Manual of Ambulatory Pediatrics – Well Child Visits & Anticipatory Guidance: 3-year to 17-year visits

This visit can be planned as a special review session to assess the growth and devel- opment that have taken place during the past 3 years. Identifying both accomplished and unaccomplished tasks will provide a guide for the next critical period of growth: the preschool years, ages 3 to 6.

1. Overview
   1. Special visit
      1. Review accomplishments of 3
      2. Health and personality patterns well-established
      3. Investigation of any concerns or problems will have better results now than ever
   2. Parents
      1. Assessment and appreciation of child’s accomplishments
      2. Identify any abuse of family

 

 

1. Child
   1. Physical
      1. Following growth chart pattern
      2. Accepting simple balanced meals
      3. Sleep: Dreams and nightmares may frighten child from wanting to follow usual bedtime
      4. Toilet training accomplished: Girls earlier than boys
      5. Systems review ( see Guidelines, p. 178)
   2. Emotional: Increasing confidence and independence
   3. Intellectual: Using language for things important to him or her
   4. Social
      1. Enjoys peers: Carefully watches their activities but little inter- action
      2. Plays equally well with either sex
   5. Risk factors
      1. Frequent illnesses and slow recovery
      2. Impulsive behavior or excessive shyness
      3. No eye contact
      4. No primary caregiver to help establish behavior control
   6. Injury prevention
   7. Review safety protocol.
      1. Memory sufficiently established so that recent past activities and their consequences can be used to restrict behavior. Increased lan- guage ability also aids in behavior Reasoning with toddler is ineffective; setting consistent limits is imperative.
         1. 3 to 4 years: Child still in dangerous world of make-believe
         2. 4 to 5 years: Child more realistic in behavior, but often needs to try out some new activity without being able to predict the out- come
         3. 5 to 6 years
            1. Child’s language skills and behavior control make it more likely that he or she will act
            2. Child can begin to take some responsibility for own
            3. Child’s widening environment needs careful assessment: Playground, school, bus, strangers

• Child abuse
  1. Age-specific concerns
     1. Increased physical ability may lead to injuries that are not the result of abuse. Detailed history is
     2. Corporal punishment may be a pattern of abuse by caregivers in an attempt to establish behavioral
  2. At-risk child
     1. Insufficient impulse control
     2. Overly passive or aggressive
     3. Health problems
     4. Fearful or aggressive when touched during physical examination

 

 

5. Other members of family being abused
6. Assessment of all adults with access to child

1. Verbal and psychological abuse needs to be

1. Review outline
   1. Parents
      1. Provide basic physical and emotional needs
      2. Self-direction in identifying and coping with problems
      3. Appreciate their role in setting standards for family’s behavioral and cultural patterns
      4. Identify abuse to any member of family
   2. Children
      1. Each child has the opportunity to pass through own developmental stage without undue interference from
      2. Caring, cooperative, interactive pattern of behavior
   3. Toddler
      1. Stability and maturation of physical systems
      2. Sees self as a person of worth and competence; self-confident, cheerful, cooperative attitude
      3. Identifies sexual identity
      4. Begins to use language as a tool
   4. Health habits
      1. Nutrition
         1. Accepts simple, balanced menus
         2. Pleasure in eating, but not emphasized as a way of gaining atten- tion or a substitute for emotional needs
      2. Sleep
         1. Accepts bedtime as another pleasant part of daily routine
         2. Sleeps up to 10 to 12 hours at night, with one nap or rest period
         3. Dreams are beginning to become real, as the ability for magical thinking develops; inaccurate assessment of reality can be frightening.
      3. Elimination
         1. Daytime control usually by 3 years of age
         2. Nighttime control accomplished later
         3. Takes pride in accomplishment of this control
      4. Speech
         1. Adequate vocabulary to express needs
         2. Not all consonants articulated
         3. Labeling and categorizing
      5. Review of systems
         1. Growth
            1. Growth pattern consistent with genetics, nutrition, and illnesses
            2. Rate of growth decelerating: Height, 3 /year; weight 5 lb/year
            3. Weight four times birth weight; length half of adult size
            4. Head 80% of adult size; rate of growth slowing
            5. Legs growing faster than other body parts

 

 

1. Skeletal
   1. Bones become stronger as ratio of cartilage to bone decreases; long bones are the first to be ossified, joint bones
   2. Craniofacial development gives facial features more
   3. Skeletal age can be used as an indication of overall body
   4. Bone functions as a reservoir for calcium and bone marrow, providing adequate production of red blood
2. Muscle
   1. Muscle tissue development influenced by hormones, nutrition, and exercise.
   2. Muscle strength depends on amount of tissue, age, and
   3. Because endurance relates to maturation of cardiac and respiratory systems, which supply oxygen to the muscle tissue, 3-year-olds often have less endurance than
3. Teeth
   1. Complete set of 20 deciduous teeth present; important for mastica- tion and prevention of malocclusion; dental care important
   2. Permanent teeth being formed in jaw
   3. Dental age an indication of overall body maturation
4. Skin
   1. Functioning more efficiently to maintain temperature control
      1. Number of sweat glands developing
      2. Maturity of function of capillaries
      3. Development of adipose tissue, which decreases evaporation of body fluids
   2. Increased acidity of skin aids in resistance to
   3. Increase in melanin production provides better protection from sun’s rays
   4. Sebaceous glands are less active, so skin may become
   5. Subcutaneous fat decreases until about 6 years of
5. Vision
   1. Normal acuity at 2 to 3 years: 20/80
   2. Slightly hyperopic until 7 to 8 years
   3. Astigmatism may still be present because of immaturity and distortion of
   4. Depth perception incomplete until about 6 years
6. Hearing
   1. Acuity at adult level
   2. Aware of pitch and tone
7. Central nervous system
   1. Continuation and refinement of myelination gives increasing neuro- muscular
   2. Intellectual abilities increasing because of continued development of cerebral cortex
   3. Location of sensations possible; better able to locate and describe pain

 

 

1. Cardiovascular
   1. Body temperature, pulse, and blood pressure more stable
   2. Heart size increasing
   3. Sinus arrhythmia still present; innocent heart murmur in 30% to 50% of children
2. Respiratory
   1. Increasing lung capacity, as number and size of alveoli increase and muscles of chest are stronger
   2. Diaphragmatic breathing still present until about 6 years of age
3. Digestive
   1. Digestive juices all present and functioning; all types of simple foods can be
   2. Peristalsis less sensitive, so assimilation and absorption of food more efficient
   3. Less frequent and firmer stools
   4. Habit of swallowing saliva established; drooling no longer occurs
4. Excretory
   1. Maturation of kidney function provides more stable solute levels and less danger of
   2. Increase in bladder size and sphincter control makes toilet training possible.
5. Immune
   1. Ability to produce antibodies improving, but immunoglobulin levels unstable
   2. Lymphoid tissues growing rapidly; provide protection from infec- tion until immunoglobulin production is mature
   3. Develops own set of antibodies as infections are overcome; slowly increasing resistance to infection
6. Endocrine
   1. Growth hormones well-developed
   2. Pituitary gland regulating growth rate
   3. Thyroid gland involved in regulating metabolism and skeletal and dental growth
   4. Adrenal gland regulating blood pressure, heart rate, and glucose metabolism
   5. Islets of Langerhans regulating blood sugar Immaturity of this system can cause periods of low blood sugar; nutrition and timing of food intake must be evaluated.

• Growth and development
  1. Emotional
     1. Sufficient confidence to participate in activities away from home and parents
     2. Resourceful in managing to get own way
     3. Can give and receive affection
     4. Dominant mood of cheerfulness and self-satisfaction

 

 

1. Intellectual
   1. Begins to anticipate and verbalize consequences of actions
   2. Continues to attempt to solve problems through trial and error
   3. Distorts reality with make-believe
   4. Begins to use language as a tool
2. Social
   1. Still separates from parent with some apprehension
   2. Enjoys being with peers but has little interaction with them
   3. Plays well by self
   4. Aware of sexual identity, but plays equally well with members of own and opposite sex
   5. Indicates awareness of right from wrong but shows guilt only if found doing something wrong; eager to please

• Risk factors: Child
  1. Inadequate environment to provide basic needs
  2. Inconsistent growth pattern and poor coordination
  3. Health problems not under medical supervision
  4. Impulsive and aggressive or passive behavior patterns
  5. Inability to use language as a tool
  6. Inability to show affection or accept affection from others
  7. No primary adult with whom to establish a caring relationship
  8. Child abuse, physical or verbal, identified

1. Physical examination
   1. Growth: Continues on established pattern; catch up if there was severe or prolonged illness
      1. Use CDC growth charts (2000), available at: http://www.cdc.gov/ growthcharts
      2. Calculate BMI at every well child visit during childhood (see Barlow, 2007).
   2. Appearance and behavior
      1. Color
      2. Posture
      3. Body proportion
      4. Energy level, alertness, attention to instructions, ability to control activity
      5. Good eye contact, confident manner, interaction with adults other than parent
   3. Specific factors to note during routine physical examination
      1. Skin: Bruising, burns
      2. Eyes: Strabismus
      3. Ears: Mobility of tympanic membrane
      4. Throat: Enlarged tonsil tissue
      5. Neck: Lymph nodes
      6. Chest: Increased breath sounds; diaphragmatic breathing
      7. Heart: Sinus arrhythmia; heart murmur; refer if not previously evaluated.

 

 

8. Abdomen: Muscle tone, femoral pulses, hernias
9. Genitalia: Irritation, discharge; testes
10. Musculoskeletal: Muscle development and tone; range of motion
11. Central nervous system: Gait; more refined coordination; balance; stands on one foot; hops on one foot; buttons up; beginning con- trol in using crayons

1. Parent-child interaction
   1. Parent: Pride and affection evident
   2. Child: Attention to parent for support and control of activity
2. Assessment
   1. Physical
   2. Developmental
   3. Emotional
   4. Environmental
3. Plan
   1. Immunizations: Complete schedule as needed
   2. Screening: Blood pressure; hearing and vision test yearly; dental visit Hemoglobin, hematocrit, or CBC (per office protocol); once between 15 months and 5 years
   3. Problem list (devised with parent); SOAP for each
   4. Appropriate timing for office visits

These 3 years provide the time needed to expand physical and psychosocial skills. By age 6, the child will be a competent, self-assured, friendly first-grader.

