Human Developmental Milestones PDF

Human Developmental Milestones __________ Remedios H. Fernando, RN MAN St. Luke’s College of Nursing  Learning Objectives 1. Describe the principles of growth and development , developmental stages according to major theorists. 2. Assess a child to determine the sta...

Human Developmental Milestones __________ Remedios H. Fernando, RN MAN St. Luke’s College of Nursing  Learning Objectives 1. Describe the principles of growth and development , developmental stages according to major theorists. 2. Assess a child to determine the stage of development he or she achieved. 3.Plan nursing care for a specific child  Growth and Development Definition: Growth : refers to an increase in body size (i.e. height , weight) physical change, measurable, quantitative Development refers to an increasing capacity to function at more advanced levels skills , qualitative, perform specific task Synonym: maturation  Growth and development are independent yet interrelated process. Growth generally takes place during the first 20 years of life Development persist throughout life  Factors influencing G & D: 1. Genetics –sex, physical stature , race 2. Environment – e.g hazards, smoking, socio economic 3. Culture – habits, belief, language , values 4. Religion 5. Nutrition – adequate food 6. Health status – disease state of a child 7. Family – influence of family , family bond 8. Parental attitudes – education ,childhood experience 9. Child Rearing philosophies  Heredity vs. Environment Nature vs. Nurture Nature – the inborn traits and characteristics inherited from the biological parents Nurture – environmental influences both before and after birth (family , peers,school,neighborhoods,society, culture)  How much is inherited? How much is environmentally influenced? experiences 6 Perspective of Human development 1. Psychoanalytic Behavior is controlled by powerful unconscious urges (e.g Freud’s Psychosexual Theory) Personality is influenced by society and develops through series of crises (e.g Erickson’s Psychosocial Theory) 2. Learning People are responders; the environment controls the behavior (e.g Pavlov,Skinner, Watson) Children learn in social context by observing and imitating models; person is an active contributor to learning (e.g Bandura (Social Learning/Cognitive Theory) 3. Humanistic People have the ability to take charge of their lives and foster their own development (e.g Maslow’s Self Actualization Theory ) 4. Cognitive Qualitative changes in thought occur between infancy and adolescence (e.g. Piaget’s Cognitive-Stage Theory) Human beings are processors of symbols (e.g Information Processing Theory) Organismic vs mechanistic influence 5. Ethological Human beings have the adaptive mechanisms to survive Critical or sensitive periods are stressed Biological and evolutionary bases for behavior and predisposition toward learning are important (e.g. Bowlby’s and Ainsworth Attachment Theory) 6. Contextual Development occurs through interaction between a developing a person and five surrounding interlocking contextual systems of influences (e.g Bronfenbrenner Bioecological Theory ) Child’s sociocultural context has an important impact on development (e.g Vygotsky’s Sociocultural Theory)  Principles of Growth & Development 1. Growth and development are directional and follow predictable patterns. a. cephalocaudal - can control head before trunk - the mouth, eye movement, before upper body , torso and legs  Principles of G & D b. proximodistal – midline to peripheral (center –outward) - arm movement before the fine motor finger - development is symmetrical – each side developing at same direction at the same time.  Principles of G & D c. Mass to specific (differentiation) - development occurs as a child masters simple operation before complex ones  Principles of G & D 2. Growth and development follow sequential pattern a. general to specific – cry, creep before stand - crawl before walk b. simple to complex – language - social skills (play alone – others) c. gross to refined - 3 years old use large crayons 12 years old can write with fine pen 3. Rate of growth and development are not constant. It is a continuous process a. growth spurts brief periods of a rapid increase in growth rate then alternating periods of slow or stagnant growth b. seen as the child prepares to master a significant developmental task.  Theories of Development Theory systematic statement of principles that provides a framework for explaining some phenomenon  Theories of Development Developmental task (milestone) a skill or a growth responsibility arising at a particular time in an individual’s life the achievement of which will provide foundation for accomplishment of future tasks. Basic achievement in each stage of development Must be mastered in order to move to the next level Theories of Growth and Development 1. Psychosexual Theory – Sigmund Freud 2. Psychosocial - Erik Erickson 3. Cognitive – Jean Piaget 4. Moral – Lawrence Kohlberg 5. Biocological – Urie Bronfenbrenner 6. Attachment – John Bowlby 7. Social Learning – Albert Bandura 8. Behavioral theory- Watson, Pavlov, Skinner 9. Spiritual Development by Fowler  Freud’s Psychosexual Theory Sigmund Freud (1856-1939) Viennese physician Freud’s Psychosexual Stages of Development sexual instincts significant in the development of personality At each stage, certain parts of the body assume psychological significance as source of pleasure / foci of sexual energy and conflict  Theory: Sigmund Freud “ What we do and why we do it, who we are and how we became this way are related to our sexual drive” Differences in personalities originate in differences in childhood sexual experiences. Differences in satisfying the sexuality at each stage will inevitably lead to differences in adult personalities  Theoretic Foundations: A. Id the unconscious mind the inborn component,driven by instinct Pleasure principle immediate gratification of needs.  