Pediatric Growth and Development Ana H. Corona, MSN, FNP-C Instructor December 2007 Resources: HCC 2007, UPHS 2006, PSY 501 Craig Cramer, Bernadette Flynn, and Ann LaFave.1997
Developmental Milestones • Children will demonstrate certain physical and mental skills. • These skills are called developmental milestones.
Infant -- birth to 1 year • Displays social smile • Rolls over by self • Able to sit alone, without support • Babbling • Plays peek-a-boo • Eruption of 1st tooth • Pulls self to standing position • Walks while holding on to furniture or other support • Says mama and dada, using terms appropriately • Able to drink from a cup • Understands "NO" and will stop activity in response • Walks without support
Toddler -- 1 to 3 years • Masters walking • Recognizes gender differences • Uses more words and understands simple commands • Able to run, pivot, and walk backwards • Uses spoon to feed self • Can name pictures of common objects and point to body parts • Able to walk up and down stairs • Imitates speech of others, "echoing" word back • Begins pedaling tricycle • Learns to take turns (if directed) while playing with other children • Able to feed self neatly, with minimal spilling • Able to state first and last name • Recognizes and labels colors appropriately • Able to draw a line (when shown one) • Dresses self with only minimal help • Learns to share toys (without adult direction)
Preschooler -- 3 to 6 years • Rides tricycle well • Able to draw a circle • Able to draw stick figures with 2 to 3 features for people • Hops on one foot • Catches a bounced ball • Understands size concepts • Enjoys rhymes and word play • Able to skip • Enjoys doing most things independently, without help • Balances better, may begin to ride a bicycle • Understands time concepts • Begins to recognize written words -- reading skills start • Starts school
School-age child -- 6 to 12 years • Understands and able to follow sequential directions • Beginning skills for team sports (soccer, T-ball, etc.) • Begins to lose "baby" teeth and erupt permanent teeth • Routines important for daytime activities • Reading skills develop further • Peer recognition begins to become important • Girls begin to show growth of armpit and pubic hair, breast development • Menarche (1st menstrual period) may occur in girls
Adolescent -- 12 to 18 years • Boys show growth of armpit, chest, and pubic hair; voice changes; and testicular/penile enlargement • Girls show growth of armpit and pubic hair; breast development; menstrual periods • Adult height, weight, sexual maturity • Understands abstract concepts • Peer acceptance and recognition is of vital importance
Physical and motor-skill markers:2 month old • Closure of posterior fontanelle (soft spot at the back of the head) • Several newborn reflexes, such as the dance reflex (baby appears to dance or step when placed upright on solid surface) and grasp reflex (grasping a finger), disappear • Less head lag • When on stomach, able to lift head almost 45 degrees • Less flexing of the arms and legs while on stomach
Sensory and cognitive markers:2 month old • Head turns from side to side with sound at the level of the ear • Beginning to look at close objects • Crying becomes differentiated • Coos • Vocal response to familiar voices • Smiles
Play recommendations: 2 month old • Toys and objects should be bright colors • The room should be bright with pictures and mirrors • Expose the baby to sounds outside those of the home • Take the baby for rides in the car
PHYSICAL AND MOTOR SKILLS: 4 month old • Show a slowing of weight gain to approximately 20 grams per day • Demonstrate the fading of the infant reflexes (Moro reflex, asymmetric tonic neck reflex, rooting reflex, and Perez reflex) • Have almost no head lag while in a sitting position • Be able to sit up straight if propped • Raise head 90 degrees when placed on stomach • Be able to roll from front to back • Try to reach objects with hands (may commonly overshoot) • Play with rattle when it's placed in the hands, but won't be able to pick it up if dropped • Be able to grasp rattle with both hands • Be able to place objects in mouth
SENSORY AND COGNITIVE SKILLS: 4 month old • Have well-established close vision • Have beginning eye-hand coordination • Be able to babble and coo • Be able to laugh out loud • Anticipate feeding when able to see a bottle (if bottle-fed) • Begin to show memory • Demand attention by fussing • Recognize parent voice or touch
