Growth and Development

A. Growth and development in general 1. Patterns of growth and development a. cephalocaudal: head to tail b. proximodistal: near to far c. differentiation: from simple operations to more complex activities and functions 2. Growth measures a. height b. weight c. frontal-occipital circumference 3. Theories of development a. Piaget's theory of cognitive development b. Erikson's theory of psychosocial development c. Kohlberg's theory of moral development d. language development 4. Assessment of growth and development using the Denver II developmental screening test a. screens children from birth through 6 years of age b. assesses four skills i. personal-social ii. fine motor adaptive iii. language iv. gross motor KOHLBERG'S THEORY OF MORAL DEVELOPMENT A. Describes how children develop morally in 3 stages (levels): 1. Premorality: child behaves acceptably because child fears punishment 2. Conventional morality: child behaves appropriately in order to please others 3. Postconventional morality a. An internal locus of control guides behavior b. Based on concern for what is right and good for all B. Children and adults may not progress through all levels.

ERIKSON'S THEORY OF PSYCHOSOCIAL DEVELOPMENT

A. Describes development as a series of tasks that must be accomplished in order to progress psychosocially. B. The tasks are described in positive and negative terms: 1. Infancy: trust vs. mistrust 2. Toddlerhood: autonomy vs. shame and doubt 3. Preschool: initiative vs. guilt 4. School age: industry vs. inferiority 5. Adolescence: identity vs. identity diffusion 6. Young adult: intimacy vs. isolation 7. Middle adult: generativity vs. stagnation 8. Elder adult: ego integrity vs. despair Positive resolution of each task builds a strong personality while negative resolution results in difficulty handling psychosocial problems

PIAGET'S THEORY OF COGNITIVE DEVELOPMENT

Four Periods: Sensorimotor, Preoperational Thought, Concrete Operations, Formal Operations As children mature intellectually, they are more able to understand the environment, create patterns of behavior, and reason through problems. A. Piaget's sensorimotor period: birth to two years 1. Characteristics a. reflexes are used to achieve equilibrium b. repetitive acts help establish patterns of behavior c. beginning object permanence is evident (learning that an object still exists when it is out of sight.) d. view of the world is egocentric e. active experimentation as infant progresses 2. Nursing considerations: sensorimotor stage a. children will explore their environment to learn more about it especially through use of their mouth b. cannot use logic to protect themselves c. separation from parents is not as important to infants (under six months) as it is to older children B. Piaget's period of preoperational thought: two to seven years 1. Characteristics a. object permanence becomes more established b. still egocentric in thinking c. use language as a symbol system more and more d. increased magical thinking and imagination; called animism. e. perceptions rule child's thinking and reasoning f. attention span is short. g. child has better concept of time as he/she approaches school age 2. Nursing considerations a. illness and hospitalization frighten toddlers and preschoolers. They lack the cognitive powers to grasp these experiences. b. precognitive children use fantasy and magical thinking to attempt to understand illness and hospitalization. c. precognitive children have many fears, especially separation which peaks from two through three years of age. d. these children learn best if actively involved in the learning process. e. this age group relates well to discussions about what they will see and feel. Visual and tactile learning is best. C. Piaget's period of concrete operations: seven to ten years 1. Characteristics a. thinking shifts from total egocentrism to more local awareness b. conscience develops c. perception no longer dominates reasoning- recognized cause-and-effect relationships. d. understands basic ideas of conversation, number, classification, and other concrete ideas. e. attention span increases f. can solve problems by trial and error 2. Nursing considerations a. this age group benefits from health teaching with concrete terms and explanations. b. this age group reads and understands concepts related to the human body. D. Piaget's period of formal operations: 11 years to Adult 1. Characteristics a. see new logical relationships b. analyze situations and think more logically than before c. think creatively since increased abilities to think abstractly d. concern for moral and social issues are a priority over Egocentric thinking 2. Nursing considerations a. think much more like adults b. are able to be taught health concepts at higher levels c. more likely to understand adult vocabulary

B.

