1. Pre-school, School age and Adolescent
Elisa A. Mancuso RNC, MS, FNS
Professor of Nursing 1

2. Growth and Development Preschool 3-5 years
Biological
Growth slows and stabilizes during preschool
Average weight gain 2.2 kg (5lbs)/yr
Height 7.5 cm (3”)/yr
3 yr: 32 lbs & 37”
4 yr: 37 lbs & 40”
5 yr: 42 lbs & 43”
Growth occurs in legs rather than trunk.
No longer resemble the “pot belly” toddler! 2

3. Psychosocial Development
Erickson: Initiative vs Guilt
Ability to learn & play.
Development of “can do attitude”
Behavior becomes goal directed, competitive and imaginative.
Imitate parents & gender roles.
Proud when accomplish new goals.
When criticized show feelings of guilt.
Conscience develops along with moral
development 3

4. Psychosocial Development
Freud: Phallic Stage
↑ Focus on genitals
masturbation and exploration common
Oedipal conflict
Possessive love for opposite sex parent
“Super-ego” conscience develops
guilt feelings emerge 4

5. Psychosocial Development
Piaget
Pre-operational Stage 2-7 years
Readiness for school
↑ physical activities & loud
vivid imagination and curious
Limited attention span
Time- recognizes past and future
Idiosyncratic system for organizing events
Egocentric
See the world via me
Fear of Bodily harm
Ban-aids keep everything in place! 5

6. Piaget Centering Concrete thought process
one characteristic of an object
Concrete thought process
Literal
Magical thinking
Animism
Ascribe human characteristics to objects 6

7. Developmental Skills 3 years Walking, running and jumping well @ 36
900 word vocabulary/3-4 word sentence
Copy a circle and cross
Builds a tower of 9 blocks
Ride tricycle, walk stairs alternating feet
Pour from pitcher
Asks a lot of questions!! 7

8. Developmental skills 4 years 1,500 word vocabulary/4-5 word sentence
Can copy a square
Very noisy, talkative
Exaggerates stories
Loves Rhymes & songs
Names 3 colors
Hop on one foot
Catch a ball with both hands, throws overhand
↑ Self-Care: Brushes teeth
Gets dressed ↑ Cooperation 8

9. Developmental skills 5 year old 2,100 word vocabulary/6-8 sentence
Copy diamond and triangle
Prints name
Draw person with 6 parts
Head, body, 2 arms & 2 legs
Talk constantly
Names 4 colors
Skip & Hop on alternating feet
Walks backwards
Hits a ball
Ties shoes & manage big zippers 9

10. Socialization ↑ Peer interaction & communication
Learn to relate to others
Increased cooperation & Sharing
Conform to expectations
Enjoy games with simple rules
PreSchool play-
dramatic & creative
Recognizes sociocultural
differences 10

11. Developmental Tasks Large and small muscle coordination
Uses initiative with a conscience
Becomes a participating family member
Settles into a daily routine
Dental & personal Hygiene
Sleep 11

12. Health Concerns Safety
MVA # 1 cause of injury
Being struck by car is ↑ risk
Drowning and falls
Doesn’t fully understand danger
Magical thinking & cartoons minimize the danger
Integrate safety education
Puppets, songs, rhymes and games 12

13. Health Concerns ↑ Exposures to germs Girls ↑ UTI’s
Frequent colds and ear infections
Girls ↑ UTI’s
RT anatomy and poor hygiene
Stress hand washing and proper hygiene
No sharing of utensils, pencils or pens! 13

14. Health Concerns
Eyes
Visual acuity and depth perception fully developed by age 7
Vision testing begun at 3 years
Objective screening using appropriate chart
3 years- Allen cards-images
>4 years utilize E chart
indicate direction of E
4 year 20/30-20/40
5 year 20/20-20/30 14

15. Common Eye Disorders Strabismus ↓ Coordination of EOM
Eyes are not aligned
One or both eyes can turn
In (Esotropia)
Out (Exotropia)
Up (Hypertropia)
Down (Hypotropia) 15

16. Eye Amblyopia- “Lazy Eye” Only uses 1 eye for vision
No binocular vision
↓ vision in the deviated eye
Distorted visual field
Can develop if strabismus is not treated early
If left untreated → Blindness in deviated eye
Therapy
Patch normal eye x 24 hours/day
Deviated eye must work
Surgery 16

