PEDIATRIC

NURSING
GROWTH AND DEVELOPMENT
I. PHASES OF GROWTH AND
DVELOPMENT
A. Process sequence is orderly and
predictable; rate tends to be
variable within ( more quickly/
slowly) and between (earlier/later)
individuals
1. growth increase in size (height and
weight; tends to cyclical, more rapid in
utero, during infancy, and adolescence
2. developmental maturation of phychosocial
systems to more complex state
Developmental tasks skills and
competencies associated with each
developmental stage that have an effect
on subsequent stages of development
Developmental milestone standard of
reference by which to compare the Childs
behavior at specific ages
Developmental delay(s) variable of
developmental which lags behind the
range of a given age
Principles of Growth
1. Children are individuals, not little adults,
who must be seen as part of a family.
2. Children are influenced by genetic
factors, home and environment, and
parental attitudes.
3. Chronologic & developmental ages of
children are the most important
contributing factors influencing their care.

4. Play is a natural medium for expression,
communication, and growth in children.
5. Growth is complex, with all aspects
closely related
6. Growth is measured both quantitatively
and qualitatively over a period of time.
7. Although the rate is uneven, growth is
continuous and orderly process:
Principles of Growth
Principles of Growth
7.a. Infancy: most rapid period of growth
b. Preschool to puberty: slow and
uniform rate of growth.
c. Puberty: (growth spurt) second most
rapid growth period.
d. After Puberty: decline in growth rate
till death.
8. There are regular patterns in the
direction of growth and
development, such as the
cephalocaudal law (from head to
toe) and from proximodistal law
(from center to periphery)
Principles of Growth
9. Different parts of the body grow at
different rates:
Prenatally: head grows the fastest.
During the first year: elongation of trunk
dominates
10. Both rate and pattern of growth can be
modified, most obviously by nutrition.
Principles of Growth
11. There are critical or sensitive periods in
G&D, such as brain growth during
uterine life and infancy.
12. Although there are specified sequences
for achieving G&D, each individual
proceeds at own rate.
13. D is closely R/T the maturation of the
nervous system; as primitive reflexes
disappear, they are replaced by a
voluntary activity.
Principles of Growth
Physiological Characteristics
of Growth
Circulatory System:
Heart rate decreases with increasing age
Infancy: 120 bpm
One year: 80 to 120 bpm
Childhood: 70 to 110 bpm
Adolescence to adulthood: 55 to 90
bpm
Blood pressure increases with age
1. The 50
th
percentile ranges from 55 to 70
mmHg diastolic; 100 to 110 mmHg
systolic
2. These levels increase about 2 to 3
mmHg / yr. starting at age 7 yrs.
3. Systolic pressure in adolescence: higher
in males than in females
Hemoglobin
1. Highest at birth, 17 g/100 ml of blood;
then decreases to 10 to 15 g/100 ml by
1 year.
2. Fetal Hgb (60% to 90% of total Hgb)
gradually decreases during the first yr
to less than 5%.
3. Gradual increase in Hgb level to 14.5
g/100ml between 1 & 12 yrs.
4. Level Higher in males than in females
Respiratory System
Rate decreases with increase in
age:
Infancy: 30 to 40 cpm
Childhood: 20 to 24 cpm
Adolescence & adulthood: 16 to
18 cpm
Vital Capacity
Gradual increase throughout
childhood and adolescence, with
a decrease in later life
Capacity in males exceeds that in
females
Basal Metabolism
Highest rate is found in the
newborn
Rate declines with increase in
age; highest in males than in
females.
Urinary System
Premature & full term Newborns have
some inability to concentrate urine.
Specific Gravity: (Newborn): 1.001 to 1.02
Specific Gravity: (Others): 1.002 to 1.03
GFR greatly increased by 6 months of
age; reaches adult values between 1 &
2 years; gradually decreases after 20
years.
Digestive System
Stomach size is small at birth; rapidly
increases during infancy and childhood
Peristaltic activity decreases with
advancing age
Blood Glucose levels gradually rise
from 75 to 80 mg/100 ml of blood in
infancy to 95 to 100 mg during
adolescence.
Premature infants have lower blood
glucose levels than do full-term infants.
Enzymes are present at birth to digest
proteins and a moderate amount of fat but
only simple sugars (amylase is produced
as starch is introduced)
Secretion of Hcl acid & salivary enzymes
increases with age until adolescence; then
decreases with advancing age.
Digestive System
Nervous System
Brain reaches 90% of total size by 2 yrs of
age.
All brain cells are present by the end of the
first year, although their size & complexity
will increase.
Maturation of the brainstem & spinal cord
follows Cephalocaudal & Proximodistal
Laws.
Functions of Play
Educational: learn about physical world &
associate names with objects.
Recreational: Release surplus energy
Sensorimotor: Muscle development and
tactile, auditory, visual, and kinesthetic
stimulation
Social & emotional adjustment: learn
moral values; develop the idea of sharing
Therapeutic: release of tension & stress;
manipulation of syringe and other
equipment allows control over threatening
events.
Functions of Play
Types of Play
Active, Physical: push-and-pull toys; riding
toys; sports and gym equipment
Manipulative, constructive, creative, or
scientific: blocks, construction toys such
as erector sets; drawing sets; microscope
& chemistry sets; books; computer
programs
Imitative, imaginative, and
dramatic: dolls, dress-up
costumes; puppets.
