Health Promotion of the School-Age Child and Family

Physical Changes

School-age children are more graceful than they were as preschoolers, and they are steadier on their feet. Their bodies take on a slimmer look with longer legs, varying body proportions, and a lower center of gravity. Posture improves over that of the preschool period to facilitate locomotion and efficiency in using the arms and trunk. These proportions make climbing, bicycle riding, and other activities much easier. Fat gradually diminishes, and its distribution patterns change, which contributes to the thinner appearance of children during the middle years.

Accompanying the skeletal lengthening and fat diminution is an increase in the percentage of body weight represented by muscle tissue. By the end of this age period, both boys and girls have doubled their strength and physical capabilities, and their steady and relatively consistent acquisition of refined coordination increases their poise and skill. However, this increased strength is often misleading. Although strength increases, muscles are still functionally immature when compared with those of the adolescent, and they are more readily injured by overuse.

The most pronounced changes that seem best to indicate increasing maturity in children are a decrease in head circumference in relation to standing height, a decrease in waist circumference in relation to height, and an increase in leg length related to height. These indicators often provide a clue to a child’s degree of maturity and have proved useful in predicting readiness for meeting the demands of school. There appears to be a correlation between physical indicators of maturity and success in school.

Certain physiologic and anatomic characteristics are typical of school-age children. Facial proportions change as the face grows faster in relation to the remainder of the cranium. The skull and brain grow very slowly during this period and increase little in size thereafter. Because all of the primary (deciduous) teeth are lost during this age span, middle childhood is sometimes known as the age of the loose tooth (Fig. 17-1) and the early years of middle childhood as the ugly duckling stage, when the new secondary (permanent) teeth appear to be much too large for the smaller face.

Maturation of Systems

As the gastrointestinal system matures, the child has fewer stomach upsets; better maintenance of blood sugar levels; and an increased stomach capacity, which permits retention of food for longer periods. The school-age child does not need to be fed as carefully, as promptly, or as frequently as before. Caloric needs are lower than they were in the preschool years and lower than they will be during the coming adolescent growth spurt.

Physical maturation occurs in other body tissues and organs. Bladder capacity, although differing widely among individual children, is generally greater in girls than in boys. There are individual variations in frequency of urination and differences in the same child according to circumstances such as temperature, humidity, time of day, amount of fluids ingested, and emotional state.

The heart grows more slowly during the middle years and is smaller in relation to the rest of the body than at any other period of life. Heart and respiratory rates steadily decrease, and blood pressure increases between ages 6 to 12 (see inside back cover).

The immune system becomes more competent in its ability to localize infections and produce an antibody-antigen response. Because of increased exposure to others in school classes, children can have several infections in the first 1 to 2 years of school while immunity develops.

Bones continue to ossify throughout childhood, but because mineralization is not completed until maturity, children’s bones resist pressure, and muscles pull less than with mature bones. Consequently, parents must be careful to prevent alterations in bone structure and provide children with well-fitted shoes and with chairs and desks that allow correct sitting posture with the feet able to reach the floor and the hips able to fit well back in the seat. Children should have ample opportunity to move around and be cautious about carrying heavy loads. For example, they should shift books and/or tote bags from one arm to the other. Back packs, when worn correctly, distribute weight more evenly.

Wider differences between children are seen at the end of middle childhood than at the beginning; such differences are sometimes striking. These differences become increasingly apparent and, if extreme or unique, may create emotional problems. The nurse should explain the associated characteristics of height and weight relationships, rapid or slow growth, and other important features of development to children and their families. Physical maturity is not necessarily correlated with emotional and social maturity. Seven-year-old children who look like 10-year-old children will think and act like 7-year-olds. To expect behavior appropriate for 10-year-old children from them is unrealistic and can be detrimental to their development of competence and self-esteem. Conversely, to treat 10-year-old children as though they were 7 years old is an equal disservice to them.

Prepubescence

Preadolescence is the period that begins toward the end of middle childhood and ends with the thirteenth birthday. Puberty signals the beginning of the development of secondary sex characteristics, and prepubescence, the 2-year period that precedes puberty, typically occurs during preadolescence.

Toward the end of middle childhood the discrepancies in growth and maturation between boys and girls become apparent. On the average, there is a difference of approximately 2 years between girls and boys in the age of onset of pubescence. For many, especially for girls, preadolescence is a period of rapid growth. For others, mostly boys, it is generally a period of continued steady growth in height and weight.

There is no universal age at which children assume the characteristics of preadolescence. The first physiologic signs appear at about 9 years (particularly in girls) and are usually clearly evident in 11- to 12-year-old children. Although preadolescent children do not want to be different, variability in physical growth and physiologic changes among children of the same sex, and between the two sexes, is often striking at this time. This variability, especially in relation to the onset of secondary sex characteristics, is of utmost concern to the preadolescent. Either early or late appearance of these characteristics is a source of embarrassment and uneasiness to both sexes. Early appearance of secondary sex characteristics in girls is often associated with dissatisfaction with physical appearance, greater general unhappiness, and lower self-esteem. Late-developing boys often have a negative self-concept. Both early appearance of physical characteristics in girls and late appearance in boys have been linked to participation in risk-taking behaviors (early sexual activity, substance use, and reckless vehicle use).

Preadolescence is a time when considerable overlapping of developmental characteristics occurs, with elements of both middle childhood and early adolescence apparent. However, there are sufficient unique characteristics to set this period apart as an age category. Generally, puberty begins no earlier than 10 years in girls and 12 years in boys, but its onset in either sex after the age of 8 years is considered normal. The average age of puberty is 12 years in girls and 14 years in boys. Boys experience little sexual maturation during preadolescence.

Developing a Sense of Industry (Erikson)

Successful mastery of Erikson’s first three stages of psychosocial development is probably the most important accomplishment in terms of development of a healthy personality (Erikson, 1963). Successful completion of these stages requires a loving environment within a stable family unit that has prepared the child to engage in experiences and relationships beyond this intimate group. During childhood, children affiliate with age-mates, receive the systematic instruction prescribed by their individual cultures, and develop the skills needed to become useful, contributing members of their social communities.

A sense of industry, or a stage of accomplishment, occurs somewhere between age 6 years and adolescence. The goal of this stage of development is to achieve a sense of personal and interpersonal competence through the acquisition of technologic and social skills. School-age children are eager to build skills and participate in meaningful and socially useful work. Interests expand, and, with a growing sense of independence, children want to engage in tasks that they can complete (Fig. 17-2). Failure to develop a sense of accomplishment may result in a sense of inferiority.

Many aspects of industry contribute to the child’s sense of competence and mastery. Intrinsic motivation is associated with increased competence in mastering new skills and assuming new responsibilities. Children gain a great deal of satisfaction from independent behavior in exploring and manipulating their environment and from interaction with peers. Extrinsic sources of reinforcement in the form of grades, material rewards, additional privileges, and recognition provide encouragement and stimulation. Often the acquisition of skills is a means for achieving success in special activities such as athletics or social organizations. Peer approval is a strong motivating factor.

The danger inherent in this period of personality development is the occurrence of situations that might result in a sense of inadequacy or inferiority. This may happen if the previous stages have not been successfully mastered or if a child is incapable of or unprepared to assume the responsibilities associated with developing a sense of accomplishment. Feelings of inferiority or lack of worth come from children themselves or from the social environment. Children with physical or mental limitations are sometimes at a disadvantage for acquisition of certain skills. When the reward structure is based on evidence of mastery, children who are incapable of developing these skills are at risk for feeling inadequate and inferior.

Even children without chronic disabilities show such a wide range of individual differences in capabilities and preferences that they experience feelings of inadequacy in some areas. No child is able to do well in everything, and children must learn that they will not be able to master each skill that they attempt. All children, even children who in most instances have positive attitudes toward work and their own capabilities, feel some degree of inferiority in regard to a specific skill that they cannot master.

For some children, success or aptitude in one area may compensate for failure or ineptitude in another. However, the differences in reinforcement provided for success in various areas have significant effects on feelings of adequacy. For example, in the United States, reading proficiency is more highly rewarded than the mechanical aptitude needed for tinkering with broken automobile engines. Society places a higher value on success in team sports than on success in repairing a bicycle. Compensating for the inability to excel in more socially valued skills through mastery of other, less valued skills is difficult for children. If the social environment places a negative value on any failure, feelings of inferiority may be increased in the less capable child. Repeated failures can generate such strong feelings that eventually the child is reluctant to attempt any new task or is fearful of not being able to perform as well as his or her peers. Thus intrinsic motivation toward engaging in a task for the pleasure of the challenge conflicts with the external forces that cause feelings of doubt and inferiority. Consequently, the child may no longer try.

A child’s concept of success or failure is important. Children who aspire to more than they are capable of usually experience failure. In contrast, children who set their aspirations lower than their level of achievement are likely to experience success. Most accomplishments during the school years are very public. Family, teachers, and peers are all aware of success or failure in school. In school and sometimes at home, feelings of inferiority may be produced through comparisons with others that suggest the child is not as good as a peer, sibling, or member of another group. This inadequacy becomes a source of embarrassment. The child may even be shamed for the failure. Earlier conflicts of doubt and guilt are closely associated with feelings of inferiority.

