NCM107 Growth&DEV'T.
NCM107 Growth&DEV'T.
NURSING DIAGNOSIS
When an assessment is completed, a nursing diagnosis can be identified to reflect the
problem. Examples of nursing diagnoses applicable to growth and development
include:
IMPLEMENTATION
Interventions to foster growth and development include encouraging age-appropriate
self-care in a child and suggesting age-appropriate toys or activities to parents. Role
modeling is an important ongoing intervention to help parents accept a child’s delayed
growth or appreciate a child who is scoring extremely high on standard scales and needs
increased stimulation. Modeling, for example, can demonstrate that problem solving is a
more effective approach to life’s challenges than “acting out” behaviors.
• Growth and development are continuous processes from conception until death.
Although there are highs and lows in terms of the rate at which growth and
development proceed, a child is growing new cells and learning new skills at all
times. An example of how the rate of growth changes is a comparison between
that of the first year and later in life. An infant triples in birth weight and increases
height by 50% during the first year of life. If this tremendous growth rate were to
continue, a 5-year-old child, ready to begin school, would weigh 1,600 lb and be
12.5 ft tall.
• Children pass through the predictable stages at dif erent rates. All stages of
development have a range of time rather than a certain point at which they are
usually accomplished. Two children may pass through the motor sequence at such
different rates, for example, that one begins walking at 9 months, whereas another
starts at 14 months. They are both following the predictable sequence and are
developing normally; they are merely developing at different rates.
• All body systems do not develop at the same rate. Certain body tissues mature
more rapidly than others. For example, neurologic tissue experiences its peak
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growth during the first year of life, whereas genital tissue grows little until
puberty.
• Development proceeds from gross to refined skills. This principle parallels the
preceding one. Once children are able to control distal body parts such as fingers,
they are able to perform fine motor skills (e.g., a 3-year-old colors best with a
large crayon; a 12-year-old can write with a fine pen).
• Neonatal reflexes must be lost before development can proceed. An infant cannot
grasp an item with skill until the grasp reflex has faded nor can the infant stand
steadily until the walking reflex has faded. Neonatal reflexes are replaced by
purposeful movements.
• A great deal of skill and behavior is learned by practice. Infants practice over and
over taking a first step before they accomplish this securely. If children fall behind
in growth and development because of an illness, they are capable of “catch-up”
growth to bring them equal again with their age group.
GENETICS
From the moment of conception when a sperm and ovum fuse, the basic genetic makeup
an individual is cast. In addition to physical characteristics such as eye color and
height potential, inheritance determines characteristics such as learning style. A child
may also inherit a genetic abnormality, which could result in disability or illness at birth
or later in life and so prevent optimal growth.
GENDER
On average, girls are born lighter (by an ounce or two) and shorter (by an inch or two)
than boys. Boys tend to keep this height and weight advantage until prepuberty, at
which time girls surge ahead as they begin their puberty growth spurt 6 months to 1
year earlier than boys. By the end of puberty (age 14 to 16 years), boys again tend to be
taller and heavier than girls. This difference in growth patterns is why different growth
charts are used for boys than for girls (available at http://thePoint.lww.com/Flagg8e)
(Pastor & Reuben, 2011).
HEALTH
A child who inherits a genetically transmitted disease may not grow as rapidly or
develop as fully as a healthy child depending on the type of illness and the therapy or
care available for the disease. Before insulin was discovered in 1922, for example, many
children with type 1 diabetes mellitus died in early childhood; those who lived were left
physically challenged. Currently, with good health supervision and insulin therapy, the
effects of type 1 diabetes can be minimized so that children with diabetes both grow and
thrive. Diabetes is still a major factor in the health of children, however. As more and
more children become obese because of fast-food diets and lack of an exercise program,
type 2 diabetes now has begun to occur in children as young as school age (Dea, 2011;
Morgan, 2012)
INTELLIGENCE
Children with high intelligence do not generally grow faster physically than other
children, but they do tend to advance faster in skills. Occasionally, children of high
intelligence actually fall behind in physical skills because they spend their time with
books or mental games rather than with games that develop motor skills. Intelligence
begins to make major differences as children become adolescents and begin to plan
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future careers (Viner, Ozer, Denny, et al., 2012).
TEMPERAMENT
Temperament is the usual reaction pattern of an individual or an individual’s
characteristic manner of thinking, behaving, or reacting to stimuli in the environment.
