Pre-school, School age and Adolescent

1. Pre-school, School age and Adolescent Elisa A. Mancuso RNC, MS, FNS Professor of Nursing

2. Growth and Development Preschool 3-5 years Biological • Growth slows and stabilizes during preschool • Average weight gain 2.2 kg (5lbs)/yr Height 7.5 cm (3”)/yr • 3 yr: 32 lbs & 37” • 4 yr: 37 lbs & 40” • 5 yr: 42 lbs & 43” • Growth occurs in legs rather than trunk. • No longer resemble the “pot belly” toddler!

3. Psychosocial Development • Erickson: Initiative vs Guilt • Ability to learn & play. • Development of “can do attitude” • Behavior becomes goal directed, competitive and imaginative. • Imitate parents & gender roles. • Proud when accomplish new goals. • When criticized show feelings of guilt. • Conscience develops along with moral development

4. Psychosocial Development • Freud: Phallic Stage • ↑ Focus on genitals • masturbation and exploration common • Oedipal conflict • Possessive love for opposite sex parent • “Super-ego” conscience develops • guilt feelings emerge

5. Psychosocial Development Piaget • Pre-operational Stage 2-7 years • Readiness for school • ↑ physical activities & loud • vivid imagination and curious • Limited attention span • Time- recognizes past and future • Idiosyncratic system for organizing events • Egocentric • See the world via me • Fear of Bodily harm • Ban-aids keep everything in place!

6. Piaget • Centering • one characteristic of an object • Concrete thought process • Literal • Magical thinking • Animism • Ascribe human characteristics to objects

7. Developmental Skills 3 years • Walking, running and jumping well @ 36 • 900 word vocabulary/3-4 word sentence • Copy a circle and cross • Builds a tower of 9 blocks • Ride tricycle, walk stairs alternating feet • Pour from pitcher • Asks a lot of questions!!

8. Developmental skills 4 years • 1,500 word vocabulary/4-5 word sentence • Can copy a square • Very noisy, talkative • Exaggerates stories • Loves Rhymes & songs • Names 3 colors • Hop on one foot • Catch a ball with both hands, throws overhand • ↑ Self-Care: Brushes teeth • Gets dressed ↑ Cooperation

9. Developmental skills 5 year old • 2,100 word vocabulary/6-8 sentence • Copy diamond and triangle • Prints name • Draw person with 6 parts • Head, body, 2 arms & 2 legs • Talk constantly • Names 4 colors • Skip & Hop on alternating feet • Walks backwards • Hits a ball • Ties shoes & manage big zippers

10. Socialization • ↑ Peer interaction & communication • Learn to relate to others • Increased cooperation & Sharing • Conform to expectations • Enjoy games with simple rules • PreSchool play- • dramatic & creative • Recognizes sociocultural • differences

11. Developmental Tasks • Large and small muscle coordination • Uses initiative with a conscience • Becomes a participating family member • Settles into a daily routine • Dental & personal Hygiene • Sleep

12. Health Concerns Safety • MVA # 1 cause of injury • Being struck by car is ↑ risk • Drowning and falls • Doesn’t fully understand danger • Magical thinking & cartoons minimize the danger • Integrate safety education • Puppets, songs, rhymes and games

13. Health Concerns • ↑ Exposures to germs • Frequent colds and ear infections • Girls ↑ UTI’s • RT anatomy and poor hygiene • Stress hand washing and proper hygiene • No sharing of utensils, pencils or pens!

14. Health Concerns Eyes • Visual acuity and depth perception fully developed by age 7 • Vision testing begun at 3 years • Objective screening using appropriate chart • 3 years- Allen cards-images • >4 years utilize E chart • indicate direction of E • 4 year 20/30-20/40 • 5 year 20/20-20/30

15. Common Eye Disorders Strabismus • ↓ Coordination of EOM • Eyes are not aligned • One or both eyes can turn • In (Esotropia) • Out (Exotropia) • Up (Hypertropia) • Down (Hypotropia)

16. Eye • Amblyopia- “Lazy Eye” • Only uses 1 eye for vision • No binocular vision • ↓ vision in the deviated eye • Distorted visual field • Can develop if strabismus is not treated early • If left untreated → Blindness in deviated eye • Therapy • Patch normal eye x 24 hours/day • Deviated eye must work • Surgery

17. Hearing • Early detection = better outcome • Mandatory newborn hearing screenings • Routine Audiometry screening by age 3 • Various tones @ various frequencies • Standard volume (usually 20 db) • Normal hearing ranges from 10 → +15 • By age 5 hearing is fully developed

18. Hearing Impairments Sensorineural (Nerve deafness) • Damage or malformation of structures of • inner ear/and or auditory nerve • Causes: • Infections: CMV, Rubella, Herpes, Meningitis • Heredity • Prematurity (Hypoxia) • Ototoxic meds • Hearing Loss is usually permanent • Therapy • Hearing Aids- worn ASAP to help facilitate language development • Cochlear implants = Controversy • American sign language ↑ communication

19. Hearing Impairments Conductive • Middle hearing loss affected by • inflammation, obstruction or damage • OME/OM • Cerumen impaction • Perforation • Temporary & restores to prior hearing level • Therapy • Antibiotics for infection • Myringotomy & Tympanostomy tubes

20. Biological Development School Age 6-12 years • Growth slows down • Weight: 5 - 6 lbs/year • Height: 1 - 2 inch/year • Average 6 year old • 46 lbs & 45 inches • Lose baby teeth @ 6 years. • First permanent teeth @ 6yrs (6 year molar) • “Ugly Duckling Stage” • Distorted facial proportions • Wide range of physical differences • Age 7 could look like 10-years or 5-years • Treat according to their age not appearance!

