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Growth and Development

Annette Tomlinson

in size through cell
multiplication or differentiation.
Changes in height, weight, and
number of words in the

Growth and Development

Development: Physiological, psychosocial, and
cognitive changes occurring over ones life span due
to growth, maturation, and learning; assumes that
orderly and specific situations lead to new activities
and behavior patterns.

Continuous Process Through Life
Orderly Sequence
Predictable But Unique Ranges
Systems Mature At Different Rates
More Rapid In Early Periods
Cephalocaudal Pattern (head to foot)
Proximal to distal (from center of body outward)
Gross To Refined Skills

Sensitive Periods Occur For Learning
Neonatal Reflexes Need To Be Lost
Skills Are Learned By Practice

Promotion of Normal Development

Anticipatory Guidance
Health teaching BEFORE characteristic behaviors and
concerns occur
Teach about what child is capable of doing

Developmental Screening Tools

Parental Education

Note developmental milestones

Stimulation techniques
Alert to infants/childs capabilities
Self-quieting behaviors
Promote attachment

Developmental Assessment
Focus on high-risk infants
Screen large populations

Denver Developmental Screening

Common SCREENING test
Measures language, personal/social, fine and
gross motor areas
Easy to administer
NOT an intelligence test
Must fail test twice before referral is considered
If child uncooperative test later

Nursing Implications
Although development follows an order of succession:
The rate of progress differs among people in certain life
Anticipate regression during crisis periods
Accept/support the return to progression

Nursing Implications
Transition to each stage has no definite beginning or
From each stage to the next is an overlapping process.

Nursing Implications
Be knowledgeable concerning various stages of
Be flexible when assessing and caring for people:
Respect each persons uniqueness

Be cognizant of environmental and cultural influences

on development.

Theories of Human
Freud: Psychosexual

Oral (birth to 1 yr)

Anal (1 to 3 yrs)
Phallic (3 to 6 yrs)
Latency (6 to 12 Yrs)
Genital (12 yrs to Adulthood)
o Id, Ego, Superego

Theories of Human
Development: Psychodynamic
Perspective (continued)
Erikson: Psychosocial

oTrust versus mistrust (Birth-1yr)

oAutonomy versus shame and doubt (13yrs)
oInitiative versus guilt (3-6yrs)
oIndustry versus inferiority (6-12yrs)
oIdentity versus role confusion (12-18yrs)

Theories of Human Development:

Perspective (continued)
Piaget and cognitive development
o Stages

Sensorimotor (Birth-2yrs)
Preoperational (2-7yrs)
Concrete operations (7-11yrs)
Formal operations (11- Adulthood)

Neonate (0-30 days)
Infant (31 days- 1 year)

Growth and development: Occurs in a
cephalocaudal sequence. Motor skills progress in a

proximal distal sequence.

The infant moves from reflexive to intentional actions, to
visual then physical searching for an object (looking for a
dropped object), to practicing hand-eye coordination
(shaking a rattle). At 6 months when something
disappears from his/her vision, it is completely gone.
By the end of the first year, he/she begins to understand
that an object (such as mother) exists outside of his/her
immediate perception (object permanence). The
infant also begins to associate a symbol with an event
(mother picking up purse to leave).

Physical Characteristics
6-8 pounds
Doubles by 5 months
Triples by 12 months

20 inches (20 cm.)
Grows to1 inch monthly the first 6 months

Physical Characteristics
Head circumference
33-35.5 cm.
Increases by inch (1.25) monthly for first

Fontanel closure
Posterior at 6-8 weeks
Anterior at 12-18 months

6 months

At 5-6 months teeth erupt
Lower incisors first
Causes increased saliva and drooling
Enzyme released with teething causes mild diarrhea, facial skin
Slight fever may be associated; not high fever


Newborn prefers bright moving

2-3 months Can turn head to hear for voices 180 degrees
4-6 months can watch something falling
Fixation by 6 weeks
Depth perception by 2-3 months
Acuity 20/100 to 20/50

Prefers sweet
2-3 months expresses displeasure

Newborn prefers mothers voice
Turns at 4 months localizes sound
6 months responds to name
10-12 months knows meanings of words (NO

