Growth And Development

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NCM 107: CARE OF THE CHILD GROWTH ♦ Increase in the number and size of cells; measured in terms of quantity; Orderly and predictable but not even. Parameters of Growth: 1. Weight ♦ It is measured in grams, kilograms or pounds. 2. Height ♦ is measured in inches, feet or centimeters. DEVELOPMENT ♦ Indicates an increase in skill or the ability to function; Viewed as a qualitative change in the child that is demonstrated by functioning or skill and that is achieved through maturation, and learning Ways to measure development: 1. By directly observing the child’s performance. 2. By noting parents’ description of the child’s progress. 3. By DDST (Denver Developmental Screening Test), in the Philippines, it is modified as MMDST (Metro Manila Developmental Screening Test). Five Main Areas of Development 1. Physical ♦ height, strength, muscles, systems, organs and weight 2. Emotional ♦ extend trusting relationships to other adults and to children, attitudes, show a strong sense of self as an individual, recognize and label their own feelings 3. Intellectual ♦ thinking and understanding 4. Social ♦ interaction with others 5. Spiritual ♦ concerns the broad search for transcendental meaning that may be as simple as a young child’s inquiries into how the world came into being MATURATION ♦ means development of those cells until they are ready to function; Literally, it means ripen; An increase in human competence and adaptability DEVELOPMENTAL TASK ♦ a growth responsibility that arises at a certain time in the course of development PRINCIPLES OF GROWTH AND DEVELOPMENT 1. G & D are continuous processes from conception until death 2. G and D follows an orderly pattern a. Cephalocaudal ♦ growth proceeds from head to toes b. Proximo-distal ♦ growth proceeds from the center, or midline of the body to peripheral c. General to specific (Gross to refined) ♦ Simple to complex 3. All aspects of development are interrelated ♦ The physical and the mental development of the child are mostly correlated to each other 4. Growth is continuous and gradual ♦ All parts of the body continue to grow gradually until they reach their maximum from infancy, early childhood, late childhood. Page 1 of 40

a. There are periods of accelerated & decelerated growth rate Infancy: most rapid period of growth Preschool to puberty: slow and uniform rate of growth Puberty: (growth spurt) second most rapid growth period After Puberty: decline in growth rate till death 5. Growth is not uniform ♦ Different parts of body grow at different rates 6. All individuals are different 7. Early foundations are critical 8. Each phase of development has hazards 9. Each phase of development has characteristic behavior 10. There is an optimum time for initiation of developmental experiences or learning ♦ A child cannot learn tasks until the nervous system mature enough to allow that particular learning. 11. Most developmental skills and behaviors are learned by practice 12. Neonatal reflexes must be lost before motor development can proceed 13. Development is affected by cultural changes 14. There are social expectations for every stage of development 15. Development is a product of heredity and environment ♦ The child is born with some inherited traits like physical stature and some other traits from his parents and develops by interacting with his environment Major Factors Influencing Growth and Development 1. Genetics a. Gender ♦ On the average, GIRLS ARE BORN LIGHTER (by an ounce or 2) and shorter (by an inch or 2) than boys. Boys tend to keep this height and weight advantage until pre-puberty, at which time girls surge ahead because they begin their puberty growth spurt by 6 months to 1 year earlier than boys. By the end of puberty (14 to 16 years) boys again tend to be taller and heavier than girls. b. Health ♦ A child who inherit a genetically transmitted disease may not grow as rapidly or develop as fully as the healthy child depending on the type of illness or the therapy available for the disease. c. Intelligence ♦ Children with high intelligence do not generally grow faster physically than other children but they do tend to advance faster in skills. 2. Environment ♦ Although a child has genetically programmed height potential, he may not grow taller because of some environmental factors: INADEQUATE NUTRITION because of low socio-economic status. Caregiver may lack skills or not give the child enough attention. Chronic illness a. Socioeconomic level ♦ HEALTH CARE and GOOD NUTRITION both cost money. b. Parent-child relationship ♦ Children who are loved thrive better than those who are not. It is the QUALITY OF TIME SPENT with children not the amount of time that is important. c. Ordinal position in the family ♦ First-born child, middle, youngest and only child) and size of the family has some bearing on the G & D. FIRST/ONLY CHILD generally excel in language because conversation are mainly with adults. However, they may not excel in other skills (like toilet training) because there is no example to watch. Children learn by watching other children. d. Health ♦ Children who are ill like those with heart diseases will have limited activity to play and active sport.

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3. Temperament ♦ usual reaction pattern of an individual or an individual’s characteristic manner of thinking, behaving or reacting to stimuli in the environment. ♦ Inborn characteristic. Reaction Patterns That Determine Temperament 1. Activity level – differs widely 2. Rhythmicity –child with set patterns/irregular rhythmicity. 3. Approach – child’s response on initial contact with a new stimulus. 4. Adaptability – ability to change one’s reaction to stimuli over time. 5. Intensity of reaction 6. Distractibility refers to the tendency to shift easily to a new situation. 7. Attention span and persistence refers to the ability to remain interested to a project or activity. 8. Threshold of response is the intensity level of stimulation that is necessary to evoke a reaction. 9. Mood quality state wherein a person is said to be in negative or positive condition. Categories of Temperament 1. THE EASY CHILD ♦ Easy to care for ♦ Predictable rhythmicity, approach and adapt to new situations readily. ♦ Mild to moderate intensity of reaction ♦ Overall positive mood quality. ♦ 40% to 50% of children 2. THE DIFFICULT CHILD ♦ Irregular in habits ♦ Negative mood quality ♦ Withdraw rather than approach new situations. ♦ 10% of children 3. The Intermediate Child ♦ a combination of the easy and the difficult child 4. SLO W–TO-WARM-UP CHILD ♦ Overall fairly inactive ♦ Responds mildly ♦ Adapts slowly to new situations ♦ Generally negative mood ♦ 15 % of children 4. Nutrition ♦ Nutrition has become a major focus on health promotion and disease prevention. ♦ The quality of nutrition during the growing years (including prenatally) has a major influence on his/her health and stature (natural height). ♦ Poor maternal nutrition may limit the Growth and intelligence potential of the child at birth. ♦ Children with diets that lack essential nutrients show inadequate physical growth. ♦ Lack of energy and stamina prevents children from learning at their best intellectual level. STAGES OF GROWTH AND DEVELOPMENT 1. Prenatal – from conception to birth. 2. Babyhood a. Neonatal – is the first 28 days or 4 weeks of life. b. Infancy – from 29th day to 1 year

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3. Early Childhood a. Toddler – 1 to 3 years b. Preschool – 3 to 6 years 4. Middle Childhood a. School Age – 6 to 12 years 5. Late Childhood a. Adolescence - 12 to 20 years (Pillitteri – 13 to 20) Development of mental function & personality development ♦ Personality is the arrangement of individual adjustment to his environment. It is an all-inclusive term that covers appearances, abilities, motives, emotional reactivity and experiences that have shaped him to his present person. ♦ It is the totality of one’s physical or inherited attributes as well as those psychological factors that determine one’s characteristic behavior. ♦ Psychoanalytic theory suggested that personality is mostly established by the age of five. Early experiences play a large role in personality development and continue to influence behavior later in life. Structure of Personality ID ♦ developed during infancy ♦ "I know what I want and I want it now!” ♦ the only component of personality that is present at birth. ♦ Operates on pleasure principle to reduce tension or discomfort. Thus, a newborn is said to be a “bundle of id”, seeking pleasure only to satisfy needs and demands immediate gratification to find release from physiological tension. ♦ Pleasure principle EGO ♦ developed during toddler period ♦ "I can wait for what I want!" ♦ Reality principle ♦ balances the id and superego ♦ the result of individual’s interaction with the environment. ♦ It promotes satisfactory adjustment in relation to the environment. SUPEREGO ♦ developed during preschool ♦ "I should not want that!” ♦ Conscience- Morality principle ♦ Develops as a person unconsciously incorporates standards and restrictions from both parents and society to guide behaviors, thoughts, and feelings. ♦ Emerges at around age five. Factors Affecting Personality development: 1. Heredity ♦ certain characteristics that are present at birth a. body build c. eye color, and skin b. hair type d. certain aptitudes 2. Birth order ♦ First born are likely to be achievement oriented and responsible ♦ Later born are more likely to be better in social relationships, affectionate, friendly, or rebels and risk-takers. 3. Parents a. age of the parent c. occupation e. economic status b. religious orientation d. level of education f. cultural heritage 4. Culture Page 4 of 40

INFANCY Definition of terms a. Infancy - is the period from one month to 1 year of age b. Developmental milestones – are major markers of growth and development that serve as the basis for assessing developmental delay or advancement c. Gross Motor – ability to accomplish large body movements d. Fine Motor - ability to coordinate hand movement. Characteristics of Infancy stage: 1. Infancy is the second shortest of all developmental periods. ♦ Infancy begins at 28 days and ends at 1 year 2. Infancy is a preview of later development ♦ It is not possible to predict exactly what the future development of the individual will be on the basis of the development at birth. We notice only a clue of what to expect later on. 3. Infancy is the time of radical adjustments. Major adjustments of Infancy: a. Change in temperature ♦ From 37.8 degrees C in the uterine sac to 15.6 to 21.1 degrees C in the hospital or home. b. Breathing by own starts ♦ When the umbilical cord is cut the infant must begin to breathe on its own. c. Sucking and swallowing starts. ♦ When the umbilical cord is cut off, the child gets nourishment by the reflexes of sucking and swallowing instead of receiving it from the mother through umbilical cord. d. Elimination of waste products begin ♦ Letting out urine and stools is not a matter of adjustment. But some infants are seen to have trouble with elimination matters. 4. Infancy is a hazardous period. ♦ Infancy is a hazardous period both physically and psychologically. Physically the infant finds it difficult in making adjustments to the new environment. Psychologically the infant suffers a little when the attitudes of significant people towards the infant radically changes 5. Infancy is a plateau in development. ♦ There is a slight regression such as loss of weight, less strong and healthy than it was at the time of birth. This characteristic of plateau is due to the necessity for radical adjustments to the postnatal environment. Once the adjustments are made the infant resumes its growth and development. GROWTH & DEVELOPMENT OF THE INFANT A. Biologic: Proportional changes and maturation of systems a. 1 – 4 months ♦ Head growth; posterior fontanel closes, grasp and tonic neck reflex disappear at 3 months, moro and rooting reflexes disappear at 4 months ♦ Until 3 to 4 months, extrusion reflex prevents the infant from feeding effectively ♦ Immune system becomes functional at 2 months ♦ End of first month: Weight gained = 15 ounces; 1 to 3 months : Gains 6 ounces every week; 4 mos. Raise head and chest from prone b. 4 to 7 months : Gains 1.5 – 2 pounds every month c. 5 – 6 months ♦ Birth weight doubles ♦ Length: Gains 13.75 cm (5.5 in.) by 6 mos. & gains ½ inch for the next 6 mos ♦ Eruption of teeth begins, typically central incisor ♦ Ability to adjust to cold is mature by 6 months ♦ Develop additional adipose tissues to serve as insulation ♦ Moro and palmar reflexes have completely faded

d. 7 – 9 months ♦ Teething continuous, one tooth erupts monthly Page 5 of 40

♦ Anterior fontanelle – 4-6 cm diameter; diamond shaped & closes at 9-18 mos e.10 – 12 months ♦ Birth weight is tripled ♦ Add another 7.5 cm (3 in.) at 12 mos ♦ Head and chest circumference are equal; CC is larger after 1 yr. ♦ The amount of brown fat decreases during the first year ♦ Posterior fontanelle – between parietal bones & occipital bone & closes at 4-8 wks. after birth B. Physiologic 1. Respiratory: RR = 20 – 30 bpm 2. Cardio-Vascular: HR = 80 – 120 /min.; BP = 90/55 - 100/60 3. Hematologic ♦ Physiologic anemia at 2-3 mos. ♦ Another decrease in serum iron levels at 6-9 mos. 4. GIT ♦ GIT matures gradually though liver is still immature ♦ Deciduous teeth erupts at 6 mos. 5. Endocrine System ♦ Kidneys and the endocrine are still immature 6. Neurologic and Sensory System ♦ At 6 mos, can shiver in response to cold & adipose tissues are developed to serve as insulation 7. Immune System ♦ Functional at 2 months. ♦ At 1 yr. able to produce both: a. IgG (for natural passive immunity) b. IgM (bactericidal for gram negative bacteria) c. IgA (against respiratory pathogens) d. IgE (for hypersensitivities) e. IgD (immunologic role still under investigation) are not plentiful till pre-school age. 8. Sensory changes: a. Neonatal: ♦ hearing and touch well developed at birth; sight not fully developed until 6 years b. 1 -4 months ♦ Begins to coordinate stimuli from various sense organs; hearing; locates sound by turning head and visually searching; binocular vision developing; beginning hand-eye coordination, hand regard, prefers human face; follows objects 180 degrees. Ability to accommodate is equal to adult c. 5 – 6 months ♦ With organized depth perception at 6 months; can localize sounds above and below ear; with difficulty establishing eye coordination at six months; smiles at own mirror image and responds to facial expression of others; sucking needs have decreased; chewing, biting, and taste begin to develop. d. 7 – 9 months ♦ Can fixate on small objects; depth perception has matured hence can perform transferring object from one hand to the other. e. 10 – 12 months ♦ Able to follow rapidly moving objects; visual acuity is 20/50 or better; binocularity is well established. ♦ Beginning of object permanence. Can easily locate sound in any direction and turn towards it. DEVELOPMENTAL MILESTONES: Motor development ♦ is the process of learning, controlling and integrating muscular responses a. Neonatal Period ♦ Motor development: mainly reflex controlled, lifts head momentarily, with moro reflex b. 1 – 4 months ♦ Gross: reflexes begin to fade; gains head control start of neck righting reflex, rolls from back to side; begins voluntary head to mouth activity; gains head control beyond the plane of the body at 3 months; rolls from back to side ♦ Fine: begins voluntary hand to mouth activity; At 2 mos. holds objects momentarily then drops; hands held open not in fists. At 4 mos. brings hands together and pull to their clothes; beginning thumb apposition; fingers are used in Page 6 of 40

