Growth and Development
 Child Health Status in the United States
 Disparity of mortality rates among racial classifications.
 Mortality rates increase with decreasing levels of mothers’ education.
 Mortality rates increase with decreasing income.
Health, Health Promotion, Disease Prevention and Primary Care
 Health – dynamic state of being in which the developmental and behavioral potential of an individual is realized to fullest extent possible
 Health promotion – moving individuals to actualize their full potential
 Health protection
 Disease prevention – stabilizing the human organism to resist disease
Clinical Preventive Services: Health Supervision
 Evidence based care guidelines
o Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents (AAP)
o Recommendations for Preventative Health Care (AAP)
o AMA Guidelines for Adolescent Preventive Services – GAPS
 Services include:
o Screening tests
o Immunizations
o Preventative counseling
Healthy People 2020
 Health Indicators
o Progress regarding tobacco use, immunizations, injury prevention, teenage pregnancy
o Reversal regarding physical activity, overweight
Family assessment in primary care
 Family-centered, community-based primary care
o Targeted family assessments
o Family database
o Genogram
o Ecomap
 Family assessment tools
Cultural Perspectives for Primary Health Care
 Culture is dynamic and shared
 Culture is learned
 Culture is symbolic
 Culture is integrated
 Developing cultural competence
 Communication and negotiation strategies
Developmental Principles in Primary Care
 Development – lifelong, dynamic process
 Growth and development are orderly and sequential
 Pace of growth and development is specific for each child
 Growth and development become increasingly integrated
Developmental Principles
 Developmental abilities become increasingly organized and differentiated.
 Growth and development are affected by child’s internal and external environment.
 Certain periods are critical during growth and development.
Domains of G&D
 Physical domain
 Cognitive domain
 Psychosocial domain
 Disturbances of any of these may alter growth and development
 Sequential measurements are important
Principles
 Physical growth occurs in an orderly, predictable sequence
 Direction of growth follows:
o Cephalo-caudal
o Proximal-distal
o General to specific
 Individual variability, genetic characteristics, ethnicities and cultural practices all influence physical development
Physical Domain
 Unique anatomical, physiologic, immunologic, developmental and psychological differences
 Due to size children are more vulnerable to exposures and toxicities
 Concentration
 Agents that are heavier, closer to the ground
Small Body Mass
 Less fat, less elastic connective tissue and close proximity of the chest to the abdominal organs
 BSA to mass ratio is highest at birth and diminishes with age
 BSA of head to limbs is higher (burns and hypothermia)
 The higher BSA leads to more rapid absorption and systemic effects of toxins absorbed through thinner, less keratinized, highly permeable skin.
Smaller Circulating Blood Volume/ Less Fluid Reserve
 Small amounts of volume loss can lead to hemorrhagic shock
 More vulnerable to bacterial agents- diarrhea, vomiting, dehydration, shock
Skeletal
 Bones are more pliable, incompletely calcified skeletal system with active growth centers more susceptible to fracture
 Preverbal children often have missed fractures
 Radiologic studies
Head
 Larger and heavier head compared to body proportions (larger BSA than adult)
 Major heat loss source
 Short neck and lack of well developed musculature
 Cranium is thinner and vulnerable to penetrating injury
 Brain doubles in size by 6 months and is 80% of adult size by age 2
Thorax
 Chest wall is mobile, pliable, thinner and offers little protection
 Tongue is relatively large to oro-pharynx
 Airway is narrower and angular
 Lungs are smaller
 Fewer alveoli
Ventilation
 Infants and young children have a higher minute ventilation per kilogram of body weight than adults
 More likely to feel the effects of and absorb more toxins from the lungs prior to clearing with ventilation
 Fluids need to be administered with caution
Regulation
 Thermoregulation affected by BSA-to-mass ratio, thin skin, lack of subcutaneous tissue
o Evaporative heat loss
o Increased caloric expenditure
o Hypothermia
 Limited glycogen stores
 Immature immunologic system
General Developmental differences
 Limited verbal ability
 Dependent on caretaker
 Limited motor skills
 Limited cognitive ability
 Emotionally unstable
Developmental stage alters emotions
 Younger child may exhibit regressive behavior
 School age child may exhibit depression, anger and despair
 Adolescents may be vulnerable to depression, eating disorders and high risk taking behaviors
Developmental Theories
 Cognitive-structural theories - Piaget
 Psychoanalytic theories – Freud, Erikson
 Humanistic theories – Maslow
 Moral development- Kohlberg
Parenting Styles
 Set of attributes, attitudes and ways of interacting with children that can influence child outcomes.