A sense of accomplishment also involves the ability to cooperate, to compete with others, and to cope effectively with people. Middle childhood is the time when children learn the value of doing things with others and the benefits derived from division of labor in the accomplishment of goals. Children need and want real achievement. When they can accomplish tasks that need to be done and perform well despite individual differences in capacities and emotional development, and when they are suitably rewarded, children develop a sense of industry and accomplishment that prepares them for establishing a stable identity later in life.

1. Identity—Because nothing has been added and nothing has been taken away, the pancake is still the same clay. Nothing has changed but the shape.

2. Reversibility—The clay can be reshaped into its original form (a ball).

3. Reciprocity—Although the pancake appears larger in circumference, the ball is much thicker. In this instance the child demonstrates the ability to deal with two dimensions at the same time and to comprehend that a change in one dimension compensates for a change in another.

Social Relationships and Cooperation

Daily relationships with age-mates provide the most important social interactions for school-age children. For the first time, children are able to join in group activities with unrestrained enthusiasm and steady participation. Previously, interactions were limited to short periods under considerable adult supervision. With increased skills and wider opportunities, children become involved with one or several peer groups in which they can gain status as respected members.

Valuable lessons are learned from daily interaction with age-mates. First, children learn to appreciate the numerous and varied points of view that are represented in the peer group. As they play together, children discover that there are many occupations for fathers and mothers, more than one version of the same song, different rules for the same game, and different customs for celebrating the same holiday. As children interact with peers who see the world in ways that are somewhat different from their own, they become aware of the limits of their own point of view. Because age-mates are peers and are not forced to accept one another’s ideas as they are expected to accept those of adults, other children have a significant influence on decreasing the egocentric outlook of the individual child. Consequently, children learn to argue, persuade, bargain, cooperate, and compromise to maintain friendships.

Second, children become increasingly sensitive to the social norms and pressures of the peer group. The peer group establishes standards for acceptance and rejection, and children may be willing to modify their behavior to be accepted by the group. They are judged by the physical impression they convey, the skills they possess, and other abilities they can demonstrate. The need for peer approval becomes a powerful influence toward conformity. Children learn to dress, talk, and otherwise behave in a manner acceptable to the group. A variety of roles, such as class joker or class hero, may be assumed by the individual child to gain approval from the group. However, no child can adapt perfectly to all the requirements of the peer group. If some children find differences between the values of the peer group and the values of their families to be too great, they may relinquish the pleasure of interaction with the group to abide by the regulations established in the home. Thus, to diminish conflict within the family, some children may be forced into a position outside the peer group.

Third, the interaction among peers leads to the formation of intimate friendships between same-sex peers (Fig. 17-6). School age is the time when children have “best friends” with whom they share secrets, private jokes, and adventures; they come to one another’s aid in times of trouble. In the course of these friendships, children also fight, threaten, break up, and reunite. These dyadic relationships, in which children experience love for and closeness with a peer, seem to be important as a foundation for heterosexual relationships in adulthood. The conflicts encountered in the relationship are usually resolved in terms that children are able to control. Because neither child has authority over the other, as in an adult-child relationship, children must work through their differences within the framework of their commitment to each other.

Relationships with Families

Although the peer group is highly influential and necessary to normal child development, parents are the primary influence in shaping children’s personalities, setting standards for behavior, and establishing value systems. Family values usually predominate when parental and peer value systems come into conflict. Although children may appear to reject parental values while testing the new values of the peer group, ultimately they retain and incorporate many parental values into their own value systems. Peer associations seem to remain within the social class system.

As children move into a wider world of peer-group relationships, parents are faced with the task of letting go of control. Parents may find it difficult to face the rejection that children demonstrate as they become more involved with their peer groups. Children may want to spend more time in the company of their peers, may seem eager to leave the house, and often prefer activities of the peer group to family activities. During this time, children discover that parents can be wrong, and they begin to question the knowledge and authority of the parents who previously were considered to be all-knowing and all-powerful. Parents can best serve the interests of their children through tolerant understanding and support.

Although increased independence is the goal of middle childhood, children are not yet prepared to abandon parental control. Children need and want restrictions placed on their behavior; they are not yet prepared to cope with all of the problems of their expanding environment. They feel more secure knowing that there is an authority greater than themselves to implement controls and restrictions. Children may complain loudly about the restrictions and try to break down parental barriers, but they are uneasy if they succeed in doing so. Children feel secure with reasonable, consistent controls. They respect the adults on whom they can rely to prevent them from acting on each and every urge. Children see this behavior as an expression of love and concern for their welfare.

Children also need their parents as adults, not as “pals.” Sometimes parents, hurt by their children’s rejection, attempt to maintain their children’s love and gratitude by assuming the role of pal. Children need the stable, secure strength provided by mature adults to whom they can turn during troubled relationships with peers or stressful changes in their world. During a disruption in their lives, such as times of failure, periods of illness, or a move that separates them from the security of friends, children need the firm, secure anchor of parental interest and concern. With a secure base in a loving family, children are able to develop the self-confidence and maturity needed to stand independently.

Children’s relationships with siblings change during the middle years. Children view siblings as equal in power and status. In earlier years, older siblings were influential in the younger siblings’ learning. In the middle years the relationship becomes one of companionship. Positive emotional tone increases, but sibling conflict also increases as the siblings get older. Middle childhood is a period of transition for sibling relationships, a juncture between the open bickering of early childhood and the supportive relationships observed in adult siblings.

Body Image

Body image is what children think about their bodies. School-age children are knowledgeable about the human body, and social development during this period focuses to a large extent on the body and its capabilities. School-age children can draw a recognizable human figure, although individually their portrayal of body parts may vary considerably. They are acutely aware of their own bodies as well as those of their peers and those of adults. It is important that children know body functions and that adults correct any misinformation children have about the body (e.g., what is fat).

During the school years, children focus on peer relationships and conform to group norms. They evaluate how their physical appearance, body configuration, and coordination compare with those of their peers. The head is the most noticeable and, to them, important part of the body. They also model themselves after their parents and compare themselves to favored peers and images observed in the media.

Children are aware of physical disabilities in others, and it is not unusual for them to believe that their own bodies are not the right size or the right shape or are in some way defective. They respond to such concerns in a variety of ways. For example, they will conceal perceived shortcomings of body or performance, as in the obese child who refrains from going swimming, the child who conveniently forgets a gym suit, the child who conceals an imagined defect, or the child with enuresis who declines invitations to slumber parties. Children seldom express these concerns to families. However, they need reassurance about both the uniqueness and the sameness of their bodies while their privacy is respected and they are allowed appropriate protective strategies. Children who are different become aware of the differences and may find themselves excluded from the group. When children are teased or criticized about being different, the effect can last even into adulthood.

Self-Esteem

Self-esteem is children’s pictures of their individual worth and consists of both positive and negative qualities. Children actively strive to achieve internalized goals. At the same time, they continually receive feedback on the quality of their performance from individuals they consider to be authorities. By the time they reach school age, children have received messages regarding the extent to which they are able to accomplish tasks that have been delegated to them. For example, one child may have been given prestigious responsibilities at home or at school or received special commendation for an achievement. On the other hand, another child may have been sent to a special class for slow learners or may have been the last person selected when children chose sides for a game. These and other signs serve as clues to social worth that children incorporate as part of their self-evaluation.

Children approach the process of self-evaluation from a framework of either self-confidence or self-doubt. Children who have mastered the maturational crises of autonomy and initiative are able to face the world with feelings of pride rather than shame. At first, children’s self-concepts are formed exclusively from their perceptions of their parents’ evaluation of them. During middle childhood the opinions of peers and teachers are important. Criticisms and peer approval are additional sources of data for evaluation. Parents and other adults are no longer the only persons who respond to their skills, talents, and abilities; peers also identify skills and capabilities. Each child soon begins to internalize these outside opinions. If children regard themselves as worthwhile or satisfactory persons, they have high self-esteem, self-confidence, and a positive self-concept. If they view themselves as worthless, they have low self-esteem.

Pets also influence a child’s self-esteem. Pets can have a positive effect on physical and emotional health and can teach children the importance of nurturing and nonverbal communication (Podberscek, 2006).

Children encounter difficulties assessing their own abilities because they rely on their own expectations or on the expectations expressed by others regarding their performance. They depend almost entirely on external evidence of worth, such as school grades, teachers’ comments, and parental and peer approval. Children do not yet have the capacity to develop their own independent criteria to evaluate their own accomplishments. It is especially difficult for them to assess their achievement in abstract skills.

