Pre-school, School age and Adolescent

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Pre-school, School age and Adolescent

• Elisa A. Mancuso RNC, MS, FNS
• Professor of Nursing

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Growth and Development Preschool 3-5 years

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

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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

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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

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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!

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Piaget

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

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Developmental Skills

• 3 years
• Walking, running and jumping well _at_ 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!!

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Developmental skills

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

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Developmental skills

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

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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

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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

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Health Concerns

• Safety
• MVA 1 cause of injury
• Being struck by car is ? risk
• Drowning and falls
• Doesnt fully understand danger
• Magical thinking cartoons minimize the danger
• Integrate safety education
• Puppets, songs, rhymes and games

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Health Concerns

• ? Exposures to germs
• Frequent colds and ear infections
• Girls ? UTIs
• RT anatomy and poor hygiene
• Stress hand washing and proper hygiene
• No sharing of utensils, pencils or pens!

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Health Concerns

• Eyes
• Visual acuity and depth perception fully
  developed by age 7
• Vision testing begun at 3 years
• Objective screening using appropriate chart
• 3 years- Allen cards-images
• gt4 years utilize E chart
• indicate direction of E
• 4 year 20/30-20/40
• 5 year 20/20-20/30

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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)

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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

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Hearing

• Early detection better outcome
• Mandatory newborn hearing screenings
• Routine Audiometry screening by age 3
• Various tones _at_ various frequencies
• Standard volume (usually 20 db)
• Normal hearing ranges from 10 ? 15
• By age 5 hearing is fully developed

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Hearing Impairments

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

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Hearing Impairments

• Conductive
• 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

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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 _at_ 6 years.
• First permanent teeth _at_ 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!

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Psychosocial

• Erickson- Industry vs Inferiority
• Industry
• Interest in doing work
• Learn and solve problems
• ? accomplishment RT ? motivation
• Desire to master do well in everything
• If they dont they will feel inferior.
• Reinforce that they cannot do well in everything
• Perseverance
• Self-control
• Compromise

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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

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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 _at_ 12yrs
• boys _at_ 13 ½ yrs )

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Psychosocial

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

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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.

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Developmental Skills

• 6 years
• Period of Transition
• Self centered
• Normal to cheat at board games
• Impulsive
• ?Activity RT ?coordination
• ?Dexterity drawing writing

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Developmental Skills

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

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Developmental Skills

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

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Developmental Skills

• 9 years
• ? Independence
• Refined eye-hand control
• Musical instruments
• Best friend
• Collections
• Well organized
• ?Physical complaints with stress
• May have boy/girl relationship
• but wont admit

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Development Skills

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

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Development

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

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Development

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

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Developmental Tasks

• ? Dependence on family
• ? Neuromuscular skills
• Must adjust to changes in body image
• Develop positive attitude
• Multicultural
• Social
• Economic groups

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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

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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

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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

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Diagnosis

• ADHD is an all day all domain disorder
• Based on report of parent, teacher and child
• Onset by age 7
• symptoms persist for gt6 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

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Meds

• Psychostimulants (? DA and NE)
• stimulates inhibitory CNS
• 1st line medication ? efficacy ? response
• Methylphenidates (MPH) gt 6 years
• Concerta- 12H duration
• Adderal XR- 10-12H duration
• Ritalin- 4H Duration Ritalin LA 8H duration
• Daytrana patch- 12H duration (remove after 9H)
• SEv Tics, ? appetite, sleep disruption,
• H/A, slight ? BP HR
• Contraindications
• TIC disorders Tourette Syndrome,
• Anxiety Disorder
• Risk for Abuse Potential

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Meds

• Non-stimulant
• Inhibits NE (NE Reuptake Inhibitor)
• Better for pts who cant tolerate MPH
• atomoxetine (Strattera)
• 24H Duration
• SE N V ?appetite wt.
• Tricyclic antidepressents TCAs
• Blocks re-uptake of NE and 5-HT
• imipramine (Tofranil) nortryptyline (Pamelor)
• SE anticholinergic- dry mouth,
• Urinary Retention, orthostatic ? BP

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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,
  Cows milk eggs

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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 gt Female
• Genetic Predisposition
• Affects prenatal postnatal brain development
• NO correlation with MMR vaccine
• Related Disorders
• Pervasive Developmental Disorder (PDD)
• Aspergers Syndrome,
• Childhood Disintegrative Disorder
  (CDD)
• Rhetts Syndrome

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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

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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