Theoretic Foundations: B. Ego the conscious mind serve as the reality principle C. Superego the conscience function as moral arbitrator and represents the ideal  Freud’s Period of Development 1. Oral Stage (0-1 year) (Infancy) Description: child receives stimulation and pleasure through his / her mouth answering their cry helps develop trust. Behavior to observe: Attempts to put everything into the mouth Tension reduced by sucking  Erogenous Zone: Mouth Task: Important persons mother or substitute Fear: Separation Anxiety Gratifying activities: eating, sucking,gumming, biting, swallowing Interaction with environment : mother’s breast not only source of food and drink but also represents her love.  Child’s personality controlled by id Responsive nurturing Children who receives too little or too much, or forceful feeding – at risk of fixation  Symptoms of Oral Fixation 1.Smoking 2. Constant chewing on gum, pens/pencil 3. Nail biting 4. Over eating 5. Drinking 6. Sarcasm (the biting personality) and verbal hostility  Anal (18 months -3.5 years old) (Toddler) Description of Period: child’s interest is focused on the anal region, and finds pleasure in holding on and letting go. Muscles are used for expression of control and inhibition. Children notice the pleasure and displeasure associated with bowel movements.  Behavior to observe: Engages in play that includes putting things “into” and taking thing “out of” Toilet training mastered by the end of this period  Erogenous Zone Focus: Anus Gratifying Activities: Bowel movement and withholding of such movement Interaction with the environment: toilet training Task: Accepts reality vs. Pleasure Principle Important Person: Parents Fear: Separation Anxiety  Anal fixation Anal expulsive personality if the parents are too lenient or fail to instill the society’s rules about bowel movement control, the child drive pleasure and success from expulsion disorganized,reckless/ careless, defiant  Anal fixation Anal retentive Personality child receives excessive pressure and punishment from parents during toilet training, he/she experience anxiety over bowel movement and take pleasure in being able to withhold such function. OC, meticulous  Phallic stage(Infant Genital) 4-7 years old (Preschool) Description of Period: child exhibits a great deal of intrusive behavior Boys develop sexual attachment to their mothers (Oedipus Complex) Girls develop sexual attachment to their fathers (Electra Complex) They have aggressive urges towards the same sex parents, whom they regard as rival Complexes resolve toward the end of this period. Behavior to observe: Engages in exhibitionism State plans to “marry” parent of the opposite sex. Exhibits interest in sex differences Exhibits preoccupation with loss of body parts and bodily injury (fear of body mutilation) Ask many questions about sexuality Identifies with same sex parents  Tasks: Know difference between sexes Important Persons: Basic Family Fear: Body injury , body mutilation (injection) Castration anxiety (Penis Envy) Erogenous Zone: Genitalia Gratifying activities: Masturbation and genital fondling  Latency (7-11 years old) (School Age) Description of Period: The sexual drive (libido) is controlled and repressed during this period. Emphasis development of skills and talents. Behavior to observe: Devotes energy to the accomplishment of concrete task and the acquisition of skills.  Erogenous Zone: none Interactions with the environment: focus energy on other aspects of life. Time of learning , adjusting to social environment outside home. Task: knows things related to own sex Important person: school, community, playmates of same sex Fear: displacement from school, loss of privacy  Genital Stage 12 years and above (Adolescent) Description of period Resurgence of sexual drives occurs along with recapitulation of the oedipal phase. Mastery of this period results in the development of the ability to love and to work. Behavior to observe: Separate from parents Develops relationships with members of the opposite sex Seeks a role model to replace the parent of the same sex  Erogenous Zone: Genital Gratifying Activities: Masturbation and heterosexual relationships Interaction with the environment: Renewed sexual interest and desire and the pursuit of relationship Task: Heterosexual Relationship Important person: Peer group Fear: displacement from friend  Erick H. Erickson’s Theory of Psychosocial Development German psychoanalyst (1902-1994) He developed his theory from Freud Viewed development as life long series of conflicts affected by social and cultural factors  Erickson’s Each task must be achieved at some level and conflict must be resolved for the child and adult to progress emotionally Unsuccessful resolution leaves individual emotionally disabled 8 stages of development which has a specific developmental task or conflict  1. Trust vs. Mistrust (0-12 months) (Infancy) Description of Period Major task: acquire sense of trust Trust develop when infants needs are met consistently and effectively. When physical and emotional needs are met ; learns to trust self and environment Mistrust develops when care is inconsistent and inadequate. When needs are not always met or becomes frustrated with the caregivers grow mistrustful and insecure.  Trust vs. Mistrust (0-12 months) Behavior to observe: Infant enjoys eating and sucking Infant attends to environment / reaches out for objects Mother relates to child in a positive manner Needs include: 1. Basic physical needs 2. Nurturing 3. Opportunity to explore environment Common Fear: Separation Strangers  2.Autonomy vs. Shame & Doubt (1-3 years old) (Early childhood /) Description Period Autonomy develops when the child is permitted to assert him or herself. Shame and doubt develop if the child does not develop a sense of trust and or learns that his / her assertiveness is not acceptable or that his / her actions are ineffective. Behavior to observe: Shows a sense of will; “me” Negativism Ritualistic or stereotyped behavior Temper tantrums Dawdling  Strives to control body functions; learns to do things unassisted (autonomous) Exploring the environment helps develop a sense of autonomy Differentiates self to others If can not perform a self care independently, exploration is prohibited or efforts ridiculed, he or she develops a sense of shame and doubt Common Fears: - Separation - Loss of Control - Altered rituals - Pain  3.Initiative vs. Guilt (3-6 y/o) (Late childhood/pre-school) Description of Period Initiative develops if the child is allowed the freedom to initiate small activities, to ask questions, and to engage in fantasy play.  