GROWTH AND DEVELOPMENT OF CHILDREN

INTRODUCTION:
Growth and Development of children includes varieties of
interrelated, dynamic, ongoing processes, among them, none occurs apart
from others. Such processes include:
The formation of tissues.
The enlargement of the head, trunk and limbs.
The progressive increase in strength and ability to control
large and small muscle.
The development of social relatedness, thought and
language and the emergence of personality.
The unfolding of these processes and their interactions depends both on the
child’s biological endowment and on the physical and social environment.
Thus, the process of Growth and Development starts from the conception of
the ovum and sperm and continues till adolescence when the child matures
into adulthood, hence the term ‘Growth and Development’ generally
interpreted to include all of the process, in short encompasses Growth,
Development, Maturation and Differentiation.

MEANINGS AND DEFINITIONS:

‘Growth’ is an important attribute of childhood. Growth is an essential
feature of life of a child that distinguishes him or her from an adult.
Growth is mainly due to multiplication of cells and an increase in
intracellular substance. During early embryonic period of life, an
exponential increase in the number of dividing cells occurs. The number of
the cells increases from about 0.2 x 10 12 at 60 days of fetal life to 2 x 10 12 at
birth and 6 x 1013 in a fully grown adult. This is evidenced by an increase in
the DNA content of tissues. At the early embryonic stage, fetal cells
differentiate to form tissues and organs.
‘Development’ is the result of interaction of maturation and learning,
because ‘living is learning and growing is learning’. Every species whether
animal or human, follows a pattern of development peculiar to that species.
Let us first see the definitions of ‘Development’.

1
 Definitions of ‘Growth’ and ‘Development’ by prominent authors:
The term ‘Growth’ denotes “ a net increase in the size or mass
of tissues. It is largely attributed to multiplication of cells and increase in the
intracellular substances. Hypertrophy or expansion of cell size contributes to
a lesser extent to the process of growth.” --------Dr. O. P. Ghai, AIIMS,
Delhi.
“Growth, a measure of physical maturation, signifies an
increase in size of the body and its various organs. Thus, it can be measured
in terms of centimeters and kilograms. It is mainly due to multiplication of
cells and an increase in intracellular substance. Unlike in the adult, it is an
essential feature of the child’s life.” -------- Dr. Suraj Gupte, Jammu, India.
“ Growth- an increase in the number and size of cells as they
divide and synthesize new proteins; results in increased size and weight of
the whole or any of its parts.” --- Donna L. Wong Nurse Consultant,
Oklahoma.
“ Growth is the physical increase in size and appearance of the
body caused by increasing numbers of new cells.”--- Margaret G. Marks,
Nurse Instructor, Pennsylvania.

“Development” specifies maturation of functions. It is related to the

maturation and myelination of the nervous system and indicates acquisition
of a variety of skills for optimal functioning of the individual.”—Dr. O.P.
Ghai, AIIMS, New Delhi.
“Development is a measure of functional or physiological
maturation and myelination of the nervous system. It signifies
accomplishment of mental(acquisition of skills, etc), emotional
(development of attitudes, etc.) and social ( adaptation to family and society,
etc.) abilities. ------- Dr. Suraj Gupte, Jammu, India.
“Development”- a gradual change and expansion; advancement
from a lower to a more advanced stage of complexity; the emerging and
expanding of the individual’s capacities through growth, maturation and
learning.” ----Donna L. Wong, Nurse Consultant, Okalahoma.
“Development is the progressive change in the child’s
maturation” ---- Margaret G. Marks, Nurse Instructor, Pennsylvania.
Remember:- Growth and development are so closely interrelated that it is
virtually not possible to separate one from the other. Consequently, in
practice, these terms are either used together or denote synonymous
meaning. Strictly speaking, they represent two different aspects: quantity
(growth) and quality (development). Though the two generally proceed
concurrently, this may not always be so.

2
IMPORTANCE OF STUDY OF GROWTH AND DEVELOPMENT:

The pioneer of modern nursing, Florence Nightingale has said “It

would be the great challenge to the nurse whether she can take care of the
child?”. Therefore, it is important to understand the period of growth and
development which extends throughout the life cycle of childhood, during
the principle changes occur. The knowledge would help the nurse:

Understand the behaviour of parents and other adults who provide

care for the child. Intelligent handling of the children not only
requires the knowledge of growth and development but how such
development can be influenced favorably.
Know what to expect of a particular child at any age and at what
age certain kinds of behaviour are likely to emerge in mature
forms.
Assess the children in terms of norms for specific stage of
development for guiding the children into more mature behaviour,
if the sequence of developmental behaviour is understood.
Diagnose undernutrition, infections and other diseases affecting
growth in children and also understand the reasons for the same.
Recognize the potential problems and strength of the individual
children and their parents.
Assist parents in environmental modifications to keep pace with
new emerging needs and capacities of children to enable them to
achieve optimal growth and development.
Plan the nursing management and to help in implementing the plan
for the comprehensive care of the child.
Work with children effectively in health and in sickness.

3
 FACTORS INFLUENCING GROWTH AND DEVELOMENT:

GENETIC

SOCIO- GROWTH
ECONOMICA
L
POTENTIAL
S

GROWTH
ENVIRON AND PRENATAL
MENTAL, DEVELOPMEN AND
SEASONAL T INTRA
UTERINE

CHRONIC EMOTIONA
DISEASES L

NUTRITIONA
L

Growth and Development are regulated by a complex balance between the

heredity/genetic constitution and the environmental factors, all
interdependent. Heredity determines the extent of growth and development
that is possible, but environment determines the degree to which the
potential is achieved.

4
HEREDITY/GENETIC FACTORS:
Heredity refers to the genetic constitution of an individual which is
established during conception. It is the property of organic beings by which
offsprings have nature and characteristics of parents or ancestors. From the
parents the child receives a new combination of parental genes. Every
individual’s supply of genes, the bearer of hereditary factors is given to him
once for all at the time of conception.
Color of the eyes, hair, facial features, and structure of the body,
physical peculiarities, and blood group is determined entirely by heredity.
Hereditary influences have a bearing on the traits likely to exist in a child. It
is because of this that members of a family bear physical resemblance to
each other and a high degree of correlation exists among siblings than
among unrelated persons. To stimulate the hereditary potential the
environmental stimulation must be of the right kind at the time when
development normally occurs.

Sex is determined at conception. After birth the male infant is long

and heavier than the female infant. Boys maintain superiority until about 11
years of age. Girls mature earlier than boys. During the prepubertal growth
spurt and thereafter the boys are again taller than girls.

ENVIRONMENTAL FACTORS:
Though heredity and environment are closely inter-related and each
human being at birth has a gene determined physical, mental and
biochemical potential, this potential may not be reached because of
environmental influences. Stimulation to the development of innate abilities
comes from the environment. Environment influences this potential only to a
limited extent favorably or unfavorably.

Psychological, social and cultural factors also have a considerable role

in the development of personality and behavior. Hereditary constitutions
have a distinct but limited contribution. Therefore, inborn capacities must be
stimulated by environmental factors. “Good seeds planted in poor soil
result in stunted growth.”

Children of the developing nations, whose growth and development

had been stunted because of famine and drought showed marked
improvement in their physical condition and capabilities when subjected to
better living conditions and good food.

5
 The influence of heredity and environment are so
interrelated that they are practically inseparable.
Heredity determines what the child can do and
the environment what the child does.

i) Intrauterine Environment:
Intrauterine environment is the function of maternal circulatory
pattern which provides nutrients and the gas exchange. Fetal growth is
dependent on two factors—a) intrinsic fetal growth potential and,
b)limitations of intrauterine environment. Impaired fetal growth
potential may be due to genetic abnormality at conception.
Biologically life begins at conception and then onwards the growth is
constant from embryonic period to 36 weeks of gestation. Growth of
the fetus involves an increase in the number of cells and increase in
their size.

The influence of the intrauterine environment on the future

development of the child is of great significance. The uterus protects
the fetus from the adverse effects of external conditions. It is also true
that the intrauterine environment may be substandard, thus reducing
the number of cells or the size of cells or both the size and the number
of cells. For example intrauterine rubella infection produces severe
reduction in the quantity of cells in many organs while toxemia that
appears in late pregnancy is characterized by significant increase in
cell size, although cell number is relatively normal.
The factors which have harmful effect on fetal growth are:
Nutritional deficiencies when the mother’s diet is
insufficient in quantity and quality.
Mechanical problems like malposition in utero.
Metabolic endocrine disturbances like diabetes.
Infectious diseases during pregnancy like rubella in the first
trimester may lead to abnormal development of the fetus.
Herpes and syphilis during the second and third trimester
may have adverse effects on the fetus.
Smoking and use of alcohol and drugs may result in
prematurity or deformity of the child.