Competitive and social: games;
role playing
Types of Play
Criteria for
judging the
suitability of
toys
Safety
Compatibility: childs age; level of
development; experience
Usefulness
Challenge to development of the child;
assist child to achieve mastery.
Enhance social & personality
development; increase motor & sensory
skills; develop creativity; express
emotions
Implement therapeutic procedures

Criteria for judging the
nonsuitability of toys
Unsafe
Beyond the childs level of G&D;
overstimulating; frustrating
Foster isolation from peer group
Theoretical
approaches to
development
Erickson (psychosocial approach)
(see the table XVI 1)
Social development
Role of play in
development
OVERVIEW OF ERIKSONS DEVELOPMENTAL
TASKS THROUGHOUT THE LIFE SPAN
AGE STA
GE
ERIKSO
NS
TASK
POSITIVE
OUTCOME
NEGATIVE
OUTCOME
Birth
to 18
mo.
Infa
ncy
Trust vs.
Mistrust
Trusts self
and others
Demonstrat
es an
inability to
trust:
withdrawal,
isolation
18 mo
to 3 y
Todd
ler
Autonym
vs.
Shame
and Doubt
Exercises
self control
and
influences
the
environment
directly
Demonstrates
defiance and
negativism
3 to 6
y
Pres
choo
l
Initiative
vs. Guilt
Begins to
evaluate own
behavior;
learns limits
on influences
on the
environment
Demonstrates
fearful,
pessimistic
behaviors;
lacks self
confidence`
6 to
12 y
School
age
Industry
vs.
Inferiority
Develops a
sense of
confidence;
learns limits
on influence
in the
environment
Demonstrates
feelings of
inadequacy,
mediocrity,
and self
doubt
12 to
20 y
Adoles
cence
Identity
vs. Role
Confusion
Develops a
coherent
sense of self;
plans for a
future of work/
education
Demonstrates
inability to
develop
personal and
vocational
identity
20
to
45 y
Young
adulth
ood
Intim
acy
vs.
Isolati
on
Develops
connections
to work and
intimate
relationships
Demonstrat
es an
avoidance
of intimacy
and
vocational/c
areer
commitment
s
45 to
65 y
Middle
adultho
od
Generat
ivity vs.
Stagnati
on
Involved with
established
family;
expands
personal
creativity and
productivity
Demonstrates
lack of
interest,
commitments:
preoccupation
with self
centered
concerns
65
plus
Late
adultho
od
Integrity
vs.
Despair
Identification
of life as
meaningful;
Demonstrates
fear pf death;
life lacks
meanings
Piaget ( cognitive approach)
four stages
1. Sensorimotor birth to 2 y. old
Simple incremental learning begins with
reflex activity progressing to repetitive
behavior, then to imitative behavior
Increased level of curiosity
Sense of self as differential and separate
from environment
Increasing awareness of object permanence
(things exist even if not visible)
2. Preoperational 2 to 7 y. old
Thinking and learning are concrete and
tangible, based on what is seen, hard,
felt, experienced; cannot make
generalizations/deductions
Toward the end of this stage, reasoning
is more intuitive; beginning
understanding of size, mass, times
3. Concrete operations 7 to 11
y old
Increasingly logical and coherent in
thinking; solves problems in concrete
manner
Able to sort, classify, collect, order, and
organize facts about the environment
Can manage a number of aspects of a
situation at one time but not yet able to
deal with abstractions
Can consider other points of view
4. Formal operations 12 to 15 y
old
Able to deal with abstractions and
abstract symbols
Flexible and adaptable
Can problem solve, develop hypotheses,
test them, and arrive at conclusions
Questions and examines moral, ethical,
religious, and social issues as beginning
definition of self as an adults
PIAGETS
THEORY OF
COGNITIVE
DEVELOPMENT
STAGES/
SUBSTA
NCES
APPROXI
MATE
AGE
CHARACTERISTICS
Sensori
motor
reflexes
0-2 years
old
Reliance on reflexes to
interact with environment
Pre-
operation
al
Preconc
eptual
3-7
years
old
Increase use of language
unable to put self in anothers
place, does not understand
and relationship of size,
weight, volume
Intuitive 5-7
years
old
Magical thinking,
Egocentrism:cannot take
anothers point of
view.centring:tendency to
center attention to one
feature and unable to see
other qualities
Concrete
operations
8-13
years old
Inductive reasoning (specific to
general)
Conservation-ability to understand
that a things essentially the same
even though its shape and
arrangement is altered.
Reversibility ability to
conceptualize that a complete
process can also be performed in
the reverse order.
Formal
operations
13-16
years old
Capable of introspection,
deductive reasoning (general or
universal to specific) able to
formulate and test hypothesis.
Freud
(psychoanalyti
cal approach)
experiences at different stages
influences personality traits
Oral (birth to 1 y) pessimism /
optimism, trust/suspicious
Anal ( 1 to 3 y) retentiveness/
overgenerosity, rigidity/laxity,
constricted ness/expansiveness,
stubbornness/acquiescence,
orderliness/messiness
Phallic / oedipal (3 to 6 y) brashness /
bashfulness, gaiety / sadness,
stylishness/plainness,
gregariousness/isolation
Latency (6 to 12 y) elaboration of
previously acquired traits
Genital ( 12+ y) preparation for forming
relationships and marriages

Robert
Havighurst:
Developmental
Theorist
"The developmental-task concept
occupies middle ground between two
opposed theories of education: the
theory of freedomthat the child will
develop best if left as free as possible,
and the theory of constraintthat the
child must learn to become a worthy,
responsible adult through restraints
imposed by his society.
