GROWTH AND DEVELOPMENT OF CHILDREN GROWTH AND DEVELOPMENT INTRODUCTION A solid understanding of growth and development is essential for

planning and providing nursing care for infants and children. The child's ability to cope with stress, illness, hospitalization, or terminal illness is related to physical, cognitive, and psychosocial growth and development. Nursing care is designed to foster the individual child's growth and support his or her developmental needs. DEVELOPMENTAL THEORIES PSYCHOSOCIAL DEVELOPMENT (ERICKSON) Trust Versus Mistrust, Infant (birth to 1 year): Characterized by taking in through all the senses; loving care of a mothering person is essential to develop trust; must have basic needs met; attachment to primary caretaker. The favorable outcome is faith and optimism. Autonomy Versus Shame and Doubt, Toddler (1 to 3 years): Characterized by increasing ability to control bodies, themselves, and their environment; seek independence, negativism, threatened by changes in routine, curious explorer. The favorable outcome is self-control and will power. Initiative Versus Guilt, Preschool (3 to 6 years): Characterized by enterprise and a strong imagination; develop conscience; feelings of being punished; egocentric, inquisitive, rich fantasy life, and magical thinking. The favorable outcome is direction and purpose. Industry Versus Inferiority, School-Age (6 to 12 years): Active learners, welldeveloped language skills and concept of time, concerns about body image, understands concept of death. Enjoy sorting and ordering, making collections, and super heroes. Exhibit cognitive conceit. Can assist with own care and appreciates rewards. Physically graceful and skilled; sports and clubs of same-sex peers are important. The favorable outcome is competence. Identity Versus Role Confusion, Adolescent (13 to 18 years): Characterized by ability to deal with reality and abstractions, mood swings, changing body image; preoccupied with the way they appear in the eyes of others as compared to their own self-concept. Peers of both same and

opposite-sex are very important to identity formation. The favorable outcome is devotion and fidelity to others and to values and ideologists. PSYCHOSEXUAL DEVELOPMENT (FREUD) Oral Stage (birth to 1 year): Characterized by infant-seeking pleasure via oral activities such as biting, sucking, chewing, and vocalizing. Anal Stage (1 to 3 years): Characterized by interest in the anal region and sphincter muscles (child is able to withhold or expel feces); toilet training is a major milestone (method of parent discipline, may have lasting effects on child's personality development). Phallic State (3 to 6 years): Characterized by interest and recognition in differences between the sexes and becomes very curious about these differences; often described as interest by females as penis envy and by males as castration anxiety. Latency period (6 to 12 years): Characterized by gaining increased skill on newly acquired traits and skills; interested in acquiring knowledge and vigorous play. Sexuality lies dormant while energy is focused elsewhere. Genital stage (12 years and over): Characterized by maturation of the reproductive system and production of sex hormones; genital organs become a source of tension and pleasure; interested in forming friendships and preparation for marriage as an adult. INTERPERSONAL DEVELOPMENT (SULLIVAN) Infant (0 to 1 year): Receive gratification and comfort from loving, tender care; develops trust and ability to count on others. Childhood (2 to 5 years): Engage in peer, family, neighborhood activities; need adult participation; learn to delay gratification and accept interference with wishes: gradually seek attention and approval from peers. Juvenile (5 to 12 years): Engage in socialization, competition, cooperation, and compromise; develop shared interests and genuine friendships with peers of same sex, and later with opposite sex; give more allegiance to peers than to family; promote personal identity COGNITIVE DEVELOPMENT (PIAGET) Sensorimotor (birth to 2 years): Characterized by progression from reflex activity through simple repetitive behaviors to imitative behaviors; information is gained through the senses and developing motor abilities; develop a sense of "cause and effect"; problem-solving is by trial and error;

