with friends is often spent just talking
12: jobs around the house or babysitting for money
language development
6: full sentences, using language easily and w/ meaning, define objects by their use 7: tell time in
hours, months, add and subtract, simple changes
9: dirty jokes, swear words, short period of intense fascination w/ "bathroom language", 12: carry on an
adult conversation, although stories are limited
emotional development
-ability to trust others and sense of respect for their own worth
-sense of autonomy (accomplish small tasks independently)
-practiced or mimicked adult roles
-learned to share
-discovered that learning is an adventure
-grasped the idea that doing things is more important and more rewarding than watching things being done (a
sense of initiative)
developmental task: industry versus inferiority
-learning a sense of industry or accomplishment
-prevented from achieving a sense of industry or do not receive rewards for accomplishment, they can develop
a feeling of inferiority or become convinced they cannot do things they actually can do
-need reassurance
home as a setting to learn industry
-look at parents as role model
-may feel frustrated when school ages chooses to conform to rules and insists on the right way
-conformity is vital
-8/9: spend more and more time w/ their peers and less time w/ their family
-step of independence away from parents, emotionally mature
school as a setting to learn industry
-assuming responsibility for education about sex, safety, avoidance of substances of abuse, and preparation for
family living
-discussions are generally superficial
-large classes (raise more questions)
-learning other's opinions
-should not replace parental teaching
structured activities
-Girl Scouts, the Boy Scouts, the Camp Fire Girls, and 4-H clubs
-contact sport; possible injuries (consider maturity, risk for injuries)
problem solving
-important part of developing a sense of industry
-encouraging practice
-talk about possible ways of doing it

learning to live with others

-urge children to learn compassion and thoughtfulness toward others
-empathy (writing thank you letters or shoveling an older neighbor's sidewalk)
socialization
6: play in groups, but when they are tired or under stress, usually prefer one to one contact,
7: increase awareness of family roles and responsibility, promise must be kept, tattle
8: seek the company of other children
9: take the values of their peer group very seriously, social interaction
10: enjoy groups and privacy
11: increasingly interested in opposite sex, attempt many awkward and uncomfortable social
experiences before they become comfortable forming relationship with opposite sex
12: comfortable in social situations than they did the year before
cognitive development
-age from 5-11 years is a transitional stage, where children undergo a shift from preoperational thought they
used as preschoolers to concrete operational thought or ability to reason through any problem they can
actually visualize
concrete operational stage
-decentering
-accommodation
-conservation
-class inclusion
decentering
-ability to project one's self into other people's situations and see the world from their viewpoint rather
focusing only on their own view
-enables them to feel compassion for others
accommodation
-ability to adapt thought processes to fit what is perceived such as understanding that there can be more than
one reason for other people's actions
conservation
-ability to appreciate that a change in shape does not necessarily mean a change in size
class inclusion
-ability to understand that objects can belong to more than one classification
moral and spiritual development
-preconventional reasoning, sometimes as early as 5 years
-right or wrong
-"fairness" and rule-oriented

promoting school age safety

-ready for time on their own w/o direct adult supervision
-need good education on safety practices
-as w/ adults, unintentional injuries (box 32.3) tend to occur when children are under stress or when they
distracted
-not too early for parents to look at effect of carrying heavy backpack on children's posture (chronic back pain)
-sexual maltreatment
promoting nutritional health of a school-age child
-good appetites, although meals may be influenced by day's activity
-ex: if children have had a full day of active play, they may come to dinner table ready to eat anything
establishing healthy eating patterns
-encouraged to eat healthy breakfast to ensure the ability to concentrate during the school day
-prepare a nutritious lunch to take to school (healthy choices, active role in nutrition education)
-qualify for a free or reduced price school lunch and breakfast (milk (8 oz), protein (2 oz), one starch serving, a
vegetable (¾ cup), and fruit (¾ cup))
-nutritious after school snacks are important
-poor eating habits developed in the school-age years may last through adulthood
-lead to an increased risk of health-related diseases (type 2 diabetes, hypertension, cardiovascular disease, and
obesity)
fostering industry and nutrition
-usually enjoy helping to plan meals (simple meals with healthy ingredients)
-assist w/ preparation of more complex meals and learn the safe use of kitchen appliances (microwaves, stove)
-development of proper etiquette, parents can model this behavior and encourage meals to be eaten at the table
-meals eaten while watching tv or performing another activity (obesity)
recommended dietary intakes
-increasing energy requirement (met w/ high nutritional value)
-boys:more calories and other nutrients at this time
-girls: more iron
-adequate calcium and fluoride intake
-major deficit in fiber
vegetarian diet
-need to learn how to obtain essential nutrients
-consumption of adequate protein and calcium
-foods high in calcium: green leafy vegs, enriched bread, cereals
-foods high in protein: soybeans, legumes, grains, and immature seeds
-encourage outside activities (inc Vit D), supplemented iron if needed
other areas of concern
-dress
-sleep
-exercise
-hygiene
-care of teeth
dress
-not skilled at taking care of their clothes until late in the school age years
-teach about caring for their own belongings
-definite opinions about clothing style (may become the object of exclusion)
sleep
-needs vary (younger; 10-12 hours, older; 8-10 hours)
-most 6 y.o. are too old for naps but do require a quiet time after school to get them through remainder of the day
-nighttime terrors (stress d/t school)
-early school years: enjoy a quiet talk or reading time at bedtime
-age 9: friends become important (texting or calling)
-with television sets, electronic games, or smartphones in their bedrooms not only have shorter sleep times at
night but also are more likely to be obese
exercise
-neighborhood games, walking with parents or a dog, or bicycle riding
-as children enter preadolescence, those with poor coordination may become reluctant to exercise
-urge them to participate in some form of daily exercise (if not it can cause obesity or osteoporosis)
hygiene
6/7: regulating bath water temp, cleaning ears and fingernails
8: children are generally capable of bathing themselves but may not do it well become they are too busy to take
the time or bc they do not find bathing as important as do their parents
-uncircumcised: develop inflammation under foreskin from increased secretions if they do not wash regularly
care of teeth
-w/ proper dental care, avg child today can expect to grow up cavity free
-visit dentist at least twice yearly for a checkup, cleaning, and possible fluoride treatment
-reminded to brush their teeth daily
-snacks are best limited to high protein foods (chicken and cheese)
-fruits, veg, and cereals fortified w/ minerals and vitamins (not empty calorie ones)
-if child eat candy, get the type that is eaten quickly and dissolves
promoting health family functioning
-parents need to be reminded that even simplest tasks require repeated practice before they can be
accomplished well
-displaying and using children's gifts, time honored
in talking to parents of school-age children, good questions to ask to estimate the degree of interaction
that occurs in the home and whether parents are strengthening a child's sense of accomplishment include:
-How do they correct the child when he or she does something wrong?
-Do they display school projects?
-Does the child have chores that are his or hers to accomplish?
-Do they ask the child to participate in family decision making?

