DEVELOPMENTAL ABILITIES RELATED TO RISK OF INJURY	INJURY PREVENTION
MOTOR VEHICLES
Walks, runs and climbs Able to open doors and gates Can ride tricycle Can throw ball and other objects	Use government-approved car restraint; if restraint is not available, use lap belt Supervise child while playing outside Do not allow child to play on kerb or behind a parked car Do not permit child to play in pile of leaves, snow or large cardboard container in trafficked area Supervise tricycle riding Lock fences and doors if not directly supervising children Teach child to obey pedestrian safety rules Obey traffic regulations; walk only at pedestrian crossings and when traffic signal indicates it is safe to cross Stand a step back from kerb until it is time to cross Look right, left and right again and check for turning cars before crossing street Use footpaths; when there is no footpath, walk on right, facing traffic Wear light colours at night, and attach fluorescent material to clothing
DROWNING
Able to explore if left unsupervised Has great curiosity Helpless in water, unaware of its danger; depth of water has no significance	Supervise closely when near any source of water, including buckets Keep bathroom doors and lid on toilet closed Have fence around swimming pool and lock gate Teach swimming and water safety (not a substitute for protection)
BURNS
Able to reach heights by climbing, stretching, standing on toes and using objects as a ladder Pulls objects Explores any holes or opening Can open drawers and cupboards Unaware of potential sources of heat or fire Plays with mechanical objects	Turn pot handles towards back of stove Place electric appliances, such as kettle and frying pan, towards back of counter Place guard rails in front of radiators, fireplaces or other heating elements Store matches and cigarette lighters in locked or inaccessible area; discard carefully Place burning candles, incense, hot foods, ashes, embers and cigarettes out of reach Do not let tablecloth hang within child’s reach Do not let electric cord from iron or other appliance hang within child’s reach Cover electrical outlets with protective devices Keep electrical wires hidden or out of reach Do not allow child to play with electrical appliance, wires or lighters Stress danger of open flames; teach what ‘hot’ means Always check bathwater temperature; adjust hot-water heater temperature to 50°C or lower; do not allow children to play with taps Apply a sunscreen with SPF 15 or higher when child is exposed to sunlight
POISONING
Explores by putting objects in mouth Can open drawers, cupboards and most containers Climbs Cannot read warning labels Does not know safe dose or amount	Place all potentially toxic agents (including plants) in a locked cabinet or out of reach Replace medications and poisons immediately; replace child-resistant caps properly Refer to medications as drugs, not as sweets Do not store large surplus of toxic agents Promptly discard empty poison containers; never use to store a food item or other poison Teach child not to play in garbage containers Never remove labels from containers of toxic substances DO NOT induce vomiting unless advised Keep the emergency number of the nearest Poisons Information Centre next to the telephone. This is listed in the front of the telephone book. It is 13 11 26 in most states of Australia
FALLS
Able to open doors and some windows Goes up and down stairs Depth perception unrefined	Keep screen in window, nail securely and use guard rail Place gates at top and bottom of stairs Keep doors locked or use child-resistant doorknob covers at entry to stairs, high porch or other elevated area, such as laundry chute Remove unsecured or scatter rugs Put non-skid mat in bath or shower Keep cot rails fully raised and mattress at lowest level Place carpeting under cot and in bathroom Keep large toys and bumper pads out of cot or playpen (child can use these as ‘stairs’ to climb out), then move to youth bed when child is able to crawl out of cot Avoid using walkers, especially near stairs Dress in safe clothing (soles that do not ‘catch’ on floor, tied shoelaces, pant legs that do not hang on floor) Keep child restrained in vehicles; never leave unattended in shopping trolley or stroller Supervise at playgrounds; select play areas with soft ground cover and safe equipment
CHOKING AND SUFFOCATION
Puts things in mouth May swallow hard or inedible pieces of food	Avoid large, round chunks of meat, such as whole sausages (slice lengthwise then into short pieces) Avoid fruit with pips, fish with bones, dried beans, hard lollies, chewing gum, nuts, popcorn, grapes, marshmallows Choose large, sturdy toys without sharp edges or small removable parts Discard old refrigerators, ovens and so on; if storing old appliances, remove doors Keep automatic garage door transmitter in inaccessible place Select safe toy boxes or chests without heavy, hinged lids Keep venetian blind strings out of child’s reach Remove drawstrings from clothing
BODILY DAMAGE
Still clumsy in many skills Easily distracted from tasks Unaware of potential danger from strangers or other people	Avoid giving sharp or pointed objects—such as knives, scissors or toothpicks— especially when walking or running Do not allow lollies or similar objects in mouth when walking or running Teach safety precautions (e.g. to carry fork or scissors with pointed end away from face) Store all dangerous tools, garden equipment and firearms in locked cabinet Be alert to danger of animals, including household pets Use safety glass and stickers on large glassed areas, such as sliding glass doors Teach personal safety Teach name, address and phone number and to ask for help from appropriate people (cashier, security guard, policeman) if lost; have identification on child (sewn in clothes, inside shoe) Avoid personalised clothing in public places Teach child to never go with a stranger Teach child to tell parents if anyone makes child feel uncomfortable in any way Always listen to child’s concerns regarding others’ behaviour Teach child to say ‘no’ when confronted with uncomfortable situations