Nothing succeeds like success. Significant adults in children’s lives can often manage to manipulate the environment so that children meet with success. Each small success can improve a child’s self-image. The more positive children feel about themselves, the more confident they feel in trying again for success. All children profit from feeling that they are special to significant adults. A positive self-image makes them feel likable, worthwhile, and capable of valuable contributions. Such feelings lead to self-respect, self-confidence, and a general feeling of happiness. Parents can help their school-age children develop self-esteem by being honest, by providing opportunities for creativity, by helping them succeed in activities, and by providing positive reinforcement. Nurses can enhance self-esteem by fostering supportive relationships between children and members of their families and by emphasizing children’s strengths and positive aspects of their behavior (see Community Focus box).

Sex Education

Parents may not teach young children the correct terminology for sexual organs or sexual feelings. Often the only vocabulary available to children is one that identifies sexual organs with excretory functions. If children learn that excretory organs and functions are dirty, they may associate “dirtiness” with the reproductive organs and functions. If children learn the correct terminology for the organs and their functions, this will eliminate or reduce this association.

Because parents often either repress or avoid their children’s sexual curiosity, sexual information received in childhood may be acquired almost entirely from peers. Such information is often transmitted in secret conversations and contains considerable misinformation. These communications can also create anxiety in children and inhibit spontaneous expressions or questioning of their parents.

Although middle childhood is an ideal time for formal sex education, this subject has created considerable controversy. Many parents and groups are unconditionally opposed to the inclusion of sex education in the schools. Others believe that information relating to sexual maturation and the process of reproduction should be presented as naturally as information about other natural phenomena, such as the growth of plants, the changing seasons, and the migratory habits of birds. When sex education is presented from a life span perspective and treated as a normal part of growth and development, the information is less likely to contain overtones of uncertainty, guilt, or embarrassment that could in turn produce anxiety in children.

Sex education programs have been successfully incorporated into a number of elementary school curricula. In many of these programs, sexuality is presented in the context of its central role as a biologic mechanism for the survival of the culture. Children learn that sexual maturation and reproduction represent each individual’s contribution to the natural order of things. This approach provides a natural entry into discussion of sexuality as a basis for family units, marriage, and attitudes toward children, as well as an entry into a presentation of the biologic facts of sexuality. Many sex education programs also emphasize that sexual intimacy is part of a close, personal relationship and a means of conveying love, as well as a means for ensuring the survival of the species.

Nurse’s Role in Sex Education

No matter where nurses practice, they can provide information on human sexuality to both parents and children. To discuss the topic adequately, nurses must understand the physiologic aspects of sexuality; know the common myths and misconceptions associated with sex and the reproductive process; understand cultural and societal values; and be aware of their own attitudes, feelings, and biases.

When nurses present sexual information to children, they should treat sex as a normal part of growth and development. Nurses should answer questions honestly, matter-of-factly, and at the child’s level of understanding. School-age children may be more comfortable when boys and girls are segregated for discussions; however, each group needs information about both sexes.

Children need help to differentiate sex and sexuality. Exercises focused on clarifying values, identifying role models, solving problems, and accepting responsibility are important to prepare school-age children for early adolescence and puberty. In addition, care providers need to explain sexual information that is discussed via the media or jokes. A comprehensive sex education program including information about abstinence, contraception, and birth control methods should be presented during the middle school years (Eisenberg, Bernat, Bearinger, et al, 2008). Teaching a child to be sexually responsible is an important component of sex education. Health care providers should supply specific information concerning sexually transmitted infections, human immunodeficiency virus (HIV), and acquired immunodeficiency syndrome (AIDS). Anticipatory guidance should include information about prevention, transmission, and implications of sexually transmitted infections.

Preadolescents need precise and concrete information that will allow them to answer questions such as “What if I start my period in the middle of class?” or “How can I keep people from telling I have an erection?” It is important to tell them what they want to know and what they can expect to happen as they mature sexually.

During encounters with parents, nurses can be open and available for questions and discussion. They can set an example by the language they use in discussing body parts and their function and by the way in which they deal with problems that have emotional overtones, such as exploratory sex play and masturbation. Parents need help to understand normal behaviors and to view sexual curiosity in their children as a part of the developmental process. Assessing the parents’ level of knowledge and understanding of sexuality provides cues to their need for supplemental information that will prepare them for increasingly complex explanations as their children grow older.

Children with developmental disabilities need emotional and sexual relationships. Parents of children with developmental disabilities may need special assistance and help with sex education. In 1996 the American Academy of Pediatrics developed specific guidelines that discuss ways to teach these children about human anatomy, pubertal changes, expression of physical affection, protection from sexual abuse or exploitation, and independence in personal hygiene and self-care. Sex education for children with disabilities requires individualized techniques, depending on the type and degree of disability (Murphy and Young, 2005). Nurses must bring the issue of sexuality out in the open and promote the idea that sexuality is a part of every individual’s identity in order to address educational needs (Murphy and Young, 2005).

Sometimes participation in short classes or group discussions can help parents address disturbing behaviors and anticipate their children’s questions and learning needs. It is wise to include both parents in such activities when possible. Both parents should assume responsibility for sex education in the home so that the children will not acquire a distorted view of either the male or the female role that may alter relationships with the opposite sex in later life.

Rules and Rituals

The need for conformity in middle childhood is strongly manifested in the activities and games so important in the life of school-age children. Up to this point, they have either played games they have invented themselves or have played in the company of a friend or an adult, and rules more or less evolved with the game. Now they begin to see the need for rules, and the games they play have fixed and unvarying rules that may be bizarre and extraordinarily rigid (especially those made up by the group). But part of the enjoyment of the game is knowing the rules, because knowing means belonging. Once the rules are established and agreed on, the demand for conformity is strong (Fig. 17-7).

Conformity and ritual characterize the play of school-age children, not only in games, but also in behavior and language. Childhood is full of chants and taunts, such as “Eeny, meeny, miney, mo,” “Last one is a rotten egg,” and “Step on a crack, break your mother’s back.” Children receive a great deal of pleasure and power from such sayings, which have been handed down with few changes through generations.

Quiet Games and Activities

Although the play of school-age children can be highly active, they also enjoy many quiet and solitary activities. The middle childhood years are the time for collections, and young school-age children’s collections are an odd assortment of unrelated objects in messy, disorganized piles. Collections of later years are more orderly and selective and often are organized neatly in scrapbooks, on shelves, or in boxes.

School-age children become fascinated with increasingly complex board, card, and computer games. Children play these games alone or in groups. As in all games, the adherence to rules is fanatic. There is usually much discussion and argument, but children easily resolve disagreement by learning the appropriate rules of the game.

The newly acquired skill of reading becomes increasingly satisfying as school-age children begin to expand their knowledge of the world through books (Fig. 17-9). School-age children never tire of stories, and, like preschool children, they love to have stories read aloud. They also enjoy sewing, cooking, carpentry, gardening, and creative endeavors such as painting. Many creative skills, such as those involving music and art, and athletic skills, such as swimming, riding, hiking, dancing, and karate, are acquired during childhood and continue to be enjoyed into adolescence and adulthood (Fig. 17-10).

Hero worship is another characteristic of children and adolescents. The object of the adoration can be a friend, relative, teacher, or national sports or entertainment figure. However, problems can arise when the idol proves to be an inappropriate role model.

Ego Mastery

Play also affords children the means to acquire representational mastery over themselves, their environment, and other persons. Through play, children can feel as big, as powerful, and as skillful as their imaginations will allow, and they can attain vicarious mastery and power over whomever and whatever they choose. They need to feel in control in their play. School-age children still need the opportunity to use large muscles in exuberant outdoor play and the freedom to exert their newfound autonomy and initiative. They need space in which to exercise large muscles and to work off tensions, frustrations, and hostility. Physical skills practiced and mastered in play help to develop a feeling of personal competence, which contributes to a sense of accomplishment and helps provide a place of status in the peer group.

Table 17-1 presents a summary of growth and development in middle childhood. Because each child has a unique developmental pattern, any descriptions of the typical child of any age-group can represent only an average and should not be considered as absolute criteria for any given child.

Anticipatory Socialization

By the time they enter school, most children have a fairly realistic concept of what school involves. They receive information regarding the role of pupil from parents, playmates, and the media. In addition, most children have had experience with daycare or preschool and kindergarten.

Children’s attitudes toward school and the extent of their adjustment are strongly influenced by their parents’ attitudes. Middle-class children have fewer adjustments to make and less to learn about expected behavior because the school tends to reflect dominant middle-class customs and values, although this may be tempered by the school’s location and predominant teachers and student body. Parents who view school as a place that they have helped to create and support and that is directed toward the same objectives for socialization as their own usually prepare their children with useful anticipatory socialization and furnish them with confidence to meet the challenge. Parents who view the school as an alien culture and one that they have little, if any, power to affect may unknowingly teach their children to be fearful and resentful toward school, even though the parents agree with its purposes and objectives.

The television, which influences the acquisition of information and attitudes, also provides anticipatory socialization. Television viewing has the potential to increase a child’s vocabulary, extend the child’s horizons, and enrich the school experience. However, television relies heavily on images to convey information. Consequently, it is difficult to explore complex issues by this medium. Extensive television viewing may also encourage children to seek simple answers to tough problems and to believe that violence is the most effective and quick solution to conflict.