 Four general types of parenting styles:
o Authoritative
o Authoritarian
o Permissive
o Neglectful
Authoritative
 Characterized by caring parents who convey concrete behavioral expectations and consistently enforce rules through the withdrawal of privileges.
 An authoritative parent has clear expectations and consequences and is affectionate toward his or her child. The authoritative parent allows for
flexibility and collaborative problem solving with the child when dealing with behavioral challenges. This is the most effective form of parenting.
Authoritarian
 Shows less affection toward the child
 Exhibit controlling behaviors often including physical or verbal reprimands
 Highly critical
 An authoritarian parent has clear expectations and consequences, but shows little affection toward his or her child. The parent may say things like,
"because I'm the Mommy, that's why." This is a less effective form of parenting.
Permissive
 Characterized by very affectionate behavior toward their children
 Often overindulgent
 Do not convey clear behavioral expectations
 Admonish children infrequently
 A permissive parent shows lots of affection toward his or her child but provides little discipline. This is a less effective form of parenting.
Neglectful
 Characterized by the absence of caring behaviors
 Often has few behavioral expectations
 Little or no discipline
Developing Strategies based on Parenting Style
 Strang & Loth (2011). Parenting styles & child feeding practices: Potential mitigating factors in the etiology of childhood obesity.
 Findings:
o Authoritative parenting associated with lower risk of obesity
o Authoritarian parenting results in five time increased risk of obesity
o Neglectful or permissive results in two time increased risk of obesity
o Direct link with child feeding practices
Developing Strategies
 It is important to teach parents that the:
 Parent is the responsible person
 Parent establishes the rules
 Parent is the parent, not a friend
Special Situations
 Adolescent parent
 Grandparent or alternate caregiver
 Compromised parent
o Lifestyle
o Health State
o Distractions
What is discipline?
 A method of teaching children rules of conduct through providing limits and setting boundaries.
 Punishment is a part of discipline and is the consequence of not adhering to the rules.
Discipline
 Punishment needs to fit the crime.
 Length of punishment equals the age of the child
o The punishment for a 2 year old should be 2 minutes of “time out”
 When it’s done, it’s done.
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Corporal punishment is NEVER appropriate
Tell parents “walk away”
Every child needs boundaries and routines
Reward good behavior
Be respectful of your child
Be consistent
Behavior has consequences
Development Monitoring
 Developmental surveillance – all primary care activities r/t monitoring development
 Developmental screening – first-level contact providing a quick, inexpensive method of describing progress, strengths, potential and actual concerns;
stimulates parent questions; facilitates parent education
DENVER DEVELOPMENTAL TEST
 Adjust for prematurity until 2 years
Management Strategies in Child Development
 Parental role development
o Anticipatory guidance
o Parental support
 Parental red flags
o “I am worried about…”
 Child’s developmental red flags
o Talking with parents about delays
o Implementing individualized interventions
 Early Intervention programs
 School interventions
 Family-centered care
 Care and service coordination
Gross Motor
 Good head control-2-3 months
 Rolls back to front-5-6 months
 Sits alone-6-7 months
 Pulls to a stand-9-10 months
 Stands alone-11-12 months
 Walks-11-16 months
 Walks up and down stairs-22-24 months
 Jumps- 24-18 months
Fine Motor
 Grasps & shakes rattle- 2-3 months
 Reaches for object-3-4 months
 Hand-to-hand transfer- 5-6 months
 Raking grasp- 6-7 months
 Pincer grasp- 8-10 months
 Marks on paper- 10-12 months
 Stacks 3 blocks- 16-18 months
 Stacks 6 to 7 blocks- 22-24 months
Language
