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NCM107 Growth&DEV'T.

This document discusses growth and development in children from a nursing perspective. It defines growth as a quantitative physical change, such as increases in height and weight, while development refers to qualitative improvements in skills and abilities. Several nursing diagnoses related to growth and development are provided. The document also outlines general principles of child growth and development, such as progression from head to tail and from gross to fine motor skills. Key factors that can influence a child's growth and development include genetics, gender, health, nutrition, environment, and caregiving practices.

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0% found this document useful (0 votes)
78 views19 pages

NCM107 Growth&DEV'T.

This document discusses growth and development in children from a nursing perspective. It defines growth as a quantitative physical change, such as increases in height and weight, while development refers to qualitative improvements in skills and abilities. Several nursing diagnoses related to growth and development are provided. The document also outlines general principles of child growth and development, such as progression from head to tail and from gross to fine motor skills. Key factors that can influence a child's growth and development include genetics, gender, health, nutrition, environment, and caregiving practices.

Uploaded by

R K
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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NCM107 Growth and Development and the Role of the Nurse

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:

● Risk for delayed growth and development related to lack of age-appropriate


toys and activities
● Delayed growth and development related to prolonged illness
● Readiness for enhanced family coping related to parents seeking information
about a child’s growth and development
● Health-seeking behaviours related to appropriate stimulation for infants
● Imbalanced nutrition, less than body requirements, related to parental
knowledge deficit regarding a child’s protein needs
● Deficient knowledge related to potential long-term effects of obesity in the
school-age child

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.

Principles of Growth and Development


Growing up is a complex phenomenon because of the many interrelated facets involved.
Children do not merely grow taller and heavier as they get older; maturing also involves
growth in their ability to perform skills, to think, to relate to people, and to trust or have
confidence in themselves.
The terms “growth” and “development” are sometimes used interchangeably, but
they are actually different terms.

• Growth is used to denote an increase in physical size or a quantitative change.


Growth in weight, for example, is measured in pounds or kilograms; growth in
height is measured in inches or centimeters.
• Development indicates an increase in skill or the ability to function (a qualitative
change). Development is measured by observing a child’s ability to perform
specific tasks such as how well a child picks up small objects, by recording the
parent’s description of a child’s progress, or by using standardized tests such as
the Ages & Stages Questionnaires. Maturation is a synonym for development.
Psychosexual development is a specific type of development that refers to
developing instincts or sensual pleasure (Freudian theory). Psychosocial development
refers to Erikson’s stages of personality development. Kohlberg’s theory of moral
development is the ability to know right from wrong and to apply these to real-life
situations.
Cognitive development refers to the ability to learn or understand from experience,
to acquire and retain knowledge, to respond to a new situation, and to solve problems
(see the section that follows on Piaget’s theory of cognitive development). It is
measured by intelligence tests and by observing children’s ability to function effectively
in different environments

Growth and development General principles include:

• 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.

• Growth and development proceed in an orderly sequence. Growth in height


occurs in only one sequence—from smaller to larger. Development also proceeds
in a predictable order. For example, the majority of children sit before they crawl,
crawl before they stand, stand before they walk, and walk before they run.
Occasionally, a child will skip a stage (or pass through it so quickly the parents do
not observe the stage). Occasionally, a child will progress in a different order, but
most children follow a predictable sequence of growth and development.

• 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
1656
growth during the first year of life, whereas genital tissue grows little until
puberty.

• Development is cephalocaudal.Cephalo is a Greek word meaning “head”; caudal


means “tail.” Development proceeds from head to tail. Newborns can lift only
their head off the bed when they lie in a prone position. By age 2 months, infants
can lift both the head and chest off the bed; by 4 months, the head, chest, and part
of the abdomen; by 5 months, infants have enough control to turn over; by 9
months, they can control legs enough to crawl; and by 1 year, children can stand
upright and perhaps walk. Motor development has proceeded in a cephalocaudal
order—from the head to the lower extremities.
• Development proceeds from proximal to distal body parts. This principle is
closely related to cephalocaudal development. It can best be illustrated by tracing
the progress of upper extremity development. A newborn makes little use of the
arms or hands. Any movement, except to put a thumb in the mouth, is a flailing
motion. By age 3 or 4 months, the infant has enough arm control to support the
upper body weight on the forearms, and can coordinate the hand to scoop up
objects. By 10 months, the infant can coordinate the arm and thumb and index
fingers sufficiently to use a pincerlike grasp or to be able to pick up an object as
fine as a piece of breakfast cereal on a high chair tray.