Although most children have had some experience with schooling before they enter the first grade, the extent to which early childhood education prepares children for primary school varies. Some preschool programs provide custodial care; others also emphasize emotional, social, and intellectual development. Early childhood programming that stresses cognitive more than social aspects appears to be more effective in facilitating later academic achievement.

Role of the Teacher

To facilitate the transition from home to school, teachers should have personality characteristics that allow them to deal with the needs of young children. Because they react to the teacher on the basis of past experience, children respond best to teachers with attributes that they would find in a warm, loving parent. As a parental surrogate, teachers in the early grades perform many of the activities formerly assumed by the parents, such as recognizing the children’s personal needs (e.g., a need to go to the bathroom or for assistance with clothing) and helping to develop their social behavior (e.g., manners).

Teachers, like parents, are concerned about the psychologic and emotional welfare of children. Although the functions of teachers and parents differ, both place constraints on behavior, and both are in a position to enforce standards of conduct. However, the teacher’s primary responsibility is stimulating and guiding children’s intellectual development as opposed to providing for their physical welfare beyond the school setting.

Teachers share the parental influence in shaping a child’s attitudes and values. They serve as models with whom children can identify and whom they try to emulate. Children seek a teacher’s approval and avoid a teacher’s disapproval. The teacher is a significant person in the life of the early school-age child, and hero worship of a teacher may extend into late childhood and preadolescence. It is not uncommon for the first or second grader to be heartbroken and tearful at leaving a familiar teacher at the end of the school term or to be upset when faced with a substitute teacher for even a short period.

Children’s interest in school and learning and much of their social interaction and self-concept are related to interactions with the teacher (Fig. 17-11). The differential systems of reward and punishment administered by teachers affect the emotional adjustment and self-concept of children and how they respond to school in general.

The interaction between the teacher and an individual pupil affects the pupil’s acceptance by other children, which in turn affects the child’s self-concept. Behaviors praised by the teacher usually acquire a positive value, whereas those viewed negatively by the teacher are devalued by the children. In this way the teacher exerts considerable influence in a number of areas, such as attitudes toward minority groups, the disabled, or less favorably endowed children. Teacher approval of children and their self-acceptance are closely related.

The teacher sets the emotional tone of the classroom. Those who are able to establish a positive social climate are usually concerned about the mental health and social dynamics of children. Feeling a responsibility for personality development in their pupils, they are alert and sensitive to a child’s anxieties, peer-group relationships, self-concepts, and general attitudes toward school. Learner-centered behaviors, such as supportive statements that reassure or commend children, accepting and clarifying statements that help them refine ideas and feelings to provide a sense of being understood, and constructive assistance that aids them with their own problem solving, contribute to the expansion and development of a positive self-concept.

Role of the Parents

Parents share responsibility with the schools for helping children achieve their maximum potential. Parents can supplement the school program in numerous ways (see Family-Centered Care box). Cultivating responsibility is the goal of parental assistance. Being responsible for schoolwork helps children learn to keep promises, meet deadlines, and succeed at their jobs as adults. Responsible children may occasionally ask for help (e.g., with a spelling list), but usually they like to think through their work by themselves. Excessive pressure or lack of encouragement from parents may inhibit the development of these desirable traits.

Dishonest Behavior

During middle childhood, children may engage in what is considered to be antisocial behavior. Lying, stealing, and cheating may become manifest in previously well-behaved children. This is especially disturbing to parents, who may have difficulty coping with such behavior.

Lying can occur for a number of reasons. Preschool children often have difficulty distinguishing between fact and fantasy. They do not have the cognitive capacity to deliberately mislead. Sometimes they misperceive or fail to remember an event. By the time they reach school age, they still tell stories but can distinguish between what is real and what is make-believe. If not, they need to learn to distinguish between fantasy and reality. Often children will exaggerate a story or situation as a means to impress their family or friends.

Young children lie to escape punishment or get out of some difficulty, even when the evidence of their misbehavior is before their eyes. Lying is more common in families in which punishment is severe. When parents model honesty and veracity, the children will often behave in the same way. If parents lie, the children will emulate their behavior. Older children may lie to meet expectations set by others to which they have been unable to measure up. They may also lie because of low self-esteem or as a means of getting ahead or acquiring something with little effort. However, most children are concerned with the wrongfulness of lying and cheating—especially in their friends. They are quick to tell on others when they detect cheating.

Parents need to be reassured that all children lie sometimes and that they often have difficulty separating fantasy from reality. Providers should help parents to understand the importance of their own behavior as role models and of being truthful in their relationships with children. Parents can discuss the issue with the children directly to impress on them how much of their own security and respect is lost when they are not believed.

Cheating is most common in young children, ages 5 to 6 years. They find it difficult to lose at a game or contest, and they cheat to win. They have not yet acquired the full realization of the wrongfulness of this behavior and do it almost automatically. It usually disappears as they mature. However, when children observe parental behaviors such as boasting about cheating on income taxes, they assume this to be appropriate behavior. Parents need to be aware of the types of behaviors they model for their children. When they set examples of honesty, children are more likely to conform to these standards.

As with other ethically related behavior, stealing is not an unexpected event in the younger child. Between ages 5 and 8 years, children’s sense of property rights is limited; they tend to take something simply because they are attracted to it, or they take money for what it will buy. They are equally likely to give away something valuable that belongs to them. When young children are caught and punished, they are penitent—they “didn’t mean to” and promise “never to do it again,” but they may well repeat the performance the following day. Often they not only steal but lie about it as well or attempt to justify the act with excuses. It is seldom helpful to trap children into admission by asking directly if they did the offensive thing. Children do not take on such responsibility until nearer the end of middle childhood.

Children steal for several reasons: lack of a sense of property rights, an attempt to acquire the means with which to bribe other children for favors, a strong desire to own the coveted item, or a wish for revenge to “get back at someone” (usually a parent) for what they consider to be unfair treatment. Older children may steal to supplement an inadequate income from other sources. Sometimes stealing is an indication that something is seriously wrong or lacking in the child’s life. Children may steal to make up for a perceived lack of love or another satisfaction.

In some settings in which living arrangements are crowded, children have little privacy, and much of the family property is communal, children may fail to develop a sense of property rights. Sometimes parents unintentionally confuse children with seemingly conflicting values. In an attempt to teach unselfishness, they may force children to share belongings with others, with the result that the children fail to understand property rights.

If children are told not to take money from their mother’s purse or their father’s pocket but observe the parents doing the same thing, they receive conflicting messages. Parents may go through a child’s pockets or other private areas at night and even discard, without explanation, items of which they do not approve. Children should have a place that is private to them alone that other family members respect. If children’s personal rights are respected, they are more likely to respect the rights of others.

It is difficult for many parents to cope with stealing by their children. In most situations it is best not to attempt to find a hidden or deep meaning to the stealing. A reprimand, together with an appropriate and reasonable punishment, such as having the older child pay back the money or return the stolen items, will ordinarily take care of most cases. Most children can learn to respect the property rights of others with little difficulty despite temptations and opportunities. Some children simply need more time to learn the importance of the culture’s rules regarding private property.

Fears

Several anxiety symptoms, including fear of the dark, excessive worry about past behavior, self-consciousness, social withdrawal, and an excessive need for reassurance, are considered normal developmental events for children. School-age children are less fearful of body safety than they were as preschoolers, although they still fear being hurt, kidnapped, or having to undergo surgery. They also fear death and are fascinated by all aspects of death and dying. They have less fear of noises, darkness, storms, and dogs. Most new fears that trouble school-age children are related to school and family (e.g., fear of failing, fear of teachers and bullies, or fear of something bad happening to their parents).

Parents and other persons involved with children should discuss children’s fears with them individually or through group activities. Their viewpoints must be respected, and their need to communicate their concerns should be recognized. Sometimes school-age children are inclined to hide their fears to avoid being ridiculed or labeled as a “baby” or “chicken.” Hiding fears does not end them, and children who are afraid to communicate their fears may develop displaced fears or phobias. Children need to know that their concerns are heard and understood. Parents who convey this to their children without becoming overprotective help their children to feel less lonely and less frightened.

Latchkey Children

The term latchkey children is used to describe children in elementary school who are left to care for themselves before or after school without supervision of an adult (Fig. 17-12). The increasing numbers of single-parent families and working mothers, together with a lack of available child care, have created a stress-provoking situation for many school-age children. Some latchkey children may have a chronic illness as well.

Inadequate adult supervision after school leaves children at greater risk for injury and delinquent behavior. Latchkey children feel more lonely, isolated, and fearful than children who have someone to care for them. To cope with their fears and anxieties while alone, these children may devise strategies such as hiding (in a bathroom, closet, or shower or under a bed), playing the television loudly to drown out noises, and using pets as a comfort.