Guilt develops if the child is made to feel that his or her activity is bad or wrong, that he or she is asking too many question, or his or her play is silly. Behavior to observe: Start many tasks; completes few Very imaginative Engages in fantasy play Very curious (ask many questions)  Strives to master the environment (by using “initiative”) and not to gain a sense of accomplishment from successfully completing such as tasks dressing unassisted and helping around the house. Major fears: - bodily injury - loss of control - unknown, dark, being left alone  4.Industry vs. Inferiority (6-13) (School Age) Description of period Industry develops if the child is encouraged in efforts to make things, permitted to do things by him or herself and praised for the results. Inferiority develops if the child is not encouraged to do things or if activities are seen as a nuisance. Behavior to observe Wants to learn to do things well and completes tasks Participates in a variety of activities especially in school Takes pride in accomplishments  Strives to become industrious while overcoming sense of inferiority Child wants to learn how to do and make things with others In learning to accept instruction and to win recognition by producing “things”, he opens the way for the capacity of work enjoyment.  The danger in this period is the development of a sense of inadequacy and inferiority in a child who does not receive recognition for his efforts. Child becomes increasingly peer oriented Major Fears: - loss of control - bodily injury - death - not being able to live up to the expectation of others.  5.Identity vs. Role Confusion (13-18) (Adolescence) Description of period Identity develops when the adolescent can bring together life experiences into a whole and integrate them into an acceptable self-image. Role confusion develops when the adolescent is not able to integrate life experiences into a whole and is not sure who he is or what he or she can do. Behavior to observe: Picture of self held by adolescent is similar to that held by significant others. Makes long range plans for occupation Tests social norms May engage in “group” activities to be “in” Tries out different lifestyles Develops some basic philosophy  * Develops identity by defining the self favourably in relation to others. Role confusion occurs if the adolescents has continued conflicts with the family and society over the current role anticipated future roles. Major fears: - Loss of control - Altered body image - Separation from the peer group 6.Intimacy vs. Isolation (18-25 y/o) Young adult seeks companionship , love , intimacy with another person or can become isolated from others Searching for and finding a place for self in society Initiating a career, finding a mate, developing loving relationships, marriage, establishing family, parenting. Begins to express concerns for health  Achievement oriented, working up the ladder Moves from dependency to responsibility Responsible for children and aging parents  7.Generativity vs. Stagnation(25-65) Middle aged adults strive to be productive by performing meaningful work (ie. Generativity or become stagnant and inactive) Future oriented vs. Self absorbed Working up the career ladder Empty nest syndrome may be expressed negatively or positively Mid life crisis Measuring accomplishment against goals Recognition of limitations  8.Integrity vs. Despair (60 above) Integrity results when the older person derives stimulation from an evaluation of his/her life Disappointment with life and the lack of opportunities to alter the past bring despair. Coping with life adjustments can be biggest challenge to the elderly. Many changes are perceived as losses which affect the person’s coping ability  Psychosocial Changes 1. Changes in the role/ status 2. Changes in financial situation 3. Loss of significant others 4. Reduced autonomy and self determination 5. Loss of health 6. Depression/isolation  Interventions 1. Introduce your self to the patient 2. Ask the patient how they want to be addressed – use their preferred name or title 3. Teach stress reduction strategies 4. Encourage social interactions with others 5. Make arrangements for support of religious practice’s (e.g. Arrange for clergy) 6. Provide comfort, physical contact and frequent interventions  Common Fears Loneliness Becoming a burden Pain  Nursing implication In stressful situations (hospitalization) children even those with healthy personalities evoke defense mechanism. e.g. Regression  Jean Piaget Theory of Cognitive Development Jean Piaget (1896-1980) Swiss theorist His complex theory provides a framework for understanding how thinking during childhood progresses and differs from adult thinking. As children develop intellectually as they pass through progressive stage schemata  Stages: 1. Sensori-motor (0-2 years) Learning occurs by the use of their senses Sensorimotor thought begins with simple reflexes in first few months and ends with primitive symbolic thinking. Object permanence – major task Infant’s thinking involves the entire body Reflexive behavior is gradually replaced by more complex activities( simple repetitive - imitative) Phases Age Defining Characteristics Stage 1 :Reflexes Birth to 1 month Most action is reflexive Stage 2 :Primary circular 1-4 months Stereotyped repetition,focus on Reaction own body as center of interest (infant discover own body parts) Stage 3 : Secondary 4-8 months Acquired adaptation and shifting Circular Reaction of attention to objects and environment (infant searches for things that fall) Phases Age Defining Characteristics Stage 4 : Intentionality , 8-12 months Infant actively searches for hidden Consolidation and object Coordination of Scheme Marks Coordination of Secondary Schemes Stage 5 :Tertiary circular 12-18 months Char. by interest in Reaction novelty,creativity and discovery of new means thru active experimentation Complete when Object permanence is achieved  Pre –operational / Preconceptual (2-7 y/o) Forms mental representations of objects and action patterns Language development is rapid. Associates words with objects Egocentrism (unable to put self in another’s place) Everything significant and relates to “me” Centration (ability to think only of one concept at a time)  Don’t understand relationship of size, wt. & vol Magical thinking – belief that thoughts are powerful and can cause events to occur. Events occur because of wishing Animism – perception that all object have life and feelings Transductive / intuitive reasoning - the belief that occur at the same time have a cause and effect relationship.  