high level of curiosity, experimentation, and enjoyment in novelty; begin to separate self from others; develop sense of "object permanence"; begin language development. Preoperational (2 to 7 years): Characterized by egocentrism (inability to put oneself in the place of others); interpret objects and events in terms of their relationships or use of them; cannot see another's point of view; thinking is concrete, tangible; inability to make deductions or generalizations; display high level of imagination and questioning; reasoning is intuitive. Concrete Operations (7 to 11 years): Characterized by thoughts; become increasingly logical and coherent; able to classify, sort, organize facts, and begin to problem-solve; develop conservation (realize volume, weight, and number remain the same even though outward appearances are changed); solve problems in a concrete, systematic fashion, based on visual perceptions. Formal Operations (11 to 13 years): Characterized by thoughts which are adaptable and flexible; possess abstract thinking; able to make logical conclusions; able to make hypotheses and test them; can consider abstract, theoretical, philosophical issues. Preconventional Level (2 to 7 years): Parallels Piaget's preoperational level of cognitive development and intuitive thinking. Characterized by development of: cultural values; sense of right and wrong; integrate things in terms of physical or pleasurable consequences of their actions. Initially, determines goodness or badness in terms of its consequences (attempt to avoid punishment). Later, determines right behavior consists of what satisfies own needs (and sometimes those of others). Conventional Level (7 to 11 years): Parallels Piaget's stage of concrete operations of cognitive development. Characterized by a concern with conformity and loyalty; value a specific group (i.e., the family, group, or national expectations); behavior that conforms to specific group considered good and earns approval. Values such as fairness, give and take, and sharing interpreted in a practical manner without loyalty, gratitude, or justice. Postconventional, Autonomous, or Principled Level (11 to 15 years): Parallels Piaget's stage of formal operations. Characterized by tendency/desire to display correct behavior in terms of individual rights and standards; begins to question possibility of changing existing laws/rules in terms of societal needs.

SPIRITUAL DEVELOPMENT (FOWLER) Five stages of development of faith; four are closely associated with parallel cognitive (Piaget) and psychosocial (Erickson) development in childhood. Stage 0, (Undifferentiated): Characterized by infant period of development, in which the infant is unable to determine concept of right or wrong. Development of basic trust lays the foundation for beginning faith. Stage 1, (Intuitive-projectile): Characterized by toddler period of development, in which the primary behavior is referred to as imitating religious gestures and behaviors of others. Unable to comprehend meaning or significance of religious practices; begin to assimilate religious values and beliefs held by parents; do not attempt to understand basic concepts of religion. Stage 2, (Mythical-literal): Characterized by school-age period of development, in which the child's spiritual development parallels cognitive development. Belief that spiritual development is associated with previous experiences and societal interactions. Newly-acquired conscience influences actions (good vs. bad; bad actions create guilt); petitions to an omnipotent being important; able to articulate their faith. Stage 3, (Synthetic-convention): Characterized by early phase of adolescent period of development, in which become aware of spiritual disappointments (i.e., prayers are not always answered); may begin to abandon or modify previous religious practices and those established by their parents. Stage 4, (Individuating-reflexive): Characterized by middle phase of adolescent period of development, in which the adolescent may become skeptical and begin to compare religious standards of their parents and significant others. The adolescent will begin to compare religious beliefs with scientific facts, described as a period of searching for answers; and to be uncertain about their religious ideas.