Play Recommendations: 4 month old • Place the baby in front of a mirror • Provide bright-colored toys to hold • Repeat sounds the infant makes • Help the infant roll over • Use a swing or stroller
Physical and motor-skill markers: 6 month old • Should have doubled birth weight (birth weight often doubles by 4 months, and it would be concerning if it hasn't happened by 6 months) • Able to lift chest and head while on stomach, bearing the weight on hands (often occurs by 4 months) • Able to sit in a high chair with a straight back • Beginning of teething • Increased drooling • Able to bear almost all weight when supported in a standing position • Able to roll from back to stomach • Able to hold own bottle (but many babies won't do it, or do it only for short periods) • Able to pick up a dropped object
Sensory and cognitive markers: 6 month old • Vision is between 20/60 and 20/40 • Can locate sounds not made directly at the ear level • Prefers more complex sound stimulation • Starts to imitate sounds • Sounds resemble one-syllable words • Enjoys hearing own voice • Makes sounds to mirror and toys • Begins to fear strangers • Recognizes parents • Begins to imitate actions • Begins to realize that if an object is dropped, it is still there and just needs to be picked up
Play Recommendations: 6 month old • Provide a mirror that is unbreakable • Provide large, bright colored toys that make noise or have moving parts • Play peek-a-boo • Provide paper to tear • Speak clearly • Imitate words such as "mama" to facilitate learning of language • Start naming parts of the body and the environment • Use the word "no" INFREQUENTLY • Use body movements and actions to teach language
PHYSICAL CHARACTERISTICS AND MOTOR SKILLS: 9 month old • Gains weight at a slower rate -- approximately 15 grams per day, 1 pound per month • Increases in length by 1.5 centimeters per month • Becomes more regulated in bowel and bladder systems • Shows parachute reflex to protect self from falling • Is able to crawl • Remains sitting for prolonged periods • Pulls self to standing position • Has a pincer grasp between thumb and index finger • Feeds self • Throws or shakes objects
SENSORY AND COGNITIVE SKILLS: 9 month old • Is developing depth perception • Achieves "object constancy", the understanding that objects continue to exist even when not seen • Responds to simple commands • Responds to name • Understands the meaning of "no" • Imitates speech sounds • May be afraid of being left alone • Plays interactive games
Play Recommendations: 9 month old • Provide picture books • Provide different stimuli: • Go to the mall (people) • Go to the zoo (animals) • Play ball • Build vocabulary by reading and naming people and objects in the environment • Teach hot and cold through play • Provide large toys that can be pushed to encourage walking
PHYSICAL AND MOTOR SKILLS: 12 month old • Triple the birth weight • Grow to a height of 50% over birth length • Have a head circumference equal that of the chest • Have 6 - 8 teeth • Have a nearly-closed anterior fontanel (the front soft spot on the head) • No longer have a Babinski reflex • Pull to stand and walk with help or alone • Sit down without help • Bang 2 blocks together • Turn through pages of a book by flipping many at a time • Have a precise pincer grasp
SENSORY AND COGNITIVE DEVELOPMENT: 12 month old • Follows a fast moving object • Has control over response to sounds • Comprehends several words • Can say mamma, papa, and at least 1-2 other words • Comprehends simple commands • Tries to imitate animal sounds • Associates names with objects • Searches for objects that are hidden, but unable to consider alternative locations • Points to objects with index finger • Waves bye • May develop attachment to a toy or object • Experiences separation anxiety and may cling to parents • May make brief exploratory journeys away from parents in familiar settings
Play Recommendations: 12 month old • Provide the infant with picture books • Provide the infant with different stimuli, such as going to the mall or zoo • Play ball • Build vocabulary by reading and naming people and objecting in the environment • Teach hot and cold through play • Provide large toys that can be pushed to encourage walking
PHYSICAL AND MOTOR SKILL MARKERS : 18 months • Has a closed anterior fontanel (soft spot on the front of the head) • Is growing at a slower rate and has less of an appetite compared to previous months • Is physically able to control sphincter muscles, but may not be psychologically ready to use the toilet • Runs with a lack of coordination and falls frequently • Jumps in place • Is able to get onto chairs without assistance • Walks up stairs while holding on with one hand • Can build a tower of 2 - 3 blocks • Can use a spoon and cup with help • Imitates scribbling • Can turn the pages of a book 2 or 3 at a time
