Pre-school, School Pre-school, School age and Adolescentage and AdolescentPre-school, School Pre-school, School

age and Adolescentage and AdolescentElisa A. Mancuso RNC, MS, FNSElisa A. Mancuso RNC, MS, FNS

Professor of NursingProfessor of Nursing

Growth and Development

Preschool 3-5 yearsBiological

• Growth slows and stabilizes during preschool• Average weight gain 2.2 kg (5lbs)/yr

Height 7.5 cm (3”)/yr• 3 yr: 32 lbs & 37”• 4 yr: 37 lbs & 40”• 5 yr: 42 lbs & 43”• Growth occurs in legs rather than trunk.

•No longer resemble the “pot belly” toddler!

Psychosocial Development

• Erickson: Initiative vs Guilt – Ability to learn & play.– Development of “can do attitude” – Behavior becomes goal directed,

competitive and imaginative. – Imitate parents & gender roles. – Proud when accomplish new goals.– When criticized show feelings of

guilt.

• Conscience develops along with moral

development

Psychosocial Development

• Freud: Phallic Stage– ↑ Focus on genitals

•masturbation and exploration common

– Oedipal conflict•Possessive love for opposite sex

parent

• “Super-ego” conscience develops – guilt feelings emerge

Psychosocial Development

Piaget• Pre-operational Stage 2-7 years

– Readiness for school– ↑ physical activities & loud– vivid imagination and curious– Limited attention span– Time- recognizes past and future– Idiosyncratic system for organizing

events• Egocentric

– See the world via me– Fear of Bodily harm

• Ban-aids keep everything in place!

Piaget • Centering

– one characteristic of an object

• Concrete thought process – Literal – Magical thinking– Animism

• Ascribe human characteristics to objects

Developmental Skills3 years

• Walking, running and jumping well @ 36

• 900 word vocabulary/3-4 word sentence

• Copy a circle and cross• Builds a tower of 9 blocks• Ride tricycle, walk stairs

alternating feet• Pour from pitcher• Asks a lot of questions!!

Developmental skills4 years

• 1,500 word vocabulary/4-5 word sentence

• Can copy a square• Very noisy, talkative

– Exaggerates stories– Loves Rhymes & songs– Names 3 colors

• Hop on one foot• Catch a ball with both hands, throws

overhand• ↑ Self-Care: Brushes teeth• Gets dressed ↑ Cooperation

Developmental skills5 year old

• 2,100 word vocabulary/6-8 sentence• Copy diamond and triangle• Prints name• Draw person with 6 parts

– Head, body, 2 arms & 2 legs • Talk constantly

– Names 4 colors• Skip & Hop on alternating feet• Walks backwards

•Hits a ball•Ties shoes & manage big zippers

Socialization• ↑ Peer interaction & communication

– Learn to relate to others• Increased cooperation & Sharing• Conform to expectations• Enjoy games with simple rules• PreSchool play-

– dramatic & creative

• Recognizes sociocultural • differences

Developmental Tasks

• Large and small muscle coordination

• Uses initiative with a conscience

• Becomes a participating family member

• Settles into a daily routine– Dental & personal Hygiene– Sleep

Health Concerns Safety

• MVA # 1 cause of injury– Being struck by car is ↑ risk

• Drowning and falls• Doesn’t fully understand danger • Magical thinking & cartoons

minimize the danger• Integrate safety education

– Puppets, songs, rhymes and games

Health Concerns

• ↑ Exposures to germs – Frequent colds and ear infections

• Girls ↑ UTI’s – RT anatomy and poor hygiene

• Stress hand washing and proper hygiene

• No sharing of utensils, pencils or pens!

Health ConcernsEyes

• Visual acuity and depth perception fully developed by age 7

• Vision testing begun at 3 years • Objective screening using

appropriate chart• 3 years- Allen cards-images• >4 years utilize E chart

•indicate direction of E• 4 year 20/30-20/40

– 5 year 20/20-20/30

Common Eye Disorders

Strabismus• ↓ Coordination of EOM• Eyes are not aligned• One or both eyes can turn

– In (Esotropia) – Out (Exotropia)– Up (Hypertropia) – Down (Hypotropia)

Eye • Amblyopia- “Lazy Eye”

– Only uses 1 eye for vision– No binocular vision– ↓ vision in the deviated eye – Distorted visual field

