Textbook of Growth and Development for Nursing Students KP Neeraja
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Introduction to Growth and Development of ChildrenCHAPTER 1

The period of growth and development extends throughout the life cycle, however, the period in which, the changes occurs from conception to the end of adolescence.
 
CURRENT CONCEPTS
 
Growth
Growth is an essential feature in the life cycle of every child, which will be continued from conception to later maturity in the adulthood, i.e. The process of growth starts from the time when the fertilization takes place and fertilized ovum (zygote or the conception products) starts, its divisions (both mitosis and meiosis), i.e. multiplication of cells and increase in the intercellular substance and it represents quantitative changes in the body. Growth is an increase in physical size of the whole or any of its parts.
Growth is an important attribute of childhood. All the processes lead to increase in size and maturation of various organs of the body. Every child grows and develops in response to various factors in a determined manner. Growth and development are interrelated with each other and are inseparable. They represent two aspects of the change, i.e. growth can be assessed in quantitative manner (like height) can be measured by means of inches or centimeters; weight in form of kilograms or pounds. The process of growth distinguishes the child from an adult.
 
DEVELOPMENT
The process of maturation of the functions of an individual. It is described in qualitative manner, i.e. progressive increase in skill and capacity to function. Development brings qualitative change in the childs’ functioning capacity. It increases the competency and ability to function at a higher level depending upon the child background characteristics. It is the product of growth of a child e.g. emotional ability.
 
Maturation
It produces an increase in competence, an ability to function at a higher level depending on child's heredity.
 
Methods to Study Growth and Development
  1. Cross-sectional method: A group of children's characteristics are measured at a time and generalizations will be made based on observations.
  2. 2Longitudinal method: Individual child is measured at fixed intervals throughout their stages of growth and development over a period of time.
Each child has an individual rate of growth and development, but pattern shows less variability. Growth and development are continuous and orderly processes that have predictable sequences.
 
Principles to Regulate the Stages of Growth
  • Growth proceeds from the head down to the tail (in a cephalocaudal direction). It is particularly evident during the period of gestation and the first year of life
  • Growth proceeds from the center or midline of the body to the periphery or in a proximodistal direction
  • As the child matures, general movements become more specific. Gross muscle movements occur before finer movement, control develops
  • There is a normal sequence in the development of physical abilities, mental development, emotional and social adequacy. A child should be given the opportunity for learning either by experience or by instruction—wherever readiness occurs.
 
PRINCIPLES OF DEVELOPMENT
 
1. Development Involves Change
Growth refers quantitative changes by means of height, weight, maturity in size and structure of organs; not only physical maturity occurs, as the age of child proceeds but also qualitative changes results, i.e. development. As the chronological order of the child increases, the child has a greater capacity for learning; for higher intellectual levels of functioning. For example, thinking, reasoning, imagining, remembering and recalling. The child grows mentally and physically, changes occur in size, proportions, acquisition of new features, etc. Children tends to accept and welcome each change as they feel that they are ‘grown up’; change enables the child to be more independent and it gives them added speed and strength.
Development is a progressive series of orderly, coherent, progressive change, e.g. character formation, adhering to moral, conduct and ethical behavior. The goal of developmental change is self-realization or the achievement of genetic potentials. In Maslow's hierarchy of needs, ‘self-actualization’ is the highest need, which one has to attain, i.e. striving to be the best person possible both physically and mentally, to be happy and well adjusted, a person must be given an opportunity to fulfill their urge.
Aids to achieve self-actualization in early childhood:
  • Good health helps the children in attacking the problems more vigorously
  • Developing skills in overcoming obstacles related to environmental factors
  • Provide freedom for the child and guide wherever necessary to develop realistic goals
  • Motivate the child to develop favorable self-concept and self-acceptance which gives confidence; to cope up very easily whenever the problem arises
  • Provide conducive environment to the child which encourages the development of individuality and skills in social adjustment
  • Encourage the child to develop insight about themselves, i.e. understanding their skills, abilities, strengths, weaknesses and limitations.
Early development is more critical than later development.
‘As the twig is bent, so the tree's inclined’
—Chinese Proverb.
‘If you cannot able to bend the plant, it won't be possible to bend the tree’—Telugu Proverb.
‘The childhood shows the man, as morning shows the day’
—John Milton.
Early years are more critical in the child's development, as the above mentioned proverbs states that.
 
Conditions Affecting Early Foundations
3Erickson's theory explains, the parents has to gratify the child's basic needs like physical needs (food, clothing, shelter) as well as emotional needs (love, affection, bondage), based on needs fulfillment, the child develops attitudes and perceptions about people and situations throughout life, which favors healthy personality development.
 
Good Interpersonal Relationship
Parents encourage the child to develop adequate interpersonal relationships with family members and friends. Peer group and neighbors, which is a sound basis for social life and the child is able to make good personal and social adjustment.
 
Child Training Methods
Parents play varied roles based on different situations to mould the personality of the child, e.g. ‘Authoritarian child training’, i.e. designed to mould the child's behavior to conform to the standards set by those in authority. This is done by threats or punishments. In ‘democratic child training’ where the child will be confirmed to standards by explanation.
 
Early Role Playing
Provides an opportunity for children to take care of other younger children, sharing love, cooperating with other children, protect childs’ interests, inculcate right attitude, aptitude in the childs’ mind.
 
Good Family Infrastructure
Healthy interaction, effective, caring interpersonal relationships are essential for the child within the home to mould total personality of the child, especially the childs’ emotional needs has to be fulfilled by care takers.
 
Environmental Stimulation
Stimulated environment will encourage the development of child's hereditary potentials. It also increases child's growth and development. For example, showing pictures, models, which will help the child for quick learning process. Child's family members, elders, school and neighborhood etc., has to provide stimulating environment, which will aid in child's development.
Provide opportunity for the child to learn the activities by following the principles of learning, e.g. learning by doing, learning by trail and error, learning by conditioning and learning by insight.
Family provides congenial environment in which, children can attain their potentials. Family members guide their children in early stages of learning, so that the children are kept in the right track.
Early foundations quickly develop into habitual patterns and will have a lifelong influence on child's personal and social adjustment. Patterns of attitudes and behavior established early in life, tend to persist, leads to child's adjustment for future life. Parents and significant people try to inculcate good practices, so that, in the later age, it will not be much difficult for the child to adjust to the environment whichever they have been exposed and early accommodates to the changing situations without much imbalance.
 
2. Development is the Product of Maturation and Learning
The physical and emotional development of the child depends upon heredity and environment, i.e. partly from intrinsic maturation of traits (individual's genetic endowment) and partly from effort and exercise of the individual within the environment. Child learns to use hereditary resources with environmental support, e.g. child may have a high aptitude for skilled performance but, if deprived of opportunities for practice and systematic training, the child will not develop this hereditary potential.
The child acquires certain developmental characteristics by the usage of principles of learning. Learning brings about change in the person's behavior. The child attempts to adopt the attitudes, values, motives and behavior of admired and loved persons.
4Fetal development occurs mainly from maturation. Postnatal maturation and learning are closely related and influence on each other. Development depends upon the interaction of heredity endowment, the social and cultural forces within the environment. Utilization of hereditary potentials and intellectual development may depend upon several factors like institutionalization, parental love, support, etc. These stimulations foster the development of hereditary potentials and to make the child to be alert and responsive both physically and mentally. Self stimulation is also motivating factor in achieving developmental activities, e.g. parents may have desire, that their child should become a higher grade professional or top most among their group, for achieving this, parents will provide congenial environment for effective learning; any amount of assistance may not be fruitful unless the child has self-stimulation, inclination to achieve higher goals. Hence parental support and child's self inclination and motivation are very much essential for the childs’ development.
How much stimulation the child receives, they cannot learn until they are developmentally ready to do so, i.e. the necessary physical and mental foundations must be present before new abilities can be built on them while structure and function are parallel with each other in childhood, structure precedes function. If children are not ready to learn, teaching and effort will become waste, it may lead to resistant behavior, which is against for successful learning.
If children are ready to learn, but no motivational force or they are not permitted to practice the skill, then, they may loose interest; afterwards when the time comes, the parents and teacher put efforts for the development of skill in the child, he may not learn it effectively, as he lost interest already.
Maturational readiness is the teachable moment. There are three practical criteria to determine readiness to learn:
  1. Interest in learning, i.e. child shows their desire to learn by themselves
  2. Sustained interest, i.e. eventhough obstacles occurs and encounter set backs during the process of learning, the child does not loose interest, he will continue to put his efforts until he will attain the goal. Parental and peer group pressure may be necessary and work as an aid for childs’ goal achievement. Thus stimulation is essential for complete development.
  3. Improvement—progress with practice, children who are ready to learn will show improvement in graded manner (slight, gradual). Thus, until children are ready developmentally, effectiveness in learning will not take place, eventhough encouragement or stimulation is present, certain times if their developmental and hereditary endowments are limited, the child may not achieve higher learning, as it limits the learning capacities of individual.
 