Infancy (1 month to 12 months) 1. Growth a. period of very rapid growth. b. doubles birth weight at 6 months, triples at 1 year c. by 1 year birth length has increased by almost 50% (occurs mainly in trunk) d. by 1 year head circumference has increased by almost 33% e. posterior fontanel closes 6 to 8 weeks of age f. anterior fontanel closes 12-18 months of age g. tooth eruption begins at 5 to 6 months

2.

3. 4.
5.

h. has 6 to 8 teeth by 1 year Motor development a. sits without support at 6 to 8 months of age b. rolls completely over at 6 months of age c. vocalization at 8 months of age d. pincer grasp at 9-11 months of age e. crawling 6 to 7 months of age f. stands alone 10-12 months of age g. cruises (walks holding on) 10-12 months of age h. walks at 12-15 months of age. i. begin feeding self at 11 months of age Cognitive: Piaget's sensorimotor period Psychological: Erikson's developmental task of trust vs. mistrust a. lays foundation for other developmental tasks b. stranger anxiety/separation anxiety Language development

6. 7.

1.

a. cries, smiles, coos b. produces chained syllables c. says 2 or more words by 1 year d. understands meaning of "no" by 11 months of age e. can follow simple directions at 1 year Play is solitary a. game playing such as peekaboo and pat-a-cake by 10 months of age Common fears a. from birth to 3 months - fears sudden movements, loud noises, and loss of physical support b. from 4-12 months - fears strangers, strange objects, heights, and anticipation of previous uncomfortable situations Suggested toys a. birth to 6 months - mobiles, unbreakable mirrors, music boxes, rattles b. 6 to 12 months - blocks, nesting boxes or cups, simple take apart toys, large ball, large puzzles, jack in the box, floating toys, teething toys, activity box, push-pull toys

C.

Toddlerhood (1 - 3 years) 1. Growth a. gains 1.8-2.7 kg (4 to 6 lbs) per year b. grows 7.5 cm (3 inches) per year (occurs mainly in legs) c. lordosis and potbelly are characteristic d. head circumference usually equal to chest circumference by 1 to 2 years of age e. primary dentition complete by 30 months of age 2. Motor development a. walking improves b. runs c. begins to climb and walk up and down stairs d. builds tower of 8 blocks by age 3 years e. by end of toddlerhood can copy a circle on paper f. dresses self in simple clothing 3. Cognitive: Piaget's period of preoperational thought 4. Psychological: Erikson's developmental task of autonomy vs. shame and doubt a. toilet training begins i. bowel training usually accomplished before bladder b. discipline becomes necessary c. ritualistic: need to maintain sameness and reliability d. negativism: persistent negative response to requests e. frustration may result in temper tantrums or regression 5. Moral development: Kohlberg's preconventional or premoral level 6. Language development a. vocabulary grows from 4 to 6 words at 15 months to over 300 words by age two b. "no!" and "mine!" are key words c. ability to understand speech is much greater than the number of words the child can say d. uses multiword sentences by age 2 7. Play is parallel 8. Common fears include the dark, being alone, separation from parents, some animals, and loud machines 9. Suggested toys: push-pull toys, finger paints, thick crayons, riding toys, balls, blocks, puzzles, simple tape recorder, housekeeping toys, puppets, cloth picture books, large beads to string, toy telephone, water toys, sand box, play dough or clay, chalk and chalkboard

D.