SELECTED MILESTONES GROSS MOTOR 0 to 4 months: Lifts head if in prone position with head erect or bobbing and back rounded; raises chest with support of arms flexed limbs; 0 to 1 month, startle and rooting reflex are very strong, Moro reflex begins to fade at 2 months; 2 to 4 months, decrease in head lag when pulled up to sitting position. 4 to 8 months: Holds head up and erect without support; lifts head and shoulders to 90 degree angle and rolls from back to side; turns over both ways; supports weight on legs and may pull self into sitting position; beginning at 4 months, able to sit with support; head lag disappears; by 7 months, able to sit alone without support; likes to bounce on legs when held in standing position; Moro reflex has disappeared. 8 to 12 months: Sits alone, creeps, crawls, cruises, sits from standing position without assistance, prefers being up instead of lying down; at 9 months, stands while holding onto furniture and able to pull self to standing position; at 11 months walks while holding onto furniture or with both hands held; at 12 months may be able to walk with one hand held. 12 to 15 months: Walks alone with side-based gait, creeps up stairs, throws things. 15 to 24 months: Walks alone with improvement, runs, pulls toys when walking, walks on toes, walks backwards, climbs up steps, climbs on furniture, sits on small chair, stands on one foot. 2 years: Walks with steady gait, runs with few falls, walks on toes, stands on one foot, walks up and down stairs, jumps, kicks ball, rides tricycle, throws ball overhand. 3 and 4 years: Pedals tricycle, climbs and jumps well, walks up and down stairs with alternating feet, gains increased coordination and balance, hops on one foot, throws ball overhand proficiently. 5 and 6 years: Hops; skips well; jumps rope; has improved coordination and control of muscles; active; throws and catches ball; runs without difficulty, hits nail on head. 7, 8, and 9 years: Repeats activities for mastery; active; rhythm, smoothness, and control of muscular movements increases; displays motor skills; strength and endurance increase.

 10, 11, and 12 years: Has control of timing, graceful high level of energy, explores environment, participates in team sports, builds or constructs things, interested in physical skills. FINE MOTOR 0 to 4 months: Attempts to grab object but misses, brings object to mouth, holds hands in front and plays with hands and feet, grasps object with both hands; 1 month displays grasp reflex; 3 months, hands are usually open; 2 to 4 months, looks and plays with own fingers; 3 months, when object is placed in hands, will retain briefly; 4 months, reaches for objects and picks them up with a raking action of fingers. 4 to 8 months: Grasps with thumb and fingers, explores objects, moves arms at sight of toy, reaches for object, picks up object with cupped hands, holds objects in both hands at same time, holds own bottle, puts nipple in mouth, feeds self a cookie; 5 months, able to voluntarily grasp an object; 6 to 7 months, able to transfer objects from one hand to another, enjoys banging objects together. 8 to 12 months: Releases toy or object, locates hands for play, eats with fingers, uses spoon with assistance, drinks from cup with assistance, holds crayon and makes marks on paper; 10 months, pincer grasp is present, able to pick up small objects like a raisin; 11 months, able to put objects into a container and enjoys removing them; 12 months, displays interest in building a tower of two blocks, but it often falls down. 12 to 15 months: Builds tower of 2 to 4 blocks, opens boxes, pokes finger in hole, turns pages of book, uses spoon with spilling. 15 to 24 months: Drinks from cup with one hand, uses spoon without spilling, empties jar of contents, draws vertical line, scribbles, builds tower of 4 blocks. 2 years: Builds tower of 5 to 8 blocks, turns knob to open door, drinks from glass held in one hand, makes train of cubes by manipulating play materials. 3 and 4 years: Strings beads, builds tower of blocks, learns to use and masters use of scissors, copies a circle-and-cross figures, holds crayon with fingers, unbuttons buttons on side or front, laces shoes, brushes teeth, cuts out simple pictures. 5 and 6 years: Copies letters of alphabet and prints name, dresses self with assistance, uses hammer and nails, knows right from left hand, cuts and pastes well, may tie shoes, uses fork.