scooping and raking motion. Palmar and plantar grasp disappear c. 5 – 6months ♦ Gross: Parachute reflex starts to develop; Intentional rolling over; willfully turning over from abdomen to back at five months, and back to abdomen at six months. Sits with support; 5 months – rolls over prone to supine ♦ Fine: Increased manipulative skill; can grasp and let go voluntarily; plays with toes as objects; can hold spoon and can feed himself with much spilling d. 7 – 9 months ♦ Gross: At seven months, sits alone with hands held forward. Bounces with enjoyment in standing position. Sits independently at 8 months. At 9 months, goes from prone to sitting upright, can creep, crawl, pulls self to standing position; 8 mos. Can sit with good control; 9 months – can crawl ♦ Fine: Can transfer toy from one hand to the other; develops finger thumb apposition; uses crude pincer grasp; preference for dominant hand is evident; diminished ineffective grasping at 8 months due to advanced eye-hand coordination; 7 mos. Plays with feet e. 10 – 12 months ♦ Gross: creeps with abdomen off floor; walks with help or cruises; may attempt to stand alone; can sit down from upright position; Cruising at 10 months; 11 mos. Stands with support; 12 months Attempts to climb ♦ Fine: 10 months, the pincer grasp is sufficiently established to enable infants to pick up a raisin and other finger foods. Uses one finger to point to objects; offers object to people but can’t release them. By 11 months, they put objects into a container and like to remove them. By age 1, infants try to build a tower of two blocks but fail, drink in a cup and pull up socks. Can draw a straight line using a crayon. STAGES OF LANGUAGE DEVELOPMENT ♦ Infant’s first means of verbal communication is crying 1. Pre verbal Stage One-month - Cooing 3 months - Squeals 4 months - Babbling, gurgling 5 months - says some simple vowel sounds; “goo-goo”; “gah-gah” 2. Holophrastic Stage (One- word speech) ♦ a single word (such as OK) that is used to express a complete, meaningful thought ♦ Nine months - Speaks first word “da-da”, or “ba-ba” 3. Telegraphic Stage ♦ Twelve months ♦ 11 months and 1.5 years of age "food" might be used to mean "Give me food" ; "up" could convey "Pick me up"; Mommy see – Mommy hold – Mommy milk – Mommy hurt. Daddy walk – Daddy play – Daddy run – Daddy eat. Baby draw – Baby milk – Baby sleep 4. Whole sentences ♦ Doggie is big; I want more sugar PSYCHOSOCIAL DEVELOPMENT (ERIK ERIKSON) : Developmental task: Trust versus Mistrust ♦ Cries to express displeasure ♦ The infant and parent must jointly learn to satisfactorily meet their needs for mutual regulation of frustration to occur. Trust develops: a. when the infant’s needs are met consistently when those needs arise, b. discomforts are quickly removed, who are cuddled and played with and talked to, come to view the world as safe place and people as helpful and dependable; Care must be consistent and adequate COGNITIVE DEVELOPMENT BY JEAN PIAGET : Sensorimotor : Neonatal Period - reflexive behavior only a. 1 – 4 months : Primary circular Reaction ♦ Activities related to the body, repetitive behavior ♦ Discovers own body parts ♦ Recognizes familiar faces ♦ Totally narcissistic being ♦ Is interested in surroundings

b. 4 - 8 months: Secondary circular reaction ♦ Further separation of self from environment.

♦ Beginning object permanence Page 7 of 40

♦ Able to imitate selective activity from several events. ♦ Idea of quality and quantity. ♦ Awareness of before and after the sequence of events. ♦ Can find partially hidden objects ♦ Beginning recognition of symbols as type of communication. c. 8 – 12 months: Coordination and Secondary Reactions ♦ Concept of object permanence advancing. ♦ Actively searches for hidden objects ♦ Associates symbols with events but classification is based on own experience. ♦ Distinguishes objects from related activity and perceives them as objects. ♦ Distinguishes end products from their means; attempts to remove barriers to achieve the end; Actively searches for hidden objects. ♦ Comprehends meaning of words and simple commands. ♦ Know that gestures have certain meaning (bye-bye, kiss ). ♦ Associates bye-bye with “Daddy going to work”. ♦ Able to put objects in container. ♦ Works to get toy that is out of reach. ♦ Ventures away from parents to explore surroundings. SOCIAL DEVELOPMENT: ♦ Infants social development is influenced by their reflexive behavior, such as the grasp and eventually and depends primarily on the interaction between them and the principal caregiver. ♦ Attachment of parent and child begins before birth and increasingly becomes significant until the first year of life ♦ Infant’s first means of verbal communication is crying, a biologic sign that conveys a message of urgency and signals displeasure. ♦ Personal-social behavior includes the child’s personal responses to the environment Children Learn to Socialize by : 1. Meeting, living with people of various ages & culture 2. Participating in activities of family life & the activities of their peer groups. Play: Solitary Play (Infants) 1. Use their bodies as the primary avenue to explore the world. 2. Learn to participate in and control simple social interactions with caregivers. 3. Learn to recognize, explore, and control objects, sights, sounds, textures, and tastes. 4. Explore, master, and learn to use their body parts. 5. Learn how to get desired reactions from people and objects. Examples of appropriate infant toys: mobiles, rattles, toys with wheels, stacking and nesting toys, unbreakable mirrors, washable stuffed animals and dolls, cloth and heavy cardboard books. (Try to avoid electronic toys that do things infants can't understand or control.) a. 1 -4 months ♦ Stares at parent’s faces when talking at 1 month ♦ Smiles socially at 2 months ♦ Shows excitement when happy at 4 months ♦ Demands attention, requires interaction with people at 4 months b. 5 – 6 months ♦ Vocalization: begins to initiate sound ♦ Recognizes parents, beginning separation anxiety ♦ Comfort habits begin ♦ Plays with a variety of toys that he can handle such as blocks, plastic rings, keys, rattles, squeeze toys, and clothespin at 5 months. ♦ Fear: “Stranger anxiety” – begins by 6 to 7 months, peaks by 8 months and diminishes by 9 mos. c. 7 – 9 months ♦ Verbalizes all vowels and consonants ♦ Shows increased stranger anxiety and anxiety over separation from parents ♦ Exhibits aggressiveness by biting at times ♦ Understands the word “no” ♦ Enjoys teething rings and enjoys transferring toys such as blocks, rattles, and plastic keys. ♦ Enjoys toys that have different feels to them such as velvet, fuzzy, fur, smooth or rough ♦ At 9 months, enjoys creeping out of a crib or playpen and interested with nesting toys or rings that fit on a center post, Page 8 of 40

and pot and pans that stack together. d. 10 – 12 months ♦ Imitates animal sounds, can say only 4 to 5 words but understands many more ♦ Begins to explore surroundings ♦ Plays games such a s “pat-a-cake” or “peek-a-boo” ♦ Shows emotions such as jealousy, affection, anger, fear (esp in new situation). ♦ Enjoys putting things in and out of the container ♦ Interested in pull toys as soon as they can walk ♦ Enjoys listening to nursery rhymes ♦ Most overcome the fear of stranger and are alert and responsive again when approached. ♦ Likes to play interactive nursery rhymes and dance in rhymes with others. ♦ They like being at the table and join family activities PSYCHOSEXUAL DEVELOPMENT: ORAL PHASE (SIGMUND FREUD) ♦ Site of gratification is the mouth and receives gratification through sucking. ♦ Activities: sucking, biting, crying and the like for enjoyment and to release tension and for nourishment EMOTIONAL DEVELOPMENT a. The infant usually reacts by crying and kicking. Trust is an integral part of infant’s total development. b. An infant learns to trust others through the relief of his basic needs (Erickson’s Theory) CONCERNS OF THE INFANT 1. Separation anxiety ♦ fear of being separated from parents, universal fear, begins at about six months of age and persists throughout the preschool period. The following reassure the continued presence of parents even if they are out of sight: 1. Talking to infants when leaving the room 2. Allowing them to hear one’s voice on the telephone 3. Using transitional objects (favorite blanket or toy). Three phases of Separation Anxiety Protest ♦ cries/screams for parents ♦ inconsolable by others Despair ♦ crying ends; less active; uninterested in food/play ♦ clutches “security” object if available Detachment ♦ appears adjusted; evidences interest in environment ♦ ignores parent when he/she returns ♦ resigned, not contented 2. Stranger fear / Anxiety ♦ a form of distress that children experience when exposed to people unfamiliar to them ♦ usually begins at around eight or nine months and generally lasts into the child's second year 1. Talk softly 2. Meet the child at eye level 3. Maintain a safe distance from the infant 4. Avoid sudden, intrusive gestures, such as holding the arms out or smiling broadly 3. Spoiled child Syndrome ♦ Excessive self-centered and immature behavior, resulting from the failure of parents to enforce consistent age-appropriate limits. ♦ Provide guidelines for acceptable behaviors 4. Limit setting and discipline Discipline ♦ is setting rules and road signs so children know what is expected of them. Punishment ♦ a consequence that results from a breakdown in discipline, from child’s disregard of rules that were learned. Page 9 of 40

♦ Parents should instill some sense of discipline early in life because part of it involves setting safety limits and protecting others or property. 1. Parents begin with negative voice and stern eye contact. 2. Time out commensurate with the child’s abilities 3. Parents should provide safe alternatives, put away dangerous household items during exploratory period 4. Give consistent discipline and nurturing 5. Alternative child care arrangements ♦ Basic types of care: in-home care, parent’s or caregiver’s home (family daycare) and center-based care usually in a daycare center. 6. Maternal deprivation - is the term used for an infant’s lack of a warm relationship ♦ Infants deprived from maternal care by their own mothers or by an adequate mother substitute lack all that goes with love and seldom perceive sufficient stimulation to promote normal development. PROMOTION OF HEALTH DURING INFANCY 1. Medicine Administration a. Flavor oral meds to disguise disagreeable taste. (be careful not to increase amount to beyond what child will readily take). b. Offer a drink of flavorful fluid afterwards to counter medicinal taste. c. Never administer medicine in an infants’ formula to prevent changing the taste of the formula 2. Sensory Stimulation a. Talk to infants while you care for them so they come to know you. b. Remember that infants focus longest on a human face c. Provide a crib mirror or mobile, because visual stimulation is satisfying to an infant. 3. Nutrition 0-3 months Seven to Ninth-month old a. Feed only on breast milk or formula for first year a. Intro. finger foods & cup when an infant is able to sit up b. Always hold infant when feeding and never prop b. Have infant join family at mealtimes. bottle when feeding. c. Allow self-feeding with observation to prevent choking. c. Limit water intake to ½ oz at a time. d. Offering fluids after solids. d. Avoid use of honey or corn syrup. e. Introduce limited amounts of diluted juice in a cup. e. Allow non-nutritive sucking. f. Avoid sugary deserts and soda. Four to Six-month old a. Introduce solid foods without added salt or sugar and iron-fortified cereal. b. Introduce one food at a time, waiting 5 to 7 days between new items. c. Avoid use of juice or sweetened drinks. d. Introduce the food before the formula or breast feeding when an infant is hungry e. Introduce small amounts of new food (1-2 tsp at a time) f. Use of spoon only. g. Respect infant food preferences: a child cannot be expected to like all new tastes well equally h. Use only minimal to no salt and sugar on solid foods to minimize the number of additives i. Remember that the extrusion reflex is present for the first 4-6 months of life so any food placed on an infant’s tongue will be pushed away j. To prevent aspiration., do not place food in bottles with formula k. Introduce foods with a positive, ‘you’ll like this attitude”

Tenth to Twelfth-month old a. Offer 3 meals and healthy snacks. b. Begin to wean from bottle and beginning table foods. c. Avoid fruit drinks and flavored milk. d. Avoid infant to feed self with spoon. e. A newborn’s stomach can hold approximately 2 tbsp. (30 ml). By 1 year, stomach can hold no more than approximately 1 cup (240 ml). Suggested Schedule for Introduction of Food ♦ 5-6 months iron-fortified cereal mixed with breast milk, orange juice or formula Rationale: aids in preventing iron-deficiency anemia; the least allergenic type of food; easily digested food ♦ 7 months- Vegetables Rationale: good source of vitamin A; adds new texture and flavors to diet ♦ 8 months- Fruits Rationale: best source of vitamin C, good source of vitamin A; adds new texture & flavors to diet ♦ 9 months - meat Rationale: Good source of protein, iron, & Vit. B ♦ 10 months- egg yolk Rationale: Good source of iron

Problems related to nutrition: 1. Thumb sucking and use of pacifiers Page 10 of 40