 Smiles & coos- 2-3 months
 Laughs- 4-5 months
 Babbles- 5-6 months
 “Mama-Dada”- 8-9 months
 Waves bye-bye- 8-9 months
 Understands “NO”- 9-10 months
 Points to body parts- 15-18 months
 2-word sentence- 18-22 months
 30 to 50 word vocabulary- 22-24 months
Developmental Management of Infants Birth to 1 month of Age
 Physical Development
o Gestational age
o Weight
 5% - 10% BW loss, regain in 10-14 days
 Gain – 0.5 to 1 oz/day or 2lb/month
Birth to 1 Month of Age
 Nutrition
o 110kcal/kg/day
o Breastfeeds every 2-3 hr; bottle every 3-4hr
 Sleeping – 16-20 hr/day
 Newborn reflexes
 Motor skills development - flexed; lifts head when prone
 Communication and language development – regards face; note type of cry
 Social and emotional development
 Cognitive development - sensory
Birth to 1 Month of Age
 Senses
 Vision – 9 to 12”, regards face, no tears
 Hearing
Age 1 through 3 months
 Physical development
o Weight gain - 0.5 to 1 oz/day
o Length increase – 3.5 cm/month
o Head circumference – 2 cm/month
 Nutrition
o 6-8 feedings/day; not longer than 40 min. each
o Growth spurt at 6-8 weeks
 Sleep
o 15-16 hr/day; defined sleep/wake patterns
o Fussy periods 1-3 hours in late evening
 Motor skills development
o Fine motor skills begin
 Speech and language milestones – coos, differentiated cry; localizes sound
 Social and emotional development – responsive smile
 Cognitive development
o Tracks past midline 2-3 mo
Age 4 to 5 Months
 Physical development
o Weight gain – 5 oz/week; double BW at 4-6 months
o Length increase – 2 cm/month
o Head circumference increase – 1 cm/month
 Sleep
o 12-15 hr/day
 Nutrition
o Breast milk or formula 3-5xd; rice cereal at 4-6mo.
o Double birth weight
 Motor skills
o Increasing fine motor skills – reaches, purposive grasp
o Gross motor skills – prone to supine; no head lag when pulled to sitting position
 Language development – babbles, laughs
 Social/emotional development
 Cognitive development
Age 6 to 8 Months
 Physical development
o Weight gain – 3-4 oz/wk or 1 lb/month
o Length increase – 1.2-1.5 cm/month
o Head circumference increase – 0.6 cm/mo
o Teething – lower central incisors – 6 months, lateral incisors – 8 months
 Sleep
 Nutrition – increase solids, decrease breast milk/formula
 Motor skills – gross and fine – rolls over both ways, no head lag, sits with support; transfers hand to hand
 Language development
o Nonspecific ma-ma, da-da
o Enjoy imitating oral sounds
o Distinguish facial expressions and gestures
 Social and emotional development
o Increasing ability to do for themselves
o Stranger anxiety
 Motor skills – gross and fine – rolls over both ways, no head lag, sits with support; transfers hand to hand
 Language development
o Nonspecific ma-ma, da-da
o Enjoy imitating oral sounds
o Distinguish facial expressions and gestures
 Social and emotional development
o Increasing ability to do for themselves
o Stranger anxiety
 Cognitive development
o Can see beginning of cause-and-effect relationships
o Expresses individual preferences more clearly
Age 9 to 12 Months
 Physical development
o Growth spurts with overall slower rate of growth
o Weight gain – 1 lb/mo; triples BW
o Length increase occurs in spurts
 Nutrition
o Eat solids well; food preferences
o Three meals with snacks
o Regular B/B patterns
 Sleep
o 12 hours, 2 naps
o Sleep problems start to resolve if handled consistently
 Motor skills
o Can entertain themselves for extended periods d/t fine motor development; pincer grasp, pokes with finger
o Crawling, creeping, cruising – stand alone – walk alone
 Language development
o understands a few words, responds to name by 12 months speak 3 to 4 words
 Social and emotional development
o Stranger wariness
o Enjoy mastering new skills
 Cognitive development
o Master object permanence
o Play becomes increasingly self directed
Screening Strategies for Infants
 Neonatal visit – 1 to 2 weeks after birth
o Screening for metabolic conditions
o Developmental screening tools are rarely sensitive enough
o “Tell me about your infant’s day.”