• 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).

• There is an optimum time for initiation of experiences or learning. Children


cannot learn tasks until their nervous system is mature enough to allow that
particular learning. A child cannot learn to sit, for example, no matter how much
the child’s parents have him or her practice, until the nervous system has matured
enough to allow for back control. Children who are not given the opportunity to
learn developmental tasks at the appropriate or “target” times for a task may have
more difficulty than the usual child learning the task later on. A child who is
confined to a body cast at 12 months, the time the child would normally learn to
walk, may take a long time to learn this skill once free of the cast at, say, age 2
years. The child has passed the time of optimal learning for that particular skill.

• 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.

Factors Influencing Growth and Development


Genetic and environmental influences are primary factors in determining if a child will
be able to reach his or her genetic potential.
Temperament—the typical way a child reacts to situations—is an example of

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
1659
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
1660
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
1661
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.

Theories of Child Development A theory is a systematic statement of principles that provides


a framework for explaining a phenomenon. Developmental theories are theories that provide
road maps for explaining human development. Developmental tasks are a skill or a growth
responsibility arising at a particular time in an individual’s life, the achievement of which will
provide a foundation for the accomplishment of future tasks. It is not so much chronologic
age as the completion of the task that defines whether a child has passed from one
developmental stage of childhood to another. For example, children are not toddlers just
because they are 1 year plus 1 day old; they become toddlers when they have passed
through the developmental stage of infancy. For reference, however, childhood is generally
divided into the seven age periods shown in

TABLE 28.4 BASIC DIVISIONS OF CHILDHOOD


Stage Age Period
● Neonate- First 28 days of life
● Infant -1 month–1 year
● Toddler- 1–3 years
● Preschooler- 3–5 years
● School-age child- 6–12 years
● Adolescent- 13–17 years
● Late adolescent- 18–21 years
● Sociocultural theories are those that stress the importance of
environment on growth and development.
● Learning theory suggests children are like
blank pages that can be shaped by learning.
● Cognitive theorists such as Piaget stress
learning skills are the key to achieving success in life.
● Epigenetic theories stress that
genes are the true basis for growth and development.

FREUD’S PSYCHOANALYTIC THEORY


Sigmund Freud (1856–1939), an Austrian neurologist and the founder of
psychoanalysis, offered the first real theory of personality development (Freud, 1962;
Freud & Brill, 1995). The theory, based on Freud’s observations of mentally disturbed
adults, described adult behaviour as being the result of instinctual drives of a primarily
sexual nature (libido). He described child development as being a series of
psychosexual stages in which a child’s sexual gratification becomes focused on a
particular body parts at each stage.

SUMMARY OF FREUD’S AND ERIKSON’S THEORIES OF


PERSONALITY DEVELOPMENT

Freud’s Stages of Childhood Erikson’s Stages of Childhood

Psychosexual Nursing Developmental Nursing


Stage Implications Task Implications

INFANT Provide oral Developmental Provide a primary


Oral stage: stimulation task caregiver.
Child by giving is to form a sense Provide
explores the pacifiers; do of trust versus experiences that
world by not mistrust. Child add to security.
using the discourage learns to love and
mouth. thumb be loved.
sucking

Toddler Help children Developmental Provide


Anal stage: achieve bowel and task opportunities for
bladder is to form a sense Independent
Child learns to control of autonomy decision making,
control urination without versus shame. such as
and undue Child learns to be choosing own
defecation. emphasis on independent and clothes.
its make decisions
importance. for self.
Preschooler Accept Developmental Provide
Phallic stage: children’s task opportunities for
Child learns sexual is to form a sense exploring new
sexual interest, such of initiative places or
identity as fondling versus guilt. activities. Allow
through his or her Child learns how free-form play
awareness of own genitals, to do things
genital area as a normal (basic problem
area of solving) and that
exploration doing things is
desirable.

School-age Help children have form a sense Provide


child positive of industry versus opportunities
Latent stage: experiences with inferiority. Child such as allowing
Child’s learning so their learns how to do child to
personality self esteem things well. assemble and
development continues to grow. complete a short
appears to project.
be nonactive
or dormant.

Adolescent Provide Developmental Provide


Genital stage: appropriate task opportunities for
Adolescent opportunities is to form a sense an adolescent to
develops for the child of identity versus discuss feelings
sexual to relate with role confusion. about events
maturity and opposite and Adolescents learn important to
learns to own sex who they are and him or her.
establish relationships what kind of Offer support
satisfactory person they will and praise for
relationships be. decision
with others making.