common health problems of the school age period

-head lice or ringworm
-two cause of death: unintentional injury and cancer
-minor illness are largely d/t dental caries, GI disturbances and upper respiratory infections
-learning difficulties (ADHD, ASDs)
dental caries
-progressive, destructive lesions or decalcification of tooth enamel and dentin
-pH of the tooth surface: 5.6 or lower (cause: table sugar), acid microbes found in dental plaque attack the
cementing medium of teeth and destroy it
-plaque-accumulate in deep grooves of the teeth and contact areas between teeth, making these areas most
susceptible to dental decay
-enamel on primary teeth is thinner than on permanent teeth, so these are even more susceptible to destruction
than permanent teeth
-distance from the enamel to the pulp is shorter-invasion of the tooth nerve can occur quickly
neglected caries
-poor chewing and therefore poor digestion, abscesses and pain, and sometimes osteomyelitis (bone infection) if
the jaw bone is involved
malocclusion
-upper jaw in children matures during early childhood along with skull growth; the lower jaw reaches
maturity more slowly, forcing teeth to make a prolonged series of changes until they reach their final adult
alignment and position
-deviation of tooth position from the normal
-cause: congenital (cleft palate, small lower jaw, or familial trait), thumb sucking (if persist 6-7 years, eruption of
permanent front teeth), unintentional injury
-result later on, constant mouth breathing or abnormal tongue position
-may be either cross-bite (sideways) or anterior or posterior
treatment for maloocclusion
-evaluated by orthodontist (braces or other therapy)
-oral acetaminophen or an agent (Orajel) rubbed on the ulceration
-braces: brush their teeth well and be assessed periodically to see that they are brushing properly around braces
(Waterpik is recommended)
-dental floss
-loss of retainers (common problem)
-show appropriate sympathy (appearance of braces or wearing retainer)
two of most disorders of the school-age period are
-ADHD and ASDs because these interfere so dramatically with school progress
-others: language, fear, responsibility
assessment: health maintenance schedule
-every visit: health hx, physical health, developmental milestones, growth milestones, HTN, nutrition, parent-
child relationship, behavior or school problems, vision and hearing disorders (expect formal snellen or titmus
testing, audiometer testing- at 7-9 y.o. and 10-12 y.o.), dental health
-yearly after age 8: scoliosis
-every visit after age 10: thyroid
-6-8 and 10-12 years: dyslipidemia
-TB: depends on community prevalence
-6-7 years: bacteriuria
-7-8 and 11-12: anemia
immunizations
-Diphtheria, tetanus, and pertussis: 11 or 12 years
-Hep A: if not previously administered
-HepB: if not administered in infancy or three injections were not completed
-HPV or HPV4: 11 or 12 years; second injection 2 months later; third injection 6 months after first dose:
-Inactivated poliomyelitis vaccine (IPV): if four doses not previously administered
-Influenza vaccine: yearly
-Meningococcal conjugate vaccine (MCV4): 11-12 years
-Pneumococcal vaccine (PPSV): children at high risk
-MMR: if two doses not previously administered
-Varicella: at any age after 1 year if not previously immunized, or at 11-12 years if lacking reliable history of
chickenpox
problems of language development
-most common problem: articulation
-difficulty pronouncing s, z, th, l, r, and w or substitutes w for r
-noticeable during 1st-2nd grade, disappears by 3rd grade
-persist: speech therapy
anxiety r/t beginning school
-adjusting to grade school is a big task for 6 y.o.
-one of biggest tasks of the first year of school is learning to read
-best if parents have prepared children for this by reading them since infancy, pointing to the words and pic as
they read
-many first graders are capable of mature action at school but appear less mature when they return home
-may bite their fingernails, suck their thumb, or talk baby talk
-some develop tics (irregular movements of isolated muscle groups)- disappear during sleep, occur mainly
during stress
-urge parents to spend time with them after school or in the evening
school refusal or phobia
-fear of attending school
-type of "social phobia" similar to agoraphobia (fear of going outside the home) or separation anxiety disorder
(SAD)
-resist attending school this way develop physical signs of illness, such as vomiting, diarrhea, headache, or
abdominal pain on school days
-lasts until after the school bus has left or the child is given permission to stay home for the day
-anxiety separation can occur
-require entire family to counsel, coordination among school, school nurse, and healthcare provider

homeschooling
-vocabulary may be advanced
-assess if children have peer experiences (community sport teams, clubs)
-ask if they receive exposure to other cultures or families (adjust to people different from themselves later on at
college or at work)
children who spend time independently
-concern: inc number of unintentional injuries, delinquent behavior, alcohol or substance abuse, dec school
performance from a lack of adult supervision
-suggest parents to spend time alone before or after school
-take offer for special after school programs and services
sex education
-educated about pubertal changes and responsible sexual practices
-healthcare personnel often resource persons (if some parents feel uncomfortable discussing)
-LGBT youth may not obtain the same levels of care due to fear of discrimination
-course: films and discussions, use an anonymous question box
stealing
-steal loose change at age of 7
-best handled w/o great deal of emotion
-continue to steal past age 8- require counseling
-some shoplifting (must taken seriously by parents)
violence or terrorism
-view their world as safe, so it is a shock when violence such as a school shooting or reports of terrorists enter
their lives
bullying
-alert parents that internet or texting bullying are both also possible and that a bully doesn't have to be in fact
to face contact with their child to be harmful
traits commonly associated with school-age bullies include:
-Advanced physical size and strength for their age
-Aggressive temperament (both male and female)
-Parents who are indifferent to the problem or are permissive with an aggressive child
-Parents who typically resort to physical punishment
-There is the presence of a child who is a "natural victim" (e.g., small, insecure, with low self- esteem)
bullying can be done face to face or through social media and/or texting. Suggestions for school
personnel to deal with bullies include:
-Supervise recreation periods closely.
-Intervene immediately to stop bullying.
-Insist if such behavior does not stop, both the school and parents will become involved.
-Advise parents to discuss bullying with their school-age child and help them understand that it should be
reported to allow adults to intervene.
-Parents should monitor their child's social media and texting interactions.
if bullying behavior is ingrained
therapy may be needed to correct the behavior
recreational drug use
-available in so many homes, alcohol, inhalants, and prescription drugs have also become commonly abused by
this age group
-caution adult antidepressant drug- associated w/ suicide in young children
-inhalants (airplane glue- toluene, aerosolized cooking oil)
-glue fumes (extensive liver damage or enough pulmonary edema to be fatal)
-suspect if their child regularly appears irritable, inattentive, or drowsy
-abuse of androgenic steroids or human growth hormone to enhance sports performance (cardiovascular
irregularities, uncontrollable aggressiveness, and possible cancer in later life)
-cigarette smoking (development lung cancer, other serious respiratory illness)
-caution children against experimenting with smokeless tobacco(mouth and throat cancer)
-use of e-cigarettes and vaping has increased
child of alcoholic parents
-greater risk for having emotional problems than others d/t frequent disruption in their lives
-alcoholism may have a genetic base
-learning effective coping behaviors