21. Psychosocial Erickson- Industry vs Inferiority • Industry • Interest in doing work • Learn and solve problems • ↑ accomplishment RT ↑ motivation • Desire to master & do well in everything • If they don’t they will feel inferior. • Reinforce that they cannot do well in everything • Perseverance • Self-control • Compromise

22. Psychosocial Juvenile Stage: 6-9 years • ↑ need for peers, friends • “Stage of Accomplishment” • Work concept = chores, schoolwork • Carry tasks to completion • ↑ skill and coordination • Develop + self esteem • Greater intellectual capacity • Role models = teachers/coaches • Manipulate environment • Reinforcement via grades with material reward • Move to external focus and socialization • Parents needed in times of stress

23. Psychosocial Preadolescent Stage 9-12 years • Ability to love (same sex) = best friend • Pre Pubescence • 2 years before onset of puberty. • Puberty • Period of rapid growth • Development of primary and secondary sex characteristics • girls @ 12yrs • boys @ 13 ½ yrs )

24. Psychosocial Freud - Latency period • Sexuality • plays less prominent role • Best friend same sex • Usually do not want to play with opposite sex (icky!)

25. Cognitive Development • Concrete operations and Systematic reasoning: • Conservation • Change shape but still has same volume • Classification • Group according to attributes: 1st friend, 2nd friend • Seriation • Putting things in order or series: smallest →largest • Nesting • How one concept fits into another: puzzles • Reversibility • Opposite function: Addition & Subtraction • Use thought process to experience events and • actions & see things from another point of view.

26. Developmental Skills 6 years • Period of Transition • Self centered • Normal to cheat at board games • Impulsive • ↑Activity RT ↑coordination • ↑Dexterity = drawing & writing

27. Developmental Skills 7 years • Quiets down • Solitary play • Attentive • Sensitive listener • Modest (Need Privacy) • Companionable

28. Developmental Skills 8 years • Fluctuating Behavior • ↑Graceful movements • ↑Interest in nature • Very self-critical

29. Developmental Skills 9 years • ↑ Independence • Refined eye-hand control • Musical instruments • Best friend • Collections • Well organized • ↑Physical complaints with stress May have boy/girl relationship but won’t admit

30. Development Skills 10 years • ↑ Stamina • Budgets time • ↑ Energy • Enjoys family activities • ↑ Appetite

31. Development 11 years • Moody • Strict superego-conscience • Strong morals/values • Best behavior is away from home

32. Development 12 years • ↑ Personality integration • ↑ Self discipline • ↑ Self control • Tactful • Mutual understanding with parents

33. Developmental Tasks • ↓ Dependence on family • ↑ Neuromuscular skills • Must adjust to changes in body image • Develop positive attitude: • Multicultural • Social • Economic groups

34. Health Problems • Generally not a sick age • Injury Prevention • Unintentional accidents/injury are the leading cause of death in any age group • MVC remains # 1 • No Seat belts, air bag injuries or hit as pedestrian/riding bike • Sports- • skateboards, bikes, all-terrain vehicles need helmets!! • Burns- • cooking, firecrackers, matches, candles Guns Access to loaded guns

35. Attention Deficit Hyperactivity Disorder ADHD • Most common chronic behavioral disorder • Affects 6-9 % school age children • 40 % persist into adult • ADHD has 3 cardinal signs: • Inattention • Impulsiveness • Hyperactivity • Unable to self regulate & inhibit behaviors • ↓ Academic Performance • RT ↑ Distractible & ↓ Task completion • ↓ Self Esteem = ↓ Peer relationships • ↑ Risky Behavior = ↑ Substance Abuse & MVA Sequela: Conduct, Mood & Anxiety Disorders

36. ADHD Etiology • Familial Tendency with 1st degree relative • Males 3x more than females • Environment • Toxins (Pb), meds, food allergies, lead, smoking, alcohol, sugar??? • ↓Neurotransmitters: ↓ NE, ↓ DA and ↓ 5-HT • NE - attention, impulsivity and control • DA - motivation/reward. • Needed for prioritizing and learning • 5-HT – mood, aggressive/impulsive behavior • Other neurological disorders can impact: • Fragile X, Turner or Klinefelter

37. Diagnosis • ADHD is an all day all domain disorder • Based on report of parent, teacher and child • Onset by age 7 • symptoms persist for >6 months • Behavior Rating Scale • Have 6/9 characteristics listed in DSM-IV • Affect 2 - 3 areas; • school, home or social situations • Complete multidisciplinary evaluation Medical, developmental and behavioral history & R/O: Absence seizures, Learning Disability ↓Hearing