17. Hearing Early detection = better outcome
Mandatory newborn hearing screenings
Routine Audiometry screening by age 3
Various various frequencies
Standard volume (usually 20 db)
Normal hearing ranges from 10 → +15
By age 5 hearing is fully developed 17

18. Sensorineural (Nerve deafness)
Hearing Impairments
Sensorineural (Nerve deafness)
Damage or malformation of structures of
inner ear/and or auditory nerve
Causes:
Infections: CMV, Rubella, Herpes, Meningitis
Heredity
Prematurity (Hypoxia)
Ototoxic meds
Hearing Loss is usually permanent
Therapy
Hearing Aids- worn ASAP to help facilitate language development
Cochlear implants = Controversy
American sign language ↑ communication 18

19. Hearing Impairments Conductive Middle hearing loss affected by OME/OM
inflammation, obstruction or damage
OME/OM
Cerumen impaction
Perforation
Temporary & restores to prior hearing level
Therapy
Antibiotics for infection
Myringotomy & Tympanostomy tubes 19

20. Biological Development School Age 6-12 years
Growth slows down
Weight: lbs/year
Height: inch/year
Average 6 year old
46 lbs & 45 inches
Lose baby 6 years.
First permanent 6yrs (6 year molar)
“Ugly Duckling Stage”
Distorted facial proportions
Wide range of physical differences
Age 7 could look like 10-years or 5-years
Treat according to their age not appearance! 20

21. Erickson- Industry vs Inferiority
Psychosocial
Erickson- Industry vs Inferiority
Industry
Interest in doing work
Learn and solve problems
↑ accomplishment RT ↑ motivation
Desire to master & do well in everything
If they don’t they will feel inferior.
Reinforce that they cannot do well in everything
Perseverance
Self-control
Compromise 21

22. Psychosocial Juvenile Stage: 6-9 years ↑ need for peers, friends
“Stage of Accomplishment”
Work concept = chores, schoolwork
Carry tasks to completion
↑ skill and coordination
Develop + self esteem
Greater intellectual capacity
Role models = teachers/coaches
Manipulate environment
Reinforcement via grades with material reward
Move to external focus and socialization
Parents needed in times of stress 22

23. Preadolescent Stage 9-12 years
Psychosocial
Preadolescent Stage 9-12 years
Ability to love (same sex) = best friend
Pre Pubescence
2 years before onset of puberty.
Puberty
Period of rapid growth
Development of primary and secondary sex characteristics
12yrs
13 ½ yrs ) 23

24. Psychosocial Freud - Latency period Sexuality
plays less prominent role
Best friend same sex
Usually do not want to play with opposite sex (icky!) 24

25. Cognitive Development
Concrete operations and Systematic reasoning:
Conservation
Change shape but still has same volume
Classification
Group according to attributes: 1st friend, 2nd friend
Seriation
Putting things in order or series: smallest →largest
Nesting
How one concept fits into another: puzzles
Reversibility
Opposite function: Addition & Subtraction
Use thought process to experience events and
actions & see things from another point of view. 25

26. Developmental Skills 6 years Period of Transition Self centered
Normal to cheat at board games
Impulsive
↑Activity RT ↑coordination
↑Dexterity = drawing & writing 26

27. Developmental Skills 7 years Quiets down Solitary play Attentive
Sensitive listener
Modest (Need Privacy)
Companionable 27

28. Developmental Skills 8 years Fluctuating Behavior ↑Graceful movements
↑Interest in nature
Very self-critical 28

29. Developmental Skills 9 years ↑ Independence Refined eye-hand control
Musical instruments
Best friend
Collections
Well organized
↑Physical complaints with stress
May have boy/girl relationship
but won’t admit 29

30. Development Skills 10 years ↑ Stamina Budgets time ↑ Energy
Enjoys family activities
↑ Appetite 30

31. Development 11 years Moody Strict superego-conscience
Strong morals/values
Best behavior is away from home 31

32. Development 12 years ↑ Personality integration ↑ Self discipline
↑ Self control
Tactful
Mutual understanding with parents 32

33. Developmental Tasks ↓ Dependence on family ↑ Neuromuscular skills
Must adjust to changes in body image
Develop positive attitude:
Multicultural
Social
Economic groups 33