6
Good prenatal care helps in the prevention of many of the adverse
conditions thus ensuring better prenatal environment for the fetus.
While the prenatal period is short one it is nevertheless one of
extremely rapid period of development.

ii) Social and Economic Conditions:

Poverty, crowded living conditions, ignorance and lack of interest on
the part of the parents may lead to retardation of the normal growth
and development of children. The specific reasons for these
environmental influences are difficult to determine but these probably
include a combination of factors such inadequate diet, lack of
sunlight, and less careful supervision of the children’s daily habits by
parents. Studies of 160,000 women in some thirty developing
countries analyzed by the WHO show that higher the female literacy
rate is, the lower is the infant mortality.

iii) Cultural Influences:

The effect of a particular culture on a child begins the way a cultural
group takes care of the female children of its community and the
women.
Dr. Meharban Singh states, “Care for the female child”, as she is the
seed and she is the soil. That in no way means that the male child
needs less care.

The nutrients, that the mother is expected to eat during pregnancy is

culturally determined. There may be religious taboos against certain
types of food during pregnancy and postnatal period. Birth practices
also influence the growth of a child which means whether the child is
delivered in a sterile environment or in an unclean environment with
an untrained person.

After birth also the child is cared, according to the child rearing
practices of a group or community. Many cultural characteristics are
reflected in the child rearing practices of a family and are transmitted
to the next generation. Children from large families are prone to
infections and malnutrition. In every economic setting the children of

7
 literate women have a better chance of survival than those of illiterate
women.

iii) Nutrition:
It has been established that prolonged malnutrition of the expectant
mother is one of the most common causes of low birth weight, fetal
and neonatal deaths and incurably damaged infants. This fact is
especially serious in early marriages because it means that many
young mothers may suffer from malnutrition when they become
pregnant.

Any disease condition of the mother that affects her general

metabolism will influence to a certain extent the development of the
unborn child. The conditions believed to be most serious are:
Endocrine disorders.
Infectious disease.
Prolonged wasting disease.
The Rh blood factors.
Alcohol and tobacco consumption.

BLUE PRINT OF DEVELOPMENT:

( BASIC PREDICTABLE CHARACTERISTICS OF DEVELOPMENT )

Living is learning and growing is learning. Development is the result

of interaction of maturation and learning. Every species whether animal or
human, follow a pattern of development peculiar to that species. In prenatal
development there is a genetic sequence and the same orderly pattern is
evident in the postnatal development of the child also.
Gessel ( founder of the clinical child development of Yale University)
has concluded from the genetic studies of children—“although no two
children are alike, all normal children tend to follow a general sequence
of growth” Every child has a unique pattern of growth but that pattern is
variant of the basic blue print. The species sequences are part of an
established order of nature. There are certain basic predictable
characteristics of this basic blue print of development. These are as follows:

1.Development is Similar for All.

8
 All children follow a similar pattern of development with one stage
leading into the next. e.g. the baby stands before he walks, the
baby draws circle before a square. In no instance is this order
normally reversed.
The very bright child and the very dull child likewise follow the
same developmental sequence as the average. The very bright
child develops at a more rapid rate and the very dull at a slower
rate.

2. Development Proceeds from General to Specific.

In mental as well as motor responses general activity always
precedes specific activity. Before birth the fetus moves the whole
body but is incapable of making specific responses.
Generalized body movements occur before fine muscle control is
possible. At first the infant can make random movement of the
arm.
There is a normal sequence in the development of physical abilities
just as it is for mental development and emotional and social
adequacy.
A child should be given an opportunity to practice the skills by
either experience or instruction wherever readiness occurs.
3. Development is Continuous.
Development is continuous from the moment of conception to
death but occurs at different rates sometimes slowly and
sometimes rapidly.
What happen at one stage has influence on the following stage.
e.g. the speech, in a child does not develop overnight; the child
coos, gurgles and babbling sounds are made by the child from the
time of birth and keep getting refined into language.
4. Development Proceeds at Different Rates.
During the period of growth and development of the total body and
its subsystems, growth is sometimes rapid and at times it slows
down.
Rapid growth occurs during gestation and infancy.
In the preschool years growth levels off. It slows down again
during school years.
A spurt of growth occurs in puberty and early adolescence. The
pubertal growth broadens the physical difference among boys and
girls. Women become the weaker sex but become physically
attractive to men.

9
5. There is correlation in Development.
Correlation in physical and mental abilities is especially marked.
There is marked relationship between sexual maturation and
patterns of interest and behavior.

6. Development comes from Maturation and Learning.

The sudden appearance of certain traits that develop through
maturation is quite common; for example a baby may start to walk
literally overnight. Behavioral changes occur at the time of
puberty suddenly without any reason.
Learning is development that comes from exercise and effort on
the part of an individual . Unless the child had opportunity for
learning, many of his hereditary potentials will never reach their
optimum development.
A child may have aptitude for musical performance because of his
superior neuromuscular organization but if he is deprived of
opportunity for practice and systematic training, he will not reach
his hereditary potential.
Maturation sets limits beyond which development cannot go even
if learning is encouraged. Intrinsic growth is the gift of the nature.
It can be guided, it can not be created. Innate capacities however
should be stimulated by environmental factors.

7. There are Individual Differences:

Although the pattern of development is similar for all children,
each child follows a predictable pattern in his own way and at his
own rate.
Each child with his unique heredity and nurture (environment) will
progress at its own rate in terms of size, shape, capacity and
developmental status.
Mental development too is influenced by heredity and
environment. Therefore, we can not expect all children of the
same age to be ready for the same learning experience at the same
time.

8. Early development is more significant than later development.

In building the house the foundations are more important than the
superstructure, so is the development of physical and mental
traits.

10
 Unfavorable environmental conditions during prenatal and
postnatal period can have damaging effect on the later growth and
development of the child.

9. Development proceeds in stages.

Development is not abrupt; it proceeds in various stages such as

fetal, infancy, babyhood, childhood and adolescence.

10. Predictable patterns of Development.

Both during the prenatal and postnatal period, two laws of

predictable pattern of development emerge.
1. The cephalocaudal law.
2. The proximodistal law.
According to the cephalocaudal law development
spreads over the body from the head to foot. This
means that improvement in structure and functions
of the body comes first in the head region than in
the trunk and last in the leg region.
According to the proximodistal law development
takes placed from near to far that is outward from
the central axis of the body towards the extremities.
In prenatal period the head and trunk are fairly well
developed when the limb buds appear. Slowly the
arms lengthen followed by hands and fingers.
Functionally too the baby can use his arms before
his hands and child can use the whole hand before
his fingers.
Teeth also follow the predictable pattern of physical
development. The lower teeth erupt before the
upper teeth

DEVELOPMENTAL THEORIES

11
 Personality and cognitive skills develop in much the same manner as
biologic growth—new accomplishments build on previously mastered skill.
Many aspects depend on physical growth and maturation. First we will see
the summary of personality, cognitive and moral deve lopment theories of
various Psychologists.
Stage/Age Psychosexual Psychosocial Radius of Cognitive Moral
Stage(Freud) Stage(Erikson) Significant Stage Judgment
Relationship (Piaget) Stages
(Sullivan) (Kohlberg)

I Infancy Oral sensory Trust vs mistrust Maternal Sensori-

Birth to Person Motor
1 Year ( Unipolar- Birth to 2
bipolar ) Year.
II Toddler Anal-urethral Autonomy vs Parental Pre- Pre-
hood. shame and persons operational conventional
1-3 year. doubt (tripolar) thought, (premoral)
Preconceptual level
phase punishment
(transductive and
reasoning) obedience
e.g. specific- orientation.
to specific)
( 2-4 years)
III Phallic- Initiative vs Basic family Pre- Pre-
Early locomotion guilt. operational conventional
Childhood thought, (premoral)
3-6 years. intuitive level
phase Native
(transductive instrumental
reasoning) orientation.
( 4- 7 years)
IV Latency Industry vs Neighbour- Concrete Conventional
Middle Inferiority hood. Operations level
Childhood (inductive Good-boy,
reasoning and Nice-girl
beginning orientation
logic. Law and
(7-11 years) order
orientation

Stage/Age Psychosexual Psychosocial Radius of Cognitive Moral

Stages Stages significant Stages judgment
(Freud) (Erikson) Relationship (Piaget) Stages.

12
 (Sullivan) (Kohlberg)

V Genitality Identity and Peer group Formal Post

Adolescence Repudiation vs and out operations Conventional
12-19 Identity groups. (deductive or
years. confusion. models of and abstract principled
leadership reasoning) level
partners in ( 11-15 years) Social
friendship, contract
sex, orientation.
Competition,
cooperation

VI Intimacy and Divided

Early solidarity vs labour and
adult isolation. shared
hood. house-
hold

VII Generativity Mankind

Young and “my kind”
and self
middle absorption.
adult
hood.

VIII Ego
Later integrity
adult Vs
hood. despair.

Now we will discuss briefly about these Theories of development of

mental function and personality.