The preschooler

The preschool period refers to those years between the ages of 3 and 5. Children of preschool age refine the mastery of their bodies and have increasing emotional, psychosocial and cognitive capacity to meet formal educational challenges. Many people consider these the most intriguing years of parenting, because children effectively interact and communicate with adults. Physical development continues to slow, whereas cognitive and psychosocial development are both rapid.

Physical changes

Several aspects of physical development continue to stabilise in the preschool years. See Table 20-5 for average heart rates, respiratory rates and blood pressure ranges. Preschoolers gain, on average, 2–3 kg a year and grow 6–7.5 cm a year, having doubled their birth length at about 4 years (Glasper and Richardson, 2010). There is an elongation of the legs that results in the preschooler appearing more slender. Little difference exists between the sexes, although boys are slightly larger with more muscle and less fatty tissue.

Large and fine muscle coordination improves, enabling preschoolers to run well, walk up and down steps with ease and learn to hop. By 5 years of age they can usually skip on alternate feet, use a skipping rope and begin to swim. Improving fine motor skills allows intricate manipulations. They learn to copy crosses and squares. Triangles and diamonds are usually mastered between 5 and 6 years of age. Scribbling and drawing help to further develop fine muscle skills and eye–hand coordination (Glasper and Richardson, 2010).

Preschoolers need opportunities to learn and practise new physical skills. Nursing care of healthy and ill children includes an assessment of the availability of these opportunities. Although children of preschool age with acute illnesses benefit from rest and exclusion from usual daily activities, those experiencing chronic conditions or who have been hospitalised for long periods need ongoing exposure to developmental opportunities. Thus, it is important that parents and nurses work together to weave these opportunities into the daily experiences of children who are hospitalised or being cared for at home, depending on their abilities, needs and energy level.

• CRITICAL THINKING

From your learning thus far, can you think of some developmental activities that would be appropriate for a preschooler who has been hospitalised?

Cognitive changes

Preschoolers continue to master Piaget’s preoperational stage of cognition that you read about in Chapter 19. You may recall that the first phase of this period, from 2 to 4 years of age, is known as preconceptual thought and is characterised by perceptual-bound thinking, in which children judge persons, objects and events by their outward appearance, or what seems to be. That is, preschoolers during this stage have difficulty reasoning, thinking logically or comprehending that some things stay the same even if their appearance has changed. An example of this concept is if a volume of fluid is poured from a wide container into a narrow container—the preschooler will still assert that the narrow vessel contains more fluid because it is at a higher level within the container (Glasper and Richardson, 2010).