♦ Thumb sucking starts in utero and should be stopped at school age. ♦ Thumb sucking may begin at 3 months peaks at about 18 months. ♦ An infant who completes feeding and still seems restless and discontent, and who actively searches for something to put on his mouth may need a pacifier. ♦ Parents should attempt to wean the infant from pacifier anytime after 3 months and when the sucking reflex is fading at 6 to 9 months ♦ thumbsucking is done when infant is tired, scared, bored, sick, or trying to adjust to challenges because it's comforting and calming ♦ The best approach is to be certain an infant has adequate sucking pleasure and then ignore thumb sucking ♦ consider distracting her with substitute activity, like a rubber ball to squeeze or finger puppets to play with 2. Colic ♦ any healthy, well-fed infant who cries more than 3 hours a day, more than 3 days a week, for more than 3 weeks Due to: a. A growing digestive system with muscles that often spasm b. Gas c. Hormones that cause stomach pain or a fussy mood d. Oversensitivity or overstimulation by light, noise, etc. e. A moody baby f. A still-developing nervous system 3. Spitting up ♦ The peak age for spitting up – also known as reflux – is 4 months. ♦ Breastmilk oversupply or forceful let-down ♦ Food sensitivities ♦ Babies with Gastroesophageal Reflux Disease (GERD) ♦ Caused by teething a. Smaller, more frequent feedings can be easier to digest. b. Positioning baby in a semi-upright or sitting position when breastfeeding, c. Fussy, reluctant feeders: try lots of skin to skin contact, breastfeeding in motion (rocking, walking), in the bath or when baby is sleepy. d. Ensure good latch to minimize air swallowing. e. Allow baby to completely finish one breast (by waiting until baby pulls off or goes to sleep) before you offer the other. 4. Weaning ♦ when a baby moves from breast milk to other sources of nourishment Supplementary Feedings ♦ Feedings provided in place of breastfeeding ♦ may include expressed or banked breast milk Complementary Feedings ♦ Feedings provided in addition to breastfeeding after 6 months ♦ A NB’s stomach holds 30 ml but a 1 yr. old hold 240 ml. ♦ Needs 100 ml / kg BW due to rapid growth When is the Infant Ready for Solid Foods : 1. He is nursing every 3-4 hrs. taking more than 32 oz. of formula a day and does not seem satisfied 2. When extrusion reflex fades (3-4 mos.) and sucking reflex is diminished 3. Biting movement begins at 3 mos. while chewing movement begin at 7-9 mos. 4. Able to keep his head in a steady, upright position 5. Sitting well when supported to swallow well 6. Curiosity about what the family is eating Principles in giving complementary feeding: 1. Introduce one solid at a time every 5 days: a. To help discern possible food allergy b. Helps establish sense of trust because it minimizes the number of new experiences in any one day. 2. Feed first solid food with infant held in parent’s arm to minimize the amount of stress associated with it. 3. An infant’s introduction to solid food should be a pleasant experience 4. A small serving is all that an infant will take at first Page 11 of 40

5. A new food should be offered before his formula. 6. The feeder should be calm, patient, gentle, and pleasant in her approach to the infant. ♦ A NB’s stomach holds 30 ml but a 1 yr. old’s hold 240 ml. ♦ Needs 100 ml / kg BW due to rapid growth ♦ Offer 2 to 4 ounces of water per day in a sippy cup Sequence of foods to offer a. Pureed or semi-liquid food b. Strained or mashed food c. Small pieces of finger foods 5. Teething ♦ A physiologic process with some discomfort as the crown of the tooth breaks through the periodontal membrane. ♦ Giving frozen teething ring or ice cube wrapped in a cloth The following manifestations are not normal during tooth eruption: a. High fever c. Diarrhea b. Seizures d. Vomiting ♦ Check articles within baby’s reach to be sure that they are safe to chew or edible as teething infants tend to place almost any object in the mouth ♦ Give frozen teething ring or ice cube wrapped in a cloth 6. Baby Bottle syndrome ♦ Tooth decay in infants and very young children ♦ Happens when sweetened liquids or those with natural sugars (like milk, formula, and fruit juice) cling to an infant’s teeth for a long time. ♦ Bacteria in the mouth thrive on this sugar and make acids that attack the teeth a. Wipe the baby's gums with a clean gauze pad or washcloth after each feeding. b. Begin brushing your child's teeth, without toothpaste, when his or her first tooth comes in. If you choose to use toothpaste, use a fluoride-free one. c Clean and massage gums in areas without teeth. d. Floss once all the baby teeth have come in. e. Make sure your child is getting enough fluoride, which helps lessen cavities. If your local water supply does not contain fluoride, ask your dentist or doctor if you need to use a supplement. f. Schedule regular dental visits by your child's first birthday. Dentists also offer special sealant coatings, which can help prevent tooth decay in children. g. Don't fill bottles with sugar water and soft drinks. Bottles are for milk, water, formula, and special electrolytecontaining solutions when the child has diarrhea. Juices, mixed half and half with water to avoid empty calories, are a way to interest your child in a "sippy cup." Soft drinks are not recommended for children, as they have no nutritional value. h. Never allow your child to fall asleep with a bottle containing anything but water. i. Never give your child a pacifier dipped in anything sweet. j. Reduce the sugar in your child's diet, especially between meals. 7. Constipation ♦ babies 0 to 4 months of age poop on average three to four times a day, and after the introduction of solid foods, that reduces to approximately one bowel movement per day. ♦ milk-protein allergy or intolerance, dairy in mom's diet that's passed through the breast milk. ♦ A change in formula or in Mom's diet ♦ fruits and veggies, such as pears and broccoli 8. Loose Stools ♦ An infection with a virus, bacteria, or parasite. ♦ Babies can pick up these germs through contact with unclean food or water or when they touch germy surfaces and then put their hands into their mouths. ♦ A food allergy or sensitivity to medicines ♦ Drinking too much fruit juice


2. Skin Care Common skin problem a. Seborrhea ♦ a common skin problem which causes a red, itchy rash and white scales b. Diaper rash ♦ infection that can cause a baby's skin to become sore, red, scaly, and tender. c. Miliaria ♦ prickly heat 3. Care of teeth ♦ Deciduous teeth, baby teeth, temporary teeth, milk teeth ♦ 20 temporary or deciduous teeth ♦ The last of the permanent teeth to appear are called “third molars,” or “wisdom teeth.” They usually begin to erupt—pushing their way through the gums—between ages 17 and 21 years. 4. Dressing 5. Sleep and Activity Sleep Problems ♦ Breast-fed infants tend to wake up more often than formula fed infants because breast milk is easily digested thus, infants get hungry sooner ♦ Remaining awake for long periods of time and waking at night is common during the late infancy period ♦ To eliminate night waking or cope with this situation the following should be done: 1. Delay bed time for 1 hour 2. Shorten afternoon sleep period 3. Do not respond immediately to infants so that they can have time to sleep on their own 4. Provide soft toys and music to allow infant to play quietly alone Newborns (0-3 months) ……….… 14-17 hrs / day Infants (4-11 months) ……….…… 12-15 hrs / day Toddlers (1-2 years) ……….……. 11-14 hrs / day Preschoolers (3-5) ………….……. 10-13 hrs / day School age children (6-13) …….… 9-11 hrs / day

Teenagers (14-17) ……………………… 8-10 hrs / day Younger adults (18-25) …………………. 7- 9 hrs / day Adults (26-64) ……………………………. 7- 9 hrs / day Older adults (65+) ……………………….. 7-8 hrs / day

6. Play ♦ Infants learn many things thru play 1. Infants practice motor skills 2. General coordination of movement and specific coordination of hand-eye movements 3. Infants learn to relate to objects and people 4. Express their feelings and ward off frustrations 5. Play is important in the development of the child’s personality Essential factors in the selection of toys: 1. Should be safe for the child’s use 2. Should be washable 3. Easy to handle 4. Smooth with rounded edges, no sharp points 5. Not too heavy 7. Safety ♦ Accidents are leading causes of death in children from one month through 24 years of age, but second to acute infections as a cause of acute morbidity and physician visit. ♦ Preventive measures for infants: 1. Know the whereabouts of the infants at all times. 2. Choose babysitters carefully and explain and enforce all precautions when babysitters are in-charge. 1. Aspiration Precaution a. Potential threat for infants throughout the first year. Round, cylindrical objects, (an inch, 3.2 cm, such as a hotdog and carrot) can totally obstruct infant’s airway. b. Deflated balloon can be sucked into the mouth obstructing in the same way. c. Feeding bottles should not be propped and left when feeding infants. d. Nothing should come within the reach of infants. Page 13 of 40

e. When solid foods are introduced, encourage parents to offer small piece of hot dogs or grapes, not large chunks. f. Children under 5 years of age should not be offered popcorn or peanuts because of the danger of aspiration. g. Parents should check small parts of toys as infants become more adept at toys. h. Pacifiers should come in one-construction with flange large enough to keep it from entering the child’s mouth. 2. Fall Prevention ♦ Second major cause of infant accidents. ♦ Focus is teaching parents to be prepared for their infants to roll over by 2 months of age. ♦ Two months is about the maximum length of time infants can safely sleep in a bassinet a. Never leave an infant on a raised/unprotected surface, such as a bed or couch, even the child is in an infant seat. If a child sleeps in a crib, the rails should be 2 3/8 in. apart. b. Place a gate at the top and bottom of stairways c. Do not allow an infant to walk with a sharp object in the hands or mouth (it could pierce the throat in a fall). d. Be sure crib sides are raised and locked before walking away from the crib. e. Ensure that the space between the mattress and headboard is small enough to trap the child’s head. 3. Safety with Siblings a. Parents should be reminded that children below 5 years of age are not responsible enough or knowledgeable enough about infant to be left unattended with them. b. They might introduce an unsafe toy or engage in a play that is too rough for the infant. c. The preschoolers might be jealous of a new baby that they physically harm the infant if left alone. 4. Suffocation a. Allow no plastic bags within the infant’s reach. b. Do not use pillows in a crib. c. Store unused appliances such as refrigerators or stoves with the door removed. d. Buy a crib that is approved for safety (spacing of siderails is not over (2 3/8 inch) 6 cm apart e. Remove constricting clothing such as bib from neck at bedtime. 5. Drowning ♦ Do not leave infants alone in a bath tub or unsupervised near water (even buckets of cleaning water). 6. Animal Bites ♦ Do not allow an infant to approach a strange dog ♦ Supervise play with family pets. 7. Poisoning a. Never present medication as a candy b. Buy medications in containers with safety caps: put away immediately after use c. Never take medications in front of infants. Place all medications and poisons in locked cabinets d. Never leave medication in a pocket or hand bag. e. Use no lead-based paint in any area of the home. f. Hang plants per set on high surfaces g. Post telephone number of the poison control center by telephone. 8. Burns a. Test warmth of formula and food before feeding b. Do not smoke or drink hot liquids while holding an infant c. Use sunscreen on a child over 6 months when in direct sunlight; limit the sun exposure to less than 30 min. d. Monitor infants near candles e. Keep electric wires and cords out of reach; Cover electrical outlets with safety plugs f. Keep sharp jagged objects out of child’s reach g. Keep diaper pins closed 9. Car Safety a. Never transport unless an infant is buckled into an infant car seat in the back seat of the car. Be aware of the proper technique for placing an infant in a car seat. b. Infants up to 20 lbs should be placed in rear-facing seats in the back because an inflating front-seat airbag could suffocate the infant. c. Do not be distracted by an infant while driving. d. Do not leave an infant unattended in a parked car (can become dehydrated form excess heat or can be abducted) 10. Bodily damage a. Keep sharp jagged objects out of child’s reach. Page 14 of 40

b. Keep diaper pins closed. 11. Immunizations ♥ Process whereby a person is made immune or resistant to an infectious disease, typically by the administration of a vaccine. Fully immunized child ♥ if the child has received BCG vaccine at birth, three doses each of polio and pentavalent (diphtheria-tetanuspertussis-hepatitis B (Hep), OPV each and one dose of measles by the age of 12 months. "First Expiry and First Out" (FEFO) ♥ vaccine system practiced to assure that all vaccines are utilized before its expiry date. Catch-up immunization ♥ recommended to individuals who missed doses that were supposed to be given at a particular age Booster shot ♥ An additional dose of a vaccine needed periodically to 'boost' the immune system Obstacles faced by family with regards to immunization 1. Belief: immunization causes fever 2. Ignorance: some parents are not aware of the importance of immunization 3. Lack of money: although health centers give free immunization, some vaccines are not available in the health centers. PRIMITIVE REFLEXES ♦ are the special reflexes that develop in the brain stem before birth ♦ Most of these Primitive Reflexes go away through the first year of life as higher functions of the brain and muscle control develop. Moro Reflex ♦ Primitive fight or flight reaction ♦ Begins at 28 weeks of gestation ♦ Fades at 2 to 4 months ♦ May become over sensitive and over reactive to sensory stimulus resulting in poor impulse control, sensory overload, anxiety and emotions and social problems Rooting Reflex ♦ Automatic response to turn towards food ♦ assists in the act of breastfeeding and is activated by stroking a baby’s cheek, causing her to turn and open her mouth ♦ 28 weeks IU; Well established at 32-34 weeks intrauterine ♦ Disappears – 3-4 months ♦ May result in difficulty with solid foods, poor articulation and thumb sucking. Sucking / Swallowing reflex ♦ Touching lips or placing something in baby’s mouth causes baby to draw liquid into mouth by creating vacuum with lips, cheeks & tongue ♦ Onset: 28 weeks intrauterine ♦ Well established: 32-34weeks IU ♦ Disappears: around 12 months Palmar Grasp Reflex ♦ Automatic flexing of fingers to grab ♦ Begins at 32 weeks of gestation ♦ Fades at 5 to 6 months ♦ child may have difficulty with fine motor skills, stick out tongue while writing and exhibit messy handwriting Tonic Neck Reflex (TNR) ♦ Fencing Reflex ♦ Present at birth ♦ Fades at 6 months ♦ can cause motor issues, reading, math, and other learning problems; will have difficulty walking normally when turning his head or problems writing and reading when head movement is needed. For example, writing while looking back and forth to the blackboard or a book. Walking/Stepping Reflex ♦ When sole of foot is pressed against a flat surface, baby tries to walk; Legs prance up & down Page 15 of 40

