N146

January 5, 2010

GROWTH AND DEVELOPMENT

Nature vs. Nurture

– genetics and environment
– some say environment is more important because there aren’t very many genes to account for the vast
differentiation in humans
– twin studies have shown differences among twins who were raised separately
– pediatric nurses play a big role in educating parents and families in making healthy lifestyle choices

Erik Erikson: Social and Emotional Development

– 1902-1994
– 8 stages of psychosocial development (in the 50s-60s)
– his approach to the personality is an extension of Freud’s psychosexual theory
– Erikson’s theory is unique in that is encompasses the entire life cycle and recognizes the impact of society,
history, and culture on personality
– still the basic building block of how we look at human development
Stage Age Basic Conflict Important Summary
Event
1) Oral-Sensory Birth-18 Trust vs. Feeding The infant must form a first loving,
months Mistrust trusting relationship with the caregiver,
or develop a sense of mistrust.
2) Muscular-Anal 18 months – 3 Autonomy vs. Toilet Training The child’s energies are directed toward
years Shame/Doubt the development of physical skills,
including walking, grasping, and rectal
sphincter control. The child learns
control but may develop shame and
doubt if not handled well.
3) Locomotor 3-6 years Initiative vs. Independence The child continues to become more
Guilt assertive and to take more initiative,
but may be too forceful, leading to guilt
feelings.
4) Latency 6-12 years Industry vs. School The child must deal with demands to
Inferiority learn new skills or risk a sense of
inferiority, failure, and incompetence.
This is an important time to help them
succeed.
5) Adolescence 12-18 years Identity vs. Peer The teenager must achieve a sense of
Role Confusion relationships identity in occupation, sex roles,
politics, and religion.
6) Young 19-40 years Intimacy vs. Love The young adult must develop intimate
Adulthood Isolation relationships relationships or suffer feelings of
isolation.
7) Middle 40-65 years Generativity vs. Parenting Each adult must find some way to
Adulthood Stagnation satisfy and support the next generation.
8) Maturity 65-death Ego Integrity Reflection on The culmination is a sense of oneself as
vs. Despair and one is and of feeling fulfilled.
acceptance of
one’s life
– “met needs” does not motivate behavior
– support people’s approaches to things, suggest things in an unthreatening way by demonstration
– pay attention to family dynamics and how they affect the child’s health
– be careful of projecting your own opinions on to other people, it’s important to be an observer

Jean Piaget: Cognitive Development

– 1896-1980
– Object Permanence
– Egocentrism
– He described the mechanism by which the mind processes new information. He said that a person
understands whatever information fits into his established view of the world. When information does not fit,
the person must reexamine and adjust his thinking to accommodate the new information. This is what
makes us human—we can learn and change ourselves.
– Piaget described four stages of cognitive development and relates them to a person’s ability to understand
and assimilate new information.
1
 1.Sensorimotor (birth to about age 2 years): During this stage, the child learns about himself and his
environment through motor and reflex actions. Thought derives from sensation and movement. The
child learns that he is separate from his environment. Not just an extension of your mother.
2.Preoperational (2-7 years, begins about the time the child starts to talk): Applying her new
knowledge of language, the child begins to use symbols to represent objects. Oriented to the present,
the child has difficulty conceptualizing time. Her thinking is influenced by fantasy—and she assumes
that others see situations from her viewpoint. She takes in information and then changes it in her
mind to fit her ideas. Pros of fantasy: fosters creativity, imagination, coping mechanisms, etc. Cons of
fantasy: not knowing reality, may affect ability to care for the child. For nursing, create a safe
environment that still allows exploration.
3.Concrete (6-12 years, about first grade to early adolescence): During this stage, accommodation
increases. The child develops an ability to think abstractly and to make rational judgements about
concrete or observable phenomena.
4.Formal Operations (12-18 years, adolescence): This stage brings cognition to its final form. This
person no longer requires concrete objects to make rational judgements. At this point, he is capable of
hypothetical and deductive reasoning.

Lawrence Kohlberg: Moral Development

– 1927-1987
– Expanding on Piaget’s work, Kohnberg determined that the process of moral development was principally
concerned with justice, and that it continued throughout the individual’s lifetime
– Level 1 (Pre-Conventional)
○ Obedience and punishment orientation (How can I avoid punishment?)
○ Self-interest orientation (What’s in it for me?)
– Level 2 (Conventional)
○ Interpersonal accord and conformity (Social norms) (The good boy/good girl attitude)
○ Authority and social-order maintaining orientation (Law and order morality)
– Level 3 (Post-Conventional)
○ Social contract orientation
○ Universal ethical principles (Principled conscience)
(test mostly on Piaget and Erikson)