Pain response
1 week general body response
3 months specific withdraw of the body part

Adipose tissue insulates infant
Epidermis easily separates
Scalp hair replaced at 1 month

Fetal hemoglobin present first 5 months
Maternal iron stores 5-6 months
Heart larger, transverse angle

BMR highest in infancy
Caloric requirements highest in infancy

Water requirements highest in infancy

80% in extracellular compartment


Small, round stomach

Relaxed sphincter
Rapid peristalsis and transit
Predisposed to spitting up, diarrhea, vomiting and

Rounded shape of chest
Number of alveoli increases first year
Predisposed to respiratory infections

Closeness of trachea and bronchi

Short, straight eustachian tubes
Immature, mucosal lining
Immature immune system

Immature nephrons
Decreased filtration and absorption
Less ability to concentrate urine
Predisposed to dehydration

No new nerve cells appear after 6 months of
fetal age
Increased size and intricacies

Stranger Anxiety
Develops when attachment is in place
6 months prefers mother
8 months protests loudly when Mom leaves

Adaptive Behaviors
Gross Motor

3 months head control

4 months rolling over
7 months crawling
8 months sitting alone
12 months- walking

Fine Motor
1-4 months reflex
5 months rakes
10 months pincer

10 months No, Mama, Dada
12 months 2-3 other words & obeys simple commands

6 weeks social smile
4 months laughs
10 months simple games

Psychological Aspects
Trust vs Mistrust
Acquires a sense of trust
Cannot spoil meet needs

Influences attachment
Easy, difficult, slow to warm up
Active, average, quiet

Formula or breast milk for 1 year
Solid foods begin at 4-6 months
Cereal, fruit, vegetable, meat

Finger foods at 8-9 months

Cup at 10 months
No bottle propping
Bottle weaning at 1 year

Accident Prevention

Anticipate Development
Aspiration small toys, food
Suffocation pillow, plastic
Falls crib, steps
Poisoning plants, makeup
Burns, Body damage
Cars no car seat

Parental Concerns

Pacifier/Thumb sucking
Teething 4-6 months
Sleeping in own bed
Returning to work
Child care

Crises because of limited coping mechanisms
Separation anxiety
Forced immobilization
Painful procedures

Nursing Interventions

Rooming in
Liberal visitation
Include mother in planning
Security objects
Familiar schedule
Playroom is safe

Approaching the Infant

Position on parents lap/table
Warm hands
Quiet with pacifier/bottle
Do heart/lungs when quiet
Distract with toy/talking
Elicit reflexes during exam
Restrain with parent assist
Do mouth/ears last



Erikson: Trust vs. Mistrust the infant develops a sense of

self from the development of a trusting relationship with a
consistent primary caregiver. Basic needs are for warmth,
food and comfort. Interference in this relationship may result
in delays in growth and development.
Freud: Oral Stage- sucking, swallowing, chewing and biting
are not only pleasurable, but also crucial for survival. Demand
for immediate gratification by crying (from being hungry, wet
or uncomfortable) and is gradually modified over the months
to finding ways to achieve fulfillment.
Piaget: Sensorimotor Stage-the infant is learning through
all his/her senses and motor activities. This is the time when
all future cognitive functioning is laid down. The infant is
egocentric. Everything is perceived in relation to self.
Kohlberg: Egocentric Orientation Stage of the
Preconventional morality level. This is the stage that which is
good is what one likes and wants. Judgments are made on the
basis of liking that which helps and disliking that which hurts.




3 Months

Social smile

Responds to stimuli with whole body

Knows primary caregiver

Squeals aloud to show pleasure

6 Months

Apprehensive of strangers

Rolls from side to side well

Babbles and coos

Sits with assistance

Observes environment


3 Months

3 Months

Lifts head and chest in prone position

Music box

Follows objects with eyes


Moves arms and legs simultaneously


Can hold a rattle

6 Months

6 Months
Soft toys

transfers objects from hand to hand

rolls from back to abdomen

holds bottle and sits in high chair

9 Months

Waves bye-bye

Sits well without assistance

Mama, Dada indiscriminately

Uses pincer grasp

Stranger anxiety

Creeps on hands and knees

Exhibits object permanency

Stands with assistance

9 Months

Bright colors

9 Months
Soft toys
Bright colors

12 Months

Imitates behaviors

Walks with assistance

Push and pull

Cooperates with dressing

Turns pages in a book

Cloth books

Mama, Dada has meaning

Stands without assistance

Surprise toys

Shows jealousy

Attempts to stack blocks


Birth weight tripled

12 Months

12 Months

1-3 Years

Physical Characteristics
Step-like Growth
Begins to slow down
Weight at 2 years 26 pounds
Height at 2 years 34 inches

