Growth & Devt[1].

PEDIATRIC NURSING GROWTH AND DEVELOPMENT

I. PHASES OF GROWTH AND DVELOPMENT Process – sequence is orderly and predictable; rate tends to be variable within ( more quickly/ slowly) and between (earlier/later) individuals growth – increase in size (height and weight; tends to cyclical, more rapid in utero, during infancy, and adolescence

2. developmental – maturation of phychosocial systems to more complex state Developmental tasks – skills and competencies associated with each developmental stage that have an effect on subsequent stages of development Developmental milestone – standard of reference by which to compare the Childs behavior at specific ages Developmental delay(s) – variable of developmental which lags behind the range of a given age

Principles of Growth Children are individuals, not little adults, who must be seen as part of a family. Children are influenced by genetic factors, home and environment, and parental attitudes. Chronologic & developmental ages of children are the most important contributing factors influencing their care.

Play is a natural medium for expression, communication, and growth in children. Growth is complex, with all aspects closely related Growth is measured both quantitatively and qualitatively over a period of time. Although the rate is uneven, growth is continuous and orderly process: Principles of Growth

Principles of Growth 7.a. Infancy : most rapid period of growth b. Preschool to puberty : slow and uniform rate of growth. c. Puberty : (growth spurt) second most rapid growth period. d. After Puberty : decline in growth rate till death.

There are regular patterns in the direction of growth and development, such as the cephalocaudal law (from head to toe) and from proximodistal law (from center to periphery) Principles of Growth

Different parts of the body grow at different rates: Prenatally: head grows the fastest. During the first year: elongation of trunk dominates Both rate and pattern of growth can be modified, most obviously by nutrition. Principles of Growth

There are critical or sensitive periods in G&D, such as brain growth during uterine life and infancy. Although there are specified sequences for achieving G&D, each individual proceeds at own rate. D is closely R/T the maturation of the nervous system; as primitive reflexes disappear, they are replaced by a voluntary activity. Principles of Growth

Physiological Characteristics of Growth Circulatory System: Heart rate decreases with increasing age Infancy: 120 bpm One year: 80 to 120 bpm Childhood: 70 to 110 bpm Adolescence to adulthood: 55 to 90 bpm

Blood pressure increases with age The 50 th percentile ranges from 55 to 70 mmHg diastolic; 100 to 110 mmHg systolic These levels increase about 2 to 3 mmHg / yr. starting at age 7 yrs. Systolic pressure in adolescence: higher in males than in females

Hemoglobin Highest at birth, 17 g/100 ml of blood; then decreases to 10 to 15 g/100 ml by 1 year. Fetal Hgb (60% to 90% of total Hgb) gradually decreases during the first yr to less than 5%. Gradual increase in Hgb level to 14.5 g/100ml between 1 & 12 yrs. Level Higher in males than in females

Respiratory System Rate decreases with increase in age: Infancy: 30 to 40 cpm Childhood: 20 to 24 cpm Adolescence & adulthood: 16 to 18 cpm

Vital Capacity Gradual increase throughout childhood and adolescence, with a decrease in later life Capacity in males exceeds that in females

Basal Metabolism Highest rate is found in the newborn Rate declines with increase in age; highest in males than in females.

Urinary System Premature & full term Newborns have some inability to concentrate urine. Specific Gravity: (Newborn): 1.001 to 1.02 Specific Gravity: (Others): 1.002 to 1.03 GFR greatly increased by 6 months of age; reaches adult values between 1 & 2 years; gradually decreases after 20 years.

Digestive System Stomach size is small at birth; rapidly increases during infancy and childhood Peristaltic activity decreases with advancing age Blood Glucose levels gradually rise from 75 to 80 mg/100 ml of blood in infancy to 95 to 100 mg during adolescence.

Premature infants have lower blood glucose levels than do full-term infants. Enzymes are present at birth to digest proteins and a moderate amount of fat but only simple sugars (amylase is produced as starch is introduced) Secretion of Hcl acid & salivary enzymes increases with age until adolescence; then decreases with advancing age. Digestive System

Nervous System Brain reaches 90% of total size by 2 yrs of age. All brain cells are present by the end of the first year, although their size & complexity will increase. Maturation of the brainstem & spinal cord follows Cephalocaudal & Proximodistal Laws.