immediate problems that can occur with children of alcoholic parents include:
-feeling of guilt that they are the cause of the parent's drinking
-constant worry that the alcoholic parent will become sick or die, leaving the child alone; at the same time, the
child may fear the alcoholic parent and wish the parent would leave
-feeling of shame that prevents the child from inviting friends home or asking for help
-decreased ability to trust adults because the parent has been unreliable so many times
-poor nutrition and decreasing grades in school because the alcoholic parent's behavior is so erratic that no
regular schedule of bedtime or meals exists
-anger at the alcoholic parent for drinking and at the nonalcoholic parent for not doing more to correct things
-helplessness to change the situation
child with long term illness or physical cognitive challenge
-time lost from school
-threatens not only their academic achievement but also their relationships with peers
-assign them household chores just like other children and to allow them to participate in peer activities, such
as Girl or Boy Scouts, in which accomplishment is encouraged (fostering industry)
-choose short-term activities that can be completed independently, as with all school age children
nutrition and the school age child with a challenge
-need extra time during the day to make up for these lost socializing experiences
-children who must eat special diets are usually tempted to select the same food as everyone else rather than
limit what they choose
-allow choices of food when possible and respect food preferences.
-provide small food servings that child can finish, which encourages a sense of accomplishment.
child who is overweight or obese
-many as 50% of school-age children are obese
-endomorphic build (a natural tendency to accumulate body fat) are more likely to be obese at any time in life
than those with a mesomorphic (normal) or ectomorphic (slender) build
-cause: fast foods, lack of nutritional food in school, genetics and environmental influences
-poor self image, little motivation for self improvement
type of weight-reduction program that will probably work best is one that emphasizes long- term lifestyle
changes and contains features such as:
-intake of about 1,200 calories a day (no more than 30% as fat), with lifestyle changes such as a structured
family meal, eliminating eating or snacking in front of the television, decreasing portion sizes, and eliminating
sugar-rich drinks.
-active exercise program, including monitoring and limiting time spent in physical inactivity (e.g., watching
television, playing computer and video games, surfing the Internet, texting).
-counseling program to discuss aspects such as self-image and motivation to reduce weight.
total caloric intake should not be reduced too drastically in children
need calories to form new body tissue for continued growth.
-caution children not to try faddish high-protein diets (as most adults should not)
-diets do not supply enough carbohydrates and may produce a heavy renal solute load (the breakdown product
of proteins) to the kidneys
-helps if children aim to lose 5 lb over a short time rather than 50 lb over a year
-short-term goal coincides better with the task of developing industry.
surgical techniques such as an intestinal bypass or lap band surgery are obviously
-extreme measures and inappropriate for children
-children who are obese might request one, however, in an attempt to avoid the not insignificant difficulty of
long-term weight loss
Adolescence
-generally defined as the period between ages 13 and up to 20 years
-time that serves as a transition between childhood and becoming a late adolescent
-early period-->13-14
-middle period--> 15-16
-late period--> 17-20
-The drastic change in physical appearance and the change in expectations of others (especially parents)-->
can lead to both emotional and physical health concerns
-feel a sense of pressure throughout this period because they are mature in some respects but still young in
others
Adolescents both grow rapidly and mature dramatically:
-during the period from age 13 to 18 to 20 years
The major milestones of physical development in the adolescent period
-onset of puberty at 8 to 12 years of age
-cessation of body growth around 16 to 20 years
Girls
-most are 1 to 2 in. (2.4 to 5 cm) taller than boys coming into adolescence
-generally stop growing within 3 years from menarche--> are shorter than boys by the end of adolescence
-grow 2 to 8 in. (5 to 20 cm) in height
-gain 15 to 55 lb (7 to 25 kg)
-Growth stops with closure of the epiphyseal lines of the long bones--> about 16-17yo

Boys
-typically grow about 4 to 12 in. (10 to 30 cm) in height
-gain about 15 to 65 lb (7 to 30 kg)
-Growth stops with closure of the epiphyseal lines of the long bones--> about 18-20yo
adolescents may have insufficient energy and become fatigued trying to finish the various activities that
interest them
-bc the heart and lungs increase in size more slowly than the rest of the body
Pulse rate and respiratory rate
-decrease slightly (to 70 beats/min and 20 breaths/min, respectively)
blood pressure
-increases slightly (to 120/70 mmHg) by late adolescence
-becomes slightly higher in males than in females bc more force is necessary to distribute blood to the larger
male body mass
androgen
-stimulates sebaceous glands to extreme activity--> sometimes resulting in acne
Apocrine sweat glands
-glands present in the axillae and genital area
-produce a strong odor in response to emotional stimulation
-form shortly after puberty
Teeth
-second molars--> about 13yo
-third molars--> between 18-21, may be as early as 14 or 15
-jaw reaches adult size only toward the end of adolescence
-adolescents whose third molars erupt before the lengthening of the jaw is complete--> may experience pain and
may need these molars extracted because they do not fit their jawline
Puberty
-the time at which an individual first becomes capable of sexual reproduction
-usually occurs between the ages of 11-14
A girl has entered puberty when:
-she begins to menstruate
a boy enters puberty when:
-he begins to produce spermatozoa
The age of first menstruation in girls is gradually decreasing from a mean of 13 years to 12.4 years, which
is probably related to:
-more weight gain in girls
secondary sexual characteristics
-example--> body hair configuration and breast growth
-characteristics that distinguish the sexes from each other but that play no direct part in reproduction
Sexual maturity in males and females
is classified according to Tanner stages
Female breast development sexual maturity rating: 1
-Prepubertal; elevation of papilla only.
Female breast development sexual maturity rating: 2
-Breast buds appear; areola is slightly widened and projects as a small mound.
Female breast development sexual maturity rating: 3
-Enlargement of the entire breast with no protrusion of the papilla or the nipple.
Female breast development sexual maturity rating: 4
-Enlargement of the breast and projection of areola and papilla as a secondary mound.
Female breast development sexual maturity rating: 5
-Adult configuration of the breast with protrusion of the nipple; areola no longer projects separately from
remainder of breast.
Female pubic hair development sexual maturity rating: 1
-Prepubertal; no pubic hair.
Female pubic hair development sexual maturity rating: 2
-Straight hair extends along the labia
Female pubic hair development sexual maturity rating: between 2 and 3
-straight hair extends along the labia and begins on the pubis.
Female pubic hair development sexual maturity rating: 3
-Pubic hair increases in quantity, becomes darker, and is present in the typical female triangle but in a smaller
quantity.
Female pubic hair development sexual maturity rating: 4
-Pubic hair more dense, curled, and adult in distribution but less abundant.
Female pubic hair development sexual maturity rating: 5
-Abundant, adult-type pattern; hair may extend onto the medial part of the thighs.`
Ratings for male pubic hair and genital development:
-can differ in a typical boy at any given time because pubic hair and genitalia do not necessarily develop at the
same rate.