♦ Present at birth ♦ disappears at approximately 2-4 months ♦ With daily practice of reflex, infants may walk alone at 10months Gallant reflex ♦ when the skin along the side of an infant’s back is stroked, the infant will swing towards the side that was stroke ♦ Present at birth ♦ Fades at 3 to 9 months ♦ may affect a child’s posture, coordination, attention and ability to sit still. Tonic Labyrinthine Reflex (TLR) ♦ Basis for head management and helps prepare an infant for rolling over, creeping, crawling, standing and walking. ♦ Present while still in utero ♦ Fades at 3 ½ yrs ♦ can lead to poor muscle tone, tendency to walk on toes, motion sickness nd poor balance Landau reflex ♦ Seen in horizontal suspension with the head, legs & spine extended; If the head is flexed, hip knees and elbows also flex ♦ disappears at 12-24 months ♦ may experience short term memory problems, poor motor development and low muscle tone Blink reflex ♦ A bright light suddenly shone into the eyes, a puff of air upon the sensitive cornea or a sudden loud noise will produce immediate blinking of the eyes ♦ to protect the eyes from foreign bodies and bright light Symmetrical Tonic Neck Reflex (STNR) ♦ Crawling reflex ♦ Preparation for crawling; helps the body divide in half at the midline to assist in crawling ♦ as the head is brought towards chest, the arms bend and legs extend ♦ appears at 6 to 9 months ♦ disappears at 9 to 11 months ♦ Developmental delays related to poor muscle tone, tendency to slump while sitting, and inability to sit still and concentrate Extrusion Reflex ♦ Prevents the infant from feeding effectively ♦ disappear at 3-4 months Parachute reflex ♦ Elicited by holding the child in ventral suspension and suddenly lowering him to the couch; Arms extend as a defensive reaction ♦ Fades at 6 to 8 months

TODDLER ♦ a child whose age is from 1 year old to 3 years old Page 16 of 40

♦ The toddler period is marked primarily by increasing strength and skill in performance CHARACTERISTICS OF TODDLERHOOD: 1. A true foundation of age ♦ Many behavior patterns, attitudes and emotional expressions are established ♦ It is a critical period in setting the pattern for personal and emotional adjustments 2. Age of rapid growth and change ♦ They grow physically and psychologically ♦ Change in height and weight; develop interests and attitudes ♦ There is development of body control (Sitting, standing, walking) 3. Age of decreasing dependency ♦ Begins to do things himself ♦ Rebellion against being treated as a baby ♦ A protest comes in forms of angry outbursts and crying when independence is denied 4. Age of increased individuality ♦ Develop along lines suited to their interests and abilities ♦ Individuality is shown in appearance and in patterns of behaviors ♦ No longer thrive on same food or same schedules of eating and sleeping 5. Beginning of socialization ♦ Able to understand many things and communicate needs and wants ♦ Show desire to become part of groups and start protesting when left alone ♦ Try to win the attention of others by all means ♦ Exhibit attachment behavior and develops strong emotional ties with their mothers 6. Beginning of sex-role typing ♦ Begins stereo-typed toys 7. Appealing age ♦ Babies are disproportionate and are appealing because of the big heads, protruding abdomens, small thin limbs and tiny hands and feet ♦ When they are dressed in baby clothes and wrapped in baby-blankets, they become even more appealing ♦ Their helplessness and dependency make them more appealing 8. Beginning of creativity ♦ Because of lack of muscle coordination and their inability to control their environment, babies are incapable of doing anything that can be regarded as creative. ♦ They are learning however in these early months of life to develop interests and attitudes that lay the foundations of later creativity. 9. A hazardous age ♦ The physical hazards are illness, accidents, disabilities and death. Psychological hazards are disinterests and negative attitudes GROWTH & DEVELOPMENT OF THE TODDLER Biologic: ♦ This is a period of slow growth ♦ Weight: gain of approximately 11 lb (5 kg) during this time; (birth weight x4 by 2½ years ♦ Height: grows 20.3 cm (8 inches); adult height about 2 times height at 2 years ♦ Head circumference: 19½ - 20 inches by 2 years; anterior fontanel closes by 18 months ♦ Pulse 110; respirations 26; blood pressure 99/64 ♦ Primary dentition (20 teeth) completed by 2½ years ♦ Develops sphincter control necessary for bowel and bladder control ♦ Have prominent abdomen - pouchy- belly although walking well their abdominal muscles are not yet strong enough to support abdominal contents. They have forward curvature of the spine at the sacral area ( lordosis), waddle or walk with wide stance but it will correct itself naturally.

Maturation of Body Systems: ♦ Respirations slow slightly but continue to be mainly abdominal. Page 17 of 40

♦ HR slows from 110 to 90 bpm ; ♦ blood pressure increases to about 99/64 mmHg. ♦ Brain develops about 90% of adult size. ♦ Respiratory system - the lumens of vessels enlarge progressively so respiratory infection threat becomes less. ♦ GIT: Stomach secretions become more acidic; Stomach capacity increases to a point a child can eat three meals a day. ♦ GUT: Control of the urinary and anal sphincters becomes possible with complete myelination of the spinal cord. ♦ Immune System: IgG and IgM antibody production becomes mature at 2 years of age. ♦ Passive immunity obtained intrauterinely is no longer operative. ♦ Primary dentition (20 teeth) completed by 2½ years. Eight new teeth (canines & first molars erupt during the 2nd year. ♦ Develops sphincter control necessary for bowel and bladder control. Developmental milestones 1. Motor development a. Gross Motor: ♦ Mobility: walks alone by 15 months; climbs stairs and furniture by 18 months; can walk up an down the stairs holding on to a person’s hand or railing at 18 months; walks up alone the stairs by 24 mo; jumps from step or chair by 2 ½ years; balances on one foot momentarily by 2 ½ years; rides tricycle by 3 years b. Fine Motor: ♦ By age 15 months, they can drop a pellet into a narrow-necked bottle. Scribbles voluntarily with a pencil or a crayon; holds a spoon well but still turns upside down on the way to the mouth; Casting or throwing objects and retrieving them become an almost obsessive activity, ♦ By 18 months, spoon no longer rotates; they can throw a ball overhand without losing their balance. turns doorknob; unscrew lids. ♦ Ability to build tower of blocks: 3 blocks; 24 months - 6-7 blocks; 30 months – a tower of eight or more; ♦ 36 months – copies circle, uses scissors, button and unbuttons. PSYCHOSOCIAL DEVELOPMENT (ERIK ERIKSON) : Autonomy versus Shame and doubt ♦ increases independence; better able to tolerate separation from primary caregiver ♦ Less likely to fear strangers ♦ Able to help with dressing/undressing at 18 months; dresses self at 24 months ♦ Has sustained attention span ♦ May have temper tantrums during this period; should decrease by 2 ½ years ♦ Vocabulary increases from about 10 – 20 words to over 900 words by 3 years ♦ Has beginning awareness of ownership at 18 months; shows proper uses of pronouns by 3 years ♦ Moves from hoarding and possessiveness at 18 months to sharing with peers by 3 years ♦ Beginning of problem solving ♦ Toilet training usually completed by 3 years. COGNITIVE DEVELOPMENT (JEAN PIAGET) : 12 – 18 months: Tertiary Circular reaction ♦ Knows own name by 12 months; refers to self; ♦ Able to identify geometric forms by 18 months ♦ Achieves object permanence ♦ Uses “magical” thinking; believes own feelings affect events ♦ Experiments by trial and error ♦ Uses ritualistic behavior ♦ May develop dependency on “transitional object” ♦ Insatiable curiosity about the environment. ♦ Uses all sensory cues for exploration. ♦ Ventures away from parents for longer periods. ♦ Uses physical skills to achieve a particular goal. ♦ Can find hidden objects, but only in first location. ♦ Able to insert round objects into a hole. ♦ Fits smaller objects into each other (nesting). ♦ Gestures “up” and “down”. ♦ Puts objects into container and takes them out. ♦ Realizes that out of sight is not out of reach, opens doors and drawers to find objects. Page 18 of 40

♦ Gains comfort of parents voice even if not visible 18 to 24 months: Invention of New Means Through mental combinations ♦ Searches for objects at several hiding places. ♦ Follows simple direction by 2 years ♦ Begins to use short sentences at 18 months to 2 years ♦ Can remember and repeat 3 numbers by 3 years ♦ Gives first name by 24 months; gives full name by 3 years ♦ Will infer cause by associating 2 experiences such as candy missing, sister smiling. ♦ Can pretend and use deferred imitation; object permanence is complete ♦ Imitates words and sounds of animals. ♦ Imitates adult behavior (domestic mimicry). ♦ Follows directions and understands requests. ♦ Uses words “up”, “down”, “come”, and “go” with meaning. ♦ May sit at table for meals at short periods. ♦ Has some sense of time,; wait in response to just a minute; may use word “now”. ♦ Refers to self by name. ♦ Engages in parallel play; demonstrates awareness of ownership. ♦ Concerned with ritualistic, routinized schedule. 2 to 3 years: Preoperational Thought period ( Preconceptual) ♦ Children become more symbolic ♦ Can arrive at answers mentally instead of thorough physical attempt. ♦ Can not view one object as necessarily being different from another ♦ Child is egocentric and unable to see viewpoint of another. ♦ Able to use assimilation or change situation to fit thoughts ♦ Displays static thinking. ♦ Concept of time is now, and concept of distance is only as far as he can see. ♦ They draw conclusions from obvious facts they see (prelogical reasoning) The key features of the preoperational stage: 1. Centration ♦ the tendency to focus on only one aspect of a situation at one time 2. Egocentrism ♦ child's inability to see a situation from another person's point of view ♦ Each child is absorbed in its own private world and speech is egocentric. The main function of speech at this stage is to externalize the child’s thinking rather than to communicate with others 3. Symbolic Representation ♦ the ability to make one thing - a word or an object - stand for something other than itself ♦ Pretend (or symbolic) play: Toddlers often pretend to be people they are not (e.g. superheroes, policeman), and may play these roles with props that symbolize real life objects. ♦ Children may also invent an imaginary playmate 4. Animism ♦ the belief that inanimate objects (such as toys and teddy bears) have human feelings and intentions. Piaget has identified four stages of animism: a. First stage (Up to the ages 4 or 5 years) ♦ child believes that almost everything is alive & has a purpose b. Second stage (5-7 years) ♦ only objects that move have a purpose c. Third stage (7-9 years) ♦ only objects that move spontaneously are thought to be alive d. Fourth stage (9-12 years) ♦ the child understands that only plants and animals are alive

5. Artificialism ♦ This is the belief that certain aspects of the environment are manufactured by people (e.g. clouds in the sky) Page 19 of 40

6. Irreversibility ♦ the inability to reverse the direction of a sequence of events to their starting point SOCIAL DEVELOPMENT: Play: Parallel play ♦ Imitation of adults often part of play ♦ Begins imaginative and make-believe play ♦ Provide toys appropriate for increased locomotive skills ♦ Give toys to provide outlet for aggressive feelings ♦ Provide toys to help develop fine motor skills, problem solving abilities ♦ At 15 months:Names familiar objects; 4 to 6 words undress, point 2 – 3 body part; ♦ 24 months: use 2 – 3 word phrases ♦ 30 months – gives first and last names ♦ 36 months – Tells stories, talks non-stop, 500 – 900 vocabularies Factors in selecting toys for toddler 1. Consider toddler’s likes and dislikes 2. Toddler’s like to pull and push toys and enjoys pedal propelled toys 3. Consider toddlers’ being imaginative 4. No small, removable parts nor flammable

5. No sharp edges 6. No rough edges 7. Should be safe 8. Should not be lead painted

Examples of appropriate toddler toys 1. Pull-push toys 2. Blocks 3. Assortment of balls 4. Picture books 5. Play Doh with simple tools (craft sticks and wooden rollers) 6. Containers, scoops, sifters, and other objects for sand and water play 7. Toys and props for dramatic play like scarves, hats, a toy telephone, stuffed animals, and generic baby dolls 8. Large pegged-top puzzles 9. A small climbing structure SPIRITUAL DEVELOPMENT (James Fowler) : Stage I – Intuitive-projective stage ♦ Faith is magical and inventive, a faith derived primarily from significant others or parents. ♦ Child is egocentric. ♦ Child's imagination is formed but reality is not well-differentiated from fantasy. For this reason, adults preaching about the negative aspects of religion - the devil and the evils of sin - can cause great harm to a child of this age, leading him toward a very rigid, brittle and authoritarian personality as an adult. MORAL (LAWRENCE KOHLBERG) : Level I- Preconventional, Stage 1 – Obedience and punishment ♦ The child does right because the parent tells him/her to avoid punishment. The child is good because the parent said the child must be, not that it is right to be good. ♦ Children see morality as something external to themselves, as that which the big people say they must do. ♦ Nursing implication: Child needs help to determine what are right actions. Give clear instructions to avoid confusion. PSYCHOSEXUAL DEVELOPMENT (SIGMUND FREUD) : Anal phase ♦ The childs interest widens and his main interest is focused on the anal region. Elimination takes a new importance. ♦ He finds pleasure in both retention of feces and in defecation. This anal’s interest is a part of child’s discovery of self and a way of exerting his independence The process of toilet training is regarded as the resolution of this conflict. ♦ Toilet training usually completed by 3 years. CONCERNS OF TODDLERS 1. Toilet training ♦ one of the biggest tasks the toddler must achieve, during this period. ♦ Important development levels that must be reached before toilet training begins: one physiologic, and 2 cognitive Markers of readiness: a. Can stand, squat and walk alone Page 20 of 40