Many communities and persons concerned about such children’s welfare are trying to help children and their parents deal with this potentially serious problem. School-age child care programs have been implemented by some communities and employers. Some guidelines appropriate for presentation to parents and/or children to help alleviate their stress and increase the children’s safety are listed in the Family-Centered Care box. Other types of programs include those designed to teach self-help skills to children, hotlines that provide telephone check-in and reassurance programs for children, and programs that link latchkey children with reassuring older persons in their community.

Nurses should be aware of services in their communities designed to meet the needs of latchkey children and include this information in anticipatory guidance of school-age children and their families. It is vital that children have adequate supervision and companionship.

Outside Influences

With the influence of the mass media and the temptation of an immense variety of “junk food,” it is all too easy for children to fill up on empty calories—foods that do not promote growth, such as sugars, starches, and excess fats. They have more freedom to move without parental supervision and often have small amounts of money to spend on candy, soft drinks, and other easily accessible treats. Midafternoon snacks are common, and it is wise to encourage consumption of fruit, nuts, and other wholesome finger foods to meet this need. Nutrition is a joint responsibility of both the child and the family.

The popularity of fast-food restaurants has aroused the interest of nutritionists and other health care professionals concerned with children’s nutrition. The restaurants provide fast service, they are relatively inexpensive and appealing to children, and their convenience makes them attractive to busy parents as an alternative to eating at home. Because the nutritional content of fast foods is usually available, it is easier for nutrition-conscious parents to help children select appropriate items from the available menu. Nurses can support consumer advocate groups to encourage restaurants to offer items higher in nutritional value (such as skimmed milk, broiled meats, and fresh fruits and vegetables) and to list ingredients on the menu as required for packaged foods.

Childhood obesity is an increasingly prevalent health problem in school-age children. It is estimated that approximately 17% of American children ages 6 to 11 years are overweight (Centers for Disease Control and Prevention, 2009b). The easy availability of high-calorie foods, the tendency toward more sedentary activities (such as watching television and playing or working at a computer), and the trend away from walking or cycling and toward transportation by automobile and bus have reduced caloric expenditure. The consumption of a high-fat diet also contributes to obesity. The problem of childhood obesity is discussed further in Chapter 21. Given the threat of obesity and a diet-conscious society, many school-age children start to diet in an effort to prevent obesity or lose weight or to conform to peer behaviors and pressures. Children need education about food selection and the importance of body-building nutrients as opposed to empty caloric intake.

School Programs

Working parents assume that their children are sufficiently mature and frequently leave the responsibility of meal preparation to them. Although most older school-age children are capable of preparing simple meals, all too often breakfast and lunch may be inadequate, makeshift, or nonexistent. In recognition of this problem, the federal government has established the National School Lunch Program and the School Breakfast Program in many areas. These meals must meet specified nutritional requirements and furnish one third of the daily recommended dietary allowance for children in the United States. Most schools subscribe to the programs, and although the results are difficult to measure directly, it is believed that these school meal programs positively influence the behavior and learning capacity of children. However, the average school lunch may also exceed the recommended dietary guidelines for saturated and total fat. In addition, children who purchase school lunches often select only the items they want. In general, food choices of American children do not meet recommended intakes outlined in the U.S. Department of Agriculture MyPyramid. Many Americans consume too many foods and drinks high in fat and carbohydrates and too little nutrient-dense foods and drinks such as fruits, vegetables, and low-fat milk (Wells and Buzby, 2008).

Sleep Problems

During middle childhood, nighttime sleep is usually continuous, and the child has developed a repertoire of tactics (such as reading or playing quietly without involving the parents) to deal with occasional difficulties in falling asleep. If a child has a sleep problem, a thorough assessment may be necessary to plan appropriate interventions.

The cause of bedtime resistance is not always clear. For some children it is related to normal fears of their age, such as fear of the dark, strange noises, intruders, or other imagined phenomena. Children who are subject to frightening dreams are hesitant to retire, and their sleep is more likely to be disturbed after emotional stimulation before bedtime. Sometimes children are unwilling to give up an exciting or interesting activity, or they are reluctant to leave the protective social circle of the family. Another factor associated with reluctance to go to bed is related to status. For example, older children are given the privilege of a later bedtime than younger children. Promotion to a later bedtime is highly prestigious, and age-mates compare their bedtimes. This may explain why children who believe that playmates enjoy a more privileged position strongly oppose parental decisions. In some situations going to bed is used as a method of control. When going to bed early is imposed as a punishment or when staying up late is a reward, children may view bedtime as punitive or status degrading.

Some children resort to multiple “curtain calls,” such as wanting a drink of water, asking for one more story, needing to go to the bathroom, or wanting to watch television. Some children persist in coming out of their rooms repeatedly after being put back to bed. Some voice fears, such as “there is someone outside the window.” Parents may have difficulty determining whether the fear is legitimate or whether the behavior is a bid for attention. Consistent reassurance and limit setting usually resolve the problem. Children feel tense and insecure when limits are applied inconsistently, such as when parents grant permission one night and punish the next for the same behavior.

The night terrors of preschool children may be replaced by sleepwalking and sleep talking. Like night terrors, sleepwalking is associated with the transition from stage 4 to stage 1 of non–rapid eye movement sleep. When children arouse from stage 4 sleep, it is often difficult for them to reach a fully alert, wakeful state rapidly. Sleepwalking occurs in the first 3 to 4 hours of sleep. Children often have no memory of sleepwalking in the morning. The episode begins when the child sits up abruptly and walks. During sleepwalking, movements are clumsy and repetitive; parents often observe finger and hand movements. Most commonly, children move about restlessly, then lie down and return to sleep. However, they may get out of bed and engage in nonpurposeful walking. They rarely perform purposeful acts during sleepwalking. Any attempts to communicate with the child elicit only mumbled and slurred responses. Sleep talking, like sleepwalking, is not purposeful, and speech is usually incomprehensible and monosyllabic.

The best approach is to leave sleepwalking children alone unless they are in danger or may endanger others. However, clumsiness and stereotyped movements can make sleepwalking very dangerous. If the environment is not safe, children can get hurt. Instruct parents to gently redirect children back to bed without waking them, if possible. If children must be wakened, it is best to call them by name slowly and softly, orient them to where they are, explain that they were walking in their sleep, and assure them that it will not happen when they are more relaxed. Preventive measures include avoiding over-fatigue in children, making certain they get adequate rest, employing relaxation techniques, and relieving any stress the children may be experiencing.

Sleepwalking is usually self-limiting and requires no treatment. Persistent sleepwalking occurs in some older children and adolescents who are well behaved and tend to repress strong emotions, such as anger. They may benefit from learning to express their feelings and from doing self-relaxation before bedtime.

Nightmares are a part of the normal developmental process; 70% to 90% of young adults reported experiencing nightmares at some time during childhood (Schredl, Biemelt, Roos, et al, 2008). However, repetitive nightmares or increased nightmare frequency may indicate a specific underlying conflict or stressor that is strongly influencing the child’s behavior and thought. Resolving worries or stress will often reduce nightmares. If nightmares become chronic, parents should consider professional counseling (Schredl, Biemelt, Roos, et al, 2008).

A traumatic event often produces posttraumatic nightmares, which are anxiety provoking and literal in their depiction of the trauma. As time goes on, the dreams of affected children may consist of “modified repetitions” that may add more current material to the recurrent dreams (e.g., involving others who were not a part of the traumatic event). Current external stresses, movies, or stories may also precipitate a nightmare by reactivating old traumas. (For a comparison of nightmares and night [or sleep] terrors, see Table 15-2.)

Physical Fitness

The development of physical fitness is a goal for all children. This goal was easy to accomplish in the past when school-age children spent a considerable amount of time each day playing on playgrounds, walking to school, and participating in games or sports at school or in their communities. With the advent of technology and the information age, many children are less active physically and spend large portions of their day in front of a computer or television (see Research Focus box).

Counseling should include developing goals, identifying fun and safe physical activities, addressing potential barriers, and encouraging support from family and friends. Nurses can further promote efforts to include physical fitness in school programs and encourage children to engage in aerobic physical activities during their free time. Such activities provide cardiopulmonary benefits, maintain normal weight, and have the potential to contribute to lifelong fitness.

Acquisition of Skills

School-age children demonstrate increasing capacity in fine muscle facility and complex artistic skills. Handedness is well established by the beginning of the school years, and children make great strides in writing and drawing during this age period. It is a time of energetic and vibrant creative productivity. With the tools of language and reading, children can create poems, stories, and plays. With more advanced fine motor skills, they are able to master an unlimited variety of handicrafts, such as ceramics, needlework, wood carving, and beadwork. They avidly pursue these skills in solitude, with a friend, or in programs offered through organizations such as boys’ or girls’ clubs or special interest groups that use crafts as a means to occupy, entertain, and educate children.

Music is a favorite form of expression in middle childhood (Fig. 17-13). Music stimulates and invigorates school-age children. They can sing in harmony, play instruments in orchestras and bands, and manage music at a more complex level. They can compose original songs, learn lyrics almost effortlessly, and turn any empty moment into an occasion for singing.

