32
Nursing Care of a Family With a SchoolAge Child
Shelly Lewis is an 11-year-old girl who recently started middle school. Her mother
tells you that Shelly, who is overweight, says she likes school and wants to try out for
cheerleading, but she has developed a lot of nervous habits such as nail biting since
she started attending her new school. Her mother asks you if this is “normal.”
The previous chapter discussed developmental aspects of the preschool child.
This chapter focuses on the changes, both physical and psychosocial, that occur
during the school-age years and provides the foundation for health education for
this age group.
How would you advise Shelly’s mother?
KEY TER MS
accommodation
caries
class inclusion
conservation
malocclusion
nocturnal emissions
OBJ EC TIV ES
After mastering the contents of this chapter, you should be able to:
1. Describe the normal growth and development pattern and common parental
concerns of the school-age period.
2. Identify 2020 National Health Goals related to school-age children that nurses can
help the nation achieve.
3. Assess a school-age child for normal growth and developmental milestones.
4. Formulate nursing diagnoses related to both school-age children and their families.
5. Establish expected outcomes for nursing care of school-age children to help
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children and parents manage seamless transitions across differing healthcare
settings.
6. Using the nursing process, plan nursing care that includes the six competencies of
Quality & Safety Education for Nurses (QSEN): Patient-Centered Care, Teamwork
& Collaboration, Evidence-Based Practice (EBP), Quality Improvement (QI),
Safety, and Informatics.
7. Implement nursing care to promote normal growth and development of a schoolage child, such as counseling parents about helping their child adjust to a new
school.
8. Evaluate expected outcomes for achievement and effectiveness of care.
9. Integrate knowledge of growth and development in school-age children with the
interplay of nursing process, the six competencies of QSEN, and Family Nursing to
promote quality maternal and child health nursing care.
The term “school age” refers to children between the ages of 6 and 12 years. Although
these years represent a time of slow physical growth, the school-age child’s cognitive
growth and development continue to proceed at rapid rates. There are many differences
among children at each year of this age group. For example, 7- and 10-year-old children
have very different needs and outlooks than do 11- and 12-year-old children. Because of
these big differences, always assess children as individuals to understand the particular
developmental needs of each child based on what developmental status has been
achieved, not on what stage you think the child should have reached (Lowe, Godoy,
Rhodes, et al., 2013).
Unlike the infant or toddler periods, when progress is marked by obvious new
abilities and skills such as the ability to sit up or roll over or the ability to speak a full
sentence, the development of a school-age child is much more subtle. In addition, the
child may demonstrate contradictory responses. For example, what the child enjoys on
one occasion may change over time. It is not uncommon for a child to ask his or her
parents for a guitar and lessons and subsequently lose interest in music and prefer
another activity. School-age children become increasingly more influenced by the
attitudes of their friends. They may select activities based on the interests of their peers.
Parents who don’t understand this normal aspect of development may engage in
excessive conflicts with their child. The school-age period is the initiation of
independent decision making. Parents unprepared for this may experience conflicts with
their child. Box 32.1 lists 2020 National Health Goals related to the school-age period.
BOX 32.1
Nursing Care Planning Based on 2020 National Health Goals
A number of 2020 National Health Goals address the health of the school-age
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population:
• Increase the proportion of public and private schools that require daily physical
education for elementary school students from a baseline of 3.8% to a target of
4.2%; for middle school students, from 7.9% to 8.6%.
• Increase the proportion of public and private schools that require students to wear
appropriate protective gear when engaged in school-sponsored physical activities
from 76.8% to 84.5%.
• Reduce the proportion of children who have dental caries (in permanent or
primary teeth) to no more than 49% from a baseline of 54.4%.
• Increase age-appropriate vehicle restraint system use in children from 78% to
86%.
• Increase the number of states that require helmet use by bicyclists from 19 to 27
states (U.S. Department of Health and Human Services, 2010; see
www.healthypeople.gov).
Nurses can help the nation achieve these goals by urging children to begin and
maintain a consistent exercise program, to brush teeth and go for dental checkups
regularly, and to follow safety rules for bicycles and automobiles.
Nursing Process Overview
FOR HEALTHY DEVELOPMENT OF A SCHOOL-AGE CHILD
ASSESSMENT
History and physical examination are used to assess growth and development of
school-age children. History questions include school progress and extracurricular
activities. School-age children are interested and able to contribute to their own
health history. The school-age child may be interviewed with his or her parent and
separately depending on the circumstances. During a physical examination, be
attentive to the school age child’s need for privacy when undressed. Parents of
school-age children often mention behavioral issues or conflicts during yearly health
visits. This is a time period where children begin to express their own opinions and
beliefs.
School personnel may be involved in a child’s health care as optimal school
functioning has the greatest potential when a child is healthy physically, emotionally,
and socially.
NURSING DIAGNOSIS
Common nursing diagnoses pertinent to growth and development during the schoolage period include:
Health-seeking behaviors related to normal school-age growth and development
Readiness for enhanced parenting related to improved family living conditions
Anxiety related to slow growth pattern of child
Risk for injury related to deficient parental knowledge about safety precautions
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for a school-age child
OUTCOME IDENTIFICATION AND PLANNING
When identifying expected outcomes and planning care, keep in mind that school-age
children tend to enjoy small or short-term projects rather than long, involved ones. In
her early school years, a child with diabetes, for example, may gain a feeling of
achievement by learning to assess her own serum glucose level, but she may have
difficulty continuing glucose assessments on a regular basis.
Behavior problems need to be well defined before outcomes are identified and
interventions planned. Often, it is enough for parents to accept the problem as one
consistent with normal growth and development. Refer parents to helpful websites
and other resources when appropriate (see Chapter 28).
IMPLEMENTATION
School-age children are interested in learning about adult roles, so this means they
will watch you to note your attitude as well as your actions in a given situation. When
giving care, keep in mind that children this age feel more comfortable if they know
the “hows” and “whys” of actions. This means that they may not cooperate with a
procedure until they are given a satisfactory explanation of why it must be done.
OUTCOME EVALUATION
Yearly health visits covering both physical and psychosocial development are
important at this age (American Academy of Pediatrics [AAP], 2016). Examples of
expected outcomes include:
Parent states that he permits the child to make his own age-related decisions.
Child identifies books he has read together with parents in the past 2 weeks.
Child states he understands the variations of growth as related to the growth
chart.
Child does not sustain injuries from sports activities.
Growth and Development of a School-Age Child
The school-age period is a relatively long time span, and even though growth is slow,
children grow and develop extensively during this time period.
PHYSICAL GROWTH
The average annual weight gain for a school-age child is approximately 3 to 5 lb (1.3 to
2.2 kg); the increase in height is 1 to 2 in. (2.5 to 5 cm). Children who did not lose a
lordosis and knock-kneed appearance during the preschool period lose this now.
By 10 years of age, brain growth is complete, so fine motor coordination becomes
refined. As the eye globe reaches its final shape at about this same time, an adult vision
level is achieved. If the eruption of permanent teeth and growth of the jaw do not
correlate with final head growth, malocclusion with teeth malalignment may be present
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(Massignan, Cardoso, Porporatti, et al., 2016).
The immune globulins IgG and IgA each reach adult levels, and lymphatic tissue
continues to grow in size until about age 9 years. The resulting abundance of tonsillar
and adenoid tissue in early school children is often mistaken for disease because the
tonsils seem to fill the entire back of the throat. This may also result in temporary
conduction deafness from eustachian tube obstruction until the tissue recedes normally.
The appendix is also lined with lymphatic tissue, so swelling of this tissue in the narrow
tube can lead to trapped fecal material and inflammation (appendicitis) in the early
school-age child (Bishop, 2011). Frontal sinuses develop at about 6 years, so sinus
headaches become a possibility (before then, a headache in children is rarely caused by
a sinus infection) (Smith, 2011).
The left ventricle of the heart enlarges to be strong enough to pump blood to the
growing body. Innocent heart murmurs may become apparent due to this extra blood
crossing heart valves. The pulse rate decreases to 70 to 80 beats/min; blood pressure
rises to about 112/60 mmHg. Maturation of the respiratory system leads to increased
oxygen–carbon dioxide exchange, which increases exertion ability and stamina.
Scoliosis may become apparent for the first time in late childhood (Fletcher & Bruce,
2012). All school-age children older than 8 years should be screened for this at all
health appraisals (see Chapter 51).
Sexual Maturation
At a set point in brain maturity, the hypothalamus transmits an enzyme to the anterior
pituitary gland to begin production of gonadotropic hormones, which then activate
changes in the testes and ovaries to cause puberty. Hormone changes that occur with
puberty are discussed in detail in Chapter 5. Table 32.1 describes the usual order in
which secondary sex characteristics develop.
TABLE 32.1 CHRONOLOGIC DEVELOPMENT OF SECONDARY SEX
CHARACTERISTICS
Age (in
Years)
Boys
Girls
9–11
Prepubertal weight gain occurs.
Breasts: elevation of papilla with
breast bud formation; areolar
diameter enlarges.
11–12
Sparse growth of straight, downy,
slightly pigmented hair at base
of penis.
Scrotum becomes textured;
growth of penis and testes
begins.
Sebaceous gland secretion
Straight hair along the labia; vaginal
epithelium becomes cornified.
pH of vaginal secretions becomes
acidic; slight mucous vaginal
discharge is present.
Sebaceous gland secretion increases.
Perspiration increases.
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12–13
increases.
Perspiration increases.
Pubic hair present across pubis.
Penis lengthens.
Dramatic linear growth spurt.
Breast enlargement may occur.
Dramatic growth spurt.
Pubic hair grows darker; spreads over
entire pubis.
Breasts enlarge, still no protrusion of
nipples.
Axillary hair present.
Menarche occurs.
Timing of the onset of puberty varies widely, between 8 and 14 years of age
(Edmonds, 2012), partly due to genetic and cultural differences, and is rated according
to Tanner stages (shown in Chapter 33). The length of time it takes to pass through
puberty until sexual maturity is complete also varies. Sexual maturation in girls usually
occurs between the years of 12 and 18; in boys, between 14 and 20 years. Puberty is
occurring increasingly earlier, however, and in a class of 11-year-old sixth graders, it is
not unusual to discover more than half of the girls are already menstruating. This
change in the onset of puberty is important because it means, for sex education to be
effective, parents or schools must introduce this material as early as when their children
are in grade school. Precocious puberty is an abnormal onset of puberty and is discussed
in Chapter 47.
Sexual and Physical Concerns
The changes in physical appearance that come with puberty can lead to concerns for
both children and their parents. The school-age period is a time for parents to discuss
with children the physical changes that will occur and the sexual responsibility these
changes dictate. This is also a time to reinforce previous teaching with children that
their body is their own, to be used only in the way they choose. Specific measures for
children to help prevent sexual maltreatment are discussed later in this chapter. Nurses
can play a major role in this type of education (Breuner & Mattson, 2016).
In both sexes, puberty brings changes in the sebaceous glands. Under the influence
of androgen, glands become more active, setting the stage for acne (see Chapter 33).
Vasomotor instability commonly leads to blushing; perspiration also increases.
Concerns of Girls
Prepubertal girls are usually taller by about 2 in. (5 cm) or more than preadolescent boys
because their typical growth spurt begins earlier. In a culture in which boys are expected
to be taller than girls, this can cause concern. Sometimes, a girl notices the change in
her pelvic contour when she tries on a skirt or dress from the year before and realizes
her hips are becoming broader. She may misinterpret this finding as a gain in weight
and attempt a crash diet. You can assure her that broad bone structure of the hips is part
of an adult female profile.
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Girls are usually conscious of breast development. A girl who develops ahead of her
peers may tend to slouch or wear loose clothing to hide the size of her breasts. Another
girl studies herself in a mirror and wonders whether her breasts are going to develop
enough. Breast development is not always symmetrical, so it is not unusual for a girl to
have breasts of slightly different sizes. After the condition has been checked during a
physical examination to assure her that no tumors are present to make one breast larger
or that the other is diseased in some way to make it smaller, she can be reassured this
development is normal. Supernumerary (additional) nipples may darken or increase in
size at puberty. Be sure girls understand that a supernumerary nipple is affected by the
hormones in her body in the same way as other breast tissue, so she isn’t concerned by
the accessory nipple enlarging with puberty or in a future pregnancy.
Early preparation for menstruation is an important preparation for future
childbearing and for a girl’s concept of herself as a woman (AAP, 2016) (Box 32.2). A
girl who is told menstruation is a normal function that occurs every month in all healthy
women has a different attitude toward her body than a girl who wakes up one morning
to find blood on her pajamas and is told bluntly, “You’d better get used to that. You’ll
have to put up with it for the rest of your life.” In the first instance, the girl can trust her
body: It is doing what every woman’s body does. In the second instance, the girl may
feel her body is out of control. How can she accept and enjoy growing up if it involves
something so unpredictable?
BOX 32.2
Nursing Care Planning Tips for Effective Communication
Shelly, 11 years old, comes into the nurse’s office at her school in her gym clothes.
She was sent to the office because she refused to change into her school clothes. She
asks to go home because she needs to change her clothes. She is crying and asking
the nurse to call her mother.
Tip: Through effective communication and listening, you can help them talk about
their problems and concerns. In the past, when topics such as menstruation were
discussed only in whispers, and neither television nor magazines advertised tampons
or medicine for menstrual discomfort, most 11-year-old children had little idea about
what to expect at puberty. Today, with this information readily available, it is easy to
forget that preadolescents still may not know much about what to expect at puberty.
Nurse: Hello, Shelly. What can I do for you?
Shelly: I’m having cramps.
Nurse: Are you having your period?