A developmental task is midway between
an individual need and societal demand. It
assumes an active learner interacting with
an active social environment" (1971, p.
vi).
The Developmental Task
Concept
From examining the changes in your own
life span you can see that critical tasks
arise at certain times in our lives.
Mastery of these tasks is satisfying and
encourages us to go on to new
challenges. Difficulty with them slows
progress toward future
accomplishments and goals.
six major age periods:
infancy and early childhood (0-5 years),
middle childhood (6-12 years)
adolescence (13-18 years),
early adulthood (19-29 years),
middle adulthood (30-60 years), and
later maturity (61+).

Developmental Tasks of Infancy
and Early Childhood:
Learning to walk.
Learning to take solid foods
Learning to talk
Learning to control the elimination of body
wastes
Learning sex differences and sexual modesty
Forming concepts and learning language to
describe social and physical reality.
Getting ready to read
Ages birth to 6-12
Learning physical skills necessary for
ordinary games.
Building wholesome attitudes toward
oneself as a growing organism
Learning to get along with age-mates
Learning an appropriate masculine or
feminine social role
Ages birth to 6-12
Developing fundamental skills in reading,
writing, and calculating
Developing concepts necessary for
everyday living.
Developing conscience, morality, and a
scale of values
Achieving personal independence
Developing attitudes toward social
groups and institutions
Developmental Tasks of Adolescence:
Ages birth to 12-18
Achieving new and more mature
relations with age-mates of both sexes
Achieving a masculine or feminine social
role
Accepting one's physique and using the
body effectively
Achieving emotional independence of
parents and other adults
Developmental Tasks of Adolescence:
Ages birth to 12-18
Preparing for marriage and family life
Preparing for an economic career
Acquiring a set of values and an ethical
system as a guide to behavior;
developing an ideology
Desiring and achieving socially
responsible behavior
Developmental Tasks of Early
Adulthood
Selecting a mate
Achieving a masculine or feminine social
role
Learning to live with a marriage partner
Starting a family
Rearing children
Developmental Tasks of Early
Adulthood
Managing a home
Getting started in an occupation
Taking on civic responsibility
Finding a congenial social group
Developmental Tasks of Middle
Age
1. Assisting teen-age children to become
responsible and happy adults
2. Achieving adult social and civic responsibility
3. Reaching and maintaining satisfactory
performance in one's occupational career
4. Developing adult leisure-time activities
5. Relating oneself to one's spouse as a person
6. To accept and adjust to the physiological
changes of middle age
7. Adjusting to aging parents
Developmental Tasks of Later
Maturity
1. Adjusting to decreasing physical strength and
health
2. Adjustment to retirement and reduced income
3. Adjusting to death of a spouse
4. Establishing an explicit affiliation with one's age
group
5. Adopting and adapting social roles in a flexible
way
6. Establishing satisfactory physical living
arrangements
Super Vocational Development
Stages
Growth B-14 Development of Abilities,
Interests, Needs Associated with Self-
Concept
Exploration 15-24 Tentative Plans, Choices
Narrowed not Finalized
Establishment 25-44 Stable Career Identity
Maintenance 45-64 Small Adjustments
Decline 65 + Reduced Productivity and
Retirement
Lawrence
Kohlberg
Stages of
Reasoning
Stage 1 - Obedience and Punishment
The earliest stage of moral development is especially
common in young children, but adults are capable of
expressing this type of reasoning. At this stage,
children see rules as fixed and absolute. Obeying the
rules is important because it is a means to avoid
punishment.
Stage 2 - Individualism and Exchange
At this stage, children account for individual points of
view and judge actions based on how they serve
individual needs. In the Heinz dilemma, children
argued that the best course of action was whichever
best-served Heinzs needs. Reciprocity is possible,
but only if it serves one's own interests.

Level 1. Preconventional Morality
Level 2. Conventional Morality
Stage 3 - Interpersonal Relationships
Often referred to as the "good boy-good girl"
orientation, this stage is focused on living up to
social expectations and roles. There is an
emphasis on conformity, being "nice," and
consideration of how choices influence
relationships.
Stage 4 - Maintaining Social Order
At this stage of moral development, people begin
to consider society as a whole when making
judgments. The focus is on maintaining law and
order by following the rules, doing ones duty, and
respecting authority.
Level 3. Postconventional
Morality
Stage 5 - Social Contract and Individual
Rights
At this stage, people begin to account for the
differing values, opinions, and beliefs of other
people. Rules of law are important for maintaining
a society, but members of the society should
agree upon these standards.
Stage 6 - Universal Principles
Kolhbergs final level of moral reasoning is based
upon universal ethical principles and abstract
reasoning. At this stage, people follow these
internalized principles of justice, even if they
conflict with laws and rules.

Criticisms of Kohlberg's Theory
of Moral Development:
Does moral reasoning necessarily lead to moral behavior?