 2 – 12 months of age
o Denver II
o Ages and Stages Questionnaire
o Parents’ Evaluation of Developmental Status (PEDS)
Birth – 1 Month of Age Anticipatory Guidance
 Regulation and Sleep/Wake Patterns
o Consistent daily routines to establish good sleep/wake cycle
o Put to sleep awake
o Rhythmicity
 Strength and Motor Coordination
o Prone to play/tummy time
 Feeding and Self-Care
o Organize feeding responses
o Face-to-face feeding
o Paced feedings
 If >40 minutes or < 20 minutes with follow-up feed within the hour need evaluation
o Amount and frequency of feeds
o Indicators of adequate intake
o Discuss breastfeeding techniques
 Communication and language
o Infant nonverbal communication techniques
o Promptly attend to infant crying
 Social and emotional growth
o Brief periods of social interaction in alert state
o Encourage infant holding
o Discuss role of sibling involvement
 Cognitive and environmental stimulation
o Infant’s need for variety in environment
1 – 3 Months Anticipatory Guidance
 Regulation and sleep/wake patterns
o Continue routine
o Repetitive stimulation for quieting; stimulus variation for awakening
 Strength and motor coordination
o Change of positions
o Play stations 10-15 min/each
 Feeding and self-care
o Drooling may appear; not a sign of teething
o Need for nonnutritive sucking
o Infant cues regarding feeding
 Communication and language
o Discuss parents’ observations and intuitions
o Encourage parents to sing to, talk to, and rock infants
 Social and emotional growth
o Prompt response to infant cries
o Discuss emergence of infant temperament
o Encourage social games and eye contact
o Support parents’ need for own relationships
o Assist in identifying child care resources
 Cognitive and environmental stimulation
o Increasing visual awareness
o Appropriate toys
4 – 5 Months Anticipatory Guidance
 Regulation and sleep/wake patterns
o Discuss self-soothing measures
o Nighttime rituals
o Respond to crying in a consistent and timely manner
 Strength and motor coordination
o Childproofing from infant’s eye level
o Discourage use of walkers
o Supervised play
 Feeding and self-care
o Infant self-regulation
o Initiate solids, use of spoon
o No bottle propping
o Social interaction
 Communication and language
o “Back and forth talking”
o Quiet time activities
 Social and emotional growth
o Continue responding to cries
o Clarify each parent’s expectations
o Discuss discipline versus punishment
o Parenting classes
o Discuss day care
 Cognitive and environmental stimulation
o Provide new experiences
o Safe toys
6 – 8 Months Anticipatory Guidance
 Regulation and sleep/wake patterns
o Assistance to resume sleep/wake patterns after illness
o Transition from play to sleep
o Delayed gratification
 Strength and motor coordination
o Discuss opportunities for crawling and walking
o Safety/childproofing
 Feeding and self-care
o Encourage infant self-feeding
o Structured mealtimes
o Encourage cup feeding
o No MVI unless at risk
o Dental hygiene
o Teething - no benzocaine
 Communication and language
o Respond to infant’s vocalizations
o Read to infant
o Name body parts
 Social and emotional growth
o Limit setting; parental consensus
o Positive parental responsiveness and attention
 Cognitive and environmental stimulation
o Appropriate toys
o Transitional object
9 – 12 Months Anticipatory Guidance
 Regulation and sleep/wake patterns
o Transitional object
o Temperament – “Goodness of fit”
 Strength and motor coordination
o “Cheer on” achievements
o Childproofing/supervision
 Feeding and self-care
o Dental hygiene
o Self-feeding; transition foods
o Meal settings; no grazing
o Weaning
 Communication and language
o Encourage verbalizations
o Encourage reading versus TV
 Social and emotional growth
o Autonomy
o Use of teaching loop (attention, verbal instruction, modeling, performance, positive feedback)
o Stranger anxiety
o Separation ritual
 Cognitive and environmental stimulation
o Parental expectation re: toilet training
o Interactive play, messy play
Milestones by age
2 to 5 months
 Smiles and coos
 Watches a person’s face with intent
 Follows people and objects with eyes
 Laughs aloud
 Lifts head & chest when prone
 Holds head steady when pulled to sit
 Grasps rattle placed in hand
 Startles to a loud noise
6 to 9 months
 Babbles and combines vowel/ consonant sounds
 Turns to sound
 Responds to name
 Rolls over
 Sits independently
 Transfers objects
 Supports weight on feet