Primary teeth in place
Time to brush and floss

Physiological Systems
Attains voluntary control
Increased ability to maintain body temperature
Produces antibodies

Psychosocial Aspects
Sense of Autonomy

Holding on Letting go modality

Negativism expresses will (NO)
Temper Tantrums
Ego Development learns delayed gratification
Maternal attachment in place
During this time they know how to dress an undress

Psychosocial Aspects (cont)

Separation Anxiety in place
Can cope with brief separation

Coping mechanisms
Regression returns to previous behaviors when a crisis
Ritualism maintains sameness. Dont like changes.

Adaptive Behaviors
Gross Motor
Walks well
Climbs stairs

Fine Motor
Increased coordination
Grasp and release

Adaptive Behaviors
200 words at 2 years

Personal Social
Increased independence

Parallel Play
Imitative play they see on tv.

Toys push-pull, sound-type, use crayons, trycicles

They have increase cognitive abilities

Anticipatory Guidance
Physiologic anorexia due to slowed growth
Decreased calorie and protein needs
Picky, fussy eater
Use nutritious snacks, small portions, finger
foods and a variety of food groups
Poisoning need syrup of ipecac on hand
- Call poison control first

Parental Concerns
Limit setting for safety and security
Separate child from the behavior
Teach right behavior
Ignore temper tantrums
- dont spank them
Avoid yes/no questions

Parental Concerns
Toilet Training
Definite need for physical,
psychological and language readiness
Praise with success
If no success, wait
- Dont get angry or scream at them.

Parental Concerns
Sibling Rivalry
Arrival of a newborn is a crisis
Prepare toddler for the arrival late in
the pregnancy
Have special times
Allow toddler to help
Expect some jealousy
Protect newborn

Parental Concerns
Limit over-stimulation
Offer verbal reassurance
Use night light if necessary

Approaching the Toddler

Position sitting/lying on parents lap
Ignore/avoid eye contact initially
Introduce equipment slowly
Remove clothing as examined
Shine light on hand before using
Use restraints as necessary

Major Toddler Tasks

Differentiation of
self from significant
Tolerates separation
from parent
Ability to withstand
Control over bodily

Acquisition of
socially acceptable
Verbal means of
Ability to interact
with others in a
less egocentric




15 Months
Uses 4-6 words

15 Months
Walks without assistance

Knows 1 body part

Push and pull

Builds tower of 2 blocks

24 Months
Understands possession

15 Months

24 Months
Walks up and down stairs


24 Months
Push and pull


Transitional object

Removes clothes

Separation anxiety

Build tower of 6 blocks

Parallel play

Turns doorknob

Temper tantrums

Sphincter control


Riding toys
Jack in box
Water play

Walks and runs fairly well

Picks up objects without falling
36 Months
Agreeable behavior
Shares well
Fear of monsters