3. The Developmental Pattern is Predictable
Every species in nature follows certain developmental pattern, it starts from conception and continues upto the end stage of life, death. Thus development is continuous but the individual rate of development may vary with each other, e.g. physical, emotional behavior and intellectual pattern of development will vary according to their age, genetic endowments and environmental influences. The physical development of the child follows cepalocaudal law and proximodistal law.
As developmental pattern in all aspects is predictable, it serves as a foundation for the study of development in different areas. It is also helpful to measure size, educational planning. Parents can be able to prepare the child for next stage, the therapist can be able to plan vocational training and tries to adopt different guidance techniques based on their developmental pattern.
Developmental pattern has certain predictable characteristics like physical, mental and intellectual development.
 
a. Similarity in Developmental Patterns
The general pattern is not altered by individual variations in the speed of development. Almost 5all children follow a similar developmental pattern with one stage leading to the next like
  • Generally babies after sitting, they will try to stand and then tries for walking
  • Child learns to draw circles then learn squares
  • Intelligent children speeds up the rate of learning rapidly, followed by average children and dull children.
 
b. Development Proceeds from General to Specific Responses
In physical development the fetal movements were general than in postnatal period, the child develops general, random movements of arms followed by specific responses like reaching the object held before them.
In emotional development, the newborn and neonate will have vague fear for general or sudden sounds then gradually the fears become more specific in response to specific stimuli and exhibited by different patterns such as crying, running away from the situation, not wiling to expose for stimuli or hiding, etc.
 
c. Development Occurs at Different Rates
Development does not occur at even pace, we may observe varied patterns in development like greater intensity and equilibrium. Upto puberty the growth of girls will be at higher rate; among boys after puberty until adolescence rapid changes occurs and disequilibrium in the rate of speed also one can observe; whereas in adult, middle aged persons are able to perceive balanced type of behavior.
 
d. Different Areas Develop in Different Rates
Creative imagination develops rapidly in childhood and reaches its peak early in adolescence whereas reasoning develops more slowly. Memory for concrete objects and facts develops rapidly in childhood than for abstract concepts.
 
e. There is Correlation in Development
Physical development is marked by changes in body proportions and increase by size. Mental development is characterized by different rates of development like memory, reasoning, association, thinking and other mental abilities.
 
4. Individual Differences in Development
Although similar developmental pattern is observed among children in a predictable manner but each child will vary in their own way, at their own rate. The variation like slow, smooth, gradual in step wise manner or in spurt manner. All the children may not reach the same point of development at the same age because of varied factors like genetic endowments, environmental influences, inherent capacity, emotional climate, attitudes and social relationships, e.g. a child who will brought up in a low socio-economic and culturally deprived family will possess the similar characteristics like the child grown up in well cultured, high socio-economic families. Hence based on socio-cultural background, each child will contribute something different to the group activities. Depending upon parents’ and childs’ interests, the child rearing practices are individualized, e.g. certain children responds favorably to authoritarian control, as it gives security feeling while another child will respond with antagonism and resentment.
Eventhough the developmental pattern is predictable it may not be possible to predict always as in each child, it may vary, e.g. one person may find a joke in a funny manner, while the other may feel it, as boring.
 
5. Periods in Developmental Pattern
Though development is continuous, there is evidence that at different ages certain traits standout more conspicuously than others as development takes place in a rapid rate.
For example, certain developmental periods in life, i.e. prenatal period, infancy, babyhood, childhood and puberty. These periods may be characterized by equilibrium and disequilibrium. The health care professionals, school teachers and parents can plan child training programs to copeup during the imbalance in developmental pattern. 6Special provisions must be made in taking care of child during imbalance stage in the individual's developmental pattern.
 
6. There are Social Expectations for Every Developmental Period
Social expectations are otherwise called as ‘developmental tasks’; child learn and experiences, follows certain behavioral pattern which will be accepted by society, e.g. accepting and obeying and following the norms, standards set by the society.
Achievement of task gives happiness, failure of it leads to unhappiness. People of all ages are well aware of these norms and insist the child to behave in a socially approved pattern by following the societal norms, which will keep the child in the right track and develops general maturity. In the changing culture, however, the new generation performs new developmental tasks; old tasks which are less important may be substituted with new tasks. Inculcate in the mind of the child to develop interest and for that, strong motivation is required. Self approval increases self confidence and provides a strong motivation to live in society and establish harmonious relationship.
 
7. Every Area of Development will have Potential Hazards
Each area of development interfere with hazards which affect the normal pattern of development. Hazards may be environmental in origin, adequate supervision by the parents and teachers are essential to prevent childhood accidents and safeguard their children by their potential hazards.
 
8. Happiness Varies at Different Periods of Development
Happiness is a state of wellbeing or contentment, a condition determined by pleasurable satisfaction. Happiness is a subjective experience. Early childhood (birth–6 years) is a happy period, which forms a basis for good adjustment to adult life. Majority of parents takes care of their child and tries to meet their total needs as they understand the helplessness nature of the child. The emotional development of the child is as follows:
Infancy
-
Trust Vs Mistrust
Toddler
-
Sense of autonomy Sense of shame, doubt, shyness
Preschool period
-
Sense of initiativeness Vs Sense of guilt
School-age child
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Sense of industry Vs Sense of inferiority
Early adolescence
-
Sense of identity Vs identity diffusion
Late adolescence
-
Sense of intimacy Vs Psychological isolation
Parents have clear understanding about emotional development of their child and give appropriate guidance and provide congenial environment for making the child to be happy and adjust to the life situations. Child's happiness is largely determined by family members’ interaction and treatment given to the child. Every stage of life there may be chance, that the child may be subjected to unhappiness, parents takes adequate care to handle this situation.
 
ESSENTIALS OF HAPPINESS (FIG. 1.1)
 
Acceptance
Accepting self and accepting others; children who are accepted by others find it easy to like and accept themselves. Children become well adjusted and popular among their group.
 
Affection
When the child is accepting themselves and others, the child receives more affection and develops bondage from others.
 
Achievement
For children to be happy, their achievement must be in an area regarded as important to the 7members of the social groups with which they are identified.
The child sets realistic goals, which are within the childs’ capacity to workout and attain the set goals. Children's happiness depends on reaching the goals, which they set for themselves and feel a sense of achievement that is essential to self acceptance as well as acceptance by others.
zoom view
Fig. 1.1: Essentials of happiness
  • Happy children are normally healthy and energetic
  • Happy children turn their energy into purposeful activities
  • Gives cheerful expression, reacts positively with cheerfulness
  • Happiness supplies a strong motivation to do the activities effectively
  • Happiness gives emotional maturity and emotional balance for the child, so that they will not be subjected to imbalances; when they get any frustration or conflict, copeup with the situation very easily and reaches the goal
  • Happiness encourages social contacts and child will actively participate in social activities
  • With repetition, happiness becomes a habit
  • Happiness lays the foundation for success.
 