Functions of Play Educational: learn about physical world & associate names with objects. Recreational: Release surplus energy Sensorimotor: Muscle development and tactile, auditory, visual, and kinesthetic stimulation

Social & emotional adjustment: learn moral values; develop the idea of sharing Therapeutic: release of tension & stress; manipulation of syringe and other equipment allows control over threatening events. Functions of Play

Types of Play Active, Physical: push-and-pull toys; riding toys; sports and gym equipment Manipulative, constructive, creative, or scientific: blocks, construction toys such as erector sets; drawing sets; microscope & chemistry sets; books; computer programs

Imitative, imaginative, and dramatic: dolls, dress-up costumes; puppets. Competitive and social: games; role playing Types of Play

Criteria for judging the suitability of toys

Safety Compatibility: child’s age; level of development; experience Usefulness Challenge to development of the child; assist child to achieve mastery. Enhance social & personality development; increase motor & sensory skills; develop creativity; express emotions Implement therapeutic procedures

Criteria for judging the nonsuitability of toys Unsafe Beyond the child’s level of G&D; overstimulating; frustrating Foster isolation from peer group

Theoretical approaches to development

Erickson (psychosocial approach) (see the table XVI – 1) Social development Role of play in development

Demonstrates an inability to trust: withdrawal, isolation Trusts self and others Trust vs. Mistrust Infancy Birth to 18 mo. NEGATIVE OUTCOME POSITIVE OUTCOME ERIKSON’S TASK STAGE AGE OVERVIEW OF ERIKSON’S DEVELOPMENTAL TASKS THROUGHOUT THE LIFE SPAN

Demonstrates fearful, pessimistic behaviors; lacks self confidence` Begins to evaluate own behavior; learns limits on influences on the environment Initiative vs. Guilt Preschool 3 to 6 y Demonstrates defiance and negativism Exercises self – control and influences the environment directly Autonym vs. Shame and Doubt Toddler 18 mo to 3 y

Demonstrates inability to develop personal and vocational identity Develops a coherent sense of self; plans for a future of work/ education Identity vs. Role Confusion Adolescence 12 to 20 y Demonstrates feelings of inadequacy, mediocrity, and self – doubt Develops a sense of confidence; learns limits on influence in the environment Industry vs. Inferiority School age 6 to 12 y

Demonstrates an avoidance of intimacy and vocational/career commitments Develops connections to work and intimate relationships Intimacy vs. Isolation Young adulthood 20 to 45 y

Demonstrates fear pf death; life lacks meanings Identification of life as meaningful; Integrity vs. Despair Late adulthood 65 plus Demonstrates lack of interest, commitments: preoccupation with self – centered concerns Involved with established family; expands personal creativity and productivity Generativity vs. Stagnation Middle adulthood 45 to 65 y

Piaget ( cognitive approach) – four stages Sensorimotor – birth to 2 y. old Simple incremental learning – begins with reflex activity progressing to repetitive behavior, then to imitative behavior Increased level of curiosity Sense of self as differential and separate from environment Increasing awareness of object permanence (things exist even if not visible)

2. Preoperational – 2 to 7 y. old Thinking and learning are concrete and tangible, based on what is seen, hard, felt, experienced; cannot make generalizations/deductions Toward the end of this stage, reasoning is more intuitive; beginning understanding of size, mass, times

3. Concrete operations – 7 to 11 y old Increasingly logical and coherent in thinking; solves problems in concrete manner Able to sort, classify, collect, order, and organize facts about the environment Can manage a number of aspects of a situation at one time but not yet able to deal with abstractions Can consider other points of view

4. Formal operations – 12 to 15 y old Able to deal with abstractions and abstract symbols Flexible and adaptable Can problem solve, develop hypotheses, test them, and arrive at conclusions Questions and examines moral, ethical, religious, and social issues as beginning definition of self as an adults

PIAGET’S THEORY OF COGNITIVE DEVELOPMENT

Reliance on reflexes to interact with environment 0-2 years old Sensorimotor reflexes CHARACTERISTICS APPROXIMATE AGE STAGES/SUBSTANCES

Magical thinking, Egocentrism:cannot take another’s point of view.centring:tendency to center attention to one feature and unable to see other qualities 5-7 years old Intuitive Increase use of language unable to put self in another’s place, does not understand and relationship of size, weight, volume 3-7 years old Pre-operational Preconceptual

Capable of introspection, deductive reasoning (general or universal to specific) able to formulate and test hypothesis. 13-16 years old Formal operations Inductive reasoning (specific to general) Conservation-ability to understand that a things essentially the same even though its shape and arrangement is altered. Reversibility – ability to conceptualize that a complete process can also be performed in the reverse order. 8-13 years old Concrete operations

Freud (psychoanalytical approach) experiences at different stages influences personality traits

Oral (birth to 1 y) – pessimism / optimism, trust/suspicious Anal ( 1 to 3 y) – retentiveness/ overgenerosity, rigidity/laxity, constricted ness/expansiveness, stubbornness/acquiescence, orderliness/messiness

Phallic / oedipal (3 to 6 y) – brashness / bashfulness, gaiety / sadness, stylishness/plainness, gregariousness/isolation Latency (6 to 12 y) – elaboration of previously acquired traits Genital ( 12+ y) – preparation for forming relationships and marriages

Robert Havighurst: Developmental Theorist

"The developmental-task concept occupies middle ground between two opposed theories of education: the theory of freedom— that the child will develop best if left as free as possible , and the theory of constraint— that the child must learn to become a worthy, responsible adult through restraints imposed by his society.