34. Health Problems Generally not a sick age Injury Prevention
Unintentional accidents/injury are the leading cause of death in any age group
MVC remains # 1
No Seat belts, air bag injuries or hit as pedestrian/riding bike
Sports-
skateboards, bikes, all-terrain vehicles need helmets!!
Burns-
cooking, firecrackers, matches, candles
Guns
Access to loaded guns 34

35. Attention Deficit Hyperactivity Disorder ADHD
Most common chronic behavioral disorder
Affects 6-9 % school age children
40 % persist into adult
ADHD has 3 cardinal signs:
Inattention
Impulsiveness
Hyperactivity
Unable to self regulate & inhibit behaviors
↓ Academic Performance
RT ↑ Distractible & ↓ Task completion
↓ Self Esteem = ↓ Peer relationships
↑ Risky Behavior = ↑ Substance Abuse & MVA
Sequela: Conduct, Mood & Anxiety Disorders 35

36. ADHD Etiology Familial Tendency with 1st degree relative
Males 3x more than females
Environment
Toxins (Pb), meds, food allergies, lead, smoking, alcohol, sugar???
↓Neurotransmitters: ↓ NE, ↓ DA and ↓ 5-HT
NE - attention, impulsivity and control
DA - motivation/reward.
Needed for prioritizing and learning
5-HT – mood, aggressive/impulsive behavior
Other neurological disorders can impact:
Fragile X, Turner or Klinefelter 36

37. Diagnosis ADHD is an all day all domain disorder
Based on report of parent, teacher and child
Onset by age 7
symptoms persist for >6 months
Behavior Rating Scale
Have 6/9 characteristics listed in DSM-IV
Affect areas;
school, home or social situations
Complete multidisciplinary evaluation
Medical, developmental and behavioral history & R/O:
Absence seizures,
Learning Disability
↓Hearing 37

38. Meds Psychostimulants (↑ DA and NE) stimulates inhibitory CNS
1st line medication ↑ efficacy = ↑ response
Methylphenidates (MPH): > 6 years
Concerta- 12H duration
Adderal XR H duration
Ritalin- 4H Duration & Ritalin LA 8H duration
Daytrana patch- 12H duration (remove after 9H)
SE:√ Tics, ↓ appetite, sleep disruption,
H/A, slight ↑ BP & HR
Contraindications:
TIC disorders: Tourette Syndrome,
Anxiety Disorder
Risk for Abuse Potential 38

39. Meds Non-stimulant atomoxetine (Strattera)
Inhibits NE (NE Reuptake Inhibitor)
Better for pts who can’t tolerate MPH
atomoxetine (Strattera)
24H Duration
SE: N & V ↓appetite & wt.
Tricyclic antidepressents TCA’s
Blocks re-uptake of NE and 5-HT
imipramine (Tofranil) nortryptyline (Pamelor)
SE: anticholinergic- dry mouth,
Urinary Retention, orthostatic ↓ BP 39

40. Behavior Therapy Education & Psychosocial
Consistent approach by family & school
Follow rules
Complete tasks
↑ Self control
Positive Reinforcement
Time Out
Modify Environment
↓ Distractions
Predictable
clearly define acceptable behavior & consequences
Diet Therapy?? Not EB (evidence Based)
Limit sugar, aspartame (NutraSweet), Chocolate, Cow’s milk & eggs

41. Autism Spectrum Disorder ASD
Complex neurodevelopmental disorders
Core deficits in 3 areas:
Social Interaction
Verbal & nonverbal communication
Restricted interests, repetitive behaviors & resistant to change
Male 3-4x > Female
Genetic Predisposition:
Affects prenatal & postnatal brain development
NO correlation with MMR vaccine
Related Disorders:
Pervasive Developmental Disorder (PDD)
Asperger’s Syndrome,
Childhood Disintegrative Disorder (CDD)
Rhett’s Syndrome

42. ASD Clinical Signs Inappropriate social behavior Repetitive behaviors:
Unable to maintain eye contact
Avoid body contact
Lack emotional reciprocity
Impaired expressive & receptive language skills
Delayed echolalia
Inability to sustain or initiate conversation
Repetitive behaviors:
Opening & closing doors, flipping light switches,
H2O play, shredding paper, prefer item movements & ritualistic behaviors
Insist on “sameness”
Self-Stimulatory behaviors:
Finger licking, hand flapping, body rocking, run in circles
Deep pressure stimulation-crawl into tight spaces
Self-injury RT ↟↟ Pain Threshold, aggressive behaviors
GI Symptoms- Constipation ➔ Mega rectum