Stages of Growth and Development
  • Prenatal period/antenatal period (from conception to delivery)
  • Newborn period (birth to 7 days)
  • Neonatal period (birth or 7 days to one month)
  • Infancy (1 month to one year)
  • Toddler (1 year to 3 years)
  • Pre school age (3-5 years)
  • School age (5-12 years)
  • Adolescence (pre adolescence—12-13 yr, middle adolescence—13-15 yr, late adolescence—15-19 yr)
  • Adulthood (early adulthood—20-40 yr, middle adulthood 40-60 yr)
  • Old age (60 yr and above)
 
Knowledge of Growth and Development is Essential/vital for Nursing Students
  • To observe and asses each child in terms of norms for specific levels of development. A child may be guided into matured behavior, if the sequence of developmental behavior is understood
  • Helps to determine whether the child is healthy, mentally alert and well adjusted to environment or not.
  • To plan for nursing management and To help in formulating the plan for the total care of each child in a comprehensive manner
  • For better understanding and provide rationale for particular conditions and illness that occur in various age groups
  • To teach caregivers, special focus to parents the procedure for observeing their children's optimal growth and development, which aids them, to put effort to attain optimal development of their children
  • To identify any deviations, potential problems and to take appropriate strategies and remedial measures
  • Helps the health care professionals to work effectively with children in health and sickness and to carryout guidance activities or training programs as well as school teachers to make the child to be grown in a matured manner
  • Parents and teachers are guided by the health care providers for successful development of the child, by identifying the normal developmental pattern and guide the child's learning capabilities at appropriate times, e.g. a 12 month old child is ready to walk independently, parents should provide opportunity to practice walking, to the child until he develops mastery over walking skills
  • 8Aids in identifying the factors influencing growth and development and able to rectify the same to bring effective growth of the child
  • Enables to set up guidelines in the form of height-weight scales; age-weight scales; age-height scales; social or emotional or developmental scales; as the pattern of development for all normal children is approximately the same. It is then possible to evaluate each child in terms of the norm for that child's age, to know what to expect of a particular child at any given age and at what age certain kinds of behavior are likely to emerge in more mature form, i.e. physical maturity and behavior pattern
  • For example, if too much is expected at a given age of the child by the parents and teachers, children are likely to develop feeling of inadequacy; on the other hand, if too little is expected of them, they are deprived of incentives to develop their potentialities.
  • If development is typical, it implies that the child is making normal adjustment to social expectations
  • Nurses can carryout training activities for parents and teachers, whereby it will be easy to prepare the child ahead of time for the changes that will take place in their body, their interests or their behavior
  • School age children and pubescents can be taught about the secondary sexual characteristics; how to act adequately when situation arises, like menstrual hygiene
  • To conduct research studies where researchers are interested to observe developmental pattern of particular group of children in selected population and in selected area, e.g. longitudinal and cross-sectional studies
 
FACTORS INFLUENCING FETAL GROWTH AND DEVELOPMENT
Growth and development of child is a complex phenomena and is regulated by varied factors which are interdependent on each other.
 
Heredity
It determines the extent of growth and development that is possible; it is the genetic constitution of an individual which is established during conception. Embryonic life begins with the cytoplasm and the nucleus of the fertilized ovum which will be genetically determined by both parents through genes. It is the property of organic beings by which, off springs possesses nature and characteristics of ancestor or parents. The child receives a new combination of parental genes at the time of conception. Hereditary has an effect on the traits likely to exist in the child, due to this, members of a family bear physical resemblance with each other and a high degree of correlation exists among sibling characteristics.
Hereditary endowment serves as the foundation for later development. Mother will establish a favorable prenatal environment through maintaining good physical health and by healthy attitudes towards unborn child. Certain physical and emotional characteristics like height, physical appearance, stature, body built, color, skin texture, temperaments, intellectual levels, etc. will transmit from generation to generation.
Many aspects of human behavior and development including the complex patterns of social and intellectual behavior, which are influenced by a person's genetic environment. They include nature of glandular functioning and physical deficiencies. Heredity is the source of both similarities and differences among individuals.
 
Sex Determination
Sex will be determined at the time of conception based on sex chromosomes constitution (XX or XY). The direct effect of sex on development comes from hormonal conditions (Androgen and estrogen their quantities). Indirect effect of sex on development comes from environmental conditions such as culturally approved social patterns, social pressures, family background, peer and school group, child rearing practices, etc.
 
Number of Off-spring
9Single child are children who born alone; or multiple birth (twins, triplets, quadriplets) will be determined at the time of conception. Twins are identical or fraternal. Because of identical hereditary endowment, identical twins resemble each other very closely in all their hereditary traits as they possess same assortment of genes. Nonidentical twins lack similarity in the physical and mental make up of the twins. When the chromosomes of the two ova divide, the grouping is not likely to be the same for both. Each will have its own assortment of chromosomes.
Among twins, developmental lag in physical, motor, intellectual and speech pattern is observed. This lag is due to prematurity, parental over protectiveness and mutual dependence. Special abilities among twins also observed due to similar environmental conditions. Mutual dependency will prevent individuality development.
Triplets are of identical/two identical and one sibling/three siblings (each came from a separate fertilized ovum). There is a lag in tempo of development or developmental traits. Such as sitting, walking, standing, etc. mental abilities are normal like single born child.
Quadriplets will have limited endowments, they are emotionally immature, dependent on adults and unable to conform to social expectations. They will have difficulty, in thinking independently and tend to project the blame for their acts on others.
 
ENVIRONMENT
It determines the degree to which the potential is achieved. The influences of hereditary and environment are so interrelated that they are practically inseparable.
 
Prenatal Environment
Biological life begins at the moment of conception onwards. The growth and development are more rapid inside the womb than at any other time in life. Prenatal conditions are part of the environmental climate in which the child develops in relation to probable optimal development.
Its influence starts when the uterus shields the fetus from the full impact of external adverse conditions. The entire family has to shoulder responsibility to receive the child happily. Its preparation starts from prenatal period, social and emotional environment of the mother should be healthier. Proper antenatal care has to be provided like high caloric, high protein diet, immunization, rest and sleep, exercise, information about warning signs, checkups, follow ups visits, preparation for delivery, etc. should be emphasized. If the antenatal mother is in good physical condition, the child's health also will be good.
Harmful prenatal factors which influence the fetus growth and development (results in abnormal development in the fetus) are:
  • Inadequate dietary intake
  • Mechanical problems may be present owing to malposition in utero
  • Mother suffering from metabolic, endocrine disturbances, e.g. diabetes mellitus, cancer and its radiation, infectious diseases like rubella in 1st trimester of pregnancy, toxoplasmosis, syphilis, herpes infection in 2nd and 3rd trimesters, habits like smoking, drug abuse, alcoholism causes prematurity or deformity of the child, erythroblastosis fetalis due to Rh-incompatibility, faulty placental implantation or malfunctions lead to nutritional impairment or anoxia. Smoking, stunts the baby's growth; if the women is drug addict, specifically narcotics and tranquilizers, the baby will go through the shock of drug withdrawal. If the woman had rubella infection in antenatal period, it causes congenital defects in the fetus and the newborn. If the woman suffers with malnutrition, it will cause damage to the fetus nervous system
  • Vitamin and glandular deficiencies
  • 10Certain times in rare occasions and situations like instrumental delivery, obstructed labor and precipitated labor may cause defects in newborn.
 
Psychological Hazards
Mothers’ thoughts, emotions and actions leads to resentments of the baby towards the mother.
‘A persistent form of heightened, unpleasant emotional feelings’, e.g. fear, anger, grief leads to maternal stress which will affect the fetal health.
 
Stressors like
  • Poor maternal health, family financial problems, overwork in the home, strained interpersonal relationship with family members especially with husband, etc. will cause hypersecretions of hormones which will affect the fetal development
  • Maternal emotional stress will increases the fetal heart rate and fetal activity and it will affect newborn adjustments in the postnatal period.
  • Newborn with adjustmental problem will affect mother, child and family relationship also the child will feel rejected and unloved
  • Unfavorable attitude of significant personnel towards unborn child such as not wanting the child at that time, sex preferences, etc. on their postnatal development may be equally as serious and often more far-reaching than the effects on their prenatal development
  • If the pregnant woman suffers with systemic illnesses like tuberculosis, hypertension, will effect over the general metabolism, which influence to a certain extent in the development of unborn child.
 