PSYCHOSEXUAL DEVELOPMENTAL STAGE ( SIGMUND FREUD) :

13
 Most modern psychologist base their understanding children at least
partly on the work of Sigmund Freud. His theories are concerned primarily
with the libido (sexual drive or development). Although Freud did not study
children, his work focused on childhood development as a cause of later
conflict. Freud believed that a child who did not adequately resolve a
particular stage of development would have a fixation (compulsion) that
correlated with that stage. Freud described three levels of consciousness: the
id, which controls physical need and instincts of the body; the ego, the
conscious self, which controls the pleasure principle of the id by delaying
the instincts until an appropriate time; and the superego, the conscience or
parental value system. These consciousness levels interact to check behavior
and balance each other. The psychosexual stages in Freud’s theory are the
oral, the anal, the phallic, the latency and the genital stages of development.
1. Oral sensory stage: ( Infancy – Ages 0- 1 year )
The newborn first relates almost entirely to the mother (or
someone taking a motherly role), and the first experiences with
body satisfaction come through the mouth.
Not only of sucking but also of making noises, crying,
obsessive eating and often, breathing.
Through the mouth baby expresses needs and finds satisfaction
and thus begins to make sense of the world.

2. Anal stage : ( Toddlerhood, 1-3 years )

Interest during the second year of life centers in the anal region
as sphincter muscles develop and children are able to withhold
or expel fecal material at will.
At this stage climate surround toilet training can have lasting
effects on children’s personalities.

3. Phallic stage: ( Early childhood, 3-6 years )

During the phallic stage the genitals become an interesting and
sensitive area of the body.

Children recognize differences between the sexes and become

curious about the dissimilarities.

This is the period around which the controversial issues of the

Oedipus (desire to be a male) and Electra complexes (girls’
attraction with father). Penis envy and castration anxiety are
centered.

14
 4. Latency stage: ( Middle childhood, 6-12 years )
During the latency period children elaborate on previously
acquired traits and skills.
Physical and psychic energy are channeled into the acquisition
of knowledge and vigorous play.

5. Genital stage: ( Adolescence, 12-19 years)

The last significant stage begins at puberty with maturation of
the reproductive system and production of sex hormones.
The genitals become the major source of sexual tension and
pleasure, but energies are also invested in forming friendships
and preparing for marriage.

PSYCHOSOCIAL DEVELOPMENTAL STAGE (ERIK ERIKSON):

The most widely accepted theory of personality development is that
advanced by Erikson (1963). Although built on Freudian theory, it is known
as the theory of psychosocial development and emphasizes a healthy
personality as opposed to a pathologic approach. Erikson also uses the
biological concepts of critical periods and epigenesist, describing key
conflicts or core problems that the individual strives to master during critical
periods in personality development.
Each psychosocial stage has two components—the favorable and the
unfavorable aspects of the core conflict—and progression to the next stage
depends on resolution of this conflict. No core conflict is ever mastered
completely but remains a recurrent problem throughout life. No life situation
is ever secure. Each new situation presents the conflict in a new form. For
example, when children who have satisfactorily achieved a sense of trust
encounter a new experience (e.g. hospitalization), they must again develop a
sense of trust in those responsible for their care in order to master the
situation.
Erikson’s life span approach to personality development consists of
eight stages; however, only the first five relating to childhood are included
here, they are:

1. Trust vs mistrust (birth to 1 year)

The first and most important attribute to develop for a healthy
personality is a basic trust; establishment of basic trust dominates

15
 the first year of life and describes all of a child’s satisfying
experiences at this age.
Corresponding to Freud’s oral stage, it is a time of “getting” and
“taking in” through all the senses. Trust exists only in relation to
something or someone; therefore consistent, loving care by a
mothering person is essential to its development.
Mistrust develops when trust-promoting experiences are deficient
or lacking or when basic needs are inconsistently or inadequately
met.
2. Autonomy vs shame and doubt (1 to 3 years)
Corresponding to Freud’s anal stage, the problem of autonomy
can be symbolized by the holding onto and letting go of the
sphincter muscle.
The development of autonomy during the toddler period is
centered around children’s increasing ability to control their
bodies, themselves, and their environment.
Children want to do things for themselves by using their newly
acquired motor skills of walking, climbing, and manipulating and
their mental powers of selection and decision making.
Much of children’s learning is acquired through imitating the
activities and behavior of other.
Negative feelings of doubt and shame arise when children are
made to feel small and self-conscious, when their choices are
disastrous, when others shame them, or when they are forced to
be dependent in areas in which they are capable of assuming
control.
The favorable outcomes are self-control and willpower.
3. Initiative vs guilt (3 to 6 years)
The stage of initiative corresponds to Freud’s phallic stage and is
characterized by vigorous and intrusive behavior, enterprise, and a
strong imagination.
Children explore the physical world with all of their senses and
powers. They develop their conscience.
Children sometimes undertakes goals or activities that are in
conflict with those of parents or others, and being made to feel
that their activities or imaginings are bad produces a sense of
guilt.
Children must learn to retain a sense of initiative without
impinging on the rights and privileges of others. The lasting
outcomes are direction and purpose.

16
4. Industry vs inferiority (6 to 12 years)
The stage of industry is the latency period of Freud.
Having achieved the more crucial stages in personality
development, children are ready to be workers and producers.
They want to engage in tasks and activities that they can carry
through to completion; they need and want real achievement.
Children learn to compete and cooperate with others, and they
learn the rules.
It is decisive period in their social relationship with others.
Feeling of inadequacy and inferiority may develop if too much is
expected of them or if they believe they cannot measure up to the
standards set for them by others.
The ego quality developed from a sense of industry is competence.

5. Identity vs role confusion (12 to 18 years)

Corresponding to Freud’s genital period, the development of
identity is characterized by rapid and marked physical changes.
Previous trust in their bodies is shaken, and children become
overly preoccupied with the way they appear in the eyes of others
as compared with their own self-concept.
Adolescents struggle to fit the roles they have played and hope to
play with the current roles and fashions adopted by their peers, to
integrate their concepts and values with those of society and to
come a decision regarding an occupation.
Inability to solve the core conflict results in role confusion.
The outcome of successful mastery id devotion and fidelity to
others and to values and ideologies.

INTERPERSONAL DEVELOPMENTAL THEORY (SULLIVAN)

Also built on Freudian theory, the interpersonal development theory
by Sullivan emphasizes the interpersonal relationship in which children
engage and the importance of social approval and disapproval in
developing a self-concept. What children interpret as unfavorable
interactions results in tension and anxiety; the outcome of favorable
relationships is a sense of comfort and security. Through repeated
interactions children acquire a repertoire of actions and behaviors that
produce a feeling of security and avoid anxiety.
The first interactions are those between infants and their “mothering”
figure, usually the mother, who gratifies and comforts. This bipolar

17
relationship gradually extends to include others in the family group.
Between ages 2 and 5 , children not only become more outgoing but also
direct their social gestures to a wider audience outside yet still near the home
land family, such as relatives and neighborhood children. They engage in
peer play, family events, and other aspects of social learning. Observational
studies suggest that 2 to 3 years olds are more likely than older children to
remain near an adult and to seek physical affection, whereas the sociable
behaviors of 4 to 5 year olds normally consist of playful bids for attention
or approval that are directed at peers rather than adults.
During the school years, children enter into a wider range of
relationships with other persons and authority figures at school and in the
community. They develop “chumpships,” a special relationship between two
peers—the shared intimacy and common interests of genuine friendships
that are lacking in earlier relationships. Personal identity in adolescence is an
outgrowth of intimate relationships, first with friends of the same sex then
friends of the opposite sex.
Although Sullivan’s theory recognizes the importance of environment
in development and has some predictive value, it does not recognize the
biologic maturation process.

COGNITIVE DEVELOPMENT (JEAN PIAGET)

Cognitive development consists of age-related changes that occur in
mental activities. The best-known theory regarding children’s thinking, and
a more comprehensive developmental theory than those already described,
has been developed by the Swiss psychologist Jean Piaget. According to
Piaget, intelligence enables individuals to make adaptations to the
environment that increase the probability of survival; through their behavior
individuals establish and maintain equilibrium with the environment.
Piaget proposes three stages of reasoning :(1)Intuitive, (2) concrete
operational, and (3) formal operational.
When children enter the stage of concrete logical thought at
approximately 7 years of age, they are able to make logical inferences,
classify, and deal with quantitative relationships about concrete things. Not
until adolescence are they able to reason abstractly with any degree of
competence.
According to Piaget, children proceed through the stages of mental
activity in an orderly and sequential manner. The mechanisms that enable
them to adapt to new situations and to move from one stage to the next are
assimilation and accommodation. By assimilation children incorporate new
knowledge, skill, ideas, and insights into cognitive schemes (Piaget uses the

18
term ‘schema’=pattern of action and / or thought.) already familiar to them.
For new situations that do not fit into an established schema, children
accommodate. They change and organize existing schemas to solve more
difficult tasks and form new schemas, children’s understanding of a new
experience is based on all relevant previous experiences. Thus children
achieve an accurate understanding of reality and come to deal with
increasingly complex problems in an increasingly effective manner.
Piaget believed there are four major stages in the development of
logical thinking. Each stage is derived from and builds on the
accomplishments of the previous stage in a continuous, orderly process.