b. Can communicate toilet needs c. Can maintain himself/herself dry for an interval of 2 hours Stages of Toilet Training: a. Bowel control – 18 months b. Daytime bladder control – 2 ½ yrs of age c. Nighttime bladder control – 3 yrs 2. Ritualistic behavior ♦ Repetitive phenomena, such as rituals and rigid routines frequent between the ages of two and four years old ♦ Engaging in repetitive behavior may be a toddler’s way of trying to establish predictability and order in a world where they have little to no control or understanding of the world around them, which can be anxiety provoking. ♦ can be reduced by setting rules and guidelines, and not letting the child to be over dependent. 3. Negativism ♦ signals the transition from babyhood to childhood. ♦ child’s way of asserting herself - seeing how it feels to make decisions on her own. And part of making these decisions is disagreeing with her parents. a. Offer your child a choice of limited options: "Do you want a cheese sandwich or a peanut butter sandwich for lunch today?" rather than "What do you want for lunch today?" b. Use as few commands as possible, and insist on obedience only when absolutely necessary. c. Emphasize the positive. "We will have a treat later" works much better than "You cannot have a cookie now." Negative statements from you can prompt negative behavior from your child. d. Limit the number of questions asked of the child. Making statements instead of asking questions can avoid a great many negative responses. 4. Discipline ♦ is setting rules and road signs so children know what is expected of them. Punishment is a consequence that results from a breakdown in discipline, from the child’s disregard of the rules that were learned. ♦ Parents should instill some sense of discipline early in life because part of it involves setting safety limits and protecting others or property. General rules to follow when teaching discipline: a. Parents need to be consistent b. Rules are learned best if correct behavior is praised rather than the wrong behavior punished. c. Timeout is a technique of helping children learn that actions have consequences. To use it effectively, parents need to be certain that their child understands the rule they are trying to enforce. d. Give warning first before giving a time out. The length of time is 1 min per year of age. 5. Separation anxiety ♦ ``begins at about six months of age and persists throughout the preschool period. ♦ a child becomes fearful and nervous when away from home or separated from a loved one -- usually a parent or other caregiver -- to whom the child is attached Stages of Separation Anxiety 1. Protest – clinging to parents, pleading for parents to stay 2. Despair – child is hopeless and becomes quiet, withdrawn, apathetic 3. Detachment – lack of protest when parents leave but if parents reappear, child may ignore Prevention: 1. Reduce anxiety in the child 2. Develope a sense of security in the child and the caregivers 3. Educate the child and family/caregivers about the need for natural separations 4. Reinforce a child's independence and self-esteem through support and approval 6. Temper tantrums ♦ the frontal lobe of your toddler’s brain (the part that controls logic, reasoning, planning, judgment, self-control, and emotional processing) is underdeveloped. ♦ Feels frustrated and angry that he can’t do something, but he can’t mentally process those feelings. He lacks the self-control necessary to keep those emotions in check. And he certainly can’t express his feelings verbally, the way an adult would. Therefore, he resorts to kicking and shrieking and throwing things, because those are skills he does have. a. Give your toddler choices, when possible. Page 21 of 40

b. Institute a countdown. institute a countdown before a transition takes place: “3 more books, and then it’s bedtime” or “5 more minutes to play trucks, and then we have to stop and eat lunch”. c. Avoid attempts to reason with your toddler. Remember, your toddler is not a creature of logic. calmly and firmly offer a short explanation that he can understand and then repeat it as necessary. d. Remain calm and consistent. If your toddler sees that she is not able to get a rise out of you, she will probably calm down faster. It is also important that you remain firm and consistent – avoid giving in to your toddler’s demands when she’s throwing a tantrum. e. Avoid overtiredness. Try to watch for your toddler’s sleep cues. Is she rubbing her eyes? Yawning? Looking glassy-eyed? If so, then get her to bed quickly. It is worth repeating: an exhausted toddler is more likely to throw a whopper of a tantrum before nap time or bedtime than a toddler who’s well-rested. So try to stay ahead of the overtiredness, and make sure she is getting the rest she needs. 7. Sibling Rivalry ♦ It can be tough for a toddler to welcome a new baby into his domain. As siblings get older, they may show their jealousy by arguing, name-calling, teasing, pushing, and occasionally fighting. But the toddler won't understand his feelings of jealousy, or what he can do about that annoying newborn. He just wants attention, and may react by misbehaving or even regressing. a. Tell the toddler about the approaching birth f. Ask the toddler for help and advice b. Explain what's going to happen once the baby arrives g. Spend time with the toddler c. Let the toddler get involved in the preparations h. Be prepared for aggression d. Involve the toddler in looking after the baby i. Don't compare the children e. Teach the toddler to resolve conflicts on his own PROMOTION OF HEALTH 1. Safety measures A. Motor Vehicle Accidents 1. Always use a car seat 2. Keep child safe in strollers and carts B. Burns 1. Have and maintain smoke detectors 2. Plan and practice escape routes 3. identify dangers in the home and remove them or block child’s access to them 4. Prevent children from getting near firecrackers or fireworks 5. Keep toddler out of the sun; if not, cover child's skin with hats and clothing. Protect any bare skin with a small amount of sunscreen. 6. Small bodies can develop heat exhaustion much more quickly than adults. Do not keep child out in warm weather for long periods, and keep water or other drinks on hand. C. Drowning 1. Supervise all baths at all times 2. Deal with water hazards and teach swimming safety 3. Keep pools and hot tubs safe 4. Empty all buckets and coolers when not in use 5. Keep toilet lids down, and consider securing them with safety latches. D. Falls 1. Don't allow your child to walk or run with objects in his or her mouth. 2. Avoid using baby walkers. Children can fall down stairs and get hurt. An activity center is a better choice. 3. High chairs should have a wide, stable base and make sure the high chair is locked in the upright position before use. Use the safety straps, and supervise your child at all times while he or she is in the high chair. 4. Changing tables should have a railing on all sides that is 2 in. (5.1 cm) high. Always use the safety strap, and keep one hand on your child. Have diapers and other items handy, but keep them out of your child's reach. E. Poisoning 1. Wash your hands and working surfaces while preparing food 2. Cook foods to safe temperatures, and refrigerate foods promptly 3. Identify any products that could harm the child when eaten or inhaled. 4. Store these products out of your child's reach. 5. Children may chew on contaminated paint flakes or painted objects. 6. Use a carbon monoxide detector, and have your furnace checked each year. Page 22 of 40

7. Protect the child from second hand smoke, mold, and other indoor air pollutants F. Choking ♦ Child can choke on things smaller than 1.25 in. (3.2 cm) in diameter and 2.25 in. (5.7 cm) long. These include button batteries and coins. 1. Keep items like these out of your child's reach. 2. Learn to recognize signs of choking (a child who is choking can't talk, cry, breathe, or cough) G. Strangulation and Suffocation 1. Keep cords for blinds and drapes out of child's reach. 2. Cords with loops should be cut and given safety tassels instead. 3. Never use accordion-style gates. A baby or young child may trap his or her head in the gate and may strangle. 4. Make sure that furniture does not have cut out portions or other areas that can trap your child's head. 5. Always lock car doors, and keep the keys out of your child's sight and reach. 6. If you are storing an old refrigerator or freezer, remove the door. 7. Do not let your child play with plastic sacks, and keep them out of his or her reach. Many children like to play with sacks and put them over their heads. 8. Cribs should have less than 2.4 in. (60 mm) of space between slats. 9. Playpens should have spaces in the mesh material that do not exceed 0.25 in. (0.6 cm) across. Wooden slats should measure less than 2.4 in. (60 mm) apart. 10. Grown up children can get tangled in mobiles or may use larger toys 2. Nutrition Specific suggestions for feeding toddlers: a. Serve food in small portions. Child likes plain food and eats one food at a time. b. Chop or cut the food into small pieces c. Diet for each day should include the following: Toddlers should consume at least 1,300 kcal daily c.1. meat and fish – one serving, one egg daily or cheese c.2. liver – one or more servings a week. c.3. green and yellow vegetables – two or more servings a day c.4. citrus fruits, raw or cooked – fruit two or more servings a day (one could be citrus or tomato juice) c.5. cereal and bread enough to meet his caloric needs c.6. butter or margarine c.7. milk 16 ounces to a maximum of 1 quart or part of which may be used in cooking or on cereals d. Satisfy the child’s appetite with nutritious foods and avoid offering him candy cake, ice cream and the like. Nutritious snacks may be given between meals. e. Give vitamins as suggested by the physician f. Since child is growing less rapidly, he may eat less than he did at the end of the first year. Don’t force him to eat. g. High sugar should be avoided. h. Fats should generally not be restricted for children under 2 years old however, children over 2 years old should consume no more than 30% of total daily calories from fat. i. Adequate calcium and phosphorus intake is important. j. Milk should be whole milk until 2 years 3. Daily physical care: a. Bath should be given as part of his care b. Prevention of tooth decay in the deciduous dentition is important c. Clothing should be light and bright colored with large easily managed buttons, straps placed where child can reach them d. Amount of sleep the toddler needs depends upon his health, age, emotional tension and activity during the day.

PRE SCHOOLER ♦ The Preschooler is a child from 4 to 6 years old Page 23 of 40

♦ period preceding the child’s entry into school THE CHARACTERISTICS OF A PRESCHOOLER 1. A toy age ♦ The age of playing with toys most of the time 2. A pre gang age ♦ The child is learning the foundations of social behavior. This learning prepares him for the more highly organized social life of the school. 3. An Exploratory age ♦ They want to know what their environment is and how it works, how it feels, and how they can be a part of it. Child explores the environment and gains control over it 4. A questioning age ♦ At first questions are concerned with physical causality and then on diverse number of categories. If not satisfied with the answer, they raise more and more questions in chain until they are satisfied. 5. An imitative age ♦ They imitate speech and actions of others 6. A creative age ♦ They try to learn various skills by repeated trials and adventurous attempts. They also engage in games and modified form of sports without toys 7. A Problem age ♦ Behavior problems are more frequent than the physical care problems. Thus, they develop distinctive personalities and aspire for independence. ♦ They are very often obstinate, stubborn, disobedient, protesting and antagonistic. ♦ They are often bothered by daydreams at night and irrational fears during day times and suffer from jealousies. ♦ They also demand independence and are incapable of handling things. THE PHYSICAL CHANGES IN A PRESCHOOLER ♦ The baby look has disappeared but facial features remain small. The body is more proportioned. ♦ Slower growth rate continues ♦ Weight: increases 4-6 lbs a year ♦ Height: increases 2 inches a year ♦ Birth length doubled by 4 years ♦ Head circumference has an increase by 1 inch per year ♦ Vital signs decrease slightly: pulse 90 – 100; respirations 24-25; BP 85-100 / 60-70 ♦ Slimmer, taller, more of child-like proportions from previously wide-legged gait, prominent lordosis and protuberant abdomen. ♦ Contour changes are definite that future body type- ectomorphic (slim body build) and endomorphic (large body build) becomes apparent. ♦ Lymphatic tissues begin to increase in size particularly tonsils. ♦ Levels of IgG and IgA antibodies increase making preschool illnesses more localized. ♦ Physiologic splitting of heart sounds and innocent heart murmurs are heard for the first time. This occurs owing to the changing heart size in reference to the thorax. The APD and TD of the chest reach adult proportions. ♦ Pulse rate decreases to about 85 bpm, BP at 100/60 mmHg. ♦ Bladder is easily palpable above the symphysis pubis, voiding is frequent (9 to 10 times a day), play is interrupted. ♦ The indeterminate longitudinal arch on the foot becomes a well-formed arch now. ♦ Can perform gymnastics because of more noticeable muscles. ♦ Many exhibit genu valgus (knock-knees) which disappear with skeletal growth near the end of preschool period. ♦ Have all the 20 deciduous teeth by the end of three years ♦ Rarely do new teeth erupt during the preschool period.

GROSS MOTOR ♦ Walks up the stairs using alternate feet by 3 years

FINE MOTOR DEVELOPMENT ♦ Builds a tower of blocks by 3 years Page 24 of 40

♦ Rides tricycle by 3 years ♦ Stands on 1 foot by 3 years ♦ Walks down the stairs using alternate feet by 4 years ♦ Hops on 1 foot by 4 years ♦ Skips and hops on alternate feet by 5 years ♦ Throws and catches ball by 5 years Age 4 ▪ color recognition of primary colors ▪ Triples in height ▪ Jump ▪ Goes up and down in stairs ▪ Uses scissors perfectly ▪ Imitates square ▪ Ties his shoe laces ▪ Writes his name ▪ Draws 3 parts of the body ▪ 1500 vocabularies ▪ Able to tell tales

♦ Hand dominance is established by 5 years ♦ Ties shoes by 5 years ♦ Ability to draw changes over this time ♦ Handles scissors well by 5 years

Age 5 ▪ Learns to balance ▪ Jumps in rope ▪ Eruption of permanent dentition ▪ Imaginative play ▪ Imitates the triangle ▪ Prints letters ▪ Draws a man ▪ Hammers nails ▪ Dresses himself/herself alone

PSYCHO SOCIAL DEVELOPMENT: INITIATIVE VS. GUILT Initiative ♦ The child with a well-developed sense of initiative would discover that learning new things is fun. ♦ If children are criticized or punished for attempts at initiative, they develop a sense of guilt for wanting to try new activities or have new experiences. ♦ They need exposure to a wide variety of experiences and play materials so they can learn as much about the world as possible. ♦ They need to go places: zoo, or amusement park where they could learn more vocabularies. ♦ Encourage creative play where they could use their hands: clay, finger paints, soapy water, sand, mud, homemade dough. COGNITIVE DEVELOPMENT ♦ Preoperational: Intuitive thought ♦ lack sight to view themselves as others see them or put themselves in another’s place, so they feel they are always right. This causes them to argue with forcefulness believing they are always 100% correct. ♦ They are not yet aware of the property of conservation. Imitation ♦ Preschoolers need free rein to imitate the roles of the people around them. Hence role playing should be fun and need not be accurate. ♦ They generally imitate activities they see their parents performing at home ♦ They learn new words by introducing the other self of the parents at work such as: photocopier, secretary, lawyer, sales clerk and the like. PSYCHOSEXUAL DEVELOPMENT : Phallic Stage Oedipus Complex ♦ refers to the strong emotional attachment of a preschool boy to his mother. Electra complex ♦ refers to the strong emotional attachment of a preschool girl to her father. ♦ Each child competes with the same-sex parent for the love and attention of the other parent. This is normal. ♦ Parents feel left out, and need help in handling feelings of jealousy and anger especially if the child is vocal in expressing feelings: “I hate you! I only love Daddy!” Gender Roles ♦ Preschoolers need exposure to an adult of the opposite sex so they could become familiar with the opposite gender roles. ♦ If a child is hospitalized during the preschool period, a male nurse could help fill this role. ♦ Children’s gender-typical actions are strengthened by parents, strangers, nursery school teachers, other family members and other children. LANGUAGE DEVELOPMENT ♦ The 3-year old child has a vocabulary of 900 words. Page 25 of 40