Age
  • Younger primi—The woman at younger age are not prepared for pregnancy both physically and mentally, they may be affected with anemia, pregnancy induced hypertension. As the fetus passage way is small, even normal fetus also feels difficulty to pass through, which leads to cephalo-pelvic disproportion. In postnatal period, lactation failure occurs
  • Whereas in elderly primigravida larger babies were observed.
 
Stature
  • If the woman is too short for her age, smaller babies may born.
 
Fetal Factors
  • Chromosomal anomalies, inborn errors of metabolism, congenital anomalies, hydrops fetalis, blood group incompatibility, etc. will alter the growth and development of the fetus.
 
Nutrition
  • Nutrients that the mother is expected to eat during pregnancy and postnatal period is culturally determined. When the mothers’ diet is insufficient in quantity or quality leads to nutritional deficiencies, prolonged malnutrition of the expectant mother is one of the causes for low birth weight, fetal and neonatal morbidity and mortality.
 
Attitudes of Significant People
Attitudes of family members will influence pregnant women attitude, which serves as a base towards the child after birth. The maternal attitude, family environment, relationship, their contact with the child in the early formative years of postnatal life everything will affect the child's life. Parents’ attitudes towards their children are influenced by their concept of the role of parenthood. These emotional attitudes are either positive (joy, happiness) or negative (anger, fear). Certain factors which will influence the parental attitudes are: Desire to have children. Many Indian families will believe that without a child, family tie will not be completed.
 
Cultural Influences
  • 11An environment that provides satisfying experiences for the mother and child will promote child's growth.
  • The effect of a particular culture on a child begins before birth because of the manner in which the culture views and treats the members of the pregnant woman in her family
Whether the mother is expected to deliver her baby in the sterile environment of a hospital with the father in attendance or to deliver her baby alone while she works in a field, is also culturally determined.
 
FACTORS INFLUENCING GROWTH AND DEVELOPMENT OF CHILD
 
Postnatal Period—External Environment
 
a. Cultural Influences
The culture of a group consists of
  • Shared ways of behavior and feelings
  • A set of ideals or norms that regulate or govern the particular and recurring activities within the group
  • Values, beliefs, ideas, practices: provides a basis for understanding, how people behave in their man-made environment and on how these behavior are passed on from one generation to the next generation
  • The effect of a particular culture on a child begins before birth because of the manner in which the culture views as and treats the members of the pregnant woman's family.
  • The nutrients, the mother is expected to eat during pregnancy and in postnatal period are culturally determined
  • After birth, the child is cared based on the culturally sanctioned pattern, rearing practices, e.g. eating, dressing, utilization of health care facilities
  • The child learns the language of the family, begins to internalize the ideals, traits, abstractions of the cultural group of which, the family is a part
  • The expected behaviors of the child at each stage of growth and development are culturally defined
  • Many cultural characteristics are reflected in the child rearing practices of a group and are transmitted to the next generation by the primary group: family, neighbors, friends, teachers
  • The standards in traits which are culturally determined are: honesty, intellectual inquiry, manners, aggression, individual industry, achievement and, moral values (right or wrong).
 
b. Socio-economic Status of the Family
Low social standards and low economy leads to morbidity and mortality among children, e.g. lack of money to buy essential nutrients requirements which leads to ill health and malnutrition.
Poverty, over-crowding, lack of interest in children and family, less supervision in childs’ daily activities, poor childrearing practices, large family size, illiteracy and ignorance about child care, etc. leading to retardation of growth and development.
 
c. Nutrients are Essential
  • To sustain life
  • To allow for energy expenditure
  • To promote growth and development. Nutritional needs of a child depend upon age, sex, rate of growth, levels of activity. Certain periods of rapid growth require more nutrients, e.g. such as; infancy, prenatal period, puberty, adolescence.
 
d. Climate and Season
Due to seasonal variations, the activity levels of children varies. Climatic conditions will influences growth rates, e.g. height, weight; Weight gain is lowest in spring and early summer and greatest in late summer and autumn.
 
e. Deviations from Positive Health
Heredity or congenital conditions/defects may contribute to growth impairment or alteration in 12weight, e.g. dwarfism, Turner syndrome (gonodal dysgenesis), Turner phenotype (Noonan syndrome) in which weight will be reduced, Marfan syndrome (arachnodactyly), increase in height, Klinefelter syndrome. Chronic illnesses; like cystic fibrosis/malabsorption syndrome–reduces weight.
 
f. Exercise
Increased blood circulation promotes physiological activity, stimulates muscular development. Fresh air and moderate sunshine will favors healthy growth.
 
g. Ordinal Position in the Family
The ordinal position in the family has a bearing effect on the parent child relationship and the child rearing practices, that are followed.
  • The first-born child will receive all the parental attention, until the second child is born. The first born, therefore may be raised rigidly and with anxiety. The child develops more anxious, perfectionistic personality than do the later siblings and is more confirming intelligent and achievement oriented and may learn at an early age to control and organize the behavior of others
  • Only child is likely to develop intellectually, more rapidly than the children with siblings. Since only child constantly have companionship with adults which is mentally stimulating and only child may have higher self esteem, more dependent on others
  • Motor development may be slow, as they do not have siblings to lead them to various activities
  • When the child begins to do activities independently, parents may not allow them to do the activities with their own efforts
  • The middle child, many times gets less attention from the parents than does the first-born, especially if their birth dates are close together (close birth intervals)
  • Parents of the middle child are more relaxed about their parental roles and stress to the child, the values of responsibility and cooperation with other family members
  • The child born between the first-born and the youngest, learns how to be adaptable and how to compromise traits, that will be valuable in adult life
  • Less achievement oriented, less aggressive in meeting the life goals
  • The youngest child, more peer-oriented, Less intellectually inclined, less achievement oriented than siblings, slow in certain areas of development because of finding little need for exploring the unknown, receives a great deal of love and attention and therefore tends to develop a good natured, friendly, warm-personality with high self-esteem.
Children deserve ‘All the parental love’ respect and affection which they can get as individual members of their families to develop their personalities to the fullest extent possible.
 
Internal Environment
 
Intelligence
Intelligence influences mental and social development. The child of high intelligence is likely to be taller and better developed than is the less gifted child. Intelligence influences mental and social development.
 
Hormonal Influences
  1. Somatotropic hormone (Growth hormone): This hormone is secreted by adenohypophysis of pituitary gland—it is utilized largely during childhood. Its major effect is on
    • Linear growth in height, i.e. excess secretion leads to gigantism; less secretions leads to dwarfism
    • Proliferation of cartilage cells at the epiphyseal plates
    • Stimulates skeletal and protein anabolism through the production of somatomedins or intermediary hormones
  2. Thyroid hormones (T3 and T4): Stimulates the general metabolism and which are 13necessary for growth and development of the child produces advanced linear growth. If secretions are lowered cretinism results in stunted growth (physical), mental retardation (cretinism). The Adrenocorticotropic hormone (Stimulates gonads, effective in adolescent period) (Adenohypophysis—stimulates hypothalamus to produce) gonadotropic hormones which stimulates the interstitial cells of the testes to produce testosterone; ovaries—estrogen which produces secondary sexual characteristics and production of ova. Excessive amounts of estrogen or testosterone results in precocious puberty, decreased secretions results in delayed sexual development.
  3. Insulin, parathormone, cortisol and calcitonin. Hormones have influence over the childs’ growth and development.
 
Relationship with Significant Persons
Parents, siblings, peers, teachers play a vital role in the emotional, physical, social, and intellectual development of the child.
  • Initially the caregiver, i.e. mother has the greatest influence on the child. As the mother meets the infant's basic needs and provides the stimulation necessary for the child to learn. After the infant learns to trust the mother, trust is extended to other significant persons in the environment. Because the mother repeatedly emphasizes socially approved behavior, the child learns early to act in a way that will gain approval from her
  • The father assumes the responsibility of providing food, comfort, warmth, love and protection. The child develops qualities like love, affection, warmth, protection etc., from their parents
  • Siblings are child's earlier peer group, the way, children in a family interact gives some indication of how they will relate later to peer group outside the home
  • The way a child relates and is influenced by outside playmates and classmates depends largely on the parent-child relationship in the home
  • The way a child relates to and is influenced by outside playmates and classmates depends largely on the parent child relationship in the home
  • As the child grows older, neighbours, teachers, play group, authority, peer group, friends etc., have significant influence on emotional, social and personality development of the child.
 