A developmental task is midway between an individual need and societal demand. It assumes an active learner interacting with an active social environment" (1971, p. vi).

The Developmental Task Concept From examining the changes in your own life span you can see that critical tasks arise at certain times in our lives. Mastery of these tasks is satisfying and encourages us to go on to new challenges . Difficulty with them slows progress toward future accomplishments and goals.

six major age periods: infancy and early childhood (0-5 years), middle childhood (6-12 years) adolescence (13-18 years), early adulthood (19-29 years), middle adulthood (30-60 years), and later maturity (61+).

Developmental Tasks of Infancy and Early Childhood: Learning to walk. Learning to take solid foods Learning to talk Learning to control the elimination of body wastes Learning sex differences and sexual modesty Forming concepts and learning language to describe social and physical reality. Getting ready to read

Ages birth to 6-12 Learning physical skills necessary for ordinary games. Building wholesome attitudes toward oneself as a growing organism Learning to get along with age-mates Learning an appropriate masculine or feminine social role

Ages birth to 6-12 Developing fundamental skills in reading, writing, and calculating Developing concepts necessary for everyday living. Developing conscience, morality, and a scale of values Achieving personal independence Developing attitudes toward social groups and institutions

Developmental Tasks of Adolescence: Ages birth to 12-18 Achieving new and more mature relations with age-mates of both sexes Achieving a masculine or feminine social role Accepting one's physique and using the body effectively Achieving emotional independence of parents and other adults

Developmental Tasks of Adolescence: Ages birth to 12-18 Preparing for marriage and family life Preparing for an economic career Acquiring a set of values and an ethical system as a guide to behavior; developing an ideology Desiring and achieving socially responsible behavior

Developmental Tasks of Early Adulthood Selecting a mate Achieving a masculine or feminine social role Learning to live with a marriage partner Starting a family Rearing children

Developmental Tasks of Early Adulthood Managing a home Getting started in an occupation Taking on civic responsibility Finding a congenial social group

Developmental Tasks of Middle Age 1. Assisting teen-age children to become responsible and happy adults 2. Achieving adult social and civic responsibility 3. Reaching and maintaining satisfactory performance in one's occupational career 4. Developing adult leisure-time activities 5. Relating oneself to one's spouse as a person 6. To accept and adjust to the physiological changes of middle age 7. Adjusting to aging parents

Developmental Tasks of Later Maturity 1. Adjusting to decreasing physical strength and health 2. Adjustment to retirement and reduced income 3. Adjusting to death of a spouse 4. Establishing an explicit affiliation with one's age group 5. Adopting and adapting social roles in a flexible way 6. Establishing satisfactory physical living arrangements

Super” Vocational Development Stages Growth B-14 Development of Abilities, Interests, Needs Associated with Self-Concept Exploration 15-24 Tentative Plans, Choices Narrowed not Finalized Establishment 25-44 Stable Career Identity Maintenance 45-64 Small Adjustments Decline 65 + Reduced Productivity and Retirement

Lawrence Kohlberg Stages of Reasoning

Stage 1 - Obedience and Punishment The earliest stage of moral development is especially common in young children, but adults are capable of expressing this type of reasoning. At this stage, children see rules as fixed and absolute. Obeying the rules is important because it is a means to avoid punishment. Stage 2 - Individualism and Exchange At this stage, children account for individual points of view and judge actions based on how they serve individual needs. In the Heinz dilemma, children argued that the best course of action was whichever best-served Heinz’s needs. Reciprocity is possible, but only if it serves one's own interests. Level 1. Preconventional Morality

Level 2. Conventional Morality Stage 3 - Interpersonal Relationships Often referred to as the "good boy-good girl" orientation, this stage is focused on living up to social expectations and roles. There is an emphasis on conformity, being "nice," and consideration of how choices influence relationships. Stage 4 - Maintaining Social Order At this stage of moral development, people begin to consider society as a whole when making judgments. The focus is on maintaining law and order by following the rules, doing one’s duty, and respecting authority.

Level 3. Postconventional Morality Stage 5 - Social Contract and Individual Rights At this stage, people begin to account for the differing values, opinions, and beliefs of other people. Rules of law are important for maintaining a society, but members of the society should agree upon these standards. Stage 6 - Universal Principles Kolhberg’s final level of moral reasoning is based upon universal ethical principles and abstract reasoning. At this stage, people follow these internalized principles of justice, even if they conflict with laws and rules.