Criticisms of Freud’s Theory


To construct his theory, Freud relied on his knowledge of people seen in his practice
and looked at circumstances that lead to mental illness (Freud & Brill, 1995). This
“looking at illness” rather than “looking at wellness” perspective limits the
applicability 1679
of the theory as a health promotion measure. The theory is also criticised as being
gender biassed because females are viewed in a less favourable light than males.
Gender bias has the potential to perpetuate gender inequality, which doesn’t provide a
level playing field for women (Brandt, 2011).

ERIKSON’S THEORY OF PSYCHOSOCIAL DEVELOPMENT


Erik Erikson (1902–1996) was trained in psychoanalytic theory but later developed his
own theory of psychosocial development, a theory that stresses the importance of
culture and society in development of the personality (Erikson, 1993). One of the main
tenets of his theory, that a person’s social view of self is more important than instinctual
drives in determining behavior, allows for a more optimistic view of the possibilities for
human growth. Whereas Freud looked at ways mental illnesses develop, Erikson looked
at actions that lead to mental health. He describes eight developmental stages covering
the entire life span. At each stage, there is a conflict between two opposing forces. The
resolution of each conflict, or accomplishment of the developmental task of that stage,
allows the individual to go on to the next phase of development. Table 28.5 summarizes
Erikson’s developmental stages through adolescence as compared to Freud’s stages

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

The School-Age Child


Erikson (1993) viewed the developmental task of the school-age period as developing
industry versus inferiority, or self-confidence rather than inferiority. During the
preschool period, children learned initiative (i.e., how to do things). During school age,
children learn how to do things well. A school-age child, while doing a project, will ask,
“Am I doing this right? Is it okay to use blue?” When they are encouraged in their
efforts to do practical tasks or make practical things and are praised and rewarded for
the finished results, their sense of industry grows (Fig. 28.5). Parents who see their
children’s efforts at making and doing things as merely “busy work” or who do not
show appreciation for their children’s efforts may cause them to develop a sense of
inferiority rather than pride and accomplishment
School-age children develop a sense of industry by
working on projects that result in a feeling of accomplishment.
During this stage of life, a child’s world grows to include the school and
community; success or failure in those settings can have as lasting an impact as
experiences at home. Children with an intelligence quotient of 80 or 90 (slightly below
normal), for example, may have a learning style so different from the average child’s
that they have difficulty competing. This leads to repeated failures in their efforts to
learn and reinforces a sense of inferiority even when their sense of industry has been
rewarded and encouraged at home. However, children whose sense of industry has not
been supported at home may have it revitalized at school through the efforts of a
committed teacher. A nurse during a hospitalization could also fulfill this role
The Adolescent
The new interpersonal dimension that emerges during adolescence is the development
of a sense of identity versus role confusion. To achieve this, adolescents must bring
together everything they have learned about themselves as a son or daughter, an athlete,
a friend, a fast-food cook, a student, a garage band musician, and so on, and integrate
these different images into a whole that makes sense. If adolescents cannot do so, they
are left with role confusion or are left unsure of what kind of person they are or what
kind of person they want to become. Some adolescents may seek a negative identity:
being identified as a drug abuser or runaway is not a positive identification but may be
preferable to seemingly having no identity at all. Body piercing and tattooing are ways
adolescents can help establish their identity because they are outward expressions of
who adolescents think they are

● Adolescents express their identity in different ways. Body


piercing and tattoos makes a strong statement.

The Late Adolescent


The developmental crisis of late adolescence is achieving a sense of intimacy versus
isolation. Intimacy is the ability to relate well with other people in preparation for
developing future relationships.
A sense of intimacy grows out of earlier developmental tasks because people need a
strong sense of identity before they can reach out fully and offer deep friendship or love
to others. Because there is always the risk of being rejected or hurt when offering love
or friendship, individuals cannot offer it if they do not have confidence that they can
cope with rejection or if they did not develop a sense of trust as an infant or autonomy
as a toddler. This is important for maternal and child health nursing because parents
without a sense of intimacy may have more difficulty than others accepting a pregnancy
and beginning to love a new child.

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.