2 phases: a. Preconceptual (2-4) forms concepts that are less complete and logical than adult Makes simple classifications Associates one event with a simultaneous one (transductive reasoning) Exhibits egocentric thinking  b. Intuitive Thought (4-7 y/o) Magical thinking ,animism,egocentric,centration Capable of classifying, quantifying and relating objects but still unaware of the principles behind Intuitive thought- aware that something is right but can not say why Uses many words appropriately but lacks real knowledge of meaning  Concrete operations (7-11 y/o) Development of logical thinking and ability to perform operation on concrete objects Inductive reasoning ( specific - general),logical operations and concrete thought Transition from egocentric to objective thinking Focus on immediate physical reality with inability to transcend the present  Difficulty in dealing with remote, future or hypothetical matters Development of various mental classifying and ordering activities  Concrete operations (7-11 y/o) Develop new concept permanence: Conservation – ability to understand that thing is essentially the same even its shape and arrangement is altered. Reversibility – ability to conceptualized that a complete process can also be performed in reverse order  Classification -able to group objects according to shared characteristics (classify, sort, order, organize) Combination – ability to manipulate numbers and learn basic math  Formal Operations (11 – 15) Abstract reasoning – inductive and deductive Connect separate events and ability to understand later consequences Uses rational thinking Reasoning is deductive and futuristic Adaptability and Flexibility Idealism Hypothesizes that relationships as causal and analyzes their effects.  Formal Operations A systematic approach to problems replaces random cognitive behavior Idealism – envisioning of perfect world Egocentrism – preoccupation with one owns power of thought. (e.g Imaginary audience) “everyone is watching me and is concerned about me”  Nursing Implication of Piaget’s Piaget believed that learning should be geared to the child’s level of understanding and that the child should be an active participant in the learning process. For health teaching to be effective nurse must understand the different cognitive abilities of children at various stage.  Lawrence Kohlberg’s Stages of Moral Development (1927-1987) Kolberg’s Theory of Moral Development Discussed moral development as complicated process involving the acceptance of the values and rules of society in a way that shapes behavior Based on cognitive development.  Preconventional level (Premoral Level) Culturally oriented to the labels of good/bad and right and wrong Obey without questions Centered toward punishment and obedience Toddler bases judgement on avoiding punishment and obtaining reward. Appropriate discipline measures by providing simple explanations why certain behaviors are unacceptable, and praising appropriate behavior Stage 0 (0-2 years) – infant no awareness of right or wrong and does not consider the effect of action of others; egocentric Stage 1 (2-3 years) – the child obeys rules to avoid punishment and acts to avoid displeasing those who are in power. Stage 2 (4-7 years) – the child conforms to rules to obtain rewards or have favours returned  Conventional level (7-12) Conforms to societal expectations of family, group or nation to win approval of authority Increase desire to please others Obeying rules / respect the authority Stage 3 – good boy / good girl orientation (7-10) Stage 4 – Law and Order Orientation (10-12 y/o) - focus on the rules - social order / respect for authority  Post conventional Level (Principled level) 12 years and above Stage 5 Social Contract Orientation Social contract and autonomous decisions Conform with universal rules  Urie Bronfenbrenner Bioecological Theory Every biological organism develops within the context of ecological systems that support or stifle it’s growth Development through increasingly complex processes  Urie Bronfenbrenner how everything in a child and the child’s environment affect how the child grow and develop Interactions with others and the environment is critical to development and that human experience with multiple types of environment Microsystem- immediate environment such as family, peer group or neighborhood Mesosystem interaction of two microsystems environments such as connection of child’s home and school Exosystem Environment in which is external to the child’s experience, but still affects him or her e.g. parent’s workplace Macrosystem larger cultural environment Chronosystem events that occur in the context of time  Attachment Theory John Bowlby developed of the earliest theories on child development, suggesting that a child’s early relationships with caregivers play a crucial role in the development and influence other relationship through out life.  Came from Ethological perspective of Konrad Lorenz and Niko Tinbergen John Bowlby a British psychologist extended ethological perspective in human development in 1950.  