 Uses thumb and fingers to pick up objects
 Crawls
10 to 12 months
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Takes simple action upon request
Purposefully says Mama & Dada
Sits independently and plays
Pulls to stand / cruises furniture
Communicates by reaching and pointing
Moves purposefully to get desired object
Has increasing curiosity
Recognizes people
Uses both hands equally well
13 to 18 months
 Scribbles with large crayon
 Walks alone
 Feeds self with fingers and begins to use spoon
 4 to 10 word vocabulary
 Follows simple directions
 Coordinates use of both hands
 Points to 2 pictures upon request
 Long jabbering sentences
 Throw ball overhand
19 to 24 months
 Walks up and down steps
 Jumps with both feet
 Completes simple puzzle
 Circle first shape
 Stacks 6 to 7 blocks
 Uses 2 word sentences
 30 to 50 word vocabualry
Red Flags
 Growth measurements changes < or > 2 standard deviations on growth curve or no increase
 No red light reflex
 Poor state transitions; poor alert stat
 Asymmetrical movements
 Scissoring
 Difficulty with self-soothing > 6 months
 Persistent newborn reflexes > 6 months
 Strabismus > 6 months
 Does not sit with support > 6 months
 Head lag > 6 months
 Does not look at caregiver or seek comfort
 Asymmetric movements
 No self-feeding or solids > 9 months
 Not pulling to stand > 12 months
 Persistent mouthing > 12 months
 No response to interactive activities > 12 months
 Does not point or gesture > 12 months
Part 2
The Toddler
 1 to 3 years of age
 Your toughest customer
 Stage of negativism, inquisitiveness and lack of impulse control
 Quest for autonomy and independence dominate all aspects of daily life
 Focus of your health history is Temperament
 Focus of your physical exam is Cooperation
 Focus of your anticipatory guidance is SAFETY
 Toddlers need boundaries and routines
Physical Appearance
 Lumbar Lordosis
 Pot belly appearance
 Flat feet
 Mildly bowlegged
 Presence of In-toeing
In-toeing: Establish the cause
 Metatarsal Adduction: seen birth to 6 months. Determine whether it is fixed or flexible
 Medial tibial torsion: seen 12-18 months.
 Femoral anteversion: seen 2-5 years of age
The Toddler’s Speech
 By age 2, speech should be 50% intelligible.
 By age 4, speech should almost completely intelligible.
 Stuttering is normal in toddlerhood
 Confusion with consonant sounds (“w” for “r” or “d” for “th”)
 Limited speech
Toddler’s Appetite
 Appetite will taper down; less interest in food, more interest in activities.
 Toddler should drink approximately 16-24 ounces of whole milk per day; offer water or diluted fruit juice.
 Should eat 3 meals & 2 snacks.
 Tablespoon per year rule
 Opportunity to use utensils
 Perseverance with Food Jags
 Offering a choice is confusing
 Using food as a reward should be discouraged
 Limit fast food consumption
Toddler’s Sleep Pattern
 Should sleep 10-12 hours per night with a short afternoon nap
 Should sleep in their own bed
 Establish a bedtime ritual
 Appearance of nightmares at age 3
Toddler’s Social Interactions
 Attendance at Day Care or Pre-school
 Should be able to separate from parent for short period of time
 Time for “learning the rules”
 Time-Out
Toddler’s Bowel Habits
 Mastery of Potty Training
 Opportunities to sit on potty at regular interval
 Autonomy vs. Shame & Doubt
 Accidents due happen
 Nighttime continence is more difficult and takes longer
Toddler Discipline
 Needs boundaries
 Management of Temper tantrums
 Any behavior that is reinforced continues
 Gently encourage parents to resist corporal punishment
Frequent Complains of the Toddler’s Parent
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“He has another cold…is that alright?”
“He won’t give up that…pacey, blankey, other comfort object. Is that alright?”
“He hasn’t been to the Dentist yet. Is that alright?”
“He’s always on the go. Is that alright?”
“He won’t keep his hands out of his pants. Is that alright?”
Frequent Colds
 On average a young child gets 5-10 colds per year
 Exposure to other children especially in day care or school setting.
 Poor hygiene
 Anatomic predispositions
Comfort Objects
 The toddler is experiencing lots of changes and may need a security object to assist with the stress of these transitions.
 Blanket, toy, pacifier
 Behavior that will be outgrown
High Energy
 Need for exploration is great
 Great pride in newly acquired skill set
 Lack of self regulation
 Need for boundaries
 SAFETY, SAFETY, SAFETY!