PIAGET’S THEORY OF COGNITIVE DEVELOPMENT


Jean Piaget (1896–1980), a Swiss psychologist, introduced concepts of cognitive
development, or the way children learn and think. The theory has roots similar to those
of both Freud and Erikson, but with differing aspects (Inhelder & Piaget, 1958). Piaget
defined four stages of cognitive development, within the stages of growth, then finer
units or schemas. To progress from one period to the next, children reorganize their
thinking processes to bring them closer to adult thinking.
PIAGET’S STAGES OF COGNITIVE DEVELOPMENT

Stage of Development Age Span Nursing Implications

Sensorimotor

Neonatal reflex 1 month Stimuli are assimilated into


beginning mental
images. Behavior entirely
reflexive.

Primary circular reaction 1–4 months Hand–mouth and ear–eye


coordination
develop. Enjoyable activity
for this period:
a rattle or tape of parent’s
voice

Secondary circular 4-8 mos. Infant learns to initiate,


reaction recognize, and repeat
pleasurable experiences
from environment.
Good toy for this period:
mirror; good
game: peek-a-boo

Coordination of 8-12 mos. Infant can plan activities to


secondary reactions attain specific
goals. Good toy for this
period: nesting toys
(i.e., colored boxes).

Tertiary circular reaction 1 12-18 mos. Child is able to experiment


to discover new
properties of objects and
events. Good game
for this period: throw and
retrieve.

Invention of new means 8-24 mos. Transitional phase to the


through mental preoperational
combinations thought period. Good toys
for this period:
those with several uses,
such as blocks or
colored plastic rings.

Preoperational thought 2-7 yrs. old Thought becomes more


symbolic; can arrive at
answers mentally instead of
through
physical attempt.
Comprehends simple
abstractions but thinking is
basically
concrete and literal. Child is
egocentric
(unable to see the viewpoint
of another).
Displays static thinking
(inability to
remember what they started
to talk about so
at the end of a sentence
children are talking
about another topic).
Concept of time is
now, and concept of
distance is only as far
as they can see. Centering
or focusing on a
single aspect of an object
causes distorted
reasoning. No awareness of
reversibility
(for every action there is an
opposite action)
is present. Unable to state
cause–effect
relationships, categories, or
abstractions.
Good toy for this period:
items that require
imagination, such as
modeling clay.

Concrete operational 7-12 yrs. old Concrete operations


thought includes systematic
reasoning. Uses memory to
learn broad
concepts (fruit) and
subgroups of concepts
(apples, oranges).
Classifications involve
sorting objects according to
attributes such
as color; seriation, in which
objects are
ordered according to
increasing or
decreasing measures such
as weight; and
multiplication, in which
objects are
simultaneously classified
and seriated using
weight. Child is aware of
reversibility, an
opposite operation or
continuation of reasoning
back to a starting point
(follows a
route through a maze and
then reverses
steps). Understands
conservation, sees
constancy despite
transformation (mass or
quantity remains the same
even if it changes
shape or position). Good
activity for this
period: collecting and
classifying natural
objects such as native
plants or sea shells.
Expose child to other
viewpoints by asking
questions such as, “How do
you think you’d
feel if you were a nurse and
had to tell a boy
to stay in bed?”

Formal operational 12 years Can solve hypothetical


thought problems with
scientific reasoning. Good
activity for this
period: “talk time” to sort
through attitudes
and opinions.

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:

• Complete their understanding of object permanence.


• Begin to be able to use symbols to represent objects.
• Start to draw conclusions only from obvious facts that they see.

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 School-Age Child


Piaget viewed school age as a period during which concrete operational thought begins
because school-age children can be seen using practical solutions to everyday problems
as well as begin to recognize cause-and-effect relationships. A child who understands
water does not change in amount just because it is poured from one glass to another has
grasped the concept of conservation. Conservation of numbers is learned as early as age
7 years, conservation of quantity at age 7 or 8 years, conservation of weight at age 9
years, and conservation of volume at age 11 years (Wadsworth, 2003). Reasoning
during school age tends to be inductive or proceeds from specific to general: A school age
child holding a broken toy reasons the toy is made of plastic, and therefore, all
plastic toys break easily.

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).

A Criticism of Piaget’s Theory


Piaget is criticized because he used only a small sample of subjects to establish his
theory (his own children). Because children today begin activities to learn counting and
identifying color or reading much earlier than they did at the time the theory was
1690
devised, the age groups and norms may no longer be accurate. Playing computer games
during the preschool period will probably impact the rate and type of children’s
cognitive developments in the future

KOHLBERG’S THEORY OF MORAL DEVELOPMENT


One more developmental theory that has relevance to maternal and child health nursing
is Kohlberg’s (1927–1987) theory of moral development. A German psychologist,
Kohlberg (1984) studied the reasoning ability of boys and, based on Piaget’s
development stages, developed a theory on the way children gain knowledge of right
and wrong or moral reasoning.