Around 4 years of age, the intuitive phase of preoperational thought develops, and children’s ability to think in a more complex way is demonstrated by their ability to classify objects according to size or colour and by questions such as ‘Why do they call it the thirty-first day of the month instead of the thirty-last?’ Egocentricity persists, but during these years it is slowly replaced with social interaction, as illustrated by the 5-year-old child who offers a sticking plaster to a child with a cut finger. Children become aware of cause-and-effect relationships, as illustrated by the statement ‘The sun sets because people want to go to bed’. Early causal thinking is also evident in preschoolers’ transductive thoughts (reasoning occurs from one particular to another). If two events are related in time or space, children link them in a causal fashion. The hospitalised child, for example, may reason: ‘I cried last night, and that’s why the nurse gave me the injection.’ As children near age 5, they begin to use or can be taught to use rules to understand causation. They then begin to reason from the general to the particular. This forms the basis for more-formal logical thought. The child can now reason: ‘I get an injection twice a day, and that’s why I got one last night.’

Preschoolers’ knowledge of the world remains closely linked to concrete (perceived by the senses) experiences. Even their rich fantasy life is grounded in the perception of reality. The mixing of the two aspects can lead to many childhood fears, and may be misinterpreted by adults as lying when children are actually presenting reality from their perspective. The greatest fear of this age group appears to be that of bodily harm, and it can be seen in children’s fear of the dark, animals, thunderstorms and medical personnel. This fear often interferes with their willingness to allow nursing interventions such as measurement of vital signs. Preschoolers may cooperate if they are allowed to help the nurse measure the blood pressure of a parent or if they are allowed to manipulate the nurse’s equipment.

The preschooler’s moral development expands to include a beginning understanding of behaviours considered socially right or wrong. The child continues to be motivated, however, by the wish to avoid punishment or the desire to obtain a reward. The main differences between this stage of moral development and that of a toddler are that a preschooler is better able to identify behaviours that elicit rewards or punishment, and begins to label these behaviours as right or wrong.

With regard to language development, a preschooler’s vocabulary continues to increase rapidly so that by 5 years of age they are able to use more than 2000 words, can define familiar objects, identify colours and express desires as well as frustrations. Language is more social, with questions expanding to ‘Why?’ and ‘How?’ in the quest for information. Phonetically similar words such as die and dye or wood and would may cause confusion in preschool children. These aspects of language development are important for nurses to keep in mind when preparing children for procedures and assessing comprehension of explanations.

Psychosocial changes

The preschooler’s world expands beyond the family into the neighbourhood, where children meet other children and adults. Their curiosity and developing initiative lead to the active exploration of the environment, the development of new skills and the making of new friends. Preschoolers have a surplus of energy that permits them to plan and attempt many activities that may be beyond their capabilities, such as pouring milk from a two-litre container into their cereal bowls. Guilt arises within children when they overstep the limits of their abilities and feel they have not behaved correctly. Children who in anger have wished their sibling were dead experience guilt if that sibling becomes ill. Children of preschool age need help to understand that ‘wishing’ for something to happen does not make it occur. You may recall from Chapter 19 that Erikson recommends parents help their children strike a healthy balance between initiative and guilt by allowing them to do things on their own while setting firm limits and providing guidance.

During times of stress or illness, preschoolers may revert to bedwetting or thumb-sucking and want their parents to feed, dress and hold them. Box 20-6 lists potential sources of stress in the preschooler. These dependent behaviours are often confusing for or embarrassing to parents, who may benefit from the nurse’s reassurance that they are normal preschooler coping behaviours. In this situation, nurses caring for children of preschool age need to provide experiences that they can master and perceive as success to help them return to their prior level of independent functioning. As language skills develop, children should be encouraged to talk about their feelings. Play is also an excellent way for preschoolers to vent frustration or anger and is a socially acceptable way to deal with stress.