School-age children are capable of assuming responsibility for their own needs, although their distaste for soap and water and “dress” clothes is legendary. School-age children can and want to assume their share of household tasks, which usually are related to the male and female roles that have been defined by their culture (Fig. 17-14). Many also assume responsibility for tasks outside the home, such as baby-sitting, yard work, or paper routes.

Television, Videogames, and the Internet

For some time, child development specialists and parents have been concerned about the effect of media on child development and behavior. Children spend a significant amount of time each day involved in media-related activities, including the use of television, computers, videogames, and CD players. Children ages 8 to 18 years spend close to 4 hours every day watching television or videos, with 20% of these children watching more than 5 hours a day (Rideout, Roberts, and Foehr, 2005). Because of the long periods of exposure, the media have more time to develop children’s attitudes than do parents and teachers.

There is no doubt that children learn from television, but the values and attitudes depicted on television are not always realistic and may conflict with values that children were previously taught. School-age children can distinguish fantasy from reality, and some have had sufficient life experience to view television programs with skepticism. However, television rarely depicts the reality of day-to-day situations that confront children. When children view characters they admire using violence, such as Superheroes, it can teach them to become more violent (Christakis and Zimmerman, 2007). In addition, repeated exposure to violence can desensitize children to violence, can convey a message that violence is acceptable, and can teach children that initiating violent behavior is a way to protect themselves (Christakis and Zimmerman, 2007).

Violence in the media can also increase fear and anxiety in children. Events such as the 9/11 terrorist attacks and the war in Iraq have infiltrated television, frequently exposing children to real-life violence. Viewing violence in the news causes more fear and worry in children than viewing the same content in a fictional setting (Van Der Molen and Bushman, 2008).

Parents should make the ultimate decisions about which programs their child will watch. To reduce exposure to violence and maximize the beneficial effects of television, parents are advised to monitor program selection, view programs with their children, and discuss program content when the programs are finished (Christakis and Zimmerman, 2007). (See Chapter 2 for a more in-depth discussion of children and television.)

Videogames have been both criticized and supported in relation to their effect on children and adolescents. Critics maintain that videogames keep children from schoolwork and can cause tension, sleeplessness, and violence. Others support the activity as a means for improving eye-hand coordination and as a substitute for the inactivity of passive television viewing. Benefits may also include development of inductive reasoning (drawing generalizations from specific observations), improving spatial perception, and learning to handle multiple variables that interact simultaneously.

Research suggests that videogames may affect physical and psychologic functioning. Physical effects may include triggering of epileptic seizures. (See seizure discussion, Chapter 37.) However, research has noted some positive applications of videogames with dyslexic children (American Psychological Association, 2005).

Computers and the Internet are becoming a popular means for obtaining educational and recreational information. Children with home computers increased from 73% in 2000 to 86% in 2005, and an estimated 45 million U.S. children ages 10 to 17 years use the Internet every day (Rideout, Roberts, and Foehr, 2005; Williams and Guerra, 2007). Although the Internet provides valuable educational opportunities for children, there are also many risks that parents must acknowledge before children access the Internet. Major risks include exposure to inappropriate, dangerous, or illegal material; exposure to harassment through e-mail or chat rooms; revelation of financial information that leads to negative consequences; and safety issues relating to sharing personal information or meeting strangers (McColgan and Giardino, 2005). The best way to eliminate potential risks is to educate parents and children about the Internet and to provide adult supervision when children use the Internet.

Parent and teacher education relating to television, videogames, and the Internet should include recommendations to limit playing time, monitor game selection and content, and increase access to games and information that are educational.

Brushing

The most effective means of preventing dental caries is a regimen of proper oral hygiene tailored to the individual child by the dentist. Children should learn to carry out their own dental care with the supervision and guidance of parents. Parents should learn proper brushing technique along with their children and should inspect their children’s efforts until the children can assume full responsibility for their own care.

Most practitioners believe that the majority of children do not possess the fine motor skills needed to brush their teeth properly until approximately second grade. Children under 10 years of age may need parental assistance to brush back teeth. Ideally, children should brush teeth after meals, after snacks, and at bedtime. The bedtime brushing is especially important because there is more time overnight for interaction between oral bacteria and unremoved substrate on the tooth substance. Children who brush their teeth frequently and become accustomed to the feel of a clean mouth at an early age usually maintain the habit throughout life.

The thoroughness of plaque removal (cleaning) can be checked using a plaque-disclosing agent that stains any remaining plaque red. The child should inspect the teeth closely with the aid of a mirror and under adequate light. The teeth then are again cleansed with a fluoridated dentifrice to remove the remaining plaque and provide further protection. This procedure may be carried out regularly or occasionally, according to instructions from the child’s dentist. Toothpastes recommended by the American Dental Association Council on Dental Therapeutics carry a seal of approval, which is easily identified on the package. They have been submitted to testing and demonstrate the ability to reduce the incidence of dental caries when used correctly.

For school-age children with mixed and permanent dentition, the best toothbrush is one with soft nylon bristles and an overall length of about 21 cm (8 inches). There are numerous methods of brushing the teeth for children, but no conclusive evidence indicates that one method is superior to another. The thoroughness of the cleaning is more important than the specific technique used. The dentist will assess all factors, such as the child’s manipulative skills and special needs, and suggest the most appropriate brushing technique and regimen. Flossing follows brushing. Parents usually floss until children acquire the manual dexterity needed. Most children are not able to floss properly until about 8 or 9 years of age.

Health Education

Health education of school-age children focuses on providing knowledge of health and influencing habits, attitudes, and conduct in relation to health (Box 17-8). A viable health education program is based on sound health concepts but should be adjusted to meet specific local needs, objectives, and legal requirements. Parents must understand and approve the health education curriculum so that its teaching will be reinforced at home. A comprehensive approach to health education is more successful in developing positive health practices than one in which the subjects are taught in isolation. Many topics presented in health education classes are associated with differing social and cultural attitudes and should be presented accurately and with sensitivity to these attitudes.

Health education concerning AIDS is a specific example. Most authorities agree that AIDS education should begin in the elementary grades to prevent high-risk behaviors. However, educational programs concerning AIDS must be developmentally appropriate and, to be effective, must be implemented with parental and community support. Young children need information on how HIV is transmitted, in simple, accurate terms without elaborate, unnecessary discussions of sex. Misconceptions that increase children’s anxiety about contracting the virus should be corrected. Although many children have heard that sex and drugs cause AIDS, some children also have misconceptions about AIDS. Children need information that HIV is transmitted through infected blood on shared drug needles and that the virus is not spread through common forms of expressing affection such as hugging and holding hands.

School Nursing Services

School nurses assume a major role in the school health program and can affect the lives of school-age children significantly. Working in collaboration with others in the school and community, school nurses provide health supervision, health counseling, and health education. The responsibilities of the school nurse can include providing education and interventions for acute and chronic illness, injuries, communicable diseases, obesity and nutrition, mental health, dental disease, and sexually transmitted infections (American Academy of Pediatrics, 2008b). These functions are not necessarily limited to the confines of the school environment but extend into the community in which the students live. As a health practitioner, the school nurse is in a position to promote and evaluate health services throughout the community as they affect children and to collaborate with agencies in planning for health and safety. For some children, especially those in poverty, the school nurse may be the only contact with illness prevention and health promotion. For children with chronic health conditions, the school nurse provides leadership within the school health team and assesses the student’s health status, identifies potential barriers of the educational process, and develops an individualized health care plan (American Academy of Pediatrics, 2008b).

Traditionally, school nurses have been viewed from a limited perspective that placed them in the role of disease detector, applier of bandages, and official caregiver in cases of illness and injury. Although these are still important functions, this traditional role has acquired much broader dimensions. School nurses develop, implement, and evaluate health care plans and programs. In some settings a school-based health center is near or within a school to provide additional health services. In these centers, school nurse practitioners provide primary health care, including assessment of physical, psychomedical, psychoeducational, behavioral, and learning disorder problems, as well as comprehensive well-child care (American Academy of Pediatrics, 2008b).

The minimum qualifications for a school nurse should include a baccalaureate degree from an accredited college or university and licensure as a registered nurse (American Academy of Pediatrics, 2008b). Unlicensed assistive personnel (UAP) may be a part of the school health care team. These paraprofessionals have a state certification and are trained to assist a professional but must be supervised by the school nurse (American Academy of Pediatrics, 2008b). The school nurse must use good assessment and professional judgment in deciding which procedures may be delegated to UAP.

The passage of Public Laws 94-142 and 99-457 required the integration of children with chronic illness or disability into regular classrooms. School nurses are responsible for the medical and nursing needs of these children in the school setting. School nurses assess and monitor all health problems in children who come into the school and compile a health care list of all of these problems and their associated therapies. The nurse may call the parents of the child and arrange a visit to the home, made by either the school nurse or a public health nurse. After gathering information, the nurse can develop a nursing care plan for use in the school. The nurse collaborates with the family and includes their suggestions in the care plan. The nurse then discusses the plan with the child’s teachers and provides any needed education. School nurses are the only ones in the school system qualified to deal with medical problems. However, in many instances school nurses can collaborate with teachers to provide atraumatic care (see Community Focus box).