Unlike cognitive or moral development, temperament is not developed in stages but is
an inborn characteristic set at birth. Understanding that children are not all alike (e.g.,
some adapt quickly to new situations, others adapt slowly, some react intensely, some
react passively based on an inborn disposition) helps parents better understand why
their children are different from one another and help them plan individualized care for
each child.
Reaction Patterns
Chess and Thomas (1985) are the researchers who identified nine separate
characteristics that define temperament, or how children react to common situations.
Each child’s pattern is made up of a combination of these individual elements.
Activity Level
The level of activity among children differs widely right from birth. Some babies seem
to be constantly on the go and rarely are quiet. They wiggle and squirm in their crib as
early as 2 weeks of age. Parents put such children to sleep in one end of a crib and find
them in the other end an hour later; such children will not stay seated in bathtubs and
refuse to be confined in playpens. Other babies, by contrast, move little, stay where they
are placed, and appear to take in their environment in a quieter, more docile way. Both
patterns are normal; they merely reflect the extremes of activity level, one characteristic
of temperament.
Rhythmicity
A child who has rhythmicity manifests a regular rhythm in physiologic functions. Even
as infants, such children tend to wake up at the same time each morning, are hungry at
regular 4-hour periods, nap the same time every day, and have a bowel movement at the
same time every day. They are predictable and easy to care for because their parents
learn early on what to expect from them. On the other end of the scale are infants who
rarely awaken at the same time 2 days in a row. They may go a long time without eating
1 day and the next day appear hungry almost immediately after a feeding. Such children
are typically more difficult to care for because it is difficult to anticipate a schedule for
them. Parents must constantly adapt their own routine to the child’s routine.
Approach
Approach refers to a child’s response on initial contact to a new stimulus. When
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introduced to a new situation, some children approach the challenge in an unruffled
manner. They smile and “talk” to strangers and accept a first feeding or a new food
without spitting up or fussing. They explore new toys without apprehension. Other
children demonstrate withdrawal rather than approach. They cry at the sight of
strangers, new toys, and new foods; they fuss the first time they are placed in a bathtub.
They are difficult to take on vacation or to meet a new childcare provider because they
react so fearfully to new situations.
Adaptability
Adaptability is the ability to change one’s reaction to stimuli over time. Infants who are
adaptable can change their first reaction to a situation without exhibiting extreme
distress. The first time such children are placed in a bathtub, they might protest loudly,
for example, but by the third time, they sit splashing happily. This is in contrast to
infants who cry for months whenever they are put into a bathtub or who cannot seem to
accustom themselves to a new bed, new car seat, or new caregiver.
Intensity of Reaction
A child who has an intensity of reaction meets new situations with their whole being.
They cry loudly, thrash their arms, and begin temper tantrums when their diapers are
wet, when they are hungry, and when their parents leave them. Other children, probably
equally frustrated or angry, rarely demonstrate such overt symptoms or have a mild- or
low-intensity reaction to stress.
Distractibility
Children who are easily distracted or who can easily shift their attention to a new
situation (distractibility) are easy to care for. If they are crying over the loss of a toy,
they can be appeased by the offer of a different one. If children cannot be distracted this
way, their parents may describe them as stubborn, willful, or unwilling to compromise
because they persistently return to an activity or refuse to adapt or change.
Attention Span and Persistence
Attention span is the ability to remain interested in a project or activity for an average
length of time. Like other aspects of temperament, this can vary a great deal among
children. Some play by themselves with one toy for an hour; others spend no more than
1 or 2 minutes with each toy. The degree of persistence also varies. Some infants keep
trying to perform an activity even when they fail time after time; others stop trying after
one unsuccessful attempt.
Threshold of Response
The threshold of response is the intensity level of stimulation necessary to evoke a
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reaction. Children with a low threshold need to meet little frustration before they react;
those with a high threshold need intense frustration before they become upset over a
situation or with a person.
Mood Quality
A child who is always happy and laughing is said to have a positive mood quality.
Obviously, this can make a major difference in the parents’ enjoyment of a child;
parents tend to spend more time with a child with a positive mood quality than with a
child who seems always unhappy and whining or has a negative mood quality.