Natural Curiosity
 Toddlers love to explore and are very curious
 They enjoy being naked
 Parents should discuss “private parts” and begin to teach children that self-stimulation is acceptable but done in private.
 Keep it simple. The toddler is very literal.
Injury Prevention
 TIPPS guidelines
 http://www.aap.org/family/tippmain.htm
 Reviewed at EVERY visit
The PSAC
 Ages 3-5
 Magical thinker
 Becoming more cooperative
 Asks some questions of the child but depend on the parent for information
 Receptive language is much greater than expressive language
 Knows their gender and association
 Should be able to listen to the reading of a book
 Should be able to guess what’s going to happen next in a story
 Is a sponge for information
 Still takes literal meaning
Language
 Average 3 year old knows 900 words
 Average 4 year old 1500 words
 Understands plurals, pronouns, some prepositions
 Understands concepts of big/ little, up/ down
 Speaks in longer sentences
 Knows colors
 Speech improves with conversation opportunities
 Parents are encouraged to spend individual time with child
 Ask questions and ask for details
 Encourage imagination
o Open ended stories
o Rhyming
Social Development
 Can separate easily from parents
 Attends school
 Understands rules
 Helps with simple chores
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Consistent discipline
Making choices
Learning consequences
Still needs limits and boundaries
Praise
 Encourage opportunities and activities that make the child feel good about what he can do
o Dressing himself
o Performing chores
o School performance
 Reward with time
Discipline
 Consistency, consistency
 Parents need to be careful of their own language and behavior
 Watch the message you are giving
 Time-out rule still applies
 Child knows behavior is wrong & understands greater consequence
Television
 Limit to 1-2 hours per day including DVD’s and computer time
 Engage in other physical activities
 Encourage to “read”, play games, imaginary play
 Able to take turns, share with others
 Develop social and language skills
Nutrition
 “Food Wars”- If child does not like what is offered, they receive nothing until next meal.
 Eats with utensils
 1% or 2% Milk- limit to 24 ounces per day
 Offer variety of choices
 BMI at every visit
Safety
 Reinforce safety-proofing home
 Water safety
 Bike safety
 Fire safety
 Animal safety
 Street safety
 Safe touch/ Stranger safety
Anticipatory Guidance
 Emphasize need for constant vigilance, supervision and patience
 Encourage activities that stimulate the mind and imagination and are rewarding and gratifying to the child
 Baby-sitting
 School Readiness
Care of Toddler and Preschooler
 Motor skills (gross/fine)
o Up and down stairs, kicks ball by 2 years,
o Rides tricycle, jumps, balances on one foot by 3 years
o Uses spoon and cup; fork by 3 years
o Scribbles; copies circle and cross by 3 years
o Dominant hand between 2 to 4 years
o Draws a person with three parts by 4 years
 Communication and language
o One of the most sensitive indicators of cognitive development
o Understand more words than they can express
o 2 year old – use words to convey thoughts and feelings; 200 words; two word sentences
o 2 year old – 25% of speech intelligible to a stranger (50% intelligible to a parent).
