LS CH 5 Theories of Growth and Development.pdf

7589_Ch05_053-068 29/08/17 1:58 PM Page 53 CHAPTER 5 Theories of Growth and Development Key Words Chapter Outline accommodation animistic assimilation autonomy cephalocaudal compensation conscious conversion defense mechanisms denial development displacement ego ego integrity Electra complex ge...

7589_Ch05_053-068 29/08/17 1:58 PM Page 53 CHAPTER 5 Theories of Growth and Development Key Words Chapter Outline accommodation animistic assimilation autonomy cephalocaudal compensation conscious conversion defense mechanisms denial development displacement ego ego integrity Electra complex generativity growth heredity id identification libido maturation Oedipus complex personality projection proximodistal puberty rationalization reaction formation regression Characteristics of Growth and Development Psychoanalytical Theory Defense Mechanisms Freud’s Stages of Psychosexual Development Oral Stage Anal Stage Phallic Stage Latency Stage Genital Stage Psychosocial Theory Trust Versus Mistrust (Birth to 18 Months) Autonomy Versus Shame and Doubt (18 Months to 3 Years) Initiative Versus Guilt (3 to 6 Years) Industry Versus Inferiority (6 to 11 Years) Identity Versus Role Confusion (12 to 20 Years) Intimacy Versus Isolation (20 to 30 Years) Generativity Versus Stagnation (30 to 65 Years) Ego Integrity Versus Despair (65 Years and Over) Cognitive Theory Sensorimotor Stage (Birth to 2 Years) Preoperational Stage (2 to 6 Years) Concrete Operational Stage (6 to 12 Years) Formal Operational Stage (12 to 15 Years) Human Needs Theory Physiological Needs Safety Needs Belonging Self-Esteem Self-Actualization Theory of Moral Development Level I: Preconventional Thinking (4 to 10 Years) Level II: Conventional Thinking (10 to 13 Years) Level III: Postconventional Thinking (Postadolescence) Summary Critical Thinking Multiple-Choice Questions Learning Objectives A t th e e n d of th i s ch ap te r , y ou s h ou l d b e ab l e to: • • • • • • • Describe the five common characteristics of growth and development. Name the two major influences on an individual’s growth and development. Compare Freud’s psychoanalytical theory and Erikson’s psychosocial theory of development. Describe the common defense mechanisms used to reduce anxiety. Describe Piaget’s theory of cognitive development. Describe Kohlberg’s theory of moral development. Describe Maslow’s theory of human needs. 53 7589_Ch05_053-068 29/08/17 1:58 PM Page 54 54 Journey Across the Life Span Key Words (continued) schema stagnation subconscious sublimation CHARACTERISTICS OF GROWTH AND DEVELOPMENT Growth and development are natural topics of interest for most people. Curious about their beginnings and about what their futures hold, families question why one child looks more like one parent or acts more like the other. To support and guide parents, the health care worker needs to understand the normal patterns of growth and development and learn to recognize any variations from the norm. Several characteristics, patterns, and theories of growth and development are explored in this chapter. The terms growth and development are frequently used together but have different meanings. Growth refers to an increase in physical size. Growth is quantitative: It can be measured in inches or centimeters, pounds, or kilograms. Development, however, refers to the progressive acquisition of skills and the capacity to function. Development is qualitative and proceeds from the general to the specific. Growth and development occur simultaneously and are interdependent. See Box 5.1 for universally accepted characteristics of growth and development. Development results from learned behavior and from maturation. Maturation, similar to development, is a total process in which skills and potential that are independent of practice or training emerge. Maturation is the attainment of full development of a particular skill. Two directional terms used to explain growth and development are cephalocaudal and proximodistal. Cephalocaudal is best described as growth and development that begins at the head of the individual and progresses downward toward the feet. Proximodistal describes growth and development that progresses from the center of the body toward the extremities (Fig. 5.1). In the infant, shoulder control precedes mastery of the hands, which is followed by finger dexterity. superego suppression unconscious undoing B O 5.1 X Characteristics o f G ro wth and Dev elo pment • Occur in an orderly pattern from simple to • • • • complex. One task must be accomplished before the next one is attempted. For example, infants must learn head control before they can learn to sit. Are continuous processes characterized by spurts of growth and periods of slow, steady growth. For example, infancy is a period of very rapid growth; after infancy, the rate of growth slows down until adolescence. Progress at highly individualized rates that vary from child to child. Individuals have their own growth timetables, and one child’s pattern of growth should not be compared to another’s. Affect all body systems but at different times for specific structures. Although many organs mature and develop throughout childhood, the reproductive organs mature at puberty. Form a total process that affects a person physically, mentally, and socially. As discussed in Chapter 1, health is influenced by both genetic and environmental factors. Genetics and environment are also the major influences on an individual’s growth and development. Genetics, or heredity, includes characteristics such as hair color, eye color, and body size and shape. Heredity is discussed in greater detail in Chapter 6. Every person goes through certain stages of development from infancy to old age. As individuals progress through these stages, they are exposed to different environmental factors that influence their inherited makeups. The resultant behavior is unique to that person and is known as personality. Personality consists of the behavior patterns that distinguish one person from another—the individual’s style of behavior (Fig. 5.2). Personality traits remain 7589_Ch05_053-068 29/08/17 1:59 PM Page 55 Theories of Growth and Development A B B A FIGURE 5.1 Principles of growth and development include cephalocaudal and proximodistal development. 