36 Months
Runs well

Dresses and undresses
Jumps from a step

Peddles forward & backwards

Knows first & last name

Holds pencil with tripod grip

Knows sex difference

Walks on tip toe

Ritualistic behavior

36 Months
Dress up clothes


Teach injury prevention: childproof home, suffocation (plastic bags, pacifier, toys),
burns (ovens, heaters, stoves, sunburns, check water and food temperature) Aspiration
related to latex balloons
Toilet Training
The childs bladder and bowel muscles and innervations must be physically mature and
the bladder large enough to hold urine for several hours at a time. The child should be
able to remove pants and underwear independently, sit quietly for short periods,
imitate behaviors, and want to please parents. Success should be praised and
accidents cleaned up without comment. If the child is not interested, it is best to stop
and wait a month.
Suddenly, the compliant infant has now turned into a negative toddler. Discipline
becomes a major issue. Parents should set simple rules and apply them consistently
to acquire socially acceptable behaviors.
Temper Tantrums
Temper tantrums are a normal behavior occurring because of a toddlers inability to
control his feelings when frustrated. Since they cannot use language to express
feelings, they use their body. Do not give in to their demands; it rewards them to try
Sibling Rivalry
The next baby is often born when the first child is in the toddler years. The toddler may
perceive the baby as a rival for the mothers affections and time and may verbally and
sometimes physically attempt to harm the infant. Allow the toddler to assist in the
preparation for the new infant. Schedule times during the day for just the toddler.


Physical Characteristics
Height and weight stabilizes
Weight increases 4-6 pounds a year
Height increases 2 inches a year
Birth length doubled by 4 years

Psychosocial Aspects
Sense of Initiative
Period of energetic learning
Beginning of conscience development
Can understand reasons for behavior
Becomes independent
Less need for direct supervision
Gender specific behavior

Cognitive Development
Focuses on one idea at a time
Concrete thinkers
Awareness of sexual and racial
differences begins
Understanding of time develops
Shifts from egocentrism to regard for
Able to separate

Adaptive Behaviors
Hand dominance by 5 years
Vocabulary of 2000 words by 5 years
Stands on 1 foot by 4 years
Dresses self
Rides tricycle by 3 years

Associative Play
Play is dramatic and imaginative
Imaginary playmates common
More prevalent in bright children
Helps child deal with loneliness and
Abandoned by school age

Anticipatory Guidance
Food fads
Use small portions and wise snacks

Parental Concerns
Sex education
Keep short and to the point
Real and imagined
Sleeping problems
Bedtime rituals
Speech problems
Stuttering and articulation

Approaching the Preschooler

Position on table
Allow to inspect equipment
Compliment on appearance
Reassure if no shots
Use positive statements for instructions
Fun games

Nursing Interventions:
Caregiver rooming in
Primary nursing
Transitional object
Offer appropriate choices
Set limits

Magical Thinking
Imitates adult behavior
Associative play



Kicks well


Copies a triangle
Threads beads

Coloring books
Play house

Speaks in complete sentences

Uses alternate feet on stairs

Inquisitive questions

Uses scissors

Fear of body mutilation


Catches a ball
Draws a person

Story time
Arts & crafts


Identifies with the same sex parent

Balances on alternate feet by 5 yrs.

Vocabulary to 2100 words by 5 yrs.

Uses adjectives and pronouns

Skips & hops on one foot by 4 yrs. Tricycle

Rides a tricycle


Erikson: Initiative vs Guilt the child develops a sense of self-esteem through
task accomplishment. There is less need for direct supervision. The child asks
many questions and begins to take responsibility for his/her own actions. There is
beginning conscience development and regard for others. The preschooler wants
to conform to others. Conflict will arise when the child oversteps the limits of
his/her abilities and will acquire a sense of guilt for not behaving appropriately.
Freud: The Phallic stage which focuses on knowledge of gender differences,
competition for the parent of the opposite sex, conflict and final resolution through
the identification with the parent of the same sex (Oedipal/Electra Complex).
There is exploration of his/her body as well as others. The preschooler fears
mutilation, especially any threat to the genital area.
Piaget: The Preoperational stage continues during the preschool years with the
Intuitive phase. During this phase egocentrism lessens. There is energetic
learning. The child becomes sophisticated in the use of symbols and language.
Pre-logical thinking appears.
The preschooler blends fantasy with reality. They exhibit magical thinking.
Preschoolers believe that nothing happens by chance.
Kohlberg: Preschoolers are completing the second and third stages in his
Preconventional morality level. The younger preschooler exhibits the
PunishmentObedience orientation stage. He/she is good because a parent say
he/she must be. He/she avoids punishment and obeys without question those who
have authority. For the older preschooler, right behaviors consist of that which
satisfies his/her own needs.