Shelly: No. I haven’t started them yet.
Nurse: Can you describe your cramps to me?
Shelly: Both my sisters started their periods when they were 10.
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Nurse: Are you sick to your stomach?
Shelly: I’m the only girl in my gym class who doesn’t have her period yet.
Nurse: You sound as if you’re more worried about that than what you came in for.
Shelly: I need to know why I’m so different. Will I be able to have children?
Nurse: Let’s talk about that.
In addition to an explanation of the reason for menstrual flow, girls need an
explanation of proper hygiene and reassurance they can bathe, shower, and swim during
their periods. They can use either sanitary napkins or tampons; if they choose tampons,
they must take precautions to avoid toxic shock syndrome (see Chapter 47).
Girls also need to know that vaginal secretions will begin to be present. If this is not
explained, a girl may fear needlessly she has contracted an infection. Explain that any
secretions that cause vulvar irritation should be evaluated by a healthcare provider
because this does suggest infection.
Most girls have some menstrual irregularity during the first year or two after
menarche (the start of menstruation). This occurs primarily because a girl’s cycles are at
first anovulatory. With added maturity and the onset of ovulation, cycles become more
regular.
Irregular periods can cause concern because girls need to know when their periods
will occur so they can get used to this new phenomenon and learn to trust their bodies
(AAP, 2016). A girl in college can explain matter-of-factly that she prefers not to go to
the beach because she is having her period, but for a preadolescent, this topic may be
too sophisticated and too emotionally charged to discuss openly. Preteenagers want to
be able to plan activities to avoid having to make such explanations.
This means that menstrual irregularity can be a significant concern for
preadolescents. A girl may fear that irregular periods indicate a hormone imbalance. She
may worry about her future ability to conceive, or she may be ill informed about how
conception occurs and may fear irregularity of her periods means that she is pregnant.
Both malnourishment and obesity possibly influence menstrual regularity. Emotions can
also affect consistent cycles. If irregularity continues beyond the first year, a careful
history of the girl’s nutrition; overall health; and school, social, and home adjustment
should be taken. Dysmenorrhea, or painful menstruation, is discussed in Chapter 47.
For a nominal charge, manufacturers of sanitary napkins or tampons will mail an
introductory kit of their products, together with well-illustrated, factual booklets, to
introduce girls to menstruation. Such kits are useful if they supplement a parent’s or a
nurse’s discussion, but they should not take the place of individual discussions.
Concerns of Boys
Boys who are not prepared for the physical changes of puberty worry about them in the
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same way as girls. Just as girls become keenly aware of breast development, boys
become aware of increasing genital size. If they do not know testicular development
precedes penis growth, they can worry that their growth will be inadequate.
Hypertrophy of breast tissue (gynecomastia) can occur in prepubescent boys, most
often in those who are obese. A youth with this condition may be concerned a breast
tumor is present or may feel embarrassed about his growing breasts. He can be assured
that this is a transitory phenomenon and, although it makes him self-conscious, will fade
as soon as his male hormones become more mature and active.
Some boys can also become concerned because although they have pubic hair, they
cannot yet grow a beard or do not have chest hair, which are outward, easily recognized
signs of maturity. You can assure them that pubic hair normally appears first and that
chest and facial hair may not grow until several years later.
As increased seminal fluid begins to be produced, boys begin to notice ejaculation
during sleep, termed nocturnal emissions (Widaman & Helm, 2012). Preadolescent
boys may believe the old myth that loss of seminal fluid is debilitating; also, boys may
have heard the term “premature ejaculation” and worry this is a forewarning of a
problem in years to come. Both are fallacies.
Concerns for Transgender Children
Transgender children identify with the gender that is not their natal (sex assigned at
birth) sex. Studies on the mental health of transgender children reported a higher
incidence of psychosocial disorders such as depression and anxiety (Olson, Durwood,
DeMeules, et al., 2015). Children who are supported by their family may experience
less anxiety and depression. A study by Olson et al. (2015) sought to compare the
difference in anxiety and depression scores, as rated by their parents, between
transgender children (ages 3 to 12 years) and a control group. Seventy-three children
were recruited in each group, including 49 siblings in the control group. The mean age
was 7.5 years. The children were recruited from support groups, a website, conferences,
and word of mouth. The results of the depression scores between the transgender
children and the control group were not statistically different. The results of the anxiety
scores were slightly higher in the transgender children compared with the control group
but not in the preclinical or clinical range. The findings may be difficult to generalize to
all children as the family income was $125,000 or more in 50% or more of each group.
The majority of the children in the study were self-identified by the parents as
White/non-Hispanic. The study was promising in supporting the premise that family
and community support is a protective factor for transgender children. All children
benefit from being treated as unique individuals unrelated to their gender preference.
Transgender children are no different in this respect. In the past, it was thought that
gender preference was fluid until the child reached late adolescence. It is now known
that gender preferences are often identified in early childhood (Sherer, 2016). This
would indicate that support for transgender children should begin early in childhood. It
is important that children are not ridiculed or isolated secondary to their gender
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preference because exposure to positive interaction with adults regardless of gender
preference is helpful in promoting healthy child development.
Teeth
Deciduous teeth are lost and permanent teeth erupt during the school-age period (Fig.
32.1). Because of this, the average child gains 28 teeth between 6 and 12 years of age:
the central and lateral incisors; first, second, and third cuspids; and first and second
molars (Fig. 32.2).
Figure 32.1 Early school-age children typically have a missing upper
incisor as deciduous teeth are replaced by permanent teeth.
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Figure 32.2 The eruption pattern of permanent teeth.
DEVELOPMENTAL MILESTONES
As with all ages, you can measure school-age children’s progress by whether they meet
typical developmental milestones.
Gross Motor Development
School-age development is summarized in Table 32.2. At the beginning of the schoolage period (age 6 years), children endlessly jump, tumble, skip, and hop. They have
enough coordination to walk a straight line, many can ride a bicycle, and they learn to
skip rope with practice.
TABLE 32.2 SUMMARY OF SCHOOL-AGE DEVELOPMENT
Age (in
Years)
Physical Development
Psychosocial and Cognitive Development
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6
A year of constant
First-grade teacher becomes authority figure;
motion; skipping is a
adjustment to all-day school may be
new skill; first molars
difficult and may lead to nervous
erupt.
manifestations of fingernail biting, etc.
Defines words by their use (e.g., a key is to
unlock a door, not a metal object).
7
Central incisors erupt;
A quiet year; striving for perfection leads to
difference between
this year being called an eraser year. Learns
sexes becomes
conservation (e.g., water poured from tall
apparent in play (e.g.,
container to a wide, flat one is the same
video games vs.
amount of water); can tell time; can make
dolls); spends time in
simple change.
quiet play.
8
Coordination definitely
improved; eyesight
fully develops;
playing with friends
becomes important.
“Best friends” develop; whispering and
giggling begin; can write in cursive as well
as print; understands concepts of past,
present, and future.
9
All activities done with
friends
Friend or club age; a 9-year-old club is
formed to spite someone, has secret codes,
is all boy or all girl; clubs disband and
reform quickly.
10
Coordination improves.
Ready for camp away from home; collecting
age; likes rules; ready for competitive
games.
11
Active, but awkward
and ungainly
Coordination improves.
Insecure with members of opposite sex;
repeats off-color jokes.
A sense of humor is present; is social and
cooperative.
12
A 7-year-old child appears quiet compared with the more active 6-year-old. Gender
differences usually begin to manifest themselves in play: where girls may gravitate to
more traditional female roles and activities and boys may gravitate to more traditional
male roles and activities.
The movements of 8-year-olds are more graceful than those of younger children,
although, as their arms and legs grow, they may appear awkward in their play and
eating habits. They ride a bicycle well and enjoy sports such as gymnastics, soccer, and
hockey.
Nine-year-olds are on the go constantly, as if they always have a deadline to meet.
They have enough eye–hand coordination to enjoy baseball, basketball, and volleyball.
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By 10 years of age, children are more interested in perfecting their athletic skills than
they were previously.
At 11 years of age, many children feel awkward because of their growth spurt and
drop out of sports activities rather than look ungainly attempting them. They may
channel their energy into constant motion instead: drumming fingers and tapping
pencils or feet. This fall in sports participation may bother parents who see sports as the
key to popularity, self-esteem, fitness, and teamwork.
Twelve-year-olds plunge into activities with intensity and concentration. They often
enjoy participating in sports events for charities such as walkathons. They may be
refreshingly cooperative around the house, able to handle a great deal of responsibility
and complete given tasks.
Fine Motor Development
Six-year-olds can easily tie their shoelaces. They can cut and paste well and draw a
person with good detail. They can print, although they may routinely reverse letters.
Seven-year-olds concentrate on fine motor skills even more than they did the year
before. This has been called the “eraser year” because children are never quite content
with what they have done. They set too high a standard for themselves and then have
difficulty performing at that level.
By 8 years of age, children’s eyes are developed enough so they can read regularsize type. This can make reading a greater pleasure and school more enjoyable (Fig.
32.3). Eight-year-olds are able to write script in addition to print. They enjoy showing
off this new skill in cards, letters, or projects. By age 9 years, their writing begins to
look mature and less awkward.
Figure 32.3 One of the biggest discoveries of childhood is that
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reading and writing are fun. These are activities that can help a child
pass the hours during an illness.
Older school-age children begin to evaluate their teachers’ ability and may perform
at varying levels depending on each teacher’s expectations. The middle school
curriculum involves more challenging science and mathematics courses than previously
and includes good literature. This may be a child’s first exposure to reading as a
fulfilling and worthwhile experience rather than just as an assignment and may be the
time a child is “turned on” to reading.
Play
Play continues to be active at age 6 years; however, when children discover reading as
an enjoyable activity that opens doors to other worlds, they can begin to spend quiet
time with books. Many children spend hours playing increasingly challenging video
games, an activity that can either foster a healthy sense of competition or create
isolation from others.
By 7 years of age, children require more props for play than when they were
younger. To be a police officer, for example, a 7-year-old may need a badge and gun,
whereas before, a pointed finger sufficed. This is the start of a decline in imaginative
play, which will continue unless a child receives adequate encouragement to use
imagination. At age 7 years, children begin to prefer teenage dolls if they play with
dolls, and their coordination is good enough that they can button the miniature dresses
and pull on the tiny boots.
Around 7 years of age, children also develop an interest in collecting items such as
baseball cards, dolls, rocks, or marbles. The type of item is not as important as the
quantity. These collections become structured as a child reaches 8 years of age; time is
spent sorting and cataloging. Most girls and boys of this age also enjoy helping in the
kitchen with jobs such as making cookies and salads or frosting cakes. They start to be
more involved in simple science projects and experiments. Eight-year-olds also like
table games but hate to lose, so they tend to avoid competitive games. They may change
the rules in the middle of a game to keep from losing.
Nine-year-olds play hard. They wake in the morning, squeeze in some activity
before school, and plan something the moment they arrive home again. They may have
difficulty going to bed at night because they want to play just one more game. Play is
rough; children are not as interested in perfecting their skills as they will be in another
year. Some parents or coaches expect children of this age to be more interested in
perfecting their skills, so conflicts can arise.
Many schools begin music lessons for children at about 9 years of age. Children do
well if others in their group are taking similar lessons. Talent for music or art becomes
evident, and children respond with new interest in school or wherever they are exposed
to these arts. Nine years of age is also a time when children use social media. This is an
activity parents need to supervise as they may not realize that their accounts are
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available to the public and potential child predators.
Many 10-year-olds spend most of their time playing screen games. Boys and girls
play separately at age 10 years, although interest in the opposite sex is apparent. Boys
show off as girls pass their group; girls talk loudly or giggle at the sight of a familiar
boy. Girls become more interested in the way they look and dress. Slumber parties and
campouts become increasingly popular.
During their 10th year, children become very interested in rules and fairness. Before
this time, they gave younger children breaks in games, allowing extra turns or hints.
Now, they strictly enforce rules (Fig. 32.4). Club activities become structured, with a
president, a secretary, and rules of order.
Figure 32.4 By 10 years of age, children are ready for competition.
These two children enjoy a game of chess.
Children age 11 and 12 years enjoy dancing and playing table games; they are
accommodating enough again to be able to play with younger siblings who need the
rules modified to their advantage. Time with friends is often spent just talking. Twelveyear-olds typically like to do jobs around the house or babysitting for money. State laws
vary on when a child may care for younger children without adult supervision. Both
boys and girls seem to feel they are on the verge of something great and anxiously wait
to turn 13 years old and become teenagers. The website www.healthychildren.org
provides guidance for parents on developmental norms.
LANGUAGE DEVELOPMENT
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Six-year-olds talk in full sentences, using language easily and with meaning. They no
longer sound as though talking is an experiment but appear to have incorporated
language permanently. They still define objects by their use (e.g., a key is to unlock a
door, a fork is to eat with).
Most 7-year-olds can tell the time in hours, but they may have trouble with concepts
such as “half past” and “quarter to,” especially with the prevalence of digital clocks.
They know the months of the year and can name the months in which holidays fall.
They can add and subtract and make simple change (if they have had experience), so
they can go with a parent to a store and make simple purchases. Much of children’s talk
is concerned with these concepts as they practice them and show them off for family or
friends.
Because children discover “dirty” jokes at about age 9 years, they like to tell them to
friends or try to understand those told by adults. They use swear words to express anger
or just to show other children that they are growing up. They may have a short period of
intense fascination with “bathroom language,” as they did during the preschool years.
As before, if parents want to discourage this, it should be made clear that they find such
language unacceptable, and they refrain from using it themselves in their child’s
presence.