 7, 8, and 9 years: Hand-eye coordination improves; enjoys video games; writes rather than prints words; may play musical instruments, sew, build models, work jigsaw puzzles; adds details to drawings and uses perspective in drawing, uses both hands independently. 10, 11, and 12 years: Uses increased detail in work, handwriting skill improves, more refinement to motor activities, gradual improvement to adult level. LANGUAGE 0 to 4 months: Cries, whimpers; responds to sounds or activity; coos, gurgles, and babbles; smiles in response to adult sounds and makes sounds. 4 to 8 months: Laughs out loud, vocalizes, uses two syllable sounds like da da without meaning, imitates expressions, cries if scolded. 8 to 12 months: Responds to adult emotional tone, says one or two words, uses sounds to identify objects or persons, uses wide range of sounds, understands use of no, knows own name, communicates with others and self. 12 to 14 months: Uses jargon, names for familiar pictures or objects; points to desired object or vocalizes wants, knows at least 10 words or more; uses short phrases; points to body parts. 2 years: Uses about 300 words, uses pronouns, speaks 3 to 4 word sentences, enjoys stories, does not ask for help. 3 and 4 years: Uses about 900 to 1500 words; talks in sentences; asks questions consistently; states own name; talks whether someone present or not; uses plural form of words; repeats words and sentences at will; may omit prepositions, adverbs, adjectives in speech; asks how and why; boasts and tattles; tells a story; counts to at least 3, understands simple questions. 5 and 6 years: Identifies colors, uses 2,100 words, knows names of days of week, asks thoughtful questions, uses prepositions and conjunctions, uses complete sentences, shares experiences with others through language, expands vocabulary with exposure and stimulation, errors in sound disappear, begins to have a concept of abstract words. 7, 8, and 9 years: Increases use of words to express self, increases use of words for exchange and communication, considers what others say, uses all parts of speech. 10, 11, and 12 years: Uses 50,000 words, uses compound and complex sentences, understands abstract words.

PLAY AND SOCIALIZATION 0 to 4 months: Stares at environment, smiles indiscriminately or responsively, enjoys having others around, recognizes familiar faces, determines that face is unfamiliar and freezes gaze, establishes cycle for sleep and awake periods; 0 to 1 month, prefers to look at faces, at black and white geometric designs, able to follow objects in line of vision; 2 to 4 months, follows objects 180, turns head to look for voices and sounds. 4 to 8 months: Self-centered, begins to be fearful of strangers; 4 to 6 months, watches the course of a falling object, responds readily to sounds, smiles at self in mirror, fascinated by own fingers and toes; 6 to 8 months, recognizes own name and responds by smiling when it is heard, seeks attention, imitates faces and sounds in play. 8 to 12 months: Plays simple peek-a-boo, prefers mother, cries when upset, becomes anxious if separated, recognizes family members' requests if one at a time, displays various emotions. 12 to 24 months: Plays pat-a-cake, is curious and gets into everything, has short attention span, enjoys solitary play or watching others play, has a favorite toy or object. 2 years: Unable to distinguish right from wrong, imitates parents and others, enjoys parallel play, wants things own way, refuses to share, is possessive, sees self as a separate person, rituals important, benefits from transitional objects such as teddy bear. 3 and 4 years: Able to share with peers and adults, interested in new activities and learning from them, may have an imaginary playmate, participates in imaginative play and imitation of adults. 5 and 6 years: Likes achieving, wants to accept responsibilities, has strong feeling for family and home, identifies with parent of same sex, participates in fair play and cooperation, shows off. 7, 8, and 9 years: Independently plays, able to reason and has a concept of right or wrong, likes rewards and praise, peer group gains in importance, short-lived interests, completes tasks. 10, 11, and 12 years: Feels positive about self; is more tolerant; interested in rules and money; relates well with peers, friends, relatives; likes conversation, change, and variety in activities; avoids doing tasks; develops conscience. Enjoys sports, games.

PLAY Play is described as the work of childhood. Children use play to learn about themselves and the world and also to cope with new or stressful events. Child development experts recognize play as a significant coping strategy for children. For example, children may use play as an outlet for self-expression, to manipulate experience, and to attempt to master the environment. Play provides the child with a measure of control over events and settings. Children's play also promotes social, cognitive, and physical development. Illness, treatment, and hospitalization create emotional stress for children. Reactions may include crying, clinging to parents, loss of sleep, and regression. Structured and/or medical play has been shown to be therapeutic in helping children preserve usual coping strategies and maintain emotional health. Therapeutic play has been identified as an effective intervention to help children prepare for, cope with, assimilate, and master painful procedures and the stress of hospitalization. A significant nursing intervention is to provide the child with a pleasurable play experience at the onset of hospitalization, that may ease the emotional distress associated with invasive procedures or with the hospitalization process itself. The nurse bases the choice of play activity offered on the child's developmental level, play preferences, and therapeutic goals. Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005)