1. Sensorimotor (birth to 2 years)

The sensorimotor stage of intellectual development consists of
six sub stages and that are governed by sensation in which
simple learning takes place.
Children progress from reflex activity through simple,
repetitive behaviors to imitative behavior. They develop a
sense of “cause and effect” as they direct behavior toward
objects.
Problem solving is primarily trial and error. They display a high
level of curiosity, experimentation, and enjoyment of novelty
and begin to develop a sense of self as they are able to
differentiate themselves from their environment.
They become aware that objects have permanence—the objects
exist even when no longer visible.
Toward the end of the sonsorimotor period, children begin to
use language and representational thought.

2. Preoperational ( 2 to 7 years )
The predominant characteristic of the preoperational stage of
intellectual development is egocentrism, which in this sense
does not mean selfishness or self-centeredness but rather the
inability to put oneself in the place of another.
Children interpret objects and events not in terms of general
properties but in terms of their relationships or their use to
them.
They are unable to see things from any perspective other than
their own; they cannot see another’s point of view, nor can
they see any reason to do so.

19
 Preoperational thinking is concrete and tangible. Children
cannot reason beyond the observable, and they lack the ability
to make deductions or generalizations. Thought is dominated
by what they see, hear, or otherwise experience.
Through imaginative play, questioning, and other interactions,
they begin to elaborate concepts and to make simple
associations between ideas.
In the latter stage of this period their reasoning is intuitive (e.g.
the stars need to go to bed just as they do).
Reasoning is also transductive—because two events occur
together, they cause each other or knowledge of one
characteristic is transferred to another. (E.g. all women with
big bellies have babies.)

3. Concrete operations (7 to 11 years )

At this age thought becomes increasingly logical and coherent.
Children are able to classify, sort, order, and otherwise
organize facts about the world to use in problem solving.
Develop new concept of permanence—conservation i.e. they
realize that physical factors such as volume, weight, and
number remain the same even though outward appearances are
changed.
They are able to deal simultaneously with a number of different
aspects of a situation. They do not have the capacities to deal
in abstraction; they solve problems in a concrete, systematic
fashion based on what they can perceive.
Reasoning is inductive. Through progressive changes in
thought processes and relationship with others, thought
becomes less self-centered.
Children can consider points of view other than their own.
Thinking has become socialized.

4. Formal operations ( 11 to 15 years )

Formal operational thought is characterized by adaptability and
flexibility. Adolescents can think in abstract terms, use abstract
symbols, and draw logical conclusions from a set of
observations, e.g. they can solve “ if A is larger than B, and B

20
 is larger than C, which symbol is the largest?” ( the answer is
A)
They can make hypotheses and test them; they can consider
abstract, theoretic, and philosophic matters.
They may confuse the ideal with the practical; most
contradictions in the world can be dealt with and resolved.

MORAL DEVELOPMENT (KOHLBERG)

It is theorized that children develop moral reasoning in an invariant
developmental sequence. To understand the stages in the development of
moral judgment, it is important to be aware of the stages of logical thought
and its relationships to cognitive development and moral behavior. Moral
development is based on cognitive developmental theory and consists of
three major levels, each with two stages (Kohlberg, 1968)
Kohlberg’s theory allows for prediction of behavior but pays little
attention to individual differences. Questions arise relative to observed sex
differences in attainment of the various sequences of moral development. It
has been argued that the theory was derived from interviews with male
adults and may not reflect feminine moral reasoning.
The preconventional level of morality parallels the preconceptual
level of cognitive development and intuitive thought. At this level morality
is external because children conform to rules imposed by authority figures.
Culturally oriented to the labels of good/bad and right/wrong, children
integrate these labels in terms of the physical or pleasurable consequences of
their actions. The two stages of this level are:
Stage: 1. The punishment-and-obedience orientation.
Children determine the goodness or badness of an action in
terms of its consequences.
They avoid punishment and obey unquestioningly those who
have the power to determine and enforce the rules and
labels.
They have no concepts of the underlying moral order that
supports these consequences.

Stage: 2.The instrumental-relativist orientation.

The right behavior consists of that which satisfies the child’s
own needs (and sometimes the needs of others).

21
 Elements of fairness, reciprocity, and equal sharing are
evident; they are interpreted in a very practical, concrete
manner without the element of loyalty, gratitude, or justice.

At the conventional level children are concerned with conformity and

loyalty; actively maintaining, supporting, and justifying the social order; and
personal expectations of those significant in their lives. They value the
maintenance family, group, or national expectations regardless of
consequences. This level correlates with the concrete operational stage in
cognitive development and consists of two stages:
Stage: 3. The interpersonal concordance or “good boy-nice girl”
orientation.
Behavior that meets with approval and pleases or helps others is
viewed as good.
Conformity to the norm is the “natural” behavior, and one earns
approval by being “nice”.

Stage: 4. The “law and order” orientation.

Obeying the rules, doing one’s duty, showing respect for
authority, and maintaining the social order is the correct
behavior.
The rules and authority can be social or religious, depending
on which is most valued.

At the postconventional, autonomous, or principled level children have

reached the cognitive formal operational stage, and they endeavor to define
moral values and principles that are valid and applicable beyond the
authority of the groups and persons holding these principles. This level is
not associated with the individual’s identification with these groups.
Stage: 5. The social-contract, legalistic orientation.
Correct behavior tends to be defined in terms of general
individual rights and standards that have been examined and
agreed on by the entire society.
Procedural rules for reaching consensus become important,
with emphasis on the legal point of view; there is also
emphasis on the possibility of changing law in terms of
societal needs and rational considerations.
Agreement and contract outside the legal realm are binding
elements of obligation.

22
The most advanced level of moral development is one in which self-chosen
ethical principles guide decisions of conscience. These are abstract, ethical,
and universal principles of justice and human rights with respect for the
dignity of persons as individuals. It is believed that few persons reach this
stage of moral reasoning.

STAGES OF GROWTH AND DEVELOPMENT

Most authorities in the field of child development conveniently

categorize child growth and behavior into approximate age stages or in terms
that describe the features of an age group. The age ranges of these stages are
admittedly arbitrary. Because they do not take into account individual
differences, they cannot be applied to all children with any degree of
precision. Nevertheless, this categorization affords a convenient means by
which to describe the characteristics associated with the majority of children
at periods when distinctive developmental changes appear and specific
developmental task must be accomplished.

Developmental Age Periods:

Prenatal Period: conception to birth.

Germinal(Ovum): conception to approximately 2 weeks ( 14 days)
Embryonic: 2 to 8 week ( 14 days to 9 weeks—Dr. O.P. Ghai )
Fetal: 8 to 40 weeks ( 9 week to birth –Dr. O.P. Ghai )

A rapid growth rate and total dependency make this one of the most
crucial periods in the developmental process. The relationship between
maternal health and certain manifestations in the newborn emphasizes the
importance of adequate prenatal care to the health and well-being of the
infant.

Perinatal Period: 22 week of gestation to 7 days after birth ( WHO )

Infancy Period: Birth to 12 months.

Neonatal ( Newborn) : Birth to under 28 days or first four week after
birth.
Infancy : 1 to approximately 12 months.

23
 The infancy period is one of rapid motor, cognitive, and social
development, through mutuality with the caregiver (parent), the infant
establishes a basic trust in the world and the foundation for future
interpersonal relationships. The critical first month of life, although part of
the infancy period , is often differentiated from the remainder because of the
major physical adjustments to extrauterine existence and the psychologic
adjustment of the parent.

Early Childhood: 1 to 6 years.

Toddler: 1 to 3 years.
Preschool : 3 to 6 years.
( in some studies children under 5 years are classified as preschool
children)
This period, which extends from the time the children attain upright
locomotion until they enter school, is characterized by intense activity
and discovery. It is a time of marked physical and personality
development. Motor development advances steadily. Children at this age
acquire language and wider social relationship, learn role standards, gain
self-control and mastery, develop increasing awareness of dependence
and independence, and begin to develop a self-concept.

Middle Childhood:
School age: 6 to 10 years (girls)
6 to 12 years (boys)

Commonly referred to as the “school age”, this period of development

is one in which the child is directed away from the family group and is
centered around the wider world of peer relationships. There is steady
advancement in physical, mental, and social development with emphasis on
developing skill, competencies. Social cooperation and early moral
development take on more importance with relevance for later life stages.
This is a critical period in the development of a self-concept.