By 12 years of age, children can carry on an adult conversation, although stories are
limited because of a lack of experience.
EMOTIONAL DEVELOPMENT
Ideally, children enter the school-age period with the ability to trust others and with a
sense of respect for their own worth. They can accomplish small tasks independently
because they have gained a sense of autonomy. They should have practiced or
mimicked adult roles, learned to share, discovered that learning is an adventure, and
grasped the idea that doing things is more important and more rewarding than watching
things being done (a sense of initiative).
Developmental Task: Industry Versus Inferiority
During the early school years, children attempt to master their new developmental step:
learning a sense of industry or accomplishment (Erikson, 1993). If gaining a sense of
initiative can be defined as learning how to do things, then gaining a sense of industry is
learning how to do things well.
If children are prevented from achieving a sense of industry or do not receive
rewards for accomplishment, they can develop a feeling of inferiority or become
convinced they cannot do things they actually can do. These children can have difficulty
tackling new situations later in life (e.g., new job, new school, new responsibility)
because they cannot envision how they will be successful in handling them. This can
result in frustration in school or work activities.
The questions a preschool child asks reflect curiosity, such as “how,” “why,” and
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“what.” During the early school years, children concentrate their questions on the “how”
of tasks: “Is this the right way to do this?” “Am I making this right?” and “Is this
good?” Often, school-age children will comment, “I can’t do anything right” because
their craft project falls short of expectations. School-age children need reassurance that
they are doing things correctly, and this reassurance is best if it comes immediately after
a task is completed.
Concept Mastery Alert
Children benefit from honest praise and are quick to identify praise that is
undeserved. Situations in which the child can be successful—and for which they can
receive honest and deserved recognition—are vital to the development of confidence.
The books preferred by school-age children have many short chapters; children
experience a sense of accomplishment as they finish each chapter. Small chores that can
be completed quickly also give this type of reward. Children can survey their finished
work and see they have done a good job. A child may dislike vacuuming, for instance,
because the rug may not look very different when the task is complete. Picking up the
scattered contents of a toy box, however, is a task that clearly makes a difference in the
appearance of the room and so offers a reward.
Hobbies and projects also are enjoyed best if they are small and can be finished
within a short time. Most school-age children, for example, prefer putting together two
or three fairly simple model-car kits to assembling one extremely complicated kit. The
three kits offer three rewards, whereas the involved one delays the reward so long that
the child may become bored and never complete it. With adolescence will come more
respect for quality. Teenagers realize that if they want the better model, they will have
to spend the extra energy and attention and that quality products involve quality work
(Fig. 32.5).
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Figure 32.5 Assembling this simple model in a short time helps a
school-age child gain a sense of industry. (© Stephen Frisch/Stock
Boston.)
Home as a Setting to Learn Industry
Parents of a school-age child may need to take a step forward in development along
with their child. For the first time, they realize their child has begun to look to other role
models than themselves. Parents who enjoyed fostering imagination in a preschooler
may feel frustrated when a school-age child chooses to conform to rules and insists on
the “right way” to do things. They may feel they have failed to encourage the child’s
creativity, but conformity is vital to children at this age. It is how they learn more about
their world’s rules (Weisleder, Cates, Dreyer, et al., 2016).
Children 8 or 9 years of age begin to spend more and more time with their peers and
less time with their family. They forget to do household chores they once enjoyed, such
as setting the table or mowing the lawn, or they may do the work sloppily so they have
more time to spend with their friends. Although this may seem like a regression in
behavior, it is actually a step of independence away from the parents and into the larger
world, a developmental step toward helping them become emotionally mature. This is
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an example of a new role the child is trying out, one of many that will be tried in the
process of reaching maturity, when an eventual “right fit” is found.
School as a Setting to Learn Industry
Adjusting to and achieving in school are two of the major tasks for this age group.
Ideally, a child’s teacher will think of learning as fun and will encourage a child to
plunge into new experiences.
Schools are increasingly assuming responsibility for education about sex, safety,
avoidance of substances of abuse, and preparation for family living. These discussions
are generally superficial, however, and, if the classes are large, may raise more
questions than they answer. Although learning these skills with peers helps children
learn other people’s opinions in these areas, such classes should not replace parental
teaching.
Structured Activities
The Girl Scouts, the Boy Scouts, the Camp Fire Girls, and 4-H clubs are respected
school-age activities. If the local chapters are well run by leaders who understand
children’s needs, they can provide hours of constructive activity and strengthen a sense
of industry. Merit badge systems are geared to the needs of school-age children,
offering small but frequent rewards. As with school activities, parents should determine
the worth of each organization for their individual child.
Urge parents to evaluate competitive sports programs as well. Before children can
compete successfully in these, they must be able to lose a game without feeling
devastated—in other words, be able to say, “I lost because I played badly,” not “I lost
because I am a bad person.” Children do not usually develop sufficient ego strength to
do this until they are about 10 years old.
Another problem to consider with organized contact sports is the possibility of
athletic injuries. Encourage parents to consider their child’s maturity and the risk of
injury (see Chapter 52) before they decide whether team competition is right for their
child (Theisen, Frisch, Malisoux, et al., 2012). Parents should encourage children to
vary the type of sport throughout the year to avoid repetitive use injuries by using the
same muscle groups.
Problem Solving
An important part of developing a sense of industry is learning how to solve problems.
Parents and teachers can help children develop this skill by encouraging practice. When
a child asks, “Is this the right way to do this?” a parent can encourage problem solving
by saying, “Let’s talk about possible ways of doing it” rather than offering a quick
solution.
The world depends on machinery, so mishaps and breakdowns (and therefore
sudden changes) do occur. A child who can create an indoor playhouse with a card table
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and blanket when it is too wet or cold to use an outdoor one will be able, as an adult, to
problem solve another solution to a data distribution problem when a computer
malfunctions. This attitude of optimism rather than pessimism toward problem solving
produces adults who rarely say, “It can’t be done.” Just as important, it leaves these
adults with confidence, a sense of pride, and feeling good about themselves because
they have control of their environment and abilities.
QSEN Checkpoint Question 32.1
QUALITY IMPROVEMENT
According to Erikson, a sense of industry or accomplishment is the developmental
task of the school-age period. When planning care, what would be the best activity to
introduce to Shelly to help her achieve this?
a. Encourage her to establish a new club.
b. Suggest she begin a diary in which she records her secret thoughts.
c. Help her with spelling so over a year’s time she becomes an expert at this.
d. Locate small projects she could complete in 1 day and feel rewarded.
Look in Appendix A for the best answer and rationale.
Learning to Live With Others
School-age children are sometimes so interested in tasks and in accomplishing
physical projects that they forget they must work with people to achieve these goals. A
good time to urge children to learn compassion and thoughtfulness toward others is
during the early school years, when children are first exposed to large groups of other
youngsters. Writing thank you letters or shoveling an older neighbor’s sidewalk are
examples of activities that can help children develop empathy toward others.
Learning to give a present without receiving one in return or doing a favor without
expecting a reward is also a part of this process, and this can be taught by example.
Children should see their parents doing such things with an attitude not of “What will I
get out of this?” but “What can I contribute?”
Children may show empathy toward others as early as 20 months, but cognitively,
they cannot relate others’ experiences to their own until about 6 years of age. Therefore,
it is usually ineffective to lecture a child by saying, “That was cruel to call Mary
names.” The child may feel she had every right to do so. A better technique is to ask
children to put themselves in Mary’s place for a minute and imagine how they would
feel if they were Mary. A school-age child will generally be able to do this and
understand why name-calling hurts. Following this, a simple statement such as “It
doesn’t feel good to be called names, does it?” may suffice.
Socialization
Six-year-old children play in groups, but when they are tired or under stress, they
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usually prefer one-to-one contact. In a first-grade classroom, for example, students
compete actively for a few minutes of special time with their teacher. At the end of a
day, they enjoy spending individual time with parents. You may have to remind parents
that this is not babyish behavior but that of a typical 6-year-old.
Seven-year-olds are increasingly aware of family roles and responsibility. Promises
must be kept because 7-year-olds view them as definite, firm commitments. Children
this age tattle because they have such a strong sense of justice (Loke, Heyman, Forgie,
et al., 2011).
Eight-year-olds actively seek the company of other children. Most 8-year-old girls
have a close girlfriend; boys have a close boyfriend. Girls begin to whisper among
themselves as they share secrets with close friends, annoying both parents and teachers.
Nine-year-olds take the values of their peer group very seriously. They are much
more interested in how other children dress than in what their parents want them to
wear. This is typically the friend or club age because children form groups, usually
“spite clubs.” This means if there are four girls on the block, three form a club and
exclude the fourth. The reason for exclusion is often unclear; it might be that the fourth
child has a chronic disease, she has more or less money than the others, she was at the
dentist’s the day the club was formed, or simply that the club cannot exist unless there is
someone to exclude. Such clubs typically have a secret password and secret meeting
place. Membership is generally all girls or all boys.
If an excluded child does not react badly to being shut out, the club will probably
disband after a few days because its purpose is lost. The next day, the excluded member
may meet with two others and snub a different child. Parents need to use caution
deciding whether to intervene with this type of play because loyalties shift quickly: The
child who is club president today may be the excluded one tomorrow.
Because they are so ready for social interaction, 9-year-olds are ready for activities
away from home, such as a week at camp. They can take care of their own needs and
are mature enough to be separated from their parents for this length of time. Going to
camp before this age usually results in homesickness and can be a negative introduction
to being away from home.
Although 10-year-olds enjoy groups, they also enjoy privacy. They like having their
own bedroom or at least their own dresser, where they can store a collection and know it
is free from parents’ or siblings’ eyes. One of the best gifts for a 10-year-old is a box
that locks.
Girls become increasingly interested in boys and vice versa by 11 years of age.
Favorite activities are mixed-sex rather than single-sex ones. Children of this age are
particularly insecure, however, and girls tend to dance with girls, whereas boys talk
together in corners. Better socialization patterns need not be rushed. Just as infants
crawl before they walk, so 11-year-olds must attempt many awkward and
uncomfortable social experiences before they become comfortable forming relationships
with the opposite sex.
Twelve-year-olds feel more comfortable in social situations than they did the year
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before. Boys experience erections on small provocation and so may feel uncomfortable
being pushed into boy–girl situations until they learn how to better control their bodies.
Because some children develop faster than others, every group has some members who
are almost adolescent and some who are still children, making social interactions
sometimes difficult.
QSEN Checkpoint Question 32.2
INFORMATICS
Shelly belonged to a series of clubs when she was 9 years old. How would the school
nurse describe the typical characteristic of a 9-year-old’s club to the nursing student?
a. Clubs have formal rules and regulations.
b. Clubs are designed to help shy children get outside of their “comfort zone.”
c. Clubs invariably exclude one or more children.
d. Clubs always include both boys and girls.
Look in Appendix A for the best answer and rationale.
COGNITIVE DEVELOPMENT
The age from 5 to 11 years is a transitional stage where children undergo a shift from
the preoperational thought they used as preschoolers to concrete operational thought or
the ability to reason through any problem they can actually visualize (Piaget, 1969)
(Fig. 32.6).
Figure 32.6 School-age children learn concrete operational thought or
concentrate on phenomena they can actually see occurring. For
example, children may have closely catalogued collections of action
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figures, science specimens, sports materials, or books and spend much
time attending to and enhancing such collections.
Children can use concrete operational thought because they learn several new
concepts during school age, such as:
• Decentering, the ability to project one’s self into other people’s situations and see
the world from their viewpoint rather than focusing only on their own view.
• Accommodation, the ability to adapt thought processes to fit what is perceived
such as understanding that there can be more than one reason for other people’s
actions. A preschooler might expect to see the same nurse in the morning who
was there the evening before, whereas a school-age child will understand that
different nurses work different shifts.
• Conservation, the ability to appreciate that a change in shape does not
necessarily mean a change in size. If you pour 30 ml of cough medicine from a
thin glass to a wide one, the preschooler will say that one glass holds more than
the other; a school-age child will know that both glasses hold an equal amount.
• Class inclusion, the ability to understand that objects can belong to more than
one classification. A preschooler is able to categorize items in only one way, for
example, stones and shells are found at the beach; a school-age child can
categorize them in many ways such as by different materials or by a difference in
sizes and shapes, not just that they are found at the beach.
These cognitive developments lead to some of the typical changes and
characteristics of the school-age period. Decentering enables a school-age child to feel
compassion for others, which was not possible in younger years. Because understanding
the principle of conservation is possible, a school-age child is not fooled by perceptions
as often as before. The ability to classify objects leads to the collecting activities of the
school-age period. Class inclusion is also necessary for learning mathematics and
reading, systems that categorize numbers and words.
What If . . . 32.1
The nurse makes Shelly’s hospital bed one day and then gives her an
injection. What if the next day she begins to cry while the nurse is making her
bed because she “doesn’t want a shot”? The lack of what cognitive process led
her to believe the nurse’s actions would be exactly the same the second day?
MORAL AND SPIRITUAL DEVELOPMENT
School-age children begin to mature in terms of moral development as they enter a stage
of preconventional reasoning, sometimes as early as 5 years of age (Kohlberg, 1984).
During this stage, if asked, “Why is it wrong to steal from your neighbor?” school-age
children will answer, “The police say it’s wrong,” or “Because if you do, you’ll go to
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jail.” They concentrate on “niceness” or “fairness” and cannot see yet that stealing hurts
their neighbor, the highest level of moral reasoning. Because they are still limited in
their ability to understand others’ views, they may interpret something as being right
because it is good for them, not because it is right for humanity as a whole.