38. Meds Psychostimulants (↑ DA and NE) • stimulates inhibitory CNS • 1st line medication ↑ efficacy = ↑ response • Methylphenidates (MPH): > 6 years • Concerta- 12H duration • Adderal XR- 10-12H duration • Ritalin- 4H Duration & Ritalin LA 8H duration • Daytrana patch- 12H duration (remove after 9H) • SE:√ Tics, ↓ appetite, sleep disruption, • H/A, slight ↑ BP & HR • Contraindications: • TIC disorders: Tourette Syndrome, • Anxiety Disorder • Risk for Abuse Potential

39. Meds Non-stimulant • Inhibits NE (NE Reuptake Inhibitor) • Better for pts who can’t tolerate MPH • atomoxetine (Strattera) • 24H Duration • SE: N & V ↓appetite & wt. Tricyclic antidepressents TCA’s • Blocks re-uptake of NE and 5-HT • imipramine (Tofranil) nortryptyline (Pamelor) • SE: anticholinergic- dry mouth, • Urinary Retention, orthostatic ↓ BP

40. Behavior Therapy • Education & Psychosocial • Consistent approach by family & school • Follow rules • Complete tasks • ↑ Self control • Positive Reinforcement • Time Out • Modify Environment • ↓ Distractions • Predictable • clearly define acceptable behavior & consequences • Diet Therapy?? Not EB (evidence Based) • Limit sugar, aspartame (NutraSweet), Chocolate, Cow’s milk & eggs

41. Autism Spectrum Disorder ASD • Complex neurodevelopmental disorders • Core deficits in 3 areas: • Social Interaction • Verbal & nonverbal communication • Restricted interests, repetitive behaviors & resistant to change • Male 3-4x > Female • Genetic Predisposition: • Affects prenatal & postnatal brain development NO correlation with MMR vaccine • Related Disorders: Pervasive Developmental Disorder (PDD) Asperger’s Syndrome, Childhood Disintegrative Disorder (CDD) Rhett’s Syndrome

42. ASD Clinical Signs • Inappropriate social behavior • Unable to maintain eye contact • Avoid body contact • Lack emotional reciprocity • Impaired expressive & receptive language skills • Delayed echolalia • Inability to sustain or initiate conversation • Repetitive behaviors: • Opening & closing doors, flipping light switches, • H2O play, shredding paper, prefer item movements & ritualistic behaviors • Insist on “sameness” • Self-Stimulatory behaviors: • Finger licking, hand flapping, body rocking, run in circles • Deep pressure stimulation-crawl into tight spaces • Self-injury RT ↟↟ Pain Threshold, aggressive behaviors • GI Symptoms- Constipation ➔Mega rectum

43. Treatment • Developmental Screening • DDST, Modified Checklist for Autism in Toddlers (M-CHAT) • Childhood Autism Rating Scale (CARS) • Physical Exam • Hearing & Vision screening, Neuro, EEG, Metabolic studies (Pb), Genetic testing • Multidisciplinary approach • Early intervention programs • Highly structured and intensive behavior modification programs; • Promote positive reinforcement • Increase social awareness of others • Increase verbal communication skills • Decrease unacceptable behavior • Use brief, concrete communication • Minimal holding & eye contact to avoid outbursts • Gradually introduce new situations • Medications Atypical antipsychotic- Risperidone ↡ behavioral symptoms only

44. Scoliosis • Abnormal lateral curvature • >10% of the spine • Severe type can ↓ thoracic capacity • ↑ risk for osteopenia • Develops in preadolescent growth spurt • Higher risk in females 85%

45. Functional/Idiopathic/Secondary • Most common • Rapid growth & Poor posture • Unequal leg Therapy Exercises PT for posture Shoe Lifts

46. Structural/Congenital/Neuromuscular • Muscle or bone deformity • congenital or result of neuromuscular disorders • S shaped curved with vertebral rotation • Asymmetric • thoracic cavity • scapula, breasts, shoulders and hips • ↑ deformity during periods of growth

47. Therapy Depends on degree of curve • 10-20 degree • observe and follow-up X-Rays q 4-6months • Exercises and improving posture • >20-40 degrees Milwaukee brace-worn 23 hours/day • ↓ compliance (15%) • ↓ comfort and body image • Prevents disease progression • will not resolve current distortion.

48. Therapy • Boston Brace- • low profile (lowest angle) • Thoracolumbar -sacral orthosis • Most widely used • ↑ 61 % compliance • Providence Brace- -New shows promise used only at night!!!! ↑↑ compliance

49. Therapy Surgery- curvature >40% • Harrington Rod- • internal spinal fixation- “flat back” • post-op immobilization required • Lugue Segmental System- • flexible wires threaded through spine- • no post-op immobilization required, • ↑ risk for nerve damage • Spinal fusion for severe scoliosis • Iliac bone graft

50. Post-op Care • Log rolling • Neurovascular checks • Pain management • Skin care • Urinary retention • Mesenteric Artery Syndrome- • Shift of abdominal organs = Abdominal distension/emesis