Later Childhood: (Adolescence)

Prepubescent : 10 to 12 years (girls)
12 to 14 years (boys)
Pubescent : 12 to 14 years (girls)

24
 14 to 16 years (boys)
Postpubescent : 14 to 18 years (girls)
16 to 20 years (boys)

The period of rapid maturation and change known as adolescence is

considered to be transitional period that begins at the onset of puberty
and extends to the point of entry into the adult world—usually high
school graduation. Biologic and personality maturation are accompanied
by physical and emotional turmoil, and there is redefining of the self-
concept. In the late adolescent period the child begins to internalize all
previously learned values and to focus on an individual, rather than a
group, identity.

Developmental Tasks:
A developmental task is a set of skills and competencies unique to each
developmental stage, which children must accomplish or master in order
to deal effectively with their environment.

The following is a brief outline of important developmental milestones at a

glance, as per the well known authority, Professor R.S. Illingworth.

Important Milestone Age.

25
Social smile 4 to 6 weeks
Head Holding 3 month
Sits with support 6 months
Reaches out for a bright objects and 5 to 6 months
gets it
Transfers objects from one hand to 6 to 7 months
the other
Starts imitating a cough 6 to 7 months
Crawls 8 to 10 months
Creeps 10 to 11 months
Stands holding furniture 9 months
Walks holding furniture 12 months
Stands without support 10 to 11 months
Says one word with meaning 12 months
Says 3 words with meaning 13 months
Joins 2 or 3 words into sentences 15 to 18 months
Feeds self with spoon 13 months
Climbs stairs 15 to 18 months
Takes shoes and socks off 15 to 18 months
Puts shoes and socks on 24 months
Takes some clothes off 24 months
Dry by day 2 years
Dry by night 3 years
Dresses self fully 3 to 4 years
Knows full name and sex 3 years
Rides tricycle 3 years
Stands on one leg for seconds 3 years
Jumps with both feet 3 years
Builds tower of 9 blocks 3 years

PATTERNS OF GROWTH AND DEVELOPMENT OF CHILDREN

NEWBORN

Indian Newborn’s Weight (Range) : 2.540 Kg to 4.150 Kg.

26
 Indian Newborn’s Length (Range) : 46.44 to 54.40 cm
Indian Newborn’s Head circumference ( Range ):
32.60 to 37.20 cm
Expected loss of weight during first week : 10% of the birth weight.
Expected gain of weight after 1 week to 4weeks : 500 gm./month (up to age
of 3 months.)
Emerging Patterns of Behavior:-
Prone: Lies in flexed attitude; turns head from side to side; head
sag on ventral suspension.
Supine: Generally flexed and a little stiff.
Visual: May fixate face or light in line of vision; doll’s eye
movements of eye on turning of the body.
Reflex: Moro response active; stepping and placing reflexes;
grasp reflex.
Social: Visual preference for human face.
Language cries; coos

INFANT: ( 1 MONTH TO 1 YEAR)

Pattern of Growth:

Age Approximately Approximately Growth in Growth in Recommended

Daily weight Monthly Length. Head Daily
Gain.(gm) Weight (cm/month) Circumference allowance.
Gain.(lb) ( cm/month) Kcal/kg/day
0-3 30 2 3.5 2.00 115
month
3-6 20 1.25 2.0 1.00 110
months
6-9 15 1 1.5 0.50 100
months
9-12 12 13 oz 1.2 0.50 100
months

Emerging Pattern of Behavior

At 4 week:
Prone: Legs more extended; holds chin up; turns head; head
Lifted momentarily to plane of body on ventral

27
 suspension.
Supine: Tonic neck posture predominates; supple and relaxed;
head lags on pull to sitting position.
Visual: Watches persons; follows moving objects.
Social: Body movements in cadence with voice of other in social
contact; beginning to smile.
At 8 week:
Prone: Raises head slightly further; head sustained in plane of
body on ventral suspension.
Supine: Tonic neck posture predominates; head lags on pull to
sitting position.
Visual: Follow moving objects 180 degrees.
Social: Smiles on social contact; listens to voice and coos.
At 12 weeks:
Prone: Lifts head and chest, arms extended, head above plane of
body on ventral suspension.
Supine: Tonic neck posture predominates; reaches toward and
misses objects; waves at toy.
Sitting: Head lags partially compensated on pull to sitting
position, early head control with bobbing motion;
back rounded.
Reflex: Typical Moro response has not persisted; makes
defensive movements or selective withdrawal reactions.
Social: Sustained social contact; listens to music; says “aah,
ngah”
At 16 weeks:
Prone: Lifts head and chest; head in approximately vertical axis;
legs extended.
Supine: Symmetric posture predominates, hands in midline;
reaches and grasps objects and brings them to mouth.
Sitting: No head lag on pull to sitting position; head steady;
tipped forward; enjoys sitting with full truncal support.
Standing: When held erect, pushes with feet.
Adaptive: Sees pellet; but makes no move to it.
Social: Laughs out loud; may show displeasure if social contact
is broken; excited at sight of food.
At 28 weeks:
Prone: Rolls over; pivots; crawls or creep-crawls ( knobloch).
Supine: Lifts head; rolls over; squirming movements.
Sitting: sits briefly with support of pelvis; leans forward on hands

28
 back rounded.
Standing: May support most of weight; bounces actively.
Adaptive: Reaches out for and grasps large object; transfers objects
from hand to hand; grasp uses radial palm; rakes at
pellet.
Language: Polysyllabic vowel sounds formed.
Social: Prefers mother; babbles; enjoys mirror; responds to
changes in emotional content of social contact.
At 40 weeks:
Sitting: Sits up alone and indefinitely without support,
back straight.
Standing: Pulls to standing position; “cruises” or walks holding on
to furniture.
( cont.)

Motor: Creeps or crawls.

Adaptive: Grasps objects with thumb and forefinger; pokes at
things with forefinger; picks up pellet with assisted
pincer movements; uncovers hidden toy; attempts to
retrieve dropped object; releases object grasped by other
person.
Language: Repetitive consonant sounds ( mama, dada)
Social: Responds to sound of name; plays peek- a boo or
pat – a cake; waves bye-bye.
At 52 weeks:
Motor: Walks with one hand held ( 48 weeks); rises
independently, takes several steps.
Adaptive: Picks up pellet with unassisted pincer movement of
forefinger and thumb; releases object to other person on
request or gesture.
Language: A few words besides “mama, dada”
Social: Plays simple ball game; makes postural adjustment to
dressing.

NUTRITION OF THE 0-1 YEAR CHILD:

For Newborn:

29
 Breast-feeding is the ideal form of feeding in the neonate. Artificial
feeding exposes the infant to infections and results in over a million deaths
annually world-wide due to its ill effects.
Breast-feeding should be initiated as soon as possible afterbirth
(within half an hour after normal delivery and four hours of caesarean
section). Nothing should be given to the baby before initiation of breast-
feeding. The baby should be given only breast milk and nothing else( not
even water ) for first 4 months of life. Breast-feeding should be given,
whenever baby feels hungry (demand feeding). Now-a-days under exclusive
breast-feeding concept a baby should be breast-feed at least for 6 months.

After 4-6 months: (weaning)

The human milk alone, even in reasonable quantities, cannot provide
all the energy and protein required for maintaining an adequate velocity of
growth for the infant after the age of 4-6 months. It is, therefore, necessary
to introduce more concentrated energy dense nutritional supplements or iron
containing food supplements after the age of 5-6 months to prevent iron
deficiency anemia.
Weaning refers to accustoming the infant to nourishment other than
the mother’s milk. Weaning is a difficult period in the infant’s life, because,
if the food supplements or substitutes are not adequate in quantity or quality,
the child becomes malnourished. Unhygienic feeding practices may result in
enteric infections and diarrhea, further compromising the nutritional state.
It is imperative that the weaning food should be :
Culturally acceptable, in consonance with the traditional
feeding practices;
Adequate to provide all the nutritional requirements of the
infant with respect to energy, protein, vitamins and
minerals;
Locally available and inexpensive;
Easily prepared at home, with the existing facilities;
Clean and hygienic, so that it should not become a source
of infection; and
Physiologically suitable, easily digestible, and nourishing.

In the most parts of India, a well cooked gruel (Khichri, Kanji )

prepared from rice (3 parts) , legume (1part ), green leafy vegetable and
some milk curd is a satisfactory weaning food. Local variations of the
weaning food may be made according to the availability of food in the
region. In some weaning foods, soyabean replaces dals or lentils.