Bowlby (1951) was convinced of the importance of the mother-baby bond and warned against separating mother and baby without providing a good substitute. Infant and parent are biologically predisposed to becoming attached to each other Attachment promotes the baby’s survival e.g. EINC,KMC (Kangaroo Mother Care)  Spiritual Theory Fowler’s Spiritual Theory: He believed that faith or the spiritual dimensions is a force that gives meaning to a person’s life Faith is a relational phenomenon It is an active “mode of being in relation” to another or others in which we invest commitment , belief , love, risk and hope  He believes that the development of faith is an interactive process between the person and the environment In each of Fowler’s stage new pattern of thought, values and beliefs are added to those already held by individual therefore the stages must follow sequence  Stage 3: Synthetic conventional Faith Students begin developing ability to reflect upon their own thinking Still heavily influence by faith within the context of the community of believers to which they relate Place a strong emphasis on doctrines, creeds and traditions that are expected norms of members Stage 4: Individual Reflective Faith Individual growing awareness of sexuality in a homophobic and heterosexist society forces a reexamination of previously held beliefs and values.  John Westerhoff Experienced Faith Infant and Junior The patterns of believing, trusting and doing are the product of what is learned from others (given faith)  Affiliative Faith Adolescence Teens identify with the faith of their friends They are dominated by feelings and affections and they questions authority.  Searching Faith Late Teens Teenagers develop their sense of identity and become dissatisfied with previous answer to questions of meaning and purpose They find that going along with the crowd is inadequate so they start with new philosophies and beliefs in search for the truth  Owned Faith Early Adulthood The searcher has found faith for themselves Refer as conversion It is the culmination of a move from a “faith given” through nurture to “faith owned” Thank You!  HDM 2 __________ Remedios H. Fernando, RN MAN St. Luke’s College of Nursing  Denver Developmental Screening Test (DDST) Use to screen children from 1 month up to 6 years old for gross motor skills, fine motor skills ,language development and personal social development. A type of secondary prevention Easy to administer and potentially identify developmental issues Assesses development based on performance of series of age appropriate tasks  Language development Stage Significance Pre-linguistic From birth to 10 months: first crying; then cooing; then “baby (before talking) talk” 1st meaningful words Holoprastic Stage Sometimes associated with thoughts; the child uses one word to (one word) ask/state something when older children would use a sentence. This stage generally begins at about 1 year of age.  Language development Stage Significance Telegraphic Stage This is the time when the child uses only significant words (noun,verbs) without prepositions, articles etc. This generally begins around 18-24 months Pre-school Sometime between 2-5 years, the child begins to talk in full sentences; the vocabulary grows and becomes more complex Middle Childhood At this time the child learns the rules of grammar, writing and complexities of her/his culture’s language`  PLAY It is the work of children Task done to amuse one self – behavioral, social and psychomotor rich activity, intricately woven with meaning and purpose Play in children is similar to adult work - undertaken by the child to accomplish developmental tasks and master environment  In play they learn about shape,color,cause and effect They learn social interaction and psychomotor skills  Classification of play 1. Practice Play (Functional or Sensorimotor) Involves repetitive muscle movements e.g. running, manipulating objects dumping, gathering  Classification of play 2. Skill play Have ability to grasp and manipulate, persistently demonstrate and exercise their newly acquired abilities repeating an action over and over again 3. Symbolic Play (dramatic /pretend play) uses games and interactions that represents an issue or concerns to be addressed Uses one or more objects, a theme/plan or roles  e.g. object :syringe, theme : getting an injection role: nurse-patient Valuable for children who have experienced or will experience multiple procedures/hospitalization 4. Games Children learn to play rules and to take turn 3 types a. imitative b. formal c. competitive  Functions of Play 1. Sensorimotor 2. Cognitive 3. Emotional Development 4. Social Development 5. Moral Development 6. Creativity 7. Therapeutic value 8. Familiarization  Functions of Play 1. Sensorimotor (Physical) Development aids in the development of fine and gross motor activity children repeat certain body movement purely for pleasure and these movements in turn aid in the development of body control 2. Cognitive Development Children increase their understanding of size shape and texture through play 3. Emotional Development Children who are experiencing an anxiety producing situation are often helped by role playing Coping with emotional conflict 4. Social Development Child begins to experience the joy of interacting with others and soon initiates behaviour that involves others e.g. infants discover that when they coo, their mother coo back 5. Moral Development children when engage in play with their peers and their families, they begin to learn which behaviours are acceptable and which is not Quickly they learn that taking turns is rewarded and cheating is not. Children must adhere to accepted codes of behaviour of the culture e.g. honesty , fairness , self control , consideration to others 6. Creativity Children can experiment and try out their ideas in play through medium at their disposal including raw materials, fantasy and exploration 7. Therapeutic Value it provides a means for release from tension and stress encountered in the environment E.g play room, treatment room 8. Familiarization Play Allows the children to handle and explore health care materials in non threatening and fun ways. This is helpful but not limited to, preparing