Kohlberg's theory is concerned with moral thinking, but there is
a big difference between knowing what we ought to do versus
our actual actions.

Is justice the only aspect of moral reasoning we should
consider? Critics have pointed out that Kohlberg's theory
overemphasizes the concept as justice when making moral
choices. Other factors such as compassion, caring, and other
interpersonal feelings may play an important part in moral
reasoning.

Does Kohlberg's theory overemphasize Western philosophy?
Individualistic cultures emphasize personal rights while
collectivistic cultures stress the importance of society and
community. Eastern cultures may have different moral outlooks
that Kohlberg's theory does not account for.

C. Chronological phases
Prenatal conception until birth: rapid
growth and development
Neonatal birth until 4 wk of age:
adjustment to extra uterine life
Infancy 4 wk to 12 or 18 mo (upright
locomotion); rapid and incremental
growth and motor, cognitive, and social
development (see table XIV 2)
INFANT GROWTH AND DEVELOPMENT
1 mo 3 mo
Head sags
Early movements
Can bring objects to mouth at will
Head held erect, steady
Binocular vision
Miles mothers presence
Laughs audibly
2 mo 4 mo
Closing of posterior fontanelle
Diminished tonic neck and Moro
reflexes
Able to turn from side to back
Eyes begin to follow a moving
object
Social smile first appears
Appearance of thumb apposition
Absent tonic neck reflex
Evidence of pleasure in social
contact
Drooling
Moro reflex absent after 3 4 mo
5 mo
Birth weight usually doubled
Takes objects presented to
him/her
6 mo
Average weight gain of 4 oz
per week during second 6 mo
Teething may begin (lower
central incisors)
Can turn from back to
stomach
Early ability to distinguish and
recognize strangers
7 mo
Sits for short periods
Grasps toy with hand
(partially successful)
Fear of strangers begins
to appear
Liability of mood (abrupt
mood shifts)
8 mo
Anxiety with strangers
9 mo
Elevates self to sitting
position
Rudimentary imitative
expression responds to
parental anger
Expressions like dada
may be heard
10 mo
Crawls well
Pulls self to standing
position with support
Brings hands together
Vocalizes one or two words
11 mo
Erect standing posture with
support
12 mo
Birth weight usually tripled
Needs help while walking
Sits from standing position
without assistance
Eats with fingers
Usually says two words in
addition to mama and
dada
AGE APPROPRIATE TOYS
Birth to 2
months
Mobiles
2 4 mo Rattles, cradle gym
4 6 mo Brightly colored toys ( small enough to
grasp, large enough for safety)
6-9 mo Large toys with bright colors, movable
parts, and noisemakers
9-12 mo Books with large pictures, push pull
toys, teddy bears
Toddler
12/18 mo to 3 y: slowed growth: marked
physical and personality development
characterize by profound activity,
curiosity, and negativism (see Table XIV
3)
Physical birth weight quadrupled by 2
years; height grows about 8 in (20.3 cm); pulse
110, respiration 26, BP 99/64;20 teeth by 2 1/2
; has sphincter control needed for toilet
training; appetite lessens because of
decreased growth needs
Motor walks well forward and backward,
stoops and recovers, climbs, runs, jumps in
place, throws overhand, voluntarily releases
hand, uses spoon, drinks from cup, scribbles,
builds two then four block towers
Pychosocial
indicates wants by behaviors other than
crying, may have temper tantrums;
increases vocabulary from 10 20 words
to about 900 at 3 y; imitates, helps with
household chores; points to body parts,
recognizes animals; almost
dressing/undressing with help at 18 to 24
mo (cannot zipper, button, tie shoes);
attachment to security blanket/stuffed
animal
Play parallel play; appropriate toys
include push-pull toys, riding toys, work
bench, toy hammers, drums, pots and
pas, blocks, puzzles with very few large
pieces, finger paints, crayons;
dolls/stuffed animals
Stresses separation from parents
(bedtime may be seen as desertion);
alteration in environment/routine/rituals
(expect regression/temper tantrums);
toilet training; loud noises/animals
Safety accidents (i.e., motor vehicle, burns,
poising, falls, choking/suffocation round,
cylindrical, and pliable objects, such as
balloons, are most dangerous) are leasing
cause of death because of continued
clumsiness associated with increased mobility,
as well as striving for independence and
heightened curiosity accompanied by the
ability to open things but without cognitive
ability to understand potential dangers;
requires vigilant child-proofing and supervision
while promoting independence; child restraint
in motor vehicles is absolute
Three phases of separation
Protest cries/screams for parents;
inconsolable by others
Despair crying ends; less active;
uninterested in food/play; clutches
security object if available
Denial appears adjusted; evidences
interest in environment; ignores parent
when he/she returns; resigned, not
contented
TODDLER GROWTH AND DEVELOPMENT
15 mo 24 mo
Walks alone
Builds 2 blocks tower
Throws objects
Grasps spoon
Names commonplace
objects
Early efforts at jumping
Builds 5 to 6 block
tower
300 word vocabulary
Obeys easy command
18 mo 30 mo
Anterior fontanelle
usually closed
Walks backward
Climbs stairs
Scribbles
Builds 3 block tower
Oral vocabulary 10
words
Thumb sucking
Walks on tiptoe
Builds 7 to 8 block
tower
Stands on one
foot
Has sphincter
control for toilet
training
AGE APPROPRIATE TOYS
Push pull toys Dolls
Low rocking
horses
Stuffed animals
Preschool
3 to 6 y; steady growth and
development distinguished by
acquisition of language, social
skills and imagination as well as
enhanced self-control and
mastery (see Table XIV 4)
Physical
weight increases 4 6 lb/y (1.8 2.7 kg);