 

1. Overview
   1. Guidelines
      1. Should be viewed as a continuum as each child passes through these developmental stages at own pace
      2. Chronologic age may not be
   2. Parents
      1. Parents’ interest, support, and affection will  help  guide  the child from 3-year-old and his or her world of magic to a realistic 6-year-old ready for school and friends.
      2. Identify any form of abuse to family
   3. Child
      1. Physical
         1. Health
            • Following growth pattern
            • Frequent colds while slowly building up own immunity

 

 

• Eating
  • Selective and independent about food
  • Wide variety of foods offered with no choices or discussion
  • Food not used as threat or reward
• Sleeping
  • See
  • Nightmares are common at 3 to 4 years of age, but investigation is needed if still frequent by 6

2. Emotional
   1. Continuing development of self-esteem and confidence to turn from security of home to outside world of peers and school
   2. May be a difficult path, with frequent regressive or aggres-

sive behavior

1. Child can maintain expected behavior with positive re- inforcement.
2. Beginning to distinguish right from wrong
3. Consistent caregiver needed to turn to for guidance and encouragement
4. See guidelines for childrearing practices of each

3. Intellectual
   1. Learning through increased memory of experiences and their consequences
   2. Initiating own activities and creative play
   3. Television watching/computer use can inhibit these creative activities.
   4. See guidelines for each age’s
4. Social
   1. Enjoys being with peers, but watching each other rather than participating in interactive play. Listening to children’s conversations is a way to observe how each child is carrying on own independent
   2. Practices how to maintain own egocentric wishes
   3. Sexual identity
      • Plays equally well with either sex
      • See guidelines for each age’s expectations and childrear- ing
   4. Risk factors
      1. Poor health or serious illness
      2. Overly shy or overly aggressive behavior
      3. Poor language development
      4. No appropriate role model
   5. Watch for:
      1. Cheerful, mischievous, energetic child
      2. Good eye contact with adults

 

 

3. Pride and self-confidence in accomplishments
4. Understandable language to others besides family members
5. Directives given to others but not always accepting of sugges- tions from others
6. Accepting behavioral standards; guilt if found doing something

wrong

7. Unhappy, aggressive, whining child needs special

1. Expectations of this period
   1. Physical maturity
      1. Increasing muscle strength and endurance
      2. Developing immunity to infectious disease
   2. Magic and fantasy give way to
   3. Language skills Child begins to attend to what others are saying; by 6 years, interactive speech is possible.
   4. Values of environment are being internalized, and actions are being

guided by these standards.

• Family status
  1. Parents
     1. Provide basic physical and developmental needs
     2. Responsible for adequate child care arrangements
     3. Household tasks scheduled and responsibilities for each family member defined
     4. Emergency planning: Accidents, illness, fire, telephone contacts
     5. Family meetings to share experiences, plan activities, and give support to each other
     6. Identify abuse to any family member
  2. Children
     1. Each developing according to own capabilities without being overpowered by parents or siblings
     2. Demonstrating tolerance, affection, and support for each other
     3. Developing interactive techniques without teasing or aggression
     4. Abuse identified
  3. Health patterns
     1. Nutrition
        1. Child is selective and more independent about
        2. Encourage some involvement in food preparation and
        3. Encourage good breakfast habits in anticipation of school
        4. Offer small amounts of nutritious foods often during the
        5. Encourage eating of vegetables and fruits (children often prefer these raw) as
        6. Do not force child to eat; poor appetite needs
        7. Do not use food as a bribe, threat, or
        8. 4- to 6-year-olds need 90 kcal/kg or about 1,800 cal/d
        9. 4- to 8-year-olds should continue to have adequate iron, vita- min C and about 800 mg/d of

 

 

1. Health
   1. Frequent colds expected because of child’s associating with other children and still building up immunity to infections
   2. If recovery prolonged, evaluation of basic health pattern needed
2. Sleep
   1. Regular pattern established (up to 10 to 12 hours at night)
   2. Naps: Help child become aware of periods of fatigue and pro- vide a rest
   3. Dreams can be frightening, as child is still learning to distin- guish dreams from reality. Investigate overstimulation, anxi- ety,
   4. Teeth grinding: Correlates with frequency of nightmares; can

be a way of releasing unrelieved emotional pressures

1. Elimination
   1. Regular pattern established; learning to manage self
   2. Occasional accidents, usually due to illness, changes in world, or some traumatic experience
   3. Continued soiling or return to bed-wetting needs
   4. Enuresis (see Enuresis in Part II, p. 284)
2. Growth and development
   1. Physical
      1. Growth rate about 2 in./year from 6 to 12 years
         1. Legs growing the fastest
         2. Facial bones developing and fat pads disappearing; by age 5 years, child looks as he or she will as an
         3. Muscle development and strength increasing through activ- ity; not sex-dependent
      2. Gross motor: Improving coordination makes hopping, skipping, and dancing
      3. Fine motor: By age 5 to 6 years, child can draw recognizable
      4. Speech
         1. Vocabulary
            • Increasing seemingly without any effort
            • By 5 to 6 years of age, child uses verb tenses and plurals correctly.
         2. Articulation
            • Stuttering is occasionally present, as ideas come faster than words can be
            • Lisping until ages 5 to 6 years may be a matter of maturation.
         3. Emotional development. Erikson: Initiative vs. Guilt. This stage sees the progression from activities motivated merely by responses to stimuli or imitative actions to purposeful activity. Initiating activity, both physical and intellectual, continues the development of compe- tence and feeling of independence. Without the opportunity or the physical skills to explore, manipulate, and challenge the environ- ment, the competencies and independence that could have been

 

 

attained are delayed or never developed. These experiences deter- mine the ratio of self-confidence to inferiority. Begin to use child behavior checklist (see Appendix P, p. 579).

1. Emotions become more stable as the child
   1. Feeling of competence in doing things for self
   2. Able to manage away from home
   3. Able to make friends and relate to adults other than parents
   4. Increase in intellectual capacity, so child understands world and can plan activities
2. Temperament
   1. Egocentric: Enjoys being with peers, but not until age 7 to 8 when he or she will listen to another’s point of view
   2. Innovative in activities
   3. Mischievous, joyful
   4. Affection: An egocentric reaction for approval and attention
   5. Assertive: Improving memory and language skills used to direct activities and influence others
   6. Aggression
      • Mode of behavior that continues through observing adult role models
      • Means of getting rid of unrelieved frustrations
      • Egocentric needs not met
   7. Cooperation: Continues to bargain appropriate behavior for approval and attention
   8. Fear: Expected reaction to world of fantasy and increase in physical daring
   9. Shyness
      • Lack of feelings of competency and independence
      • Personality characteristic
   10. Passivity: Overcontrol by adults can make child fearful to act on own. Lack of developed built-in behavioral controls can prevent child from attempting
   11. So much is to be accomplished in these 3 years that occa-

sional reversals to earlier behavior patterns can be expected.

1. Intellectual development. Piaget: These years continue the child’s egocentric way of seeing the Learning intuitively through self- activity, having little concern for reality, and using increasing memory and language, children keep reconstructing their world to fit their needs. By 6 years of age, the influence of peers and their own expe- riences force children to take a more realistic view of the world around them.
   1. Expectations
      1. 3 to 4 years of age
         • Intuitive learning through free-wheeling activities
           • Pretending; trying on role activities of others
           • Increase in mental functioning and memory; learn- ing cause and effect of activities

 

 

• Investigating and manipulating everything that can be reached
• Watching activities of others
• Magical world: Limited experience gives incorrect explanations of

• Memory continues storing up events and their

1. 4 to 5 years of age
   • Intuitive learning continues through the initiative to attempt new and creative ways to do
   • Magical world is giving way to reality as past experiences

are used to predict the correct outcome, often causing an unhappy, rebellious child.

• Logical reasoning is still a long way

1. 5 to 6 years of age
   • Beginning to learn through language
   • Can maintain a single line of thought
   • Listens to others, but with little exchange of ideas
   • Integrates past experiences to form a more reliable ver- sion of reality and time, making for a more contented, cooperative child
2. Language
   1. 3 to 4 years of age
      • Makes declarative statements about his or her own wants and feelings
      • Thinks out loud; cannot be expected to keep a secret
      • Conversations consist of each child talking only for self, not attending to or responding to ideas of others
      • Enjoys being read to and memorizing nursery rhymes
      • Body language supplements these limited language
   2. 4 to 5 years of age
      • A quarrelsome period of learning to interact with peers
      • Quarrels force child to express ideas and listen to the ideas of
   3. By 5 years of age
      • Listening skills are improving, but not until 7 to 8 years can child listen to others well enough to have an exchange of
      • Improving ability to use words in place of action; needs

role model of people doing this and help in developing this skill

3. School readiness by 6 years of age
   1. Able to manage away from home
   2. Able to accept behavior control expectations
   3. Able to interact with adults other than parents
   4. Language skills sufficient to express ideas
   5. Listening skills sufficient to attend to directions of others
   6. Sufficient self-esteem to be able to carry on independent activity

 

 

4. Television watching
   1. Passive activity; replaces important learning from self-initiated activity
   2. Child fascinated by color, sound, motion; energy put into

watching, not taking in story

1. Child cannot distinguish between fantasy and reality.
2. By age 5, child relates to characters as role models; aggres- sive behavior seen as appropriate
3. Usurps family conversations and interaction

5. Television control
   1. Discuss as a family what programs are to be selected, each member having a limited
   2. Discuss
   3. Watch programs with
   4. Pay attention to snacks eaten while watching TV; often they are junk foods, high in calories and fat and low in
   5. Set up play equipment near TV set as an alternative to

watching.

1. Set up definite times for TV watching/computer use and definite times when turned

1. Social development
   1. Expectations: Sequential development in becoming a mem- ber of society; by the time child enters first grade, the follow- ing expectations must be met so that child is freed of egocentric needs and can reach out to learn and enjoy the companionship of others:
      1. 3 to 4 years of age
         • Manages away from home; sufficient ability to control behavior
         • Observant of what is going on around him or her; peer

relationships consist of watching each other but playing independently.

• Instigates own activities
• Turns to adults for help and support

1. 4 to 5 years of age
   • Easily accepts expected appropriate behavior
   • Peer relationships are often quarrelsome, as each child attempts to argue for his or her own
   • Eager to please primary caregiver, remorseful if caught

doing wrong

1. 5 to 6 years of age
   • Able to join peers in simple interactive games
   • Dogmatic; changes rules as needed to benefit self
   • Internalizes behavioral patterns; standards of family and peer group accepted
   • Sufficient self-esteem for independent activities without

constant demanding of attention

 

 

2. Gender identity
   1. From ages 3 to 5 years, child is usually indiscriminate as to which sex he or she is with; will take on role of either sex in dramatic play
   2. By age 6, prefers company of own sex; this preference con-

tinues until adolescence.