Remember that school-age children are rule oriented; when they ask for something,
because they were good, they expect to receive what they are asking.
What If . . . 32.2
When the nurse tells Shelly it would be good if she lost some weight, she says
the nurse isn’t being fair. Is this a typical school-age response?
Health Promotion for a School-Age Child and Family
Because of still limited judgment, school-age children need guidelines in reference to
safety, nutrition, and daily care. These are always excellent topics for discussion at
healthcare visits.
PROMOTING SCHOOL-AGE SAFETY
School-age children are ready for time on their own without direct adult supervision.
This means that they need good education on safety practices (Box 32.3). As with
adults, unintentional injuries tend to occur when children are under stress or when they
are distracted.
BOX 32.3
Nursing Care Planning Based on Family Teaching
COMMON SAFETY MEASURES TO PREVENT UNINTENTIONAL
INJURIES DURING THE SCHOOL YEARS
Q. Shelly’s mother tells you, “She’s constantly on the go. How can I keep her free
from accidents when I’m not always with her?”
A. Putting preventive steps in place, such the ones that follow, is the key.
Source of Unintentional Injury Preventive Measure
Motor vehicle
Encourage children to use seat belts and a booster seat if
needed; role model seat belt use.
Teach street-crossing safety; stress that streets are no place
for roughhousing, pushing, or shoving.
Teach parking lot and school bus safety (e.g., do not walk in
back of parked cars, wait for crossing guard).
Bicycle
Teach bicycle safety, including wearing a helmet and not
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giving “passengers” rides.
Community
Teach to avoid unsafe areas, such as train yards, grain silos,
and back alleys.
Stress to not go with strangers (parents can establish a code
word with child; child does not leave school with anyone
who does not know the word).
Teach children to say “no” to anyone who touches them if
they do not wish it, including family members (most
sexual maltreatment is by a family member, not a
stranger).
Teach children not to arrange a meeting with people they
meet on the Internet.
For older school-age children, teach rules of safer sex so
they know these rules before they need to use them a first
time.
Burns
Teach safety with candles, matches, and campfires and that
fire is not fun. Also teach safety with beginning cooking
skills (e.g., be certain to include microwave oven safety,
such as closing firmly before turning on oven; not using
metal containers).
Teach safety with sun exposure; use sun block.
Teach to not climb electric poles.
Falls
Educate that roughhousing on fences or climbing on roofs is
hazardous.
Teach skateboard, scooter, and skating safety.
Sports injuries
Teach that wearing appropriate equipment for sports (e.g.,
face masks for hockey; mouthpiece and cup for football;
helmet for bicycle riding, skateboarding, or in-line
skating; batting helmets for baseball) is not babyish but
smart management.
Stress not to play to a point of exhaustion or in a sport
beyond physical capability (no pitching baseballs or toe
ballet for an early grade-school child).
Use trampolines only with adult supervision to avoid serious
neck injury.
Drowning
Teach how to swim; dares and roughhousing when diving or
swimming are not appropriate. Stress not to swim beyond
limits of capabilities.
Drugs
Help your child avoid all recreational drugs; prescription
medicine should only be taken as directed. Teach to avoid
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tobacco and alcohol.
Firearms
Teach firearm safety. Keep firearms in locked cabinets with
bullets separate from gun.
General
School-age children should keep adults informed as to where
they are and what they are doing; cell phones can help
with this.
Be aware the frequency of unintentional injures increases
when parents are under stress and therefore less attentive.
Special precautions must be taken at these times.
Caution that some children are more active, curious, and
impulsive and therefore more vulnerable to unintentional
injuries than others.
QSEN Checkpoint Question 32.3
Safety
Teaching safety is an important area to consider for school-age children. Which
advice would be best?
a. “Keep your backpack filled to capacity to avoid falling on frequent trips back
to your locker.”
b. “As soon as you no longer need an automobile booster seat, you’ll no longer
need a seatbelt either.”
c. “Gaining weight isn’t serious in the school-age years; it only becomes a real
problem after age 18 years.”
d. “You’re old enough to tell if you are sick or not; your mother’s opinion isn’t
as important as when you were younger.”
Look in Appendix A for the best answer and rationale.
School age is not too early for parents to look at the effect of carrying heavy
backpacks on children’s posture. A backpack that weighs more than 10% of the child’s
body weight is enough to cause a child to have to lean forward chronically to bear the
weight. This can lead to chronic back pain (Kistner, Fiebert, & Roach, 2012).
Sexual maltreatment is an unfortunate and all-too-common hazard for children.
Teaching points to help children avoid sexual maltreatment are summarized in Box 32.4
(see also Chapter 55).
BOX 32.4
Nursing Care Planning Based on Family Teaching
TEACHING POINTS TO HELP CHILDREN AVOID SEXUAL
MALTREATMENT
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Q. Shelly’s mother wants to protect her daughter from being abused sexually. She
asks you, “What are good rules to teach children without scaring them?”
A. A number of suggestions include:
1. Your body is your property and you can decide who looks at it or touches it.
2. Secrets are fun things to keep. If a person asks you not to tell about something that
was done to you that you didn’t like, however, it’s not a secret. It’s all right to tell
someone about it.
3. Don’t go anywhere with a stranger (a stranger is someone you do not know, not
someone “strange”). Don’t be fooled by people asking you to give them directions
or to go with them because your mother is sick or hurt or because they have lost a
pet.
4. Being touched by someone you like is a good feeling. You don’t have to allow
anyone to touch you in a way you don’t like. Don’t allow yourself to be left alone
with a person you are uncomfortable with because that person touches you in a
way you don’t like.
5. Avoid meeting with people you talk with on social media and the Internet because
they may not be the age or the person whom they say they are.
6. A “private part” is the part of you a bathing suit touches. If anyone asks you to
show them a private part or touches a private part, tell them to stop, and tell
someone what happened.
7. If the person you tell doesn’t believe you, keep telling people until someone does
believe you.
PROMOTING NUTRITIONAL HEALTH OF A SCHOOL-AGE CHILD
Most school-age children have good appetites, although meals may be influenced by the
day’s activity. If children have had a full day of active play, they may come to the
dinner table ready to eat anything. If a day was filled with frustration—a child received
a poor mark in school, had an argument with a friend, or has a big game to think about
—the child’s appetite may be affected. This is no different from the way adults feel at
times and so should be respected.
Establishing Healthy Eating Patterns
School-age children should be encouraged to eat a healthy breakfast to ensure the ability
to concentrate during the school day. It is helpful if parents model this behavior.
School-age children can help prepare a nutritious lunch to take to school. If they
purchase lunch at school, healthy choices should be discussed with the child. Healthcare
personnel can play an active role in nutrition education at health maintenance visits.
Many children qualify for a free or reduced-price school lunch and breakfast
(Hirschman & Chriqui, 2012). A government-regulated school lunch provides milk (8
oz), protein (2 oz), one starch serving, a vegetable (¾ cup), and fruit (¾ cup). Serving
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sizes vary according to age to provide one third of a child’s nutrition requirements for a
day (Fig. 32.7). Children with food allergies should be provided with alternative foods.
Depending on the severity of the allergy, such as peanuts, they may need to sit at an
allergy-free table at school.
Figure 32.7 School lunch programs are being modified to better
provide nutritious meals to school-age children.
Nutritious after-school snacks are important in this age group.
Poor eating habits developed in the school-age years may last through adulthood
and lead to an increased risk of health-related diseases, such as type 2 diabetes,
hypertension, cardiovascular disease, and obesity.
Fostering Industry and Nutrition
As a part of fostering industry, school-age children usually enjoy helping to plan meals.
They can prepare simple meals with healthy ingredients. They can assist with the
preparation of more complex meals and learn the safe use of kitchen appliances such as
the microwave and stove.
The development of proper etiquette is important in the school-age years. Parents
can model this behavior for their child and encourage meals to be eaten at the table
rather than while watching television. Meals eaten while watching television or
performing another activity is a risk factor for obesity.
Recommended Dietary Intakes
Although parents may have less to say about what a school-age child eats, it is
important that the increasing energy requirements that come with this age (often in
spurts) are met daily with foods of high nutritional value.
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During the late school years, the recommended dietary intakes for children begin to
be separated into different categories for girls then for boys because boys require more
calories and other nutrients at this time. Both girls and boys require more iron in
prepuberty than they did between the ages of 7 and 10 years. Adequate calcium and
fluoride intake remains important to ensure good teeth and bone growth. A major deficit
may be fiber because school-age children typically dislike vegetables.
A Vegetarian Diet
School-age children who are vegetarians or vegans need to learn how to obtain essential
nutrients whether they pack their lunch or purchase it at school. The consumption of
adequate protein and calcium is important for muscle, bone, and dental development.
Foods highest in calcium are green leafy vegetables such as spinach and turnip
greens, enriched bread, and cereals. Soybeans, legumes, grains, and immature seeds
such as green beans, lima beans, and corn are relatively high in protein. Encourage
outside activities for sun exposure to increase vitamin D. Iron may need to be
supplemented as well, especially in girls with heavy menstrual flows (Whitney &
Rolfes, 2012).
PROMOTING DEVELOPMENT OF A SCHOOL-AGE CHILD IN
DAILY ACTIVITIES
With life centered on school activities and friends, a school-age child still needs parental
guidance for most daily activities because the habits and lifestyle patterns gained during
this period will form the basis for the patterns of living later in life. Figure 32.8 shows a
day in the life of a family with school-age children. Along with nutritional needs, areas
of concern for a school-age child and family include dressing, sleep needs, exercise,
hygiene, and dental care.
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1900
Figure 32.8 A day in the life of a family with young children.
Dress
Although school-age children can fully dress themselves, they are not skilled at taking
care of their clothes until late in the school-age years. This is the right age, however (if
not started already), to teach children the importance of caring for their own belongings.
School-age children have definite opinions about clothing styles, often based on the
likes of their friends, a popular sport, or a popular musician rather than the preferences
of their parents. Help parents be aware that a child who wears different clothing than
others may become the object of exclusion from a school club or group. In schools with
a gang or bullying culture, children may not be able to wear a certain color or style lest
they be mistaken for a gang member or become a bully’s victim (White & Mason,
2011). A number of schools require uniforms or have a dress code to eliminate such
concerns.
1901
Sleep
Sleep needs vary among individual children. Younger school-age children typically
require 10 to 12 hours of sleep each night, whereas older children require about 8 to 10
hours. Most 6-year-olds are too old for naps but do require a quiet time after school to
get them through the remainder of the day. Nighttime terrors may continue during the
early school years and may actually increase during the first-grade year as a child reacts
to the stress of beginning school.
During early school years, many children enjoy a quiet talk or a reading time at
bedtime. At about age 9 years, when friends become important, children generally are
ready to give up bedtime talks with parents in preference to phoning or text messaging a
friend. Some parents may need some help to take at face value their child’s statement,
“I’m tired. I’d rather go to sleep,” rather than feel rejected.
Children with television sets, electronic games, or smartphones in their bedrooms
not only have shorter sleep times at night but also are more likely to be obese (Chahal,
Fung, Kuhle, et al., 2013).
Exercise
School-age children need daily exercise. Although they go to school all day, they do not
automatically receive much exercise because school is basically a sit-down activity.
Children who are bused or driven by a parent to school may therefore return home
without having spent much time in active exercise.
Increasing time spent in exercise need not involve organized sports. It can come
from neighborhood games, walking with parents or a dog, or bicycle riding. As children
enter preadolescence, those with poor coordination may become reluctant to exercise.
Urge them to participate in some form of daily exercise, however, or obesity or
osteoporosis can result later in life (Eagle, Sheetz, Gurm, et al., 2012; Gunter, Almstedt,
& Janz, 2012).
Hygiene
Children 6 or 7 years of age still need help in regulating bath water temperature and in
cleaning their ears and fingernails. By age 8 years, children are generally capable of
bathing themselves but may not do it well because they are too busy to take the time or
because they do not find bathing as important as do their parents.
Both boys and girls become interested in showering as they approach their teen
years. This can be encouraged because perspiration increases with puberty, along with
sebaceous gland activity. When girls begin to menstruate, they may be afraid to take
baths or wash their hair during their period if they have heard this is not safe. They need
information that both of these practices are safe during their menses. Boys who are
uncircumcised may develop inflammation under the foreskin from increased secretions
if they do not wash regularly (Meng & Tanagho, 2013).
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QSEN Checkpoint Question 32.4
EVIDENCE-BASED PRACTICE
Shelly has told the nurse she wants to try out for cheerleading when she gets to high
school. This is a sport appealing to school-age children and adolescents because of its
combinations of dance and gymnastics, the friendships that can develop, and the
school status it almost automatically creates. To investigate what type of injuries
typically occur with cheerleading, researchers reviewed all cheerleading injuries
(over 4,000) presented to U.S. emergency departments during a 5-year period. The
types of injuries most often seen were sprains/strains (44%), fractures (16%), and
contusions (16%). The activities resulting in the most injuries were body collisions
(29%), stunting (19%), tumbling (11%), and tossing (2.5%) (Currie, Fields, Patterson,
et al., 2016).
Based on the study, how would the nurse best advise Shelly?
a. Cheerleading will be good for her because she is likely to lose weight from
the exercise.
b. She will need to drink an extra source of calcium every day to avoid broken
bones.
c. She should pursue a sport or activity that is safer.
d. She should be aware that cheerleading may be beneficial to her but does carry
some risks.
Look in Appendix A for the best answer and rationale.
