Human development has been studied by psychologists and educators to explain some behavioral phenomena related to growth. Theorists have categorized human development in terms of stages of growth. In this Child Development Assignment (CDA), the pediatric group observed belonged to the early childhood development stage (ages 3-6). It will explain some theories explaining development in this particular stage as well as describe the children in this stage of development. It will also discuss appropriate nursing diagnosis based on the observed developmental assessment of preschoolers and finally, describe the role of the pediatric nurse in providing anticipatory guidance and promoting the health and well-being of the young children.
The children observed belonged to Piaget’s Pre-Operational Stage of Cognitive Development. This stage is characterized by the emergence of the ability to represent objects and knowledge through imitation, symbolic play, drawing, mental images and spoken language (Piaget and Inhelder, 1969). Lack of conservation skills is also characteristic of this stage. “Conservation is defined as the knowledge that the number, mass, area, length, weight, and volume of objects are not changed by physically rearranging the objects” (Brewer, 2001). Preschool children are very open to learning and they are able to express what they learn in a variety of media. They enjoy engaging in magical thinking either by themselves or with peers. However, they can still be very egocentric and have difficulty seeing other people’s perspective.
Preschoolers belong to Erikson’s Initiative vs. Guilt Stage of Psychosocial Development. These children are into doing things on their own and showing everyone how much they have grown in many ways. Having developed more skills, a child exhibits competence in some tasks more than before. He craves for freedom to make choices to have a positive view of himself and follow through on his projects. However, at this stage, children may be awkward, and their good intentions may backfire as in destroying some things in the process. When this happens, they are overcome with guilt. Not being allowed to make their own decisions makes them develop guilt over taking initiative. Hence, the tendency is to take a passive stance and let others choose for them (Erikson, 1963).
Preschool-aged children are in between Freud’s Anal and Phallic Stage of Psychosexual Development. They begin to explore their body and discover that some parts give them pleasure. Also, at this stage when they are mastering their toilet skills, they may sometimes fail to comply with adult rules of going to the bathroom, hence, it is still likely that they may wet or soil their underwear (Brewer, 2001). Psychologically, with regards to the Anal stage, preschoolers may be ambivalent in keeping the room orderly and clean, however, there are times when they would just want to mess everything up.
Children’s emotional development is also linked to their moral development. Kohlberg (1984) came up with a theory of moral development based on a hypothetical moral situation calling on children’s decision-making skills, and his theories attracted much attention from moral philosophers. His proposed dilemma was about a husband named Heinz who needed to decide whether to steal an overpriced drug to save his dying wife. It was theorized that young children conceptualize morality in terms of obedience to adults’ rules and regulations. They know that it makes them good children. This is so because they think in concrete, physical, egocentric ways and their social worlds are dominated by adults.
Growth and development rapidly advances in the early childhood years. Although these young children seem to be small, they grow at an increasingly fast pace that parents and teachers often wonder how they’ve grown so much in such a short time, like in a span of one school year. The following discusses how children’s skills are developed in the different developmental areas.
Physically, preschool children develop more strength as their bodies’ proportions become more adult-like. Beginnings of athletic skills such as running, jumping and hopping are manifested. With regards to their gross motor development, as children grow older, they are more able to move their large muscles in more well-coordinated movements so they are able to do more challenging things with their bodies such as skipping, running with agility, dancing with flexibility, tumbling and the like. On the other hand, children’s fine motor skills are slower to develop. Younger children’s fine motor skills, eye-hand coordination and body coordination are much less developed and more awkward than their older counterparts. As they grow, they also gain more control of their fine motor muscles to enable them to do more things with their hands, such as cutting, drawing and writing.
By the time a child steps into the early childhood stage, his brain has attained 90% of its adult weight by age 5 (Child Development, 2011). This develops faster than any other body part.
Many factors affect a child’s cognitive development. Their intellectual capacity may be inherited from their parents or other blood relatives. Nature and nurture may work together to affect a child’s intellect. Children who are constantly stimulated intellectually with activities that promote creative and critical thinking skills grow up using these skills when the situation calls for it.