1. Social expectations of each sex are
   • Boys are more combative and
   • Girls use words as weapons and coyness and guile to get their own
2. Modification of sex-typing patterns
   • Gentleness, non-punitive punishment
   • Develop feelings of competence and industry by devis- ing more challenging physical activities and intellectual projects.
3. Risk factors: Child
   1. Physical development
      1. Basic health patterns not becoming routine
      2. Somatic complaints being used for emotional support
   2. Intellectual development
      1. Passive and cautious in activities
      2. Magical thinking still dominating activity at age 4 to 5
      3. Impulsive, quarrelsome behavior at age 4 to 5
      4. No primary adult to provide support and affection
      5. Unable to use language as a controller of action
      6. Too quiet; retreating into silence in confrontations
      7. Continued baby talk and poor fluency
   3. Social development
      1. Parents with low self-esteem have difficulty enforcing consistent behavioral
      2. Inadequate environment for active, curious child
      3. Few opportunities to be with other children; little supervision if with other children
      4. No primary caring adult

• Childrearing practices
  1. General
     1. No rewards for illness
     2. Responsibility for wellness becoming part of child’s learning
     3. Provide openness to talk about unusual discomforts, body func- tions, and
  2. Emotional development
     1. 3 to 4 years of age
        1. Short periods of peer companionship under adult super- vision; child needs sufficient time by self to develop pleasure from initiating and accomplishing
        2. Open spaces and large equipment for play

 

 

1. Safe boundaries and consistent limits on behavior
2. Primary adult listener, confidant, and giver of attention and approval

2. 4 to 5 years of age
   1. More time with peers, but with continued supervision
   2. Variety of activities and experiences to broaden response pattern
   3. Learning to use language rather than aggressive acts to get own way
   4. Give opportunities to take responsibility for
   5. Primary adult listener, confidant, and giver of attention and approval
3. 5 to 6 years of age
   1. Opportunity to use increased skills for independent planning and performance of activities
   2. Plan peer interaction and participation in simple group

games.

1. Improve interaction by asking child to repeat ideas given by others.
2. Child still needs primary adult for attention and

1. Intellectual development
   1. Safe areas where high-level energy can be expended
   2. Variety of activities with opportunity for some association with children who are slightly older
   3. Play equipment: For large muscle activity, for perceptual learn-

ing; materials and opportunity for dramatic play

4. Discussion of activities; time for someone to listen to child
5. Primary adult to provide support and affection
6. Language
   1. Avoid correcting errors; child will make own corrections
   2. Pay no attention to stuttering; increased concern will add to problem.
   3. Provide good speech and language role
   4. Provide a patient listener to hear child express feelings and ideas.
7. Social development
   1. Promoting acceptable behavior
      1. Safe environment with sufficient space and equipment for constructive activities
      2. Consistent daily schedule; expected behavior defined and

maintained

1. Caregivers understand child’s ability to comply with
2. Child spends some time with older children; imitating is easiest way for child to
3. Positive reinforcement, such as hugs and kisses; approval

needed for each small step; be aware of things child is doing right

 

 

1. Remember that logic and reasoning are not part of child’s skills

2. Discipline
   1. Expect child to control behavior for attention and
   2. Give positive reinforcement for all appropriate
   3. Harmful behavior to self and others must be stopped but must not be the only way for the child to get
   4. Frequent aggressive and uncontrolled behavior needs inves- tigation into the child’s role models, unrelieved pressures, and physical
   5. Punitive punishment feeds into anger and

• Safety
  1. Accidents happen most frequently:
     1. When usual routine changes (holidays, vacations, illness in family)
     2. After stressful events (for caregivers or for child)
     3. When caregivers are tired or ill
     4. Late in the afternoon
  2. Accident prevention
     1. Child is beginning to understand consequences of
     2. Responsibilities given as child demonstrates reliability
     3. Magical thinking makes child think he or she can do the
     4. Family rules established and discussed
        1. Responsibilities outlined for each family member
        2. Fire drills practiced and meeting place established
        3. Emergency plans established and rehearsed
        4. Telephone numbers posted and practiced
     5. Investigate frequent injuries as possible child neglect or
     6. Instructions to babysitters

The attitudes of competence, self-worth, and initiative that the 6-year-old has devel- oped provide the impetus to separate more completely from family and home. Both the child and family enjoy their increasing independence. Attending school and associating with teachers and peers provide the child with new challenges to develop his or her own capabilities and self-confidence within the enlarging world.

1. Overview
   1. Parents
      1. Observing carefully child’s ability to:
         1. Cope with long day away at school
         2. Maintain appropriate behavior and independence with new friends
         3. Talk about daily experiences, although child still has difficulty expressing ideas and feelings
      2. Identify abuse of any family member

 

 

1. Child
   1. Physical
      1. Slow growth rate for both sexes
      2. Enjoys food and accepts a well-balanced diet; family emphasis on physical fitness enjoyed
      3. Sleeps up to 10 to 12 hours; nightmares less frequent
      4. Speech: Articulation of all sounds
      5. Loosing teeth in same order as eruption
   2. Emotional: Initiates own activities but has difficulty following activities of others; still attempts to control own world and expects things to be done his or her way
   3. Intellectual: No longer interested in magical world but thinks concretely: How things are and how they work
   4. Social
      1. Experiments with ways to interact successfully with teachers and peers
      2. Prefers associating with own sex
      3. Cultural and ethnic patterns of others difficult to understand
   5. Risk factors
      1. Poor school adjustment or inappropriate school
      2. Frequent illness or using illness as a way to escape new develop- mental tasks
      3. No loving caregiver to listen to him or her
   6. See guidelines for specific factors to be noted in physical
2. Injury prevention
   1. Review safety
   2. Many new challenges face children from 6 to 9 years of age as they reach a wider environment and have less surveillance of their
   3. Injury-prevention education needs to be available for
   4. Accident frequency: Accidents, most common in this age group
      1. Bicycles, particularly riding without proper helmet
      2. Skateboards and in-line skates, without proper equipment
      3. Contact sports: Equipment and supervision needed
      4. Swimming accidents
      5. Guns when ammunition not locked away
   5. Societal health problems
      1. Problems they will soon face are drugs, sexual abuse, eating disorders, alcohol, and
         1. Special attention and education needed
         2. Must learn how to handle advances made by strangers
      2. Peer group pressure needs to be countered by a caring
      3. Home-alone children must have strict regulations and emergency planning.

• Child abuse
  1. Age-specific factors
     1. Children should now be able to verbalize any unwanted physical touching or May be better able to talk away from parents, for instance, during privacy of physical examination

 

 

1. Areas to investigate
   1. Sexual abuse
   2. Corporal punishment
   3. Overreaction to pain
   4. Confronting sexual harassment and harassers
2. At-risk child
   1. Continued health problems
   2. Unhappy, depressed or aggressive, arrogant
   3. Verbal and psychological abuse
   4. No caring adult with whom to relate
3. Developmental process
   1. Parents
      1. Understand the importance of change from home- and family- centered child to teacher- and peer group-centered child
      2. Have consistent expectations of appropriate behavior
      3. Continue to provide safe, supportive environment
      4. Identify child abuse
   2. Child
      1. Maintains appropriate behavior, accepting cultural values of family
      2. Busy and happy with projects at school and with friends
      3. Continues to turn to family for support
   3. Family status
      1. Parental concerns and problems: Ability to identify problems and to cope
      2. Illnesses in family since last visit
      3. Parental assessment of child’s development
      4. Family interaction and support for each other
         1. Organization of responsibilities for each member
         2. Review and updating of emergency planning
         3. Meetings for group decisions, problem-solving, and sharing of experiences
         4. Sibling rivalry problems; referrals as needed
      5. Fear of violence or abuse identified
   4. Health habits
      1. Nutrition and diet history
         1. Children 7 to 8 years need 70 kcal/kg.
         2. Intake of food during school hours; snacks
         3. Child learning basics of nutrition
         4. Ethnic eating patterns evaluated
         5. Continued involvement in shopping and preparation of foods
         6. Dietary recommendations for all children over age 2 by the American Heart Association are found at http://circ.ahaorg/cgi/content/Full/112/13/2061.
      2. Sleep
         1. Restful 10 hours with fewer disturbances from nightmares
         2. Falls asleep easily unless overtired or overstimulated
         3. Beginning to realize when he or she needs rest and sleep

 

 

1. Elimination
   1. Managing independently
   2. Family routine allows regular time of bowel
   3. Problems or discomforts discussed with caregiver
   4. Enuresis (see Enuresis in Part II, p. 284)
   5. Encopresis: Rule out constipation, then refer to physician or specialty

• Growth and development
  1. Physical
     1. Growth follows established
        1. Participates in activities to develop endurance and large muscles, such as climbing, swimming, or running
        2. Develops muscle coordination with games of rhythm, music, and using large balls
        3. Baseball requires slowly developing eye–hand
        4. Activity program needed that is designed to develop individual skills.
        5. Family emphasis on importance of physical fitness
        6. Careful supervision to de-emphasize competitive games until child is physically and emotionally ready
     2. Teeth
        1. Loses teeth in the same order as eruption
        2. Child takes responsibility for daily
        3. Dental care available
     3. Speech development
        1. Articulates all sounds by 6 to 7 years of age
        2. Correctly uses verb tenses, plurals, pronouns
        3. Vocabulary increases, and most words used appropriately
     4. Emotional development. Erikson: Initiative vs. Guilt. Child demon- strates that he or she feels competent to manage daily routine, can make friends, and can accept and return affection of primary caregivers. Use child behavior checklist (see Appendix P, p. 579)
        1. Enthusiastic about daily happenings but cautious about routine changes and new experiences
        2. Enjoys companionship of peers but continues to want to do things his or her way
        3. Instigates and carries through new projects
        4. Continues to turn to caregivers for affection and approval
        5. If these attitudes are not present, further assessment is
     5. Intellectual development. Piaget: From intuitive learning to concrete thinking. Child continues through sufficient experiences to distinguish fact from fantasy. His or her world of reality is established through increased memory and ability to symbolize
        1. Learning
           1. Enjoys school, learning of Rather than “What does that do?” child asks, “How does it work?”

 

 

1. Turns to stories of actual adventures; no longer interested in fairy tales
2. Can define ways to solve a problem and understand its consequences

2. Language
   1. Enjoys words, riddles, puns
   2. Experiments with sounds: Chants, songs, poems
   3. Exchanges factual information, but has trouble expressing ideas and feelings
3. Social development: Continuing task is to learn to interact successfully with those in child’s enlarging world of school and
   1. Inconsistent behavior in trying to find successful interactive patterns
   2. Frequent changes in friendships
   3. Depends on own rules for expected ways of acting for self and playmates
   4. Turns to adults as guides to cultural and moral behavior; internal- izes behavioral patterns of culture

• Risk factors
  1. Family
     1. Needs not being met
     2. Inappropriate and inconsistent expectations of child
     3. Abuse of any family member
  2. Child
     1. Inappropriate behavior patterns
        1. Lack of behavior control
        2. Not showing guilt when doing wrong
        3. No appropriate role models
     2. Developmental lags (specifically neurologic and speech)
     3. Inability to relate appropriately to siblings, peers, and adults
     4. Poor adjustment to school
  3. Physical examination
     1. Appearance
        1. Body proportion
        2. Muscle development
     2. Behavior
        1. Makes eye contact
        2. Cooperative
        3. Interested in visit
        4. Able to contribute to history taking
     3. Growth
        1. Continues on established pattern
        2. Investigate if more than two standard deviations in height or weight. Use CDC growth charts (2000), available at: http://www.cdc.gov/growthcharts
        3. Calculate BMI at every well child visit during childhood (see Barlow, 2007).