Criticisms of Kohlberg's Theory of Moral Development: Does moral reasoning necessarily lead to moral behavior? Kohlberg's theory is concerned with moral thinking, but there is a big difference between knowing what we ought to do versus our actual actions. Is justice the only aspect of moral reasoning we should consider? Critics have pointed out that Kohlberg's theory overemphasizes the concept as justice when making moral choices. Other factors such as compassion, caring, and other interpersonal feelings may play an important part in moral reasoning. Does Kohlberg's theory overemphasize Western philosophy? Individualistic cultures emphasize personal rights while collectivistic cultures stress the importance of society and community. Eastern cultures may have different moral outlooks that Kohlberg's theory does not account for.

C. Chronological phases Prenatal – conception until birth: rapid growth and development Neonatal – birth until 4 wk of age: adjustment to extra uterine life Infancy – 4 wk to 12 or 18 mo (upright locomotion); rapid and incremental growth and motor, cognitive, and social development (see table XIV – 2)

Appearance of thumb apposition Absent tonic neck reflex Evidence of pleasure in social contact Drooling Moro reflex absent after 3 – 4 mo Closing of posterior fontanelle Diminished tonic neck and Moro reflexes Able to turn from side to back Eyes begin to follow a moving object Social smile first appears 4 mo 2 mo Can bring objects to mouth at will Head held erect, steady Binocular vision Miles mother’s presence Laughs audibly Head sags Early movements 3 mo 1 mo INFANT GROWTH AND DEVELOPMENT

Average weight gain of 4 oz per week during second 6 mo Teething may begin (lower central incisors) Can turn from back to stomach Early ability to distinguish and recognize strangers 6 mo Birth weight usually doubled Takes objects presented to him/her 5 mo Anxiety with strangers 8 mo Sits for short periods Grasps toy with hand (partially successful) Fear of strangers begins to appear Liability of mood (abrupt mood shifts) 7 mo

Crawls well Pulls self to standing position with support Brings hands together Vocalizes one or two words 10 mo Elevates self to sitting position Rudimentary imitative expression responds to parental anger Expressions like ‘dada” may be heard 9 mo Birth weight usually tripled Needs help while walking Sits from standing position without assistance Eats with fingers Usually says two words in addition to “mama” and “dada” 12 mo Erect standing posture with support 11 mo

Books with large pictures, push – pull toys, teddy bears 9-12 mo Large toys with bright colors, movable parts, and noisemakers 6-9 mo Brightly colored toys ( small enough to grasp, large enough for safety) 4 – 6 mo Rattles, cradle gym 2 – 4 mo Mobiles Birth to 2 months AGE – APPROPRIATE TOYS

Toddler 12/18 mo to 3 y: slowed growth: marked physical and personality development characterize by profound activity, curiosity, and negativism (see Table XIV – 3)

Physical – birth weight quadrupled by 2 ½ years; height grows about 8 in (20.3 cm); pulse 110, respiration 26, BP 99/64;20 teeth by 2 1/2 ; has sphincter control needed for toilet training; appetite lessens because of decreased growth needs Motor – walks well forward and backward, stoops and recovers, climbs, runs, jumps in place, throws overhand, voluntarily releases hand, uses spoon, drinks from cup, scribbles, builds two then four – block towers

Pychosocial indicates wants by behaviors other than crying, may have temper tantrums; increases vocabulary from 10 – 20 words to about 900 at 3 y; imitates, helps with household chores; points to body parts, recognizes animals; almost dressing/undressing with help at 18 to 24 mo (cannot zipper, button, tie shoes); attachment to “security blanket”/stuffed animal

Play – parallel play; appropriate toys include push-pull toys, riding toys, work bench, toy hammers, drums, pots and pas, blocks, puzzles with very few large pieces, finger paints, crayons; dolls/stuffed animals Stresses – separation from parents (bedtime may be seen as desertion); alteration in environment/routine/rituals (expect regression/temper tantrums); toilet training; loud noises/animals

Safety – accidents (i.e., motor vehicle, burns, poising, falls, choking/suffocation – round, cylindrical, and pliable objects, such as balloons, are most dangerous) are leasing cause of death because of continued clumsiness associated with increased mobility, as well as striving for independence and heightened curiosity accompanied by the ability to open things but without cognitive ability to understand potential dangers; requires vigilant child-proofing and supervision while promoting independence; child restraint in motor vehicles is absolute

Three phases of separation Protest – cries/screams for parents; inconsolable by others Despair – crying ends; less active; uninterested in food/play; clutches “security” object if available Denial – appears adjusted; evidences interest in environment; ignores parent when he/she returns; resigned, not contented

Early efforts at jumping Builds 5 to 6 block tower 300 – word vocabulary Obeys easy command Walks alone Builds 2 blocks tower Throws objects Grasps spoon Names commonplace objects 24 mo 15 mo TODDLER GROWTH AND DEVELOPMENT

Walks on tiptoe Builds 7 to 8 block tower Stands on one foot Has sphincter control for toilet training Anterior fontanelle usually closed Walks backward Climbs stairs Scribbles Builds 3 block tower Oral vocabulary – 10 words Thumb sucking 30 mo 18 mo