Care of Teeth
With proper dental care, the average child today can expect to grow up cavity free. To
ensure this happening, school-age children should visit a dentist at least twice yearly for
a checkup, cleaning, and possibly a fluoride treatment to strengthen and harden the
tooth enamel or sealants on secondary teeth (Tubert-Jeannin, Auclair, Amsallem, et al.,
2011) (Fig. 32.9). Remind them that not all bottled water is fluoridated, so they don’t
want this to be their main source of drinking water. Some children develop a fear of
dentists and, if a dentist visit was painful, want to avoid going at all. The advantage of
frequent visits permits problems to be addressed early and familiarizes the child with
the dental visit. Pedodontists specialize in caring for children’s teeth and understand the
developmental level of their patients. The parents of children who tend to develop caries
might be encouraged to visit a pedodontist if one is available and affordable.
1903
Figure 32.9 Dental caries are the number one health problem in
school-age children. Stress to parents that good dental health is
important and encourage school-age children to visit a dentist twice a
year.
School-age children have to be reminded to brush their teeth daily. For effective
brushing, a child should use a soft toothbrush, fluoride-based toothpaste, and dental
floss to clean between teeth to help remove plaque. Electric toothbrushes can be used
safely by school-age children.
Snacks are best limited to high-protein foods such as chicken and cheese rather than
candy. Fruits, vegetables, and cereals fortified with minerals and vitamins (not empty
calorie ones) can all be fun after-school snacks for school-age children. If the child does
eat candy, a type that is eaten quickly and dissolves quickly is better than slowly
dissolving or sticky candy because these types stay in contact with the teeth longer.
QSEN Checkpoint Question 32.5
TEAMWORK & COLLABORATION
1904
Shelly tells the nurse she collected “a ton of candy on Halloween. Because of how
common this phenomenon is, in consultation with a dental hygienist, you would teach
children that what type of candy is less likely to cause dental caries?
a. Salt water taffy
b. A chocolate bar
c. Chewy caramels
d. Hard candy
Look in Appendix A for the best answer and rationale.
PROMOTING HEALTH FAMILY FUNCTIONING
To their parents’ annoyance, many 6-year-olds often quote their teacher as the final
authority on all subjects. This may be the first time the parents see someone surpassing
them in their child’s eyes, and accepting the situation can be painful. Children also cite
their friends as guides for behavior; for example, “Mary Jane doesn’t have to go to bed
until 10 o’clock” or “Carlos’s mother lets him go to the movies every Saturday.”
Parents may require help to realize these remarks are a normal consequence of being
exposed to other adults and children. A simple statement such as “There are all kinds of
ways to do things, but in our house, the rule is this” shows no criticism of Carlos’s or
Mary Jane’s family yet conveys a special and secure “our house” feeling.
Parents may also need to be reminded that even the simplest tasks of everyday life
require repeated practice before they can be accomplished well. The way parents correct
children as they learn these tasks influences children’s opinions of themselves and their
ability to continue learning. “Putting all the silverware in a pile is one way of putting it
away; another way would be to divide spoons, forks, and knives separately” is always
preferable to “What a silly way to put away silverware!” Comments such as “Can’t you
do anything right?” or “Why don’t you ever do what I say?” should always be avoided
because children will rise only to the level expected of them.
If parents have difficulty telling what a child’s completed project is supposed to be,
the time-honored “Tell me about it” is preferable to “What is it?” It is good for parents
to find a redeeming characteristic in a project, no matter how shakily it is put together:
“I like the bright color you painted it” or “That must have been fun to make.”
Displaying and using children’s gifts are part of having school-age children in a family.
A finger painting hung on the refrigerator door enhances, not detracts from, the most
elegant home.
In talking to parents of school-age children, good questions to ask to estimate the
degree of interaction that occurs in the home and whether parents are strengthening a
child’s sense of accomplishment include:
• How do they correct the child when he or she does something wrong?
• Do they display school projects?
• Does the child have chores that are his or hers to accomplish?
• Do they ask the child to participate in family decision making?
1905
COMMON HEALTH PROBLEMS OF THE SCHOOL-AGE PERIOD
Children in their early school years may have many small health concerns such as head
lice or ringworm (see Chapter 43). At the same time, they have one of the lowest rates
of death and serious illness of any age group. The two causes of death seen most
frequently are from unintentional injury and cancer. Minor illnesses are largely due to
dental caries, gastrointestinal disturbances, and upper respiratory infections (Heron,
2012).
Because learning difficulties such as attention deficit hyperactivity disorder
(ADHD) and autism spectrum disorders (ASDs) are identified during the school-age
years, they are important parental concerns (see Chapter 54). Table 32.3 shows the usual
health maintenance pattern for a school-age child (AAP, Committee on Practice and
Ambulatory Medicine, 2012). Table 32.4 lists problems that parents may have in
evaluating illnesses in school-age children.
TABLE 32.3 HEALTH MAINTENANCE SCHEDULE, SCHOOL-AGE PERIOD
Area of Focus
Methods
Frequency
Health history
Health interview
Every visit
Physical health
Physical examination
Every visit
Developmental
milestones
History and observation
Every visit
Growth
milestones
Height and weight plotted on
standard growth chart; body
mass index (BMI)and physical
examination
Every visit
Hypertension
Blood pressure
Every visit
Nutrition
History and observation; height
and weight information
Every visit
Parent–child
relationship
History and observation
Every visit
Behavior or
school
problems
History and observation
Every visit
Vision and
hearing
disorders
History and observation
Every visit
Formal Snellen or Titmus testing
At 7–9 years and 10–12 years
Audiometer testing
At 7–9 years and 10–12 years
Assessment
1906
Dental health
History and physical examination Every visit
Scoliosis
Physical examination
Yearly after age 8 years
Thyroid
Physical examination and history
Every visit after age 10 years
Dyslipidemia
Cholesterol and triglycerides
6–8 years and 10–12 years
Tuberculosis
Purified protein derivative (PPD)
skin test
Depending on prevalence of
tuberculosis in community
Bacteriuria
Clean-catch urine
At 6–7 years
Anemia
Hematocrit and hemoglobin
At 7–8 years and 11–12 years
Immunizations
Check history and past records, inform caregiver about any risks and side effects, and
administer immunization in accordance with healthcare agency policies.
Diphtheria,
tetanus, and
pertussis
vaccine
(DTaP)
11–12 years
Hepatitis A
vaccine
(HepA)
If not previously administered
Hepatitis B
vaccine
(HepB)
If not administered in infancy
or three injections were not
completed
Human
(HPV or HPV4)
papillomavirus
vaccine
11 or 12 years; second injection
2 months later; third injection
6 months after first dose
Inactivated
poliomyelitis
vaccine
If four doses not previously
administered
(IPV)
Influenza vaccine (IIV)
Yearly
Meningococcal
conjugate
vaccine
(MCV4)
11–12 years
Pneumococcal
vaccine
(PPSV)
To children at high risk
Measles, mumps, (MMR)
rubella vaccine
If two doses not previously
administered
Varicella vaccine (VAR)
At any age after 1 year if not
previously immunized, or at
11–12 years if lacking
1907
reliable history of
chickenpox
Anticipatory Guidance
School-age care
Active listening and health
teaching
Every visit
Expected growth Active listening and health
and
teaching
developmental
milestones
before next
visit
Every visit
Unintentional
injury
prevention
Counseling about street and
personal safety
Every visit
Active listening and health
teaching regarding cigarette
smoking, substance abuse, sex
education, school adjustment,
etc.
Every visit
Problem Solving
Any problems
expressed by
caregiver
during course
of the visit
American Academy of Pediatrics, Committee on Practice and Ambulatory Medicine. (2012). Recommendations for
preventive pediatric health care. Washington, DC: Author; and Centers for Disease Control and Prevention.
Birth–18 years & “catch up” immunization schedules. Washington, DC: Author.
TABLE 32.4 PARENTAL DIFFICULTIES EVALUATING HEALTH
PROBLEMS IN THE SCHOOL-AGE CHILD
Difficulty
Helpful Suggestions for Parents
Evaluating
For the first time, a school-age child may view illness as a way to
seriousness of avoid unpleasant activities (e.g., school, a coach who asks too
illness
much, household chores). Evaluating whether the child has
symptoms when asked to do a favorite thing often reveals the
difference between exaggeration and an ill child (e.g., too sick to
eat spinach, not too sick to eat ice cream; too sick to go to school,
not too sick to go ice skating). If the child uses symptoms of illness
as a means of avoiding situations, parents must evaluate what it is
about the situation they could improve or see if some change
should be made in their expectations.
Evaluating
nutritional
intake
Many school-age children eat lunch at school, and they may spend
weekends away from home and weeks away at camp. As with all
ages, noting whether they are growing and active is better than
1908
monitoring any one day’s food intake.
Evaluating
puberty
changes
There is a wide variation in the time secondary sex characteristics
occur (8–17 years for girls; 10–20 years for boys). Children should
be examined if and when they or their parents are concerned
pubertal changes are delayed or appearing too early.
Age-specific
School age is a time to evaluate vision because vision changes occur
diseases to be
with increased maturity of the eye globe. Squinting, rubbing the
aware of
eyes, or poor marks in school may be signs of poor vision.
Streptococcal sore throats occur frequently in early school-age
children. Those with sore throats should be examined by a
healthcare provider to prevent complications, such as
glomerulonephritis or rheumatic fever, from developing. Girls, in
particular, must be evaluated for scoliosis (curvature of the spine).
Parents may detect this by noticing that a girl’s skirt hangs
unevenly or bra straps are uneven.
Parents may need to be cautioned that vomiting or a headache in the
morning that passes fairly quickly (at about the same time the
school bus leaves) may be a symptom of school phobia, but a
physical examination is in order because these are also symptoms
of other conditions.
Absence seizures, a neurologic condition that typically arises in the
school-age years, can be confused with behavior problems if
observation is not thorough (see Chapter 49). Attention deficit
hyperactivity disorder (ADHD) (see Chapter 54) can also lead to
behavior or inattention disorders.
Dental Caries
Caries (cavities) are progressive, destructive lesions or decalcification of the tooth
enamel and dentin. When the pH of the tooth surface drops to 5.6 or below (which
happens after children eat readily fermented carbohydrates, such as table sugar), acid
microorganisms (acidogenic lactobacilli and aciduric streptococci) found in dental
plaque attack the cementing medium of teeth and destroy it. Plaque tends to accumulate
in deep grooves of the teeth and contact areas between teeth, making these areas most
susceptible to dental decay. The enamel on primary teeth is thinner than on permanent
teeth, so these are even more susceptible to destruction than permanent teeth. The
distance from the enamel to the pulp is shorter also, so invasion of the tooth nerve can
occur quickly. Neglected caries result in poor chewing and therefore poor digestion,
abscesses and pain, and sometimes osteomyelitis (bone infection) if the jaw bone is
involved.
As stated earlier, dental caries are largely preventable with proper brushing and use
of fluoridated water or fluoride application. When caries do occur, it’s important they be
1909
treated quickly and the child’s dental hygiene practices be evaluated and improved if
necessary. Most importantly, children must believe that they have a stake in the health
of their teeth, so even though they are cavity free, they willingly undertake the self-care
measures necessary to ensure healthy teeth with parental support rather than parental
command (Wen, Goldberg, Marrs, et al., 2012). Dental visits are recommended every 6
months. With the eruption of the permanent teeth, sealants can be applied at dental visits
to lessen the development of dental decay.
Malocclusion
The upper jaw in children matures during early childhood along with skull growth; the
lower jaw reaches maturity more slowly, forcing teeth to make a prolonged series of
changes until they reach their final adult alignment and position. Good tooth occlusion,
in which the upper teeth overlap the lower teeth by a small amount and teeth are evenly
spaced and in good alignment, is necessary for optimal formation of teeth, health of the
supporting tissue, optimal speech development, and what most people view as a
pleasant physical appearance. Malocclusion (a deviation of tooth position from the
normal) may be congenital due to conditions such as cleft palate, a small lower jaw, or
familial traits tending toward malocclusion. The condition can result later on from
constant mouth breathing or abnormal tongue position (tongue thrusting). Thumbsucking is still another possibility if it persists past the time of eruption of the permanent
front teeth (6 to 7 years) (Sandler, Madahar, & Murray, 2011). The loss of teeth due to
extraction or an unintentional injury may lead to malocclusion if not properly treated so
that alignment is maintained.
Malocclusion may be either crossbite (sideways) or anterior or posterior. Children
with a malocclusion should be evaluated by an orthodontist to see if orthodontic braces
or other therapy is necessary. The time to begin correction varies with the extent of the
malocclusion and jaw size. Braces are painful when they are first applied and at periodic
visits when they are tightened to maintain pressure for further straightening. Some
children develop mild, shallow ulcerations (canker sores) on the buccal membrane from
friction of metal wires. Rubbing the offending wire with dental wax dulls the surface
and gives relief. Oral acetaminophen or an agent such as Orajel (an over-the-counter
drug) rubbed on the ulceration may also offer relief.
All children who wear braces need to brush their teeth well and be assessed
periodically to see that they are brushing properly around the braces (a Waterpik is often
recommended for thorough cleaning). They should use dental floss to remove plaque
from around wires.
After the removal of braces, many children usually wear retainers to maintain the
correction the braces achieved. Although braces are wired into place, retainers are not.
Loss of a retainer can be a problem if it must be removed when eating; check bedside
food trays of school-age children before removing them to be certain a child has not
placed a retainer on the tray.
Show appropriate sympathy and help children problem solve if they are bothered by
1910
the appearance of braces or wearing a retainer. Once thought of as implements to be
made fun of, teeth braces have become such a common feature of life for schoolchildren
that most children who wear them find comfort in not being the only one to suffer this
indignity and, once used to their own appliances, experience little reluctance in letting
their classmates see them. Some even view them as a mark of pride or a status symbol
(Hamdan, Singh, & Rock, 2012).