♦ These are used to ask questions constantly, mostly “how”, and “why”. Examples: “Why is snow cold?” “How do worms hear?” “What does your tongue do?” ♦ They need simple answers, so curiosity, vocabulary building and questioning are encouraged, and also the depth of child’s understanding is deceptive ♦ They would just follow what has been told to them but then return and ask why it was so. ♦ Preschoolers imitate language exactly, so if they hear less-than-perfect language, that is the language pattern they adopt. ♦ They may imitate and use “bathroom language” if not corrected. ♦ Preschoolers are egocentric so they define objects in relation to themselves. PLAY ♦ Preschoolers do not need so many toys. Their imaginations are keener than they will be at any other time in their life, so they enjoy games that use imitation such as playing ♦ They imitate what they see parents doing: eating meals, mowing the lawn, cleaning the house, washing, ironing arguing, etc. ♦ They pretend to be teachers, firefighters, cowboys, store clerks. They have imaginary friends. These exist until they formally begin schooling. ♦ Four and 5-year-olds divide their time between rough-housing and imaginative/imitative/associative play. SOCIALIZATION ♦ Since 3-year-olds are capable of sharing, they play with other children their age much more agreeably than do toddlers, which is why preschool period is a sensitive and critical time for socialization. ♦ Children at age 4 are involved in arguments more than they did at age 3, especially as they become more certain of their role in the group. ♦ Five-year-olds begin to develop “best” friendships perhaps on the basis of who they walk with to the school, or who lives closest to them Fantasy ♦ Preschoolers begin to differentiate cartoon characters from real ♦ Children are fond of imitating and pretending to be something ore someone else, a fantasy role: like rabbit, batman, superman. ♦ Parents should be encouraged to support the fantasy but still reassuring the child that she/he is still herself/himself, the difference between the child and the role. MORAL DEVELOPMENT : Pre-conventional Level; Stage 2: Individualism and Exchange ♦ Does the right thing in exchange for something SPIRITUAL DEVELOPMENT : Intuitive projective ♦ Begin to have elemental concept of God if they have been provided some form of religious training. ♦ Belief is an outside force aids in the development of conscience (Kohlberg,1984) CONCERNS RELATED TO GROWTH AND DEVELOPMENT 1. Preschool and kindergarten experience ♦ Transition to kindergarten should begin a year before. ♦ Practice and guidance is essential to prevent stress. ♦ Children should have preschool skills such as: being able to retell a simple story, able to recognize letters in their names, trace the shapes of letters and numbers on paper, following simple instructions, matching rhyming sounds, properly holding a pencil and listening to a story with a group, new social experiences like taking turns and being in school for an entire day, interacting with new friends 2. Sex education ♦ Sex education isn't a single tell-all discussion. Instead, take advantage of everyday opportunities to discuss sex. a. Open the door to sex education by teaching child the proper names for his or her sex organs, perhaps during bath time. b. If child points to a body part, simply tell him or her what it is. This is also a good time to talk about which parts of the body are private. c. When child asks questions about his or her body — or yours, take the questions at face value, and offer direct, age-appropriate responses. Page 26 of 40

3. Gifted children ♦ The range for average intelligence is 85 to 115 ♦ Children whose IQ scores are at least 120 to 130 are considered gifted. ♦ Some gifted children realize they're "different" from their peers. This can make them feel isolated and withdrawn. It may also make them targets for bullying. They may begin to feel intensely frustrated because they can think more rapidly than they can express themselves, verbally or physically. ♦ If child appears unusually angry or frustrated, consider consulting a mental health professional. 4. Aggression ♦ The preschooler is learning a lot of new skills and she can easily become frustrated with everything she is trying to accomplish ♦ Child is tired and hungry or maybe if she feels resentful or neglected on top of everything else. She doesn’t quite know what to do about it, so she responds by biting, hitting, or throwing a tantrum. a. Help her realize and talk about it. b. Let her know instantly when she’s done something wrong c. Remove her from the situation for a brief time out for three or four minutes to connect her behavior with the consequence that if she hits or bites, she’ll miss out on the fun. d. Reinforce responsibility that if her aggression damages property or make a mess, she should help make it right again. e. Reward good behavior 5. Speech problems a. Stuttering ♦ repeating the first sound or syllable in a word or the first word in a sentence. It is more likely to happen when a child is tired, excited, or in a competitive situation, like trying to express herself better or faster than her peers. b. Lisping ♦ make substitutions of an easy sound for one that is more challenging for them to make, such as "th" for "s," thus, "thand" for "sand." or "w" for "r," saying "wabbit" for "rabbit." c. Lengthy pauses ♦ the appearance of long pauses between words or thoughts. A sign that child is groping for the correct word or thinking about how to structure her next sentence. Some tips 1. Talk a lot with the child to help her learn new words. 7. Point out words you see 2. Speak to the child in the language you know best. 8. Listen and respond when the child talks. 3. Encourage child to ask questions. 9. Reduce child's stress. 4. Give child time to answer questions. 10. Read to the child. 5. Set limits for watching TV and using electronic media. Use the time for talking and reading together. 6. Eat dinner as a family to regularly participate in conversation with adults 6. Lying ♦ Maybe due to active imagination; They struggle to tell the difference between what’s real and what’s not. After all, most preschoolers engage in a lot of pretend play. ♦ Maybe due to forgetfulness, the angel syndrome; A child who recognizes that his parents think he can do no wrong starts to believe it himself a. Encourage truth-telling. b. Don't accuse. ♦ Couch your comments so they invite confession, not denial c. Don't overburden your child. ♦ Don't weigh your child down with too many expectations or rules, he may feel compelled to lie to avoid your disappointment. d. Build trust. e. Establish a household rule about honesty to make your expectations clear. 7. Whining ♦ the sound of a child who feels powerless and is pitching his request in higher and higher tones so someone will pay attention to him.

♦ Toddlers often don't know how else to express what they want or when they don’t get their way a. Acknowledge your child's need for attention d. Respond consistently Page 27 of 40

b. Show her a better way to address the problem. c. Avoid triggers.

e. Try a diversion

8. Stress ♦ body's reaction to a physical or emotional situation that causes imbalance in a person's life. ♦ Negative sources of stress: physical abuse, separation, rejection, and fights, parent losing a job, or the death of a parent, grandparent, or sibling ♦ Positive sources of stress: birthday parties, new pets, and the birth of new siblings, everyday family obligations, events, and routines ♦ Possible Signs of Stress in Young Children are: Accident proneness, Hitting, Anger, Kicking, Anxiety, Insomnia, Appetite Loss, Stuttering, Baby Talk, Indigestion, Bed-wetting, Thumb sucking, Biting, Pounding Heart, Crying spells, Grinding Teeth, Detachment, Fingernail Biting, Excessive Aggressiveness, Respiratory Tract Illness, Excessive Laziness, Tattling a. Acknowledge their feelings so they understand what they are feeling b. Promote a positive environment by praising children for the acceptable things that they do c. Help children through stories d. Make an effort to cut down on activities when you see signs of stress e. Teach children tricks for calming themselves f. Plan plenty of time for play to allow them to express their feelings g. Books, art activities, puppetry, play and drawing allow children to think through and label their feelings. h. Give children a lot of cuddles, reassurances, and familiar routines 9. Common Fears a. Fear of darkness d. Fear of annihilation f. Fear of animals b. Fear of ghosts e. Pain g. Fear of mutilation c. Sexual matters – castration anxiety ♦ Some fears are a result of concrete experiences but some is due to their developing imagination. a. Approach the fear in steps. d. Problem-solve together. b. Explain, expose, and explore. e. Practice through pretend play c. Use love objects. These can offer an anxious child lasting reassurance PROMOTION OF HEALTH 1. Safety a. Keeping Children Safe, Strong and FREE b. Warn child never to talk to a stranger. c. Teach child to call for help in case of emergency. d. Describe what a police officer looks like and express that a police officer can help in emergency situation. e. Explaining about secrets f. Explain that bullying behavior from other children is not to be tolerated but reported so they can receive help managing it. g. Wear safety helmet when riding a bicycle 2. Nutritional Needs ♦ Would be based on the food pyramid. ♦ Caution should be made, since vitamins for this period are made in such a way that they are attractive, and should be kept in a safe place far from children’s reach. 3. Daily Activities a. Dressing ♦ have difficulty in buttons, prefer bright and printed clothes that oftentimes mismatch. b. Sleep ♦ Sleep 12 hours a night ♦ They don’t take a nap no matter how tired they are ♦ Are afraid of the dark ♦ Night waking from nightmares or night terrors reaches its peak. ♦ Needs a night light.

c. Exercise ♦ Active period. ♦ They receive a great deal of exercise, Rough-housing, love time-honored games. d. Bathing ♦ Fond of taking a bath but are not paragons of eatness. e. Care of teeth ♦ Deciduous teeth should be preserved to protect the dental arch. f. Night grinding or Bruxism (grinding the teeth at night) ♦ usually to release tension, “letting go”

SCHOOLER ♦ 6 – 12 YEARS OLD Page 28 of 40

CHARACTERISTICS OF A SCHOOLER 1. Troublesome Age ♦ no longer willing to do what they are told ♦ influenced by their peers 2. Sloppy Age ♦ children are careless ♦ slovenly about their appearance ♦ rooms are cluttered 3. Quarrelsome stage ♦ emotional climate of the home is far from pleasant for all family members 4. Elementary school age ♦ time to learn essential skills both curricular and co-curricular 5. Critical Period !!! ♦ formation of habit: achievers or underachievers (working above/below up to one's capacity tend to persist into adulthood) 6. Gang Age ♦ Major concern: acceptance of peers ♦ age of conformity BIOLOGIC DEVELOPMENT ♦ Weight: doubles over this period ♦ Height: 2 inches per year ♦ Height increases to 1-2 inches (2.5-5 cm) ♦ At age 9, both sexes - same size; ♦ Age 12, girls bigger than boys ♦ Adult vision level is achieved; hand-eye coordination develops completely ♦ IgA and IgG reach adult levels, and lymphatic tissue continues to grow up until age 9. ♦ By 10 years of age, brain growth is complete, so fine motor coordination becomes more refined. ♦ Innocent heart murmurs are heard due to extra blood crossing the heart valves. ♦ Pulse rate decreases to 70-80 bpm; ♦ Blood pressure rises to about 112/60 mmHg PHYSICAL GROWTH ♦ Dentition ▪ loses first primary teeth at about 6 years ▪ by 12 years, has all permanent teeth except final molars ▪ Malocclusion with teeth mal alignment may result if the eruption of the permanent teeth and growth of the jaw do not correlate with final head growth. ♦ Bone growth faster than muscle and ligament development ♦ Posture becomes more erect MOTOR DEVELOPMENT ♦ Gross motor skills ▪ predominantly involving large muscles ▪ children are very energetic; develop greater strength, coordination, and stamina ♦ Fine motor development ▪ Develops smoothness and speed in fine motor control PSYCHOSEXUAL DEVELOPMENT : Latency Stage ♦ Energy is used to gain new skills and social relationship and knowledge. ♦ Sexual drive (libido) controlled and repressed SPIRITUAL DEVELOPMENT : Stage 2: Mythic - Literal Faith ♦ Start sorting out the real from the make-believe. ♦ Beliefs, moral rules and attitudes are also held literally. Thus, God is an anthropomorphic (having human characteristics) being in the sky; Heaven and hell are viewed as actual places. Page 29 of 40

♦ The person is also more able to take the perspective of another person but his view of reciprocity is also rather literal. "If I follow the rules, God will give me a good life." "If I pray, God will grant my wish.” MORAL DEVELOPMENT: Level II: Conventional Stage 3: Good Interpersonal Relationship: Good Boy/Girl Attitude ♦ Taking turns is fair, stealing is not. ♦ They lie to disguise that they have been involved in an action that is not nice. ♦ When asked why it is wrong to steal, “because it is not nice or fair”. PSYCHOSOCIAL DEVELOPMENT : Industry Vs Inferiority ♦ Sense of initiative means learning how to do things. ♦ Sense of industry means learning how to do things well. ♦ The questions asked reflect curiosity by using “how”, “why” and “what”. ♦ Best type of book has many short chapters, they feel a sense of accomplishment if they finish each chapter. ♦ They like small chores that can be finished quickly and the difference is visible from the previous on. Settings where to learn industry: ♦ Home ♦ Structured activities ♦ School ♦ Problem solving ♦ Learning to live with others. ♦ If the child doesn’t receive rewards or prevented from achieving a sense of industry he develops a feeling of inferiority. ♦ These children will have difficulty tackling new situations later in life ( new job, new school, new responsibility) because they cannot envision how they could be successful in handling them frustrations in work and school. COGNITIVE DEVELOPMENT : Stage 3: Concrete Operational Stage a. Decentering ▪ ability to consider multiple aspects of a situation b. Conservation ▪ child understands that changing the form of a substance or object does not change its amount, overall volume, or mass c. Accommodation ▪ altering one's existing schemas, or ideas, as a result of new information or new experiences. d. Class inclusion ▪ Ability to classify objects as belonging to two or more categories simultaneously SIX-YEAR OLD Physical: ♦ A year of constant motion ♦ skipping is a new skill ♦ first molar erupts Cognitive ♦ First grade teacher becomes authority figure ♦ adjustment to all day school may be difficult and lead to nervous manifestations of fingernail biting.,etc. ♦ Defines words by their use EIGHTH-YEAR OLD Physical ♦ Coordination definitely improved ♦ playing with gang becomes important ♦ eyes becomes fully developed Psychosocial ♦ “Best friends” develop ♦ whispering and giggling begin Cognitive ♦ Can write as well as print ♦ understand concepts of past, present and future. TEN-YEAR OLD Physical

SEVEN-YEAR OLD Physical ♦ Central incisors erupt ♦ difference between sexes becomes apparent in play ♦ spends time in quiet play Psychosocial ♦ A quiet year ♦ striving for perfection thus, called an eraser year. Cognitive ♦ Conservation is learned ♦ can tell time ♦ can make simple change NINE-YEAR OLD Physical ♦ all activities done with gang Psychosocial ♦ Gang age: a 9 year old club is formed to spite someone ♦ has secret codes ♦ is all boy or all girl ♦ gangs disband and reform quickly

ELEVEN-YEAR OLD Physical Page 30 of 40

♦ coordination improves Psychosocial ♦ ready to camp away from home ♦ collecting age ♦ likes rules ♦ ready for competitive games

♦ Active but awkward and ungainly Psychosocial ♦ Insecure with members of opposite sex ♦ repeats off- color jokes

TWELVE-YEAR OLD Physical ♦ coordination improves Psychosocial ♦ A sense of humor is present ♦ is social and cooperative SOCIAL DEVELOPMENT ♦ Daily relationship with age-mates provides the most important social interaction of school- aged children. ♦ They practice or mimic adult roles. ♦ Explore the social environment. ♦ They have sense of initiative. ♦ They learn to share, & discover, ♦ Learning is fun and adventure, ♦ Doing things is more rewarding than watching things being done. ♦ Children become increasingly sensitive to social norms and pressure of the peer groups. ♦ Interaction to peers lead to the formation of intimate friendships with same sex peers LANGUAGE DEVELOPMENT AT SIX YR OLD ♦ talk in full sentences, using language easily and with meaning. ♦ They still define objects by their use.