SENSORY AND COGNITIVE MARKERS: 18 month old • Shows affection • Listens to a story or looks at pictures • Can say 10 or more words when asked • Identifies parts of the body • Understands and is able to point to and identify common objects • Frequently imitates • Feeds self • Is able to take off some clothing items, such as gloves, shoes, and socks • Begins to feel a sense of ownership identifying people and objects by saying "my"
Play Recommendations: 18 month old • Encourage and provide the necessary space for physical activity • Provide safe replicas of adult tools and equipment for the child to play with • Allow the child to help around the house and participate in the daily responsibilities of the family • Encourage play that involves building and creativity • Read to the child • Control the type and quantity of television viewing • Control the type and quantity of games played
Physical and motor-skill markers: 2 year old • Should have the first 16 teeth (can be a wide variation of the actual number of teeth) • The height is roughly half the total height the child will attain as an adult • May be psychologically ready for toilet training • Can run with better coordination, while the stance may remain wide • Can kick ball without losing balance • Can build a tower of 6 to 7 cubes • Can browse through a book one page at a time • Able to turn a door knob • Can pick up objects while standing, without losing balance (often occurs by 15 months, and would be concerning if you don't see it by 2 years)
Sensory and cognitive markers: 2 year old • Vision fully developed • Vocabulary has increased to about 50 to300 words (healthy children demonstrate wide variations) • Can organize phrases of 2 to 3 words • Able to communicate needs such as thirst, hunger, need to use the restroom • Increased attention span • Able to clothe self in simple clothes (frequently more adept at removing clothes than putting them on)
Play Recommendations: 2 year old • Encourage and provide the necessary space for physical activity • Provide safe replicas of adult tools and equipment • Allow the child to help around the house and participate in the daily responsibilities of the family • Encourage play that involves building and creativity • READ TO THE CHILD • Try to avoid watching television at this age (recommendation of the American Academy of Pediatrics) • Parents should control both the content and quantity of television viewing. Limit television viewing to less than 3 hours per day, and preferably 1 hour or less. Avoid programming with violent content. Re-direct the child to reading or play activities • Control the type and quantity of games played
Physical and motor skills: 3-year-old: • Gains about 5 pounds • Grows about 3 inches • Has improved balance • Has improved vision • May have daytime control over bowel and bladder functions (may have nighttime control as well) • Can briefly balance on one foot • May walk up the stairs with alternating feet • Can construct a block tower of more than 9 cubes • Can easily place small objects in a small opening
In sensory and cognitive skills, a child: 3 year old • Has a vocabulary of many hundreds of words • Composes sentences of 3 to 4 words • Frequently asks questions • Can dress self, only requiring assistance with laces, buttons, and other fasteners in awkward places • Has longer attention span • Feeds self without difficulty • Acts out social encounters through play activities • Has some decrease in separation anxiety for short periods of time • At age 3, nearly all of a child's speech should be understandable.
Play Recommendations: 3 year old • Provide a safe play environment and constant supervision. • Encourage and provide the necessary space for physical activity. • Instruct the child how to participate in and learn the rules of sporting activities. • Encourage play with other children to help develop social skills. • Encourage creative play. • Read together. • Limit both the time and the content of television viewing. • Expose your child to different stimuli by visiting local areas of interest. • Encourage your child to learn by answering questions and providing activities related to the child's particular interests. • Encourage your child to learn simple chore such as picking up their toys or room. Welcome their help in small household tasks.