children for procedures and the whole experience of hospitalization  Social Aspects of Play 1. Solitary play independent / play alone Enjoy being near them but no attempt to play with them Plays alone with toys that are different from those chosen by other children in the area Begins in infancy; common in toddlers 2. Parallel Play play side by side with similar toys but there is a lack of interactive activity use their toys to play out what they want and how they want things to be play in an independent fashion Common in children in any age group 3. Associative play Group play without a group goals. Children do not set rules Although they may all be playing with the same types of toys and may even trade toys, there is a lack of formal organization Begin during toddlerhood to preschool 4. On looker play Child observes others playing Although the child may ask questions of the players the child does not attempts to join the play 5. Cooperative play Begin in late pre-school organized and has a group goals there is at least one leader and children are definitely in or out of the group Age Type of Play 3-12 months Exploring and examining , the infant learns to grab and hold articles and begins to be able to explore once he/she crawl 1-8 years Imitation is the common type of play Imitating adults using toy replicas (e.g. computers,cash registers,doctor’s equipment Having imaginary friends is typical Age Type of Play 8-12 years Less interested in toys Begin to develop interests like hobbies , sports or playing organized games Older children Play and imagine themselves as the hero liked by everyone That everyone thinks they are beautiful or wonderful Or may be acting as though they are victims feeling sorry about themselves  Concepts of Death in the Child Infants and toddler have no concept of death They have separation anxiety and react to change but no concept of forever  Concepts of Death in the Child Pre-schooler Often think of death as temporary state like sleep Afraid of separation and may see death as punishment  Concepts of Death in the Child School Age Begin to understand that death is irreversible May think of it as violent Death is natural and going to happen to everyone But have difficulty understanding that they(themselves ) may die  Concepts of Death in the Child Late-school Age understand that death is final May want to know the biological details and information about funerals and body preparation  Concepts of Death in the Child Adolescents understand death but continue to deny that they could die anytime soon Tend to participate in high risk behaviors Often have difficulties when there is death and may not be able to admit that they need the support the others.  Separation Anxiety Begins to develop at 4-8 months Becomes aware of separateness between themselves and others or objects By 12 months, most children are cued by parental behaviors when their departure is imminent. Begin to protest through crying and clinging behaviors. May overcome this by having variety of people around  Separation anxiety can continue through toddler and preschool years with varying degree Generally reaction is stronger when fearing loss of a mother rather than a father Separation anxiety often presents when child begins school  Most children deal with this successfully and transition to school day well. Some children deal with strong dependent relationship with the parent may have longer and more difficult transition Nurses should be aware of separation anxiety to a hospitalized child. Assess and explore the fears. Allow to verbalize fears General trends in Physical Growth during Childhood Age Weight Height 0-5 months Weekly gain (5-7 Oz) Monthly gain (1 inch) Birth weight doubles by 4- 6 mos 6-12 months Weekly gain (3-5oz) Monthly gain (0.5 inch) Birth weight triples by the end of first year, app 50% by the end of first year Toddler Birth weight quadruples by Height at 2 years is app age 2 ½ years 50% of eventual adult Yearly gain (4-7 pounds) height  General trends in Physical Growth during Childhood Age Weight Height Pre-schooler Yearly gain (4-7 pounds) Birth length doubles by 4 years of age School Age Yearly gain (4-7 pounds) Yearly gain after 6 year (2 inches) Birth length triples by about 13  Physical Growth Pattern during Childhood Very rapid growth during infancy Slow, steady growth during childhood Growth spurt during puberty Maximum height is attained within 2 inches shortly after the onset of menses in females  Height An infant’s length at birth is an average of 20 inches During the first year of life, the child increases birth length by approximately 10 inches During the second year of life the child typically grows five inches  Height Growth of three inches per year occurs during the preschool period In the sixth to tenth year the annual height gain is two inches The maximum growth in height occurs during pubescent period The peak of height increase in boys usually occurs at age 14  Height The peak of height increase in boys usually occurs at age 14 Peak growth in girls occurs at age 13 The growth in height typically ceases between 18 and 20 years old  Weight The appropriate weight for gestational age at term is 5-9 pounds at birth Weight typically doubles by 4th or 5th month Child weight gain triples by his or her first birthday  Weight During the preschool year the weight may increase to 5 pounds each year Small increase s in weight occur during school age years Rapid weight gain may accompany the pubescent period  Bone Formation Bone development is progressive ; the process is completed in the twenties Bone age can be determined by x-ray Growth of long bones is complete when the epiphyses and diaphysis are fused Bone development of the wrist and hand is complete at age 17 for girls and 19 for boys.  Tooth Formation At birth all the primary (deciduous) tooth buds are present under the gums, and the permanent teeth are developing below the decidous teeth The two lower incisors appear at approximately at 6 months of age  Tooth Formation Although the appearance of the teeth varies among children, a typical patterns of eruption occurs at the two upper central incisors appear after the central bottom and top incisors Many children have six teeth at 1 year and all twenty by age 20 years.  