Nursing Implications and Temperament
Four categories or levels of temperament are shown in Box 28.3. Children who have a
usual activity level and regular rhythmicity; who approach and adapt to new situations
easily; and who have a long attention span, a high level of persistence, and a positive
mood quality are “ideal” or “easy” children to care for from a parent’s point of view.
Highly active infants are much more difficult for parents to care for, especially if they
demonstrate irregular physiologic rhythms, withdrawal rather than approach, and little
ability to adapt. Such children require more planning and creative distraction measures.
The Infant
According to Erikson (1993), the developmental task for infants is learning trust versus
mistrust (other terms are “learning confidence” or “learning to love”). When an infant is
hungry, a parent feeds and makes the infant comfortable again. When an infant is wet, a
parent changes his or her diaper and the infant is dry again. When an infant is cold, a parent
holds the baby closely. By these simple processes, infants learn to trust that when they have
a need or are in distress, a parent will come and meet that need. If care is inconsistent,
inadequate, or rejecting, infants learn mistrust; they become fearful and suspicious of people
and then of the world. Like a burned child who avoids fire, emotionally burned children shun
the potential pain of further emotional 1680 involvement. This can cause children to be
“stuck” emotionally at this stage, although they continue to grow and develop in other ways.
Fortunately, because not all children achieve developmental tasks readily, each task need
not be resolved once and for all the first time it arises. The problem of trust versus mistrust,
for example, is not resolved forever during the first year of life but arises again at each
successive stage of development. Children who enter school with a sense of mistrust may
come to trust a teacher with whom they form a close relationship; given this second chance,
children can overcome early mistrust. Likewise, children who come through infancy with a
sense of trust intact may have a sense of mistrust activated at a later stage if their parents
divorce under unpleasant circumstances or if the child is maltreated.
The Toddler The developmental task of the toddler is to learn autonomy versus shame or
doubt. Autonomy (self-governance or independence) arises from a toddler’s new motor and
mental abilities. Children not only take pride in the new things they can accomplish but also
want to do everything independently, whether it is pulling the wrapper off a piece of candy,
selecting a vitamin tablet out of a bottle, flushing the toilet, or replying, “No!” Infants appear
to have difficulty differentiating between their bodies and those of others; they think of their
bodies as extensions of their parents or their primary caregivers. When infants approach
toddlerhood, they begin to make the differentiation. As they recognize they are separate
individuals, toddlers also realize they do not always have to do what others want them to do.
From this realization comes the reputation toddlers have for being negativistic, obstinate,
and difficult to manage. This reputation probably exists because parents misinterpret
children’s cues. For example, children’s refusal to accept help putting on shoes may be seen
by a parent as disobedience, whereas children may view this as insisting on performing a
task they can do independently—a positive expression of autonomy. Children who are
constantly told not to try things because they will hurt themselves may be left with a stronger
sense of doubt than confidence at the end of the toddler period. Children who are made to
feel it is wrong to be independent may leave the toddler period with a stronger sense of
shame than autonomy. If parents recognize that toddlers need to practice those things they
are capable of doing, at their own pace and in their own time, their children will develop a
sense of being able to control both their muscles and impulses. However, if children leave
this stage with less autonomy and shame or doubt, they can be disabled in their attempts to
achieve independence and can lack confidence in their abilities to achieve well into
adolescence and adulthood
The Preschooler
The developmental task of the preschool period is learning initiative versus guilt, or
learning how to do things such as drawing, building an object from blocks, or playing
dress up. Children initiate motor activities of various sorts on their own or no longer
merely respond to or imitate the actions of other children or their parents. The same is
true for language and fantasy activities.
Another word for initiative is creativity. Whether children leave this stage with a
sense of initiative outweighing a sense of guilt depends largely on how parents respond
to self-initiated activities. When children are given much freedom and opportunity to
initiate motor play such as running, bike riding, sliding, and wrestling or are exposed to
such play materials as finger paints, sand, water, and modeling clay, their sense of
initiative is reinforced. Initiative is also encouraged when parents answer a child’s
questions (intellectual initiative) and do not inhibit fantasy or play activity. In contrast,
if children are made to feel their motor activity is bad (perhaps in a small apartment or
in a hospital), their questions are a nuisance, or their play is silly, they can develop a
sense of guilt over self-initiated activities that will persist in later life. Those who do not
develop initiative have limited brainstorming and problem-solving skills later in life;
instead, they wait for clues or guidance from others before acting. They may also be
unable to use simulated learning effectively
A Criticism of Erikson’s Theory Erikson’s main contribution to human development was the
creation of stages, so that development can be broken down into separate phases for study.