Interaction of Heredity and Environment
 
Heredity
Every person begins life as a single fertilized cell. This single cell, the zygote, results from the union of two germ cells, a sperm cell from the father and an egg cell from the mother. The key to hereditary transmission is contained in the germ cells. Each of these cells like all living cell processes a nucleus surrounded by cytoplasm (living substance). Each cell of an animal body has chromosomes, which are equal in number, each species has a characteristics number of chromosomes arranged in 23 pairs.
The hereditary factors hidden within the chromosomes are the genes. They are ‘packets of chemicals’ strung along the chromosomes like small beads on a thread. Action of the genes on the cytoplasm changes the shape and other characteristics of cells. The heredity basis of individual difference lies in the ultimate variety of possible gene combinations that can occur. The genes are made up of DNA and RNA. RNA acts as a specific catalyst for the production of the infinite variety of protein substances contained in the many varieties of body tissues. DNA contains the genetic code or directions which regulate the functioning of RNA. The DNA passes on the genetic code to RNA, which in turn translates it in the body tissues. When this genetic code is miss spelt, it may lead to gene 14mutations or deviations from normal characteristics. It was observed that certain chromosomal abnormalities are responsible for certain abnormal syndrome like Turner's syndrome, mongolism, etc. The role of genetic factors was clearly demonstrated in these cases.
 
Environment
It has been found that environment also plays its role in human behavior and development. The temperature of the environment can affect the development of skin color. When we treat patients in hospitals, we try to bring about change by influencing the environment. The environmental influences are those which act upon the organism at the earlier stages of development within the mother's womb and later external environment after birth.
The nucleus, chromosomes and genes are surrounded by a jelly like substance known as cytoplasm. The cytoplasm, is an intracellular environment, because the genes surrounded its characteristics. The outcome of the organism is determined by the cytoplasm as well as its heredity. A new internal environment comes into existence, after the interaction of genes and cytoplasm has produced several cells. The actual structure of the cell depends upon its relation to other cells.
Later endocrine glands and hormones produce another intercellular influence. Many congenital deformities are the result of over-active or under-active endocrine functioning. The social psychological environment in which the child is born provides social heritage. The custom, socio-economic status, family environment, interaction among family members and later peers and the school environment cause a variety of conditions to determine individual differences.
 
Hereditary Vs Environment; Nature Vs Nurture
Today no one believes that nature alone or nurture alone, completely determines the course of our development. The development is shaped by the interaction of heredity and the environment. Within this interaction, our genetic endowment for many characteristics provides us with a reaction range of possible levels that we may ultimately reach, depending on the quality of our experience in the environment.
When we speak of environment, we generally think of the external word and all the forces that affect the individual directly or indirectly. But we have to consider two other environments, they are the inter-cellular and the intra-cellular environment. The inter-cellular environment relates to embryonic development. Intra-cellular environment shelters the baby during prenatal life. It deals with substances which by passing the placental barrier can adversely affect the unborn child. Viruses, bacteria and drugs can cause damage to the child. So, the nurse, as a teacher can help pregnant women to understand their responsibility for maintaining the necessary hygiene for the growth of a healthy infant.
Children brought up in an impoverished kind of environment where intellectual stimulation is lacking, show lower IQ than children who were exposed to an enriched environment. Children of parents who are in intellectually superior professions and those living in urban areas show higher intellectual capacity when compared to children of rural areas.
 
TYPES OF GROWTH AND DEVELOPMENT
The development of children can be divided into
  • Physical development
  • Motor development
  • Sensory development
  • Mental development
  • Emotional development
  • Social development
  • Moral development
  • Spiritual development
  • Language and Speech development
  • Intellectual development
  • Sexual development.
Individual develops a body image and a life perspective. These divisions of development 15usually progress together in the process of maturation and learning.
 
Physical Growth and Development
 
Changes in General Body Growth
Result from different rates of growth in different parts of the body during consecutive stages of development, for example,
  • The infant's head constitutes ¼ of the entire length of the body at birth
  • The adult's head is only one-eighth of body length.
 
Height or Length
Yearly increments in height diminish from birth to maturity. The pubescent spurt is the only exception to this downward trend in the rate of growth.
 
Weight
Weight is influenced by all the increments in size and it is best gross index of nutrition and health.
 
Head Circumference
The circumference of the head is an important measurement since it is related to intracranial volume. An increase in circumference permits an estimation of the rate of brain growth.
 
Thoracic Diameter
Chest measurement increases as the child grows, along with the shape also changes.
At birth the transverse and antero-posterior diameters are nearly equal. The transverse diameter increases more rapidly than does the antero-posterior diameter, i.e. the width becomes greater than the depth.
Abdominal and pelvic measurement
Abdominal circumference is affected by
  • The infant's nutritional status
  • Muscle tone
  • Gaseous distention
  • The phase of respiration.
Pelvic bicristal diameter is the maximal distance between the external margins of the iliac crest.
 
Motor Development
It depends on the maturation of the:
  • Muscular system
  • Skeletal system
  • Nervous system
The sequence of motor skills follows either the cephalocaudal direction or proximodistal direction.
 
Gross Motor Development
The acquisition of increasing mobility and independent locomotion. It proceeds fine motor activities, e.g. turning, reaching, sitting, standing, and walking.
 
Fine Motor Development
The reflexes give way to the acquisition of motor dexterity. As the neural tract matures, reflexes disappear and are replaced by purposeful activities, e.g. the child learns to use the hands and fingers for thumb apposition, palmar grasp release. Motor development is not affected by sex, education and geographical residence, etc. Motor development is affected by adequate nutrition and good health.
 
Sensory Development
The sensory system is functional at birth. The child gradually learns the process of associating meaning with a perceived stimuli, e.g.
  • At birth senses of taste and smell are very minimal
  • Touching a neonate results in total body response
  • As myelinization of the nervous system is developed, the child is able to respond to specific stimuli
  • The visual system is the last to mature at about 6 to 7 years
 
Mental Development
16It is demonstrated by problem solving. Infants at first are confronted with physical problems and the normal reflex actions of their bodies helps to solve them. The first problem is ingestion of milk.
  • Sucking the mother's breast and swallowing the milk are the processes that require little or no practice to perform successfully
  • Newborn babies, when brought near the breast for the first time may have difficulty in getting hold of the nipple and may sputter and choke as the colostrum or milk begins to flow. But they soon learn as they have many opportunities to practice sucking.
  • An infant learns to know, they want a smiling mother, as she brings comfort
  • An early problem, then, is to make mother smile
  • The infant learns not to do those things that make her say in a decisive voice, ‘no, no’.
 
Intellectual Development
It occurs from infancy through the years when behavior changes as a result of:
  • Maturation of innate capacities
  • Conditioning—learning by conditioning, association of a stimulus with a response
  • Reinforcements of appropriate behaviors
  • Imitation of the behavior of others
  • Insight
Intelligence is the ability to adjust to new situations to think abstractly (verbal and numerical skills, spatial relations) and to reason or profit from experience.
I.Q. levels vary, based on chronological and mental age.
Aptitude tests are designed to test the child's basic capacity to learn;
Achievement tests are designed to test the child's learned characteristics.
 
Piaget's Theory Concerning Intellectual or Cognitive Development
The child gradually develops an integration or coordination of the various sensory inputs from touch, taste, smell, sight and sound into an organized and objective understanding of reality.
Symbols will be used to represent reality is another important stage in development. It leads to language development, which in turn produces greater symbolism leading to further mental development.
According to Piaget, four major stages of development:
  1. The sensory motor stage (birth–2 years) – children are primarily concerned with learning about physical objects.
  2. They preoccupied with symbols in language, dreams and fantasy (3-7 years).
  3. The concrete operational stage (7-11 years) – child move into the abstract world, mastering numbers and relationships; and how to reason about them.
  4. The formal operational stage (11-15 years) – child tackle purely logical thought, i.e. thinking about their own thinking as well as that of others.
 