• Can develop if strabismus is not treated early

• If left untreated → Blindness in deviated eye

• Therapy – Patch normal eye x 24 hours/day

•Deviated eye must work – Surgery

Hearing• Early detection = better outcome• Mandatory newborn hearing

screenings • Routine Audiometry screening by age

3 – Various tones @ various frequencies – Standard volume (usually 20 db)

• Normal hearing ranges from 10 → +15

• By age 5 hearing is fully developed

Hearing ImpairmentsSensorineural (Nerve deafness)

• Damage or malformation of structures of– inner ear/and or auditory nerve

• Causes:– Infections: CMV, Rubella, Herpes,

Meningitis– Heredity– Prematurity (Hypoxia)– Ototoxic meds

• Hearing Loss is usually permanent• Therapy

– Hearing Aids- worn ASAP to help facilitate language development

– Cochlear implants = Controversy– American sign language ↑

communication

Hearing ImpairmentsConductive

• Middle hearing loss affected by– inflammation, obstruction or damage– OME/OM– Cerumen impaction– Perforation

• Temporary & restores to prior hearing level

• Therapy – Antibiotics for infection– Myringotomy & Tympanostomy tubes

Biological Development

School Age 6-12 years

• Growth slows down – Weight: 5 - 6 lbs/year– Height: 1 - 2 inch/year

• Average 6 year old – 46 lbs & 45 inches

• Lose baby teeth @ 6 years. – First permanent teeth @ 6yrs (6 year molar)

• “Ugly Duckling Stage”– Distorted facial proportions

• Wide range of physical differences– Age 7 could look like 10-years or 5-years – Treat according to their age not appearance!

PsychosocialErickson- Industry vs Inferiority

• Industry – Interest in doing work– Learn and solve problems– ↑ accomplishment RT ↑ motivation– Desire to master & do well in everything– If they don’t they will feel inferior. – Reinforce that they cannot do well in

everything

• Perseverance• Self-control • Compromise

Psychosocial Juvenile Stage: 6-9 years• ↑ need for peers, friends• “Stage of Accomplishment”

– Work concept = chores, schoolwork– Carry tasks to completion– ↑ skill and coordination– Develop + self esteem

• Greater intellectual capacity• Role models = teachers/coaches• Manipulate environment • Reinforcement via grades with material

reward• Move to external focus and socialization• Parents needed in times of stress

Psychosocial Preadolescent Stage 9-12 years

• Ability to love (same sex) = best friend

• Pre Pubescence – 2 years before onset of puberty.

• Puberty– Period of rapid growth – Development of primary and

secondary sex characteristics – girls @ 12yrs – boys @ 13 ½ yrs )

Psychosocial

Freud - Latency period• Sexuality

– plays less prominent role • Best friend same sex • Usually do not want to play

with opposite sex (icky!)

Cognitive Development

• Concrete operations and Systematic reasoning:– Conservation

•Change shape but still has same volume– Classification

•Group according to attributes: 1st friend, 2nd friend

– Seriation •Putting things in order or series: smallest

→largest – Nesting

•How one concept fits into another: puzzles– Reversibility

•Opposite function: Addition & Subtraction• Use thought process to experience events and • actions & see things from another point of

view.

Developmental Skills

6 years• Period of Transition• Self centered

– Normal to cheat at board games• Impulsive• ↑Activity RT ↑coordination• ↑Dexterity = drawing & writing

Developmental Skills

7 years•Quiets down•Solitary play•Attentive•Sensitive listener•Modest (Need Privacy)•Companionable

Developmental Skills

8 years•Fluctuating Behavior• ↑Graceful movements• ↑Interest in nature•Very self-critical

Developmental Skills9 years

• ↑ Independence• Refined eye-hand control

– Musical instruments• Best friend• Collections

– Well organized • ↑Physical complaints with stress May have boy/girl

relationship but won’t admit

Development Skills

10 years• ↑ Stamina• Budgets time• ↑ Energy • Enjoys family activities• ↑ Appetite

Development

11 years•Moody•Strict superego-conscience

–Strong morals/values•Best behavior is away from

home

Development

12 years• ↑ Personality integration• ↑ Self discipline• ↑ Self control•Tactful•Mutual understanding with

parents

Developmental Tasks

• ↓ Dependence on family• ↑ Neuromuscular skills• Must adjust to changes in body

image• Develop positive attitude:

– Multicultural– Social – Economic groups

Health Problems• Generally not a sick age• Injury Prevention• Unintentional accidents/injury are the

leading cause of death in any age group• MVC remains # 1

•No Seat belts, air bag injuries or hit as pedestrian/riding bike

• Sports- •skateboards, bikes, all-terrain

vehicles need helmets!!• Burns-

•cooking, firecrackers, matches, candles

Guns Access to loaded guns

Attention Deficit Hyperactivity Disorder

ADHD• Most common chronic behavioral disorder• Affects 6-9 % school age children

– 40 % persist into adult• ADHD has 3 cardinal signs:

– Inattention– Impulsiveness– Hyperactivity

• Unable to self regulate & inhibit behaviors– ↓ Academic Performance

•RT ↑ Distractible & ↓ Task completion– ↓ Self Esteem = ↓ Peer relationships– ↑ Risky Behavior = ↑ Substance Abuse &

MVA Sequela: Conduct, Mood & Anxiety Disorders

ADHD Etiology• Familial Tendency with 1st degree relative• Males 3x more than females• Environment

– Toxins (Pb), meds, food allergies, lead, smoking, alcohol, sugar???

• ↓Neurotransmitters: ↓ NE, ↓ DA and ↓ 5-HT– NE - attention, impulsivity and control– DA - motivation/reward.

• Needed for prioritizing and learning– 5-HT – mood, aggressive/impulsive behavior

• Other neurological disorders can impact:– Fragile X, Turner or Klinefelter

Diagnosis• ADHD is an all day all domain disorder• Based on report of parent, teacher and child• Onset by age 7

– symptoms persist for >6 months – Behavior Rating Scale

• Have 6/9 characteristics listed in DSM-IV• Affect 2 - 3 areas;

– school, home or social situations• Complete multidisciplinary evaluation

Medical, developmental and behavioral history & R/O: Absence seizures, Learning Disability ↓Hearing

MedsPsychostimulants (↑ DA and NE)

– stimulates inhibitory CNS– 1st line medication ↑ efficacy = ↑

response• Methylphenidates (MPH): > 6 years

– Concerta- 12H duration– Adderal XR- 10-12H duration– Ritalin- 4H Duration & Ritalin LA 8H

duration – Daytrana patch- 12H duration (remove

after 9H)– SE:√ Tics, ↓ appetite, sleep disruption, – H/A, slight ↑ BP & HR

• Contraindications:– TIC disorders: Tourette Syndrome, – Anxiety Disorder– Risk for Abuse Potential

MedsNon-stimulant

– Inhibits NE (NE Reuptake Inhibitor)– Better for pts who can’t tolerate MPH

• atomoxetine (Strattera)– 24H Duration– SE: N & V ↓appetite & wt.

Tricyclic antidepressents TCA’s – Blocks re-uptake of NE and 5-HT

• imipramine (Tofranil) nortryptyline (Pamelor) – SE: anticholinergic- dry mouth, – Urinary Retention, orthostatic ↓ BP

Behavior Therapy• Education & Psychosocial• Consistent approach by family & school

– Follow rules– Complete tasks– ↑ Self control– Positive Reinforcement– Time Out

• Modify Environment– ↓ Distractions– Predictable

•clearly define acceptable behavior & consequences

– Diet Therapy?? Not EB (evidence Based)•Limit sugar, aspartame (NutraSweet),

Chocolate, Cow’s milk & eggs

Autism Spectrum Disorder ASD

• Complex neurodevelopmental disorders• Core deficits in 3 areas:

– Social Interaction– Verbal & nonverbal communication– Restricted interests, repetitive behaviors &

resistant to change• Male 3-4x > Female• Genetic Predisposition:

– Affects prenatal & postnatal brain developmentNO correlation with MMR vaccine

• Related Disorders: Pervasive Developmental Disorder (PDD) Asperger’s Syndrome, Childhood Disintegrative Disorder (CDD) Rhett’s Syndrome

ASD Clinical Signs• Inappropriate social behavior • Unable to maintain eye contact• Avoid body contact• Lack emotional reciprocity• Impaired expressive & receptive language skills• Delayed echolalia• Inability to sustain or initiate conversation• Repetitive behaviors:

– Opening & closing doors, flipping light switches, – H2O play, shredding paper, prefer item movements &

ritualistic behaviors– Insist on “sameness”

• Self-Stimulatory behaviors:– Finger licking, hand flapping, body rocking, run in

circles– Deep pressure stimulation-crawl into tight spaces

• Self-injury RT ↟↟ Pain Threshold, aggressive behaviors

– GI Symptoms- Constipation ➔ Mega rectum

Treatment• Developmental Screening

– DDST, Modified Checklist for Autism in Toddlers (M-CHAT)

– Childhood Autism Rating Scale (CARS)• Physical Exam

– Hearing & Vision screening, Neuro, EEG, Metabolic studies (Pb), Genetic testing

• Multidisciplinary approach• Early intervention programs• Highly structured and intensive behavior modification

programs;– Promote positive reinforcement– Increase social awareness of others– Increase verbal communication skills– Decrease unacceptable behavior

• Use brief, concrete communication• Minimal holding & eye contact to avoid outbursts• Gradually introduce new situations• Medications

Atypical antipsychotic- Risperidone ↡ behavioral symptoms only

Scoliosis

• Abnormal lateral curvature – >10% of the spine – Severe type can ↓ thoracic capacity– ↑ risk for osteopenia

• Develops in preadolescent growth spurt

• Higher risk in females 85%

Functional/Idiopathic/Secondary

• Most common – Rapid growth & Poor posture– Unequal leg

TherapyExercises PT for postureShoe Lifts

Structural/Congenital/Neuromuscular

• Muscle or bone deformity – congenital or result of neuromuscular

disorders

• S shaped curved with vertebral rotation

• Asymmetric – thoracic cavity– scapula, breasts, shoulders and hips

• ↑ deformity during periods of growth

TherapyDepends on degree of curve• 10-20 degree

– observe and follow-up X-Rays q 4-6months

– Exercises and improving posture

• >20-40 degrees

Milwaukee brace-worn 23 hours/day– ↓ compliance (15%)

• ↓ comfort and body image– Prevents disease progression – will not resolve current distortion.

Therapy• Boston Brace-

– low profile (lowest angle)– Thoracolumbar -sacral

orthosis• Most widely used

– ↑ 61 % compliance

• Providence Brace- -New shows promise

used only at night!!!! ↑↑ compliance

Therapy

Surgery- curvature >40%• Harrington Rod-

– internal spinal fixation- “flat back”– post-op immobilization required

• Lugue Segmental System-– flexible wires threaded through spine-– no post-op immobilization required, – ↑ risk for nerve damage

• Spinal fusion for severe scoliosis – Iliac bone graft

Post-op Care

• Log rolling• Neurovascular checks• Pain management• Skin care• Urinary retention• Mesenteric Artery Syndrome-

– Shift of abdominal organs =

Abdominal distension/emesis

Varicella

• Contagious virus- – 1 day before eruption to 1

week after outbreaks of vesicles

– until all vesicles have crusted over

• Incubation – 2-3 weeks

Signs and Symptoms • Low grade temp • Anorexia• Rash

– 1st Macular – papular– 2nd Vesicular → crusted lesions

• Outbreaks occur in crops @↑temp 104

• Trunk → face → upper extremities• Very itchy (pruritic)

Therapy

• Palliative • Antihistamines (benadryl)• Antipyretics (Calamine lotion)• Acyclovir

– ↓ # of lesions-when given within 24H of rash

– mostly for high risk pt’s

• Varicella zoster immune globulin (VZIG)– given within 96 hours for high risk pt’s

• Strict isolation in hospital

Lice - Pediculosis Capitus

• Highly contagious infestation of scalp

• “itchy” from crawling mites and saliva

• ↑ @ occipital area• ↑ @ night• √ Environment

– Stuffed animals– Bedding– Clothing (fur)

Therapy • Rid/Nix-Permethin 1 %

– One application– Kills lice and nits. – Not for kids < 2 years

• Kwell- Lidane – Two applications – Repeat in 7-10 days after eggs

hatch

Pinworms Enterobiais

• Infects 1/3 of all children• Contagious

– Inhalation, ingestion or contact• Worms (intestines) migrate & lay

eggs in anal area @ night• Very itchy anal area = ↑ scratching• Spread fecal → fingernails → mouth• Tape test √ eggs @ anus• mebendazole (Vermox) > 2 years