Male sexual maturity rating: 1

-Prepubertal; no pubic hair; genitalia unchanged from early childhood.
Male sexual maturity rating: 2
-Light, downy hair develops laterally and later becomes dark; penis and testes may be slightly larger; scrotum
becomes more textured.
Male sexual maturity rating: 3
-Pubic hair extends across the pubis; testes and scrotum are further enlarged; penis is larger, especially in length.
Male sexual maturity rating: 4
-More abundant pubic hair with curling; genitalia resemble those of an adult; glans has become larger and
broader; scrotum is darker.
Male sexual maturity rating: 5
-Adult quantity and pattern of pubic hair, with hair present along inner borders of thighs; testes and scrotum are
adult in size.
male 13-15yo
-Growth spurt continuing
- pubic hair abundant and curly
-testes, scrotum, and penis enlarging further
-axillary hair present
-facial hair fine and downy
- voice changes happen with annoying frequency
male 15-16yo
-Genitalia adult
-scrotum dark and heavily rugated
-facial and body hair present
-sperm production mature
male 16-17yo
-Pubic hair may extend along medial aspect of thighs
-testes, scrotum, and penis adult in size
-may have some degree of facial acne
-gynecomastia (enlarged breast tissue), if present, fades
male 17-18yo
-end of skeletal growth

female 13-15yo
-Pubic hair thick and curly, triangular in distribution
- breast areola and papilla form secondary mound
- menstruation is ovulatory, making pregnancy possible
female 15-16yo
-Pubic hair curly and abundant
-may extend onto medial aspect of thighs
-breast tissue appears adult
- nipples protrude
-areolas no longer project as separate ridges from breasts
- may have some degree of facial acne
female 16-17yo
-end of skeletal growth

Thirteen-year-old children
-change from school-age activities of active games to more adult forms of recreation such as listening to music,
texting or chatting, or following a sports team's wins and losses
Beginning at age 16 years
-most adolescents want part-time jobs to earn money
-can teach young people how to work with others, accept responsibility, and how to save and spend money
wisely
According to Erikson, the developmental task in early and mid-adolescence is:
-to form a sense of identity versus role confusion
According to Erikson, the developmental task in late adolescence is:
-to form a sense of intimacy versus isolation
The task of forming a sense of identity
-is for adolescents to decide whom they are and what kind of person they will be
The four main areas in which they must make gains to achieve a sense of identity include:
-Accepting their changed body image
-Establishing a value system or what kind of person they want to be
-Making a career decision
-Becoming emancipated from parents
If young people do not achieve a sense of identity:
-they can have little idea what kind of person they are or may develop a sense of role confusion--> can lead
to difficulty functioning effectively as adults--> can lead to acting-out (attention-getting) behaviors bc they
believe it is better to have a negative image than to have none at all
Adolescents who were able to develop a strong sense of industry during their school-age years:
-learned to solve problems and are best equipped to adjust to the changing body image that comes with
adolescence
self-esteem
-may undergo major changes during the adolescent years and can be challenged by all the changes that occur
during adolescence
Several researchers have proposed that adolescence:
-is a period of particular crisis for girls who are trying to find a place in a male-dominated society
Value system
-Adolescents develop their values throughout their childhood as they interact with their family
-increase the amount of time they spend with their peer group--> may question these values and participate
in experiences that may put them at risk for physical and/or psychological harm
In early adolescence, individuals tend to dress and behave similarly to other members of:
-their peer group
Emancipation from parents
-can become a major issue during the middle and late adolescent years-->some parents may not yet be ready for
their child to be totally independent, and some adolescents may not yet be sure they want to be on their own
-the closer the tie adolescents feel with their parents--> the more severe can be their struggle
-Both parents and adolescents may need help to understand that emancipation does not mean severance of a
relationship but rather a change in a relationship
Developing a sense of intimacy
-means a late adolescent is able to form long-term, meaningful relationships with persons of the opposite as well
as their same sex(erikson)
Those who do not develop a sense of intimacy:
-are left feeling isolated; in a crisis situation, they have no one to whom they feel they can turn to for help or
support
Early teenagers
-may feel more self-doubt than self-confidence when they meet another adolescent with whom they would like
to begin a lasting relationship
Both male and female early adolescents
-tend to be loud and boisterous, particularly when someone whose attention they would like to attract is nearby
Many 13-year-olds
-begin to experience "crushes," or infatuations with schoolmates
-spend more time longing for someone than they do instituting an in-depth and rewarding relationship-->
have too little experience with life and too limited a frame of reference yet to know how to offer a deep
commitment to another or accept one from that person