43. Treatment Developmental Screening
DDST, Modified Checklist for Autism in Toddlers (M-CHAT)
Childhood Autism Rating Scale (CARS)
Physical Exam
Hearing & Vision screening, Neuro, EEG, Metabolic studies (Pb), Genetic testing
Multidisciplinary approach
Early intervention programs
Highly structured and intensive behavior modification programs;
Promote positive reinforcement
Increase social awareness of others
Increase verbal communication skills
Decrease unacceptable behavior
Use brief, concrete communication
Minimal holding & eye contact to avoid outbursts
Gradually introduce new situations
Medications
Atypical antipsychotic- Risperidone
↡ behavioral symptoms only

44. Scoliosis Abnormal lateral curvature
>10% of the spine
Severe type can ↓ thoracic capacity
↑ risk for osteopenia
Develops in preadolescent growth spurt
Higher risk in females 85% 44

45. Functional/Idiopathic/Secondary
Most common
Rapid growth & Poor posture
Unequal leg
Therapy
Exercises
PT for posture
Shoe Lifts 45

46. Structural/Congenital/Neuromuscular
Muscle or bone deformity
congenital or result of neuromuscular disorders
S shaped curved with vertebral rotation
Asymmetric
thoracic cavity
scapula, breasts, shoulders and hips
↑ deformity during periods of growth 46

47. Therapy Milwaukee brace-worn 23 hours/day Depends on degree of curve
observe and follow-up X-Rays q 4-6months
Exercises and improving posture
>20-40 degrees
Milwaukee brace-worn 23 hours/day
↓ compliance (15%)
↓ comfort and body image
Prevents disease progression
will not resolve current distortion. 47

48. Therapy Boston Brace- low profile (lowest angle)
Thoracolumbar -sacral orthosis
Most widely used
↑ 61 % compliance
Providence Brace-
-New shows promise
used only at night!!!!
↑↑ compliance 48

49. Therapy Surgery- curvature >40% Harrington Rod-
internal spinal fixation- “flat back”
post-op immobilization required
Lugue Segmental System-
flexible wires threaded through spine-
no post-op immobilization required,
↑ risk for nerve damage
Spinal fusion for severe scoliosis
Iliac bone graft 49

50. Post-op Care Log rolling Neurovascular checks Pain management
Skin care
Urinary retention
Mesenteric Artery Syndrome-
Shift of abdominal organs =
Abdominal distension/emesis 50

51. Varicella Contagious virus-
1 day before eruption to 1 week after outbreaks of vesicles
until all vesicles have crusted over
Incubation
2-3 weeks 51

52. Signs and Symptoms Low grade temp Anorexia Rash
1st Macular – papular
2nd Vesicular → crusted lesions
Outbreaks occur in 104
Trunk → face → upper extremities
Very itchy (pruritic) 52

53. Therapy Palliative Antihistamines (benadryl)
Antipyretics (Calamine lotion)
Acyclovir
↓ # of lesions-when given within 24H of rash
mostly for high risk pt’s
Varicella zoster immune globulin (VZIG)
given within 96 hours for high risk pt’s
Strict isolation in hospital 53

54. Lice - Pediculosis Capitus
Highly contagious infestation of scalp
“itchy” from crawling mites and saliva
occipital area
night
√ Environment
Stuffed animals
Bedding
Clothing (fur) 54

55. Therapy Rid/Nix-Permethin 1 % Kwell- Lidane One application
Kills lice and nits.
Not for kids < 2 years
Kwell- Lidane
Two applications
Repeat in 7-10 days after eggs hatch 55

56. Pinworms Enterobiais Infects 1/3 of all children Contagious
Inhalation, ingestion or contact
Worms (intestines) migrate & lay eggs in anal night
Very itchy anal area = ↑ scratching
Spread fecal → fingernails → mouth
Tape test √ anus
mebendazole (Vermox) > 2 years
100mg & repeat in 2 weeks
pyrantel (Pamoate pin-X) > 2 years
11mg/kg & repeat in 2 weeks 56