Sometimes all that is required is conducting an assessment and making the teacher aware that the child has a health problem. In other cases more complex teaching is needed, such as how to observe for certain signs (e.g., insulin reaction), how to perform certain techniques (e.g., tracheostomy suctioning, gastrostomy or nasogastric tube feedings), and how to manage emergencies (e.g., care of a child during a seizure). School nurses instruct teachers in the necessary procedures and review their performance.

The American Academy of Pediatrics (2008a) has established guidelines for emergency medical care of children in schools. These guidelines include developing emergency policies and procedures, clarifying school staff roles, collecting emergency data on all school children, making emergency equipment and medication easily accessible, and adequately training staff. It is recommended that at least one staff member, in addition to the school nurse, have cardiopulmonary resuscitation, first aid, and automated external defibrillator training (American Academy of Pediatrics, 2008a).

A child who must take medication at school needs written authorization from his or her attending physician and/or written permission from the parents allowing the nurse to administer or supervise the administration of the medication. The medication must be brought to the school in a container appropriately labeled by the pharmacist or physician. Medications are kept locked up in the nurse’s office; usually the child is not allowed to carry medications at school. The policy may vary in some school districts or situations. For example, some children may be allowed to carry metered-dose inhalers that contain their asthma medication, provided that their physician and a parent provide the required authorization. Guidelines for administration of medications in schools are also available from the National Association of School Nurses.*

Risk-Taking Behavior

Achieving social acceptance is a primary objective for school-age children. They often attempt dangerous acts (sometimes extreme behaviors) to prove themselves worthy of acceptance and improve their status in the peer group. Peer pressure is a normal part of psychologic development, but it is also a major contributor to risk-taking behaviors. Peer challenges often encourage problem behaviors that place children at risk for injury or hazardous habits. School-age children are in the process of moving from preoperational to concrete operational thinking and are only beginning to understand causal relationships. Therefore they may attempt certain activities without planning or evaluating the consequences.

Children who are risk takers may have inadequate self-regulatory behavior. These children need to learn the motivation or the incentives for such behavior and to visualize the possible consequences if the risk-taking behavior ends in a tragic outcome.

Motor Vehicle Injury

As in all other age-groups, the most common cause of severe accidental injury and death in school-age children is involvement in motor vehicle accidents—either as a pedestrian or as a passenger. In 2007 approximately 18% of traffic-related fatalities involved pedestrians (National Highway Traffic Safety Administration, 2007). Most of the injuries occur when children misinterpret traffic signs or disobey common traffic safety regulations, cross the street against a red light, cross at places other than designated crosswalks, dart into the street, or walk in the same direction as the traffic. Parents consistently overestimate the street-crossing skills of young children ages 5 to 6 years and need education about their children’s developmental abilities and competence as pedestrians. Nurses can help parents to develop more realistic expectations of their children’s behavior and teach them to model safe street-crossing behaviors through pedestrian skills training programs.

Use of restraint systems, door-lock mechanisms, and appropriate passenger seating and behavior are simple but effective measures for eliminating noncrash injuries and reducing the severity of crash injuries. The importance of the correct use of seat restraints is essential. School-age children do not usually require special car seats. However, despite evidence that safety belt use saves lives and prevents injury, estimates of seat belt use in school-age children are still discouragingly low.

In 2006, 1335 children ages 0 to 14 years died in motor vehicle accidents and 184,000 received injuries requiring emergency department treatment (Centers for Disease Control and Prevention, 2009a). Investigations of motor vehicle accidents showed deployment of passenger-side air bags critically or fatally injured children seated in the right front seat (Newgard and Lewis, 2005). Therefore the National Highway Traffic Safety Administration recommends that children under age 13 years not ride in the front passenger seat of vehicles with air bags.* The American Academy of Pediatrics reiterates this view and strongly emphasizes that the rear seat of any vehicle is the safest place for children to ride. When in the car, school-age children should always be buckled properly in a weight-, height-, and age-appropriate seat. If the child weighs more than 18 kg (40 lb), a convertible safety seat that is positioned in the semiupright and forward-facing position may be used if the child fits in it well. If the child has outgrown the convertible safety seat but is still too small for a regular lap-shoulder belt, a booster seat restraint device equipped with a combination lap-shoulder belt should be used.

Injuries to children ages 5 to 9 years restrained in adult-type seat belts are related to anatomic differences between adults and children. The child’s sitting height is less than the adult’s, and the child’s center of gravity is located above the level of the lap belt. Consequently, the greater proportion of body mass above the belt may cause more forward motion and jackknifing over the belt, which increases the risk of head injury from impact with interior vehicle parts. The child’s smaller and less developed iliac crests are not suited to serve as an anchor for belts designed to restrain adults, and their intra-abdominal organs are less protected by the bony pelvis. The natural behavior of children, such as readjusting the seating position, moving about, and otherwise altering the fit of the restraint, also influences its effectiveness.

When children use adult-type seat belts, parents should make certain that the restraints are fitted to their children and fastened correctly. To reduce their risk of sliding beneath the standard seat belt during a collision, children should sit up straight and well back in the seat, and the seat should be moved forward until the feet fit firmly against the toe board. Caution children against assuming alternate seating positions, such as tailor fashion, while riding in the car. (See Chapter 14 for a comprehensive discussion of safety restraints.)

Each year 23.5 million children are transported to and from school on school buses. The majority of school travel–related injuries and deaths occur from passenger vehicles, while only 4% of school travel injuries and 2% of school travel deaths occur in school buses (American Academy of Pediatrics, 2007). However, the National Highway Traffic Safety Administration and the American Academy of Pediatrics have developed minimum standards to enhance school bus safety. These standards state that all children should travel to and from school in an age-appropriate, properly secured child-restraint system; all school buses should be equipped with lap-shoulder restraint systems that can accommodate safety seats, booster seats, and harness systems; and school districts should encourage appropriate education on safety devices (American Academy of Pediatrics, 2007).

All-terrain vehicles (ATVs), designed for off-road use by children and adolescents, are popular with children under 16 years of age but are responsible for a significant number of childhood injuries. These vehicles have a short wheelbase and low profile, which makes them relatively unstable and unable to be seen easily. The vehicles can also achieve substantial speed. Most injuries occur when the driver loses control of the vehicle, is thrown from the vehicle, or collides with fixed objects or other vehicles. Immature judgment and poorly developed motor skills also contribute to injury. The American Academy of Pediatrics views ATVs as a major hazard to the health of children, opposes their use by children younger than 16 years of age, and has created a safety bill outlining requirements to enhance ATV safety (Killingsworth, Tilford, Parker, et al, 2005). However, for parents who allow their use, the committee provides safety guidelines (see Family-Centered Care box).

Bicycle Injury

The majority of school-age children have bicycles and love riding them, but this increases their risk of injury on streets and byways. In 2008 bicycle injuries in children ages 5 to 15 years accounted for approximately 13,000 nonfatal injuries and 89 fatal injuries (National Highway Traffic Safety Administration, 2008).

Many injuries are related to violations of traffic laws by the bicyclist, including wrong-way riding (facing traffic), failure to yield the right of way, and turning violations. Others are related to road conditions described as hazardous: bumps, potholes, and gravel. Bicycle-related injuries occur in young children playing in their own neighborhoods and in older children using their bicycles for transportation on streets with heavy traffic.

In addition to major injuries, cuts and bruises from falls and collisions account for a large number of injuries. Other injuries include trauma to internal organs. These injuries initially seem trivial, but injured children can develop serious symptoms (e.g., pain, vomiting, or collapse) hours later.

Many of the injuries to school-age children on bicycles occur because of the child’s developmentally limited range of vision and their inability to process perceptions of road situations sufficiently well and quickly enough to ride safely in traffic. Other important factors are lack of instruction in use of the equipment, lack of safety equipment, and unfamiliarity with the bicycle (e.g., having ridden the bicycle for less than a month).

To prevent bicycle injuries, both parents and children should learn and periodically review bicycle safety. Children need bicycles that are suited to their size and age; they should be able to stand with the balls of both feet on the ground when seated on the bicycle, be able to place both feet flat on the ground when straddling the center bar, and be able to grasp the brake lever comfortably and easily enough to apply sufficient pressure to brake the bicycle. Discourage parents from buying their child a bicycle that the child can “grow into.”

Because head injury is the major cause of bicycle-related fatalities, the single most important aspect of bicycle safety is to encourage the rider to wear a protective helmet (Fig. 17-16). Helmet use has caused an 88% reduction in head and brain injury and 65% reduction in face-related injuries (Okun and Adam, 2008). Hard-shelled helmets lined with expanded polystyrene (Styrofoam) provide the best head protection. The helmet should be one that can be adjusted to the individual child’s head, fits securely, and does not limit the child’s vision or hearing. A brightly colored helmet improves visibility. The helmet should carry a seal indicating that it is approved by the U.S. Consumer Product Safety Commission. All helmets should be replaced after any damage or crash.