Stuffed animals Low rocking horses Dolls Push – pull toys AGE – APPROPRIATE TOYS

Preschool 3 to 6 y; steady growth and development distinguished by acquisition of language, social skills and imagination as well as enhanced self-control and mastery (see Table XIV – 4)

Physical weight increases 4 – 6 lb/y (1.8 – 2.7 kg); birth length doubled by 4 y; pulse 90-100, respirations 24-25, BP 85 – 100/60-70; permanent molars appear behind deciduous teeth, maximum potential for amblyopia/ “lazy eye” (reduced visual acuity in one eye); handedness is established

Motor rides tricycle walks up (3 y) then down (4 y) stairs alternating feet; hops on one foot, tandem walks; draws circle, then cross, then triangle; dresses with assistance, then with supervision, then alone

Psychosocial knows first name, then age, then last name; uses plurals and three – word sentences, progressing to complex sentences, follows directions, counts; knows simple songs, name of colors, coins, meaning of many words; asks inquisitive questions; evidence of gender specific behavior by 5 y; become more eager to please; may develop imaginary playmates

Play associative/ interactive/cooperative play; appropriate toys include tricycles and playground equipment; construction set, illustrated books, puzzles, modeling clay, paints/crayons, simple games; imitative and dramatic play (dress-up, doll house, puppets); supervise TV

Stresses illogical fears (inanimate objects, the dark, ghosts); separation from parents, may be evidenced as anorexia, continued quiet crying, and/or aggression; bodily injury, mutilation ( fear that puncture will not close and insides will leak out) and pain; intrusive procedures are threatening

Safety similar to toddler; can understand and learn about potential dangers; shoulders harness and lap belt appropriate when child is either 40 lbs., 40 in, or 4 yr old

PRESCHOOL GROWTH AND DEVELOPMENT

Copies a circle Builds bridge with 3 cubes Less negativistic than toddler, decreased tantrums Rides tricycle Walks backward and downstairs without assistance Undresses without help 900 – word vocabulary uses sentences May invent “imaginary” friend 3 YEARS

Climbs and jumps well Laces shoes Brushes teeth 1,50 – word vocabulary Skips and hop on one foot Throws overhead 4 YEARS

Runs well Jumps rope Dresses without help 2,100 – word vocabulary Tolerates increasing periods of separation from parents Beginnings of cooperative play Gender – specific behavior Skips on alternate feet Ties shoes 5 YEARS

Child imitative of adult patterns and roles. Offer playground materials, housekeeping toys, coloring books, tricycles with helmet AGE – APPROPRIATE TOYS AND ACTIVITIES

School Age 6 to 11/12 y; constant progress in physical, mental, and social development, skill, competency, and self-concept (see Table XIV – 5)

Physical – continued slow growth; begins losing temporary teeth early in this phase and has all permanent teeth, except final molars by the end; bone growth exceeds that of muscle and ligament, resulting in susceptibility to injures/fractures Motor – skips, skates, tumbles tandem walks backward, prints progressing to script, ties knots then bows

Psychosocial has significant peer relationships, assumes complete responsibility for personal care; school occupies most of time and has social as well as cognitive impact; developing morality, dominated by moral realism with strict sense of right/wrong until 9 y, then development of moral autonomy recognizing different points of view; able to acknowledge own strengths and weaknesses; developing modesty

Play – group play with leader and organized rules/ rituals; usual activities include team games/sports/organizations; board games, books, swimming, hiking, bicycling, skating Stresses – possible school phobia; fear of death, disease/ injury, punishment Safety – decreasing incidence of accidents except for injuries associated with sports/activities, requires appropriate supervision and education about proper use and maintenance of equipment and hazards of risk taking

SCHOOL – AGE GROWTH AND DEVELOPMENT Temporal perception improving Increased self – reliance for basic activities Team games/sports/organization Develops concept of time Boys prefer playing with boys and girls with girls 7 years Self – centered, show – off, rude Extreme sensitivity to criticism Begins losing temporary teeth Appearance of first permanent teeth Ties knots 6 Years

Friends sought out actively Eye development generally complete Movements more graceful Writings replaces printing 8 years SCHOOL – AGE GROWTH AND DEVELOPMENT

SCHOOL – AGE GROWTH AND DEVELOPMENT Skilful manual work possible Conflicts between adult authorities and peer group Better behaved Conflict between needs for independence and dependence Like school 9 Years

Remainder of teeth (except wisdom) erupt Uses telephone Capable of helping Increasingly responsible More selective when choosing friends Develops beginning of interest in opposite sex Loves conversation Raises pets 10 -12 years SCHOOL – AGE GROWTH AND DEVELOPMENT

Use of tools Participation in repair, building, and mechanical activities Construction toys AGE – APPROPRIATE TOYS, GAMES AND ACTIVITIES