30
Commercially available weaning foods are good but expensive. These offer
no distinct advantages over the home made weaning foods.
Daily Recommended Dietary Intakes (RDI) for Infants

NUTRIENTS 0-6 MONTHS 6-12 MONTHS

Energy ( k cal) 108/kg 98/kg
Protein ( gm) 2.05/kg 1.65/kg
Calcium (mg) 500 500
Iron (mg) 70/kg 70/kg
Vitamin Retinol (ug) 350 350
Or carotene 1200 1200
Thiamine (ug) 55/kg 50/kg
Riboflavin (ug) 65/kg 60/kg
Niacin (ug) 710/kg 650/kg
Ascorbic Acid (mg) 25 25
Folic Acid (mg) 25 25
Vitamin B 12 (ug) 0.2 0.2

PLAY MATERIALS FOR 0-1 YEAR CHILD:

Suggested Toys:
Birth to 6 months.
Nursery mobiles.
Unbreakable mirrors
Music boxes
Musical mobiles
Stuffed animals
Soft cloths
Weighted suction toys
Small handle clear rattle.
Contrasting colored sheets………..etc

6-12 months.
Various colored blocks.
Books with rhymes and bright pictures.
Rattles of different size
Soft, different-texture animals and dolls
Activity box for crib.
Push pull toys.

31
 Sponge toys.
Teething toys.
Large ball
Large puzzles…………………….etc.

EARLY CHILDHOOD

TODDLERHOOD:

The term terrible twos has often been used to describe the toddler
years, the period from 12 to 36 months of age. It is a time of intense
exploration of the environment as the children attempt to find out how things
work, what the word “no” means, and the power of temper tantrums,
negativism, and obstinacy. “Getting into things is their way of learning
about their world, especially relationships. Successful mastery of the tasks of
this age requires a strong foundation of trust during infancy and frequently
necessitates guidance from others when parent and toddler face the struggles
of toilet training, limit-setting, and sibling rivalry. Nurses who understand
the dynamics of growth and development of the toddler can help families
deal effectively with the tasks of this age.

Pattern of growth of the toddler:

Age Approximately Approximately Growth in Growth in Recommended

Daily weight Monthly Length. Head Daily
Gain.(gm) Weight (cm/month) Circumference allowance.
Gain.(lb) ( cm/month) Kcal/kg/day
12-36 8 13 1.0 0.25 100
month

32
 Emerging Pattern of Behavior from 15 months to 3 years

At 15 months:
Motor: Walks alone; crawls up stairs
Adaptive: Makes tower of 3 cubes; makes a line with crayon;
inserts pellets in bottle.
Language: Jargon; follows simple commands; may name a familiar
Object (ball)
Social: Indicates some desires or needs by pointing huge parents.
At 18 months:
Motor: Runs stiffly; sits on small chair; walks up stairs with one
hand held; explores drawers and waste baskets.
Adaptive: Makes a tower of 4 cubes; imitates scribbling; imitates
vertical stroke; dumps pellet from bottle.
Language: 10 words (average); names pictures; identifies one or
more parts of body.
Social: feeds self; seeks help when in trouble; may complain
when wet or soiled; kisses parent with pucker.

At 24 months:
Motor: Runs well; walks up and down stairs, one step at a time;
opens doors; climbs on furniture; jumps.

Adaptive: Tower of 7 cubes ( 6 at 21 months); circular scribbling;

imitates horizontal stroke; folds paper once imitatively.
Language: Puts 3 words together ( subject, verb, object)
Social: Handles spoon well; often tells immediate experiences;
helps to undress; listens to stories with pictures.
At 30 months:
Motor: goes up stairs alternating feet.
Adaptive: Tower of 9 cubes; makes vertical and horizontal strokes,
but generally will not join them to make a cross; imitates
circular stroke, forming closed figure.
Language: Refers to self by pronoun “I” ; knows full name.
Social: Helps put things away; pretends in play.

33
At 36 months:
Motor: Rides tricycle; stands momentarily on one foot.
Adaptive: Tower of 10 cubes; imitates construction of “bridge” of 3
cube; copies a circle; imitates a cross.
Language: Knows age and sex; counts 3 objects correctly; repeats 3
numbers or a sentence of 6 syllabus.
Social: Plays simple games ( in “parallel” with other children);
helps in dressing ( unbuttons clothing and puts on shoes);
washes hands.

PRESCHOOL:
(3 TO 6 YEARS)

Pattern of growth of the Preschool

Age Approximatel Approximately Growth in Growth in Recommended

y Monthly Length. Head Daily
Daily weight Weight (cm/year) Circumference allowance.
Gain.(gm) Gain.(lb) ( cm/year) Kcal/kg/day
36-72 6gm 6 oz 3 cm 1 cm 90-100
month

Emerging Pattern of Behavior of the Preschool

At 48 months:
Motor: Hops on one foot; throws ball overhand; uses scissors to
cut out pictures; climbs well.
Adaptive: Copies bridge from model; imitates construction of
“gate” of 5 cubes; copies cross and square; draws a man
with 2 to 4 parts besides head; names longer of 2 lines.
Language: Counts 4 coins accurately; tells a story.
Social: Plays with several children with beginning of social
interaction and role-playing; goes to toilet alone.

At 60 months:
Motor: Skips

34
 Adaptive: Draws triangle from copy; names heavier of 2 weights.
Language: Names 4 colors; repeats sentence of 10 syllables; counts
10 coins correctly.
Social: Dresses and undresses; asks questions about meaning of
words; domestic role-playing.

At 72 months:
Motor: Active age; constant activity.
Adaptive: cuts, folds, pastes paper toys, sews crudely if needle is
threaded. Takes bath without supervision. Tries out own
abilities. Likes table games, simple card games.
Language: Defines common objects such as fork and chair in terms
of their use. Obeys triple commands in succession.
Differentiates ‘pretty’ and ‘ugly’ from series of drawings
of faces. Knows right and left hand.
Social: Has great need for children of own age. Can share
And cooperate better. Often jealous of younger brother or
sister. Has own way of doing things. Increases
socialization.

NUTRITION OF THE EARLY CHILDHOOD

Daily Recommended Dietary Intakes (RDI) for the early childhood.

NUTRIENTS 1-3 YEARS 4-6 YEARS

Energy (kcal) 1240 1690
Protein (gm) 22 30
Calcium (mg) 400 400
Iron (mg) 12 18
Vitamin Retinol 400 400
or Carotene 1600 1600
Thiamine ( mg) 0.6 0.9
Riboflavin (mg) 0.7 1.0

35
 The requirements are given in terms of total intake, the requirement
for boys and girls in each category is same.
Breakfast Ideas
Paushtik roti with curd
Bajra-potato roti with curd
Paneer (cottage cheese ) on bread with soft fruits like banana,
papaya, mango.
Rice flakes in sweetened curd with banana or any fruit.
Puffed rice in milk with fruit
Dalia ( whole wheat porridge made with milk)
Scrambled egg on toast
Buttered slice with boiled egg
Buttered toast with jam and milk

Main Meal Ideas

Dal, chapatti with vegetable
Rice, dal with vegetable
Stuffed pulse puri with vegetable
Mixed vegetable pulao with curd
Rice, fish curry with green leafy vegetable
Biryani ( pulao with meat and vegetable)
Meat curry with vegetable and chapatti
Stuffed-pulse paratha with mint raita
Idli
Dosa with sambar

Nutritious Snacks
Wheat besan ladoo
Bhaji or pakoda
Spinach-potato gram tikki
Spinach-groundnut burfi
Sago-peanut vada
Vegetable cutlet
Groundnut-jaggery burfi
Sprouted moong chat (mixture)
Sprouted moong bonda

36
 PLAY MATERIAL FOR EARLY CHILDHOOD

Provide space for the children to run, jump and climb.

Teach child to swim.
Teach simple sport and activities.
Suggested toys:
Medium height slide
Adjustable swing
Vehicles to ride
Tricycle
Wading pool
Wagon
Skates, speed graded to skill
Toy typewriter
Doctor and nurse kits
Grooming aids, play makeup
Books
Jigsaw puzzles
Picture games
Poster paint, large brushes
Black board and chalk
Magnifying glass, magnet.

MIDDLE CHILDHOOD

Age considerations:
School age: 6-10 years (girls)
6-12 years (boys)

Pattern of growth of the school age children

Age Approximately Growth in

In yearly height.
Year. Weight (cm/year)
6-12 Gain.(kg)
years 2-3 kg/yr 5-6 cm/yr
Emerging Pattern of Behavior of the school age

37
At 7 years:
Motor: more cautious; swims; printing smaller than 6 year old’s
Activity level lower than 6 year old.
Adaptive: b,p,d,q, confusion resolved; can copy a diamond.
Cognitive: Begins to use simple logic; can group in ascending order;
Grasps basic idea of addition and subtraction;
conversation of substance; can tell time.
Language: can name day; month, season; produces all language
sounds.
Social: More cooperative; same sex play group and friend; less
egocentric.

At 8 years:
Motor: Movements more graceful; writes in cursive; can throw
and hit a baseball; has symmetric balance and can hop.
Adaptive: can catch a ball; visual acuity is 20/20; perceives pictures
in parts and whole.
Cognitive: Increasing memory span; interest in causal relationships;
conversation of length .
Language: gives precise definition; articulation is near adult level.
Social: Adheres to simple rules; Hero workship begins; same sex
peer group

At 9-10 years:
Motor: Good coordination; can achieve the strength and speed
needed for most sports.
Adaptive: Eye-hand coordination almost perfected.
Cognitive: classifies objects; understands explanations; conservation
of area and weight ; describes characteristics of objects.
Can group in descending order.
Language: Can use language to convey thoughts and look at other’s
point of view.
Social: Enjoys team competition moves from group to best
friend; hero worship intensifies.