 

 

1. Specific factors to note during routine physical examination
   1. Skin: Excessive bruises, burns
   2. Eyes: Equal tracking
   3. Ears: Mobility of tympanic membrane
   4. Teeth: Losing teeth in order of appearance; occlusion; cavities
   5. Throat: Tonsils—size, color, pitting
   6. Heart: Sinus arrhythmia
   7. Abdomen: Muscle tone, hernia
   8. Genitalia: Irritation, discharge, phimosis
   9. Musculoskeletal: Muscle development, strength, tone; scoliosis
   10. Neurologic: Coordination—gait, skip, hop; fine motor (draws tri- angle horizontal, vertical)
2. Parent-child interaction
   1. Parent: Pride and affection evident
   2. Child: Responds to parent in positive manner
3. Assessment
4. Plan: Screening tests: AAP recommends screening hearing and

Continue yearly blood pressure. Cholesterol screen if high-risk (see USPSTF guidelines, 2007; available at: http://pediatrics. aappublications.org/cgi/content/abstract/120/1/e189)

Like the other age periods, the years 6 to 9 are not a single unit. Contrasting a 6-year-old and a 9-year-old shows what a big step this is. The 6-year-old retains many characteristics of earlier periods, including struggling to find a way to establish himself or herself with peers and turning back to the family for overt signs of affection. In contrast, the 9-year-old is a firm member of a peer group, accepting its rituals and rules and taking disappointments and hurts stoically. This period, the first that can be recalled chronologically, includes years of free- dom, fun, and fond memories.

1. Overview
   1. Parents
      1. Appreciate role of establishing family standards and cultural values
      2. Discuss expectations with child and devise plans toward coop- eration in maintaining them
      3. Plan sufficient time with child to listen and talk about experiences
      4. Provide opportunities for successful experiences at school and with friends
   2. Child
      1. Physical
         1. Slower growth pattern for both sexes but agility and coordi- nation improving

 

 

1. Early-maturing girls can begin hormonal changes by age 9; evident by developing chubbiness
2. Diet: Learning to take responsibility for eating balanced diet
3. Elimination: Boys have more evidence of encopresis and enure- sis; important to elicit this information and refer to physician
4. Safety: Accident-prone behavior needs

2. Emotional
   1. Successful experiences are important to continue child’s growth toward self-esteem and self-confidence. Without these, a feeling of inferiority can take over child’s attitude toward self and his or her
   2. See guidelines for characteristics of
3. Intellectual
   1. Developing ability to think realistically helps child manage self and affairs
   2. See guidelines for school and learning expectations for each

age group.

4. Social
   1. Child turns from needing only a few friends to expecting  to become a member of own peer group. Community activities, such as scouts, church, and sports, can provide appropriate
   2. See guidelines for age-appropriate
5. Risk factors
   1. Poor school adjustment, not working up to capacity
   2. Using aggressive behavior to gain attention
   3. Accident-prone or frequent illnesses
   4. Depending on TV or computer games for entertainment rather than enjoying companionship of others
6. Safety and accident prevention: See guidelines for accident
7. Watch for:
   1. Development of a positive or negative attitude toward self and world
      1. Positive role model: Authority figure who demonstrates

gentleness, fairness, affection, respect, and cooperation

1. Adult who listens carefully to child’s ideas and helps him or her express ideas and feelings
2. Self-fulfilling prophecy: “I’m OK”
3. Family, school, and community taking responsibility to help child develop positive behavioral pattern

2. Now is the time to identify children without a supportive adult

and to make appropriate referrals and follow-up.

1. Expectations of this period
2. By age 9 years, the child
   1. Is separating from the family and making independent
   2. Can relate successfully to peers and adults other than

 

 

1. Enjoys school and is eager to
2. Instigates projects; has perseverance and derives pleasure from completing
3. Turns to family for support and
4. Is guided in behavior by rules of family and peers and under- stands consequences of

• Family status
  1. Basic needs being met; self-direction in coping with problems
  2. Parents
     1. Take pride in and enjoy child
     2. Foster independence and new experiences
     3. Take time for listening, discussions, and support
     4. Give responsibility as child demonstrates he or she can accept it
     5. Act as a moral guide and role model of love and affection
     6. Spend time to see that family rules are adhered to
     7. Report abuse of any family member
  3. Child
     1. Moves away from a close association with family to own peer group
     2. Accepts household responsibilities and schedules
     3. Returns to family for support and belonging
     4. Begins challenging family values with the values of peers and school; moral judgment limited by inability to appreciate views of others
     5. Learns to accept consequences of actions
  4. Health patterns
     1. Nutrition
        1. Learns nutritional standards, such as the four basic food groups; knows nutritious foods versus junk foods
        2. Participates in meal planning and shopping
        3. Keeps chart for adequate calories and nutrition as needed
     2. Elimination
        1. Responsibility for regular schedule
        2. Boys have more frequent problems with constipation and soil- ing than girls; refer to physician if a continuing
        3. Enuresis (see Enuresis in Part II, p. 284)
     3. Sleep
        1. Individual pattern (8 to 10 hours)
        2. Older child can stay up later than younger child; this gives parents time with each child and gives the children a feeling of individuality.
        3. Can awaken on time in the morning and has sufficient energy

for day’s activities

1. Exercise
   1. High energy level and muscular development require adequate opportunity for

 

 

2. Diverse supervised sports program in and after school for both boys and girls; watch for emphasis on one sport which can lead to overuse injuries
3. Free play periods: Safe environment, necessary limits
4. TV watching/computer use limited

1. Responsibility for own health
   1. Adequate role models
   2. Realizes pleasure and advantage of good health and disadvan- tage of illness
      1. Knowledge and willingness to obtain health care
      2. Social and emotional problems identified; parents or school personnel used as resource
   3. Safety
      1. Realistic thinking promotes more
      2. Accident-prone children: Investigate
         1. Awkwardness
         2. Daredevil behavior to get attention from peers
         3. Unstable environment causing inattention and high level of frustration
      3. Growth and development
         1. Physical
            1. Growth continues at a slow pace for both
               1. Chubbiness at age 8 to 9 years does not mean future obe- sity; after puberty, there is usually a return to the previous pattern but watch for signs of continued overweight Chart BMI and growth charts regularly.
               2. Muscle growth equal for both sexes; amount of exercise

now determines muscle strength.

2. Teeth: Age of the loose tooth
   1. Teeth replaced in same order as eruption of deciduous teeth
   2. Dental care: Discuss fluoride treatments with dentist if no fluoride in drinking water
3. Eyes: By age 7 years, visual acuity of 20/20 to 20/30
4. Speech
   1. Articulation: Refer to speech therapist if problems with enun- ciation, slurring, or fluency
   2. More complex sentences used (five to seven words).
   3. Rapid increase in vocabulary
   4. Careless enunciation can be improved by whistling, repeat- ing jingles and tongue twisters, and singing; listening to tape of own voice also is
5. Development of secondary sex characteristics: Organ enlarge-

ment begins 2 to 4 years before puberty.

1. Girls: Growth spurt at 9 to 14 years; breast enlargement at 8 to 13 years; menses at 10 to 16 years
2. Boys: Growth spurt at 10.5 to 13.5 years; enlarged testes at

9.5 to 13.5 years

 

 

1. Emotional development. Erikson: Industry vs. Inferiority. Building on previously developed attitudes of self-confidence, competence, and independence, the child attempts new projects. Completing these projects fosters pleasure and satisfaction in doing and succeeding. These same skills apply to participating in school and making new friends successfully. Without opportunities for these successes, feel- ings of inferiority
   1. Temperament
      1. Egocentric thinking continues until age 7 to 8, when child can include peer group in his or her
      2. Affection: Turns from family to teacher and peer group for

affection and approval

1. Spontaneous and enthusiastic; enjoys new outside world
2. Assertive: Attempts to persuade others to do things his or her way; demands own share, own turn, and own belongings
3. Frustration: Learns to cope with disappointments; learns to

have more realistic expectations

2. Self
   1. Self-concept: Sees self as different from others and begins to perceive own abilities
   2. Self-identity: Moves away from family; becomes dependent

on peers’ assessment

1. Self-esteem: Approval or disapproval of those important to him or her reflects view of
2. Sexual identity: Interacts best with own sex (both adults and

peers); takes on society’s role expectations; by age 8 to 9, curiosity; needs facts and proper vocabulary

1. Intellectual development. Piaget: During this period, child progresses

from learning through intuition to learning through concrete experi- ences. Difference between fantasy and reality is being sorted out and replaced by facts and order, systematic thinking, organizing, and classifying. Problems need to be tested in actuality; hypotheses are not yet comprehended.

1. Expectations
   1. 6 to 7 years
      • Still learning intuitively, but with good memory and building up of experiences; will soon become a realist
      • Eager for learning
      • Can still be unrealistic in explanations of events
      • Can remember letters and numbers
      • Expends much energy in learning to manage away from home and to interact with teacher and peers—can cause learning difficulties if this becomes an overriding concern
   2. 7 to 8 years
      • Learning concretely; logical reasoning improving
      • Can sit still longer
      • Lengthening attention span and improving listening skills

 

 

1. 8 to 9 years
   • Looks for cause and effect (scientist)
   • Comprehends reading material more easily
   • Time and place: Past becomes important; interest in far-off places
   • Basic writing, spelling, and reading skills accomplished
2. Identify intellectual behavior by the child’s ability to:
   • Successfully adapt to new situations
   • Change thinking to new requirements
   • Manage self and affairs effectively
   • Have an acute sense of humor
   • Be goal-directed
3. Language
   1. Vocabulary development important for expression of increasing range of feelings and experiences
   2. Expresses ideas and feelings; used as a coping and problem- solving mechanism
   3. Writing skills
      • By age 6 years, has muscle control for printing large letters
      • By age 7 to 8 years, writes simple, short sentences; one idea or fact, few adjectives or adverbs
      • By age 9 years, can write composition of 200 words
      • Spelling: Connecting sound to written form demands atten- tion to detail, a difficult task for a child with other concerns
   4. Social development
      1. Expectations
         1. 6 to 7 years of age
            • Successfully managing a whole day at school; taking the bus; eating away from home; bathroom independence; now able to sit still, listen, answer questions, and, most particularly, be aware of what others are doing
            • Interaction with teacher established
            • Still controls behavior for attention and approval
            • Makes friends with a few classmates
         2. 7 to 8 years of age
            • Enjoys school; eager to learn
            • Reliable, accepts behavioral expectations
            • Makes friends but changes affections frequently
            • Groups have loose ties and easily change
            • Rules not absolute, change to serve own purpose
         3. 8 to 9 years of age
            • Exceptional period of good health, good academic skills, good friends, and few concerns
            • Peer groups: Behavioral phenomenon that appears to develop in all societies
              • Rules and rituals are rigid and form boundaries of behavior.