Adolescence approximately 11/12 to 12/20 (depending on gender and individual rate); rapid and dynamic biological, physical, and personality maturation characterized by emotional and family turmoil, leading to redefinition of self-concept and establishment of independence (see table XIV – 6)

Physical – vital signs approach adult levels; wisdom teeth appear about 17 -21 y; puberty is related to hormonal changes and is universal in pattern but not rate (females tend to develop earlier than males)

Growth spurt occurs early Girls – height increases approximately 3 in/y, slows dramatically at menarche and ceases around age 16; fat is deposited in thighs, hips, and breasts; pelvis broadens Boys – height increase 4 in/y starting about age 13 and slows in late teens; weight doubles between 12 and 18 y old, related to increased muscle mass; broader chest

Sweat production and increased body odor result from increased Apocrine gland activity: acne may occur related to increased sebaceous activity

Sexual characteristics and functioning develop Females Increase in pelvic diameter Breast development – bud stage with protuberant areola; complete about time of menarche Nature of vaginal secretions changes Axillary and pubic hair appear Menarche – first menstrual period occurs around 12 ½; for first 1-2 y anovulatory, frequently irregular menses

Males Increase in genital size beginning about 13 y is first sign of sexual maturation; continues until reproductive maturity ( age 17-18) Possible temporary breast swelling of short duration Pubic, facial, Axillary, and chest hair appear Voice deepens Production of functional sperm Nocturnal emissions – normal physiologic reflex to ejaculate build up of semen occurring during sleep; masturbation increases as a way to release semen Motor – often clumsiness associated with growth spurt, motor ability is at adult levels

Psychosocial Early – preoccupied with changing body; ambivalent relationship with parents/authority figures; seeking peer affiliations; may begin “dating”; wide and intense mood swings; limited capability for abstract thinking; seeking to identify values

Middle – very – centered ; rich fantasy life; idealistic; major conflicts with parents/authority figures; strong identification with peer group; multiple “love”/sexual relationships (homosexuality is recognized by this time); tends to be more introspective and withdrawn; enhanced ability for abstract reasoning; concerned with philosophical, political, and social issues

Late – established body image; irreversible sexual identity and gender role definition; independent from and less conflict with parents/authority figures; establishing stable individual friendships with both sexes and committed intimacy relationship; more stability in emotions; able to think abstractly; develops life philosophy (values, beliefs); makes occupational decisions

Activities – primarily peer group oriented Stresses – threat of loss of control, fear of altered body image; separation primarily from peer group Safety – accidents, especially related to motor vehicles, sport, firearms, homicide, and suicide, are leading causes of death; may be significantly related to drug and/or alcohol use; education is paramount

ADOLESCENT GROWTH AND DEVELOPMENT Attainment of sexual maturity Rapid alterations in height and weight Girls develop more rapidly than boys Onset may be related to hypothalamic activity, which influences pituitary gland to secrete hormones affecting testes and ovaries Testes and ovaries produce hormones (androgens and estrogens) that determine development of secondary sexual characteristics Pimples or acne related to increased sebaceous gland activity Physical Development – Puberty

Increased sweat production Weight gain proportionally greater than height gain during early stages Initial problems in coordination – appearance of clumsiness related to rapid unsynchronized growth of many systems Rapid growth may cause easy fatigue Preoccupation with physical appearance Physical Development – Puberty ADOLESCENT GROWTH AND DEVELOPMENT

Increase in genital size Breast swelling Appearance of pubic, facial, Axillary, and chest hair deepening voice Production of functional sperm Nocturnal emissions Male Changes Increases in pelvic diameter Breast development Altered nature of vaginal secretions Appearance of Axillary and pubic hair Menarche – first menstrual period Females Changes

Masturbation experience of sexual tension Sexual fantasies Experimental sexual Intercourse Psychosexual Development More complete development of secondary sexual characteristics Improved motor coordination Wisdom teeth appear (ages 17-21) Physical Development – Adolescent

Preoccupied with rapid body changes, what is normal” Conformity to peer pressure Moody Increased daydreaming Increased independence Moving toward a mature sexual identity Psychosocial Development

Early and middle adulthood 18/20 to 65 y; developmental state and function characterized by self-sufficiency in pursuit of occupation/ vocation and defined relationships (see Tables XIV – 7 and XIV – 8)

Physical/cognitive – stabilized growth state (weight is variable) and functioning, refines formal operational abilities, undergoes, menopause, begins physical/physiological degeneration Psychosocial – develops self – sufficiency, pursues vocation/occupation, has intense interpersonal relationships (most frequently marriage and children)