Communications in Children Parents and other family members play a crucial role in pedia clients Identify mutual goals to facilitate positive outcome – Establish rapport More than words going on from one person’s mouth to another person’s ears.  Components of Effective Communication in Children 1. Choices of words 2. Touch 3. Physical Proximity and Environment 4. Listening Skills 5. Visual Communication 6. Body Language 7. Cultural differences 1. Choices of words identify level of patient choose the right words 2. Touch can be positive or negative depends on the level can convey warmth, comfort, reassurance,security, trust, care and support In infant- message of love,security,comfort e.g. holding,cuddling,gentle stroking,patting  Infants do not have cognitive understanding of words they hear, but they sense the emotional support Toddlers and pre-schoolers finds it comforting to be held and rocked School age and adolescent appreciate giving and receiving hugs and reassuring pats Nurse should request for permission 3. Physical Proximity and environment Children at ease in their home environment unfamiliar environment causes anxiety Nurses try to put yourself in their position Create a supportive / inviting environment Respect each other’s personal space Provide privacy 4. Listening Important part of communication process Nurse can be effective listener if they have active listening skills: - attentiveness - clarification through reflection - empathy - impartiality 5. Visual communication Eye contact helps confirm attention & interest Consider their culture Clothing, physical appearance objects being held are examples of visual communication Some children are visual learners 6. Tone of voice Tone and quality of voice Infants no cognition on words – soft and smooth voice more comforting Children can detect anger , frustration or joy 7. Body Language Open body stance and positioning invite communication and interaction Nurses needs to learn to read children’s body language 8. Timing Appropriate time to communicate information  Family Centered Care Involve family in the care of the child Create partnership with family Nurse respect the family diversity  Elements of FCC 1. Establish rapport 2. Availability and openness to questions 3. Family education and empowerment 4. Effective management of conflict 5. Feedback from Children and families 6. Spirituality 1. Establish rapport Nurse’s ability to convey genuine respect and concern during the first encounter Non judgemental approach and willingness to assist family members 2. Availability and openness to questions Families want and need unrushed and uninterrupted time with the nurse E.g. nurse who leaves room immediately after giving the medications / doing procedure 3. Family education and empowerment Educate parents about the child’s condition Ensure their continued involvement in the plan of care Teach them skills and empower them 4. Effective managemenf of conflict When conflict occurs it should be addressed in an expedient manner to prevent breakdown in communication Bridge the gap Consider their culture 5. Feedback from children and families Nurse must be alert for verbal and non verbal cues Routinely check with family about their hospital experience in general e.g. PEF , patient experience 6. Spirituality Spiritual care vital Children coping for acute illness or injury Facing fear, anger and guilt  Communication with Children with Special Needs The child with visual impairment The child with hearing impairment The child who speaks another language The child who is aphonic The child with a profound neurologic impairment Thank You!  HDM 3 GROWTH AND DEVELOPMENT __________ Remedios H. Fernando, RN MAN St. Luke’s College of Nursing Infancy Stage __________  Newborn to 1 month FOCUSED ASSESSMENT : How have you been feeling? Have you made your postpartum check up appointment? How have you and your partner been adjusting to the baby? Do you have other children? How are they adjusting? Have you discussed child-rearing philosophies? Does anyone in your household use substances?  Have you recently been exposed to or had any sexually transmissible disease? Have you experienced any periods of sadness or “feeling down”? Do you have any concern about the costs of the baby’s care? Do you feel that you and the baby are safe? DEVELOPMENTAL MILESTONES Personal/social: looks at parent’s face Fixates, tracks, follows to midline smiles responsively prefers brightly colored objects Language/cognitive Prefers human female voice, responds to sounds Begin to vocalize DEVELOPMENTAL MILESTONES Fine Motor: Newborn reflexes present hands usually closed Strong grasp reflex May grasp toys DEVELOPMENTAL MILESTONES Gross motor: Equal movements turns head to side, lifts head for short period and chin (by 1 month) Head lag HEALTH MAINTENANCE Immunizations: see recommendation by DOH Health Screening: New Born Screening Hearing Screening Visual Inspection for congenital defects Physical Measurements: Weight 7.5 to 8 lb (3.4 to 3.6 kg) - Losses 10% of body weight after birth but gains it back by 2 weeks - Gains ½ to 2/3 oz per day on average for the first 6 months Length: average 20 inches (50cm) - gains 1 inch (2.5cm/month) for the first several months Physical Measurements: Head Circumference: 13 to 14 inches (33 to 35.5cm) - gains average of ½ inch (1.2cm/month) until 6 months of age - Posterior fontanel closes by 2 to 3 months and anterior by 12 to 18 months  Anticipatory Guidance Nutrition Breast milk on demand and at least every 2-3 hours Iron Fortified formula 2-3 oz every 3-4 hours Burp and place on the right side after feeding Elimination Six wet diapers Stools depends and related to feeding method  ANTICIPATORY GUIDANCE (cont) Dental Continue prenatal vitamins and calcium if breast- feeding Sleep Place back or side to sleep Sleeps 16 or more hours Hygiene: Sponge bath until cord falls off Circumcision care (as necessary)  