birth length doubled by 4 y; pulse 90-
100, respirations 24-25, BP 85 100/60-
70; permanent molars appear behind
deciduous teeth, maximum potential for
amblyopia/ lazy eye (reduced visual
acuity in one eye); handedness is
established
Motor
rides tricycle walks up (3 y) then down (4
y) stairs alternating feet; hops on one
foot, tandem walks; draws circle, then
cross, then triangle; dresses with
assistance, then with supervision, then
alone
Psychosocial
knows first name, then age, then last
name; uses plurals and three word
sentences, progressing to complex
sentences, follows directions, counts;
knows simple songs, name of colors,
coins, meaning of many words; asks
inquisitive questions; evidence of gender
specific behavior by 5 y; become more
eager to please; may develop imaginary
playmates
Play
associative/ interactive/cooperative play;
appropriate toys include tricycles and
playground equipment; construction set,
illustrated books, puzzles, modeling clay,
paints/crayons, simple games; imitative
and dramatic play (dress-up, doll house,
puppets); supervise TV
Stresses
illogical fears (inanimate objects, the
dark, ghosts); separation from parents,
may be evidenced as anorexia,
continued quiet crying, and/or
aggression; bodily injury, mutilation ( fear
that puncture will not close and insides
will leak out) and pain; intrusive
procedures are threatening
Safety
similar to toddler; can understand and
learn about potential dangers; shoulders
harness and lap belt appropriate when
child is either 40 lbs., 40 in, or 4 yr old
PRESCHOOL
GROWTH AND
DEVELOPMENT
3 YEARS
Copies a circle
Builds bridge with 3 cubes
Less negativistic than toddler, decreased
tantrums
Rides tricycle
Walks backward and downstairs without
assistance
Undresses without help
900 word vocabulary uses sentences
May invent imaginary friend
4 YEARS
Climbs and jumps well
Laces shoes
Brushes teeth
1,50 word vocabulary
Skips and hop on one foot
Throws overhead
5 YEARS
Runs well
Jumps rope
Dresses without help
2,100 word vocabulary
Tolerates increasing periods of separation
from parents
Beginnings of cooperative play
Gender specific behavior
Skips on alternate feet
Ties shoes
AGE APPROPRIATE TOYS
AND ACTIVITIES
Child imitative of adult patterns
and roles. Offer playground
materials, housekeeping toys,
coloring books, tricycles with
helmet
School Age
6 to 11/12 y; constant progress
in physical, mental, and social
development, skill, competency,
and self-concept (see Table XIV
5)
Physical continued slow growth;
begins losing temporary teeth early in
this phase and has all permanent
teeth, except final molars by the end;
bone growth exceeds that of muscle
and ligament, resulting in susceptibility
to injures/fractures
Motor skips, skates, tumbles
tandem walks backward, prints
progressing to script, ties knots then
bows
Psychosocial
has significant peer relationships, assumes
complete responsibility for personal care;
school occupies most of time and has social
as well as cognitive impact; developing
morality, dominated by moral realism with
strict sense of right/wrong until 9 y, then
development of moral autonomy
recognizing different points of view; able to
acknowledge own strengths and
weaknesses; developing modesty
Play group play with leader and organized
rules/ rituals; usual activities include team
games/sports/organizations; board games,
books, swimming, hiking, bicycling, skating
Stresses possible school phobia; fear of
death, disease/ injury, punishment
Safety decreasing incidence of accidents
except for injuries associated with
sports/activities, requires appropriate
supervision and education about proper use
and maintenance of equipment and hazards of
risk taking
SCHOOL AGE GROWTH AND DEVELOPMENT
6 Years
Self centered, show off, rude
Extreme sensitivity to criticism
Begins losing temporary teeth
Appearance of first permanent teeth
Ties knots
7 years
Temporal perception improving
Increased self reliance for basic activities
Team games/sports/organization
Develops concept of time
Boys prefer playing with boys and girls with girls
8 years
Friends sought out actively
Eye development generally complete
Movements more graceful
Writings replaces printing
SCHOOL AGE GROWTH AND DEVELOPMENT
SCHOOL AGE GROWTH AND DEVELOPMENT
9 Years
Skilful manual work possible
Conflicts between adult authorities and
peer group
Better behaved
Conflict between needs for independence
and dependence
Like school
10 -12 years
Remainder of teeth (except wisdom) erupt
Uses telephone
Capable of helping
Increasingly responsible
More selective when choosing friends
Develops beginning of interest in opposite
sex
Loves conversation
Raises pets
SCHOOL AGE GROWTH AND DEVELOPMENT
AGE APPROPRIATE TOYS,
GAMES AND ACTIVITIES
Construction toys Participation in
repair, building,
and mechanical
activities
Use of tools
Adolescence
approximately 11/12 to 12/20 (depending
on gender and individual rate); rapid and
dynamic biological, physical, and
personality maturation characterized by
emotional and family turmoil, leading to
redefinition of self-concept and
establishment of independence (see
table XIV 6)
Physical vital signs approach
adult levels; wisdom teeth
appear about 17 -21 y; puberty
is related to hormonal changes
and is universal in pattern but
not rate (females tend to develop
earlier than males)
Growth spurt occurs early
Girls height increases approximately 3 in/y,
slows dramatically at menarche and ceases
around age 16; fat is deposited in thighs, hips,
and breasts; pelvis broadens
Boys height increase 4 in/y starting about
age 13 and slows in late teens; weight
doubles between 12 and 18 y old, related to
increased muscle mass; broader chest