By age 14 years
-teenagers have become quieter and more introspective
-becoming used to their changing bodies, have more confidence in themselves, and feel more self-esteem
Most 15-year-olds
-fall "in love" five or six times a year
-many of these relationships are based on attraction because of physical appearance, not because of inner
qualities or characteristics that are compatible with their own
By age 16 years
-boys are becoming sexually mature
-Both sexes are better able to trust their bodies than they were the year before
By age 17 years
-they tend to have adult values and responses to events
-have left behind the childish behaviors they used in early adolescence—shoving and punching
—to get the attention of others
formal operational thought
-the final stage of cognitive development
-begins at age 12 or 13 years
-grows in depth over the adolescent years
-may not be complete until about age 25 years
-involves the ability to think in abstract terms and use the scientific method (deductive reasoning) to arrive at
conclusions
-They can create a hypothesis and think of consequences
Almost all adolescents
-question the existence of God and any religious practices they have been taught(Kohlberg)--> natural part of
forming a sense of identity and establishing a value system at a time in life when they draw away from their
families
Unintentional injuries
-most commonly those involving motor vehicles
-leading cause of death among adolescents
-need to rebel against authority or to gain attention through risk-taking leads them to take careless actions
Motor vehicle
-Always use a seat belt whether a driver or a passenger.
-Never use a cell phone or text while driving.
-Do not drink alcohol while driving and always refuse to ride with anyone who has been drinking (name a
designated driver or arrange with your parents to be picked up or provide money for a taxi).
-Wear a helmet and long trousers as driver or passenger on a motorcycle.
-Accepting dares has no place in safe driving.
-Take graduated driver programs seriously so you learn safe driving habits for both two-wheel and four-wheel
vehicles.
Firearms
-Always consider all guns loaded and potentially lethal.
-Learn safe gun handling before attempting to clean a gun or hunt.
Drowning
-Learn how to swim.
-Follow safe water rules, such as never swimming alone, no diving into the shallow end of swimming pools, no
hyperventilating before swimming underwater, and no swimming beyond one's own limit.
-taking dares has no place in water safety
Sports
-Use protective equipment, such as facemasks for hockey and pads and a helmet for football.
-Do not attempt to participate beyond physical limits.
-Keep well hydrated by drinking fluid before and after play.
-Careful preparation for sports through training is essential to safety.
-Recognize and set one's own limit for sports participation.
Other common causes of death in adolescents:
homicide and self harm--> related to the easy accessibility of guns when added to depression, binge drinking,
and impulsivity, gang violence and the desire to protect themselves are additional factors
Unintentional gunshot injuries
-increase in early adolescence, often for the same reason that drowning increases--> youngsters want to impress
friends by showing they can handle guns.
Adolescents experience such rapid growth that they may always:
-feel hungry
One form of adolescent rebellion:
-is to refuse to eat foods that parents stress as important
weight-loss diet
-is appropriate during adolescence--> must be supervised to ensure the adolescent is consuming sufficient
calories and nutrients for growth
diet that omits breads and cereals
-can be deficient in vitamins B1 (thiamine) and B2 (riboflavin)--> which are necessary for growth An
adolescent needs an increased number of calories over that needed previously to support: the rapid body
growth that occurs
The nutrients that are most apt to be deficient in both male and female adolescent diets are:
iron, zinc, Ca
Iron
-is necessary to meet expanding blood volume requirements
-Females require a high iron intake--> increasing blood volume and iron begins to be lost with menstruation
-Girls with a heavy menstrual flow (menorrhagia) and those who participate in strenuous athletics--> may
need to take an additional iron supplement to prevent iron-deficiency anemia
-meat and green vegetables are good sources
Increased calcium and vitamin D plus physical exercise
-are necessary for rapid skeletal growth as well as to "stockpile" calcium to prevent osteoporosis later in life
Zinc
-is necessary for sexual maturation and final body growth
-meat and milk are high in zinc
Textured vegetable protein or tofu
-can be added to vegetarian meals to increase the amount of protein supplied and help meet adolescent growth
needs
the source of carbohydrate that best sustains athletes comes from:
-the breakdown of glycogen because this supplies a slow and steady release of glucose
Glycogen loading
-is a procedure used to ensure there is adequate glycogen to sustain energy through an athletic event
-Several days before a sports event--> athletes lower their carbohydrate intake and exercise heavily to deplete
muscle glycogen stores--> they then switch to a diet high in carbohydrate
-With the renewed carbohydrate intake--> muscle glycogen is stored at two to three times the usual level-->
supplies them with up to twice the glucose needed for sustained energy
Although glycogen loading is used by many high school athletes
-the effects of frequent glycogen loading in this age group are not well studied and so should be done cautiously
Dress and hygiene
-adolescents are capable of total self-care and, bc of their body awareness, may even be overly conscientious
about personal hygiene and appearance
-Adolescents can be acutely aware of how their peers dress
-Needing to look like everyone else--> undoubtedly a factor in adolescent shoplifting
Care of teeth
-very conscientious about tooth brushing because of a fear of developing bad breath
-should continue to use a fluoride paste rather than a brand advertised as providing white teeth
-continue to drink fluoridated water--> firm enamel growth
-too much fluoride--> fluorosis(blue discoloration of teeth)
-teens with braces--> must be extremely conscientious about tooth brushing to prevent plaque buildup on hidden
tooth surfaces
Because protein synthesis occurs most readily during sleep and adolescents are building so many new
cells, this age group:
-may need proportionately more sleep than any other age group
chronic lack of sleep
-can lead to chronic fatigue or depression
-medication is not usually recommended for adolescents
-urged to reduce activity to get more sleep
Exercise
-adolescents need exercise every day both to maintain muscle tone and to provide an outlet for tension
-adolescents often receive very little real exercise
Sun exposure
-critical time for them to avoid excessive sun exposure so they don't develop skin cancer (melanoma) from
ultraviolet rays
-encourage teenagers to use sunscreen, avoid tanning beds, and report to their primary healthcare provider any
skin mole that changes in shape or color
When a child reaches about age 15 years
-parent-child friction tends to peak
-adolescents have discovered from careful observation that most adults are far from perfect
By the time they are 16 years old
-adolescents generally become more willing to listen and talk about problems--> may learn adults are not as
inadequate as they previously thought
Most 17-year-old adolescents
-looking ahead to leaving a school system with which they may have been involved since they were very young
may give them a feeling of losing security
-Even if going away to college or beginning a full-time job seems exciting--> can also be an unwelcome
change from the people and routines they feel so comfortable with to new contacts and new regulations that
appear strange and even hostile
HTN
-present if BP is above the 95th percentile, or 127/81 mmHg for 16-year-old girls and 131/81 for 16-year-old
boys for two consecutive readings in different settings
-risk factors--> obese, black, diet high in salt, family hx
-All children older than 3 years of age--> should have their blood pressure routinely taken at all health
assessments
Poor posture
-particularly those who reach adult height before their peers, demonstrate poor posture, a tendency to round
shoulders and a shambling, slouchy walk to not be taller than those around them
-due to the imbalance of growth that arises from the skeletal system growing a little more rapidly than the
muscles attached to it
-Girls, especially, may slouch so as not to appear taller than boys or to diminish the appearance of their breast
size if they are developing more rapidly than their friends
-may be related to carrying backpacks that are too heavy
Body piercings and tattoos
-have become a way for adolescents to make a statement of who they are and that they are different from their
parents
-Be certain they know the symptoms of infection at a piercing or tattoo site (redness, warmness, drainage,
swelling, mild pain)--> report these to their healthcare provider if they occur because serious staphylococcal or
streptococcal infections can occur at piercing sites
Because so many adolescents comment that they feel fatigued to some degree, it can be considered:
normal for the age group
Fatigued adolescents
-always assess the diet, sleep patterns, and activity schedules
-if the fatigue began as a short period of extreme tiredness--> suggests disease more so than a long, ill-defined
report of always feeling tired
-Blood tests may be indicated to rule out anemia and common infections in adolescents, such as infectious
mononucleosis(mono)
Acne
-is a self-limiting inflammatory disease that involves the sebaceous glands, which empty into hair shafts (the
pilosebaceous unit)
-most common skin disorder of adolescence--> occurring in as many as 80% to 95% of adolescents
-girls--> peak age for lesions is 14-17yo
-boys--> peak age for lesions is 16-19yo
-genetic factors may play an influence(although not proven)
Changes associated with puberty that cause acne to develop include:
-androgen levels rise in both sexes--> sebaceous glands become active
-output of sebum(largely composed of lipids, mainly triglycerides) increases
-Trapped sebum causes whiteheads, or closed comedones.
-As trapped sebum darkens from accumulation of melanin and oxidation of the fatty acid component on
exposure to air, blackheads, or open comedones, form.
-Leakage of fatty acids causes a dermal inflammatory reaction.
-Bacteria (generally, Propionibacterium acnes) lodge and thrive in the retained secretions and ducts.
Comedones
-blocked hair follicle
Categorization of acne
-mild--> comedomes
-moderate--> papules and pustules are also present
-severe--> cysts are present
most common locations of acne lesions
-face, neck, back, upper arms, and chest
Acne flare-ups
-associated with emotional stress, menstrual periods, or the use of greasy hair creams or makeup that can
further plug gland ducts
Acne lesions
-less noticeable in summer months--> increased exposure to the sun-->increases epidermal peeling
-reduction in stress as a result of being out of school
assessment of adolescents with acne
-ask adolescents at health assessments if they are troubled with acne and to what extent it interferes with their
self-image--> can be a major cause of stress in adolescents
-Inspect for facial, chest, and back lesions on physical examination
The goal of therapy for acne is threefold:
-decrease sebum formation
-prevent comedomes
-control bacterial proliferation
External acne medications
-peel away the superficial skin layer to prevent sebum plugs from forming and are sufficient if only
comedones are present
tretinoin (Retin-A cream)
-reduces keratin formation and plugging of ducts
-Caution adolescents using a vitamin A cream to avoid prolonged sun exposure and to use a sunblock of SPF
15 or higher--> the preparation makes their skin more susceptible to ultraviolet rays
Additional creams frequently prescribed contain:
-benzoyl peroxide or azelaic acid
Caution adolescents that for the first week or two of acne therapy:

- peeling or oxidizing agents may make the complexion appear worse

topical antibiotic creams--> dapsone, tetracycline, or doxycycline

-may be prescribed if the adolescent has bacterial lesions
Tetracycline
-is not prescribed for children under age 12 years bc it can cause permanent staining of teeth and may possibly
interfere with growth of long bones
-contraindicated for adolescents who are or may become pregnant as it is teratogenic
-500 mg twice daily the first week and then tapered to 250 mg daily for maintenance
-effective against the anaerobic bacteria that break down sebum to form irritating acids
-Food impairs the absorption of oral tetracycline so the drug should be taken on an empty stomach (2 hours
before or after eating)
-must be certain of the date of expiration of the drug--> outdated tetracycline breaks down into an extremely
toxic composition
In pustular and cystic acne
-systemic(oral) antibiotics may be helpful
Systemic antibiotics
-have anti-inflammatory properties, and they are effective against P. acnes
-Improvement is not generally seen for 2 to 4 weeks--> may need to support adolescents to continue to take the
medication during the waiting period
doxycycline and minocycline
-more lipophilic than tetracycline--> generally more effective
Females taking systemic antibiotics for long periods of time
-become susceptible to developing candidal vaginitis and need to be instructed about the symptoms of
this(white, pruritic vaginal discharge)
-antibiotic use may interfere with oral contraceptives, adolescent girls who are sexually active should use
another method of birth control while taking the antibiotic
erythromycin or clindamycin
-alternative antibiotics
-avoid the complications of tetracycline--> may not produce the same effective results
Estrogen, alone or in combination with progesterone
-suppresses sebaceous gland activity--> useful therapy in some girls with acne
Estrogen
-tends to close epiphyseal centers of long bones, causing bone growth to halt
-long-term therapy side effects--> embolism and thrombophlebitis
Isotretinoin (Accutane)
-last resort in acne tx
-a retinoid or vitamin A compound
-short term use
-extremely teratogenic
-linked to IBS
-should not be taken at the same time as tetracycline--> can lead to brain edema
Many adolescents
-are left with some degree of scarring following teenage acne lesions--> laser therapy is a follow-up
possibility to reduce the effect of scarring
Obesity
-inheritance and environment play a part in the development of adolescent obesity
-can interfere with developing a sense of identity
-Bc of stress related to weight--> attempted suicide rate for obese female adolescents is higher than for non-
obese adolescents
Some adolescents may be unaware that their food intake is excessive because they have been told:
-they need excess nutrients for healthy adolescent growth and everyone in their family eats large portions
If adolescents eat a diet too low in protein for any length of time, they can develop:
-a faulty nitrogen balance, which can lead to seriously impaired growth--> Therefore, a diet of fewer than
1,400 to 1,600 calories per day can rarely be tolerated by adolescents--> generally do better and will stick
with a diet closer to 1,800 calories per day
General measures to help adolescents decrease overeating include:
-Making a detailed log of the amount they eat, the time, and the circumstances (including how they felt while
they were eating) and then changing those circumstances
-Always eating in one place (the kitchen table) instead of while walking home from school or watching
television
-Slowing the process of eating by counting mouthfuls and putting the fork down between bites, or being served
food on small plates so helpings look larger
flunitrazepam (Rohypnol)
-aka date rape drug
-colorless, odorless, and flavorless benzodiazepine drug
-dropped into a drink--> causing drowsiness, impaired motor skills, and amnesia for a time
-urine specimen analysis will reveal the drug's metabolites or that the drug was ingested
Adolescent asks "how will I know I am ready for sex", here are a few guidelines:
-It is your choice whether to participate in sexual relations. Do not be influenced by friends who may be
exaggerating stories to impress you or who ask you to do something you do not want to do. When you say no,
be firm and clear about your wishes.
-There is no 100% method to prevent pregnancy or a sexually transmitted infection (STI) except abstinence. Be
direct with a sexual partner in discussing abstinence or reproductive and infection prevention measures.
-Sexual relations neither add to nor detract from your physical strength or general wellness.
-The mark of an adult sexual relationship is that the activity is pleasurable to both partners. If sexual partners
are not interested in your enjoyment as well as their own, you should reconsider the relationship.
-There is no "normal" mode of sexual expression. Any activity that is pleasurable to both partners is "normal."
-Learn about safer sex techniques and practice them.
Stalking
-refers to repetitive, intrusive, and unwanted actions such as constant and threatening pursuit directed at an
individual to gain the individual's attention or to evoke fear
-avoiding stalking--> adolescents should be aware of and avoid situations where they will be vulnerable to
being alone with a stalker and, with assistance, report stalking to law enforcement
Bullying, which begun during school age:
can easily continue into adolescence and actually becomes more serious bc this can be the time the bullied child
has the ability to retaliate through self-destructive behavior or school violence
Hazing
-a form of organized bullying
- refers to demeaning or humiliating rituals that prospective members have to undergo to join sororities,
fraternities, adolescent gangs, or sports teams
Substance use disorder
-formerly referred to as substance abuse disorder
-refers to the use of chemicals to improve a mental state or induce euphoria
-common among adolescents that as many as 50% of high school seniors report having experimented with some
form of drug
-desire to expand consciousness, peer pressure, or a desire to feel more confident and mature; can be a form of
adolescent rebellion related to childhood adversity or violence
Adolescents may first begin drug experimentation by:
taking drugs prescribed for another family member or a pet such as sedatives, pain medication, ketamine (an
anesthetic used in veterinary medicine), or cough syrup containing codeine or dextromethorphan (DXM)-->
called "pharming" adolescents
Methylphenidate (Ritalin)
-a stimulant frequently prescribed for ADHD
-when oral tablets are crushed and injected intravenously--> produce a feeling of giddiness and extreme well-
being--> oral tabs do not completely dissolve, the resultant small particles remaining in the bloodstream can
result in complications(pulmonary embolus or emphysema)--
> very dangerous practice
Mephedrone
-commonly called "bath salts"
-a stimulant that creates an enjoyable "high"