55 Most of these theories are covered in greater depth in the chapters that follow. Freud’s theory provides the foundation from which other theories developed. We chose to present his theory in this chapter because nurses need to have a basic knowledge of personality development. This will enable them to identify the behaviors that are associated with the various stages and better understand whether the behavior is appropriate or inappropriate for a particular developmental level. Unlike later theorists, Freud believed that infancy and childhood are the critical periods for development and change. Freud’s theory discusses only these stages. As authors, we believe that development is ongoing throughout the life cycle; therefore, we limited the discussion of Freud to this chapter alone but refer to other theorists in later chapters because their theories apply to each stage of growth and development. All developmental theories are divided into stages and are considered progressive. Ideally, an individual accomplishes a task or skill at one stage before moving on to a later stage. However, conflicts and stressors can delay or prolong the completion of a task or even cause some temporary backward movement, known as regression. After the resolution of the conflict or stress, individuals usually return to their appropriate developmental levels. The specific age ranges given for these developmental stages are approximate and vary somewhat for individuals. It is even possible for stages to overlap, allowing individuals to work on several tasks at the same time. PSYCHOANALYTICAL THEORY FIGURE 5.2 Each infant demonstrates a unique personality. identifiable throughout a person’s life span. A solid understanding of personality development can assist the health care worker in promoting health and delivering care. Although no single theory explains the personality development of all individuals, several major theories provide key frameworks that help nurses understand different aspects of personality development. This chapter includes a brief overview of Sigmund Freud’s psychoanalytical theory, Erik Erikson’s psychosocial theory, Jean Piaget’s cognitive theory, Abraham Maslow’s human needs theory, and Lawrence Kohlberg’s theory of moral development. Sigmund Freud made many important contributions to the understanding of personality development. Three parts of his theory include levels of awareness, components of the personality or mind, and psychosexual stages of development. According to Freud, the levels of awareness include the conscious, subconscious, and unconscious. The conscious level refers to all those experiences that are within one’s immediate awareness. It is based in reality and logic. The subconscious, or preconscious, level of awareness stores memories, thoughts, and feelings. These can be recalled with a little effort and brought into the conscious level. The unconscious level refers to that part of the mind that is closed to one’s awareness. These stored memories are usually painful and are kept in the unconscious to prevent anxiety and stress. Freud believed that 7589_Ch05_053-068 29/08/17 1:59 PM Page 56 56 Journey Across the Life Span behavior could be understood by delving into the forces of the unconscious mind. The levels of awareness became the basis for Freud’s theory of psychoanalysis. Freud further believed in the three functional components of the mind known as the id, the ego, and the superego. The id refers to the body’s basic primitive urges. Primarily concerned with satisfaction and pleasure, the pleasure principle, or libido, is the driving force behind most human behavior. The id operates according to the pleasure principle. The id demands immediate satisfaction of its drives. The ego, also known as the “executive of the mind,” is the part that is most closely related to reality. This part develops as a result of the demands of the id and the forces in the environment. Through interactions with the environment, the child learns to delay immediate satisfaction of his or her needs. This learned behavior is the development of the ego. The superego is a further development of the ego. It judges, controls, and punishes. It dictates right from wrong and acts in a similar way to what is thought of as a conscience. These three components—id, ego, and superego— are in constant conflict with one another. Ideally, a balance or compromise should be reached between them. Someone once attempted to explain what each of these components is trying to communicate. The id says, “I want it now!” The superego states, “You can’t have it.” And the ego attempts to compromise by saying, “Well, maybe later.” Unrestrained id dominance can result in a breakdown of the personality, leading to childlike behavior persisting throughout adult life. An extremely harsh superego can cause the blockage of reasonable needs and drives. Figure 5.3 illustrates Freud’s components of the mind. DEFENSE MECHANISMS Defense mechanisms, also known as mental mechanisms, are techniques used at all stages of the life cycle to help individuals cope with the threat of anxiety. Many of these mechanisms were first recognized by Sigmund Freud as a way to protect one’s ego. Most mechanisms are at the unconscious level, with the exception of suppression. Depending on the frequency of their use they can be helpful or harmful. On a short-term basis the use of a defense mechanism may help the person by allowing her or him time to adjust to a stress while developing acceptable coping methods. Overuse or maladaptive use of defense mechanisms prevents the individual from achieving personal growth and satisfaction. The frequency and intensity of their use will determine whether defense mechanisms help or hinder by distorting reality. Suppression is the one mechanism that operates on the conscious level. This is best described as the conscious putting out of awareness of one’s distressing feelings. These feelings can be brought back into focus any time at will. All individuals use suppression as a means of concentrating on what is at hand. For example, the person who just had an argument with his or her