Emotional Development
 
Erikson's Theory of Socio-emotional Development
Erikson, a follower of Sigmund Freud and a psychoanalyst in 1950 developed ‘Developmental theory of the eight stages of man’ it covered the entire life span. According to this theory, the most important force driving human behavior and the development of personality was social interaction. The social environment combined with biological maturation provides each individual a set of ‘crises’ that must be resolved. The individual is provided with a ‘sensitive period’ in which, successfully resolve each crisis before a new crisis is represented. The result of the resolution, whether successful or not are carried forward to the next crisis and provide the foundation for its resolution (Table 1.1).
  1. The infants learn to trust the adults, who care for them and are sensitive to their needs. Trust Vs Mistrust (negative outcome).
  2. The Toddler: Sense of autonomy Vs Sense of doubt, Shyness and shame.
    17
    Table 1.1   Eight stages of development of man
    Age
    Emotional development
    Expected resolution
    Infancy
    Trust Vs Mistrust
    Child develops a belief that the environment will be influencing to meet his or her basic physiologic and social needs
    Toddler
    Autonomy Vs Shame and doubt
    Child develops a sense of free will and control when inappropriate use of self control results in sense of regret and sorrow
    Early childhood
    Initiative Vs Guilt
    Child wants to explore, to do activities by imagination; if the child is unable to perform actions successfully, they will feel guilty
    Middle childhood
    Accomplishment, industry Vs Inferiority
    Child learns to do the things correctly with much hard work feels enjoyment in accomplishing the tasks; if they fails to do so, they will compare with others and feels inferiority
    Adolescence
    Identity Vs Role confusion
    Adolescents want to identify by them with other group members. They wants to be recognized based on their abilities, goals, possibilities; and they wants to fulfill internal thoughts and desires
    Young adult
    Intimacy Vs Isolation
    Develops ability to give and receive love, wants to develop intimate relationship; begins to make long-term commitment relationship; otherwise they will feel isolated and develops withdrawal nature. They will adopt control, commitment and challenges in fulfilling activities. The issues of adulthood are to live (emotional, financial) to love (intimacy) to learn (achievement in the world of work) to leave a legacy (generativity)
    Middle adulthood
    Generativity Vs Stagnation
    Develops interest in guiding the next generation with creative ideas, generate relative working goals. Otherwise they will feel that, they are stagnated in activities, no fruitful production, worthlessness in their activities
    Old age
    Ego integrity Vs Despair
    Develops a sense of acceptance of life, understands the relationships that the individual developed throughout their life span. If the things are not going according to their expectations; relationship were not maintained properly they will despair and feels loneliness, thinks that their life is waste
    Infants develop from clinging, dependent creatures into human beings both with mind and wills of their own.
    If children succeed in this stage, in their maturing process, they will have a degree of self-control by the feelings of self-esteem.
    If they do not succeed they will doubt their own worth with that of others and will have a sense of doubt, shyness and shame
  3. The preschool child – sense of initiativeness Vs sense of guilt.
    Children wants to learn what they can do for themselves.
    They have active imaginations
    • Imitating adult behavior
    • Wanting to share in adult activities
    • Following their wills to the extreme limit.
    The positive maturing outcome of this force within children is a sense of initiative delineated by conscience or superego, which is developed from parental attitudes.
  4. The school-age child (6-12 years) sense of industry/duty Vs sense of inferiority
    Wants to engage in tasks in their social world that they can carry out successfully and they want their success to be recognized by adults and by their peers.
  5. 12-15 years (The beginning of adolescence) Sense of identity Vs identity diffusion
    Adolescents want to clarify who they are and what their roles in society are to be.
    Success in this period brings self-esteem, an attitude towards self, i.e. essential to the normal breaking away from dependency upon their parents and to plan for their future 18Identify diffusion occurs when they face in reality and in their dreams of the future a life full of conflicting desires, possibilities and chances.
  6. Late adolescence (15-18 years): Sense of intimacy Vs psychological isolation.
    After puberty, adolescents have stormy period with ambivalent feelings, out grow the ‘gang age’, when they find it essential to belong to a group of their own sex and age.
  7. Young people develop a sense of intimacy with individuals of their own and the opposite sex and with themselves. Failure to establish such intimacy results in psychological isolation – keeping relations with others on a formal basis that lacks warmth.
 
SOCIAL DEVELOPMENT
Socialization or social development means training a child in the culture of their own group.
A newborn infant is not a social being. Children are prepared for their adult roles through a process of socialization that takes place from birth to adulthood.
Children learn to socialize by meeting and communicating with people of various ages and by participating in the activities of family life and in peer and community groups.
Learning to live happily with family and with other adults is quite different from making friends in a peer group. In general, in the adult-child relationship, the child learns to live within certain restrictions set by adults even, though at times these restrictions may not be consistently imposed. A child who adjusts well with adults may be unable to get along with other childrens and help the child does eventually to learn to be one among peer group.
Attitudes towards parents, the self and the opposite sex influence the roles and responsibilities and all of them assume these roles after the period of childhood. Many prepare to take the responsibilities of marriage and establishing a home. Parents become dependent upon them, as they mature and grow older.
As adults, they learn to take their places in the economic life of the country and to fulfill their roles as citizens.
 
MORAL DEVELOPMENT
 
Piaget's Theory
It parallels mental development.
  1. Respect for rules (3-11 years)/morality of restraint.
    Rules are considered sacred because they are laid down by the parents or other adults in authority.
  2. A sense of justice/morality of reciprocity or cooperation (12 years onwards).
    The adolescent can think abstractly and is becoming increasingly sensitive to other persons, rules can be changed if this action is advantageous to all.
As the child develops, ideas of justice also changes because of continual interaction with the peer group, the older child and adolescent learn a concept of justice and personality develops. The child learns that other people have feelings and that a cooperative effort will achieve optimal results.
 
Lawrence Kohlberg Theory
A moral sense, ‘It is acquired through an internal and personal series of changes in attitudes’.
According to this theory three levels and six stages are there.
 
Level I. Pre-conventional Morality—Egocentricity
Children make moral judgments only on the basis of what will bring them a reward (right act) or punishment (wrong act).
Stage 0. (0-2 years) Egocentric
Loving/liking—which helps them
Disliking/hating—which hurts them
Stage 1. (Punishment—obedience orientation) 2-3 years
Children of this age believe that if they are not punished their acts are right. If they are punished their acts are wrong. Children therefore act to avoid displeasing those who are in power. (When mothers repeatedly say ‘no, no’)
19
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Fig. 1.2: Psychologic horizons of youth
Stage 2. Instrumental hedonism and concrete reciprocity (4-7 years)
Children focus on the pleasure motive. They consider those actions right, that meet their own needs or those of others. They carry out rules to satisfy themselves.
 
Level II. Conventional Morality
Correct behavior is that, which those in authority will approve and accept, if behavior is not acceptable, children will feel guilty.
Stage 3. Orientation to interpersonal relations of mutuality (7-8 years).
 
Socially Sensitive
Wants to gain the approval of others.
If their actions help them, gains the approval of their family, peers and teachers and feels that they are right. If disturbed relationships results, their actions are wrong. Justice means reciprocity or equality between individuals.
Stage 4. Maintenance of social order, fixed rules and authority (10–12 years).
The idea of right— these children assume a metaphysical or perhaps a religious tone.
Children want to do what is right and what they consider to be their duty. They obey rules for their own sake. Children see justice or reciprocity between individuals and the social system.
 
Level III. Postconventional Morality (Adolescence and Adulthood)
Adolescent makes choices on the basis of principles that have been thought about, accepted and internalized.
Whatever actions conform to these principles are considered right inspite of the praise or blame of others.
Stage 5A: Stage of contract, utilitarian law-making.
Stage 5B: Higher law, conscience orientation.
  • 20Adolescents place culturally appropriate values on attitudes and actions which benefits society and that leads cooperation and the good of all.
  • Good laws be created that will maximize the individual's welfare
  • They think in rational terms
  • They give as well as take
  • They do not want something without paying for it, and if they belong to a group they work toward its goals
    Stage 6: Universal ethical principle orientation
  • Highest moral value
  • The period in which individuals can motivate and evaluate themselves. They reached the level of self actualization
  • They have a feeling of rightness about themselves, have internalized standards, integrity is of utmost importance
  • Do what they think is right and condemn themselves if they do what they consider wrong
  • Can obey the law, but feel guilty if they have gone against their own principles
 
SPIRITUAL DEVELOPMENT
A family's religion may be closely tied to its cultural background. It influences the family's interpersonal relationships and responsibilities.
 