YOUNG ADULTHOOD GROWTH AND DEVELOPMENT

(there is some overlap in years) Self questioning Fear of middle age and aging Reappraises the past Discards unrealistic goals Potential changes of work, marriage partnership Sandwich” generation – concerned with children and aging parents Increased awareness of Potential loss of significant others Period of discovery, rediscovery of interests and goals Increased sense of urgency Life more serious Major goals to accomplish Plateaus at work and marriage partnership Sense of satisfaction Decrease hero worship Increased reality Independent from parents Possible marriage, partnership Realization that everything is not black or white, some “gray” areas Looks toward future, hopes for success Peak intelligence, memory Maximum problem solving ability 35 to 45 Years 33 to 40 Years 20 TO 33 Years

MIDDLE ADULTHOOD GROWTH AND DEVELOPMENT

Increasing forgetful Accepts limitations Modifications of lifestyle Decreased power retirement Less restricted time, able to chooses different activities There is some overlap in years) Increasing physical decline Sets new goals Defines value of life, self Assesses legacies – professional, personal Serenity and fulfillment Balance between old and young Accepts changes of aging Graying hair, wrinkling skin Evaluates past Pains and muscle aches Reassessment Realization – future shorter time span than past Menopause Decreased sensory acuity Powerful, policy makers. leaders relates to older and younger generations 60 to 65 Years 48 to 60 Years 45 to 55 years

late adulthood – 65 years until death (see Table XIV – 9) Physical/cognitive – has general slowing of physical and cognitive functioning Psychosocial – needs to establish highest degree of independence (self-sufficiency) physically possible by adapting environment to ability; reflects on life accomplishments, events, and experiences; continues interpersonal relationships despite changes and loss

Signs of aging very evident Few significant relationships Withdrawal, risk of isolation Self-concern Acceptance of death, faces mortality Increased losses Decreased abilities Physical decline Loss of significant others Appraisal of Life Appearance of chronic diseases Reconciliation of goals and achievements Changing social roles > 80 Years 65 to 80 Years LATE ADULTHOOD GROWTH AND DEVELOPMENT

Displacement from friends Peer group Heterosexual relationship Puberty Identity vs. role diffusion Adolescent 12 Displacement from school loss of privacy School/community playmates of same sex Knows related to own sex Latency Quieting dawn pd. in sexual devt. Loss of interest in opposite sex Industry vs. inferiority School 6-12 Body injury castration complex Basic family Knows difference between the sexes Phallic/Genitals Very curious esp. in sex Initiative vs. Guilt Pre-school 3-6 Separation anxiety Parents Accepts reality vs. pleasure principle Anal Best started on toilet training Autonomy vs Shame and /doubt TODDLER Favorite word “no” 1-3 Separation anxiety MOTHER OR SUBSTITUTE RECOGNIZES THE MOTHR ORAL TRUST VS MISTRUST INFANCY 0-1 FEAR IMPORTANT PERSONS TASK FREUD’S PSYCHOSEXUAL ERICKSONS PSYCHOSOCIAL AGE

Sees own as meaningful, is productive, accepts physical changes Integrity vs. despair 65 y to death Establishes a family and oversees next generation, is productive, shows concern for others Generativity vs. Stagnation 30-65 y Develops lasting intimate relationships and good work relationships Intimacy vs isolation 18-30 y Thinks abstractly, uses logic and scientific reason, masters independence through rebellion, develops firm sense of self, is strongly influenced by peers, develops sexual maturity, explores sexual relationships Formal operational Genital phase or adolescence Identify vs role diffusion 12-18 y Sees cause and effect and draws conclusions, develops allegiance to friends, uses energy to industriously create and perform tasks, shows competency in school and with friends Concrete operational Latency or school Indusrty vs inferiority 6-12 y Learns symbols and concepts, assertiveness against environment: learns sex role identify Preoperational intuitive Phallic stage or preschool Initiative vs guilt 3-6 y Learns to manipulate environment, learns self control in toilet training, parallel play Develops expensive language and symbolic play Preoperational Anal phase or toddlerhood Autonomy vs shame and doubt 18 30-3 y Recognizes and attaches to primary caretaker, develops simple motor skills, moves from instant gratification to coping with anxiety Learns about self through the environment Sensorimotor Oral stage or infancy Trust vs. mistrust Birth -18 mo Piaget Freud Erikson Normal Findings Stage of Development Age PSYCHOSOCIAL DEVELOPMENT

D. factors affecting growth and development

1. Genetic defects Increased risk in certain groups of people who demonstrate increased incidence of specific defects, e.g., African Americans for sickle cell disease, Northern European descendants of ashkenazic Jews for Tay-Sachs disease, Mediterranean ancestry for thalassemia; couples with a history of a chills with a defect; family history of a structural abnormality or systemic disease that may be hereditary; prospective parents who are closely blood-related; women over 40

Chromosomal alteration – may be numeric or structural Down’s syndrome (trisomy 21) – increased in women over 35 y; characterized by a small, round head with flattened occiput; low set ears ‘ large fat pads at the nape of a short neck; protruding tongue; small mouth and high palate; epicanthal folds with slanted eyes; hypotonic muscles with hypermobility of joints; short, broad hands with inward curved little finger; transverse simian palmar crease; mental retardation