neonate: 0-30 days, used interchangeably with newborn

Developmental Standards: Newborn to 3 Months

Assessment: Physical/Motor/Sensory
– Primitive reflexes (Babinski, Moro, startle grasp)
– Visual tracking, maintains eye contact when quiet and alert
– Voids 6x/day, 2-6 stools/day, pattern will vary depending on bottle fed or breast fed
○ Always ask about I/O
– Sleeps most of day
– Poor development of head control—important to have good support when holding
– Responds to light and sound
– Startles easily
– Sucks on hands and objects for tension release
Interventions
– Promote sucking reflex
– Provide visual/auditory/tactile stimuli
– Cluster patient care, limit unnecessary interruptions to promote development of sleep/awake patterns

Assessment: Cognitive/Language
– Differentiated cry begins (caretaker should know what each cry means)
– Cooing begins at the end of this stage
Interventions
– Encourage vocalizations, talk to infant
– Repeat infant’s early vocalizations (to motivate them to keep vocalizing)
– Provide opportunities for face to face interactions

Assessment: Psychosocial/Social Emotional

– May have low threshold for external stimuli, still attempting to organize behavior in response to environment
– Orients to sound and visual stimuli, able to make sustained eye contact
– At 6-8 weeks, may start to see a social smile
Interventions

2
– Decrease stimulation (TV, bright lights, etc.)
– Encourage parent visitation to promote bonding
– If needed, assist parents in reading infant’s cues
– Encourage parents to bring objects from home to promote normalization

Assessment: Safety
– Infant may fall from open crib
– Infant should be held for feeds
– Position infant safely in crib
Interventions
– Instruct family in safe use of crib rails, keep crib rails up when adult not at bedside
– No small objects in crib
– Use rolled blankets for safe positioning
– If needed provide parents info on bottle propping (teeth can be rotted before they come through the gum, if
formula/milk is just sitting in mouth; also can choke; also good for infant to associate feeding with caretaker;
bonding)
– Will REQUIRE care seat for discharge (at least 6 years old and 60 pounds to not use a car seat)
Assessment:
Fears/Issues Related to Hospitalization
– Disruption in sleeping, eating, awake routines
– Separation from primary caregiver
Education/Preparation
- Infant will respond to stress/anxiety of parent/primary caregiver
Sources of Comfort
– Parent/Primary caregiver
– Swaddling, holding, soft music, low lighting
– Pacifier, bottle, breast feeding
Interventions
– Encourage parents to visit, active participation in the infant’s care
– Utilize consistent, primary caregivers
– Support parent(s) ability to calm/comfort infant
– Provide parent(s) w/ adequate info/preparation to reduce anxiety
– Talk to infant and parent about what you are doing
– Promote use of sources of comfort

(see videos on CD-ROM)

– babies change every minute, every week; always something new happening
– caregivers need to be aware and be educated about the rapidly changing stages

Developmental Standards: Infants (6-9 months)

Assessment: Physical/Motor/Sensory
– Manipulates and transfers objects from hand to hand (5-7 months)
– Learning to sit independently (9 months, sits without support)
– Beginning to crawl
– Fine motor skills improving, including hand mouth coordination, may be able to hold own bottle
– May begin to self-feed with fingers or hold cup by self
8-9 months
– Infant is learning voluntary release and grasp, enjoys dropping games
– Reactions move from reflexive to intentional
– By end of this stage, may pull to a stand (don’t push it before they are ready; leg bones are not fully
developed)
At 9-10 months, begins to develop a sense of Object Permanence (i.e. Peekaboo; understanding that
something exists even if it’s not in their presence)
Interventions
– When possible, allow infant play time out of crib
– Encourage parents/caregivers to take infant to playroom for regular sessions if not on isolation
– Encourage parents to bring developmentally appropriated toys
– d

Assessment: Cognitive/Language
– Infant more aware of and responsive to social interaction
– Vocal play increases with changes in intonation, increase in
– a
Interventions

3
– d
– d

Assessment: Psychosocial/Social Emotional

– Looks to parent(s) or primary caretakers for comfort and support
– Experiences separation anxiety when separated from parent(s), wary of strangers including hospital
personnel
– Infant has increased needs for normal play routines and activity
Interventions
– Support maintenance of family bonds, encourage parents

Assessment: Safety
– Infant may fall out of open crib
– “Mouths” objects, strong drive to bring objects to mouth
– Will require care seat for D/C
– Beginning to physically explore environment
– May become tangled in balloon ribbons or strings if tied to bed rails
Interventions
– Instruct family of safe use of crib rails, keep crib rails up when no adult is at the bedside
Assessment: Fears/Issues Related to Hospitalization
– Most secure with a stable daily routine and primary caretakers
– May react with acute distress to changes in routine and/or care providers
– Senses hospital environment, hospital staff as unfamiliar, may experience stranger anxiety
Interventions
– Encourage parents to visit, active participation in infant’s care
– Promote maintenance of daily routines and use of primary caregivers whenever possible
– Approach infants gently, be aware of infant’s stranger anxiety