SEVEN TO NINE-YEAR OLD ♦ They know simple arithmetic. ♦ They can add and subtract and make simple change, so they can go to the store & make simple purchases ♦ At 9, when they discover dirty jokes, they like to tell them to friends and try to understand those told by adults. ♦ They use swear words to express anger or just to show to other children they are growing-up.

AT SEVEN YR OLD ♦ they can tell time in hours, but have trouble with concepts such as half past and quarter to especially with digital clocks and watches. ♦ They know the months of the year and can name the months in which holidays fall. NINE TO TWELFTH-YEAR OLD ♦ They have short period of intense fascination with bathroom language, as they did during preschool years. ♦ By 12 years of age, sense of humor is apparent . ♦ They can carry on an adult conversation, although stories are limited because of their lack of experience.

EMOTIONAL DEVELOPMENT 1. Children enter this period with the ability to trust others and with a sense of respect for their own worth. 2. There’s sense of autonomy ♦ Can accomplish small tasks independently. ♦ They practice or mimic adult roles. ♦ Explore the social environment. 3. They have sense of initiative. ♦ They learn to share ♦ Discover learning is fun and adventure ♦ Doing things is more rewarding than watching things being done. Seven-year old boy ♦ Children require more props for play than when they were younger. Page 31 of 40

♦ Start of the decline in imaginative play. Seven-year old girl ♦ Girls prefer teenage dolls ♦ with good coordination to button the miniature dresses and pull on the tiny boots. Seven-year old ♦ They develop an interest in collecting items such as baseball cards, dolls, rocks, marbles. ♦ The type is not as important as the quantity. ♦ They start to sort out by age 8. Eighth-year old ♦ They like table games but hate to lose, so they tend to avoid competitive games. ♦ They change the rules in the middle of the games to keep from losing. Eighth to ninth-year old ♦ They enter a phase of reading comic books. These can be read quickly, so they accomplish a sense of industry. ♦ If parents forbid, they read under the covers at night or read them at other children’s houses. Nine-year old ♦ Children play hard. ♦ They squeeze in some activity before going to school, and plan something the moment they arrive home. ♦ They have difficulty in going to bed at night because they want to play just one more game. ♦ Play is rough and not interested in perfecting skills. ♦ Conflict arises when parents expect perfection. ♦ Talent for music or art becomes evident. ♦ Children do well if others in their group are taking similar lessons. Ten-year old ♦ Children spend most of their time paying handheld or television-remote controlled games. ♦ Boys and girls play separately although interest in the opposite sex becomes apparent. ♦ Boys show off as girls pass their group, while girls talk loudly or giggle at the site of a familiar boy. ♦ Girls become more interested in the way they look and dress. ♦ Slumber parties and camp-outs become increasingly popular. ♦ The children talk, giggle, rough-house in the middle of the night. ♦ Children are interested in rules and fairness. ♦ They strictly enforce rules. ♦ Club activities become structured with a president, a secretary, and rules of order. Eleven to Twelfth-year old ♦ Children enjoy dancing to popular music and playing table games and are accommodating enough to be able to play with younger siblings who need the rules modified to their advantage. ♦ Time with friends is often spent just talking. ♦ They use their bedroom to meet with friends. ♦ They like to do jobs for money. ♦ They feel that they are on the verge of something great and anxiously wait to become a teenager. CONCERNS OF SCHOOL AGE CHILDREN 1. School experience ♦ School serves as an agent for transmitting societal values and a setting for many peer relationships and Therefore, exerts influence on the social development of children a. Anticipatory socialization ♦ someone adopting the standards, values & social norms of a group they are not a part of to gain acceptance. b. Role of the teacher ♦ acts as parental surrogate c. Role of the parents 2. Limit setting and discipline 3. Coping with stress a. Fears

b. Latchkey children ♦ a child who returns from school to an empty home because their parent or parents are away at work, or a child who Page 32 of 40

is often left at home with little parental supervision. HEALTH PROMOTION DURING SCHOOL-AGE PERIOD 1. Health Behaviors 2. Nutritional Health a. Prepare healthy snacks & meals, but do not demand that child eat certain amount of food at one sitting. b. Limit high-calorie, high-fat, and sugary snacks. These foods lack essential nutrients and will diminish child's desire to eat at mealtime. c. Make mealtime environment fun and relaxing, and allow your child to eat at his/her own pace. d. Limit distractions & stressful situations during mealtimes, such as television, family arguments, & discipline. e. Allow your child to help prepare snacks and meals. f. Constantly encourage your child to try new foods and continue to make available those foods that are not well-liked. Begin the meal by serving your child's least favorite foods. g. Keep your child's food idiosyncracies in mind when preparing meals. h. Avoid using food to reward or punish your child. This practice serves only to firmly establish these foods as desirable to child. Establishing healthy eating patterns Protein ♦ important for growth, strength and muscle maintenance. ♦ Children ages 4 to 8 need at least 19 grams of protein, kids ages 9 to 13 require 34 grams of protein, teen girls ages 14 to 18 need 46 grams and teen boys ages 14 to 18 require at least 52 grams of protein every day. ♦ High-protein foods include lean red meat, chicken, turkey, seafood, eggs, dairy foods, peanut butter, soy products, legumes, nuts and seeds. Carbohydrates ♦ the main source of energy. ♦ Children ages 1 and older consume at least 130 grams of carbohydrates every day. ♦ Choose carbohydrates from whole grains, milk products, fruits, vegetables and legumes instead of refined grains and added sugars Fats, especially omega-3 fatty acids ♦ are important for child’s cognitive development. ♦ Children ages 4 and older consume 25 to 35 percent of their daily calorie intake from fats, especially monoand poly unsaturated fats found in vegetable oils, avocados, peanut butter, hummus, nuts and seeds. Foods high in omega-3 fatty acids include purified fish oils, canola oil, walnut oil, walnuts, soybeans, soybean oil, algal oil, flaxseeds, flaxseed oil and pumpkin seeds. Calcium ♦ found in dairy products and dairy-free calcium-fortified beverages, iron in meats and iron-fortified grains, vitamin A found in fruits, vegetables and dairy products, vitamin D in fish and dairy products and iodine, which is abundant in seafood, dairy products, enriched grains and iodized salt. Recommended daily dietary allowances Girls ♦ Ages 4 to 8 need 1,200 to 1,800 calories ♦ Ages 9 to 13 require 1,400 to 2,200 calories ♦ Ages 14 to 18 need about 1,800 to 2,400 calories each day. Boys ♦ Ages 4 to 8 require 1,200 to 2,000 calories ♦ Ages 9 to 13 need 1,600 to 2,600 ♦ Ages 14 to 18 need about 2,000 to 3,200 calories per day 3. Health in daily activities a. Sleep and rest - 10 and 11 hours of sleep per night

How to help your school-aged child sleep well a. Develop a regular sleep schedule. Page 33 of 40

b. Maintain a consistent bedtime routine. c. Set up a soothing sleep environment. Child’s bedroom should be comfortable, dark, cool, and quiet. Nightlight is fine; a television is not. d. Set limits. (time lights off; how many bedtime stories) e. Turn off televisions, computers, and radios. f. Avoid caffeine (found in sodas, coffee-based products, iced tea) b. Exercise and Physical activity ♦ At least 60 minutes of physical activity every day from moderate activity (such as cycling and playground activities), to vigorous activity (such as running and tennis) c. Dental health 1. Most bottled water does not contain enough fluoride to prevent tooth decay 2. Help child brush their teeth with fluoride toothpaste twice a day 3. Serve healthy meals and snacks 4. Take your child to the dentist for regular cleanings and check-ups. 5. Ask your dentist about dental sealants 6. Get the child into the habit of flossing and brushing the tongue, the insides of the cheeks and roof of mouth d. Hygiene 1. Teach handwashing 2. Use handkerchief when sneezing and coughing ♦ Germs travel far and wide. A sneeze travels up to 100 miles per hour and can send 100,000 germs into the air. 3. Remind child not to touch their eyes or pick their nose. ♦ Germs are easily transmitted into the body through the mucous membranes in the eyes, the nose, and mouth. e. Bath Time ♦ Many parents find that evening baths are the best way to relax a child before bed. f. Grooming their fingernails ♦ Fingernails are a breeding ground for bacteria g. Dress ♦ This is the right age to teach children the importance of caring for their own belongings. ♦ Have definite opinion about clothing styles. 4. School health ♦ Classroom teaching on the subject of health/ hygiene ♦ Health education attempts to close the gap between what is known about optimum health practice and that which is actually practiced 5. Injury prevention a. Use seatbelts and bicycle safety around cars. b. Risk taking behavior ♦ They want new experiences ♦ They need to explore their own limits and abilities, as well as the boundaries set. ♦ They need to express themselves as individuals. It’s all part of their path to becoming independent young adults, with their own identities. ♦ Examples of risk- taking behaviors are: fighting, truancy (the action of staying away from school without good reason), unprotected sexual activity, tobacco smoking, alcohol use and binge-drinking, illegal substance use, dangerous driving, illegal activities like trespassing or vandalism. c. Motor vehicle prevention and other vehicle related injuries d. Injuries at school e. Sexual abuse is an unfortunate and all-too-common hazard for children. Teaching Points To Help Children Avoid Sexual Abuse a. Your body is your property and you can decide who looks at it or touches it. b. Secrets are fun things to keep. c. Don’t go anywhere with stranger. d. Being touched by someone you like is a good feeling e. A “private part is the part of you a bathing suit touches. f. If the person you tell doesn’t believe you, keep telling people until someone believes you. COMMON HEALTH PROBLEMS 1. Dental Caries Page 34 of 40

♦ Drinking carbonated soft drinks regularly can contribute to the erosion of tooth enamel. ♦ Enamel breakdown leads to cavities. ♦ Foods that are high in carbohydrates, as well as some fruits, juices and sodas, peanut butter, crackers and potato chips are culprits. Factors that cause tooth decay: a. the frequency in which the foods are eaten b. the time they remain as particles in the mouth. 2. Malocclusion (poor bite) ♦ caused by thumb-sucking, finger-sucking, and pacifier use in young children. But when a child stops the sucking habit, the teeth naturally begin moving back to their normal positions. ♦ thumb and finger-sucking and pacifier use for more than 4 to 6 hours in 24 hours can eventually: a. Push the upper front teeth (incisors) outward and the lower incisors inward (overjet). b. Prevent the incisors from coming in (erupting) completely (open bite). c. Cause the top molars to bite inside the lower molars (cross bite). 3. Language Problem ♦ Articulation - difficulty in pronouncing s, z, th, l, r and w There are three kinds of language disorders: a. Receptive language issues involve difficulty understanding what others are saying and could also have difficulty following simple directions and organizing information they hear. b. Expressive language issues involve difficulty expressing thoughts and ideas and may be late to start talking and not speak until age 2. At age 3, they may be talking but hard to understand. c. Mixed receptive-expressive language issues involve difficulty understanding and using spoken language. 4. Fear and Anxieties a. Anxiety related to beginning of school e. Sex Education i. Violence or terrorism b. Recreational Drug Use f. School Phobia j. Stealing c. Children of alcoholic parents g. Bullying k. Home schooling d. Latchkey children h. Obesity

PUBERTY ♦ a transitional period between the juvenile state and adulthood during which a growth spurt occurs ♦ secondary sexual characteristics appear, fertility is achieved, and psychological changes take place ♦ A girl has entered this period when she begins to menstruate, and a boy when he begins to produce spermatozoa ♦ These events occur between 11 and 14 years ♦ Follows same pattern for all races and cultures ♦ Related to hormonal changes CHARACTERISTICS OF PUBESCENT STAGE 1. An overlapping period ♦ it encompasses the closing years of childhood and the beginning years of adolescence 2. A short period ♦ lasts for only 2 to 4 years ♦ children who pass through puberty in 2 years or less are regarded as “rapid maturers” while those who require 3 to 4 years are regarded as “slow maturers” 3. Puberty is divided into stages Stages of Puberty 1. Pre-pubescent (“Maturing”) ♦ overlaps the closing year or two of childhood ♦ one who is no longer a child but not yet an adolescent ♦ secondary sex characteristics begin to appear but the reproductive organs are not yet fully developed 2. Pubescent (“mature”) ♦ occurs at the dividing line between childhood and adolescence ♦ criteria of sexual maturity appear - menarche in girls and first nocturnal emission in boys ♦ secondary sex characteristics continue to develop and cells are produced in the sex organs 3. Post pubescent ♦ overlaps the first year or two of adolescence Page 35 of 40