Turner’s syndrome (female with only one X) – characterized by stunted growth, fibrous streaks in ovaries, usually infertile, no intellectual impairment; occasionally perceptual problems klinefelter’s syndrome (male with extra X) – normal intelligence to mild mental retardation; usually infertile

Autosomal defects – defects occurring in any chromosome pair than the sex chromosomes

Autosomal dominant – abnormal gene overshadows the normal gene, thus the condition is always demonstrated when the gene is present; the affected parent has a 50% chance of passing on the abnormal gene in each pregnancy

Autosomal recessive – requires transmission of abnormal gene from both parents for expression of condition Sex-linked transmission traits – trait carried on sex chromosome (usually the X chromosome); may be dominant or recessive, but recessive is more prevalent; e.g., hemophilia, color blindness

Inborn errors of metabolism disorders of protein, fat, or carbohydrate metabolism reflecting absent or defective enzymes that generally follow a recessive pattern of inheritance

Phenylketonuria (PKU) – uncommon disorder due to autosomal recessive gene, creating a deficiency in the liver enzyme phenylalanine hydroxylase, which metabolizes the amino acid phenylalanine; results in the failure to metabolize phenylalanine, allowing its metabolites to accumulate in the blood; toxic to brain cells

Tay – Sachs – autosomal recessive trait resulting from a deficiency of hexosaminidase A, resulting in apathy, regression in motor and social development, and decreased vision Cystic fibrosis (mucoviscidosis or fibrocystic disease of the pancreas) – an autosomal recessive trait characterized by generalized involvement of exocrine glands, resulting in altered viscosity of mucus – secreting glands throughout the body

Racial and ethnic influences Environment – may influence development more than genetic factors Family’s socioeconomic factors Adequate nutrition Climate Intrapersonal factors State of health Emotional state

Assessment of growth and development

Growth Repeated measurements must be done and recorded accurately on regain basis to establish pattern and identify deviations; at least five times in first year and then yearly at very well – child visit and sick-child visit as appropriate

Assessing length/height- infant or toddler positioned supine on exam table with legs extended is measured from crown of head to heels using flexible nonstretchable tape, while another person maintains child’s position; for the older child, standing measurement is easer and more accurate

Standardized growth chart Individual’s length/height, weight, and head and chest circumference (until 3 y) is assesses in relation to general population, to previous pattern, and to each other Necessary to reevaluate and report measurements >97th percentile and <3rd percentile or deviations from established pattern

Development evaluates current developmental function, identifies need for follow-up, helps parents to understand the child’s behavior and prepare for new experiences, and provides basis for anticipatory guidance

Evaluation should include all the subsystems of development, biophysical (gross and fine motor), cognitive, language, social, affective Developmental tools

Denver Developmental Screening Test (DDST) evaluates children from birth to 6 y in four skill areas: personal – social, fine motor, language , gross motor Age adjusted for prematurity by subtracting the number of months preterm Questionable value in testing children of minority. ethnic groups

Muscular coordination and control – proceeds in head –to-toe (cephalocaudall), trunk-to-periphery (proximodistal), gross to fine developmental pattern Intellectual – related to genetic potentialities and environment; intelligence tests used to determine IQ; mental age x 100 = IQ

Mild (IQ range 55 to 70) G&D @ Preschool-age often do not seem very different than other children to most people ; are slower than most children to walk, feed themselves, and talk. Children with mild MR, when given special education, can learn practical skills and useful reading and math to a 3rd- to 6th-grade level. As adults, they can usually achieve social and job skills and live by themselves. However, they may need some guidance and support during times of unusual stress.

Moderate (IQ range 40 to 54) Preschool-age children with moderate MR show noticeable delays in development of motor skills and speech. Older children can learn simple communication, health and safety habits, and self-help skills. They are not able to gain useful reading or math skills. As adults, they can do simple tasks under special conditions and can travel alone in familiar places. They usually cannot live completely by themselves.

Severe (IQ range 25 to 39) Preschool-age children with severe MR have marked delay in motor development and little or no communication skills. With training, these children may be able to learn basic self-help skills, such as feeding themselves and bathing. As they grow older they can usually walk. They may have some understanding of speech and some response to it. As adults, they can get used to routines, but will need direction and supervision in a protective environment.

Profound (IQ less than 24) Children with profound MR frequently have other medical problems, such as cerebral palsy, and may need nursing care – Gross retardation, minimal-capacity functioning. They have delays in all areas of development. They show basic emotions and with training, may be able to use their legs, hands, and jaws. These children need close supervision. As adults they usually have simple speech and may walk. They usually benefit from regular physical activity. They are unable to take care of themselves. Someone will need to give them complete support for daily living.

Growth & Devt[1].

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Growth & Devt[1].