o 3 year old – 90% intelligible to a parent
o 4 year old – completely intelligible except for difficult consonants
o 3 and 4 year old – stuttering normal
 Social and emotional development
o Toddler – Anal stage, autonomy, ritualism, mood swings
o Toddler – learns to give love and find satisfaction in pleasing parents, amoral to preconventional stage
o Preschooler - Oedipal phase, sense of initiative, conventional moral stage
o Preschooler – develop ideas of giving and sharing; begin to learn social skills but still self-centered
 Social and emotional development
o Toddler – parallel play
o Preschooler – cooperative play, imaginary play; cheating is common
o Toddler – concerned about bodily injury/integrity
o Preschooler – curious about body functions
o Magical thinking, animism may increase fears but should decrease with time
 Cognitive development
o Highly concrete; peoperational thinking (preconceptual and intuitive)
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Very literal
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Learns by trial and error
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Symbolic thinking
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Egocentric; fascinated with their body
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Fantasy play
Physical Development Screening
 Anthropomorphic measures
 BP after 3 years
 Hearing, dentition, TB, lead,
cholesterol screening for at risk
 Visual acuity testing at 3 years
 Parental questioning regarding bodily functions, ADLs, gross and fine motor skills, play activities
Care of Toddler and Preschooler
 Social and emotional development
o Success in making friends, developing social circle
o Appropriate play – parallel, cooperative
o Feelings of contentment and security
o Development of self-control and self-monitoring skills
 Cognitive development
o 1- to 3-year old - Ask parents about typical day and activities; follows simple instructions; knows name, sex, age
o 4- to 5-year-old – Knows some colors, numbers, concepts of time, play, draw a person, involvement in preschool
Anticipatory Guidance for Toddler and Preschooler
 Strength and motor coordination
o Importance of play
o Practice motor skills in daily routines
o Car seat use – rear seat with harness until 2 years of age
 Feeding and self-care
o Three meals and two nutritious snacks
o Food jags
o Discuss weaning
o Allow self-care mastery
 Introducing new foods
o Offer when child is hungry
o Allow child to taste a little of the food rather than a full portion
o 1 Tbs per food per year to start
o Provide an example of parents enjoying the food
o Prepare the food the way child prefers: few spices, lukewarm, recognizable
o Associate food with pleasant experiences
o Never force food on child
 Communication and language
o Model appropriate language
o Discourage parental pressure on child to perform
o Learn receptive language then expressive
o No TV under 2 years
o Limit Screen time (TV, etc) to 1 to 2 hours per day
 Social and emotional growth
o Balance between dependence and independence in flux
o Development of delayed gratification, controlling emotional states
o Reinforce positive child behavior
o Explain importance of myths or fables
o Provide a feeling of safety and security
 Avoid putting parental meaning on child’s behavior or statements
 Why!!
Common Developmental Issues
 Toddler fears
o Separation anxiety
o Strangers
o Physical injury
 Preschool fears
o Imaginary creatures
o Animals
o Darkness
o Being alone
o Some separation anxiety
Red Flags for Toddler and Preschooler
 Missing or delayed milestones
 Language delays (language is best indicator of cognitive development)
 Refer if:
o Irrelevant verbalizing > 18 months
o Not talking by 2 years
o Use of mostly vowels > 1 year
o Word endings consistently dropped > 5 years
o Loss of language skills
o Child embarrassed or withdrawn regarding speech
o Monotone, extremely loud, poor quality
The School Age Child: Ages 6-12
 Generally more cooperative
 Include child as well as the parents
 6 to 8 year old may have some trouble verbalizing details
 10-12 year old should be able to talk with you without the parent in the room
Development
 Moving away from their family
 Increased independence and less direct supervision
 Increased physical maturity
o Increased motor skills (completed myelinization)
o Increased immune system
o Prepubertal development as early as 8 years in girls and 10 years in boys
Physical Development
 Average height per year= 2-3 inches
 Average weight per year = 6 pounds
 Kcals/day = 2000-3000 depending on physical activity
Development
 Freud: Latency period
 Erickson: Industry vs. Inferiority
 Piaget: Operational stage, conservation, classification
o Improved motor skills
o Engage in more adventure and look for challenges
o SAFETY, SAFETY, SAFETY!!!