Preschool age (3 - 6 years) 1. Growth a. average weight gain about 2 to 3 kg (five lb) per year b. height: increase of 6.75 to 7.5 cm (2.5 to 3 inches) per year (occurs in legs) 2. Motor development a. very active b. can hop on one foot c. pedals tricycle d. refinement of previous learned motor skills e. draws a person with 1 body part/year 3. Cognitive: Piaget's period of preoperational thought 4. Psychological: Erikson's developmental task of initiative vs guilt a. sexual curiosity, and b. imitation of adult roles with dress-up games. 5. Moral development: Kohlberg a. 2 to 4 years: punishment and obedience b. 4 to 7 years: naive instrumental orientation 6. Language development a. by age 5, has vocabulary of 2,100 words b. knows name and address c. asks questions constantly d. uses fantasy in stories e. "why?" is favorite word 7. Preschool play is associative and cooperative. a. dress-up b. fantasy play c. imaginary playmates 8. Common fears of preschool child include body mutilation, animals, supernatural beings, monsters, ghosts, unfamiliar routines, separation from trusted adults, and abandonment, annihilation 9. Suggested toys: tricycle, gym and sports equipment, sandboxes, blocks, books, puzzles, computer games, dress-up clothes, blunt scissors, picture games, construction sets, musical instruments, cash registers, simple carpentry tools School age (6 - 12 years) 1. Growth a. growth is slow and steady until growth spurt of adolescence. b. between ages 6 to 12, growth at average of 2 to 3 kg (4.56.5 lbs) per year c. brain growth is complete by 9-10 years of age. d. height: average growth of 5 cm (2 inches) per year e. loss of deciduous teeth/acquisition of permanent teeth f. child is usually lean, but some may become overweight depending on eating habits and activity 2. Motor development a. full of energy b. rides bicycle and plays active games c. most enjoy sports d. writes in cursive e. more awkward as adolescence approaches 3. Cognitive: Piaget's period of concrete operations 4. Psychological: Erikson's developmental task of industry vs. inferiority

E.

5.

6.

a. develops a sense of accomplishment through completion of tasks b. joins clubs c. has same-sex friends d. peer approval is strong motivating power Moral development - Kohlberg a. develops a moral code and social rules b. views rules not just as dictates from authority, but as necessary principles of life c. can judge flexibly and decide if rules apply to a given situation Language development

1. vocabulary of approximately 14,000 words 2. reading skills improve dramatically 2. Play is cooperative. 1. sports and games with rules 2. fantasy play in early years 3. clubs 4. hero worship 5. cheating 3. Suggested toys/activities: board or computer games, books, collections, scrapbooks, sewing, cooking, carpentry, gardening, painting F. Adolescent (age 12-20) 1. Growth a. boys increase in muscle mass; girls increase in fat deposits b. may experience growth spurts c. puberty i. primary sex characteristics and secondary sex characteristics/Tanner stages ii. dentition is complete PUBERTY

A. Individuals vary widely in the timing of physical changes; following are general guides 1. Girls tend to begin puberty earlier than boys 2. Right before puberty, height and weight increase B. Hormonal bases of pubertal changes 1. Physical changes are the result of hormonal changes when the hypothalamus begins to produce gonadotropin-releasing hormones 2. Gonadotropic hormones stimulate the ovaries to produce estrogen and testicular cells to produce testosterone 3. Estrogen and testosterone govern development of secondary sex characteristics and play a critical role in reproduction C. Obvious physical changes of puberty include 1. Skeletal growth spurt 2. Appearance of pubic hair and axillary hair 3. In females a. Breast development b. Menarche c. Ovulation d. Widening and deepening of pelvis 4. In males a. Enlargement of testes and scrotal sac b. Voice changes - becomes deeper or lower-toned c. Spermatogenesis d. Facial hair e. Shoulders widen

2.

Motor development a. increase in gross and fine motor abilities b. increase in risk-taking behaviors 3. Cognitive: Piaget's period of formal operations 4. Psychological: Erikson's developmental task of identity vs role diffusion a. begins to develop a sense of "I" b. peers become most significant group c. separates from parents 5. Moral development: Kohlberg a. healthy adolescents consolidate moral development b. understand that rules are not absolutes, but cooperative agreements that can be changed to fit the situation c. judge themselves by internalized ideals d. group values become less significant in later adolescence

6. 7.

e. sense of right and wrong develops from applying values to daily decisions Language development - increases as cognitive skills increase Play / recreation a. centers around social interactions: dating, phone calls, etc. b. sporting and cultural activities

G.