CONCERNS AND PROBLEMS OF THE SCHOOL-AGE PERIOD
Two of the most important disorders of the school-age period are ADHD and ASDs
because these interfere so dramatically with school progress (see Chapter 54). Other
problems concern language, fears, and responsibility.
Nursing Diagnoses and Related Interventions
Nursing Diagnosis: Parental anxiety related to less-than-expected behavior of a
school-age child
Outcome Evaluation: Parent states undesired behavior has decreased in frequency;
parent feels less stress about the child’s health or future.
Problems Associated With Language Development
The common speech problem of the preschool years is broken fluency; the most
common problem of a school-age child is articulation. The child has difficulty
pronouncing s, z, th, l, r, and w or substitutes w for r (“westroom” instead of
“restroom”) or r for l (“radies’ room” instead of “ladies’ room”). This is most noticeable
during the first and second grades; it usually disappears by the third grade. Unless it
persists, speech therapy for this normal developmental stage is not necessary.
Common Fears and Anxieties of a School-Age Child
School-age children are old enough to experience adult reactions to problems at home
or school.
Anxiety Related to Beginning School
Adjusting to grade school is a big task for 6-year-olds (AAP, Council on Early
Childhood, Council on School Health, 2016). Even if they attended preschool, grade
school is different: The rules are firmer, and the elective feeling (e.g., “If I don’t like it,
I can quit”) no longer applies. School is for keeps until age 16 years or longer, a time
span too long for a young child to even imagine. Also, where preschool learning was
carried out through fun activities, part of every day in grade school involves obvious
1911
work (Box 32.5 shows an interprofessional care map for a child with school concerns).
Some instances of anxiety may be a reflection of a parent’s anxiety (Pass, Arteche,
Cooper, et al., 2012).
BOX 32.5
Nursing Care Planning
AN INTERPROFESSIONAL CARE MAP FOR A SCHOOL-AGE CHILD
BEGINNING MIDDLE SCHOOL
Shelly Lewis is an 11-year-old girl who recently started middle school. Her mother
tells you that, although Shelly, who is overweight, says she likes school and wants to
try out for cheerleading, she has developed a lot of nervous habits such as nail biting
since school started.
Family Assessment: Child lives with mother, stepfather, and three younger
stepsisters in a four-bedroom home. Family owns a boarding kennel for dogs; both
parents work full-time at business. Mother describes finances as “Okay. It’s hard with
a big family.”
Patient Assessment Child: Child has been “chubby” since preschool. States she
likes to read rather than play sports. Is in seventh grade (age appropriate). Observed
to be restless in chair during conversation with mother about the new school. Mother
states, “Her sisters have no trouble with change; she always does. Don’t you think if
she lost weight she’d fit in better?”
Nursing Diagnosis: Anxiety related to beginning a new school.
Outcome Criteria: Child states she feels more comfortable with new school setting;
nail biting has decreased in intensity; child agrees to begin weight-reduction program.
Team Member
Responsible
Assessment
Intervention
Rationale
Expected
Outcome
Activities of Daily Living, Including Safety
Nurse
Assess what
Review with
activities patient patient the
enjoys.
advantages of
participating in
activities that
involve more
exercise than
reading.
Support
cheerleading;
suggest walking
with a friend.
1912
Effective weight
reduction calls
for increased
exercise. Books
on tape can
supply reading
enjoyment while
walking.
Child states she
will try some
active activity
for at least 20
minutes each
day.
Teamwork and Collaboration
Nurse/nurse
practitioner
Assess if child
would be
interested in a
weightreduction class
at the health
center.
Suggest
different options
available such
as a weight-loss
group or a
commercial
weightreduction
program.
Children
respond well to
group activities.
Other group
members supply
friendship as
well as increase
motivation.
Child states
whether she
would like to
join a weightreduction group.
Help child
“walk through”
a day at school
and discuss how
small changes
could affect her
fitting in to
school.
Talking with the
child allows her
to share feelings
and concerns
openly and
safely, possibly
increasing her
awareness of
them and their
impact on her.
Child describes
a typical day
and points she
would like to
see change.
Review with
child changes
that would
reduce calories,
yet maintain her
lifestyle.
Eleven-year-old
children are old
enough to take
responsibility
for what and
when they eat.
Patient reviews
her dietary
intake and
makes at least
three
suggestions on
things she will
attempt to
change.
Review with
mother and
child ways to
reduce stress
when
encountering
new situations,
It is easy for
parents to view
11-year-olds as
able to handle
new situations
better than they
can because of
Mother states
she may have
been taking the
change in
school too
lightly and
agrees to offer
Procedures/Medications for Quality Improvement
Nurse
Ask child to try
to identify if she
feels something
is upsetting
about the new
school; if so,
ask what it is.
Nutrition
Nurse/nutritionist Assess child’s
intake by 24hour recall
history.
Patient-Centered Care
Nurse
Assess if family
members
appreciate the
stress a new
school setting
can create.
1913
such as equating pseudomaturity. more support.
them with
something
already known.
Psychosocial/Spiritual/Emotional Needs
Nurse/nurse
practitioner
Assess family
functioning
with child’s
mother.
Stress that all
children are
individuals and
what works for
her stepsisters
may not work
for the patient.
Being
constantly
compared to
siblings can
create feelings
of low selfesteem, which
can lead to
difficulty
solving
problems.
Mother states
she will try to
reduce
comparisons to
stepsisters to
help reduce
stress at home.
It is difficult for
a family to
make internal
changes if they
are too
emotionally
involved to be
objective.
Mother and
child express
their
preferences
based on their
future plans.
Informatics for Seamless Healthcare Planning
Nurse
Assess if child
or mother
thinks an early
follow-up
appointment
would be
helpful.
Arrange for a
follow-up clinic
appointment
within 1 month
with the mother
and daughter if
desired.
Because school requires an adjustment, a health assessment of all school-age
children should include an inquiry about progress in school by a question such as “How
is Shelly doing in school?” followed by a second question “How does her teacher say
she is doing?” If there is a discrepancy between those two answers, the situation bears
study. Some parents may have to alter their expectations of how much their child should
be achieving to conform to their child’s actual ability. This can obviously be difficult.
One of the biggest tasks of the first year of school is learning to read. It is best if
parents have prepared children for this by reading to them since infancy, pointing to the
words and pictures as they read. This helps children realize that sentences flow from left
to right and that the words, not the pictures, tell the story. Box 32.6 offers some useful
hints to help parents encourage reading in their young school-age child.
BOX 32.6
Nursing Care Planning to Respect Cultural Diversity
1914
With the activities of children in modern cultures turning more toward electronic
games than opening books, reading for pleasure is threatened with becoming a lost
art. A number of tips for making reading more enjoyable and increase cultural
understanding for children include:
• Read books yourself to set an example so your child thinks of reading as an adult
activity. If you spend most of your free time watching television, your child will
think reading is mainly for children and assume that it is not important.
• Make reading more fun by encouraging your child to make practical use of what
he or she reads. Ask the child to read culturally different recipes while you cook or
to read road signs during a car trip.
• Play a treasure hunt game where you hide a small object, such as a favorite toy,
and then write simple clues on slips of paper: “Look under a lamp,” “Look in a
book,” and so on until your child has been led to the hidden object. Your child can
develop writing skills by playing the same game for you to follow.
• Suggest to relatives that a gift certificate from a bookstore would be a good
present. Let your child browse the store to select the book.
• Talk about books the child has read—what was good, what was bad, or what the
child learned while reading.
• Read a book together as a bedtime family activity.
Many first graders are capable of mature action at school but appear less mature
when they return home. They may bite their fingernails, suck their thumb, or talk baby
talk. Some develop tics (irregular movements of isolated muscle groups), such as
wrinkling the forehead, shrugging the shoulders, clearing the throat, or frequently
blinking. Such movements may occasionally be confused with seizure activity. Tics,
however, disappear during sleep and occur mainly when the child is subjected to stress
or anxiety. Scolding, nagging, threatening, or punishing does not stop either tics or nail
biting and invariably makes these problems worse. Methods such as using bad-flavored
nail polish and restraining the child’s hands to prevent nail biting are also ineffective.
These behaviors stop when the underlying stress is discovered and alleviated. Urge
parents to spend some time with the child after school or in the evening so the child
continues to feel secure in the family and does not feel pushed out by being sent to
school. If such behavior manifestations persist despite attempts to eliminate their cause,
the family might benefit from formal counseling, cognitive behavioral therapy, and
possibly pharmacology support for the child (Pringsheim, Doja, Gorman, et al., 2012).
School Refusal or Phobia
School refusal is a fear of attending school. It is a type of “social phobia” similar to
agoraphobia (fear of going outside the home) or separation anxiety disorder (SAD).
Children who resist attending school this way develop physical signs of illness, such as
vomiting, diarrhea, headache, or abdominal pain on school days. This lasts until after
1915
the school bus has left or the child is given permission to stay home for the day.
A particular child may be reacting to a situation such as a harsh teacher, having to
shower in gym class, or facing a class bully every day. In these instances, counseling
may help the child manage the situation better. School refusal may also occur if the
child is overly dependent on the parents or may be reluctant to leave home because of
worry that younger siblings will usurp the parents’ affection. The anxiety of separation
may also result because the parent is overprotective of the child or is the one having the
most difficulty separating.
Because the problem of school refusal is usually only partly the child’s, the entire
family generally requires counseling to resolve the issue. As a rule, once it has been
established that the child is free of any illness and the resistance stems from separation
anxiety or phobia, the child should be made to attend school. Reinforcement by parents
to go to school this way helps to prevent problems such as school failure, peer ridicule,
or a pattern of avoiding difficulties. Some children may benefit from a gradual program
of school involvement, such as walking to school but not going in for one day, then
going to school but staying for only 1 hour the next day, then staying for half a day, and
so on until the child can stay all day every day. Give support to parents so they can
matter-of-factly treat the child’s illness symptoms (a great deal of reassurance that these
symptoms are not major will be necessary) so they can take the child firmly to the bus
or to the classroom.
Managing school refusal requires coordination among the school, the school nurse,
and the healthcare provider who identifies the problem. A nurse is the ideal person to
coordinate such efforts and to help parents allow the child some independence not only
in going to school but also in other activities. A few children have such difficulty that
they require formal counseling and pharmacologic therapy to overcome school refusal
(Scheffer, 2011).
What If . . . 32.3
Shelly’s mother tells the nurse that the many nervous habits she began since
starting middle school are increasing. What suggestions would the nurse make
to her mother regarding this?
Homeschooling
Because of religious or personal preference or because of disillusionment with the
school system, a growing number of children are homeschooled today (Anthony &
Burroughs, 2010). Because their main contact has been with well-educated parents at
home, the vocabulary of homeschooled children may be advanced or may suggest they
are older than their actual age. When discussing homeschooling with parents, assess if
children have peer experiences, perhaps through participation in community sports
teams or clubs. Ask if they receive exposure to other cultures or families, so they can
1916
better adjust to people different from themselves later on at college or at a job.
Children Who Spend Time Independently
Children whose parents both work outside the home may spend time alone without adult
supervision for a part of each weekday. Such children have become a prominent
concern because, in as many as 90% of families today in the United States, both parents
work at least part time outside of the home. Few parents have work hours so flexible
that they can always be at home when a child leaves for or returns from school.
Extended family members who once watched children after school are often working as
well or may no longer be close at hand; many communities are no longer close-knit
enough to have neighbors who can be depended on to help out with informal child care.
A major concern of children staying home alone is that they will experience an
increased number of unintentional injuries, delinquent behavior, alcohol or substance
abuse, or decreased school performance from a lack of adult supervision. For children
who are responsible and feel safe in their community, however, a short period of
independence every day may actually be beneficial because it encourages problem
solving in self-care (Mack, Dellinger, & West, 2012).
Suggestions for parents whose children must spend time alone before or after school
are shown in Box 32.7. Many communities and schools offer special after-school
programs so children do not have to be home alone. Nurses are in a position to educate
parents about such services so their children can feel both safe and stimulated creatively
during this time. Both Boy and Girl Scouts, the Boys & Girls Clubs of America, and
Camp Fire USA are examples of organizations that offer programs in many
neighborhoods to help children adjust to being home alone. Many communities also
organize hotline numbers that a child who is alone can call if a problem arises. At health
visits, assess whether parents and a child appear to have a concern with or are
uncomfortable about after-school arrangements. For a child who is extremely fearful or
impulsive or who finds problem solving difficult, time alone after school may not be
appropriate. Determine the individual circumstances and recommend changes as
appropriate. State laws vary as to when children can provide self-supervision.
BOX 32.7
Nursing Care Planning to Empower a Family
TIPS FOR CHILDREN WHO SPEND TIME INDEPENDENTLY AND THEIR
PARENTS
Q. Shelly stays by herself after school for a half hour each week day. Her mother asks
you, “What are good tips for being sure it’s safe to let her do that?”
A. Think in a number of areas:
Safety Points for Children
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Always lock doors and never show keys to others or indicate you stay home alone.
When answering the telephone, say a parent is busy, not absent from home.
Have a plan in the event you lose your key (e.g., stay with a neighbor).
Don’t go into the house if the door is open or a window is broken.
Learn fire safety (practice a fire drill from all rooms of the house).
Check in with parents by telephone or laptop when you first arrive home.
Identify a caller before opening the door. Agree on a secret code word; you should
not open the door or go with a person unless the person knows the word.
Learn how to change light bulbs safely if it will be dark before parents return home.
If appropriate, learn how to change fuses or reset circuit breaker switches.