♦ secondary sex characteristics become well developed & sex organs begin to function in a mature manner 4. A time of rapid growth and change ♦ “adolescent growth spurt” rapid changes lead to confusion, feelings of inadequacy and insecurity, and in many cases to unfavorable behavior 5. A negative phase ♦ negative attitudes and behavior are characteristic mainly of the early part of puberty and the worst of the negative phase is over when the individual becomes sexually mature Major Milestones of Development ♦ Onset of puberty and the cessation of body growth; Physiologic growth and development of adult coordination occur. ♦ Initially, the gain in physical growth is mostly in weight, leading to stocky appearance of prepubescence, è thin, gangly appearance of late adolescence. ♦ Fast period of growth ♦ Results in change in body structure, development of secondary sex characteristics, and reproductive maturity ♦ Girls: height increases approximately 3 inches/yr; slows at menarche; stops around age 16 ♦ Vital signs approach adult norms SEXUAL MATURATION ♦ At a set point in brain maturity, the hypothalamus transmits an enzyme to the anterior pituitary gland to begin production of gonadotropic hormones, which activate changes in testes and ovaries and produce puberty. ♦ Time of the onset of puberty varies widely, between 10-14 years of age. ♦ Sexual maturation in girls occurs between 12 and 18 years old ♦ Sexual maturation in boys, between 14 and 20 years old. CHRONOLOGICAL DEVELOPMENT OF SECONDARY SEX CHARACTERISTICS AGE BOYS GIRLS 9 - 11 ♦ Prepubertal weight gain occurs ♦ Breast: elevation of papilla with breast bud formation; ♦ Areolar diameter enlarges 11 - 12 ♦ Sparse growth of straight, downy, slightly ♦ Straight along the labia. vaginal epithelium becomes pigmented hair at the base of the penis cornified ♦ Scrotum becoming textured; growth of ♦ pH of vaginal secretions acid; slight mucous vaginal penis and testes begin discharge present ♦ Sebaceous gland secretion increases ♦ Sebaceous gland secretion increases ♦ Perspiration increases ♦ Perspiration increases ♦ Dramatic growth spurt 12 - 13 ♦ Pubic hair present across pubis ♦ Pubic hair grows darker; spreads over entire pubis ♦ Penis lengthens. ♦ Breast enlarge, still no protrusion of nipples. ♦ Dramatic linear growth spurt ♦ Axillary hair present. Menarche occurs ♦ Breast enlargement occurs ADOLESCENT ♦ 12 to 18 years old ♦ A period of rapid growth and development. ♦ A period of intense physical, physiologic, and psychosocial changes usually beginning and ending in the second decade of life. Substages of adolescence 1. Early Adolescence – 10 to 14 years ♦ aware of their rapidly changing bodies and start to worry about their physical appearance. ♦ They might experience shyness, blushing, modesty, and a greater interest in privacy. ♦ May feel invincible and start to engage in risky behaviors such as smoking and alcohol use. ♦ Characterized by sexual curiosity, usually expressed through admiration of celebrities, teen idols, and musicians. 2. Middle Adolescence - 15 to 17 tears ♦ extremely concerned with how they look, and they think others are concerned too. ♦ They spend a large amount of time grooming, exercising, and modifying their physical appearance. 3. Late Adolescence - 18 to 21 years ♦ period when young adults become more comfortable with their body images and sexuality, become more self-reliant and Page 36 of 40

focus less on the opinions of peers. ♦ the time when goals for the future become defined. CHARACTERISTICS OF ADOLESCENT STAGE 1. An important period ♦ Adolescence is one of the periods when both the immediate effects and long- term effects on attitude and behavior is important. ♦ It is also important for their physical and for their psychological effects. ♦ gives rise to the need for mental adjustments and the necessity for establishing new attitudes, values and interests 2. A transitional period ♦ Transition means a passage from one stage of development to another which means what has happened before will leave its mark on what happens now and in future. 3. A time of unrealism ♦ have a tendency to look at life through rose – tinted glasses. ♦ They see themselves and others as they would like them to be rather than as they are. 4. A period of change ♦ Heightened emotionality, rapid changes that accompany sexual maturing, changes in their bodies, their interests and in the roles the social group expects them to play, interests and behavior pattern change, so do values. ♦ Most adolescents are ambivalent about changes. ♦ While they want and demand independence, they often dread the responsibilities that go with independence 5. A problem age ♦ Throughout childhood, their problems were met and solved in part at least by parents and teachers. ♦ Because adolescents want to feel that they are independent, they demand the right of coping with their own problems, rebuffing attempts on the part of the parents and teachers to help them. 6. A time of searching for identity ♦ The ambiguous status of the adolescents in the American culture of today presents a dilemma that greatly contributes to the adolescent “identity crises‟ or the problem of ego-identity. 7. The threshold of adulthood ♦ As adolescents approach legal maturity, they are anxious to shed the stereotype of teenagers and to create the impression that they are near adults. ♦ Dressing and acting like adults is not always enough so they begin to concentrate on behavior associated with adult status – smoking, drinking, using drugs, and engaging in sex are some examples. They believe that this behavior will create the image they desire. 8. A dreaded age ♦ adolescent teenagers being sloppy, unreliable individuals who are inclined towards destructiveness and antisocial behavior has led many adults who must guide and supervise the lives of young adolescents to dread this responsibility and to be unsympathetic in their attitudes towards adolescents. ♦ it creates much friction with their parents and places a barrier between them and their parents which prevents them from turning to their parents for help in solving their problems. 9. Late adolescence is also a gang age ♦ Group standards is far more important to older children than individuality eg:- in dress, speech and behavior older children want to be as nearly like their gang mates as possible. According to the World Health Organization (WHO) ♦ Adolescent age ranges from 10 to 19 years of age. ♦ Young people range from 10 to 24 years of age. ♦ Youth encompasses ages 15 to 24 years PHYSICAL GROWTH ♦ Most girls are 1 to 2 inches (2.4 – 5 cm) taller than boys coming into adolescence and generally stop growing within 3 years from menarche. Thus, those girls menstruating at 10 years of age may reach their adult height by age 13. ♦ Boys: growth spurt starts around age 13; height increases 4 inch/yr, slows in late teens ♦ Boys double weight between 12 and 18, related to increased muscle mass ♦ Body shape changes Girls Boys Weight 13 – 55 lb ( 7 – 25 kg) 15 – 65 lb (7 – 30 kg) Page 37 of 40

Height Age ( years)

2 – 8 in ( 5 – 20 cm) 16 or 17

4 – 12 in (10 – 30 cm) 18 - 20

♦ Apocrine glands cause increased body odor ♦ Increased production of sebum, and plugging of sebaceous ducts causes acne. ♦ Increase in body size does not occur in all organ system at the same rate. Example: Skeletal system: muscle; Muscle mass : heart ♦ Both sexes lack coordination ♦ Blood flow & oxygen availability is reduced because the lungs and heart increase more slowly than the rest of the body. ♦ Pulse rate and respiratory rate decrease slightly (to 70bpm and 20 breaths / min.) ♦ BP increases slightly to 120/70mmHg reaching adult levels by late adolescence. SEXUAL DEVELOPMENT (GIRLS) ♦ Development of secondary sex characteristics, sex organs and function under hormonal control ♦ Menarche ♦ Menstrual cycle: controlled by complex interaction of hormones ♦ Breast development is first sign puberty

SEXUAL DEVELOPMENT (BOYS) ♦ Enlargement of testes is first sign of sexual maturation; occurs at approx. age 13, about 1 year before growth spurt ♦ Scrotum and penis increase in size until age 18 ♦ Reaches reproductive maturity about age 17, w/viable sperm ♦ Nocturnal emission ♦ Masturbation increases ♦ Pubic hair continues to grow and spread until mid 20’s ♦ Facial hair appears ♦ Voice changes due to growth of laryngeal cartilage

Early Adolescence (12 – 14) ♦ Starts with puberty ♦ Physical body changes result in an altered self-concept ♦ Tends to compare own body to others ♦ Early and late developers have anxiety regarding fear of rejection ♦ Fantasy life, daydreams, crushes are all normal, help in role play of varying social situations ♦ Is prone to mood swings ♦ Needs limits and consistent discipline Middle Adolescence (15-16) ♦ Separate from parents (except financially) ♦ Can identify own values ♦ Can define self (self-concept, strengths and weaknesses) ♦ Partakes in peer group; conforms to values/fads ♦ Has increased heterosexual interest; communicates with opposite sex; may form “love” relationship ♦ Sex education continues Late adolescence (17-19) ♦ Achieves greater independence ♦ Chooses a vocation ♦ Participates in society ♦ Finds an identity ♦ Finds a mate ♦ Develops own morality ♦ Completes physical and emotional maturity PSYCHOSOCIAL DEVELOPMENT: Identity vs Role Confusion

COGNITIVE DEVELOPMENT: Formal Operational Stage ♦ Develops abstract thinking abilities Page 38 of 40

♦ Is often unrealistic ♦ Is capable of scientific reasoning and formal logic ♦ Enjoys intellectual abilities ♦ Is able to view problems comprehensively SPIRITUAL DEVELOPMENT: Stage 3: Synthetic Conventional ♦ Choices come from community’s norms ♦ Choices not done reflectively / critically PSYCHOSEXUAL DEVELOPMENT: Genital Stage MORAL DEVELOPMENT: Stage 5: Social Contract and Individual Rights CONCERNS OF ADOLESCENCE 1. Sexuality and Sexual Activity 2. Hazing 3. Substance Abuse PROMOTION OF HEALTH DURING ADOLESCENCE 1. Safety a. Motor vehicle accidents d. Proper use of equipment b. Sports injuries e. Risk taking behavior c. Firearms accidents f. Drug and alcohol use SAFETY ISSUES ♦ Accidents are leading cause of death: motor vehicle accidents, sports injuries, firearms accidents ♦ Safety measures include education about proper use of equipment and caution concerning risk taking ♦ Drug and alcohol use may be a serious problem ♦ Adolescent characteristics of poor impulse control and recklessness make prevention complex 2. Nutritional Needs ♦ Nutritional requirements peak during years of maximum growth: age 10 – 12 in girls, 2 years later in boys ▪ Boys require an average of 2,800 calories per day. ▪ Girls require an average of 2,200 calories per day. ♦ Appetite increases ♦ Inadequate diet can retard growth and delay sexual maturation ♦ Food intake needs to be balanced with energy expenditure ♦ Increased needs include calcium for skeletal growth; iron for increased muscle mass and blood cell development; zinc for development of skeletal and muscle tissue and sexual maturation PROMOTING DEVELOPMENT IN DAILY ACTIVITIES ♦ Dress and hygiene ♦ Sleep COMMON PROBLEMS a. Hypertension d. Body piercing & Tattoos b. Poor Posture e. Rebellion c. Fatigue f. Menstrual Irregularities

♦ Care of teeth

g. Gender discrimination h. Dealing with peer pressure i. Suicides

♦ Exercise

j. Acne k. Obesity

TYPES OF PLAY 1. Unoccupied Play Page 39 of 40

♦ Mostly seen in newborns and infants between 0 and 2 ♦ The random movements that infants make with no clear purpose ♦ Child is not engaged or actively playing with others at all. ♦ They may remain stationary and be engaged in random movements with no objective. ♦ Important setting stage for future play exploration and development 2. Solitary Play ♦ Common in young toddlers between ages 2 and 3 ♦ When children start to play on their own. Children do not seem to notice other children sitting or playing nearby ♦ Important because it teaches children how to entertain themselves 3. Onlooker Play ♦ Common in younger children between ages 2 ½ and 3 ½ ♦ Children watch others play. Child who is looking may ask questions but there is no effort to join the play 4. Parallel Play ♦ Common between 2 ½ and 3 ½ age group ♦ Children begins to play side-by-side with other children without any interaction. They are paying attention to each other ♦ These children are learning valuable social skills and actually learn quite a lot from one another 5. Associative Play ♦ Begins around ages 3 or 4, extending into the pre- school age ♦ When children start asking questions of each other. They have similar goals but there are no set rules ♦ Develops necessary skills such as cooperation, problem solving, and language development 6. Social or Cooperative Play ♦ Begins in the late preschool period, between ages 4 and 6 ♦ When children begin to share ideas and toys, and follow established rules and guidelines ♦ The culmination, bringing together all the skills learned across previous stages into action, giving the child the necessary skills for social and group interaction Characteristics of Play 1. Active ♦ Children use their bodies and minds in play by interacting with the environment, materials and other people 2. Adventurous and risky ♦ Children explore unknown or new concepts; Children engage in adventurous and risky pretend play 3. Communicative ♦ Presents a natural opportunity for children to share information and knowledge by using words or their bodies, and non-verbal cues 4. Enjoyable ♦ Children should be enjoying themselves and they can find excitement and humor in play 5. Involved ♦ Children should concentrate during their play 6. Sociable and interactive ♦ Provides a unique and formative opportunity for children to engage in social interactions and build relationships with other children and adults 7. Meaningful ♦ Children process the things they have seen and heard, what they know and what they don’t know yet 8. Voluntary ♦ Play is a self-chosen, spontaneous pursuit that children can change, alter and manipulate freely 9. Therapeutic ♦ Play can be a natural way for children to relieve stress and work through different emotions and experiences 10. Symbolic ♦ Symbolic play may just look like pretending, but it is actually laying the foundation for understanding themselves and the larger world.

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