spouse goes to work and says, “I can’t think about my anger while working.” Rationalization is the defense mechanism that is most widely used by all ages. It is used to justify or excuse undesirable actions or feelings. It is a facesaving technique that may or may not deal with the truth. This mechanism can prevent the individual from confronting reality and learning to deal with it constructively. An example of rationalization is the student who blames the teacher for his failing grade when in reality he did not study or prepare adequately for his exam. Identification is a mechanism in which one takes on the personality traits of another person, usually one held in high esteem. This mechanism is used by the child during sexual role identification. The young boy assumes the masculine characteristics admired in his father. The nursing student may copy behavior and mannerisms of a professor held in high esteem. Sublimation is another mental mechanism in which the individual channels or redirects unacceptable impulses into socially acceptable outlets. Most of these mechanisms involve primitive drives or pleasurable feelings that are channeled and expressed in socially appropriate ways. An example of sublimation is demonstrated when the jilted lover expresses his longings in poetry or song. The youngster who becomes enraged at his teacher takes his hostile feelings and punches the punching bag as his outlet. Sublimation is considered to be a positive, effective coping mechanism. FIGURE 5.3 Freud’s three functional components of the mind. 7589_Ch05_053-068 29/08/17 1:59 PM Page 57 57 Theories of Growth and Development Regression is a mental mechanism in which the individual facing a conflict returns to an earlier, more developmentally secure stage. The previously toilet-trained young child facing the stress of the birth of a new sibling starts having accidents and wetting the bed. This retreat to an earlier stage of development allows the person to feel more comfortable and less threatened. Denial is a mental mechanism that is used totally on the unconscious level. Individuals automatically use this technique when they are unexpectedly confronted with some sort of unbearable news. With this mechanism the individual is unable to recognize the event or emotions surrounding the occurrence. An example of denial is illustrated in the story of the woman who, when faced with the news that her husband was just killed in an accident, rejects the news and goes to call him in his office. Displacement is another mechanism that transfers emotions associated with a person or an object to another, less threatening person or object. A classic example of displacement is the man who is angry at his boss but yells at his wife instead. This may protect the man from losing his job, but it creates displaced hostility toward his wife. Projection is often referred to as the blaming mechanism. In projection the individual rejects unacceptable thoughts or feelings and attributes them to another person. The man is projecting when he accuses his wife of flirting and being unfaithful when it is he who has an attraction to another woman. Compensation is a mental mechanism that allows the person to make up for deficiencies in one area by excelling in another area. The school-age boy tries to excel in class to compensate for his lack of athletic abilities. This technique helps maintain his self-esteem. Undoing is a mechanism in which the individual acts in a manner that symbolically cancels a previous unacceptable thought or action. In this way the individual attempts to make up for something that is unacceptable. An example of undoing is when the teacher compliments the student’s new hairstyle after being overcritical of his homework. Reaction formation, sometimes called overcompensation, is another mechanism. In reaction formation unacceptable feelings or thoughts are kept out of one’s awareness and replaced with opposite feelings or thoughts. For example, the man who dislikes dogs meets his friend in the park who is walking his two dogs. The man acts openly friendly to his friend’s dogs. Conversion is a mental mechanism that converts unconscious feelings and anxiety into a physical symptom that has no underlying organic basis for the complaint. Conversion is illustrated by the soldier on the front line of the battlefield who finds himself unable to move his arm and hold his weapon. Refer to Table 5.1 for a summary of adaptive and maladaptive use of the common defense mechanisms. T A B L E 5.1 A d ap t i ve an d M al ad ap t i ve D efense M echanisms Adaptive Rationalization The student says, “I didn’t want to be a nurse anyway.” Maladaptive “I’m not going to study because I know I won’t pass the test.” Identification The young boy says, “I’m going to be just like Daddy when I grow up.” “Those gang members are really cool. I hope to be just like them.” Sublimation The hostile, angry teenage boy is successful as a boxer. Usually adaptive. Regression The hospitalized 5-year-old boy starts to suck his thumb again. Denial The woman just informed of her terminal illness tells her family that she will outlive all of them. The woman has a tantrum after not getting her way. The parents have kept their deceased son’s room intact for the past 10 years and speak of him as if he were going to return home. Continued 7589_Ch05_053-068 29/08/17 1:59 PM Page 58 58 Journey Across the Life Span T A B L E 5.1 A da pti ve an d M al ad ap t i ve Def ense M echanisms—co nt’ d Adaptive Maladaptive Displacement Immediately after getting a traffic ticket the mother scolds her two children. The assault victim becomes afraid to leave home. Projection The young male accuses another male friend of making sexual advances toward him when he himself has unconscious feelings toward the person he accuses. The angry young man believes that people are out to harm him. Compensation The sibling of a very popular sister becomes well known for her superior athletic ability. Usually adaptive. Undoing The youngster after his time-out goes and picks flowers for his mother. Reaction formation The alcoholic volunteers to speak to student groups about the dangers of underage drinking. Conversion The nursing student is unable to take