Transcript Pre-school, school age and adolescent

Pre-school, School age
and Adolescent
Elisa A. Mancuso RNC, MS, FNS
Professor of Nursing
Growth and Development
Preschool 3-5 years
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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!
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.
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Conscience develops along with moral
development
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
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!
Piaget
• Centering
– one characteristic of an object
• Concrete thought process
– Literal
– Magical thinking
– Animism
• Ascribe human characteristics to objects
Developmental Skills
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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!!
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
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Self-Care: Brushes teeth
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Gets dressed ↑ Cooperation
Developmental skills
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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
Socialization
• ↑ Peer interaction & communication
– Learn to relate to others
• Increased cooperation & Sharing
• Conform to expectations
• Enjoy games with simple rules
• PreSchool play– dramatic & creative
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Recognizes sociocultural
differences
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
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
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Puppets, songs, rhymes and games
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!
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
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4 year 20/30-20/40
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5 year 20/20-20/30
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)
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
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Surgery
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
Hearing Impairments
Sensorineural (Nerve deafness)
• Damage or malformation of structures of
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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
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Cochlear implants = Controversy
– American sign language ↑ communication
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
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
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Wide range of physical differences
– Age 7 could look like 10-years or 5-years
– Treat according to their age not appearance!
Psychosocial
Erickson- Industry vs Inferiority
• Industry
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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
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Self-control
Compromise
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
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Parents needed in times of stress
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
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boys @ 13 ½ yrs )
Psychosocial
Freud - Latency period
• Sexuality
– plays less prominent role
• Best friend same sex
• Usually do not want to play with
opposite sex (icky!)
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
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Reversibility
• Opposite function: Addition & Subtraction
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Use thought process to experience events and
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actions & see things from another point of view.
Developmental Skills
6 years
• Period of Transition
• Self centered
– Normal to cheat at board games
• Impulsive
• ↑Activity RT ↑coordination
• ↑Dexterity = drawing & writing
Developmental Skills
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7 years
Quiets down
Solitary play
Attentive
Sensitive listener
Modest (Need Privacy)
Companionable
Developmental Skills
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8 years
Fluctuating Behavior
↑Graceful movements
↑Interest in nature
Very self-critical
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
Development Skills
10 years
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↑ Stamina
Budgets time
↑ Energy
Enjoys family activities
↑ Appetite
Development
11 years
• Moody
• Strict superego-conscience
– Strong morals/values
• Best behavior is away from home
Development
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12 years
↑ Personality integration
↑ Self discipline
↑ Self control
Tactful
Mutual understanding with parents
Developmental Tasks
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↓ Dependence on family
↑ Neuromuscular skills
Must adjust to changes in body image
Develop positive attitude:
– Multicultural
– Social
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Economic groups
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
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
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↓ Self Esteem = ↓ Peer relationships
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↑ Risky Behavior = ↑ Substance Abuse & MVA
Sequela: Conduct, Mood & Anxiety Disorders
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
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Other neurological disorders can impact:
Fragile X, Turner or Klinefelter
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
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:
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TIC disorders: Tourette Syndrome,
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Anxiety Disorder
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Risk for Abuse Potential
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)
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SE: anticholinergic- dry mouth,
Urinary Retention, orthostatic ↓ BP
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
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Diet Therapy?? Not EB (evidence Based)
• Limit sugar, aspartame (NutraSweet),
Chocolate, Cow’s milk & eggs
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
ASD Clinical Signs
• Inappropriate social behavior
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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
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Deep pressure stimulation-crawl into tight spaces
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• Self-injury RT ↟↟ Pain Threshold, aggressive behaviors
GI Symptoms- Constipation ➔ Mega rectum
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
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Gradually introduce new situations
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Medications
Atypical antipsychotic- Risperidone
↡ behavioral symptoms only
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%
Functional/Idiopathic/Secondary
• Most common
– Rapid growth & Poor posture
– Unequal leg
Therapy
Exercises
PT for posture
Shoe Lifts
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
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.
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
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
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Iliac bone graft
Post-op Care
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Log rolling
Neurovascular checks
Pain management
Skin care
Urinary retention
Mesenteric Artery Syndrome– Shift of abdominal organs =
Abdominal distension/emesis
Varicella
• Contagious virus– 1 day before eruption to 1 week
after outbreaks of vesicles
– until all vesicles have crusted over
• Incubation
– 2-3 weeks
Signs and Symptoms
• Low grade temp
• Anorexia
• Rash
– 1st Macular – papular
– 2nd Vesicular → crusted lesions
• Outbreaks occur in crops @↑temp 104
• Trunk → face → upper extremities
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Very itchy (pruritic)
Therapy
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Palliative
Antihistamines (benadryl)
Antipyretics (Calamine lotion)
Acyclovir
– ↓ # of lesions-when given within 24H of rash
– mostly for high risk pt’s
• Varicella zoster immune globulin (VZIG)
– given within 96 hours for high risk pt’s
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Strict isolation in hospital
Lice - Pediculosis Capitus
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Highly contagious infestation of scalp
“itchy” from crawling mites and saliva
↑ @ occipital area
↑ @ night
√ Environment
– Stuffed animals
– Bedding
– Clothing (fur)
Therapy
• Rid/Nix-Permethin 1 %
– One application
– Kills lice and nits.