 

 

• Leadership by those who are largest (in boys’ group) and the best talkers (in girls’ groups) and who can understand feelings of other gang members
• Satisfies need for companionship and approval
• Needs opportunity to compare gang values with standards of family
• Becomes aware of segregation; continued sex dis- crimination, even beyond this age group (fraterni- ties, lodges, service clubs); may be part of an ethnic neighborhood group
• Organized peer groups, such as scouts or church

groups, continue society’s cultural patterns.

2. Sexual identity
   1. 6 to 7 years of age: Begins to prefer playmates of own sex
   2. 7 to 8 years of age
      • Prefers company of own sex, to whom child relates more easily
      • Boys aspire to maleness, girls to femininity; affected by mass media
      • Parents and teachers of child’s sex used as role models
   3. 8 to 9 years of age
      • Curiosity and interest in other sex
        • Secretive whisperings about sex; off-color stories; experimentation and inspection of each other; searching in dictionary for words
        • Appropriate time for information and vocabulary

to be supplied before emotions become mixed with facts

• Sex roles more clearly defined and followed
• Parents’ attitudes and actions are models for love and affection.

1. Risk factors
   1. Emotional development
      1. Attitudes of defiance, rebellion, aggression, and passivity need careful, intense
      2. Treatment now is more likely to be successful than in the
   2. Intellectual development
      1. Difficult and unhappy adjustment away from home
      2. Inappropriate schooling for child’s abilities
   3. Social development
      1. Inability to form and maintain friendships
         1. Becomes a loner or makes extra demands on teacher for approval by being especially helpful (teacher’s pet)
         2. Uses pets as center of affection (most common in girls who have difficulty maintaining friendships)
         3. Uses unacceptable behavior to get attention from peers: Class clown, daredevil, thief, and so on

 

 

1. Label received from gang can continue throughout school years: Fatty, clown, teacher’s pet, and so on
2. Bullying and teasing can be very damaging during these

2. Peer group with unacceptable behavioral standards
   1. Appreciate that peers are necessary to child for approval and affection; criticism and maligning of friends demand that child defend those on whom he or she depends for self-esteem.
   2. Open discussion important
   3. Maintenance of family behavioral standards
   4. Referrals as needed
3. Overwhelmed by pressure of school and peers; acting out or passive behavior
4. Divorce
   1. Awareness of others and their feelings
   2. Fear of abandonment

• Childrearing practices
  1. Physical development
     1. 6 to 7 years of age
        1. Child learns to interact and to play according to rules, but finds it difficult to
        2. Physical coordination allows simple games, such as kickball;

eye–hand coordination and depth perception are insufficient for much success at more skilled games.

1. Muscle strength and development progress rapidly; equip-

ment is needed to enhance this.

1. Endurance is greatly improved, but signs of fatigue need to be identified.

2. 8 to 9 years of age
   1. Sportsmanship a peer standard
   2. Child can interact well enough to enjoy team
   3. Girls need sufficient opportunities to develop muscle strength and have team
3. Emotional development
   1. Independence of parents and child; important to have specific times together for planning, companionship, and support
   2. Carefully watch child’s success and failure in school and with

friends; promote open communication so that understanding of problems is possible.

3. Provide opportunities for successful
   1. Appropriate school experience for child’s ability
   2. Playmates available of same size, age, and interests; playing with older or younger child may cause child to be bossed or to do the bossing with no possibility of reciprocal
4. Affection and approval
   1. Child keen enough to know when praise is undeserved; demands and gives honest opinions

 

 

1. Child needs help expressing affection and love; compassion- ate role model needed

5. Seek help if:
   1. Child continues to be unsuccessful in school or in making friends
   2. Child cannot control acting out or is predominantly passive
   3. Communication between parents and child is poor
   4. Signs of behavior problems or depression occur
6. Intellectual development
   1. Sincere, consistent interest in child’s schoolwork
   2. Participation in school organizations by parents
   3. Defined, realistic expectations of child, following teacher con- ference and own judgment
   4. Consistent insistence on child’s appropriate behaviors
   5. If social or academic problems arise, this is the best time to give the child a chance to catch
   6. Language
      1. Vocabulary development
         • Encourage word games, crossword puzzles, word tests of synonyms and antonyms, dictionary
         • Provide new experiences and find specific new words

from these experiences.

• Encourage reading: Read to child until reading skills are sufficient for child to take over; visit
• TV/computers: Learning from pictures and voices; can

cause difficulty in shifting to reading comprehension

1. Help in developing communication skills
   • Expressing feelings; finding precise vocabulary
   • Stating problems; defining problem areas
   • Developing “think tank” solutions
   • Predicting outcome of each solution
   • Appropriate listener available
2. Bilingual home
   • Most children handle bilingualism successfully.
   • If having problems, child should develop proficiency in one language, then return to the
3. Listening skills
   • For awareness of speech: Encourage memorizing and reciting, repeating digit lists (backward and forward), learning nonsense
   • Music: Have child learn to play an instrument; listen to

and read music.

• Encourage child to repeat statements of others before giving an
• Constant high background noise discourages efforts to

listen.

• Approving adult with whom to talk

 

 

1. Social development
   1. Expectation that family values and standards will be upheld
   2. Review developmental tasks accomplished and identify those
   3. Provide loving, approving adult with time to talk with and listen to
   4. Provide child advocate for developing a plan to remove unat-

tainable pressure on child and find a way to have child operate in an environment in which he or she can succeed.

5. Environmental and family inadequacies necessitate referral of

family to social service agencies or parent education classes.

• Safety
  1. Leading causes of death in people aged 1 to 24 years of age (2005):
     1. 1–4 years of age
        1. Accidents
        2. Congenital anomalies
        3. Malignant neoplasms
        4. Homicide
        5. Heart disease
     2. 5–14 years of age
        1. Accidents
        2. Malignant neoplasms
        3. Congenital anomalies
        4. Assault/homicide
        5. Suicide/intentional self-harm
     3. 15–24 years of age
        1. Accidents
        2. Homicide/assault
        3. Suicide/self-harm
        4. Malignant neoplasms
        5. Heart diseases
     4. Education
        1. Responsibilities given as child proves reliable
        2. Awareness of incidence of accidents
        3. Discussions and prevention planning
        4. Emergency plans established and
     5. Accident-prone children
        1. Accidents follow stressful events
        2. Accidents more frequent when aggressive behavior is a reactive pattern
        3. Accidents used as means of getting

The third cycle of growth comprises the physical and psychosocial steps from child- hood to adulthood. It is divided into two periods: a transitional stage of preadolescence (roughly ages 9 to 11) and adolescence (ages 12 to 17). Children enter and exit these stages according to their genetic, environmental, and physical status. The pre- adolescent period has been defined as one of mismatch: The child’s peers are the same chronologic age, but their physical development, interests, and abilities can be at different stages.

1. Overview
   1. Individualized guidelines
      1. Chronologic age does not determine the preadolescent’s physical and psychological stage of development, so information in these guidelines must be individualized for each
   2. Family
      1. Onset of this transitional period depends on child’s genetic, physi- cal, and environmental history. Parents’ and child’s understanding of child’s individual growth pattern can make this a successful and happy
      2. Because children of the same age may be at different develop- mental levels, peers will find they are shifting their interests and loyalties.
   3. Parents
      1. Maintain family and moral standards
      2. Provide opportunity for health care and counseling as needed
      3. Provide appropriate schooling, recreational, and community activities
      4. Give child opportunities to make independent decisions as he or she demonstrates ability to be responsible and accept the consequences of activities
      5. Provide consistent and caring listener
      6. Identify abuse of any family member
   4. Child
      1. Understanding and accepting individual pattern of development
      2. Physical
         1. See guidelines for physical changes and development of secondary sex
         2. Takes responsibility for good health habits
         3. Safety: Aware of incidence of accidents and prevention planned
      3. Emotional
         1. Period of confusion and indecision. Through trial and error, child is working toward developing confidence and self-esteem to become an independent, reliable member of This can make for a very self-conscious, indecisive, stubborn, argumen- tative preadolescent.
         2. Continues to need family to provide acceptance and feeling of self-worth
      4. Intellectual: Transitional period from concrete thinking to abstract thinking, giving child ability to express ideas and feelings better and to begin to accept ideas of others. However, because child does not have the experience to realize practical limitations, he or she can have impractical expectations of others and be critical of those around him or

 

 

5. Social: Peers, teachers, and other adults outside family give child opportunity to observe other cultures and Behavior is still directed by need to be accepted by those important to him or her. An understanding adult is important for support and for child to maintain expected behavior.

1. Risk factors
   1. Not using language to express feelings; resorting to aggressive behavior
   2. Inappropriate environment of school and peers
   3. Frequent illnesses or accidents
   4. Presence of drugs in peer group
2. See guidelines for specific factors to be noted in physical

1. Injury prevention
   1. Review safety
      1. Injury is the main cause of death and disability in adolescents. Confusing drive toward establishing independence and self-esteem can lead to trying out and showing
      2. Parents and community need to provide safety education, counsel- ing, and a safe
      3. Accident-prone adolescents need referrals and follow-up.
   2. Main concerns
      1. Traffic accidents: Cars, bicycles, pedestrian
      2. Water safety: Boating, diving, swimming alone
      3. Sports: Appropriate conditioning, proper equipment, good supervision
      4. Firearms: Unloaded gun and ammunition kept in separate locked cabinets
      5. Increased danger if drugs, alcohol, other substances, or smoking present
      6. Unsafe environment at home and at play
      7. Most accidents occur between 3 and 6 PM.