her final exam because of a headache. Suppression While driving the car, the woman says, “I’ll think about paying the bills later.” FREUD’S STAGES OF PSYCHOSEXUAL DEVELOPMENT Freud described five stages of psychosexual development: oral, anal, phallic, latency, and genital. Each stage is associated with particular conflicts that must be resolved before the child can move on to the next stage. He also believed that the experiences a child has during the early stages of growth determine later adjustment patterns and personality traits in adult life (Fig. 5.4). Oral Stage The oral stage lasts from birth to the end of the first year of life. The infant’s mouth is the erogenous (sexually arousing) area and the source of all comfort and pleasure (Fig. 5.5). If the infant’s oral needs are met, the infant gains satisfaction. The infant After a very strict, rigid upbringing the young man is obsessed with washing his hands whenever he has sexual urges. The physically abusive mother acts overprotective after injuring her child. The witness to a horrific crime suddenly becomes blind and unable to identify the suspect in the police lineup. Usually adaptive. receives pleasure by sucking and biting, using the mouth as the center of gratification. By the end of the first year of life, the infant begins to see that he or she is separate from the mother and other objects in the environment. Anal Stage The anal stage lasts from the end of the first year of life to the third year. At the beginning of this stage, the mouth continues to be an important source of satisfaction for the child. By the beginning of the second year, the center of pleasure is shared between the mouth and the anus. Instead of being repulsive to the child, the process of defecation gives the child pleasure and satisfaction. Toilet training is initially experienced as a conflict between the demands of the parent and the child’s biological needs. Resolution of this conflict gives the child a sense of selfcontrol and independence. Recommendations for toilet training will be discussed in a later chapter. 7589_Ch05_053-068 29/08/17 1:59 PM Page 59 Theories of Growth and Development 13–20 Years Genital Stage 59 Birth–18 Months Oral Stage 6–12 Years Latency Stage 18 Months–3 Years Anal Stage 3–6 Years Phallic Stage Major Developmental Tasks Oral—Relief from anxiety through oral gratification of needs Anal—Learning independence and control, with focus on the excretory functions Phallic—Identification with parent of same sex; development of sexual identity; focus on genital organs Latency—Sexuality repressed; focus on relationships with same sex peers Genital—Libido reawakened as genital organs mature; focus on relationships with members of the opposite sex FIGURE 5.4 Freud’s stages of psychosexual development. Phallic Stage The phallic stage lasts from ages 3 to 6. At this stage, the child associates both pleasurable and conflicting feelings with the genital organs. During this period the child devotes a lot of time to examining his or her genitalia. Masturbation and interest in sexual organs are normal. Exhibitionism is also typical at this age. The child appears comfortable with his or her body and likes to undress and parade around naked. Parental disapproval of the child’s preoccupation with the genitals can result in feelings of confusion and shame. The Oedipus and Electra complexes develop at this stage. The Oedipus complex refers to a boy’s unconscious sexual attraction to his mother. He wishes to have his mother to himself and sees his father as a rival for his mother’s affection. To win his mother’s affection, he resolves the conflict by eventually taking on the father’s characteristics. This process begins sex-role identification. The Electra complex occurs when a young girl is attracted to her father and wishes to get rid of her mother. Through imitation, the child copies the mothering role and eventually gains the father’s affection and approval. Resolution of the Electra complex produces sex-role identification for the female child. Latency Stage Latency lasts from ages 6 to about 12. During this time the child’s sexual urges are dormant. The sexual energies are being channeled into more socially 7589_Ch05_053-068 29/08/17 1:59 PM Page 60 60 Journey Across the Life Span FIGURE 5.6 Outdoor activities are attractive to young children. FIGURE 5.5 The infant’s mouth is the source of comfort and pleasure. acceptable means of expressions. School-age children focus mainly on intellectual pursuits. Peer relationships intensify between children of the same sex. Sports and other such activities help in the development of these peer relationships (Fig. 5.6). Genital Stage The genital stage begins with the onset of puberty. During puberty many physical changes occur that prepare the body for reproduction. Hormonal activity and maturing of the sex organs result in the awakening of sexual attraction and interest in heterosexual relationships. The child continues to struggle with a desire for independence but still has a need for parental supervision. PSYCHOSOCIAL THEORY Erik Erikson, a psychologist and close follower of Freud, broadened Freud’s theory of personality development. Erikson identified eight stages that span the full life cycle from infancy to old age. He studied the child within a larger social setting beyond the immediate family. He believed that at each stage certain critical tasks have to be accomplished. The successful completion of each task enables individuals to increase independence and feel good about themselves and others. Erikson’s eight stages of psychosocial development are discussed in the following section and are listed in Table 5.2. T A B L E 5.2 S t a ges of Devel op men t i n Er i k s o n’ s P sy cho so cial Theo ry Age Stage Major Developmental Tasks Infancy (Birth–18 months) Trust vs. mistrust To develop a basic trust in the mothering figure and be able to generalize it to others Early childhood (18 months– 3 years) Autonomy vs. shame and doubt To gain some self-control and independence within the environment Late childhood (3–6 years) Initiative vs. guilt To develop a sense of purpose and the ability to initiate and direct own activities School age (6–12 years) Industry