Learn how to report a fire and telephone police (practice this with your parents).
Safety Responsibilities for Parents
Prepare a safety kit with bandages and such; include a flashlight in case of a power
failure so children do not need to light candles.
Plan after-school snacks that do not require cooking to prevent burns.
Keep firearms locked, with the key in a place unknown to child.
Keep a list of emergency telephone numbers (including parents’ work numbers) by
the telephone.
Arrange with a neighbor who is usually home during the late afternoon for the child
to stay there in an emergency.
If an older child will be watching a younger one, be certain both children understand
the rules laid down and the degree of responsibility expected.
Be certain the child understands the rules that apply during other times also apply
during independent time (e.g., never swim alone, do not play by the railroad
tracks).
Parental Actions to Prevent Loneliness
Leave messages on the refrigerator or in the bathroom that just say “hi.”
Leave a tape- or video-recorded message for the child to play when he or she first
arrives home (make sure it is not full of tasks to do but is a welcoming message).
Be certain to make parent–child time available after work to allow for quality
relationship time.
Each morning, help the child plan an activity for that day so he or she has something
purposeful to look forward to during the time alone.
Allow special privileges such as listening to music other members of the family do
not like; consider allowing extra television hours during this time.
Consider getting a pet. Even a caged animal, such as a hamster or a bird, offers
companionship in a quiet house.
Call the child if there will be a delay in arriving home; unexpected time alone is very
frightening.
Encourage the child to read; fictional characters can serve as friends as well as help to
pass time.
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Urge the child to network with other children who spend time alone as to how they
use time effectively; talking on the telephone or e-mailing another child reduces
loneliness for both.
Parental Actions to Increase Socialization
Help the child plan after-school activities such as joining a science club for one
afternoon a week.
Explore sports programs at school or in the community because these often are held
after school.
Explore after-school programs at the school the child attends, or at a public library, a
church, or a temple.
Network with other parents or ask for flex time so child supervision can be alternated
after school.
Be certain the child has opportunities to socialize with friends on weekends or on
days when either parent is home.
Parental Actions to Increase Self-Esteem
Praise the child for the ability to take care of himself or herself for short time
intervals (e.g., rather than scold him or her that there are cracker crumbs on the
carpet).
Walk with the child through the empty house and together identify sounds (e.g., the
click of the furnace turning on, the refrigerator starting to defrost), so they can
determine the cause of sounds when home alone and not be frightened.
Help the child to view the quiet as a beneficial time in which they can do some things
more efficiently, such as homework, than at noisy times.
Do not allow the child to use their time alone role to provoke parental guilt. Allow
children to have some say in family spending so they can see how their time alone
(which allows both parents to work) contributes to family unity and progress.
Sex Education
It is important that school-age children be educated about pubertal changes and
responsible sexual practices. Also, preteens should have adults they can turn to for
answers to questions about sex. Ideally, these should be their parents, but because sex is
an emotionally charged topic, some parents may be extremely uncomfortable discussing
it with their children. As a result, healthcare personnel often become resource persons.
It’s best if sex education is incorporated into health education classes throughout the
school years in a manner that is appropriate to age and development. Topics to teach
and discuss in a sex education course for both preadolescent boys and girls include:
• Reproductive organ function and physiology of reproduction, so children
understand what menstruation is and why it occurs
• Secondary sexual characteristics, so children will understand what is happening
in their bodies
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• Male sexual functioning, including why the production of increased amounts of
seminal fluid leads to nocturnal emissions
• The physiology of pregnancy and the possibility for unintended pregnancies,
which will come with sexual maturity
• Responsibilities of sexual maturity
• Reproductive life planning measures and the principles of safer sex if appropriate
to the cultural setting (see Chapters 5 and 6). Sexual orientation questions and
concerns may arise at this time, and questions should be addressed honestly and
openly.
Lesbian, gay, bisexual, and transgender (LGBT) youth may not obtain the same
levels of care due to fear of discrimination. They may choose not to disclose their sexual
orientation or gender identity to healthcare providers or they may avoid care
completely. Nurses can take steps to improve health outcomes for LGBT youth by
providing care that is affirming and inclusive (Hadland, Yehia, & Makadon, 2016).
A sex education course that includes films and discussions is helpful for
preadolescents but never answers all of a preteen’s questions (most youngsters would
rather avoid asking a question than risk appearing ignorant in front of their peers in such
a setting). Using an anonymous question box is one method to address questions and
lessens the embarrassment that may occur with more a more public forum of asking
questions. Urge parents or other health educators to watch films or read booklets with
children to show they are truly available to answer questions.
Stealing
During early school age, most children go through a period during which they steal
loose change from their mother’s purse or father’s dresser. This usually happens at
around 7 years of age, when children first learn how to make change and also discover
the importance of money. Stealing occurs because, although a child is gaining an
appreciation for money, this appreciation is not yet balanced by strong moral principles
or an understanding of ownership.
Parents should explore the reason for the stealing, including:
• Do other children on the block receive an allowance and so have money for small
items?
• Did their child make a bet that must be paid?
• Is a child buying a bully’s friendship by purchasing gum or candy for that child?
• Does a child need more security and view money as security?
As a rule, early childhood stealing is best handled without a great deal of emotion. A
parent should tell the child the money is missing. The importance of property rights
should be reviewed: Mother’s and father’s money is theirs, the child’s money is the
child’s, and they are not interchangeable. Youngsters who continue to steal past 8 years
of age may require counseling because they should have progressed beyond this normal
developmental step by this age (Sourander, Fossum, Rønning, et al., 2012).
Some shoplifting occurs with early school-age children, but the major problem with
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this arises during preadolescence. Some of this happens for the same reason that past
generations tipped over outhouses or untied the preacher’s horse and buggy: It is a
public act of rebellion against authority, a “coming of age” ritual. It usually occurs
because of peer pressure such as when children believe they must have a certain type of
clothing to belong to the “in” crowd. It can also be an initiation ritual for gang
membership.
Shoplifting must be taken seriously by parents because it is a punishable crime, not
a prank. Just as money missing from a purse should not be ignored, shoplifting should
be confronted immediately to prevent children who succeed once from taking
something even bigger the second time. Children should be asked how they came to
possess the article and they should not be allowed to use it. Children should then be
denied access to stores until they demonstrate more responsibility. A child who shoplifts
more than once may need counseling because it reflects more than simple confusion
about property rights.
As an overall principle, parents should set good examples if they expect their child
to be honest. If one parent takes money from the other without permission, neither
should be surprised to find their child attempting to do the same. If a parent unwraps
items and eats them without paying for them in the supermarket, a parent cannot expect
a child to do otherwise.
Violence or Terrorism
Children basically view their world as safe, so it is a shock when violence such as a
school shooting or reports of terrorists enter their lives (Dowdell, 2012). Common
recommendations for parents to help children feel safe when they hear of these
instances include:
• Assure children they are safe; even if the violence is in their community, their
parents are actively involved in being certain they are not in danger.
• Observe for signs of stress such as sleep disturbances, fatigue, lack of pleasure in
activities, or signs of beginning substance abuse.
• Do not allow children or adolescents to view footage of traumatic events over
and over because this decreases their ability to feel safe.
• Watch news programs with children so it can be explained that the situation
portrayed is not near them and that their child is safe.
• Explain that there are bad people in the world, and bad people do bad things, but
not all people in a particular group or who look a particular way are bad. Lashing
out at people who resemble them only causes more harm.
• Prepare a family disaster plan, including such things as bottled water, blankets,
toiletries, pet supplies, appropriate clothing, flashlights, and information such as
what immunizations their children have had (particularly tetanus) and, if a child
is ill, a history of medical needs or care so that such items are ready in an
emergency.
• Designate a “rally point” where the family will meet if ever separated by a
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disaster or evacuation (AAP, 2012b).
Some parents may be reluctant to talk to their children about a disaster plan for the
family, believing that these preparations will frighten children unnecessarily, but such
preparations should have the major effect of increasing a feeling of safety, not
decreasing it. Fear of the unknown is always more intense than a fear of something
tangible.
Bullying
A frequent reason school-age children cite for feeling so unhappy that they turn guns on
classmates or commit suicide is because they were ridiculed or bullied to the point they
could no longer take such abuse (Cooper, Clements, & Holt, 2012). Alert parents that
Internet or texting bullying are both also possible and that a bully doesn’t have to be in
fact-to-face contact with their child to be harmful (D’Auria, 2014).
Traits commonly associated with school-age bullies include:
• Advanced physical size and strength for their age
• Aggressive temperament (both male and female)
• Parents who are indifferent to the problem or are permissive with an aggressive
child
• Parents who typically resort to physical punishment
• There is the presence of a child who is a “natural victim” (e.g., small, insecure,
with low self-esteem).
Bullying can be done face to face or through social media and/or texting.
Suggestions for school personnel to deal with bullies include:
• Supervise recreation periods closely.
• Intervene immediately to stop bullying.
• Insist if such behavior does not stop, both the school and parents will become
involved.
• Advise parents to discuss bullying with their school-age child and help them
understand that it should be reported to allow adults to intervene.
• Parents should monitor their child’s social media and texting interactions.
If bullying behavior is ingrained, therapy may be needed to correct the behavior.
Stopping bullying helps not only the victim but also the bully because statistics show
that children with this type of aggressive behavior in grade school are more apt to be
incarcerated as adults than others (AAP, 2012a).
Recreational Drug Use
Once considered a college or high school problem, illegal drugs such as marijuana,
cocaine, and amphetamines are now available to children as early as elementary school
and certainly by the time they reach the seventh and eighth grades. Because they are
available in so many homes, alcohol, inhalants, and prescription drugs have also
become commonly abused by this age group (Blake & Davis, 2011; Young, Glover, &
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Havens, 2012). Parents should be particularly aware of children who may be taking
adult antidepressant drugs from home medicine cabinets because this is associated with
suicide in young children (Adegbite-Adeniyi, Gron, Rowles, et al., 2012).
The use of hard drugs and alcohol and ways to encourage children to avoid their use
are discussed in Chapter 33. Inhalants, which are easily available to school-age children
for abuse, include airplane glue (toluene) and aerosolized cooking oil. Children do not
become physically addicted to glue but do become psychologically dependent on it. To
achieve the desired effect, they drop quantities of the glue into a paper bag and then
sniff the fumes to experience a feeling of exhilaration or giddiness. This may seem like
a harmless procedure, but, in high concentrations, glue fumes can cause extensive liver
damage or enough pulmonary edema to be fatal. Cooking spray or computer keyboard
cleaner gives this same effect. Because these products contain Freon, they can cause
severe respiratory and cardiac irregularity (Baydala, 2010).
Children who report being happy and are able to communicate with their family are
less likely to be regular users than others (Farmer & Hanratty, 2012). Parents should
suspect recreational drug use if their child regularly appears irritable, inattentive, or
drowsy.
Abuse of androgenic steroids or human growth hormone to enhance sports
performance are yet other drugs that can be found in preteen children. Counsel children
against this because abuse of steroids can lead to cardiovascular irregularities,
uncontrollable aggressiveness, and possible cancer in later life (Oberlander &
Henderson, 2012).
Cigarette smoking also begins in school-age children. With the sure knowledge that
cigarette smoking plays a large part in the development of lung cancer and other serious
respiratory illnesses, many parents assume their children will know better than to begin
smoking. Smoking is viewed as an adult activity, however, so adopting the habit can be
considered a giant step on the road to adulthood. Although the amount of cigarette
advertising targeting young people as consumers has decreased, school-age children
should still be taught to recognize advertising manipulation aimed at them. Caution
children against experimenting with smokeless tobacco as well because this can lead to
mouth and throat cancer, the same as smoking (Kamboj, Spiller, Casavant, et al., 2016).
The use of e-cigarettes and vaping has increased, and the health risks of these products
are still being uncovered (Duderstadt, 2015).
To discourage use of tobacco by school-age children, healthcare professionals and
parents need to be role models of excellent nonsmoking health behavior in hope that
children will follow their good examples.
QSEN Checkpoint Question 32.6
PATIENT-CENTERED CARE
The school-age period is the time when many young people begin smoking. To
design interventions that are effective and patient-centered, the nurse should begin by
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acknowledging which of the following?
a. Most children who try smoking do not like it.
b. The media have occasionally exaggerated the risks of smoking.
c. Many people view smoking as being an “adult” activity.
d. Children under puberty cannot become addicted to smoking.
Look in Appendix A for the best answer and rationale.
CONCERNS OF THE SCHOOL-AGE CHILD AND FAMILY WITH
UNIQUE NEEDS
A number of situations cause school-age children to have additional needs or concerns.
The Child of Alcoholic Parents
Children who live with an alcoholic parent are at greater risk for having emotional
problems than others because of the frequent disruption in their lives (Allen, GarciaHuidobro, Porta, et al., 2016). In addition, because alcoholism may have a genetic base,
children of alcoholics may be more likely to become alcoholics as adults. This makes it
imperative for such children to learn effective coping behaviors. Immediate problems
that can occur with children of alcoholic parents include:
• A feeling of guilt that they are the cause of the parent’s drinking
• Constant worry that the alcoholic parent will become sick or die, leaving the
child alone; at the same time, the child may fear the alcoholic parent and wish the
parent would leave
• A feeling of shame that prevents the child from inviting friends home or asking
for help
• Decreased ability to trust adults because the parent has been unreliable so many
times
• Poor nutrition and decreasing grades in school because the alcoholic parent’s
behavior is so erratic that no regular schedule of bedtime or meals exists
• Anger at the alcoholic parent for drinking and at the nonalcoholic parent for not
doing more to correct things
• Helplessness to change the situation
Such fears may be revealed by not only failing marks in school but also withdrawal
from friends or social activities and delinquent behavior such as stealing. With
adolescence may come depression, suicidal thoughts, or abuse of drugs or alcohol.