-available for purchase online and so is easily obtained by adolescents
-effect of using it is seen more regularly in emergency departments as the cause of reckless driving or
unconsciousness
-Listed as a schedule 1 drug, it is now illegal to obtain
Alcohol stats
-as many as 90% of high school seniors report having consumed alcohol
-as many as 25% of high school students report having engaged in episodic heavy or binge drinking
-at least 10% of high school students report driving a car or other vehicle when they had been drinking alcohol
-Nearly 30% of students report having ridden in a car or other vehicle driven by someone who had been
drinking alcohol
Heredity has a definite role in the use of alcohol, but:
-environment plays an equal part in whether an adolescent becomes a frequent user
Most adolescents will admit they use alcohol if asked two specific questions:
-"Do you drink alcohol?" and "When was your last drink?" --> Adolescents who answer yes to the first and
"within the last 24 hours" to the second are candidates for further assessment
it is well documented that cigarette smoking leads to:
increased cardiovascular and respiratory illnesses by middle age
Tobacco stats
-every day approximately 4,000 American youth aged 12 to 17 years try their first cigarette
-As many as 20% of high school students report current cigarette use
-about 14% report current cigar use
-Eight percent of high school students report current smokeless tobacco use
Adolescents usually begin smoking
-bc the habit conveys a stamp of maturity; those who are having difficulty demonstrating maturity in other
areas may view smoking as especially desirable
Adolescent girls
-the population most likely to begin smoking
One of the strongest determinants of whether adolescents will smoke a first cigarette is whether:
-their friends smoke
Cigar smoking, smokeless tobacco(chewing)
-have been gaining popularity
Chewing tobacco
-can cause gingival recession and lip and mouth cancer
-can be just as habit forming as cigarettes
Nicotine gum and nicotine patches
-have both been successfully used with adolescents
e-cigarettes and vaping
-use in recent years has inc significantly
-use has been demonstrated to actually increase the use of cigarette consumption--> become addicted to the
nicotine in the e-cigarette
-lack of regulations--> easy access
Anabolic steroids
-are derivatives of the natural hormone testosterone
-common names--> stanozolol(oral compound) and testosterone propionate(injectable form)
-enhance lean body mass and muscular development and so improve their athletic ability or appearance.
-side effects--> euphoria and lessened fatigue, which make them doubly appealing
Steroids
-can lead to early closure of the epiphyseal line of long bones, acne, elevated triglyceride levels, hypertension,
aggressiveness, possibly psychosis, abnormal liver function, and perhaps liver cancer
-athletes using them and paying vigorous sports can die from ventricular hypertrophy
Human growth hormone
-used to enhance athletic performance
-increases muscle strength and stamina and is more difficult to detect than steroid--> becoming a commonly
abused substance in athletes
-dangerous in adolescents bc side effects are joint pain and swelling and the development of diabetes
Marijuana
-derived from the leaves and stems of the Indian hemp plant Cannabis sativa
-the most frequently abused illicit substance, next to alcohol
-breakdown products of marijuana are not readily eliminated from the body and remain in the fatty cells of the
brain
-Physical and psychological effects of all forms of marijuana--> euphoria and a sense of well- being,
temporary impairment of coordination, rapid mood swings, decreased attention span, and loss of memory for
recent events (up to 1 hour's time)
-prescribed to relieve nausea and vomiting--> adolescents may view it as harmless
Marijuana withdrawal symptoms
-irritability, drowsiness, and cravings for high-carbohydrate snacks
Long term side effects of marijuana
-pulmonary disorders such as sinusitis, bronchitis, emphysema, and perhaps lung cancer (which can develop
after only 1 year of continual use compared with 20 years of cigarette use)
-lack of sperm formation or subfertility in males
Amphetamines
-group of drugs used in the treatment of hyperactivity and narcolepsy, among other central nervous system
disorders
-easily manufactured in "meth labs" in people's homes and so may be readily available to adolescents
-give the user a false sense of well-being, alertness, or self-esteem
-stronger form that produces intense symptoms is known as "ice"
-side effects--> aggressive or demanding behavior, paranoia, and extreme restlessness.
-chronic use--> destruction of teeth enamel or blackened, crumbling teeth
-appealing to adolescents--> suppress the appetite and result in weight loss
Cocaine
-is one of the most popular drugs of abuse for late adolescents
-may be sniffed into the nose (snorted), smoked, or injected intravenously
-occasionally combines with heroin and injected
-used by 3-9% of adolescents
-After absorption--> blood levels rise rapidly for the first 20 minutes, peak at 60 minutes, and then decline
over the next 3 hours
-toxic dose of cocaine is usually considered to be 600 to 700 mg, toxicity has been reported in as low as a 20 mg
dose (a single line)
Crack
-stronger form of cocaine
-manufactured by heating cocaine powder with baking soda and water--> process is dangerous in itself because it
involves using volatile solvents that can ignite or explode
-often called "freebase" or "rock,"
-so strong it can cause immediate cardiac and respiratory arrhythmias
Cocaine produces the physical effects of:
-increased pulse and respiration rates, increased temperature, increased blood pressure, and decreased appetite
Psychological effects of cocaine
-euphoria, excitement and restlessness, increased sociability, and possible hallucinations
Toxic symptoms of cocaine
-include seizures, tachyarrhythmias, tachypnea, hypertension, nausea and vomiting, abdominal pain, headaches,
chills, and fever
Cocaine is rarely ingested orally, but:
-occasionally, adolescents swallow it when trying to hide a supply from parents or school personnel
-Gastric acid destroys the action of cocaine--> unless the amount is extremely large, it is potentially harmless
when swallowed in this way
Chronic inhalation of cocaine
-can cause ulceration in the mucous membrane of the nose
Injection of cocaine
-exposes an adolescent to the risk of HIV and AIDS or hepatitis B
Cocaine during pregnancy
-can cause separation of the placenta with potential fetal and maternal death
Examples of hallucinogenic drugs used by adolescents are:
lysergic acid diethylamide (LSD), dimethyltryptamine (DMT), 2,5-dimethoxy-4- methylamphetamine (STP),
phencyclidine (PCP) hydrochloride, Salvia divinorum, mephedrone ("bath salts"), and methaqualone
(Quaalude)
The use of LSD
-has substantially increased in popularity since the 1960s when it first became available bc it is a drug that can
be manufactured by an informed adolescent in a "kitchen lab"