Early adulthood Post adolescence through age 40 1. Physical development a. period of optimal physical function b. typically free of acute or chronic illness c. effects of aging begin at about 20 years of age d. musculo-skeletal system i. growth completed about age 25 ii. height increased by 3 to 5 mm by age 30 e. cardiovascular system i. peak strength about age 30 ii. men more likely to have high cholesterol level iii. blood pressure changes noted by race, sex and weight f. gastrointestinal system i. after age 30, digestive juices decrease ii. wisdom teeth emerge iii. average person tends to gain weight during the 30s g. reproductive system i. fully mature in 20s ii. women: optimal reproductive time between 20-30 years of age Psychosocial development a. Erickson: Intimacy versus isolation b. become more self-directive in the 20s c. may question previous life choices d. life becomes more orderly e. develop a community focus Cognitive development a. brain cell development peaks during 20s b. continues to develop a higher level of cognitive functioning c. person can think abstractly d. person can now perceive many different points of view e. more realistic and objective Health threats a. emotional stress b. accidents: often related to abuse of alcohol or drugs c. sexually transmitted diseases

2.

3.

4.

H.

Middle adulthood Ages 40 to 60 1. Physical development a. signs of aging begin to show b. subtle but gradual decline in most body systems c. integumentary system i. appropriate distribution of pigment ii. graying of hair iii. progressive decrease in skin turgor d. respiratory i. anteroposterior diameter of chest increases ii. respiratory rate 16 to 21 breaths per minute

e.

iii. normal breath sounds cardiovascular i. normal heart sounds ii. pulse 60 to 100 beats per minute iii. blood pressure: systolic 95 to 135mm Hg iv. diastolic 60 to 85 mm Hg reproductive changes in menstrual cycle and flow ii. menopause (climacteric) sets in about age 45 to 50 iii. decrease in ovarian function iv. symptoms of diminished estrogen production: hot flashes, headache, palpitations, mood swings, and vaginal dryness resulting in itching, burning, and/or painful intercourse v. treatment includes diet, exercise, estrogen replacement therapy and alternative therapies such as herbs and Vitamin E vi. complications include: osteoporosis i.

f.

vii. viii. ix.

cystocele or rectocele prolapse of the uterus sexual interest / desire women: increases after age 35 men: stabilizes or decreases somewhat male erection takes longer to achieve male menopause: symptoms may include insomnia, fatigue and circulatory problems g.

i. ii.
h.

i.

sensory visual acuity decreases presbyopia cognitive i. peak of intellectual development ii. no longer views self as invincible iii. chooses battles psychosocial

j.

Erickson: generativity versus stagnation midlife transition: time for assessing one's life structure iii. community emphasis peaks iv. role reversal takes place with parents v. more empathetic towards elderly major health risks i. leading cause of death is heart disease ii. in women, osteoporosis and breast and uterine cancer iii. colorectal and lung cancer

i. ii.

I.

Elderly adult Over age 60 1. Biological theories of aging a. crosslink theory b. immunological theory c. free radical theory d. stress theory e. error theory f. biological programming Psychosocial theories of aging a. disengagement theory b. activity theory c. continuity theory Developmental tasks of elderly adult a. Erickson: ego integrity versus despair b. accepting self as aging person; coping with physiological changes c. adjusting to decreasing physical abilities d. adjusting to retirement and decreased income e. adjusting to death of spouse; redefining relationships with children f. maintaining satisfactory living arrangements, and quality of life Physical systems a. integumentary system i. dry, scaly skin ii. decreased perspiration iii. decreased elasticity iv. senile purpura

2.

3.