Issues Related to Hospitalization:

Nursing Interventions:

Separation from parents

Caregiver rooming in
Pictures of family
Telephone calls
Leave parents belongings with child

Body mutilation

Explain procedures in simple terms

Offer Band-Aids
Give examples of sensations

Loss of control

Offer appropriate choices

Set limits

6-12 YEARS

School Age
Physical Characteristics
Slow growth continues
Height: 2 inches per year
Weight: doubles over this period
Loses first primary teeth at about 6
Vision completely mature
Acquiring of skills, timing, coordination
and concentration

School Age
Psychological tasks
Sense of industry
School occupies half of waking hours;
has cognitive and social impact
Morality develops
Before age 9 things are right or wrong
After age 9 can recognizes differing
points of view
Sees gray areas

School Age
Psychological tasks
Child makes first real friends during this
Understands cooperation and compromise
Concept of time and space develops
Masters concept of conservation (ability to
understand that a mass can change in size, volume or length
without losing or adding to the original mass) .

Develops self-concept
Depends on external evidence of worth
and comes from within

School Age

By age 10 can view death as inevitable,

universal and permanent
Rules and ritual dominate
Cooperative play
Team play
Collections, board games

School Age

Parental concerns
Exercise and activity
Junk food
Safe play and proper use of equipment

Approaching the School Age Child

Position on table
Give simple explanations and teaching
Talk to distract and relax
Respect privacy
Examine genitalia last and quickly

School Age



Same sex friends

Physical skills maximized

Board games

Loves school

Cursive writing

Card games

Interactive play

Rides a 2-wheeler

Collects things

Runs, swims, dances

Video games
Computer games

School Age
Erikson: Industry vs. Inferiority- this is the age of self-concept
development. The child achieves a sense of personal and
interpersonal competence by acquisition of technologic and social skills.
They have a variety interests, learn rules and how to win/lose. Peer
group activities encourage cooperation and competitiveness. Inability
to acquire a sense of accomplishment will result in a sense of inferiority.
Freud: Latent stage- there is a resolution of the sexual conflict and
investment in other interest and peers. Sexual feelings are dormant.
Piaget: Concrete Operational- School-age children achieve a
beginning logic ability to order and relate experiences to an
organized whole (begin to see the whole picture). They demonstrate
conservation (ability to understand that a mass can change in size,
volume or length without losing or adding to the original mass). They
understand the relationship between numbers, letters, words and time,
and have the ability to classify objects. They have beginning problemsolving capabilities.
Kohlberg: The child enters the Conventional morality level of which
there are two phases. The first phase exhibited by the younger school
age child is the Good Boy Nice Girl Orientation. Behavior that
meets with approval is viewed as good. The older school age child
exhibits the Law and Order Orientation. In this orientation, it is
important to obey the law because it is the law.


School Age

There is a risk of obesity in this age group and a tendency to eat junk food.
Secondary sex characteristics begin at 10 years in girls; 12 years in boys.
Requirement is 85 kcal/kg/day. Irregular family meals schedule of working parents.
Play is primarily Group oriented, especially with the same sex.
Rules and rituals
Formalized groups/clubs
Becomes sensitive to social norms and pressures of peer groups
Anticipatory Guidance/Health Promotion Safety
The incidence of accidents/injuries is less likely. Proper use of sports equipment
should be stressed. Discourage risk-taking behaviors (smoking, alcohol, drugs, sex).
Teach injury protection concerning bicycle safety, firearms.
Sex Education Should be introduced.
TV rarely depicts reality. The violence appears to desensitize children. Imitation of
TV role models increases aggressiveness in play and life situations unless an adult
points out inappropriate TV behaviors.

13-18 YEARS


Physical characteristics
Fast period of growth
Onset in girls 2 years earlier
Girls: height increases approximately 3
inches/year; slows at menarche; stops around
age 16
Boys: growth spurt around age 13; height
increases 4 in/year; slows in late teens
Weight doubles between 12 and 18

Can be satisfying or frightening
Follows the same pattern for all races and
Increased activity of sweat and sebaceous
Gonad stimulation
Ova and sperm production

Breast changes
Increased pelvic girth
Pubic/axilla hair growth
Adipose tissue distribution
Around 12 years
Irregular first year

Enlargement of testes first sign of sexual
Scrotum and penis growth
Larynx changes
Facial/lip hair
Nocturnal emissions