– 100mg & repeat in 2 weeks• pyrantel (Pamoate pin-X) > 2 years

– 11mg/kg & repeat in 2 weeks

Bites/StingsAllergic response• May develop anaphylactic shock• Wheal formation

– Raised & reddened• Epi-pen Jr 0.01 mL/kg (1:1000) IM

Animal Bites: Dogs/cats– 80 % punctures/lacerations– Avulsions (tissue tears)– ↑ infection risk

• Wash area • Moist cool compress & dsg• √ vaccination status (Rabies)• Plastic surgery

Obesity

• Weight & Body Mass Index (BMI) >95% – Compare to age, gender and height– Culturally induced

• 30-40% ↑incidence in 6-11 year olds

• BMI = wt (kg)/ht (m2)Calculate yearly

√ rate of ↑↑ wt and ht

Etiology of Obesity• Diet

– Culturally based– Fast food/ Junk Food– ↑ fats ↑ carbs ↓ protein

• ↓ Physical activity– Computer, video games & TV

• Genes – Family Hx• Prader Willi Syndrome PWS

– Obesity, hyperphagia, hypogonadism– Small hands & feet – Mental Retardation– 70% paternal/30% maternal

Complications

• HTN & ↑ cholesterol @ age 5-10

• ↑ incidence of Type II diabetes• Obstructive Sleep Apnea (OSA)• Cardiac disease• Gallstones• Orthopedic problems• ↓ Self-Esteem

– Social Isolation

Therapy • Nutritional Counseling

– Home & School– change family eating patterns

• Behavior Modification– Healthy lifestyle habits– ↑ physical activity q day 30 -90

minutes– ↓ computer/video time– ↑ H20 intake & ↓ juice/soda

• Recognize and monitor associated risks for chronic diseases

No Gastric Bypass surgery <age 18

Adolescence 12-18 years

• Until physically and psychologically mature

• Self-sufficient• Puberty

– Period of physiological changes. – Sex organs mature, menses,

spermatoza• Growth spurt

– Reach adult height by age 17– Increase in height 2.5 inch -5 inches– Girls @ 12 Boys @ 14-15

–Need ↑ nutrition

Tanner stagesSexual Maturity Rating Scale• Stages I-V• Male secondary sex characteristics

– Androgen•↑ muscle & skeletal growth

– Testosterone •↑ facial/body hair•spermatogenesis

• Female secondary sex characteristics– Estrogen ↑ epiphysis ossification ↑ adipose deposits Ovum maturation

•

Psychosocial development

• Identity Formation vs Role Confusion– Individuality– Internal Stability– Achieve Sense of Self

•Occupation/Future Goals

• Social Development– FRIENDS!! >> Family– Peer pressure– Recognition via group identity– Dating groups vs. individual– Sexual intimacy

Cognitive Development

• Piaget - Formal Operations (11-15)– Abstract thinking– Future Oriented – Scientific Reasoning– ↑↑ Range of Logic

• Developmental Tasks– Accept body changes– Achieve satisfying sex-related role– Achieve independence & warm relationship with

parents– Develop mature set of values, work ethic & occupation

Health ProblemsACNE• Inflammatory Disease ↑ @ age 17

– Males > Females– 17 million kids/year– clogged sebaceous glands– androgens stimulate secretions– bacteria = inflammation

• TherapyTopical Antibiotics- Cleocin, EESPO Antibiotics - TetracyclineAntibacterial - Benzoyl Peroxide

Tretinoin (Retin A) interrupts keratin formation

use @ night Sunshine ↓ efficacy

Isotretinoin Retinoic Acid (Accutane) SE: depression & Teratogenic ↟ congenital defects

Document if sexually active √ HCG q month

Health Problems• Cardiac

– ↓ Growth of heart = ↓ SV– ↓ Ability to meet O2 needs & ↑ BMR = fatigue

– √ Sports physical

• Drug use– ETOH, Marijuana, Coke, E, Special K, LSD, Heroin

• Pregnancy & STDs– Early pregnancy @ age 12-14– HPV (80%), HIV– ↑ Chlymydia, genital warts, Hep B & C

• Depression and suicide• ↑ risk @ age 14• 25 % feel sad/hopeless q day more than 2

weeks• 20 % seriously consider suicide• 10 % attempted suicide• Boys successful RT violent method

Anorexia Nervosa

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