Young children develop various cognitive skills simultaneously. They enjoy asking a lot of questions and are eager to pursue their curiosity in a number of interests. Preschool-aged children think in concrete terms, but begin to use mental representations and symbols. However, fantasy and reality still gets blurred together in their minds, and ideas about the world may continue to be illogical. They hone their ideas from social interactions with their parents and playmates.
Their language skills rapidly develop, gaining, on the average a 14,000- word vocabulary and extensive grammatical knowledge by the time they reach 6 years of age (Child Development, 2011). Children at this stage learn to adjust their style of communication to who they speak to.
The children are learning what is right from wrong. At this age, they are beginning to be less egocentric and more others-aware. They are able to feel how others feel. Likewise, children genuinely express their feelings towards others and show their preference for good over bad especially with regards to story characters. They understand the moral lessons in such stories.
They have developed some tolerance for frustration and are developing some self-control. They need overt expressions of affection and have fears of abandonment. They need routines and a semblance of security (Brewer, 2001).
Socially, there are children who may be inherently shy or gregarious, as is likewise dictated by their genetic make up or as an effect of exposure to shy or gregarious parents. However, as children get older, they are provided more opportunities to be with other people and learn to deal with different personalities.
Edgington (1999) posits that children learn best in an environment that makes them feel secure and confident enough to develop their own ideas with open-ended experiences. They actively engage in learning by partaking of fun, play-based hands-on experiences while adults around them challenge and extend their thinking.
Children’s play at this stage, either alone or with others, becomes increasingly complex and imaginative. They vacillate from solitary play to associative play with their peers and back again. They may engage in dramatic play as they embody roles of different characters and even animals or objects and come up with word play to stimulate themselves. They develop a great initiative to do things, especially if they receive praise for these actions. Their increased energy makes them more daring to try out novel things. Such desire to be independent in pursuing these new discoveries and controlling their environment increases, making their parents more supervisory towards them.
From observing the children, a nurse can see if a child exhibits wellness and good health. The children’s behaviors can reveal a lot about how they feel. If a child exhibits the expected developmental behaviors appropriate to his or her age (as discussed above) – physically –moves well in terms of fine and motor coordination; cognitively – shows understanding of what is being presented to him and manifests good intellectual skills and language; socio-emotional – relates well with others and responds appropriately to certain situations; and if the child exudes a healthy and happy disposition, then the nurse can diagnose that he or she is a well child.
However, if a child is observed to be particularly sluggish, sleepy or cranky, it may be a symptom that manifests due to tiredness and lack of rest. He or she may also be hungry. Worse, it may reflect ineffective health management from the home. Since children become so preoccupied in their play, sometimes, they neglect to give attention to body signals such as hunger or tiredness. A child may also be observed to be ill when he or she is flushed, has cough and/or cold and often sneezes. This child is unwell and needs medical attention.
As children go through their developmental stages, they also become at risk. For example, muscular development and increased mobility put them at risk for injury since they would now tend to run around and explore the environment with their bodies. Climbing on playground equipment and riding on wheeled toys may be fun for them, but they need to be extra careful in estimating their movements so as to prevent accidents.
A nurse should be alert to symptoms exhibited by children which may spell a deeper and/or worse condition – rashes from allergies, bruises, awkwardness in movement, difficulty in hearing or seeing well, etc. These symptoms need to be observed further for a more accurate diagnosis by a medical professional.
Some children may be observed to be at risk of danger from the home. Bruised, sad and quiet children must be more carefully observed for signs of child abuse. Anda et al (2005) discussed in their study that the traumatic experiences of abused or neglected children often stays on with the victim into adulthood, and can even influence the raising of that victim’s own children. More often than not, abused children repeat the pattern with their own children. With other children, recovery from trauma is unlikely and they suffer from lifelong depression, anxiety and even personality disorders that keep them from living fulfilling lives. The pediatric nurse may be able to diagnose if the child is abused or not by examining the child’s bruises and interviewing him about his home life. She should be adept in reading non-verbal communication that may point to signs of abuse and network with the child’s teacher to investigate the matter further.
Children who are underweight and show a distaste for food or lack of appetite as well as not able to make better nutritional choices may be at risk for malnutrition. The Bindler-Ball Healthcare Model (2006) recommends that for cases like this, the child should be brought in for nutritional assessment with the child’s family. Parents may be interviewed as to the diet of their children and the nurse can suggest appropriate foods that can support the children’s growth and development. If there are cultural restrictions on diet, then the nurse should respect it and provide alternatives.