• Child abuse
  1. Physical abuse
     1. Adolescent should be willing to express how injuries and abuse occurred; if reticent, referral and follow-up are
     2. Sexual abuse for both boys and girls needs to be
  2. At-risk child
     1. Physically handicapped, mentally retarded
     2. Frequent illnesses and continuing health problems
     3. Accident-prone and underachievers
  3. At-risk caregivers
     1. No caring adult
  4. Developmental process
     1. Parents
        1. Understand this natural process of growth and change
        2. Establish and maintain home, school, and social guidelines and standards

 

 

3. Provide a safe, supportive environment
4. Identify abuse of any family member

1. Child
   1. Appreciates importance of this growing process
   2. Maintains school and family responsibilities and standards
   3. Develops ability to assess peer group values relative to own values
2. Family status
   1. Parental concerns and problems: Ability to identify problems and to cope; single parents, divorce, remarriage, step-parents, step-siblings
   2. Parents’ and child’s assessment of development
   3. Family interaction and support for each other
   4. Review and updating of emergency plan
3. Health habits (as maintained by child)
   1. Nutrition
      1. Understands basic nutritional requirements (nutritious versus junk foods)
      2. Participates in food shopping and preparation
   2. Sleep
      1. Maintains adequate schedule of sleep and rest to meet needs
      2. Can discuss sleep disturbances, if present
   3. Hygiene
      1. Takes pride in good grooming
      2. Understands and anticipates body changes: Increased perspiration, menstruation, acne, weight increase, nocturnal emissions
      3. Can discuss problems and concerns

• Growth and development
  1. Physical
     1. Parameters of second period of rapid growth, lasting 2 to 4 years
        1. Onset: Girls, 9 to 13 years; boys, 11 to 14 years
        2. Height: Girls, 5 in./year; boys, 4.5 in./year
        3. Weight: Girls, 10 lb/year; boys, 12 lb/year
     2. Body changes
        1. Extremities grow faster than trunk and
        2. Facial proportions change; nose and chin enlarge
        3. Figure changes: Girl’s pelvis enlarges; boy’s shoulders
        4. Subcutaneous fat
        5. Skin: Increased function of sweat glands and increased activity of sebaceous glands
     3. Secondary sex characteristics
        1. Girls
           • Breast enlargement: 8 to 13 years
           • Axillary hair: 11 to 13 years
           • Pubic hair: 10 to 12 years
           • Menarche: 10 to 16 years
        2. Boys
           • Genitalia enlargement: 9 to 13 years
           • Axillary hair: 12 to 14 years

 

 

• Facial hair: 11 to 14 years
• Pubic hair: 12 to 15 years

1. Emotional Erikson: Task of pubescence (prepuberty) is to begin developing an identity independent of family and peers. First steps in this process are:
   1. Increased self-awareness, self-consciousness, self-appraisal
   2. Preoccupation with how one measures up to peers
   3. No longer accepting only parental evaluation, but beginning to use values of peers as criteria by which to judge own values
   4. Continuing to need family for acceptance and feeling of self-worth
2. Intellectual Piaget: This stage marks the progression from concrete thinking to formal operation, the ability to conceptualize and hypothesize, and the beginning of abstract thinking.
   1. Excitement of thinking through possibilities leads to argumenta- tiveness.
   2. Joy of putting across ideas and listening to ideas (of peers) leads to a constant need for gabfests, long telephone conversations, and writing of songs and
   3. Learning is rapid and efficient if school provides a challenging program.
3. Social development
   1. School: Wide range of physical, emotional, and intellectual growth of students makes age grouping unsatisfactory; individual pro- gramming of classes and extracurricular activities is
   2. Community activities (scouts, church, sports, volunteer work)
      1. Provide contact with a wider group than child’s own clique
      2. Provide projects that help child reach beyond self-interests
   3. Sexual maturity
      1. Boys are becoming more masculine, girls more
      2. Interest in each other continues to
      3. New self-consciousness makes physical appearance to the opposite sex an overriding
      4. Behavioral patterns are less established than in the past because society’s expectations and adult role models have been
      5. Facts are needed on reproduction, female body, male body, terminology, birth control, sexually transmitted
   4. Antisocial behavior
      1. Drugs: Knowledge of classification and street names, availabil- ity, effects, physical and emotional problems with use, needed; group discussion classes helpful
      2. Sexual experimentation
         • Dependence on peer group for acceptance and attention
         • Role models from television, movies, friends, relatives
         • Inability to conceptualize consequences of behavior
      3. Need for consistent, caring adult to help adolescent evaluate behavior

 

 

1. Destructive acts toward society
   • Impulsive behavior
   • Inability to delay gratification
   • Inability to give and accept affection
   • Lack of consistent, caring adult
2. Developing sense of community
   1. Cooperation with others: Family, school, peers
   2. Leadership qualities and self-actualizing activities
   3. Willing to participate in volunteer projects

• Risk factors
  1. Family
     1. Poorly defined parental roles
     2. Lack of clear and consistent expectations for child’s behavior
     3. Inability to allow preadolescent to participate in decision-making process
  2. Child
     1. Abnormal eating habits
     2. Inability to gain peer acceptance
     3. Socially unacceptable behavior
     4. No caring adult for support and open communication
  3. Use CDC growth charts (2000), available at: http://www.cdc.gov/ growthcharts
     1. Growth: Continuing on established pattern; deviations reflected by growth spurt (see CDC growth charts [2000], available at: http://www.cdc.gov/ growthcharts)
        1. Calculate BMI at every well child visit during childhood (see Barlow, 2007).
     2. Appearance and behavior
        1. Overall hygiene, appropriateness of dress
        2. Posture
        3. Coordination
        4. Self-assurance
        5. Communication skills
        6. Interest in health care
        7. Eye contact
     3. Specific factors to note during routine physical examination
        1. Skin
           1. Enlargement of pores
           2. Bruises and burns
        2. Hair: Becoming oily
        3. Dental occlusion; need for orthodontia
        4. Decrease in lymph tissue (dependent on maturational level)
        5. Heart: Heart rate slower, particularly in athletes; normal blood pressure slowly rises
        6. Breasts: Breast budding; gynecomastia in males

 

 

7. Genitalia
   1. Boys
      • Pubic hair at first sparse and straight
      • Enlargement of testes
   2. Girls
      • Pubic hair sparse and straight along labial border
      • Labia enlarged
      • Vaginal discharge
   3. Musculoskeletal: Increased muscle mass, strength, tone; scoliosis; leg length discrepancy
8. Parent-child interaction
   1. Parent
      1. Allows child to have health maintenance visit alone, but is made aware of any problems and care plans
      2. Expresses health care concerns with provider and child
      3. Discusses emerging sexual development openly with child
   2. Child
      1. Discusses concerns with parent and provider regarding sexual abuse, fear of violence, dealing with strangers
      2. Open communication with parent: Trusting, supportive relationship
      3. Peer pressure about sexual activity, experimenting with drugs, alcohol or other substances
   3. Assessment
      1. Physical
      2. Developmental
      3. Emotional
      4. Environmental
   4. Plan
      1. Immunizations: Complete schedule as
      2. Screening: Hematocrit or hemoglobin for menstruating females, blood- pressure, hearing test yearly; Vision tests: 4, 5, 6, 8, 10, 12, 15, and

18 years (see AAP policy on eye examination in infants, children and young adults [2003], available at: http://aappolicy.aappublications.org/ cgi/content/full/pediatrics;111/4/902) AAP recommends yearly urinalysis between years 11 and 21 for sexually active male and female adolescents.

1. Problem list (devised with child); SOAP for each
2. Cholesterol screen if high-risk.
3. Appropriate timing for office visits

 

 

 

years will influence the success of the passage from childhood to adulthood. Especially important during preadolescence are the understanding and guid- ance of the family, school, and community organizations to ensure the optimal opportunities for each child to continue his or her path to maturity.

 

1. Overview
   1. Expectations
      1. Family, school, and community provide opportunities for child to continue on path to
      2. Adolescent understands and accepts own pattern of
   2. Preadolescent
      1. Physical
         1. Shares responsibility for maintaining good health habits and coping with physical
         2. Sports activities appropriate to developmental stage
         3. Health care available
      2. Emotional
         1. Moving toward having sufficient self-esteem to make appro- priate decisions
         2. Can anticipate and accept consequences of decisions
      3. Intellectual
         1. Continuing to move forward from concrete thinking to hypothesize or think abstractly, leading to indecision and being impractical and critical of others
         2. Language an important tool in this development
         3. Lack of language skills can lead to continued use of aggres- sive
      4. Social
         1. Family and school behavioral standards needed
         2. Sexual identity established; appropriate time for sex education
         3. Peer group (see Guidelines, p. 152)
      5. Safety
         1. Accident prevention important
         2. Accident proneness needs further
      6. Watch for:
         1. Unhappy child
         2. Failure to live up to potential in school
         3. Lack of significant, appropriate adult role model
         4. Now is the time when home, school, and community need to identify these boys and girls and provide them with the care, respect, and help they need to become self-actualizing and positive members of
      7. Expectations of this period
         1. Knowledge of sequence of physical changes of preadolescence, to predict individual pattern of growth
         2. Understanding of the development from concrete to abstract think-

ing to assess the preadolescent’s ability to assume responsibilities

 

 

and independent activities, to think through planned activities, and to predict outcomes

1. Opportunities for the preadolescent to have successful accomplish-

ments, thereby understanding own capabilities and continuing to develop self-esteem and self-worth

1. Consistent, caring adult to insist that standards of behavior be

upheld and to act as appropriate role model, source of encourage- ment, and patient listener

• Family status
  1. Basic needs being met; referrals as needed
  2. Parents
     1. Understand use of communication skills and problem-solving techniques
     2. Appreciate changing family dynamics and need for develop-

ing opportunities for independent decision-making by child

1. Child
   1. Able to establish close relationships outside family
   2. Maintains school and home responsibilities and behavioral standards
   3. Keen interest in outside activities, such as sports, church, or

community groups

4. Continues to return to family for support

1. Identify sexual abuse to or by any family member

1. Health patterns
   1. Nutrition: Status of growth cycle and level of activity determine nutritional
      1. Period of most rapid growth is the year before puberty; chubbi-

ness before and during this year may lead to extreme dieting, which may interfere with optimal growth.

2. Child assumes responsibility for nutritional standards, adequate

intake, and appropriate eating habits.

1. Health maintenance
   1. Knowledge about appropriate care of skin, hair, body odor, menses
   2. Respect extreme self-consciousness; appropriate fitness and

grooming classes available

3. Exercise: Team sports and competition favor those who mature early; individual sports activities are needed for those who mature late so that they also may continue to develop and appreciate their
4. Health supervision and counseling available
5. Sickness treated and evaluated; attitude toward illness assessed
6. Health care available
7. Proneness to accidents evaluated for underlying causes, and referrals made as needed

 

 

1. Growth and development
   1. Physical
      1. Growth pattern evaluated: See growth and development of well child
      2. Awkwardness expected because of large muscle growth before refinement of fine motor muscles
      3. Teeth: Dental care available; orthodontia as needed
      4. Speech
         1. Enjoyment of and interest in words, rhymes, puzzles
         2. Increasing vocabulary to handle expanding knowledge and expression of ideas and emotions
         3. Problems in speech, articulation, or syntax need
      5. Emotional development. Erikson: Identity vs. Role Confusion. First task is to move from security of family and friends and develop positive self-identity. Another task is to develop ability to make independent decisions and to understand and assume their consequences. Thus, development of child’s self-esteem and integrity

The first steps of these tasks need careful attention so that the taking on of independent activities can be geared to both the physical and intellectual stages of development.

1. Intellectual development. Piaget: Period of transition from concrete

thinking to formal (abstract) thinking. Horizons are broadened to include such learning as appreciation of the images in poetry. How- ever, because preadolescents do not have the experience to realize the practical limitations of life, they can be indecisive, accept imprac- tical ideas, and lack understanding of others.