Physical and Motor Skills: 4 year old • Gains weight at the rate of about six grams per day • Grows to a height that is double the length at birth • Shows improved balance • Hops on one foot without losing balance • Throws a ball overhand with coordination • Can cut out a picture using scissors • May not be able to tie shoelaces • May still wet the bed (normal)
SENSORY AND COGNITIVE: 4 year old • Has a vocabulary of over 1500 words • Easily composes sentences of four or five words • Can use the past tense • Can count to four • Will ask the most questions of any age • May use words that aren't fully understood • May begin using vulgar terms, depending on their exposure • Learns and sings simple songs • Tries to be very independent • May show increased aggressive behavior • Talks about personal family matters to others • Commonly has imaginary playmates • Has an increased comprehension of time • Is able to distinguish between two objects based on simple criteria such as size and weight • Lacks moral concepts of right and wrong • Is rebellious if expectations are excessive
Play Recommendation: 4 year old • Encourage and provide the necessary space for physical activity • Instruct the child how to participate in, and follow the rules of sporting activities • Encourage play and sharing with other children • Encourage creative play • Teach children to do small chores, such as setting the table • Read together • Monitor both the time and content of television viewing (preferably less than 1.5 hours of TV, no more than 3 hours maximum) • Expose the child to different stimuli by visiting local areas of interest
Physical and motor skills milestones: a 5-year-old • Erupting the first permanent teeth (the majority of children do not get their first permanent teeth until age 6) • Developing increased coordination • Skipping, jumping, and skating with good balance • Maintaining balance while standing on one foot with eyes closed • Tying own shoelaces • Showing increased skill with simple tools and writing utensils
Sensory and cognitive milestones include: 5 year old • Increasing vocabulary to over 2100 words • Composing sentences of six to eight words, and with all parts of speech • Identifying coins • Properly naming the primary colors and possibly many more • Questioning more deeply, addressing meaning and purpose • Behaving more responsibly • Decreasing aggressive behavior • Outgrowing earlier childhood fears • Accepting the validity of other points of view (while possibly not understanding them) • Demonstrating increased mathematical skill • Questioning others, including parents • Strongly identifying with the parent of the same sex
Play Recommendations: 5 year old • Reading together • Providing the necessary space for physical activity • Instructing the child to participate in -- and learn the rules of -- sporting activities • Encouraging the child to play with other children, which helps develop social skills • Playing creatively with the child • Monitoring both the time and content of television viewing • Visiting local areas of interest • Encourage the child to take responsibility for small household chores such as helping set the table • Have the child pick up his or her toys after playing
PHYSICAL DEVELOPMENT: preschooler • Gross motor development in the 3- to 6-year-old should include: • Becoming more skilled at running, jumping, early throwing and kicking • The ability to catch a bounced ball • The ability (at 3 years) to pedal a tricycle but perhaps not steer well becoming able to steer well around age 4 • The ability (at around 4) to hop on 1 foot, followed with balancing on 1 foot for up to 5 seconds • The ability to perform a heel-to-toe walk
Fine motor development milestones should include: preschooler • The ability to draw a circle upon request at about 3 years • Drawing a person with 3 parts • Beginning use of children's blunt-nose scissors • Self-dressing (with supervision) • The ability to draw a square by age 4 • The use of scissors progressing to cutting a straight line • The ability to put clothes on properly • Managing spoon and fork neatly while eating • Spreading with a knife by about age 5 • The ability to draw a triangle
Language Development • The 3-year-old uses pronouns and prepositions appropriately • The 4-year-old begins to understand size relationships • The child enjoys rhymes and word play • The 5-year-old shows early understanding of time concepts • The child is able to follow 3 simple commands
Language • Stuttering may commonly occur in the normal language development of toddlers 3 - 4 years of age. It occurs because ideas come to mind faster than the child is able to express them. It more commonly occurs if the toddler is stressed or excited. • When the child is speaking, give your full, prompt attention, and do not comment on the stuttering. If the stuttering is accompanied with other signs, such as tics, grimacing, extreme self-consciousness, or if the stuttering persists longer than 6 months, consider having the child evaluated by speech pathologist.
Behavior: the preschooler • The child's ability to cooperate with a larger number of peers increases. Although 4- to 5-year-olds may be able to start participating in games that have rules, the rules are apt to change frequently at the whim of the more dominant child. • Small group of preschoolers may see a dominant child emerge who tends to boss the others around without much resistance from the other children. • It is normal for preschoolers to test their limits in terms of physical abilities, behaviors, expressions of emotion, and thinking abilities. Having a safe, structured environment within which to explore and face new challenges is important, but well-defined limits must be included. • Early morality develops as egocentrism gives way to the desire to please parents and others of importance. This is commonly known as the "good boy" or "good girl" stage. • Elaborate story-telling may progress into lying, a behavior that -- if not addressed during the preschool years -- may continue into the adult years. Mouthing-off or backtalk in the preschooler is usually a means of getting attention and attempting to elicit a reaction from the adult it is directed toward.