4.

v.

spotty pigmentation

b.

c.

d.

e.

f.

g.

h.

respiratory reduced vital capacity ii. increased airway resistance iii. kyphosis may cramp lung expansion iv. decreased lung expansion cardiovascular i. decreased cardiac output ii. baseline systolic and diastolic blood pressure may rise iii. peripheral pulses weaker gastrointestinal i. abdomen increases in size, protrudes more ii. less saliva iii. less gastric motility and absorption iv. decreased interest in food v. decreased peristalsis vi. potential for malnutrition vii. decreased hepatic clearance of drugs and other substances viii. constipation common urinary i. decreased renal filtration ii. decreased bladder capacity iii. benign prostatic hypertrophy iv. female: urgency and stress incontinence v. male: urinary frequency and retention musculo-skeletal i. reduced muscle mass and strength ii. decreased joint mobility / decreased range of motion iii. decreased endurance iv. postmenopausal women: bone demineralization neurological i. decreased rate of voluntary or automatic reflexes ii. sleep cycle changes- require less sleep at night, frequently nap in daytime iii. impaired thermoregulation-prone to hypothermia sensory i. decreased visual acuity ii. decreased accommodation i.

iii.
iv.

presbyopia decreased hearing acuity (presbycusis)

v. vi. vii.

decreased pitch discrimination taste buds atrophy decreased sense of smell

5.

Cognitive changes a. expected: decreased short-term memory, narrowed interests b. occur when cerebral dysfunction or trauma is present 6. Psychosocial a. Erickson: ego integrity versus despair b. expected: lessened adaptability, diminished emotional responses c. retirement; change in occupational and social roles; economic changes d. social isolation; attitudinal isolation e. presentational isolation f. behavioral isolation g. geographic isolation 7. Sexual function will depend on general health, psychological health, medications 8. Housing a. home: single family, apartment, and retirement community b. assisted living c. day care d. respite care e. long-term care 9. Death

Points to Remember Growth and Development

Normally proceed in a regular fashion from simple to complex and in cephalocaudal and proximodistal patterns. Are orderly, directional, predictable, interdependent and complex processes. Are unique to individuals and their genetic potential. Occur through conflict and adaptation. Growth and development are impacted by genetics, environment, health status, nutrition, culture, and family structures and practices. Growth should be measured and evaluated at regular intervals throughout childhood. Deviations from normal growth and development should be thoroughly investigated and treated as quickly as possible.

In the care of children, key concepts are anticipatory guidance and prevention of disease. Major developmental tasks of infancy are: increase in mobility, separation, and establishment of trusting relationships. In both toddlerhood and adolescence, hallmarks are development of independence and further separation. Children and adolescents grow rapidly, so nurses must stress optimum nutrition and give anticipatory guidance related to nutrition. In children over one year of age, the leading cause of death is injuries.

Elder Adults

Elder adults must adjust to lessening physical and cognitive abilities. Over 85% have some type of chronic disease. When elder adults experience cognitive changes, check for possible substance abuse or polypharmacy. Cognitive impairment can be acute and reversible, or it can be chronic and irreversible. Up to 60% of older adults have some impairment in performance of activities of daily living. Some physiologic changes are a normal part of the aging process and do not signal disease. Elder adults need more time to complete tasks. Age is a weak predictor of survival in traumatic injury and critical illness.

Health Risks in Elder Adults

Major health problems typically include cardiovascular, cerebrovascular, and respiratory diseases; diabetes; and cancer. The elder adult will change social roles, and these changes may affect psychological health, leading to depression. Elder adults need the same nutrition as other adults, but more bulk and fiber, calcium, and vitamins C and A. Contraindications for estrogen replacement therapy include o hypertension o thrombophlebitis o cardiac dysfunction o family history of breast or uterine cancer Elder adults clear drugs from kidney and liver more slowly; so medications have longer half-lives, and they can bring on side effects and toxicity at lower doses.