3,4-Methylenedioxymethamphetamine (MDMA), also known as Molly/Ecstasy
-similar to both stimulants and hallucinogens
-gives users feelings of euphoria, pleasure, distorted time, and sensory perception
-popular at dance clubs and "raves"
-taken in tablet or capsule form or snorted
-affects typically last 3 to 6 hours
-side effects--> irritability, aggression, depression, anxiety, decreased appetite, and memory problems
-some disagreement on whether MDMA is addictive
Hallucinogens
-cause bizarre mind reactions such as distortion in vision, smell, or hearing
-Adolescents report seeing colors more vividly than they have ever seen them before, hearing sounds so clear
they cause physical pain, or perceiving themselves as being totally impervious to harm leading to "good
trips" or "bad trips"
-Recurrences or flashbacks of drug-induced experiences may recur at unpredictable times and in unexpected
places--> can be dangerous especially when operating a vehicle
Opiates
-include drugs such as heroin, meperidine (Demerol), and morphine
-can be extremely dangerous because of their tendency to decrease one's respiratory rate
American Academy of Pediatrics
-recommends screening adolescents for substance use disorders
Screening, Brief Intervention, and Referral to Treatment (SBIRT)
-is a model used to help prevent substance use disorders and to limit the progression to riskier drugs, such as
heroin
Important teaching points for avoiding drug use include:
-Whether a drug is inhaled, swallowed, or injected, it still is absorbed, enters your body, and is therefore
potentially harmful.
-Relying on drugs to give you courage to solve problems (or to help you forget you have problems) prevents
you from learning to handle life situations and maturing.
-The bottom line of substance use disorder is that you have the final say: You are the only one who can stop
chemical dependency from happening.
-Despite their social acceptability, alcohol and nicotine are drugs. A short span of daily use of either can make
you addicted.
Glue
-symptoms of use: Violence, drunken appearance, dreamy or blank expression; glue smears on clothing or
fingers; tubes of glue, paper bags in possession
-dangers: Lung, brain, or liver damage; death through suffocation or choking; anemia
heroin, codeine, morphine
-symptoms of use: Stupor, drowsiness, needle marks on body, watery eyes, loss of appetite, bloodstains on
shirt sleeve, runny nose; possession of needles or hypodermic syringes, cotton, tourniquet strings, burnt bottle
caps or spoons, glassine envelopes
-dangers: Death from overdose; addiction; liver and other infections due to unsterile needles
Cough medicines containing codeine
-symptoms of use: Drunken appearance, lack of coordination, confusion, excessive itching; possession of empty
bottles of cough medicine
-dangers: addiction
Marijuana
-symptoms of use: Sleepiness, wandering mind, enlarged pupils, lack of coordination; discolored fingers, strong
odor of burnt leaves; possession of small seeds in pocket lining, cigarette papers
-dangers: Psychological dependence
Hallucinogens (LSD, DMT, PCP)
-symptoms of use: Severe hallucinations, feelings of detachment, incoherent speech, cold hands and feet,
laughing and crying, vomiting, strong body odor; possession of cube sugar with discoloration in center
-dangers: Suicidal tendencies, unpredictable behavior; chronic exposure may have neurologic effects
Stimulants (methamphetamine, cocaine)
-symptoms of use: Aggressive behavior, giggling, silliness, rapid speech, confused thinking, no appetite,
extreme fatigue, black caries, dry mouth, shakiness, insomnia, absence of nasal hair; possession of pills or
capsules of varying colors, possession of a glass pipe
-dangers: Death from overdose; hallucinations; psychosis
Depressants (barbiturates, alcohol)
-symptoms of use: Drowsiness, stupor, dullness, slurred speech, drunken appearance, vomiting, odor of alcohol
on breath; possession of pills or capsules of varying colors
-dangers: Death or unconsciousness from overdose; addiction; seizures from withdrawal
Steroids
-symptoms of use: Aggressive behavior, increase in muscle strength and mass
-dangers: Violent actions; possibly tumor growth
Self-injury
-includes a range of self-destructive actions from cutting to suicide, the planned intent to end one's life
Cutting
-is found more frequently in girls than boys and can begin as early as grade school
Successful suicide
-occurs more frequently in males than in females, although more females apparently attempt suicide than males
(a ratio of about 8:1)
Adolescent suicides
-tend to be attempted most often in the spring or the fall--> reflecting school stress at these times of year, and
between 3 PM and midnight--> reflecting depression that increases with the dark
Suicide
-is so common in adolescents it ranks in the top four causes of death in the 10- to 24-year-old age group
-If another member of a family or a close friend commits suicide, the chance an adolescent will also do so is
greater than usual
The top four causes of death of adolescents:
-motor vehicle crashes (23%), other intentional injuries (17%), homicide (14%), and suicide (17%)
In younger adolescents:
depression may be manifested not so much by appearing sad, but by behavior problems such as disobedience,
temper tantrums, truancy, and running away
Commonly seen clues for suicide:
-Giving away prized possessions
-Organ donation questions, such as "How do you leave your body to a medical school?"
-Sudden, unexplained elevation of mood, which may indicate the individual has reached a decision about the
suicide and feels relief
-Injury proneness, carelessness, and death wishes
-Decrease in verbal communication or a statement such as "This is the last time you will see me"
-Withdrawal from peer activities or previously enjoyed events
-Previous attempt (80% of all completed suicides have been preceded by a failed attempt)
-Preference for art, music, and literature with themes of death
-Recent increase in interpersonal conflict with significant others
- Running away from home
-Recent experience of a friend or famous person committing suicide -Inquiring about the hereafter
-Asking for information (supposedly for a friend) about suicide prevention and intervention
-Almost any sustained deviation from the normal pattern of behavior
Runaway
-commonly defined as an adolescent between the ages of 10 and 17 years who has been absent from home at
least overnight without permission of a parent or guardian
-most teenagers who run away do not go far or stay away long(under 1 wk), some never return home and become
homeless youth
-most likely to be from either low- or high-income families
-frequent characteristics in their family--> family unemployment, alcoholism, sexual maltreatment, incest,
attempted suicide, and poverty
-slightly more likely to be male than female
Common health reasons for which runaway adolescents are seen at healthcare facilities:
-sexually transmitted diseases, including HIV and AIDS, rape, pregnancy, substance use disorders, hepatitis,
and vaginitis
-have a high incidence of suicide attempts