1. Opportunities provided for taking on new responsibilities with

careful supervision

2. Reading and experiences broaden the understanding of
3. Academic programs stimulate independent
4. Discussion groups help child formulate and express ideas and listen to and counter ideas of
5. Language becomes the most important tool in understanding and accepting the new experiences of this transitional
   1. Aggressive acts replaced by use of communication skills and problem-solving techniques
   2. Peer groups and best friend used to try out new ideas
   3. Broad reading programs to introduce cultural heritages
   4. Consistent, caring adult who listens to problems and new ideas and provides alternative approaches
6. Social development: It is important for the preadolescent to turn to peers, school, and community groups to observe the cultures, mores, and values of Evaluating these in relation to family patterns and establishing one’s own standards take an extended period of trial and error, with reinforcement of appropriate behavior by a significant adult.
   1. Guidelines established by family for behavioral standards, activi-

ties at home, and extracurricular activities

 

 

2. Guidelines indicate parents’ interest and concern and provide the security of behavioral
3. Sexual identity
   1. Depends on stage of growth and development with respect to awareness of and interest in opposite sex
   2. Girls’ maturing earlier than boys makes chronologic age

activities difficult, as in sports, clubs, discussion groups, social events.

1. Now is the time to provide information and vocabulary

about sex, before emotions become mixed with facts.

4. Peer group
   1. Positive developmental process
      • Facilitates learning about interpersonal relationships
      • Source of support, guidance, and esteem
      • Role model for appearance and behavior
      • Leads to awareness of social class, prestige, and power of belonging to “right” group
      • Pressure to perform provides opportunity for testing out

own values and evaluating them against values of others.

1. Parental role
   • Continue expecting conformance to family behavioral limits, values, and
   • Understand importance of peer group to preadolescent.
   • Reserve evaluation of peer group until concrete evi- dence
   • Remember that preadolescents may consider criticism

to be a personal attack.

• When intervention is necessary, explain parental responsibility to protect child. Genuine concern can be appreciated by preadolescent and used as a means of extracting himself or herself from an unhappy

1. Risk factors: Child
   1. Emotional development
      1. Regressive patterns of overdependence on family, shyness, passivity, or aggression
      2. Use of illness as a means of avoiding new challenges
      3. Use of food, either too much or not enough, as a means of gaining attention and satisfaction
      4. Lack of opportunities for taking on new responsibilities
      5. Inability to make and maintain friends; becoming a loner
   2. Intellectual development
      1. Unsuccessful in maintaining scholastic expectations
      2. Inappropriate school for developmental stage and ability
      3. Assuming responsibilities beyond ability to understand and assume consequences of these actions

 

 

4. Language
   1. Too much time watching TV and computer play inhibits discussions with peers and family and limits vocabulary development.
   2. Failure to use language to express feelings and ideas; still

resorting to aggression to take control

1. Lack of consistent listener to provide a sounding board for feelings and ideas

1. Social development
   1. Antisocial behavior
   2. Poor school performance

• Childrearing practices
  1. Time to investigate and evaluate carefully forces that are causing preadolescent to reject this next step toward becoming a responsible member of society
  2. Appropriate intervention and referrals
• Safety
  1. Education
     1. Responsibilities given as child proves reliable
     2. Awareness of incidence of accidents
     3. Discussions and prevention planning
     4. Emergency plans established and rehearsed
  2. Accident-prone children
     1. Accidents follow stressful
     2. Accidents more frequent when aggressive behavior is reactive pattern
     3. Accidents used as means of getting attention

1. The adolescent is now settling into a more stable growth and behavioral pattern. The individuality of this process can be identified and strengths and problems assessed. Physical changes can be predicted, and the emergence of a more realistic thought process helps the adolescent understand and appreciate his or her uniqueness.
   1. Guidelines
      1. During these years, increasing stability of physical and psycholog- ical development can be These guidelines can be used to identify the essential parameters of this development.
         1. Family
            • Assessment of child’s growth toward maturity, with suc- cesses and concerns identified; problem-solving session planned and referrals made as needed
            • Identify any abuse of family

 

 

1. Adolescent
   • Physical
     • Changes can be predicted and a more realistic thought process can help the adolescent understand and appre- ciate
     • Concerns and problems identified and referrals made as needed
     • Accepts responsibility for good health habits and safety practices for self and others
     • Physical abuse identified
   • Emotional
     • Develops a more self-directed and assured behavior pattern
     • Establishes confidence to rely on self-esteem and competence
     • Becomes more discriminating when making friends and group involvement
   • Intellectual
     • Can think more realistically about own capabilities and values
     • Becomes more tolerant of others
   • Social
     • Feels comfortable in society and takes on role of a responsible member of society
     • Less dependent on peer group for self-confidence
     • Establishes own standards of behavior and values
     • Accepts own values and self-awareness of sexual role
     • Awareness of violence and abuse

1. Risk factors
   1. Substance abuse
      1. Changes in behavioral habits
      2. Changes in emotional stability
      3. Withdrawal from friends and family activities
   2. Risk of suicide: Talking about this is a serious call for help; careful evaluation and intervention are
   3. Adults who may be guilty of sexual harassment or abuse
2. See guidelines for specific factors to be noted in physical
3. Aggressive and abusive pattern of behavior of adolescent and peer group

1. Injury prevention
   1. Review safety
   2. As adolescent matures toward self-confidence and taking the responsi- bility for own actions, he or she is more capable of preventing injury to self and Careful supervision and definite regulations are needed until these stages of maturity are reached.
   3. Safety concerns
      1. Main concern continues to be automobile accidents, including drinking and

 

 

2. Added to this is the attitude of infallibility (“it won’t happen to me”). The reality of these life-threatening situations can be made clear by injury prevention planning and experiences of working with the police, visits to the emergency room, and talking with accident victims. This is serious business and needs to be taken

• Child abuse: Age-specific factors
  1. Children of this age are well aware of the possibility of abuse to
     1. Fear of violence is one of their main
     2. Sexual harassment and actual sexual abuse are also of great
     3. Presence of drugs, alcohol, smoking, and so forth is a great
     4. Strangers, neighbors, relatives can be perpetrators of
     5. Adolescents can abuse each other with their irresponsible acts; therefore, families, schools, and community need to work together to help provide a safe
  2. Each adolescent needs a responsible, caring adult to help keep him or her safe from

1. Developmental process
   1. Parents
      1. Provide opportunities for adolescent to make independent decisions
      2. Assess with adolescent appropriateness of these decisions
      3. Allow increased independence when teenager can make appropri- ate and realistic decisions and bear the consequences of his or her activities
   2. Adolescent
      1. Understands physical changes and takes responsibility for health maintenance
      2. Successful accomplishments at home, at school, and in extra- curricular activities
      3. Accepts sexuality and establishes own standards for sexual behavior
      4. Sexual abuse to or by adolescent discussed
   3. Family status
      1. Basic needs being met; referrals as needed
      2. Parents
         1. Assessment of adolescent’s development
         2. Concerns identified
         3. Family communication skills and problem-solving techniques assessed
         4. Problem-solving session including parent and adolescent planned; referrals as needed
      3. Adolescent
         1. Understands and accepts individuality of development
         2. Accepts consequences of behavior
         3. Concerns and problems identified
         4. Able to relate to and cooperate with parents or another significant adult
         5. Problem-solving sessions planned; referrals as needed

 

 

1. Health habits
   1. Health maintenance
      1. Attitude toward and appreciation of health maintenance
      2. Knowledge of requirements for good health
      3. Availability of health supervision and crisis care
      4. Accident prevention
         1. Driver education
         2. Swimming and lifesaving proficiency
         3. Knowledge of sports injuries; appropriate equipment, super- vision, physical fitness needed for particular activity
         4. First-aid course and emergency planning available
         5. Proneness to accidents evaluated for underlying causes
      5. Prevention of infectious diseases
         1. Knowledge of communicability, symptoms, course of disease, complications, sequelae
         2. Most common infectious diseases of adolescents: Mononucleo- sis, upper respiratory infections, hepatitis, sexually transmitted diseases
      6. Information for sexually active adolescents
         1. Knowledge of endocrine and reproductive systems
         2. Birth-control information
         3. Symptoms of physical problems and infections
         4. Pregnancy testing and abortion counseling
         5. HPV prevention through immunization
      7. Nutrition
         1. Knowledge of nutritional requirements
         2. Nutritional assessment for poor weight gain, slow muscle tissue growth, obesity, intense physical activity
            1. 24-hour recall or diary of food intake
            2. Eating habits: More than three meals per day to spread metabolic load for better absorption
            3. Evaluate intake of protein, milk products, fruits, vegetables,
               • Protein: Two servings a day; high percentage of fish, poul- try, dried beans, peas, nuts
               • Milk products: Two servings a day, including cheese and ice cream
               • Fruits and vegetables: Four servings a day, including potatoes
               • Cereal and grains: Four servings a day
               • Fluids: Increase intake to compensate for increase in sweat glands; avoid caffeine and
               • Males 11 to 15 years old need 55 kcal/kg/d; females need 47 kcal/kg/d.
            4. Athletes and those who need to gain weight: Increase the size of servings of high-value foods (whole-grain bread, cereal, potatoes, cheese, nuts)
            5. Eating disorders (both boys and girls); referrals and follow-up
         3. Refer to nutritionist as

 

 

1. Sleep
   1. Established pattern of work and sleep
   2. Sufficient sleep to maintain daily schedule
   3. Willing to discuss problems
2. Elimination
   1. Established schedule
   2. Understanding and knowledge to cope with problems
   3. Symptoms of urinary tract infections known
   4. Willing to ask for help as needed
3. Menstruation
   1. Regular periods
   2. Premenstrual symptoms
   3. Menstrual discomforts
   4. Able to maintain daily schedule
   5. Willing to ask for information and help
4. Nocturnal emission
   1. Understanding of normal physical development
   2. Willing to ask for information and help
5. Masturbation
   1. Experimenting is
   2. If a frequent and obsessive practice, intervention and referral needed

• Growth and development
  1. Physical
     1. Slower rate of growth in height and weight; return to percentiles of preadolescent pattern
     2. Adult facial features and stature by ages 18 years for females and 20 years for males
     3. Muscle strength and size influenced by sex hormones as well as by nutrition and exercise
     4. Endurance depends on lung capacity, heart size, and muscle strength, as well as on sex hormones and physical
     5. Speech
        1. Voice changes in resonance and strength in both sexes but more pronounced in males
        2. Problems in articulation, pitch, and rhythm need
     6. Sexual maturity/Identity
        1. Adjusting to body changes and functions
        2. Accepting societal standards for sexual identity
        3. Developing own values for and self-awareness of sexual role
     7. Emotional development. Erikson: Identity vs. Role Confusion. These years see the development of a more self-directed and assured behav- ioral pattern. As in all steps to maturity, optimal growth is more easily reached when opportunities are available to try out and experiment with new roles in an understanding and safe
        1. More even-tempered and cooperative
        2. Self-directed in planning educational and vocational goals
        3. More discriminating when making friends and group involvement

 

 