Safety is extremely important for preschoolers. • The preschooler is highly mobile and able to quickly get into dangerous situations. • Car safety is critical. The preschooler should ALWAYS be in a seatbelt when riding in the car. • Falls are a major cause of injury for the preschooler. Climbing to new and adventurous heights, the preschooler may fall off playground equipment, bikes, down stairs, from trees, out windows, and off roofs. Lock doors that access dangerous areas (such as roofs, attic windows, and steep staircases) and provide strict rules for the preschooler to understand areas that are off limits. • Kitchens are a prime area for a preschooler to incur burns, either trying to help cook or coming in contact with appliances left to cool off. Encourage the child to help cook or learn cooking skills with safe, cool recipes. • Keep all household products and medicines safely locked out of the reach of preschoolers.
Introduction to Erikson's 8 Stages • Erikson's theory consist of eight stages of development. • Each stage is characterized by a different conflict that must be resolved by the individual. • When the environment makes new demands on people, the conflicts arise. • "The person is faced with a choice between two ways of coping with each crisis, an adaptive, or maladaptive way. • Only when each crisis is resolved, which involves a change in the personality, does the person have sufficient strength to deal with the next stages of development“ (Schultz and Schultz, 1987). • If a person is unable to resolve a conflict at a particular stage, they will confront and struggle with it later in life.
Stage 1: Oral-Sensory • Age: Infancy -- Birth to 1 year • Conflict: Trust vs. Mistrust • Important Event: Feeding • Description: • The important event in this stage is feeding. According to Erikson, the infant will develop a sense of trust only if the parent or caregiver is responsive and consistent with the basic needs being meet. The need for care and food must be met with comforting regularity. The infant must first form a trusting relationship with the parent or caregiver, otherwise a sense of mistrust will develop.
Stage 1 • Elements for a positive outcome: • The infant's need for care, familiarity, comfort and nourishment are met. Parental consistency and responsiveness is essential for the sense of trust to develop. • Elements for a negative outcome: • Babies who are not securely attached to their mothers are less cooperative and more aggressive in their interactions with their mothers. As they grow older, they become less competent and sympathetic with peers. They also explore their environment with less enthusiasm and persistence. • Examples: • Babies will begin to understand that objects and people exist even when they cannot see them. This is where trust becomes important.
Stage 2: Muscular-Anal • Age: Toddler period -- 1 to 2 years • Conflict: Autonomy vs. Doubt • Important Event: Toilet Training • Description: • According to Erikson, self control and self confidence begin to develop at this stage. Children can do more on their own. Toilet training is the most important event at this stage. They also begin to feed and dress themselves. This is how the toddler strives for autonomy. It is essential for parents not to be overprotective at this stage. A parent's level of protectiveness will influence the child's ability to achieve autonomy. If a parent is not reinforcing, the child will feel shameful and will learn to doubt his or her abilities. "Erikson believes that children who experience too much doubt at this stage will lack confidence in their powers later in life"(Woolfolk, 1987).
Stage 2 • Elements for a positive outcome: • The child must take more responsibility for his or her own feeding, toileting, and dressing. Parents must be reassuring yet avoid overprotection. • Elements for a negative outcome: • If parents do not maintain a reassuring, confident attitude and do not reinforce the child's efforts to master basic motor and cognitive skills, children may begin to feel shame; they may learn to doubt their abilities to manage the world on their own terms. Children who experience too much doubt at this stage will lack confidence in their own powers throughout life. • Examples: • In this stage children begin to assume important responsibilities for self-care like feeding, toileting, and dressing.
Stage 3: Locomotor • Age: Early Childhood -- 2 to 6 years • Conflict: Initiative vs. Guilt • Important Event: Independence • Description: • The most important event at this stage is independence. The child continues to be assertive and to take the initiative. Playing and hero worshipping are an important form of initiative for children. Children in this stage are eager for responsibility. It is essential for adults to confirm that the child's initiative is accepted no matter how small it may be. If the child is not given a chance to be responsible and do things on their own, a sense of guilt may develop. The child will come to believe that what they want to do is always wrong.
Stage 3 • Elements for a positive outcome: • In order for a positive outcome in this stage, the child must learn to accept without guilt, that there are certain things not allowed. Children must be guilt free when using imagination. They must be reassured that it is okay to play certain adult roles. • Elements for a negative outcome: • If children are not allowed to do things on their own, a sense of guilt may develop and they may come to believe that what they want to do is always wrong. • Examples: • A four year old passing tools to a parent who is fixing a bicycle. Children at this stage will worship heroes. Pretend games are also common.