BOX 20-6 SOURCES OF STRESS IN PRESCHOOLERS

3-YEAR-OLD

Infantile behaviour—reverts to babyish ways; can’t completely let go of babyhood

Stubbornness—although is developing an interest in social relationships and a concept of ‘we’, may lapse into uncooperative behaviour

Possessiveness—guards belongings and may be bossy about them

Jealousy—particularly when it comes to parents’ love

Separation anxiety

Stranger anxiety

Confusion—cannot always discriminate between fantasy and reality

White lies—may result from wishful thinking, fantasy and desire to please or impress

Imaginary playmate—often blamed for misdeeds

Fears—may be precipitated by imagination, may also fear dogs or other animals

Speech—may stutter or stumble over words

Activity level—seems to be in perpetual motion; may exhaust himself or herself

Eating—may forget to eat or lose interest in food

Nap or bedtime—may fear bad dreams, the dark or missing out on some fun while asleep

Destructiveness—may damage or destroy objects

Questions—continually asks ‘why’, and is upset if trusted adults do not respond or do not know the answer

4-YEAR-OLD

Insecurity—may develop nervous habits such as nail biting, facial tics, thumb sucking, genital manipulation, blinking or nose picking; may insist on bringing a familiar item from house to preschool

Exaggerations—may attempt to boost self-image with boasts

Companionship—enjoys interacting with friends, although there may be many quarrels

Silliness—tends to engage in silly play; likes words and is fascinated by rhyming syllables or foul language; is disciplined for lack of control

Property rights—protects belongings; may become bossy

Sex—interested in the human body; may engage in exhibitionism

Activity level—enjoys running, jumping and slamming doors; may be punished for disruptive behaviour

Fears—picks up fears from adults; may fear dark room, snakes and lizards or anything perceived as ‘creepy’

Attention—likes to talk and is frustrated if ignored or put off; whines to get own way

5-YEAR-OLD

Approval—parents’ love and acceptance are vital; seeks praise

School—may have difficulty adjusting to kindergarten

Separation anxiety—particularly fears loss of mother

Infantile behaviour—may occasionally lapse into babyish behaviour as a result of realising that babyhood has ended

Worrying—may develop irrational fears, take information out of context or fret over a misinterpreted, overheard conversation

Masturbation—is concerned about being ‘bad’

Belongings—protects possessions

Showing off—performs in order to gain praise

Procrastination—may dillydally now and then

Name-calling—insults others to boost self-image but is upset when she or he is the victim of mockery

Modified from Kuczen B 1982 Childhood stress: don’t let your child be a victim. New York, Delacorte Press.

The play of preschool children becomes more social after the third birthday as it shifts from parallel to associative play. In many play activities, preschoolers display awareness of social context. Sex-role identification is strengthening, and children most often assume roles of persons of their own sex. Children often mimic or repeat social experiences. This tendency is especially significant for the nurse working with hospitalised children. Through play, children may express questions, fears, anger and misunderstanding about their illnesses and care. The nurse should be alert to such clues and ensure that children can play within energy limits. Play can provide a healthy outlet for frustration when children have been subjected to painful or restrictive experiences against their will.

Pretend play involving imaginary situations depends on children’s ability to retain images of things they have seen or heard. This sociodramatic play involving other children occupies about a third of 5-year-old children’s playtime. Pretending allows children to learn to understand others’ points of view, develop skills in solving social problems and become more creative. Some children have imaginary playmates. These playmates serve many purposes—they are friends when they are lonely, they can accomplish what the child is still attempting and they can experience what the child wants to forget or remember. Imaginary playmates are a sign of health and allow the child to distinguish between reality and fantasy. Children who watch a great deal of television engage less often in imaginative play, possibly because they develop the habit of passively absorbing images rather than generating their own (Hockenberry and Wilson, 2009).

Other preschooler health considerations

Safety

As fine and gross motor skills develop and the child becomes more coordinated with better balance, falls become much less of a problem. Guidelines for injury prevention in the toddler also apply to the preschooler. The nurse should alert parents of children in this age group to the risks of poisoning and pedestrian motor vehicle accidents.

Health perceptions

Little research has explored preschoolers’ perceptions of their own health. Parental beliefs about health, children’s bodily sensations and their ability to perform usual daily activities help children develop attitudes about their health. Preschoolers are usually quite independent in washing, dressing and feeding. Alterations in this independence can influence their feelings about their own health.

Nutrition

Nutrition requirements for the preschooler vary little from the toddler. The average daily intake is 7500 kilojoules. Parents may still worry about the amount of food their child is consuming. The quality of the food is more important than quantity in most situations. Preschoolers consume about half of the average adult portions. Finicky eating habits are characteristic of the 4-year-old, but the 5-year-old is more interested in trying new foods.