1. Intellectual Piaget: Concrete thinking to formal operation; ability to conceptualize and hypothesize
   1. Continues to be excited about presenting ideas and countering ideas of others; debating and discussion groups help organize and define ideas and force him or her to listen to ideas of
   2. Can think realistically about vocational goals
   3. Accepts own capabilities and appreciates own values
2. Social development
   1. Continues to establish own standards of behavior and values
   2. Becomes less dependent on peer groups for social stature and behavior pattern
   3. Increased tolerance and appreciation of others
   4. Antisocial behavior less evident
      1. Developing better judgment toward and control of drug use, smoking, alcohol, and sexual behavior
      2. Can respond to school and community counseling groups
   5. Destructive acts toward society
      1. Impulsive behavior
      2. Need to gain attention from peer group
      3. Inability to delay gratification
      4. Inability to give and accept affection
      5. No consistent, caring adult with whom to relate
   6. Developing sense of community
      1. Cooperation with others: Family, school, peers
      2. Leadership qualities and self-actualizing activities

• Risk factors
  1. Family, school, community
     1. Not providing an understanding and safe environment
     2. Punitive measures of behavior control attempted in place of open communication, problem-solving techniques, and defined behav- ioral standards
     3. Unrealistic expectations of adolescent’s ability to control and take responsibility for actions
  2. Adolescent
     1. Physical problems not under medical supervision
     2. Failure to accept physical appearance and capabilities
     3. Failure to take on role of a self-directed, caring individual
     4. Indication of substance abuse and risk of suicide
        1. Changes in patterns of sleep, eating, friendship, and school performance
        2. Changes in personality: Boredom, agitation, bursts of anger, apathy, evasiveness, carelessness
        3. Increasing attitude of discouragement and disgust with world
        4. Difficulty in accepting disappointment and failure

 

 

1. Lack of supportive companion to share and evaluate new per- ceptions of role for self and obligations to society
2. Suicidal calls for help
   • Talking about ways of committing suicide
   • Giving away prized possessions
   • Previous attempts
   • Withdrawal from friends and family
3. Physical examination
   1. Growth: Height and weight percentiles return to preadolescent
      1. Use CDC growth charts (2000), available at: http://www.cdc.gov/ growthcharts
      2. Calculate BMI at every well child visit during childhood (see Barlow, 2007).
   2. Appearance and behavior
      1. Grooming and hygiene
      2. Posture
      3. Coordination
      4. Self-assurance
      5. Communication
      6. Interest in health care
      7. Eye contact
   3. Specific factors to note during routine physical examination
      1. Hair: Oily; body hair appears on chest and face in males; axilla in both sexes
      2. Skin: Acne on face, back, chest; large pores; presence of bruises, burns, bites evaluated
      3. Lymph: Decreased lymph tissue
      4. Teeth: Caries; dental hygiene; need for orthodontia
      5. Heart: Decreased heart rate; increased blood pressure
      6. Lungs: Decreased respiratory rate
      7. Breasts: Breasts developing; gynecomastia in males
      8. Genitalia
         1. Males
            • Pubic hair: Increase in amount to adult distribution; becomes coarse and curly
            • Penile enlargement continuing
            • Enlargement of testes
         2. Females
            • Pubic hair: Increase in amount to adult distribution; becomes coarse and curly
            • Labia mature
            • Vaginal discharge: Distinguish normal from abnormal discharge
         3. Musculoskeletal: Increased muscle mass, strength, and tone; scolio- sis; leg length discrepancy

 

 

1. Parent-adolescent interaction
   1. Parent
      1. Expects adolescent to take responsibility for basic health care
      2. Made aware of health problems and care plan
      3. Follow-up visits and financial responsibility planned
   2. Adolescent
      1. Turns to parents for support and comfort
      2. Discusses health care plans with parents and health professionals
   3. Assessment: HEADSSS(W) Assessment for Teens
      1. Home
      2. Education
      3. Activities
      4. Drug use and abuse
      5. Safety
      6. Suicide and depression
      7. Sexual behavior
      8. Weight
   4. Plan
      1. Immunizations: Complete schedule as HPV, meningitis vaccine, Tdap
      2. Screening: Hematocrit or hemoglobin for menstruating females, blood- pressure check and hearing yearly. Vision tests: 4, 5, 6, 8, 10, 12, 15, and 18 years (see AAP policy on eye examination in infants, children and young adults [2003], available at: http://aappolicy.aappublications. org/cgi/content/full/pediatrics;111/4/902) AAP recommends yearly uri- nalysis between years 11 and 21 for sexually active male and female adolescents.
      3. If sexually active, cultures appropriate for STDs; females need annual pap
      4. Cholesterol screen as per protocol
      5. Problem list (devised with adolescent); SOAP for each
      6. Appropriate timing for office visits

 

 

 

2. Family, school, and community provide opportunities for devel- opment of these
3. Adolescent develops pride in own capabilities and accepts

responsibility for his or her actions.

4. Adolescent is better able to accept changes in family structure (divorce, remarriage, step-siblings).
5. Adolescent
   1. Physical
      1. Period of rapid growth, so adequate nutrition essential
      2. Accepts responsibility for health maintenance
   2. Emotional
      1. Can evaluate positive attitudes toward self and others
      2. Negative attitudes: May need referrals
   3. Intellectual: Increased ability to think abstractly leads to more accurate and tolerant assessment of self and
   4. Social: At home, in school, and in community, now a responsi-

ble, caring member

1. Watch for:
   1. Many positive experiences at home, at school, and in the community
   2. Feelings, hopes, and concerns
   3. Caring, responsible adult to listen and to respect ideas and to help keep him or her safe from harm
2. Expectations
   1. Accepts and develops pride in capabilities
   2. Works toward vocational goals
   3. Establishes independent values that provide a framework to assess appropriate behavior
   4. Has role models of caring, responsible members of society

• Family status
  1. Basic needs being met; self-direction in coping with problems
  2. Parents
     1. Have positive attitudes toward changing emotional ties between selves and adolescent
     2. Provide time to listen (not argue) and encourage adolescent to

verbalize new ideas and feelings

3. Provide role models for maintaining family mores and cultural values
4. Identify sexual abuse to or by any family member

1. Step-parents
   1. Shift in family relationship demands that parents be role models of mature, caring
   2. Understand and appreciate adolescent’s individuality
   3. Poor adjustment can lead to behavioral and school problems for the adolescent and jealousy and abuse by the parent; make referrals as

 

 

1. Adolescent
   1. Single-parent home
      1. Has extra responsibility
      2. Feels left out of some activities
      3. Misses attention of other parent
      4. Can be embarrassed by having only one parent
   2. Divorce
      1. Better able to understand the problems
      2. Relieved by cessation of family discord
      3. Can feel despair and abandonment
   3. Remarriage
      1. Can appreciate and be happy for parent
      2. Glad to be relieved of some of the responsibility he or she has been carrying
      3. Jealousy and resentment possible if parent has been depen-

dent on adolescent for emotional satisfaction

1. Siblings
   1. Different developmental stages cause different needs and
   2. Important to provide privacy and respect for each person’s

possessions

3. Expect a united front if one sibling is hurt or

1. Step-siblings
   1. Each child must be seen as an
   2. Parents establish a caring relationship with each
   3. Parents provide opportunities for open
   4. Children are given opportunity to take part in and develop out- side
2. Health patterns
   1. Nutrition: Period of rapid physical growth, so attention to adequate nutrition essential
      1. Considerations: Ethnic food habits, past growth pattern, nutri-

tional history, familial diseases, such as high blood pressure, heart attacks, diabetes, obesity

2. Nutritional requirements
   1. 11- to 15-year-old boys: 55 kcal/kg/d
   2. 11- to 15-year-old girls: 47 kcal/kg/d
3. Problems to be evaluated
   1. Inadequate food
   2. Obesity
   3. Anorexia nervosa or bulimia
   4. Poor eating habits
4. Health maintenance: Responsibility assumed by adolescent
   1. Established patterns of grooming, elimination, sleep
   2. Physical fitness and pride in maintaining good health

 

 

3. Accepts responsibility of sexual behavior
4. Seeks help when problems arise

1. Exercise
   1. Variability of growth pattern makes individualized program necessary.
   2. Endurance and muscle strength improving, but type of activity

geared to stage of development

3. Evaluate growth progress by frequent measurement of height, weight, muscle mass, and energy

1. Safety and accident prevention
   1. Can accept reality that accidents can happen to him or her
   2. Impulsive and aggressive behavior can be a reactive pattern to stressful
   3. Able to identify and assume responsibility for own actions
   4. Can control activities for benefit of others
2. Growth and development
   1. Physical
      1. Individual growth expectation recognized
      2. Information on expected body changes provided
      3. Self-consciousness and rapid body changes can cause over- concern with health
         1. Parents and health professionals appreciate reality of the

problem for the adolescent.

1. Care plan devised with parent, adolescent, and professional
2. Identify use of illness as a way of avoiding emotional or social concerns; plan intervention and

1. Emotional development. Erikson: The preadolescent developmental

task of beginning to establish an identity as an independent, self- sufficient, caring person continues during the next years.

1. Positive developmental process
   1. Shows confidence in own judgment and accepts consequences of actions
   2. Appraises own abilities and works toward vocational goals
   3. Decreased self-concern, increased understanding of others
2. Negative developmental process
   1. Lack of self-esteem and confidence in potential abilities
   2. Frequent illnesses, accidents, and periods of depression
   3. Continued use of self-destructive behavioral patterns, such as drugs, promiscuity, cheating, stealing
3. Intellectual development. Piaget: Development from concrete think-

ing to formal operation continues at an individual pace.

1. First steps identified by ability to think abstractly
   1. Conceptualizes and theorizes about ideas that include sev- eral variables; seen by parents as having difficulty making decisions and being slow to start projects

 

1. Theorizes from own perspective and cannot incorporate ideas of others; seen by parents as stubborn, uncoopera- tive, argumentative
2. Idealistic in problem-solving because expectations are unreal-

istic; seen as disgust with stupidity of adult world

2. Final steps toward formal operation
   1. Makes decisions on basis of more accurate appraisal of options, so can become independent of societal and peer pressure
   2. Incorporates ideas of others, so can become more tolerant of

both peers and adults

1. Experience leads to less idealism about the ease of solving problems.
2. Feels comfortable in society and takes on role of responsible

member of society

1. Social
   1. Beyond their academic purpose, schools are a safe environment that can be used as a common meeting
      1. In the school environment, adolescents intellectually and

emotionally can:

• Appreciate other cultures and mores
• Observe a wide range of socioeconomic strata, with their respective privileges and inequalities
• React to the importance placed on academic perfor-

mance and the pressures of testing and scoring

• Try out and refine interpersonal skills

1. School provides opportunities for adolescent to develop abilities, find pride in accomplishments, and obtain leader- ship
2. Adolescent needs teachers and administrators who will

maintain standards by which actions and abilities can be fairly judged.

2. Community
   1. Provides adolescent with opportunity to observe and take part in projects that serve other segments of society
   2. Maintains sufficient recreational activities to provide whole-

some outlets for adolescents’ energy and need to be together

1. Demonstrates interest, concern, and pride in its adolescent

population

3. Family continues its important
   1. Provides safe, wholesome environment
   2. Offers help and encouragement when problems occur
   3. Respects adolescent’s ideas and opinions
   4. Gives open, honest answers and suggestions when asked
   5. Demonstrates roles of caring, responsible citizens