Sweat production and increased body
odor result from increased Apocrine
gland activity: acne may occur related to
increased sebaceous activity
Sexual characteristics and
functioning develop
Females
Increase in pelvic diameter
Breast development bud stage with
protuberant areola; complete about time of
menarche
Nature of vaginal secretions changes
Axillary and pubic hair appear
Menarche first menstrual period occurs
around 12 ; for first 1-2 y anovulatory,
frequently irregular menses
Males
Increase in genital size beginning about 13 y is first
sign of sexual maturation; continues until
reproductive maturity ( age 17-18)
Possible temporary breast swelling of short duration
Pubic, facial, Axillary, and chest hair appear
Voice deepens
Production of functional sperm
Nocturnal emissions normal physiologic reflex to
ejaculate build up of semen occurring during sleep;
masturbation increases as a way to release semen
Motor often clumsiness associated with growth
spurt, motor ability is at adult levels
Psychosocial
Early preoccupied with changing body;
ambivalent relationship with
parents/authority figures; seeking peer
affiliations; may begin dating; wide and
intense mood swings; limited capability
for abstract thinking; seeking to identify
values
Middle very centered; rich fantasy
life; idealistic; major conflicts with
parents/authority figures; strong
identification with peer group; multiple
love/sexual relationships
(homosexuality is recognized by this
time); tends to be more introspective and
withdrawn; enhanced ability for abstract
reasoning; concerned with philosophical,
political, and social issues
Late established body image;
irreversible sexual identity and gender
role definition; independent from and less
conflict with parents/authority figures;
establishing stable individual friendships
with both sexes and committed intimacy
relationship; more stability in emotions;
able to think abstractly; develops life
philosophy (values, beliefs); makes
occupational decisions
Activities primarily peer group
oriented
Stresses threat of loss of control, fear
of altered body image; separation
primarily from peer group
Safety accidents, especially related to
motor vehicles, sport, firearms, homicide,
and suicide, are leading causes of death;
may be significantly related to drug
and/or alcohol use; education is
paramount
ADOLESCENT GROWTH AND DEVELOPMENT
Physical Development Puberty
-Attainment of sexual maturity
-Rapid alterations in height and weight
-Girls develop more rapidly than boys
-Onset may be related to hypothalamic activity, which
influences pituitary gland to secrete hormones affecting
testes and ovaries
-Testes and ovaries produce hormones (androgens and
estrogens) that determine development of secondary
sexual characteristics
-Pimples or acne related to increased sebaceous gland
activity
Physical Development Puberty
-Increased sweat production
-Weight gain proportionally greater than height
gain during early stages
-Initial problems in coordination appearance of
clumsiness related to rapid unsynchronized
growth of many systems
-Rapid growth may cause easy fatigue
-Preoccupation with physical appearance
ADOLESCENT GROWTH AND DEVELOPMENT
Male Changes
- Increase in genital
size
- Breast swelling
- Appearance of pubic,
facial, Axillary, and
chest hair
- deepening voice
- Production of
functional sperm
- Nocturnal emissions
Females Changes
Increases in pelvic
diameter
Breast development
Altered nature of
vaginal secretions
Appearance of
Axillary and pubic
hair
Menarche first
menstrual period
Physical Development Adolescent
-More complete development of secondary
sexual characteristics
-Improved motor coordination
-Wisdom teeth appear (ages 17-21)
Psychosexual Development
-Masturbation experience of sexual tension
-Sexual fantasies
-Experimental sexual Intercourse
Psychosocial Development
-Preoccupied with rapid body changes,
what is normal
-Conformity to peer pressure
-Moody
-Increased daydreaming
-Increased independence
-Moving toward a mature sexual
identity
Early and middle adulthood
18/20 to 65 y; developmental
state and function characterized
by self-sufficiency in pursuit of
occupation/ vocation and defined
relationships (see Tables XIV
7 and XIV 8)
Physical/cognitive stabilized growth
state (weight is variable) and functioning,
refines formal operational abilities,
undergoes, menopause, begins
physical/physiological degeneration
Psychosocial develops self
sufficiency, pursues vocation/occupation,
has intense interpersonal relationships
(most frequently marriage and children)
YOUNG
ADULTHOOD
GROWTH AND
DEVELOPMENT
20 TO 33 Years 33 to 40 Years 35 to 45 Years
-Decrease hero worship
-Increased reality
-Independent from
parents
-Possible marriage,
partnership
- Realization that
everything is not black or
white, some gray areas
-Looks toward future,
hopes for success
-Peak intelligence,
memory
-Maximum problem
solving ability
-Period of discovery,
rediscovery of
interests and goals
-Increased sense of
urgency
-Life more serious
-Major goals to
accomplish
-Plateaus at work
and marriage
partnership
-Sense of
satisfaction
-(there is some overlap in
years)
-Self questioning
-Fear of middle age and
aging
-Reappraises the past
-Discards unrealistic goals
-Potential changes of work,
marriage partnership
-Sandwich generation
concerned with children
and aging parents
-Increased awareness of
-Potential loss of
significant others
MIDDLE
ADULTHOOD
GROWTH AND
DEVELOPMENT
45 to 55 years 48 to 60 Years 60 to 65 Years
-Graying hair, wrinkling
skin
-Evaluates past
-Pains and muscle aches
-Reassessment
-Realization future
shorter time span than
past
-Menopause
-Decreased sensory
acuity
-Powerful, policy makers.