It is dangerous for a nurse to jump into conclusions, that is why it is essential that he or she coordinates with a teacher or parent to jointly discuss the child’s perceived behaviors at home and in school, so when it is decided that he or she should see a doctor, the observations of both teacher, parent and nurse are well-taken into consideration for a more accurate diagnosis.
For example, a five-year old boy, Jeff, was observed to sit in a corner, quiet and seems to look into space. He plays with his top again and again and again, laughing at times, but never interacting with anyone else. The same boy does not seem to communicate at all. The researcher asked his teacher about him and she shares some of her observations which are consistent with the researcher’s. Jeff’s behavior observations as having difficulty in establishing and maintaining friendships, preference to be with adults and older children rather than his peers disliking changes in routines, becoming disruptive when he is unable to sit in his usual place all check out as characteristics of Autistic Spectrum Disorders (ASD). Chowdhury (2009) identifies the key characteristics of ASD as: (1) impairment in communication, (2) impairment in social interaction and (3) restrictive and repetitive as well as stereotyped patterns of behavior and one-tracked interests and activities. In the researcher’s observation, such patterns of behavior were exhibited by Jeff. As such, his observed behaviors may serve as a prompt to send him for assessment to a qualified developmental Paediatrician to validate if Jeff does have ASD. This medical doctor is authorized to test and dispense diagnosis and medical advise for possible interventions. He can validate whether Jeff has a developmental disability based from the observations of the parents and teachers of Jeff’s behaviours and advise the appropriate interventions.
Early childhood practitioners should be knowledgeable about the developmental expectations of children so they can identify atypical development. This is especially important if the child displays developmental delays. The child may be diagnosed for delayed growth and development related to an illness or disorder. An example is a child like Jeff, not being able to speak or relate to others at age 5 or a child who has yet to learn to walk steadily at age 3. Another child may not be responsive when his name is called and may have a difficult time understanding his teacher or classmate when they talk to him. If such symptoms are always observed by the teacher or nurse, then it may be wise to suggest a referral for diagnosis from a doctor. A medical doctor can determine a disease or disorder such as autism, muscular dystrophy, hearing impairment or other more serious disorders.
Usually, the Pediatric Nurse is constrained to the School Clinic, on hand for medical emergencies or to care for sick children in school. As with other age groups, rapport building is important for a nurse to be able to work effectively to address the medical problem. However, it is often difficult to establish rapport with very young children, especially when it is their first time to visit the clinic. That is why, they need to be approached gently and maybe engage in a game or two initially in the presence of a trusted adult. Eventually, as they feel more comfortable with the nurse, they will feel safer to be left with her.
When a nurse moves around the school and sees children who do not exhibit wellness, he or she can approach that child and talk to him about how he feels and if something is hurting, to show where and why it hurts. Anticipatory guidance comes in the form of talking to children about their health and some recommendations to the child as to what must be done to achieve good health, maintain it and prevent disease in developmentally-appropriate language they can understand.
Anticipatory guidance “applies an understanding of human development to predict the child’s upcoming developmental stages, and common situational crises experienced at those ages” (Binder & Ball, 2007, p. 121). Part of Anticipatory Guidance is communicating to parents and families about appropriate and effective health management for children. The school nurse can talk to parents about enhancing nutrition to promote a healthy development, encouraging daily physical exercise for children and not just being hooked on television or video games. However, when children are sent out of the house, safe clothing according to the weather (ex. jackets over shirts and pants with rubber-soled footwear for better ground grip) as well as safety gears such as helmets and knee pads should be worn by children as they venture to more active outdoor play such as riding tricycles to protect them from possible injury. Aside from those concerns, the school nurse can also advise parents to take their children to regular dental check-ups.
She can also provide guidelines for parents to follow in fostering the formation of their children’s positive self-concept (Bindler & Ball, 2007). This includes developmentally-appropriate discipline and encouragement of healthy self-esteem and good values.