Legislative interventions and educational campaigns have significantly increased children’s usage of bicycle helmets, with two- to five-fold increases in some areas of the United States (Okun and Adam, 2008). Although most young riders acknowledge that wearing a helmet is important for safety, reasons for not wearing them include discomfort (especially heat), presumed lack of importance for casual riding, lack of style, and peer pressure.

Parental attitudes and behaviors also influence children’s use of bicycle helmets. Parental nonuse of a helmet is strongly associated with lack of intention to require the children to use helmets. Parents, as well as children, need to be educated on safety. The American Academy of Pediatrics recommends that (1) parents be informed of the dangers of riding without a helmet, (2) retail outlets carry inexpensive helmets available at the time of bicycle purchase, (3) state and local governments continue to enact legislation requiring helmet use by all bicyclists, (4) parents and community-based programs promote bicycle safety and helmet use, and (5) the media depict helmet use in all programs and promotional materials.

Schools, hospital emergency departments, and communities have developed numerous bicycle helmet promotion programs. Programs that are most successful are those that address the cost of helmets and peer pressure and combine multimedia public education announcements with the support of community organizations. The Family-Centered Care box lists guidelines for bicycle safety, and the Critical Thinking Exercise discusses bicycle helmets.

Other Vehicle-Related Injuries

After a short period of decline, skateboards are again becoming popular, with an accompanying resurgence of related injuries. Although the majority of injuries involve the extremities, severe injuries of the head and neck can occur. School-age children often use their skateboards on streets and highways, which increases the likelihood of high-speed collisions with objects or vehicles. Recommendations for safe skateboard use are in the Family-Centered Care box.

Like skateboard injuries, roller skate or in-line skate injuries involve predominantly the upper extremities (especially the wrist and forearm) as children attempt to break a fall with outstretched arms. Safety measures are basically the same as for skateboards. Parents should carefully evaluate the skill level of the child before allowing the child to use skates. Younger children sustain injuries more frequently than older children. Some authorities believe that parents should not encourage children to engage in these activities until their bone strength and skills are sufficiently mature to decrease the risk of fracture.

Ride-on mower and other power mower injuries also occur among school-age children. Approximately 9400 children under the age of 18 years require emergency care for lawn mower–related injuries in the United States each year (Vollman and Smith, 2006). These injuries occur when children are allowed to operate a mower, when they are run over or backed over by another driver, or when they fall from a mower or from a trailer pulled by a mower. Although there are no age-specific criteria for the use of lawn mowers, children should not operate lawn mowers until they have appropriate levels of judgment, strength, coordination, and maturity, which is usually over the age of 12 years for walk-behind mowers and over the age of 16 years for riding mowers (Samson, 2006).

Similar injuries occur with snowmobiles. Most deaths and injuries involving snowmobiles occur when the vehicle collides with a stationary object or when riders fall or are ejected from the vehicle. The American Academy of Pediatrics recommends that persons under 16 years of age be prohibited from operating or riding snowmobiles (Nayci, Stavlo, Zarroug, et al, 2006).

Injuries at School

The risk of injury at school is relatively low, despite the amount of time children spend in that environment. Some injuries occur in gyms, shops, and laboratories, as well as on playgrounds and playing fields. Most injuries occur on the way to and from school. Many are related to sports activities. (See Chapter 39.) Persons concerned with child safety should be alert to hazards in the school environment and should become involved in efforts to make the environment safe in every aspect—physical facilities, equipment, training practices, and supervision.

Trampolines are popular with young children, and continue to cause significant injuries. In 2005 approximately 88,500 children suffered a trampoline related injury, with 66% of these patients ranging from 5 to 12 years old (Linakis, Mello, Machan, et al, 2007). Fractures, sprains, and head injuries have all been attributed to trampolines.

Farm Injuries

Many school-age children are involved in farm activities and play in the farm environment. They may be children of migrant workers, and as such, they constitute a significant proportion of agricultural workers. Most injuries take place during the summer when children are home from school and in the autumn when farming activity is brisk. Health facilities are also more scattered and less accessible for emergency treatment in farming areas than they are in urban communities.

Health workers need to be aware of the problems and to emphasize to the farm family the hazards related to their environment and ways to prevent injuries, especially when children are present. Rural schools should provide safety education regarding machinery operation, safety procedures, and injury prevention. Nurses in rural areas can be advocates for farm safety programs and for revision of the current farm safety legislation.

Other Injuries

Falls are still a source of injury in school-age children but less so than in preschool children and toddlers. “Flipping,” a popular activity in which children jump from an elevated surface and perform an aerial flip with the idea of landing upright, has resulted in serious injuries to the face and head and places children at risk for back and spinal cord injury. Seasonal injuries such as sledding accidents are common and more likely to occur when children ride sleds without adult supervision and in streets, as opposed to parks. Horseback riding injuries are another source of concern for parents of school-age children. The most common cause of death from horseback riding activities is head injury, followed by injuries to the chest and abdomen. Before enrolling children for riding lessons, parents should determine the instructor’s safety record with students, verify that safety helmets will be used, and confirm that the instructor is certified by a recognized organization. Injuries at public playgrounds and amusement parks (especially water slides) and around the home (power tools, ladders, fireworks) are ongoing concerns of parents and health care providers.

Injuries to eyes and teeth are a constant threat to school-age children involved in rough play. (See Chapter 24 [eyes] and Chapter 18 [teeth].) The normally shallow bony orbit of children in this age-group makes them particularly vulnerable to eye trauma, especially during contact sports or activities such as baseball or softball. Wearing protective eye and mouth gear is essential (Merriman, 2009).

Injuries have been reported from a variety of toys (slingshots, water balloons, lawn darts, chemistry sets) and household equipment (mowers, lawn trimmers). Gunshot wounds have become a significant problem during past years. The overall rate of firearm-related homicides for U.S. children younger than 15 years of age is nearly 12 times greater than that found in 25 other industrialized countries (Guralnick and Serwint, 2007). So-called toy firearms (air guns and air rifles) also cause frequent firearm injuries to children. Most of these injuries involve the face or eyes.

Nurse’s Role in Injury Prevention

Nurses are primary advocates for preventive care and guidance. Safety education and anticipatory guidance for both parents and school-age children can be incorporated in all nursing interventions. The most effective means of prevention is education of the child and family regarding the hazards of risk-taking behavior and improper use of equipment. No piece of equipment is safe unless a child is physically and mentally equipped to use it. A careful history and knowledge of normal growth and development serve as guidelines for both planned and impromptu education.

Parents are often unaware of hazards to their children at various ages, especially those related to normal developmental progress. Susceptibility to injuries and understanding of safety issues are influenced by children’s developmental level. Nurses who understand the growth and development of school-age children can provide effective safety education to parents and children and can correct misconceptions before injuries occur.

School nurses should be alert to hazards in the school and instrumental in evaluating safety risks and implementing safety programs. Characteristics of the school-age child and preventive measures are outlined in Table 17-2.

• Middle childhood, also known as the school years, is a comfortable period of life that extends from 6 to 12 years of age.

• Although growth is slower than in previous years, there is a steady gain in height and weight with maturation of body systems; primary teeth are lost and replaced by permanent teeth.

• Skeletal lengthening, an increase in the ratio of muscle mass to fat, and maturation of the gastrointestinal system are major components of biologic development during middle childhood.

• Developing a sense of industry or accomplishment is a major task during the middle years (Erikson).

• Piaget’s theoretical stage of concrete operations refers to the school-age period, when children are able to use their thought processes to experience events and actions and make judgments based on what they reason.

• Through identity, reversibility, and reciprocity, children master the cognitive task of conservation.

• Children develop a conscience and are able to understand and adhere to rules and standards set by others.

• Spiritual development entails curiosity about deities, knowledge of the difference between the natural and the supernatural, and reliance on prayers or other religious rituals.

• Entertaining different points of view, becoming sensitive to social norms of peers, and forming peer friendships are the most important features of social development in the middle years.

• Children develop a self-concept from their own self-assessment and feedback from others.

• Increased socialization, earlier pubertal development, and constant media exposure make the school years an ideal time for sex education.

• Cooperative play, team activities, and acquisition of skills are prime elements of play during the school years; rules and rituals assume greater importance.

• Optimum nutrition is often hampered by an affinity for and availability of junk foods, irregular family meals, and schedules of working parents.

• Typical parental concerns during middle childhood include dishonest behavior, lying, cheating, stealing, and school-related stress.

• The school years are an ideal time for children to begin to take responsibility for their own health.

• School health centers ideally offer programs that include health appraisal, emergency care, safety education, communicable disease control, counseling, guidance, and health education, with adjustment to individual student needs.

• The major sources of accidental injury during middle childhood include a variety of conveyances, including motor vehicles, bicycles, skateboards, and in-line skates.

• Direct injury prevention toward safety education, provision of safe play areas and equipment, and good supervision of sports activities.

Temperament in the School-Age Child

Physical Growth in the School-Age Child

Bicycle Helmets