School nurses are in an excellent position to identify such children, monitor their school
progress, and refer them to organizations such as Al-Anon or Alateen (www.alanon.alateen.org) for support.
The Child With a Long-Term Illness or Physical Cognitive Challenge
One of the biggest problems facing school-age children with a long-term illness or
1924
physical challenges is time lost from school. This threatens not only their academic
achievement but also their relationships with peers because it may make the child the
“odd person out” with respect to making friends or joining clubs. Whether children are
on home care or hospitalized, helping them to keep in contact with friends by texting, email, or letters can help foster the socialization that is so important for continued
development. Keeping up with schooling, whether it is homeschool or a distant learning
option, is also important and an area where school nurses can play an important role
(AAP, Council on School Health, 2016; Singer, 2013).
If at all possible, children with physical or cognitive challenges should attend
regular schools and classes (inclusion) based on federal law (Public Law 99-457), which
stipulates that all children have the right to equal education in the least restrictive
environment possible (Sass-Lehrer & Bodner-Johnson, 1989). The decision as to which
classroom would be best for an individual child is determined by a committee in each
school system. You may need to advocate for a child with such a committee to
demonstrate, for example, that although a child uses a wheelchair or needs continuous
oxygen, the child will be able to contribute to regular classroom activities. It may be
necessary to meet with a school nurse, teacher, or the child’s classmates (with the
parents’ permission) to increase their understanding and acceptance of a child’s illness
or to help arrange a period each day with a special resource teacher.
Urge parents of children with physical or cognitive challenges to assign them
household chores just like other children and to allow them to participate in peer
activities, such as Girl or Boy Scouts, in which accomplishment is encouraged. It is
important for such children to develop a sense of industry or accomplishment so they
can persevere in measures that will help them to be as independent as possible in the
future (Fig. 32.10).
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Figure 32.10 A school-age child who is physically challenged is
elated at a finish line. This accomplishment can go far toward her
developing a sense of industry. (© Jose Carillo/Stock Boston.)
When you are caring for a school-age child who is chronically ill or physically
challenged, choose short-term activities that can be completed independently, as with all
school-age children. Conversely, be careful not to insult a child with tasks that are
obviously not age appropriate. Table 32.5 describes some nursing actions to help foster
a sense of industry in children who are physically challenged or chronically ill.
TABLE 32.5 NURSING ACTIONS THAT ENCOURAGE A SENSE OF
INDUSTRY IN THE PHYSICALLY CHALLENGED OR CHRONICALLY ILL
SCHOOL-AGE CHILD
Category
Actions
Nutrition
Allow choices of food when possible and respect food preferences.
Provide small food servings that child can finish, which encourages a
sense of accomplishment.
Dressing
Ask for suggestions as to how bulky the child wants the dressing and
where to apply tape.
Medicine
Teach the child the name and action of medicine.
Encourage the child to keep track of medication times by clock or record.
The child may feel more in control of injections or intravenous insertions
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if allowed to choose the site from among options offered.
Allow the child to choose oral medicine form (capsules or liquid) if
possible.
Rest
Establish clear rules for rest periods (e.g., reading or watching television
is all right; playing a game is not).
Hygiene
Respect the modesty of a school-age child at an adult level.
Allow as much choice as possible such as own clothing and timing of
self-care.
Pain
Encourage the child to express and rate pain.
Encourage the child to use distraction techniques, such as counting
backward from 100 or imagery, during episodes of pain.
Explain the source and cause of pain to give the child sense of mastery.
Stimulation Encourage school work.
Encourage activities that end in a product (e.g., putting together a picture
puzzle rather than listening to a CD).
Encourage paper-and-pencil games, such as connect the dots or tic-tactoe.
Card games provide social interaction and also encourage simple addition
skills (make a deck from paper if one is not available).
Don’t suggest competitive games for children younger than age 10 years.
Encourage using the playroom for socialization.
Encourage the child to keep in contact with school friends by texting or emailing them.
Nutrition and the School-Age Child With a Challenge
Food preparation and washing the dishes are times for socializing in most households.
A school-age child who cannot be involved in these activities because of a physical
challenge may need extra time during the day to make up for these lost socializing
experiences, such as a specific hour set aside for talking or sharing a project that can be
accomplished in one sitting.
When eating in cafeterias or at a friend’s home, children who must eat special diets
are usually tempted to select the same food as everyone else rather than limit what they
choose. They may decline invitations rather than admit to requiring a special diet or
needing help with eating. Ask at healthcare visits if any of these problems are present.
Help children with special diets to plan ways they could be comfortable in social foodbased settings such as bringing a party snack that is appropriate and can be easily eaten,
or how to politely decline particular foods. Help children who are hospitalized to select
a diet that is enjoyable as well as nutritious.
The Child Who Is Overweight or Obese
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In some communities, as many as 50% of school-age children are obese by body mass
index guidelines. Some of these children have been overweight since infancy, and the
natural prepubertal weight gain makes them become obese. Children with an
endomorphic build (a natural tendency to accumulate body fat) are more likely to be
obese at any time in life than those with a mesomorphic (normal) or ectomorphic
(slender) build. Many families rely on fast-food meals several times a week, and such
foods tend to be high in calories and fat and can lead to obesity. The lack of nutritional
food in school lunches and the availability of foods of poor nutritional values available
in vending machines compound the problem. Children of obese parents are also more
apt to become obese, probably related to both genetic and environmental influences (E.
Robinson & Sutin, 2016).
By preteen years, children who are obese begin to develop many of the same health
problems as adults who are obese, such as hypertension, type 2 diabetes, and an
elevated total cholesterol level, with possible atherosclerosis. They also may be
ridiculed or bullied for their size and may be unable to participate on sports teams. This
is strong evidence of the need for active measures to help preteens regulate their weight
(Schantz, 2012). Children are influenced by promotional advertisements that influence
food selection (Emond, Smith, Mathur, et al., 2015)
Those who become so obese that friends leave them out of activities or they cannot
play sports because they tire so quickly may develop such a poor self-image they have
little motivation for self-improvement. The type of weight-reduction program that will
probably work best is one that emphasizes long-term lifestyle changes and contains
features such as:
• An intake of about 1,200 calories a day (no more than 30% as fat), with lifestyle
changes such as a structured family meal, eliminating eating or snacking in front
of the television, decreasing portion sizes, and eliminating sugar-rich drinks.
• An active exercise program, including monitoring and limiting time spent in
physical inactivity (e.g., watching television, playing computer and video games,
surfing the Internet, texting).
• A counseling program to discuss aspects such as self-image and motivation to
reduce weight.
Total caloric intake should not be reduced too drastically in children because they
need calories to form new body tissue for continued growth. Caution children not to try
faddish high-protein diets (as most adults should not) because such diets do not supply
enough carbohydrates and may produce a heavy renal solute load (the breakdown
product of proteins) to the kidneys. It helps if children aim to lose 5 lb over a short time
rather than 50 lb over a year. This short-term goal coincides better with the task of
developing industry.
Surgical techniques such as an intestinal bypass or lap band surgery are obviously
extreme measures and inappropriate for children. Children who are obese might request
one, however, in an attempt to avoid the not insignificant difficulty of long-term weight
loss.
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Nursing Diagnoses and Related Interventions
Nursing Diagnosis: Altered family dynamics related to lack of motivation to reduce
weight
Outcome Evaluation: Child states reasonable weight loss and exercise goals;
discusses feelings about being overweight and reactions from schoolmates; expresses
positive feelings about self-worth.
Motivating preteens to lose weight can be very difficult because they are not
concerned when told that people who are obese do not live as long as average weight
persons or that they have more heart attacks because this will happen so far in the
future. They do, however, have a great respect for adults who are sympathetic to their
problems. They follow better dietary regimens, therefore, if they are asked to do so
by a respected adult, such as a nurse, or if they fear being left out of social
interactions.
Overweight school-age children often do well if a healthy eating club is formed;
they are not too young to participate in formal weight-control organizations. Having
tangible support from other group members helps them follow tedious and
monotonous nutrition patterns. As a way of increasing daily activity, preadolescents
do well with formal exercise classes because, again, they enjoy the support from
other children. In addition, encourage them to increase informal exercise, such as
walking to and from school or walking a dog. Encourage coaches of childhood sports
to accept children who are obese as part of a team, not because the child will
necessarily benefit the team but because the exercise will benefit the child. Not only
does exercise burn up calories but also if children’s daylight hours are filled with
activities and friends, they have less time to eat and spend less time in sedentary
activities.
Lifestyle change is the ultimate goal for the entire family because obesity is
usually a family problem. Rather than preparing special meals for just the child who
is obese, the entire family probably needs to eat in a healthier manner. Because
preadolescents do not generally prepare their own food, the person in the home who
prepares meals requires as much information on the planned weight loss as the child.
The old concepts that used to hold (“A clean plate is good” and “How can you leave
food when people in other countries are starving?”) may have to be changed so
children and other family members reduce their intake appropriately. The importance
of exercise should also be reflected in the home. Family members should not only
encourage the child who is obese to exercise, but they should also partake in some
form of daily activity with them. The encouragement of adequate fruit and vegetable
consumption is helpful in achieving healthy eating patterns (Herrick, Rossen,
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Nielsen, et al., 2015).
There is some danger in pointing out to preadolescents that they are overweight
because some children can become so obsessed with losing weight that they develop
eating disorders (see Chapter 54). Stressing that children should “become healthier”
or “improve stamina” may be better advice than talking about losing weight (Field,
Sonneville, Micali, et al., 2012).
What If . . . 32.4
The nurse is particularly interested in exploring one of the 2020 National
Health Goals with respect to school-age growth and development (see Box
32.1). What would be a possible research topic to explore pertinent to this goal
that would be applicable to Shelly’s family and that would also advance
evidence-based practice?
KEY POINTS FOR REVIEW
School-age children mature slowly but steadily. Their average annual weight gain is
3 to 5 lb; their increase in height is 1 to 2 in.
At about age 10 years, children begin to develop secondary sex characteristics.
Preparation for this helps them accept these changes positively.
Deciduous teeth are lost, and permanent teeth erupt during the school-age period.
Erikson’s developmental task for the school-age period is to gain a sense of industry
or how to do things well.
Common health problems during the school-age period include minor respiratory
and gastrointestinal infections as well as dental caries and malocclusion.
Common parental concerns during this period are language development, fears and
anxieties, and behavior problems such as stealing and exposure to recreational drugs.
Treating preventive strategies regarding these helps in planning nursing care that not
only meets QSEN competencies but also best meets a family’s total needs.
As many as 90% of parents of school-age children are dual-earner families. This
means that many school-age children return home before their parents. Counseling
families on ways to turn this independent time into a positive experience is helpful.
Children in a concrete stage of operational thought are limited to understanding
concepts that they can actually see. When health teaching, use concrete examples
(actually let them hold a syringe, don’t just talk about it) to increase their
understanding.
School-age children thrive on rules. It is confusing for them when rules are changed
(e.g., medicine will now be taken four rather than three times a day) unless they have
a clear explanation of why the change is occurring.
School-age children look for good adult role models; it is hard for them to feel
confidence in an adult who isn’t honest with them or who fails to live up to their
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expectations by not following through on promises.
School-age children with a family tendency toward obesity may become overweight.
Helping the family learn a healthier lifestyle is important.
CRITICAL THINKING CARE STUDY
Georgia is a 6-year-old girl in the first grade whom you meet when working as a
school nurse. She lives with her 10-year-old sister and her parents in a three-bedroom
home. Her father works long shifts as a coal miner, and her mother cleans houses for
a commercial housecleaning firm.
1. Georgia’s mother tells you she received a note from her teacher asking her to help
Georgia “speak more clearly.” Is this a common concern with early school-age
children? What further information do you need to know to evaluate whether this
is a concern?
2. Georgia’s teacher is also concerned because Georgia does not share well. Is this a
developmental step that Georgia should have already mastered?
3. Georgia’s mother wants her to be popular and so has enrolled her in dance classes
two times per week, a school soccer club four times per week, violin lessons once
per week, and a gymnastics class twice per week. Despite all the effort she puts in
driving her daughter to all these sessions, the mother tells you Georgia doesn’t act
grateful. She asks you why Georgia isn’t interested in making friends.
RELATED RESOURCES
Explore these additional resources to enhance learning for this chapter:
• Student resources on thePoint, including answers to the What If . . . and Critical
Thinking Care Study questions, http://thepoint.lww.com/Flagg8e
• Adaptive learning powered by PrepU, http://thepoint.lww.com /prepu
REFERENCES
Adegbite-Adeniyi, C., Gron, B., Rowles, B. M., et al. (2012). An update on
antidepressant use and suicidality in pediatric depression. Expert Opinion on
Pharmacotherapy, 13(15), 2119–2130.
Allen, M. L., Garcia-Huidobro, D., Porta, C., et al. (2016). Effective parenting
interventions to reduce youth substance use: A systematic review. Pediatrics, 138(2),
e20154425.
American Academy of Pediatrics. (2012a). Bullying: It’s not okay. Evanston, IL:
Author.
American Academy of Pediatrics. (2012b). Terrorism disaster fact sheet. Evanston, IL:
Author.
American Academy of Pediatrics. (2016). Menstruation in girls and adolescents: Using
the menstrual cycle as a vital sign. Pediatrics, 137(3), e20154480.
American Academy of Pediatrics, Committee on Practice and Ambulatory Medicine.
1931