leaders
-relates to older and
younger generations
-There is some overlap
in years)
-Increasing physical
decline
-Sets new goals
-Defines value of life,
self
-Assesses legacies
professional, personal
-Serenity and fulfillment
-Balance between old
and young
-Accepts changes of
aging
-Increasing
forgetful
-Accepts
limitations
-Modifications of
lifestyle
-Decreased
power
-retirement
-Less restricted
time, able to
chooses different
activities
late adulthood 65 years until
death (see Table XIV 9)
Physical/cognitive has general slowing of
physical and cognitive functioning
Psychosocial needs to establish highest
degree of independence (self-sufficiency)
physically possible by adapting environment to
ability; reflects on life accomplishments,
events, and experiences; continues
interpersonal relationships despite changes
and loss
LATE ADULTHOOD GROWTH AND DEVELOPMENT
65 to 80 Years > 80 Years
Physical decline
Loss of significant others
Appraisal of Life
Appearance of chronic
diseases
Reconciliation of goals
and achievements
Changing social roles
Signs of aging very evident
Few significant relationships
Withdrawal, risk of isolation
Self-concern
Acceptance of death, faces
mortality
Increased losses
Decreased abilities
AGE ERICKSON
S
PSYCHOSO
CIAL
FREUDS
PSYCHOSEXUAL
TASK IMPORTANT
PERSONS
FEAR
INFANCY
0-1
TRUST VS
MISTRUST
ORAL RECOGNIZES
THE MOTHR
MOTHER OR
SUBSTITUTE
Separatio
n anxiety
TODDLER
Favorite
word no
1-3
Autonomy vs
Shame and
/doubt
Anal
Best started on toilet
training
Accepts reality
vs. pleasure
principle
Parents Separatio
n anxiety
Pre-school
3-6
Initiative vs.
Guilt
Phallic/Genitals
Very curious esp. in
sex
Knows
difference
between the
sexes
Basic family Body
injury
castration
complex
School
6-12
Industry vs.
inferiority
Latency
Quieting dawn pd. in
sexual devt.
Loss of interest in
opposite sex
Knows related
to own sex
School/commu
nity playmates
of same sex
Displace
ment from
school
loss of
privacy
Adolescent
12
Identity vs.
role diffusion
Puberty Heterosexual
relationship
Peer group Displace
ment from
friends
PSYCHOSOCIAL DEVELOPMENT
Age Stage of Development Normal Findings
Erikson Freud Piaget
Birth -18
mo
Trust vs.
mistrust
Oral stage or
infancy
Sensorimotor Recognizes and attaches to primary caretaker, develops
simple motor skills, moves from instant gratification to
coping with anxiety
Learns about self through the environment
18 30-3
y
Autonomy
vs shame
and doubt
Anal phase or
toddlerhood
Preoperational Learns to manipulate environment, learns self control in
toilet training, parallel play
Develops expensive language and symbolic play
3-6 y Initiative vs
guilt
Phallic stage or
preschool
Preoperational
intuitive
Learns symbols and concepts, assertiveness against
environment: learns sex role identify
6-12 y Indusrty vs
inferiority
Latency or
school
Concrete
operational
Sees cause and effect and draws conclusions, develops
allegiance to friends, uses energy to industriously create
and perform tasks, shows competency in school and with
friends
12-18 y Identify vs
role
diffusion
Genital phase
or adolescence
Formal
operational
Thinks abstractly, uses logic and scientific reason,
masters independence through rebellion, develops firm
sense of self, is strongly influenced by peers, develops
sexual maturity, explores sexual relationships
18-30 y Intimacy vs
isolation
Develops lasting intimate relationships and good work
relationships
30-65 y Generativi
ty vs.
Stagnation
Establishes a family and oversees next generation, is
productive, shows concern for others
65 y to
death
Integrity vs.