Sleep

The average number of hours of nocturnal sleep for children reduces over time. Preschoolers average 12 hours of sleep a night and take infrequent naps. Although children of this age group tend to sleep soundly, some sleep disturbances are not uncommon. Disturbances may range from trouble getting to sleep, to nightmares, to prolonging bedtime with extensive rituals. Preschoolers have frequently had an overabundance of activity and stimulation during the day, so helping them to slow down before bedtime usually results in less resistance.

School-age children and adolescents

School-age children and adolescents lead demanding and challenging lives. The developmental changes between 6 and 18 years of age are diverse, with physical, psychosocial, cognitive and moral skills being expanded and refined. The environment, which includes family, close friends, school, community and spiritual influences also expands and develops. When assessing school-age children and adolescents, it is important that the nurse keep in mind appropriate developmental theories and associated expectations. In Chapter 19 you read that children in this age group strive to achieve a sense of identity and industry within a given social and moral context. Working through this period of development may lead the younger child to establish their own peer group and the adolescent to engage in risk-taking behaviour. There are many other behavioural considerations for this age group, identified in Table 20-9.

TABLE 20-9 DEVELOPMENTAL BEHAVIOURS OF SCHOOL-AGE CHILDREN AND ADOLESCENTS

SCHOOL-AGE CHILDREN	ADOLESCENTS
RELATIONSHIPS WITH PARENTS
Children gradually learn that parents are less than perfect; they can be disillusioned with them and wish that friends’ parents were their own. Sometimes they believe that they must be adopted. They rely on parents for unconditional love, security, guidance and nurturing	Adolescents’ desires for increasing independence and autonomy and continuing need for some dependence and limit setting by parents place strain on their relationship. Effective communication and democratic parenting are best tools for meeting this challenge
RELATIONSHIPS WITH SIBLINGS
School-agers seem to be at odds with one another at home; yet they are each others’ best defenders away from home. Younger children often idolise older siblings, and this frequently leads to competition. Older children may envy attention that younger siblings require and be quite bossy and somewhat abusive.	Younger siblings rarely understand their adolescent siblings’ need for privacy to think, dream and talk with peers. Adolescents often enjoy interacting with and guiding younger brothers and sisters when timing is convenient for them and they can remain in control
RELATIONSHIPS WITH PEERS
During primary school (6–9 years), children of both sexes play together, depending on who is available and interested. Around age 8, social groupings of same-sex peers form. These ‘gangs’ allow children to declare their independence from parental rules and establish their own secret codes or languages and rules of membership and behaviour. This period is often referred to as secret society of childhood Preadolescent (10–12 years) friendships are characterised by having best friend of same sex. These relationships may be transient, but they are intense and allow discussion of all areas of life. Some interest in heterosexual relationships develops but they are usually not reciprocated	Peer group is a factor of critical influence to adolescents, who have increasing need for recognition and acceptance. Companionship offered by peer groups provides secure environment for individuals to try out new ideas and share similar feelings and attitudes. Adolescents often form cliques with peers from the same socioeconomic group with similar interests. Cliques, which are highly exclusive, help their members, who have strong emotional bonds, develop their identities. The crowd, which is more impersonal than the clique, offers opportunities for heterosexual interaction and social activities. The crowd also maintains rigid membership requirements; clique membership is usually prerequisite for crowd membership
SELF-CONCEPT
Children’s feelings of competence regarding mastery of tasks are key elements in forming self-esteem. Children need to receive positive feedback from teachers and parents regarding their efforts. It is important for children to develop skills in at least one area such as reading, music or swimming. Pets that require children’s care and attention reward them with unconditional love and promote feelings of self-worth	Formal and informal peer groups are primary force in shaping self-concept of group members. Popularity and recognition within peer group enhance self-esteem and reinforce self-concept. Total immersion in peer group may make it appear that adolescents have no original thoughts and are incapable of making decisions. Adolescents who withdraw from peers into isolation struggle with developing identity
FEARS