A criticism of his theory is that life does not occur in easily divided stages, and trying to
divide it that way can create superficial divisions.
Sensorimotor
The Infant
Piaget referred to the infant stage as the first four stages of the sensorimotor stage.
Sensorimotor intelligence is practical intelligence because an infant is not yet able to use
words and symbols for thinking and problem solving at this early age. At the beginning of life,
babies relate to the world through their senses, using only reflex behavior.
During this stage, infants learn objects in the environment—their bottle, blocks, their bed, or
even a parent—are permanent and continue to exist even though they are out of sight or
changed in some way. For example: • Infants will search for a block hidden by a blanket,
knowing the block still exists. • Infants can recognize a parent remains the same person
whether dressed in a robe and slippers or pants and a T-shirt. • Infants are only ready to play
peek-a-boo when they’ve mastered permanence because only then do they realize the
person playing with them exists behind his or her hands. • Infants identify that they are a
separate entity from objects. They learn where their body stops and their bed, playthings, or
parent begins. A great deal of the mouthing and handling of objects by infants and the
delight of watching a caregiver appear is part of discovering permanence. Infants can
identify their parents as different from other adults as early as 4 months of age. The world
begins to make sense and the developmental task of achieving trust falls into place when the
concept of permanence has been learned (i.e., infants know their parents exist and will
return to them). Gaining a concept of permanence also contributes to separation anxiety,
which can begin between 8 and 12 months of age. During this stage, infants continue to cry
for their parents because they know their parents still exist even when out of sight.
The Toddler
The toddler period is one of transitions as children complete the fifth and sixth stages of the
sensorimotor period and begin to develop some cognitive skills of the preoperative period,
such as symbolic thought and egocentric thinking (see Chapter 30). Children use trial and
error to discover new characteristics of objects and events. A toddler sitting in a high chair
who keeps dropping objects over the edge of the tray is exploring both permanence and the
different actions of toys. For example, during these periods, toddlers:
The Preschooler
Preschool children move on to a substage of preoperational thought termed intuitive
thinking. During this period, when young children look at an object, they are able to see only
one of its characteristics. For example, they see a banana is yellow but do not notice that it
is also long. Intuitive thinking is noticeable when children are learning about medicine (they
observe it tastes bitter but cannot understand it is also good for them).
Intuitive thinking contributes to the preschooler’s lack of conservation (the ability to discern
truth, even though physical properties change) or reversibility (ability to retrace steps). For
example, if preschoolers see water poured from a short, fat glass into a tall, thin one, they
will notice only one changing characteristic. They might say there is now more water in the
second glass (because the level has risen) or there is less water in the second glass
(because the second glass is thinner). When the water is poured back into the first glass,
they still will not understand the amount of water is unchanged, only its appearance. This
immature perception leads children to make faulty conclusions as it did during the toddler
period. It takes more years of development and practice for children to learn that when
thought processes (i.e., knowing the amount of water did not change) and perceptions
conflict, thought processes are more trustworthy.
Preschool thinking is also strongly influenced by role fantasy or how children would like
something to turn out. Children use assimilation (taking in information and changing it to fit
their existing ideas) as a part of this. For example, because a child wants to go outside and
play, he says the outside is calling him to come and play. Children believe their wishes are
as real as facts and dreams are as real as daytime happenings during this stage. They
perceive animals and even inanimate objects as being capable of thought and feelings (e.g.,
a dog took their doll because the dog was feeling sad, a footstool meant to trip them). This
phenomenon is often called “magical 1689 thinking.” Magical thinking fades as, later on,
children learn accommodation (they change their ideas to fit reality rather than the reverse).
The Adolescent
Adolescence is the time when cognition achieves its final form or when formal
operational thought begins. When this stage is reached, adolescents are capable of
thinking in terms of possibility—what could be (abstract thought)—rather than being
limited to thinking about what already is (concrete thought). This makes it possible for
adolescents to use scientific reasoning. They can use deductive reasoning in addition to
the induction reasoning they used during school age or can move from the general to the
specific (e.g., plastic toys break easily, the toy they are holding is plastic; therefore, it
will break easily).
Preconventional (Level I)
Conventional(Leve
l II)