vs. inferiority To achieve a sense of self-confidence by learning, competing, performing successfully, and receiving recognition from significant others, peers, and acquaintances 7589_Ch05_053-068 29/08/17 1:59 PM Page 61 Theories of Growth and Development 61 T A B L E 5.2 St ag es of Devel op m en t i n E rik so n’ s P sy cho so cial Theo ry —co nt’ d Age Stage Major Developmental Tasks Adolescence (12–20 years) Identity vs. role confusion To integrate the tasks mastered in the previous stages into a secure sense of self Young adulthood (20– 30 years) Intimacy vs. isolation To form an intense, lasting relationship or a commitment to another person, cause, institution, or creative effort Adulthood (30–65 years) Generativity vs. stagnation To achieve the life goals established for oneself while also considering the welfare of future generations Old age (65 years–death) Ego integrity vs. despair To review one’s life and derive meaning from both positive and negative events while achieving a positive sense of self-worth Source: Townsend, MC: Psychiatric Mental Health Nursing: Concepts of Care, ed. 4. FA Davis, Philadelphia, 2003, p 38, with permission. Trust Versus Mistrust (Birth to 18 Months) At birth the child is helpless and totally dependent on others to meet his or her needs. When these needs are met in a timely fashion, the child develops trust in people and in his or her environment. Trust is built by having consistency and sameness from caregivers. This helps infants cope with their needs and urges and learn trust in self. Trust is the foundation of a healthy personality. Autonomy Versus Shame and Doubt (18 Months to 3 Years) The child begins to gain control over his or her body and develop a sense of independence or autonomy (Fig. 5.7). Autonomy is characterized by the acquisition of skills involving feeding, mobility, dressing, and control of elimination. Developing independence strengthens the child’s self-concept. Without loving support from the environment, the child develops feelings of shame and doubt. Initiative Versus Guilt (3 to 6 Years) During this stage the child begins to explore his or her environment and try different roles. Imagination and curiosity allow the child to further expand and develop his or her potential. Parents and caregivers need to permit the child to explore within safe FIGURE 5.7 Infants master good upper-body control before crawling. boundaries. Without this freedom the child may develop guilt and feelings of inadequacy. Industry Versus Inferiority (6 to 11 Years) During this stage the child acquires many new social and physical skills. School-age children have the maturity to concentrate on learning and working with others. They strive for praise and recognition. Family life should support and prepare the child for school endeavors, and school must continue with 7589_Ch05_053-068 29/08/17 1:59 PM Page 62 62 Journey Across the Life Span these efforts. Without these positive responses, children may develop a sense of inferiority. Identity Versus Role Confusion (12 to 20 Years) This stage is transitional between childhood and adulthood. It is characterized by both physiological and emotional changes that create turmoil for both the child and the family. One of the chief concerns of this period is the individual’s emerging sexuality and the need to find his or her place in society. Many demands are placed on the adolescent in terms of career, vocation, education, and peer relationships. Role confusion results if the individual does not have love and support. Intimacy Versus Isolation (20 to 30 Years) A goal of this stage is to establish a close meaningful relationship with another person. The individual must be able to give of himself or herself and be committed to another. This is learned from within the family unit during the growing years. Close ties with family members and intimate relationships are essential to the well-being of the young adult. Failure to accomplish a meaningful close relationship results in loneliness and isolation. Some individuals have many superficial relationships that leave them unfulfilled. Commitment and drive are also needed for career choice and success. Generativity Versus Stagnation (30 to 65 Years) Erikson defines generativity as the process by which the middle-aged person focuses on leadership, productivity, and concern for future generations. Individuals reflect on their accomplishments and become involved with their new family roles. Generativity takes on different forms. Some adults engage in nurturing their children or grandchildren; others become involved in community projects. Still others begin new careers at this stage. Inability to establish generativity results in stagnation. Stagnation occurs when a person is unconcerned with the welfare of others and is preoccupied with himself or herself. Ego Integrity Versus Despair (65 Years and Over) During this period, life experiences are reviewed. Ego integrity is achieved if the person reaches a level where he or she is able to accept past choices as the best that could be accomplished at the time. The individual has a sense of dignity from his or her life accomplishments. Ego integrity implies that the individual has resolved the tasks of earlier stages and has little desire to relive his or her life. Dissatisfaction with life review leads to feelings of despair. The person may wish to start over and have another chance. Despair produces feelings of worthlessness and hopelessness. COGNITIVE THEORY Jean Piaget’s contribution to the field of psychology is cognitive development. He was concerned with how the individual acquires intellect and develops thought processes. Piaget believed that intelligence was an innate ability that further developed as the child adapted to the environment. Piaget believed there are three major concepts: schemas, assimilation, and accommodation. The term schema refers to patterns consisting of a number of organized ideas that grow with a child’s experiences. Initially infants have several schemas such as sucking and grasping. These schemas act as a guide that interacts with their environment. Eventually, as the infant’s experiences expand, new patterns emerge. This can be demonstrated by the infant’s