Psychosocial tasks
Sense of identity
Achieves a sense of uniqueness
Attains body image
Achieves sex role identity
Continually makes comparisons with peer

Cognitive development
Can think in the abstract
Uses logic and scientific reasoning
Can manipulate several variables

Parental concerns
Increased tensions
Resentful of control
Wide emotional swings (Due to hormones)
Intense relationships (own society)
Moves from best friends to heterosexual

Parental concerns
Personal care
Alcohol, smoking, use of substances
Related to peer pressure, fast foods,
empty calories
Need calcium for skeletal growth,
iron for muscle mass and blood cell
development, zinc for skeletal and
muscle tissue and sexual maturity
Accidents #1 cause of death!!!

Approaching the Adolescent

Needs privacy
Use a gown and sheet
Talk as a professional
Do not use slang
Give honest answers to questions
Emphasize normals

Peer pressure
Rebellious behavior
Risk taking behavior
Body image

Maximized strength
Maximized fine motor

Team activities
Video games

Erikson: Identity vs. Role Confusion-the adolescent focuses on independence from the
family and uses the peer group as a bridge between dependence on the family and complete
independent behavior. Peer group and peer acceptance is extremely important. It is a time of
trying on different roles to see how they fit and making comparisons with the peer group.
He/she has wide mood swings, and fantasizes and daydreams. There may be conflict with
parents over independence and control. He/she feels invulnerable. If the adolescent is unable
to acquire a stable sense of self, direction and place, identity diffusion may result.
Freud: Genital Stage- during this time the adolescent vacillates between dependence and
independence. Puberty can be frightening or satisfying for the adolescent. The focus is on the
genitals, with emphasis on masturbation, sexual intercourse, and feelings for others.
Kohlberg: Post Conventional levels consist of the Social Contract Orientation, Higher
Law and Conscience Orientation, and the Universal-Ethical Principle Orientation. The
age of each of these stages varies considerably among individuals, and adolescents may or
may not exhibit these stages, or may exhibit the stages later in life.
In the Social Contract Orientation, judgments are made on the basis of individual rights and
standards that have been agreed upon by the whole society.
In the Higher Law and Conscience Orientation, judgments are made on the basis of
benefiting society and leading to cooperation and the good of all.
In the Universal Ethical Principle Orientation, judgments are made on the basis of
consequence in accord with ethical principles such as justice, integrity, equality, reciprocity of
human rights, and respect for the dignity of human beings. Kohlberg believes that few
individuals reach this stage of moral reasoning.



Hollow leg stage: appetite increases. Requirements; 60 to 80 kcal/kg/day1,500 to 3,000

kcal/day (11-14 years); 2,100 to 3,900 kcal/day (15-18 years). Peers influence food choices.
Adolescents are at risk for fad diets.
The adolescent identifies with a peer group. Girls enjoy shopping, talking to friends, and
experimenting with clothes, make-up and hairstyles. Boys enjoy outdoor sports and
electronic games. Both sexes enjoy movies, popular music and access to vehicles. Interests
are subject to rapid change.
Anticipatory Guidance/Health Promotion Safety
Accidents are the chief cause of death: motor vehicle accidents (MVA), sports, and firearms.
Adolescents may display lack of impulse control, reckless behaviors, sense of invulnerability.
Related to hormonal changes. Apocrine glands become active and may develop body odor.
Development of secondary sex characteristics: girls experience breast development,
menarche (average age 12 1/2 yrs.), pubic hair; boys experience enlargement of the testes
(13 yrs.), increase in scrotum and penis size, nocturnal emission, pubic hair, vocal changes,
possibly gynecomastia.
Adolescence is a time of experimenting, including sexual experimentation. Adolescents are
at risk for sexually transmitted diseases and pregnancies. They need education on STD
prevention, HIV/AIDS, contraception and how to say NO. Education related to sexuality is
best accepted if it is truthful, realistic and relevant to their world and peer experience. Pelvic
exams/pap smears begin when teen becomes sexually active.
Substance Abuse
Adolescents experiment with legal (tobacco, alcohol, OTCs, prescribed) and illegal (street