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Scoliosis

• Abnormal lateral curvature
• gt10 of the spine
• Severe type can ? thoracic capacity
• ? risk for osteopenia
• Develops in preadolescent growth spurt
• Higher risk in females 85

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Functional/Idiopathic/Secondary

• Most common
• Rapid growth Poor posture
• Unequal leg
• Therapy
• Exercises
• PT for posture
• Shoe Lifts

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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

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Therapy

• Depends on degree of curve
• 10-20 degree
• observe and follow-up X-Rays q 4-6months
• Exercises and improving posture
• gt20-40 degrees
• Milwaukee brace-worn 23 hours/day
• ? compliance (15)
• ? comfort and body image
• Prevents disease progression
• will not resolve current distortion.

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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

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Therapy

• Surgery- curvature gt40
• 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

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Post-op Care

• Log rolling
• Neurovascular checks
• Pain management
• Skin care
• Urinary retention
• Mesenteric Artery Syndrome-
• Shift of abdominal organs
• Abdominal distension/emesis

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Varicella

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

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Signs and Symptoms

• Low grade temp
• Anorexia
• Rash
• 1st Macular papular
• 2nd Vesicular ? crusted lesions
• Outbreaks occur in crops _at_?temp 104
• Trunk ? face ? upper extremities
• Very itchy (pruritic)

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Therapy

• Palliative
• Antihistamines (benadryl)
• Antipyretics (Calamine lotion)
• Acyclovir
• ? of lesions-when given within 24H of rash
• mostly for high risk pts
• Varicella zoster immune globulin (VZIG)
• given within 96 hours for high risk pts
• Strict isolation in hospital

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Lice - Pediculosis Capitus

• Highly contagious infestation of scalp
• itchy from crawling mites and saliva
• ? _at_ occipital area
• ? _at_ night
• v Environment
• Stuffed animals
• Bedding
• Clothing (fur)

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Therapy

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

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Pinworms Enterobiais

• Infects 1/3 of all children
• Contagious
• Inhalation, ingestion or contact
• Worms (intestines) migrate lay eggs in anal
  area _at_ night
• Very itchy anal area ? scratching
• Spread fecal ? fingernails ? mouth
• Tape test v eggs _at_ anus
• mebendazole (Vermox) gt 2 years
• 100mg repeat in 2 weeks
• pyrantel (Pamoate pin-X) gt 2 years
• 11mg/kg repeat in 2 weeks

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Bites/Stings

• Allergic response
• May develop anaphylactic shock
• Wheal formation
• Raised reddened
• Epi-pen Jr 0.01 mL/kg (11000) IM
• Animal Bites Dogs/cats
• 80 punctures/lacerations
• Avulsions (tissue tears)
• ? infection risk
• Wash area
• Moist cool compress dsg
• v vaccination status (Rabies)
• Plastic surgery

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Obesity

• Weight Body Mass Index (BMI) gt95
• Compare to age, gender and height
• Culturally induced
• 30-40 ?incidence in 6-11 year olds
• BMI wt (kg)/ht (m2)
• Calculate yearly
• v rate of ?? wt and ht

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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

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Complications

• HTN ? cholesterol _at_ age 5-10
• ? incidence of Type II diabetes
• Obstructive Sleep Apnea (OSA)
• Cardiac disease
• Gallstones
• Orthopedic problems
• ? Self-Esteem
• Social Isolation

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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 ltage 18

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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 _at_ 12 Boys _at_ 14-15
• Need ? nutrition

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Tanner stages

• Sexual Maturity Rating Scale
• Stages I-V
• Male secondary sex characteristics
• Androgen
• ? muscle skeletal growth
• Testosterone
• ? facial/body hair
• spermatogenesis
• Female secondary sex characteristics
• Estrogen
• ? epiphysis ossification
• ? adipose deposits
• Ovum maturation

64
Psychosocial development

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

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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

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Health Problems

• ACNE
• Inflammatory Disease ? _at_ age 17
• Males gt Females
• 17 million kids/year
• clogged sebaceous glands
• androgens stimulate secretions
• bacteria inflammation
• Therapy
• Topical Antibiotics- Cleocin, EES
• PO Antibiotics - Tetracycline
• Antibacterial - Benzoyl Peroxide
• Tretinoin (Retin A)
• interrupts keratin formation
• use _at_ night Sunshine ? efficacy
• Isotretinoin Retinoic Acid (Accutane)
• SE depression Teratogenic
• ? congenital defects
• Document if sexually active v HCG
  q month

67
Health Problems

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

68
Anorexia Nervosa

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