There is decline in fears related to body safety such as storms, dogs, darkness, noises, scrapes and scratches. Fears of supernatural such as ghosts and witches persist and decline slowly. New fears related to school and family occur. They fear ridicule from teachers and friends and disapproval and rejection of parents. They also become frightened about death and items that they hear on news such as war and destruction of environment	Fears in this age group centre around peer group acceptance, body changes, loss of self-control and emerging sexual urges. Adolescents constantly examine their bodies for changes and signs of imperfection. Any defect, real or imagined, is cause of endless worry. Adolescents’ developing awareness of economic and political problems may result in fear of going to war with its resulting death and destruction
COPING PATTERNS
To deal with stress, school-agers use problem solving and defence mechanisms including regression, denial, aggression and suppression. Several categories of coping behaviours of hospitalised school-agers include inactivity (total silence, lack of activity and apathy), orientation or precoping (looking and listening, walking around and exploring, and asking questions), cooperation (compliance with care), resistance (attempt to get away from the situation by turning away or making physical or verbal attacks) and controlling (assuming responsibility for self-care and suggesting how things could be done)	Repertoire of coping behaviours has expanded with experiences adolescents have gained from life and from developing cognitive maturity. By age 15, most use full range of defence mechanisms, including rationalisation and intellectualisation. Adolescents’ problem-solving abilities have matured, and they can reason through philosophical discussions and complex situations that require abstract thinking and proposition of hypotheses. Some adolescents use avoidance coping strategies in which the problem is denied or repressed and an attempt is made to reduce tension by engaging in chemical abuse or avoiding people
MORALS
Children learn rules from parents, but their understanding of rules or reasons for them is limited until about 10 years. Before that, they are concerned with own needs first and may cheat to win. After 10, justice is based on ‘eye for an eye’, and punishment should correct situation (e.g. if children break something, they should pay to have it fixed)	According to Kohlberg (1964), as youths approach adolescence they reach the conventional level, where internalisation of expectations of their family and society begins. Initially there is considerable conformity to rules to win praise or approval from others and to avoid social disapproval or rejection; later, they seek to avoid criticism from persons of authority in institutions
DIVERSIONAL ACTIVITY
School-agers play cooperatively in group activities such as skipping, hopscotch, soccer and basketball. Play becomes competitive, and children often have difficulty learning to lose. Teasing, insults, dares, superstitions and increased sensitivity are characteristics of this age	Many teenagers develop special interests in certain sports and concentrate on developing maximal skills therein. Recreational activities are often determined by what is popular with peers and what can provide independence from parents (e.g. computers, cars)
NUTRITION
Children have definite likes and dislikes. Few nutritional deficiencies occur in this age group. Children have voracious appetites after school and need quality snacks such as fruit and sandwiches to avoid empty-kilojoule food such as chips and lollies	Total nutritional needs become greater during adolescence. Girls’ energy needs decrease, and their need for protein increases slightly. Iron needed by adolescents is almost twice that of adult men, and growth spurt increases calcium demand

• CRITICAL THINKING

This would be a good time to reflect on how your learning from the previous chapter together with information provided in Table 20-9 might guide you in conducting a thorough clinical nursing assessment and ongoing plan of care.

After you have done the thinking, make sure you take the time to write your hard work down and place it in your professional portfolio.

Middle childhood

Middle childhood is generally thought about as being between 5 and 12 years of age. This period of time coincides with the entry to school as well as greater exposure to adult roles in work, recreation and social interaction. As the child is exposed to these various educational and social interactions, their world expands and they undergo a transition from a life of relatively free play to a life of structured play, learning and work where certain rules, expectations and social norms become incorporated into their sense of who they are. As a consequence, the child begins to make decisions, accept responsibility and learn from life’s experiences.

Physical changes

The rate of growth during these early school years is slower than at any time since birth, but continues steadily. The early school-age child appears slimmer than the preschooler, as a result of changes in fat distribution and thickness. Children in the middle years also experience differences in rate of growth, with approximate averages for height and weight being 5 cm and 2–3 kg respectively per year (Glasper and Richardson, 2010).