ability to suck. Assimilation is Piaget’s second concept, which can be described as the ability to absorb new information into the existing schemas. The infant broadens the schema of sucking to include sucking on anything within his or her reach, such as a blanket, pacifier, toy, or fingers. Piaget’s third concept is accommodation, which occurs with new experiences that no longer fit or can be assimilated into existing schemas. As a result, schemas are changed to merge with the new information. This can be seen by the infant no longer just sucking food off a spoon but opening his or her mouth when the spoon approaches. Piaget believed that the child’s cognitive abilities progress through four stages: sensorimotor, preoperational, concrete operational, and formal operational (Table 5.3). Sensorimotor Stage (Birth to 2 Years) At birth the infant begins by responding to the environment primarily through reflexes. Schemas have object permanence or are limited to what the child can see, hear, or touch—what is out of sight will be 7589_Ch05_053-068 29/08/17 1:59 PM Page 63 Theories of Growth and Development 63 T A B L E 5.3 P i ag et ’ s St ag es of C og n i t i ve Dev elo pment Age Stage Major Developmental Tasks Birth–2 years Sensorimotor With increased mobility and awareness and development of a sense of self as separate from the external environment, the concept of object permanence emerges as the ability to form mental images evolves. 2–6 years Preoperational Learning to express self with language; developing understanding of symbolic gestures; achieving object permanence. 6–12 years Concrete operations Learning to apply logic to thinking; developing an understanding of reversibility and spatiality; learning to differentiate and classify; socializing and applying rules. 12–15 years and up Formal operations Learning to think and reason in abstract terms; making and testing hypotheses; expanding and refining logical thinking and reasoning; achieving cognitive maturity. Source: Townsend, MC: Psychiatric Mental Health Nursing: Concepts of Care, ed. 4. FA Davis, Philadelphia, 2003, p 42, with permission. out of mind (Fig. 5.8). Gradually the infant acquires knowledge by exploring the environment and attaches meaning and recognition of things. Through trial-and-error behavior, the child perfects sensory and motor reflex skills. By the completion of this stage, the child is able to see himself or herself as separate from other objects in the environment. Preoperational Stage (2 to 6 Years) The child is concerned with the development and mastery of language. This stage is characterized by egocentrism. The child sees himself or herself as the center of the universe and is unable to accept other viewpoints. He or she uses language skills and gestures to meet his or her needs. At this time objects are singular and one-dimensional to the child. This means that the child can create a mental picture of an object or person. The child lacks the ability to do reversible mental processes. An example is seen by asking a young girl, “Do you have a sister?” The girl answers, “Yes, I do.” You respond, “Does your sister have a sister?” and the child answers, “No, she doesn’t.” Thinking is described as animistic, which causes a child to believe that objects, tables, the sun, and trees have feelings and motives. For example, when the child trips near the table he cries, “Bad table.” A B FIGURE 5.8 The child in photo B thinks the object no longer exists. Can you explain why, according to Piaget? 7589_Ch05_053-068 29/08/17 1:59 PM Page 64 64 Journey Across the Life Span Concrete Operational Stage (6 to 12 Years) The increased acquisition of cognition allows the child to think and converse on many topics. The child is beginning to think logically and solve problems to some degree but is unable to deal with hypothetical or complex abstract situations. The child is less egocentric and more social. Concepts of reversibility and spatiality are developed. Children at this age can understand that water can be in liquid or solid form and can change back and forth. Children at this stage can classify objects using several characteristics. For example, they see a car not simply as a car but as a 2010 Ford Taurus. Formal Operational Stage (12 to 15 Years) The individual has the ability to think logically in hypothetical and abstract terms. He or she demonstrates both form and structure in organizing thoughts and is capable of scientific reasoning and problem solving. HUMAN NEEDS THEORY Abraham Maslow described human behavior as being motivated by needs that are ordered in a hierarchy (Fig. 5.9). At the bottom are basic survival needs (physiological needs, safety, belonging), and at the top are more complex needs (self-esteem, selfactualization). Maslow believed that people must meet their most basic needs before they can move up the hierarchy to the highest level. Physiological Needs The most basic needs are physiological and include the need for oxygen, food, water, rest, and elimination. Maslow also included sexual needs, which are important for survival of the species, among the basic needs. When these basic needs are met, an individual is free to move to the next stage. However, if these needs are not met, an individual will continue to be preoccupied with them. For example, a hungry child may lack interest in school (or anything other than food) until he or she is no longer hungry. Safety Needs The need to feel secure, safe, and free from danger is the next need to be met, but one cannot think of safety until physiological needs have been met. The young child must have feelings of security in the home and family before he or she can venture out into the larger community and school environment. Belonging Belonging is feeling loved and accepted by another person. To enter into any relationship, a person must first feel secure. Love and affection begin with bonding at the time of birth and continue throughout human development. All individuals need affection and meaningful relationships. Self-Esteem People need to feel good about themselves and their accomplishments. To arrive at this place, each person must receive approval and recognition of his or her own worth. Self-esteem is first