Fowler's Theory Concerning the Development of Faith
According to Fowler (1983) faith is universal, i.e. expressed through beliefs, rituals and symbols specific to religious traditions.
  • Faith is multidimensional and a way of learning about life
  • Faith implies trust and reliance upon another
  • Through our relationships with others, ‘we share common loyalties to supra-ordinate centers of value and power
  • Faith allows the individual to ‘construct the point of view of other persons and groups’.
  • Faith is an ongoing process in which individuals forms and reforms their way of seeing the world
  • Persons may acquire their religious beliefs and preferences in childhood and may deepen those convictions as their faith develops or they may change religious beliefs in adulthood.
 
Stage I. (Primal Faith) Infancy
Parents and child form a mutual attachment and progress through a period of give and take.
The primary care giver provides the infant with a variety of experience that encourage:
  • The development of mutuality
  • Trust
  • Love
  • Dependence and
  • Progressing in autonomy.
 
Stage II. Intuitive (Projective Faith) 3-7 years
The child forming long-lasting images, feelings, imagination, perception and feelings are the mechanism by which child explores and learns about the world at large. The cultural beliefs of the family influence the child's concepts of health and sex.
 
Stage III. Mythic—Literal Faith (Childhood and beyond)
  • Children's beliefs derive from the perspective of others. They are able to differentiate their thinking from that of others
  • Stories become the gateway to learning adult life
  • In valuing the stories, practices and beliefs of the family and the community the child reaches faith development.
 
Stage IV. Synthetic—Conception Faith (Adolescence and beyond)
  • A person's experience extends beyond the family to peers, teachers and other members of society
  • As a result of cognitive ability the individual is aware of the emotions, personality patterns, ideas, thoughts and experiences of self and others, i.e. mutual interpersonal 21perspective taking. The individual has a cluster of values, beliefs in concert with others.
  • Through the process of values and clarification the nurse can assist parents and children in exploring alternatives and deciding what is right for them.
 
DEVELOPMENT OF SEXUALITY
Sexuality is an important dimension of life, a link between individuals. Although the sex of the child is determined genetically at the time of conception, the development of a child's sexuality after birth is influenced by development in the physical, mental, emotional and socio-cultural areas of living.
Sexuality refers to, ‘The total quality of human being from the time of birth, not just to the genitals and their functions’.
Human sexuality is expressed in everyday life. It is related to many aspects of total personality functioning includes:
  • Cultural beliefs
  • Attitudes
  • Feelings, loving and caring
  • Sex-role stereo types
  • Self-image
  • Aesthetic and spiritual values
  • Beliefs in individual.
 
Sigmund Freud's Theory
  1. The oral stage (Infancy): During this period, the oral region or the sensory area of the mouth, provides the greatest sensual satisfaction for the infant.
  2. The anal stage (2nd-3rd years of life): The greatest amount of sensual pleasure for the toddler is obtained from the anal and urethral areas.
  3. The phallic stage (3rd-5th years): The site of greatest sensual pleasure is the genital region. The oedipal stage occurs in the later part of the phallic period. During this stage the child ‘loves’ the parent of the opposite sex as the provider of sensual satisfaction. The parent of the same sex is considered to be a rival.
  4. The latency stage (6-12 years): The child has resolved the oedipal conflict. During the latency period children form close relationships with other of their own age and sex.
  5. The pubescent stage and adolescence (13-19 years): Secondary sexual characteristics appear in both sexes. The psychosexual conflicts that occurred during the oedipal period are revived. If children resolve the conflicts, they are free to enter into heterosexual relationships as adults.
 
DEVELOPMENT OF LANGUAGE AND SPEECH
The ability to communicate is a significant factor in a child's intellectual, emotional and social development.
Language development refers to, ‘The increasing quality, range and complexity of language and speech over a period of time’.
‘Language is a complex system of grammatical and semantic properties’.
‘The actual utterances of the language is utterance of the language is called ‘SPEECH’.
A child is receptive to language when the language is he understands it, expressive of language when it is produced. Children are born with the physiological ability to speak, if they have normally structured and functioning oral, nasal cavities and respiratory systems and if they have normal speech control centers in the cerebral cortex. They can learn to speak if they have the intelligence and the motivation to do so, if they can hear the spoken words of others and if they are stimulated by other people in the environment. By 10-12 months, the infant usually says the first word having meaning.
Vocabulary development then slows down while the child is learning to walk. The most dramatic vocabulary development takes place between 18 months and three years of age.
22The first born child in a family develops language and speech earlier than those children born later, may be due to the attention received from adults. Single children develop language earlier than those with siblings. Girls learn earlier than boys, as boys have slower rates of neurophysiologic maturation.
 
Road to Health Chart/Growth Chart
David Morley designed the growth chart, later it was modified by WHO. It is a visual record which can be understood by care takers and health professionals.
 
Uses of Growth Chart
  • Standard method
  • Longitudinal follow up of a child can be interpreted so that changes over time will be observed
  • Reference curves can be used for the purpose of comparison
  • Weight is the most sensitive measure of growth; to identify any deviation from normal can be detected, e.g. malnutrition
  • To plan and revise the policies in relation to child health care
  • Caretakers can be educated or taught to participate more actively in growth monitoring and to carry out necessary interventions
  • Helps the health professionals to adopt the specific interventions and for easy referrals
  • To evaluate the effectiveness of special interventions made for improving child growth and development.
 
WHO Home-based Growth Chart
It has two reference curves for comparison purpose, upper reference curve represents the median for boys (50th percentile) and the lower reference curve, the third percentile for girls. Hence, it can be used for both sexes. If the child is growing normally, the growth line will be above the 3rd percentile and will run parallel to the ‘road to health’ curves. Flattening of the child's weight curve signals growth failure, the earliest sign of PEM, needs special care. In growth chart, one can chart the present information like identification data, birth date, weight, chronological age, history of sibling health, immunization status, supplementary feeding pattern, episodes of sickness, reasons for special care. The objective of child care is to keep a child in the zone that represents weight of 95% of normal healthy children i.e., parallel to ‘road to health curve’ (Fig. 1.3).
 
Growth Charts Used in India
Government of India approved growth chart which has four reference curves. Top most curve corresponds to 50th percentile of the WHO standard. The lower lines represent 70%, 60% and 50% of the standard. Indian Academy of Paediatrics formulated the above curves which indicate the degree of malnutrition. ICDS growth chart has three reference curves indicating 80%, 60% and 50% of the reference standard. When age of the child was not known, alternative methods used for growth monitoring are: height for age, weight for height and mid-arm circumference.
 
Under-five Clinic
The under-five clinic combines the concepts of prevention, treatment, health supervision, nutritional surveillance and education into a system of comprehensive health care within the resources available in the country. It is economical, useful for longer proportion of children in the community. Non-professional axillaries will assist health care professionals in carrying out the activities of under-five clinic (Fig. 1.4).
 
Care in illness
To meet the felt needs of children; the minor ailments of children can be treated by trained nurses (Fig. 1.5). The acute and chronic illnesses will be referred for proper diagnosis and treatment.
23
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Fig. 1.3: Growth chart: Head circumference for age and weight for length percentage
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Fig. 1.4: Symbol of under-five clinic
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Fig. 1.5: Under five clinic
24
 
PREVENTIVE CARE
 
Immunization
Primary and booster doses of vaccination will be given against six killer diseases for under-five children to achieve full immunization status.
 
Nutritional Surveillance
To identify sub-clinical nutritional deficiency disorders ‘Road to health chart’ has to be maintained. If any children were identified as malnourished or nearing to malnourishment, food has to be supplemented (through ICDS Anganawadi workers) to overcome malnutrition.
 
Regular Health Check-ups
Physical examination, appropriate laboratory tests will be done in regular health check ups and child health cards will be issued. Regular health check ups will be useful for identifying ‘high risk children’ and the ‘children who needs care’.
 