At 11 to 12 years:

38
BOYS:
Motor: posture is similar to an adult’s; will overcome lordosis.

Adaptive: Makes useful articles or does easy repair work; cooks or

sews in small way; raises pets; washes and dries own
hair; is successful in looking after own needs but may
need remaining to do so.
Cognitive: writes brief stories; writes occasional short letters to
friends or relatives on own initiative. Uses telephone for
practical purpose; responds to magazine, radio, t.v. or
other advertising.
Social: Loves friends; talks about them constantly; chooses
friends more selectively; may have a “best” friend; enjoys
conversations; develops beginning interest in
opposite sex; is more diplomatic.

GIRLS:
Motor: pubescent changes may begin to appear; body lines
soften and round out. Remainder of teeth will erupt and
tend toward full development except wisdom teeth.

Adaptive: is sometimes left alone at home for an hour or so; is

successful in looking after own needs or those of other
children left in his or he care.

Cognitive: reads for practical information of own enjoyment-stories

or library books of adventure or ro0mance, or animal
stories.

Social: Likes family, family really has meaning; likes mother

and wants to please her in many ways; demonstrates
affection; likes father who is adored and idolized respects
parents.

NUTRITION OF THE MIDDLE CHILDHOOD

39
 Daily Recommended Dietary Intakes (RDI) for the Middle childhood

Nutrients
Age Group (Years)
7-9 years 10-12 years 10-12 years
(Boys and Girls) (Boys ) ( Girls )
Energy 1950 2190 1970
Protein (gm) 41 54 57
Calcium (mg) 400 600 600
Iron (mg) 26 34 34
Vitamin A (ug) 600 600 600
or Carotene 2400 2400 2400
Thiamine (mg) 1.0 1.1 1.0
Riboflavin (mg) 1.2 1.3 1.2
Niacin (mg) 13 15 13
Vitamin C (mg) 40 40 40
Folic acid (mg) 60 60 60
Vitamin B 12 0.2-1.0 0.2-1.0 0.2-1.0

LATER CHILDHOOD

OR

ADOLESCENCE

Adolescence is a period of transition between childhood and

adulthood, a time of profound biological, intellectual, psychosocial, and
economic change. During this period individuals reach physical and sexual
maturity, develop more sophisticated reasoning abilities, and make
educational and occupational decisions that will shape their adult careers.

40
 According to the WHO, adolescence is the period of life that
extends from 10 years to 19 years.

According to Indian Academy of Pediatrics defines adolescence as

the period of life between 10 and 18 years .

(In United States of America, pediatrics includes individuals up to the

age 21 years. And UNICEF is contended with “up to 18 years” as the
pediatric age group.)

all these may be all right for statistical convenience rather than for
biological accuracy.

Pattern of growth of the adolescence

Phase 1:
Prepubescent : 10- 12 years (girls)
12.14 years (boys)
Moderate gain in height velocity in the prepubescent phase

Phase 2:
Pubescent : 12-14 years (girls)
14-16 years ( boys)
Both height and weight show rapid gain in the pubescent phase.

Phase 3:
Post pubescent : 14-18 years (girls)
16-20 years (boys)
Growth velocity shows deceleration though weight gain continues in
the post pubescent phase.

A remarkable feature of puberty is that as much as 50% of the adult

weight and 25% of the adult height are attained during this period of life. No
doubt, there is a wide variation in the age of onset as also the rate of puberty
spurt. Major weight gain in boys is because of dominant muscular
development. In girls, fat deposition is characteristic female distribution is
responsible for it.

41
 Developmental characteristics of the Adolescence

Characteristic Early Middle Late

Adolescence Adolescence Adolescence
Age ( years ) 10-14 14-16 17-20
Sex maturity 1 to 2 3 to 5 5
Rating
Somatic -Secondary sex -Height growth -slower growth
development characteristics, peaks,
-onset of rapid -body shape and
growth, configuration
-awkward change,
-acne appears,
-menarche,
-spermarche.
Sexual development -sexual interest -sexual drive -consolidation
much more than surges, of sexual
sexual activity -experimentation, identity.
-questions of
sexual orientation
Cognitive and -concrete operations -appearance of -idealism
Motor development. -conventional abstract thoughts -absolutism
morality. -self-centered
-questioning more
Self-concept -preoccupation -concern with -relatively stable
with changing attractiveness. body image.
body. -increasing
-self conscious introspection
Family -struggles for -struggles for -practical
greater acceptance of independence,
independence greater -family remains
autonomy. secure base.
Peers -same sex groups -dating -intimacy
-conformity -peer group possicommitment
-cliques less important

Relationship -middle school -gauging skills Career decisions

to society. adjustment and opportunities Dropout

42
 NUTRITION OF THE ADOLESCENCE

Daily Recommended Dietary Intakes (RDI) for the Adolescence

Age groups Weight Calories Protein

(years) (kg) kcal (gm)
10-12
Boys 35.54 2194 51.9

Girls 37.91 1965 55.0

13-15
Boys 47.88 2447 67

Girls 46.66 2056 62.1

16-18
Boys 57.28 2642 75.1

Girls 49.92 2064 60.4

43
 ASSESSMENT
OF
GROWTH AND DEVELOPMENT
OF
THE CHILDREN

ASSESSMENT OF GROWTH AND DEVELOPMENT

Identifying Information

Name of the child:___________Name of Father:______________________

Name of Mother____________ Sex of the child: male/female.
Age of the child:_________ days/months/ years.
Religion________ Birth date _________ Place____________ Dist._______
Type of delivery: Normal/ Instrumental________/Operation______/Hospital
Home delivery.
Any problem associated during birth________________________________
_____________________________________________________________

Immunizations taken:
Age Dose given on Booster due on
_____________ ____________ ______________
_____________ ____________ ______________
_____________ ____________ ______________
_____________ ____________ ______________
_____________ ____________ ______________
_____________ ____________ ______________
_____________ ____________ ______________

Weight:_________ Height_________ Chest Circumference__________

Head Circumference________ Midarm Circumference__________

Dentition:____________Maxillarly teeth present

____________Mandibulary teeth present.

44
ASSESSMENT OF GROWTH:
The purposes of monitoring growth and development in children are :
to assess the physical parameters and developmental
characteristics of children.
To identify the deviations in growthand development.
Tosuggest appropriate stimuli/activities to parents to
promote optimum growth and development in their
children.
Physical parameters for assessment of growth in children includes:-
Weight, height, head circumference, chest circumference, mid arm
circumference, fontanels, skinfold thickness, BMI, and Dentition.
Developmental assessment includes:-
Gross motor, fine motor, adaptive, personal-social behavioral pattern
with the help of Revised Denver Developmental Screening Test or
Trivandrum Developmental Screening Chart.
Physical and Developmental assessment must be recorded on the
“Growth chart” for the future reference concerned to the child’s health.
Weight:
Ideal Birth Weight 3.25 kg.
Weight(in Kg) at 3 to 12 month = age(months) 9
2
Weight(in Kg) at 1 to 6 years = age (years) 11

Weight( in Kg) at 7 to 12 years= age(years)×7-5

2

Weight Measurement tools:

English Salter Spring machine ( for field visit)
Beam balance/Electronic weighing machine
Adult weighing machine.(stadiometer)

45
 Ponit to remember:
Carry out the measurements, skillfully, accurately and quickly.
Balance the scale by setting it at zero before checking the weight.
Accuracy of measurement is essential to the reliable interpretation of
growth data.
Always take readings at eye level, when using spring scale/beam balance
machine.

Height:
Ideal length of a full term infant at birth is 50 cm.
Length /Height at 1 year=75 cm.

Height at 2 to 12 year= age (years) ×6+77 cm.

After 12 years, the child gains 5 cm/yr until

the onset of puberty.

Height Measurement :
Recumbent length is advisable for children under 2 years. For that
Infantometer is used, to avoid postural errors.
For older children , standing height is measured by making the child
stand against a vertical scale fixed on a stand or simply against a wall and
then marking the highest point of vertex on the wall. Make sure that the
child stands comfortably with heels, buttocks, shoulder and back of the
head touching the wall and the feet parallel. Use measure tape to
measure. Stadiometer is used to measure the height when the child is able
to stand perfectly.

Head Circumference:
Represents growth of the brain.

At birth: 35 cm
At 3 months: 40 cm
At 6 months: 43 cm
At 1 Year : 45 cm
At 2 Years : 48 cm
At 7 Years: 50 cm
At 12 Years: 52 cm
46
 For measuring head size, place the measure tape over the occiput at
the back and just above the supraorbital ridges in front and measure the point
of highest circumference.