Age (in Years) Stage Description Nursing Implications

Preconventional (Level I)

2–3 Child needs 1 Punishment/obedien Child needs help to


ce determine
orientation what are right
(“heteronymous actions. Give
morality”). Child clear instructions to
does right avoid
because a parent confusion.
tells him
or her to and to
avoid
punishment.

4-7 2 Individualism. Child is unable to


Instrumental recognize that
purpose and like situations
exchange. require like
Carries out actions actions. Unable to
to take
satisfy own needs responsibility for
rather than society’s. self-care because
Will do meeting own needs
something for interferes with this.
another if
that person does
something
for him or her.

Conventional(Leve
l II)

7-10 3 Orientation to Child enjoys helping


interpersonal others
relations of because this is nice
mutuality. Child behavior.
follows rules Allow child to help
because of a with bed
need to be a good making and other
person in such
own eyes and eyes activities. Praise for
of desired
others behavior such as
sharing

10-12 4 Maintenance of Child often asks


social order, what the rules are
fixed rules, and and if something is
authority. right. May
Child finds following have difficulty
rules modifying a
satisfying. Follows procedure because
rules of one method
authority figures as may not be right.
well as Follows selfcare
parents in an effort measures only if
to keep someone
the system working. is there to enforce
them.

Postconventional (Level III)

Older than 12 5 Social contract, Adolescents can be


utilitarian responsible for
law-making self-care because
perspectives. they view this
Follows standards of as a standard of
society for the good adult behavior.
of all
people.

Older than 12 6 Universal ethical Many adults do not


principle reach this
orientation. Follows level of moral
internalized development.
standards of
conduct.

Recognizing where a child is developmentally according to these stages can help


identify how children may feel about an illness such as whether they think it is fair that
they are ill. Recognizing moral reasoning also helps determine whether children can be
depended on to carry out self-care activities such as administering their own medicine
or whether children have internalized standards of conduct so they do not cheat when
away from external control. Moral stages closely approximate cognitive stages of
development because children must be able to think abstractly (be able to conceptualize
an idea without a concrete picture) before being able to understand how rules apply
even when no one is there to enforce them

A Criticism of Kohlberg’s Theory Kohlberg’s (1984) theory is frequently challenged as


being male-oriented because his original research was conducted entirely with boys. Carol
Gilligan (1993), a sociologist, argues that there are two modes of moral reasoning: the ethic
of justice that focuses on individual rights and the ethic of care that focuses on
responsibilities in relationships. She suggests that girls may not score well on Kohlberg’s
scale because, being more concerned with relationships than are boys, they make moral
decisions based on individual circumstances or the effect of their actions on others at a
much younger age than boys, which skews their results on a standard male-influenced scale

Using Growth and Development in Practice


An assessment of children’s growth and development should be included in all
children’s nursing care plans because whether they are growing and developing within
usual parameters is a significant mark of wellness. Because nurses do not work alone
but as members of a healthcare team, Box 28.6 shows an interprofessional care map
illustrating both nursing and team planning

KEY POINTS FOR REVIEW


● Knowledge of growth and development is important in health promotion and illness
prevention because it lays the basis for assessments and anticipatory guidance.
● Including growth and development guidelines in nursing care helps to achieve care
that not only meets QSEN competencies but also best meets a family’s total needs.
● Genetic factors that influence growth and development are gender, ethnicity,
intelligence, and health.
● Environmental influences include quality of nutrition, socioeconomic level, the
parent–child relationship, ordinal position in the family, and environmental health.
● To meet growth and development milestones, children (like adults) need to follow
basic guidelines for a healthy diet, such as eating a variety of foods, maintaining an
ideal weight, avoiding extreme levels of saturated fat, eating foods with adequate
starch and fiber, and avoiding too much sugar.
● Temperament is a child’s characteristic manner of thinking, behaving, or reacting.
Helping parents understand the effect of temperament is a nursing role.
● Common theories of development are Freud’s psychoanalytic theory and Erikson’s
theory of psychosocial development. Both of these theories describe specific tasks
children must complete at each stage of development to become a well-adapted
adult.
● Piaget’s theory of cognitive development describes ways children learn.
● Kohlberg advanced a theory of moral development or how children use moral
reasoning to solve problems.
● Although growth and development occur in known patterns, the rate that a child
develops and grows varies from child to child. Caution parents not to be concerned
that two siblings are very different as long as they both fit within usual parameters.

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