built by parental approval and acceptance. During the school years teachers and other social contacts can further strengthen a person’s self-esteem. Self-Actualization FIGURE 5.9 Maslow hierarchy diagram. Self-actualization means self-fulfillment, the achievement of one’s full potential. Maslow did not believe that everyone can be completely self-actualized. He thought that as people continue to achieve and develop healthy relationships, they progress toward this goal. As people move toward self-actualization, they become more comfortable with themselves and who 7589_Ch05_053-068 29/08/17 1:59 PM Page 65 Theories of Growth and Development they are. At this level people are self-directed in ideas and actions. Self-actualizers must be oriented to reality, flexible, and able to change as needed. Although part of a group, a self-actualized person maintains his or her own individuality. Creativity, a sense of humor, and respect for the welfare of others are fundamental to this level of achievement. THEORY OF MORAL DEVELOPMENT Lawrence Kohlberg introduced his theory of moral development by expanding Piaget’s stages of cognitive development. Kohlberg believed that the child progressively develops moral reasoning as he or she gains the ability to think logically. Kohlberg identified three levels of moral development, which are further subdivided into six stages of acquired moral reasoning, beginning at age 4 and extending to adulthood (Table 5.4). Level I: Preconventional Thinking (4 to 10 Years) The child learns reasoning through the parents’ demand for obedience. To avoid punishment the child begins to recognize right from wrong. A 4-year-old child might think, “If I’m mean to my brother, I will be punished.” Level II: Conventional Thinking (10 to 13 Years) The school-age child begins to seek approval from society. Kohlberg believed that the child at this stage is influenced by external forces in interactions with his or her peers and environment. A 12-year-old child knows that it is wrong to cheat in school and wishes to win the approval of both family and teachers. Level III: Postconventional Thinking (Postadolescence) Adolescents develop their own moral codes. Moral reasoning is based on the individual’s own principles rather than on external forces. Kohlberg further believed that some individuals never attain this higher level of moral reasoning. Those who operate at the level of postconventional thinking usually act according to their internal codes of beliefs. Most people stop at a traffic signal even when traffic is clear and they know that no one is watching them. Carol Gilligan, one of Kohlberg’s students, is one of the most outspoken critics of Kohlberg’s theory of moral development. Gilligan expresses concern that the research from which Kohlberg developed his theory failed to explore unique female experiences as they pertained to morality. She further argues that his research was biased against women because all of the subjects in his study were males. T A B L E 5.4 65 Koh l b er g ’ s St ag es of M or al Dev elo pment Level/Age* Stage Developmental Focus Preconventional (common from 4–10 years) 1. Punishment and obedience orientation 2. Instrumental relativist orientation Behavior motivated by fear of punishment Behavior motivated by egocentrism and concern for self Conventional (common from 10–13 years and into adulthood) 3. Interpersonal concordance orientation 4. Law and order orientation Behavior motivated by expectations of others; strong desire for approval and acceptance Behavior motivated by respect for authority Postconventional (can occur from adolescence on) 5. Social contract legalistic orientation 6. Universal ethical principle orientation Behavior motivated by respect for universal laws and moral principles; guided by internal set of values Behavior motivated by internalized principles of honor, justice, and respect for human dignity; guided by the conscience *Ages in Kohlberg’s theory are not well defined. The stage of development is determined by the motivation behind the individual’s behavior. Source: Townsend, MC: Psychiatric Mental Health Nursing: Concepts of Care, ed. 5. FA Davis, Philadelphia, 2006, p 43, with permission. 7589_Ch05_053-068 29/08/17 1:59 PM Page 66 66 Journey Across the Life Span According to Kohlberg, males function at a higher moral reasoning level than females. Gilligan purports that female moral development is different from, not inferior to, that of males in that females develop a morality of caring and responsibility. She believes this is true because she feels that females are more concerned than males with relationships, caregiving, and intimacy. According to Gilligan, male moral development is more concerned with morality and justice. Furthermore, Gilligan states that men make more decisions based on abstract reasoning and principles, whereas women are more concerned with how their decisions affect others. Gilligan presents her own theory of moral development in the same way as Kohlberg’s, with three stages of moral development: preconventional, conventional, and postconventional. At the preconventional stage the child is mainly selfish, dominated by survival goals. As the child grows she or he moves from this selfishness to more responsibility. During the conventional stage the child sees sacrifices as goodness. Children now begin to place more interest in relationships, and as a result they start to put others first. At the postconventional level individuals learn to think and consider others in addition to themselves. Gilligan’s theory has also come under criticism by other scholars. It has been said that Gilligan’s research is limited in that it cannot be duplicated and validated. Recently theorists have indicated their belief that both men and women exhibit some degree of justice and caring that affects their moral reasoning. Refer to Table 5.5 for an illustration of Gilligan’s theory. Understanding moral development is important for nurses to better understand moral issues that affect patients at different stages in development. An understanding of moral reasoning may also assist nurses in making ethical decisions in clinical practice. Box 5.2 is a guide to moral decision making. T A B L E 5.5 G illig an’ s Theo ry o f M o ral Dev elo pment Stage Characteristics Preconventional Self-centered Conventional Interest and concern for others Postconventional Socially responsible for oneself and others B O 5.2 X G uid e to M o ral Decisio n M ak ing The following questions will assist you in moral decision making: 1. What characteristics make an act right or wrong? 