For parents of preschool-aged children, parents may be guided accordingly in the choice of safe and non-toxic toys like those free of sharp edges and paints with lead content. Preschool children can be very active and explorative and may still have tendencies of putting objects into their mouths, so wise choices of toys are recommended for their optimal health and development. Age-appropriate toys such as those made of natural substances like wood (blocks, toy trains, etc.), clay dough, are healthy to use. Play materials with open-ended themes such as manipulative interconnecting toys, dolls, art materials and age-appropriate storybooks facilitate children’s creative thinking as well as fine motor development.
Specifically, the school nurse can communicate the importance of daily activities that enhance health such as healthy habits like eating right and keeping clean. She also encourages safety practices like taking vitamins daily and regular immunizations to prevent disease. Some parents have knowledge deficit related to the importance of immunization, so it is the nurse’s role to educate them on the benefits of each medication. However, the nurse should be aware that “teaching may need to be tailored to the particular child due to activity limitations, food sensitivities, or neighborhood characteristics” (Bindler & Ball, 2007, p. 124).
A Pediatric Nurse can contribute much to promoting health awareness in the preschool. Ensuring a child’s health also means monitoring his nourishment and maintenance of a clean and safe environment for him. She can be invited to the class to give a session on eating the right foods and developing healthy habits such as daily bathing and brushing of teeth. She can coordinate with the teacher or Physical Education teacher to develop a program for health and fitness.
Brewer (2001) suggests that a significant portion of health education should be taught as daily routines are established. Routines such as washing hands before eating, changing soiled clothing after outdoor play and rest time may be taught with reminders of why these activities are important. She adds that “although young children are not able to understand the causal relationships between germs and disease, they can understand that regular hygiene routines contribute to their staying well and feeling healthy” (p. 456).
Children will get to imbibe knowledge on health and sanitation practices by modeling the adults around them. Teachers and staff must themselves practice good hygiene and cleanliness in their surroundings.
The school nurse monitors the children’s health in school. She has access to the medical records and can organize a way to remind parents when the children are due for their shots or to conference with parents regarding some medical concerns as observed in the child in the school setting.
A more active health promotion program that reaches out to parents and the community is engaging in health research and writing some articles or brochures to disseminate to parents. These may include topics on healthy eating; benefits and disadvantages of TV viewing and computer games; article on allergenic foods and substances; tips on choosing the right foods; discussing the advantages of play and movement to health, and so many more! The school nurse may write the article herself and make herself available for consultation about the article in case anyone wants more information.
Medical missions may be organized by the school nurse, tapping some parents who may be doctors, dentists, nurses, or any health care professional. These professionals may go to a certain location to provide free medical services for the people there.
The pediatric school nurse plays multiple roles in the environment she works in. As such, she becomes an indispensable member of the school staff in promoting healthy growth and development of young children. Having her there not only ensures the safety of the children but also gives parents of these little ones more peace of mind.
Anda, R. F., V. J. Felitti, J. D. Bremner, J. D. Walker, C. Whitfield, B. D. Perry, S. R. Dube, and W. H. Giles.(2005) The enduring effects of abuse and related adverse experiences in childhood: A convergence of evidence from neurobiology and epidemiology. European Archives of Psychiatry and Clinical Neuroscience 256(3): 174–86
Ball, J., & Bindler, R. (2006) Child health nursing: Partnering with children & families. Upper Saddle River, NJ: Prentice Hall Health.
Bindler, R.C. & Ball, J.W. (2007) The Bindler-Ball Healthcare Model: A New Paradigm for Health Promotion, Pediatric Nursing, 33(2).
Brewer, J. (2001) Introduction to Early Childhood Education. Allyn & Bacon. Child Development. Web.
Chowdhury, U. (2009) Autistic Spectrum Disorders: Assessment and Intervention in Children and Adolescents, British Journal of Medical Practitioners, 2(4).
Edgington, M. (1999) Priorities in the Early Years Curriculum, course held at the University of Hertfordshire.
Erikson, E. H. (1963). Childhood and society (2nd ed.). New York: Norton.
Kohlberg, L. (1984). Essays in moral development: Vol. 2. The psychology of moral development. New York: Harper & Row.
Piaget, J. & Inhelder, B. (1969) The Psychology of the Child. New York: Basic Books.