despair
Sees own as meaningful, is productive, accepts physical
changes
D. factors
affecting
growth and
development
1. Genetic defects
a. Increased risk in certain groups of people who
demonstrate increased incidence of specific
defects, e.g., African Americans for sickle cell
disease, Northern European descendants of
ashkenazic Jews for Tay-Sachs disease,
Mediterranean ancestry for thalassemia;
couples with a history of a chills with a defect;
family history of a structural abnormality or
systemic disease that may be hereditary;
prospective parents who are closely blood-
related; women over 40
Chromosomal alteration may
be numeric or structural
1. Downs syndrome (trisomy 21) increased
in women over 35 y; characterized by a small,
round head with flattened occiput; low set ears
large fat pads at the nape of a short neck;
protruding tongue; small mouth and high
palate; epicanthal folds with slanted eyes;
hypotonic muscles with hypermobility of joints;
short, broad hands with inward curved little
finger; transverse simian palmar crease;
mental retardation
Turners syndrome (female with only
one X) characterized by stunted
growth, fibrous streaks in ovaries, usually
infertile, no intellectual impairment;
occasionally perceptual problems
klinefelters syndrome (male with
extra X) normal intelligence to mild
mental retardation; usually infertile

Autosomal defects
defects occurring in
any chromosome
pair than the sex
chromosomes
Autosomal dominant abnormal gene
overshadows the normal gene, thus the
condition is always demonstrated when
the gene is present; the affected parent
has a 50% chance of passing on the
abnormal gene in each pregnancy
Autosomal recessive requires
transmission of abnormal gene from both
parents for expression of condition
Sex-linked transmission traits trait
carried on sex chromosome (usually the
X chromosome); may be dominant or
recessive, but recessive is more
prevalent; e.g., hemophilia, color
blindness
Inborn errors of metabolism
disorders of protein, fat, or
carbohydrate metabolism
reflecting absent or defective
enzymes that generally follow a
recessive pattern of inheritance
Phenylketonuria (PKU) uncommon
disorder due to autosomal recessive
gene, creating a deficiency in the liver
enzyme phenylalanine hydroxylase,
which metabolizes the amino acid
phenylalanine; results in the failure to
metabolize phenylalanine, allowing its
metabolites to accumulate in the blood;
toxic to brain cells
Tay Sachs autosomal recessive trait
resulting from a deficiency of hexosaminidase
A, resulting in apathy, regression in motor and
social development, and decreased vision
Cystic fibrosis (mucoviscidosis or
fibrocystic disease of the pancreas) an
autosomal recessive trait characterized by
generalized involvement of exocrine glands,
resulting in altered viscosity of mucus
secreting glands throughout the body
2. Racial and ethnic influences
3. Environment may influence
development more than genetic factors
Familys socioeconomic factors
Adequate nutrition
Climate
4. Intrapersonal factors
State of health
Emotional state
Assessment of
growth and
development
Growth
Repeated measurements must be done
and recorded accurately on regain basis
to establish pattern and identify
deviations; at least five times in first year
and then yearly at very well child visit
and sick-child visit as appropriate
Assessing length/height- infant or toddler
positioned supine on exam table with legs
extended is measured from crown of head
to heels using flexible nonstretchable tape,
while another person maintains childs
position; for the older child, standing
measurement is easer and more accurate

Standardized growth chart
Individuals length/height, weight, and
head and chest circumference (until 3 y)
is assesses in relation to general
population, to previous pattern, and to
each other
Necessary to reevaluate and report
measurements >97th percentile and <3rd
percentile or deviations from established
pattern
Development
evaluates current developmental
function, identifies need for follow-up,
helps parents to understand the childs
behavior and prepare for new
experiences, and provides basis for
anticipatory guidance
Evaluation should include all the
subsystems of development,
biophysical (gross and fine
motor), cognitive, language,
social, affective
Developmental tools
Denver Developmental
Screening Test (DDST)
evaluates children from birth to 6 y in
four skill areas: personal social, fine
motor, language , gross motor
Age adjusted for prematurity by subtracting
the number of months preterm
Questionable value in testing children of
minority. ethnic groups
Muscular coordination and control
proceeds in head to-toe
(cephalocaudall), trunk-to-periphery
(proximodistal), gross to fine
developmental pattern
Intellectual related to genetic
potentialities and environment;
intelligence tests used to determine IQ;
mental age x 100 = IQ
Mild (IQ range 55 to 70)
G&D @ Preschool-age often do not seem very
different than other children to most people ; are
slower than most children to walk, feed
themselves, and talk.
Children with mild MR, when given special
education, can learn practical skills and useful
reading and math to a 3rd- to 6th-grade level.
As adults, they can usually achieve social and
job skills and live by themselves.
However, they may need some guidance and
support during times of unusual stress.
Moderate (IQ range 40 to 54)
Preschool-age children with moderate MR show
noticeable delays in development of motor skills
and speech.
Older children can learn simple communication,
health and safety habits, and self-help skills.
They are not able to gain useful reading or math
skills.
As adults, they can do simple tasks under
special conditions and can travel alone in
familiar places.
They usually cannot live completely by
themselves.
Severe (IQ range 25 to 39)
Preschool-age children with severe MR have
marked delay in motor development and little or
no communication skills.
With training, these children may be able to
learn basic self-help skills, such as feeding
themselves and bathing.
As they grow older they can usually walk.
They may have some understanding of speech
and some response to it.
As adults, they can get used to routines, but will
need direction and supervision in a protective
environment.
Profound (IQ less than 24)
Children with profound MR frequently have other medical
problems, such as cerebral palsy, and may need nursing
care Gross retardation, minimal-capacity functioning.
They have delays in all areas of development.
They show basic emotions and with training, may be
able to use their legs, hands, and jaws.
These children need close supervision.
As adults they usually have simple speech and may
walk.
They usually benefit from regular physical activity.
They are unable to take care of themselves.
Someone will need to give them complete support for
daily living.