Assessment:

Developmental Standards: 18 months—3 years (the Toddler)

Assessment: Physical/Motor, Sensory
– Walks independently, progresses to running
– Walks up and down stairs; begins to alternate feet
– Jumps in place from low objects (three years)
– Kicks and plays ball
– Builds a tower of blocks
– Can scribble, by end of this stage can copy a circle
– Begins to string beads
– Feeds and drinks with minimal assistance
Interventions
– Provide opportunities for gross motor play when possible, encourage use of playroom
– Provide appropriate toys to encourage developmentally appropriate fine motor activities
– Show child various equipment to be used, such as stethoscope, blood pressure cuff, etc.; provide
opportunities to explore through play
– Allow child to self feed, while offering assistance when needed

Psychosocial/Social Emotional
– Parents or primary caregivers are main support, fears parent(s) leaving
– May be anxious with medical staff
– May experience acute separation anxiety
– Security objects are important, favorite toy/object
– Egocentric, sees thing from own point of view
– May show oppositional behavior, experimenting with independence
– Regression may be seen as a common coping mechanism
– Daily routines are important for security
– d

Assessment: Safety
– Puts objects in mouth
– May try to climb out of crib/bed
– Actively explores the environment, cannot differentiate actions that are dangerous
– Bathroom may be a hazardous area
Interventions
4
– Will REQUIRE car seat for safe discharge
– Keep all small objects out of child’s reach
– Keep crib/bed rails up, educate parents on crib/bed safety
– When possible position IV lines, monitors, etc. so child can continue to explore environment
– Keep bathroom door closed if child is out of crib/bed

Assessment: Fears/Issues Related to Hospitalization

– Separation from parents or caregivers, fear that parents will not return
– Anxiety when medical staff approaches
– May view hospitalization as punishment for his/her behavior
– Fear of medical procedures, medical staff
– Child will respond to parent or caregiver’s level of anxiety
Interventions
– Provide honest, simple, concrete explanations during care (don’t say it’s not going to hurt if it is)
– Encourage parents to stay with child as much as possible
– Provide child with comfort and encourage trusting relationships with staff
– Transitional objects (blanket, pacifier, stuffed animal)
– Provide parent with education and preparation when about child’s care, in order to reduce their anxiety level
– Show child various equipment to be used, such as stethoscope. Allow child the opportunity to explore
medical equipment
– Explanations should be in terms of what the child will see, hear, feel, and smell
– Give one direction at a time
– Provide distraction during procedures

Pre-School (3-6 years)

Psychosocial/Social Emotional
– Significant persons are parents, primary care givers, siblings and peers
– Increasing independence and beginning to assert self
– Behavior is modified by rewards and punishment
– Learning to play cooperatively, able to follow rules
– Learns to trust people, wants friends, and wants to communicate with others
– Imaginary play is prevalent
Interventions
– Encourage involvement in playroom activities, social interaction with other children
– Promote family centered care, encourage parent involvement in care
– Provide child with opportunities
– d

Fears/Issues Related to Hospitalization

– Separation from parents/family
– Hospitalization/illness may be viewed as punishment for misbehavior
– Misconception of medical terms (i.e. flush your IV, may be viewed as, flushing down the toilet)
– Loss of control and independence
– Regressing in physical/cognitive skills
Interventions
– Provide child with realistic choices and opportunities for control
– Encourage family visitation, active involvement in care
– Provide simple explanations of medical terms
– Allow child to play out medical experiences through medical play, etc.

School-Age (6-12 years)

Physical/Motor/Sensory
– Increasing gross motor abilities, including running, sports activities, etc.
– May enjoy quiet activities as well as active games
Cognitive/Language
– Begins to think abstractly and reason
– Understands and can tell time
– d
Interventions
– d

Psychosocial/Social Emotional
– Significant people are
–
5
Interventions

Safety
– Experiments with independence
– Easily distracted
– Needs to be reminded of dangerous situations

Education/Preparation

Sources of Comfort
– Parents, siblings, friends, roommates
– Familiar hospital staff
– Playroom, play activities
Interventions
– Relaxation techniques
– Encourage use of and rehearse coping skills
– Use drawings, medical equipment and books for education and preparation
– Provide honest

Take Home Points

– Think Safety
– Think Education
– Things change quickly and often in childhood so never assume anything and stay aware