 Engage in more group activities
o Sports, clubs
 Experience peer pressure
o Bullying
 Easily distracted, unfocused
 Imitating role models
Anticipatory Guidance
 Safety: need to know name, phone number, address, use of 911
 Nutrition
 Dental Care
 Sleep
 Discipline
 Safety
Major causes of death
 Motor vehicle accidents
o Bicycle
o Skates
o Skateboard
o Dirtbikes
 Homicide
Developmental Red Flags
 School problems before 3rd grade
 School phobia
 Night terrors
 Bullying
 Stuttering
 Poor peer relations
 Extreme shyness or withdrawal
 High incidence of injuries
 Obesity and hypertension
 Inappropriate sexual knowledge
Red Flags School Age Child
 Psychosocial and Emotional
 Peer relationship problems
 Latchkey
 Flat affect, depression, withdrawal
 Cruelty to animals
 Lack of hobbies, best friend, team sports
 Lack of understanding of rules
 Risk taking behaviors
 Problems with sexuality
Red Flags- Cognitive
 Grades
 Unable to sit in class
 > 2 hours of Screen time per day
 Age 8: Unable to add or subtract, days of the week, identify left from right
 Age 10: Lack of operational thinking (cause & effect, relationship of whole and parts)
 Age 12: Difficulty with homework, organizational skills for homework
Red flags- Language and Hearing
 6 years: language is totally unintelligible
 8 years: not able to read simple phases
 10 years: problems with math and reading
 12 years: problems with understanding and following through with verbal instructions and reading comprehension
Red Flags- Fine Motor Skills
 Age 6: unable to copy a circle or draw a picture of self
 Age 8: Unable to copy diamond and square, print name, tie shows, picture if self contains less than 12-16 parts
 Age 10: difficulty holding a pencil
 Age 12: problem getting homework done
Adolescence
 Time of CHANGE
 Same sequence, different times and rates
 No two are alike
o Early versus late starters
Means of Accomplishing tasks
 Behavior Experimentation
 Authority Testing
 Dependent-Independent Struggle
 Rejection of many parental values
Tasks of adolescence
 Establishment of:
o Self-identity
o Sexual identity
o Future Vocation
o Emancipation from parents
o Dealing with pubertal changes
Development: phases of adolescence
 Early Adolescence
o M: 12-14 years; F: 11-13 years
 Middle Adolescence
o M: 14-17 years; F: 13-16 years
 Late Adolescence
o M: 17-21 years; F: 16-21 years
Early adolescence (11-14 years)
 Physical changes and concerns
 Center stage
 Invulnerability
 Wide Mood swings
 Rejection of childish things
 Non-parent Adult Role Model
 Same sex friends- BBF
Middle adolescence (15-17 years)
 Puberty is complete
 Testing- showing off new body
 Independence/ Dependence = Conflict
 Strong Peer Attachment
 Concern with Sexual Appeal
 Experimentation with Risk Taking
 Idealism- Commitment to Causes
Late Adolescence (18-21 years)
 Define adult role in society
 Define adult role in family
 Many independent decisions
 Realistic Self-identity
 Complex thinking (Abstract)
 Future oriented
 Parents seem smarter
 Redefinition of moral, religious and sexual values
Sexual Maturity Rating
 Tanner Staging
 Males
o Genitalia
o Pubic Hair
 Females
o Breasts
o Pubic Hair
 Should be completed on all patients 8 years old or greater
Pubertal Events
 PHV: Peak Height Velocity
o Females (SMR 2-3); age 12 years
o Males (SMR 3-4): age 14 years
o PWV: Peak Weight Velocity
o PHV plus 6 months
Influences on Puberty
 Genetics (greatest)
 Environment
 Nutrition
 SES
 Health Status
o Chronic Illness
o Medication
Sequence of Female Puberty
 Breast buds
 Pubic hair
 Growth spurt
 Axillary hair
 Maturing breasts
 Maturing pubic hair
 Menarche
Physical development
 Thelarche = breast budding
o Between 9 and 10 years of age
 Adrenarche = appearance of pubic hair
o Females & males: 11.5 tears of age
Menarche
 Median age in the US is 12.5 years
 Range from 10-16 years of age
 Mother/ daughter +/- 1 year
 Closer concordance in sisters
 90% by SMR 4
 2 years after breast buds
 Status post PHV & PWV
Sequence of Male Puberty
 Testicles enlarge
 Appearance of pubic hair
 Enlargement of scrotume/ penis
 Axillary hair
 First ejaculation
 Growth spurt
 Facial hair
 Adult height
Spermarche
 Not until SMR 3
 First ejaculation – SMR 2
 Transient Gynecomastia
o Transient enlargement of breast tissue
o 60% of 14 year old boys (SMR 3)
o Resolves in 1-2 years (unilateral or bilateral)
Physiologic changes
 Change in larynx
 Facial shape changes
 Caloric Requirements
o Male= 3000 calories/ day
o Females= 2400 calories/ day
 Increased Iron Requirements
Precocious Puberty
 Definition: onset of multiple features of puberty earlier than the normal range of onset.
 Males: prior to age 10
 Females: prior to age 8
 Sexual Maturity Rating (SMR or Tanner) Staging should begin at age 8.
HEADS: a psychosocial history
 H- Home, Health
 E- Education, Employment, Exercise
 A- Activities, Automobiles
 D- Danger, Drugs, Diet, Depression
 S- Sex, Sleep, Safety, Suicide, Shots, Spirituality