ANTICIPATORY GUIDANCE (cont) Safety Be sure crib is safe; slats less than 2 3/8 inches apart, firm mattress that fits the crib. Eliminate all environmental smoke Car seat Fire Prevention: smoke detectors, fire extinguishers Water temperature less than 120 ° F CPR and first aid classes ; emergency phone numbers Violence: discuss shaking, guns in the home,  The 2 month old infant FOCUSED ASSESSMENT How have things been going in the family? Are you getting enough opportunities to continue relationships and activities away from the baby? Will you describe the baby’s personality? Did the baby have any reaction to the last immunizations? If so, what happened? DEVELOPMENTAL MILESTONES Personal/social: Smiles responsively, looks at faces Language/cognitive Vocalizes making cooing or short vowel sounds, responds to a bell (ooh, aah) Attends to voices Fine motor follows to midline , some reflexes disappear Hands open more Decrease grasp reflex DEVELOPMENTAL MILESTONES Gross motor Beginning to lift head , equal movements Beginning head control when upright Decreased head lag when pulled up Head bobs to upright when held sitting  HEALTH MAINTENANCE Physical movements Measure length, weight and head circumference and plot on the growth chart Immunizations Health Screening Hearing screening Check eyes for strabismus Assess ability to follow at midline  ANTICIPATORY GUIDANCE Nutrition Breast feed per demand with increasing intervals Formula 4-6 oz six times per day Elimination Six wet diapers Stools related to feeding method May decrease in number Dental Continue prenatal vitamins and calcium if breast- feeding Do not prop baby’s bottle  ANTICIPATORY GUIDANCE (cont’) Sleep Place on back or side to sleep Move to separate room Begin to establish nigh time routine Play with baby when awake Hygiene Bathe several times per week Watch for diaper rash and seborrheic dermatitis  ANTICIPATORY GUIDANCE (cont’) Safety Review house and environmental safety and conditions for calling the doctor Posting of emergency numbers near the telephone and are safety and violence Discuss preventing falls; burns from hot liquids  ANTICIPATORY GUIDANCE (cont’) Play Imitate vocalization and smile Sing Change infant’s environment Encourage rolling over  The 4 Month Old Infant Focused Assessment What new activities is the baby doing? Is the baby able to settle down to sleep without needing to be consoled? Are both parents included in the baby’s care? Is the mother considering going back to work in the near future?  DEVELOPMENTAL MILESTONES Personal /social loves moving faces; knows parents’ voices Language/Cognitive Initiates conversation by cooing Turns head to locate sounds  DEVELOPMENTAL MILESTONES Fine motor Follow an object 180 degrees binocular vision, bats objects Begin to hold on bottle Gross motor Supports weight on feet when standing Pulls to sit without head lag / able to sit if propped Begin to roll prone to supine  CRITICAL MILESTONES Personal /social Smiles responsively , smiles spontaneously ; stares at own hand Language/Cognitive Laughs and squeals out loud Vocalizes makes “ooh” sounds  CRITICAL MILESTONES Fine motor Grasps a rattle, follows past at midline Brings hands to middle of body Gross motor Lifts head and chest at 45 and 90 degrees when in prone Head steady when sitting  HEALTH MAINTENANCE Physical measurements Continue to measure and plot length , weight, and head circumference Posterior fontanel closed Immunizations Health Screening Assess for strabismus  HEALTH MAINTENANCE Nutrition Maintain breastfeeding schedule Formula 5-8 oz five to six times per day Bottle supplement if breast feeding mother has returned to work Elimination Similar to2 month old Dental May begin drooling in preparation for tooth eruption  HEALTH MAINTENANCE Sleep Place on back or side to sleep Total sleep 15 to 16 hours Encourage self consoling techniques Hygiene Continue daily routine of cleanliness  HEALTH MAINTENANCE Safety Review car safety and violence Discuss choking hazards and management of choking Avoidance of walkers Playpen and swing safety Begin child proofing  HEALTH MAINTENANCE Play Talk with the baby frequently and from different locations Respond verbally and smile as infant does; cuddles Sing , expose to different environment sounds Supervised water play Provide bright rattles , tactile toys , mirror  The 6 month old infant Focused Assessment What kind of new activities is the baby doing? Have you begun to give the baby solid foods? How is any child care working out? Have you done anything about childproofing your home?  DEVELOPMENTAL MILESTONES Personal / social Interacts readily and noisily with parents and familiar people May be cautious with strangers Language / Cognitive Begin to imitate sounds Babbles Says single sounds Beginning object permanence Awareness of time sequence  DEVELOPMENTAL MILESTONES Fine motor Rakes objects with the whole hand Begins to transfer , mouths Can hold an object with each hand Gross motor Tripod sitting unsupported , gets on hands and knees, bears full weight on legs, swims when prone  CRITICAL MILESTONES Personal / social Reaches for toy out of reach; looks at hand, smiles spontaneously Language / Cognitive Turns to rattle sound made out of vision on each side, squeals, laughs  CRITICAL MILESTONES Fine motor Looks at raisin placed on contrasting surface; reaches out, follows completely side to side Gross motor Rolls over both directions No head lag; lifts head and chest completely  HEALTH MAINTENANCE Physical Measurements Birth weights doubles Continue to measure and plot length, weight and head circumference Immunizations Ask about previous reactions Review side effects Health Screening Initial lead screening (Box 6-5) *  ANTICIPATORY GUIDANCE Nutrition Begin introducing solid foods one at a time by spoon Use iron fortified cereals Avoid citrus and egg white, read labels Hold or place in infant seat for feeding Begin using a cup Elimination Stools darken and become more formed as solids are increased  ANTICIPATORY GUIDANCE Dental Tooth eruption begins with lower incisors May have some pain and low grade fever (