– Not for kids < 2 years
• Kwell- Lidane
– Two applications
– Repeat in 7-10 days after eggs hatch
Pinworms Enterobiais
• Infects 1/3 of all children
• Contagious
– Inhalation, ingestion or contact
• Worms (intestines) migrate & lay eggs in
anal area @ night
• Very itchy anal area = ↑ scratching
• Spread fecal → fingernails → mouth
• Tape test √ eggs @ anus
• mebendazole (Vermox) > 2 years
– 100mg & repeat in 2 weeks
• pyrantel (Pamoate pin-X) > 2 years
– 11mg/kg & repeat in 2 weeks
Bites/Stings
Allergic response
• May develop anaphylactic shock
• Wheal formation
– Raised & reddened
• Epi-pen Jr 0.01 mL/kg (1:1000) IM
Animal Bites: Dogs/cats
– 80 % punctures/lacerations
– Avulsions (tissue tears)
– ↑ infection risk
• Wash area
• Moist cool compress & dsg
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√ vaccination status (Rabies)
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Plastic surgery
Obesity
• Weight & Body Mass Index (BMI) >95%
– Compare to age, gender and height
– Culturally induced
• 30-40% ↑incidence in 6-11 year olds
• BMI = wt (kg)/ht (m2)
Calculate yearly
√ rate
of ↑↑ wt and ht
Etiology of Obesity
• Diet
– Culturally based
– Fast food/ Junk Food
– ↑ fats ↑ carbs ↓ protein
• ↓ Physical activity
– Computer, video games & TV
• Genes – Family Hx
• Prader Willi Syndrome PWS
– Obesity, hyperphagia, hypogonadism
– Small hands & feet
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Mental Retardation
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70% paternal/30% maternal
Complications
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HTN & ↑ cholesterol @ age 5-10
↑ incidence of Type II diabetes
Obstructive Sleep Apnea (OSA)
Cardiac disease
Gallstones
Orthopedic problems
↓ Self-Esteem
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Social Isolation
Therapy
• Nutritional Counseling
– Home & School
– change family eating patterns
• Behavior Modification
– Healthy lifestyle habits
– ↑ physical activity q day 30 -90 minutes
– ↓ computer/video time
– ↑ H20 intake & ↓ juice/soda
• Recognize and monitor associated risks for
chronic diseases
No Gastric Bypass surgery <age 18
Adolescence 12-18 years
• Until physically and psychologically mature
• Self-sufficient
• Puberty
– Period of physiological changes.
– Sex organs mature, menses, spermatoza
• Growth spurt
– Reach adult height by age 17
– Increase in height 2.5 inch -5 inches
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Girls @ 12
Boys @ 14-15
– Need ↑ nutrition
Tanner stages
Sexual Maturity Rating Scale
• Stages I-V
• Male secondary sex characteristics
– Androgen
• ↑ muscle & skeletal growth
– Testosterone
• ↑ facial/body hair
• spermatogenesis
• Female secondary sex characteristics
– Estrogen
↑ epiphysis ossification
↑ adipose deposits
Ovum maturation
Psychosocial development
• Identity Formation vs Role Confusion
– Individuality
– Internal Stability
– Achieve Sense of Self
• Occupation/Future Goals
• Social Development
– FRIENDS!! >> Family
– Peer pressure
– Recognition via group identity
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Dating groups vs. individual
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Sexual intimacy
Cognitive Development
• Piaget - Formal Operations (11-15)
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Abstract thinking
Future Oriented
Scientific Reasoning
↑↑ Range of Logic
• Developmental Tasks
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Accept body changes
Achieve satisfying sex-related role
Achieve independence & warm relationship with parents
Develop mature set of values, work ethic & occupation
ACNE
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Health Problems
Inflammatory Disease ↑ @ age 17
– Males > Females
– 17 million kids/year
– clogged sebaceous glands
– androgens stimulate secretions
– bacteria = inflammation
Therapy
Topical Antibiotics- Cleocin, EES
PO Antibiotics - Tetracycline
Antibacterial - Benzoyl Peroxide
Tretinoin (Retin A)
interrupts keratin formation
use @ night Sunshine ↓ efficacy
Isotretinoin Retinoic Acid (Accutane)
SE: depression & Teratogenic
↟ congenital defects
Document if sexually active
√ HCG q month
Health Problems
• Cardiac
– ↓ Growth of heart = ↓ SV
– ↓ Ability to meet O2 needs & ↑ BMR = fatigue
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Sports physical
• Drug use
– ETOH, Marijuana, Coke, E, Special K, LSD, Heroin
• Pregnancy & STDs
– Early pregnancy @ age 12-14
– HPV (80%), HIV
– ↑ Chlymydia, genital warts, Hep B & C
• Depression and suicide
• ↑ risk @ age 14
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25 % feel sad/hopeless q day more than 2 weeks
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20 % seriously consider suicide
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10 % attempted suicide
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Boys successful RT violent method
Anorexia Nervosa
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Preoccupation with food
Distorted body image
↑ Need for control
↑ Pressure to be thin
↑ Intense fear of being fat
Review from NUR 136