Oral Rehydration
To prevent child's death due to diarrheal diseases, ORT has to be supplemented in mild dehydration cases itself.
 
Family Planning
Based on the age of the couple size of family and needs of family either temporary or permanent contraceptive devices can be adviced to limit their family size. Family planning is the centre of concern for the health and well being of child. Family planning counseling services for the couple can be given through this clinics.
 
Health Education
Around the whole symbol is a border that touches all the areas. In clinics health education related to child rearing practices has to be given to the mother care givers.
 
Growth Monitoring
Periodically height and weight of the child has to be recorded on the growth chart of every child by the mother or health care professional, which will help to detect early onset of growth failure and its cause; remedial measures will be followed.
 
ANTHROPOMETRY
Anthropometric measurements are useful indices for assessing nutritional status.
  1. Weight: Weights taken over a period of time are of greater practical value than one single measurement. This period varies in children of different age groups according to their rates of growth. The younger the age, the shorter should be the minimal period between successive weighing. The younger the child, the more accurate weighing should be used. Weight has to correlated with height and age to detect the effects of under-nutrition. Weight can be recorded on road to health card. It will be maintained by health personnel and Anganawadi workers, to assess the milestones of the child under-five years of age. By this chart, we will be knowing especially the nutritional status of children, i.e. over-weight, normal growth, slight under nutrition, moderate under nutrition, severe under nutrition (Fig. 1.6).
    Weighing of Children
    • Ideal birth weight: 2.5-3.25 kg
    • Newborn loses upto 10% of weight during 1st week, however it is regained by the age of 10/30.
      zoom view
      Fig. 1.6: Checking the weight of the newborn
    • 25After this 25-30 gm/day—1st 3 months
      • 40 gm/month—3-12 months
      • Double weight—5/12 months
      • Tripe weight—1 year
      • 4 times—2 years
      • 5 times—3 years
      • 6 times—5 years
      • 10 times—10 years
    • Salter spring machine—accuracy of machine has to be checked periodically
    • A conventional beam balance scale for weight recording in hospital and clinical practice is used.
  2. Height: It is a useful index of assessing the nutritional status. Heights have to be correlated with weight and age. Height also recorded in Road to Health Card.
  3. Checking the height of the child and newborn (Figs 1.7, and 1.8).
  4. Chest circumference: The chest circumference is less than the head circumference (1”) in the newborn. By the age 9 months to one year, both become equal in normal children. In undernourished children, the head may remain large even upto 2½ - 3½ years (Fig. 1.9).
  5. Mid arm circumference: This is a simple method of assessing malnutrition between the first and the fifth years of life. Arm circumference taken at the middle of the upper arm with the arm hanging relaxed at the side, ranges between 16 and 17 cm in 2 to 5 years old well-nourished children.
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Fig. 1.7: Measuring the height of the newborn
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Fig. 1.8: Checking the height of the child
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Fig. 1.9: Measuring the chest circumference of the newborn
Technique to Measure Mid-arm Circumference
The tubercle of the acromion process is identified and marked and the lateral condyle of the humerus is marked at the lower end. At a point mid way between the two, the circumference is measured with the tape (Fig. 1.10).
Span: The length measured from the tip of the 2nd finger of one hand to the tip of the 2nd finger of the other hand with both arms outstretched by the side is called the span.
26
zoom view
Fig. 1.10: Mid-arm circumference measurement
This is almost equal to the height. In achondroplasia the span is less than the height. In Marfan's syndrome it is greater than the height.
 
Shakir's Tape
This tape is used to measure the mid-arm circumference. It has three color zones on plastic tape; the zone above 13.5 cm is green, which indicates normal mid-arm circumference; 12.5- 13.5 cm is yellow indicating borderline malnutrition. The zone colored red and measuring less than 12.5 cm indicates gross malnutrition.
Bangle test
A quick nutritional survey can be done by measuring the arm circumference, a bangle which has an internal diameter of 4 cm. If the bangle passes easily above the elbow and to the child's upper arm, the child is in a state of severe malnutrition.
Mid-arm-head Circumference Ratio
This ratio is useful if the child's age is not known.
Principle: The head circumference is not altered especially, if malnutrition is of recent origin; and at any specified time, the mid-arm head circumference index indicates changes in weight.
The normal value: 0.31
Grade 1: 0.28 – 0.30
Grade 2: 0.26 – 0.27
Grade 3: less than 0.26 (severe malnutrition)
Modified QUAC–stick Method
It reflects the nutritional status of the child. The child is made to stand in front of the QUAC-stick paper, where the height is measured and then the left arm circumference taken with the arm hanging by the side, from the gradations of the strip, the nutritional status, e.g.: 50%, 60%, 70% or 80% can be easily read.
Triceps Skin-fold Thickness
The thickness of the subcutaneous fat is used as an index for assessing the nutritional status of the child. The measurements are taken accurately with special calipers after pinching up a fold of skin and subcutaneous tissue either over the triceps or the sub-scapular muscles, just below the angle of the scapula. It has been found that, at all ages girls have a thicker triceps skin-fold than boys.
The mid-arm muscle circumference can be calculated from the triceps skin-fold and the mid-arm circumference. The mid-arm muscle circumference shows a significant positive correlation with the mid-arm circumference.
Quetlet's Index
The relationship between weight and height is expressed by:
Head Circumference
27The measuring tape must be passed over the most prominent part of the occiput behind and above the ears, over the temples on the side and above the eye brows and meet in-front at the nasion. Care must be taken not to put the fingers between the tape and any part of the head. Accurate measurement is vital to assess the growth of the head and indirectly the brain. For example, head circumference below the third percentile indicates microcephaly; large head circumference indicates hydrocephalus (Fig. 1.11).
 
UNIVERSITY REVIEW QUESTIONS
  1. Discuss the principles of growth & development (10M, RGUHS, 2003, 04; 5M, NTRUHS, 1992, 97, 99 and 2M, 5M, NIMS, 2004, 05).
  2. Discuss the interaction of heredity & environment (15M, M.Sc, RGUHS, 2005).
    zoom view
    Fig. 1.11: Measuring-head circumference
  3. Discuss the Erickson's theory of growth and development (10M, RGUHS, 2003; NTRUHS, 2003).
  4. Discuss factors influencing fetal development (10M, RGUHS, 2004; 15M, 2001).
  5. Discuss the Freud's theory of growth and development with illustrations (10M, RGUHS, 2005).
  6. Importance of learning growth and development in Nursing (5M, RGUHS, 2003).
  7. Discuss the laws of growth and development (5M, RGUHS, 2001; NTRUHS, 1999, 02).
  8. Biological principles of growth and development (5M, RGUHS, 2005).
  9. Developmental tasks (2M, RGUHS, 2003).
  10. Erikson (2M, RGUHS, 2005).
  11. Define growth and development (2M, RGUHS, 2005; 4M, NTRUHS, 1999, 02).
  12. Factors influencing growth and development (8M, NTRUHS, 2002; 10M, RGUHS, 2005 and 3M, NIMS, 2003, 04, 05).
  13. Trust Vs mistrust (5M, NTRUHS, 2002).
  14. Freud theory (2M, RGUHS, 2005).
  15. Anthropometric measurement (2M, RGUHS, 2005).
  16. Road to health chart (2M, RGUHS, 04; 5M, 04).
  17. Emotional needs of child in all age groups (5M, NTRUHS 1991, 99).
  18. Road to health chart and its values (15M, 10M, 5M, MGRUHS, RGHUS, 2003, 04, 05).
  19. List and explain five principles of growth and development (5M, NIMS, June, 2001).
  20. Define the term growth and development (1M).
  21. What do you understand by the terms growth and development (NIMS, 2002, 2M) Why it is important for a pediatric nurse to understand different stages of growth and development (3M, NIMS, 2001).
  22. Sense of initiative (5M, NIMS, 2001).
  23. Under-five clinic (MGRMU, 5M, 2001).
  24. Discuss the current concepts of growth and development (10M, RUGHS, April 06).
  25. Phallic phase (2M, RUGHS, April 06).
  26. Environment (2M, RUGHS, April 06).