2. How do rules affect moral acts? 3. What action should be taken in this specific situation? SUMMARY 1. Growth and development, terms often used together, have different meanings. Growth refers to an increase in size; development refers to acquisition of skills. 2. Growth and development occur simultaneously and are interdependent. 3. Maturation is the total process in which a child’s potential unfolds, regardless of practice. 4. The two major influences on growth and development are heredity and environment. Hereditary characteristics are all those transmitted by the genes. All other factors that affect the unborn and born child are environmental. 5. The five universally recognized basic assumptions about growth and development are that they: • Progress in an orderly manner from simple to complex • Are continuous processes • Occur at highly individualized rates • Affect all body systems and stages • Together form a total process 6. Each individual has a unique behavior known as personality. Understanding the different theories of personality development helps the nurse promote health and provide health care to individuals. 7589_Ch05_053-068 29/08/17 1:59 PM Page 67 Theories of Growth and Development 67 7. These personality theories describe stages of development. The stages are generally progressive—that is, it is necessary to complete an earlier stage before moving on to the next. However, at times an individual may temporarily regress to an earlier stage. 11. Piaget’s theory focuses on cognitive development using three concepts (schemas, assimilation, and accommodation), which proceeds through four stages (sensorimotor, preoperational, concrete operational, and formal operational). 8. Defense mechanisms are techniques used at all stages of life to assist persons in coping with anxiety. 12. Maslow believed that human behavior was motivated by human needs arranged hierarchically from the most basic to the most complex. Beginning with physiological, these needs progress to those for safety, belonging, self-esteem, and self-actualization. 9. Freud described five stages of psychosexual development: oral, anal, phallic, latency, and genital. 10. Erikson developed a theory of psychosocial development that covers the entire life span. Certain tasks need to be accomplished in each of the eight stages: trust versus mistrust, autonomy versus shame and doubt, initiative versus guilt, industry versus inferiority, identity versus role confusion, intimacy versus isolation, generativity versus stagnation, and ego integrity versus despair. 13. Kohlberg’s theory of moral reasoning identified three levels of moral development: preconventional, conventional, and postconventional. Moral development progresses within these stages in an orderly sequence. However, one does not attain the highest level of moral reasoning. 14. Gilligan proposes her theory of moral reasoning from a feminine perspective. CRITICAL THINKING Exercise #1 Jane and Bill bring their 4-month-old baby girl, Tayna, to the hospital. She is admitted for vomiting and dehydration and is not permitted anything by mouth. Both parents work and must leave the baby in the nurse’s care during the day. Using the information given and the material in this chapter, respond to the following questions or problems: 1. Identify Tayna’s psychosexual level of development according to Freud’s stages. 2. What psychosocial task, according to Erikson, would Tayna be struggling with at this stage? 3. Based on Maslow’s human needs theory, what need would be of primary concern to Tayna? 4. List one nursing action that would help Tayna in meeting the need identified above. Exercise #2 Jeremy, age 2 years, is playing at the park with his mother. When his mother tells him it is time to go home, Jeremy responds by crying “No!” and refusing to leave. 1. At what stage of development is Jeremy? 2. How can Jeremy’s mother best handle this situation? 7589_Ch05_053-068 29/08/17 1:59 PM Page 68 68 Journey Across the Life Span MULTIPLE-CHOICE QUESTIONS 1. Growth can be defined as: a. The progressive acquisition of skills b. An increase in cognitive ability c. An increase in physical size d. The rapid development of language 7. The term most associated with Maslow is: a. Pleasure principle b. Psychosocial task c. Self-actualization d. Concrete operations 2. According to Freud, what part of the mind acts as one’s conscience? a. Id b. Ego c. Superego d. Libido 8. According to Freud’s theory, the rational portion of the mind that tries to balance id impulses with the demands of the superego is: a. Conscience b. Ego c. Libido d. Oedipal period 3. According to Erikson’s stages of development, which of the following tasks would Roger, age 9, be completing? a. Trust b. Industry c. Initiative d. Autonomy 4. At the completion of Piaget’s sensorimotor stage of cognitive development, the child: a. Can problem-solve b. Can reason hypothetically c. Has abstract thinking ability d. Recognizes himself or herself as separate 5. Theories of personality help the nurse to: a. Place judgment on the patient b. Direct patient goals c. Provide individual health care d. Limit ego development 6. Maslow’s humanistic approach to development emphasizes the importance of: a. Basic goodness in humans b. The pleasure principle c. Developmental tasks d. Conditioning 9. The purpose of defense mechanisms is to: a. Perceive boundaries between self and others b. Explain life situations c. Reduce anxiety d. Provide pleasure and gratification 10. Which of the following defense mechanisms is considered to be a positive method of coping? a. Projection b. Displacement c. Reaction formation d. Sublimation 11. Moral development: a. Is the first stage of personality development b. Occurs in an orderly sequence c. Is a disorderly process d. Is the same for all individuals Visit www.DavisPlus.com for Student Resources.