Head and Chest Circumference Ratio:

At birth, head circumference is larger than chest circumference by
about 2.5 cm. by 6 to 12 months, both are equal. After first year, chest
circumference tends to be larger by 2.5 cm. By the age of 5 years, it is more
or less 5 cm greater in size than the head circumferences.
For measuring chest circumference place the tape at the level of the
nipple in plane at right angle to the spine. Record the measurement in
midrespiration.

Midarm Circumference:
Used as a criteria of malnutrition in the preschool children. If
measurement is less than 12.5 cm, it is significant malnutrition.
A specially designed tape called “Midarm circumference Tap” (MAC)
is used for the measurement.
To measure, let the left arm hang naturally bly the side of body. Then
place the tape firmly but without compressing the tissues around the upper
arm at a point midway between tip of the acromian and olecranon process.

Fontanels:
At birth, there are 6 fontanels, one each anterior and posterior and 4
lateral( 2 anterolateral and 2 posterolateral ). Posterior and lateral fontanels
close fairly early—usually within first few weeks. Anterior fontanel which is
of much clinical value measures 3×2 cm and closes between 9 months to 18
months.

BMI:( Body Mass Index)

BMI correlates well with the suncutaneous fat and the total body fat
and , yet allows a variation in the lean body mass. It is given by the
following formula:

Weight(kg)

47
 BMI=
Height (met) 2

BMI remains constant upto the age of 5 years. A BMI >95 th percentile
or >30 kg/met2 establishes existence of obesity. A BMI < 15 kg/met2 point
to malnutrition.

48
Dentition: (Primary Teeth)

CALCIFICATION AGE AT ERUPTION AGE AT SHEDDING

BEGINS AT COMPLETES AT MAXILLARY MANDIBULAR MAXILLARY MANDIBULAR

5TH FETAL 18-24 6.8 5-7 7-8 6-7

CENTRAL MONTH MONTHS MONTHS MONTHS YEARS YEARS
INCISORS

LATERAL 5TH FETAL 18-24 8-11 7-10 8-9 7-8

INCISORS MONTH MONTHS MONTHS MONTHS YEARS YEARS

6TH FETAL 30-36 16-20 16-20 11-12 9-11

CANINES MONTH MONTHS MONTHS MONTHS YEARS YEARS

FIRST 5TH FETAL 24-30 10-16 10-16 10-11 10-12

MOLARS MONTH MONTHS MONTHS MONTHS YEARS YEARS

49
SECONDARY TEETH

CALCIFICATION AGE AT ERUPTION

BEGINS AT COMPLETES AT MAXILLARY MANDIBULAR

3-4 9-10 7.8 6-7

CENTRAL MONTH YEARS YEARS YEARS
INCISORS

LATERAL 10-12 10-11 8-9 6-7

INCISORS MONTH YEARS YEARS YEARS

4-5 12-15 11-12 9-11

CANINES MONTH YEARS YEARS YEARS

FIRST 18-21 12-13 10-11 10-12

PREMOLARS MONTH YEARS YEARS YEARS

SECOND 24-30 12-14 10-12 11-13

PREMOLARS MONTHS YEARS YEARS YEARS

FIRST BIRTH 9-10 6.7 6-7

MOLAR YEARS YEARS YEARS

SECOND 30.36 14-16 12.13 12-13

MOLAR MONTHS YEARS YEARS YEARS

THIRD 7.10 18-25 17.22 17-22

MOLAR YEARS YEARS YEARS YEARS

50
 ASSESSMENT OF DEVELOPMENT, we can do with the help of
Revised Denver Developmental Screening Test (DDST) or Trivandrum
Developmental Screening Test (IAP Recommended), or with Baroda
Screening Test.
Developmental screening, a brief testing procedure designed to
identify children who should receive more intensive diagnosis or
assessment, is essential so as to detect abnormal developmental delays.

DDST : For Infant and Preschool.

Developmental charts : 3 to 15 years

Baroda DST : 0 to 30 months.

Trivandrum DST : 0 to 2 years.

Baroda DScharts : 0 to 2 years.

Gessell DST : 0 to 12 years.

Approaches to Developmental Screening:

Informal Screening:
aims at identify children with subtle development delays through
informal screening methods such as observations during routine
pediatric checkup and obtaining information from parents about
their concerns concerning child’s developmental milestones at
various ages.

Routine formal screening:

it consist in systematic developmental screening of all children with
the help of standardized screening instruments. This approach is
neither feasible nor cost-effective.

51
 Focused screening:
It comprises developmental screening in the following situations.
 Children whose parents and / or teachers suspect
developmental problems.
 High-risk neonates ( for developmental delay ), such as
VLBW, Neurological conditions IVH (grade 3 &4 ),HIE,
Apgar score 0-3 at 10, 15, and 20 minute, periventricular
leukomalacia, meningitis, persistent seizures, apnea beyond
term. Hyperbilirubinemia, septicemia.

Remember:
Screening instrument should be reliable, culturally relevant, used
only for specified purpose.
Multiple sources of information should be used.
Developmental screening should be done only by trained personnel.
Screening should be on a recurrent and periodic basis.
Family members should be part of the screening process.

RECORDING OF GROWTH AND DEVELOPMENT

We have reviewed how to assess and monitor growth and

development of children of various age groups. Now we should be able to
record the same accurately so that one can accurately assess the nutritional
status of a child. This is done in growth charts.
Growth Charts:
Measurement alone without any standard of comparison does not
serve useful purpose. A number of standards have been developed to
compare the measurement of any child to other children of the same age, sex
and race. Also the child’s present measurements are compared with former
rate of growth and pattern of progress. The standards laid down by the
ICMR are recommended for comparing the Indian children and are available
as growth charts.
 Growth charts are used to assess the growth and thus the nutritional
status of children.
 Growth charts have reference curves for purpose of comparison.
 Growth charts also provide space for recording information such as
identification, date of birth, birth weight, chronological age,

52
 immunization, introduction of supplementary food, episodes of
sickness, child spacing and reason for special care.
 It provides a visual record of the health and nutritional status of the
child, which is easily understood by mother as well as the health
workers.

Growth Charts Developed by WHO:

The growth chart developed by WHO is also called “road to health”

The zone under the curve represents the weights of 95 per cent of
normal children.
It is the direction of growth that is more important than the position of
dots on the line.
Flattening of falling of child’s weight curve signals growth failure.
The objective of child care is to keep a child in the zone that represents
weight of 95 per cent of normal healthy children i.e. parallel to “road to
health” curve.

53
The growth chart recommended by the Government of India is as:

 It has four reference curves.

 The top most curve represents the level of optimum growth .
 The lower lines i.e. II, III, & IV represent 80 per cent, 70 per cent and
60 per cent of the standard respectively.
 The purpose of these lines is to indicate the degree of malnutrition as
recommended by Indian academy of Pediatrics( Grade I, II, III)

54
The recent Growth chart by Indian Academy of Pediatric is:

This is a modified growth chart for the record of length, weight, and
head circumference.

RECORDING DEVELOPMENTAL ASSESSMENT

55
 According to the age of the child, assess development and record as
milestone completed in the “Health Card of the Child” for future reference.

This developmental assessment chart is based on Baroda

Developmental Screening Chart.
To use this chart, keep pencil vertically on the age of the child. All
milestone falling to the left of the pencil should have been achieved by the
child.

********************
*************
*********
*****
***
*

BIBLIOGRAPHY

56
Books:

1. Ghai, O.P., Essential Pediatrics, Mehta Publishers; New Delhi:

2001, p.p. 1-41, 56-64.
2. Gupte, Suraj, The short Text Book of Pediatrics, Jaypee
Brothers; New Delhi: 2004, 10th ed. p.p. 18-63, 108-112.
3. Marks, M.G., Broadbbi’s Introductory Pediatric Nursing,
J.B. Lippincott co.; Philadelphia: 1994, 4th ed.
(Chapters: 5,8,10,12,14,16)
4. Nelson, W.E., Nelson’s Text Book of Pediatrics, W.B.
Saunders co; Behram: 1999,15th ed. p.p.30-69.
5. Wong, D.L. and others, Nursing Care of Infant and Children,
Mosby co.; St.Louis: 1999, 6th ed.(chapters:6,7,8,12,14
- 15,16,17,18,19)

Modules:
1. HS3P1-Pediatric Nursing (Practical Manual) Sec.1, Part 1,
IGNOU Module, SOHS Publications; New Delhi:
2001, p.p. 7-18, 29-37.
2. HS1P2-Nutrition and Dietetics (Practical Manual) Sec.4,
(Practical 3,4,5) IGNOU Module, SOHS Publication;
New Delhi: 2001, p.p. 73-111.
3. HS3T1-Pediatric Nursing Block 1, IGNOU Module,
SOHS Publication; New Delhi: 2001, p.p.21-48, 62-66.

57
58
59
60