57. Bites/Stings Allergic response May develop anaphylactic shock
Wheal formation
Raised & reddened
Epi-pen Jr 0.01 mL/kg (1:1000) IM
Animal Bites: Dogs/cats
80 % punctures/lacerations
Avulsions (tissue tears)
↑ infection risk
Wash area
Moist cool compress & dsg
√ vaccination status (Rabies)
Plastic surgery 57

58. Obesity Weight & Body Mass Index (BMI) >95%
Compare to age, gender and height
Culturally induced
30-40% ↑incidence in 6-11 year olds
BMI = wt (kg)/ht (m2)
Calculate yearly
✔ rate of ↑↑ wt and ht 58

59. Etiology of Obesity Diet Culturally based Fast food/ Junk Food
↑ fats ↑ carbs ↓ protein
↓ Physical activity
Computer, video games & TV
Genes – Family Hx
Prader Willi Syndrome PWS
Obesity, hyperphagia, hypogonadism
Small hands & feet
Mental Retardation
70% paternal/30% maternal 59

60. Complications HTN & ↑ cholesterol @ age 5-10
↑ incidence of Type II diabetes
Obstructive Sleep Apnea (OSA)
Cardiac disease
Gallstones
Orthopedic problems
↓ Self-Esteem
Social Isolation 60

61. Therapy Nutritional Counseling Home & School
change family eating patterns
Behavior Modification
Healthy lifestyle habits
↑ physical activity q day minutes
↓ computer/video time
↑ H20 intake & ↓ juice/soda
Recognize and monitor associated risks for chronic diseases
No Gastric Bypass surgery <age 18 61

62. Adolescence 12-18 years Until physically and psychologically mature
Self-sufficient
Puberty
Period of physiological changes.
Sex organs mature, menses, spermatoza
Growth spurt
Reach adult height by age 17
Increase in height 2.5 inch -5 inches
Need ↑ nutrition 62

63. Tanner stages Sexual Maturity Rating Scale Stages I-V
Male secondary sex characteristics
Androgen
↑ muscle & skeletal growth
Testosterone
↑ facial/body hair
spermatogenesis
Female secondary sex characteristics
Estrogen
↑ epiphysis ossification
↑ adipose deposits
Ovum maturation 63

64. Psychosocial development
Identity Formation vs Role Confusion
Individuality
Internal Stability
Achieve Sense of Self
Occupation/Future Goals
Social Development
FRIENDS!! >> Family
Peer pressure
Recognition via group identity
Dating groups vs. individual
Sexual intimacy 64

65. Cognitive Development
Piaget - Formal Operations (11-15)
Abstract thinking
Future Oriented
Scientific Reasoning
↑↑ Range of Logic
Developmental Tasks
Accept body changes
Achieve satisfying sex-related role
Achieve independence & warm relationship with parents
Develop mature set of values, work ethic & occupation 65

66. Health Problems ACNE Inflammatory Disease ↑ @ age 17
Males > Females
17 million kids/year
clogged sebaceous glands
androgens stimulate secretions
bacteria = inflammation
Therapy
Topical Antibiotics- Cleocin, EES
PO Antibiotics - Tetracycline
Antibacterial - Benzoyl Peroxide
Tretinoin (Retin A)
interrupts keratin formation
night Sunshine ↓ efficacy
Isotretinoin Retinoic Acid (Accutane)
SE: depression & Teratogenic
↟ congenital defects
Document if sexually active ✔ HCG q month 66

67. Health Problems Cardiac ↓ Growth of heart = ↓ SV
↓ Ability to meet O2 needs & ↑ BMR = fatigue
✔ Sports physical
Drug use
ETOH, Marijuana, Coke, E, Special K, LSD, Heroin
Pregnancy & STDs
Early age 12-14
HPV (80%), HIV
↑ Chlymydia, genital warts, Hep B & C
Depression and suicide
↑ age 14
25 % feel sad/hopeless q day more than 2 weeks
20 % seriously consider suicide
10 % attempted suicide
Boys successful RT violent method

68. Anorexia Nervosa Preoccupation with food Distorted body image
↑ Need for control
↑ Pressure to be thin
↑ Intense fear of being fat
Review from NUR 136