School provides children with an opportunity to compare themselves with large numbers of children of varying ages. Boys are slightly taller and heavier than girls during these early school years. Approximately 2 years before puberty, children experience a rapid acceleration in skeletal growth. Girls, who reach puberty first, often begin to surpass boys in height and weight. These changes may begin as early as 7.5 years in girls and 10.5 years in boys; the average, however, is generally 10 and 12 years respectively (Glasper and Richardson, 2010).

All body functions are refined and stabilised during the early school-age years, leading to changes in heart rate, blood pressure, respiratory rate and lung function as shown in Table 20-5. Large-muscle coordination, strength, and gross and fine motor skills also improve and strengthen during this period. Activities of childhood such as running, jumping, balancing, throwing and catching, writing and colouring, and computer games all contribute to refinement of neuromuscular function and skills. Table 20-10 describes specific gross motor and fine motor skills and how they may be used in managing self-care.

TABLE 20-10 MOTOR DEVELOPMENT IN THE SCHOOL-AGE CHILD

6–7 YEARS	8–10 YEARS	10–12 YEARS
FINE MOTOR SKILLS
Uses knife to butter bread and learns to cut tender meat Cuts, folds and pastes paper Prints with pencil Draws man with 12–16 details Copies triangle at 6 years and diamond by 7 years Colours within lines of picture Needs assistance to clean teeth thoroughly	Uses knife and fork simultaneously Learns to thread needle and tie knot Uses hammer, saw and screwdriver Becomes proficient at writing cursive Uses symbols in drawing (e.g. bird, star) Builds simple models of cars and planes and does simple handicrafts Learns to play marbles Can learn to floss teeth effectively and be independent in tooth care	Learns to peel apples and potatoes Sews simple garments on machine Builds simple objects like bird-house Enjoys using decorative script Begins to use creative and artistic talents Builds complex models of cars and planes and does complex handicrafts Learns to play musical instrument Becomes proficient in caring for teeth with braces and other appliances
GROSS MOTOR SKILLS
Remains in constant motion Moves more cautiously at 7 years than at 6 years Hops and jumps into small squares Learns to rollerskate, skip, ride bicycle and swim	Can catch, throw and hit ball Engages in alternate rhythmic hopping in 2–2, 2–3 or 3–3 pattern Engages in complex styles of skipping rope accompanied by verbal jingles	Can do standing broad jump of 1.5 m Can do standing high jump of 90 cm Plays games involving simultaneous use of two or more complex motor skills such as rollerskating
SELF-CARE
Takes bath without supervision Often returns to finger feeding Learns to brush and comb hair in acceptable fashion without help Puts on most clothes but may need assistance with shirt-tails, sashes and final adjustments	Learns to clean bathroom after bath Enjoys fixing own snacks and school lunch Learns to part hair and tie hair ribbons Dresses self completely and can help younger siblings with clothes Can make own bed	Dusts, vacuums and straightens own room Learns to cook simply prepared foods Washes, dries and fixes own hair in plaits, curls and ponytails Learns to sort, wash, dry and iron own clothing Learns to care for fingernails and toenails

In the middle years, illness and hospitalisation threaten children’s control of how they care for themselves. It is therefore important to allow them to participate in their own care and to maintain as much independence as possible. This participation is still possible for children whose care demands restriction. One example might be a child who is fluid restricted. In this situation the child may be able to choose the type of fluid they consume and when they consume it.

Other physical changes take place during the middle school-age years such as steady skeletal growth in the trunk and extremities together with small- and long-bone ossification, which is generally complete by 12 years of age. With this pattern of skeletal growth, body appearance and posture change. Earlier posture, which was characterised by a stoop-shouldered, slightly lordotic stance and prominent abdomen, changes to a more erect posture. Facial bones grow and remodel, which is reflected in an alteration of eye shape that results in improved visual acuity and the attainment of normal adult vision. Screening for vision and hearing problems is easier, and results are more reliable because middle school-age children can more fully understand and cooperate with the test directions.

Dental growth is prominent during the middle school-age years. The first permanent teeth erupt at approximately 6 years of age. Figure 20-6 illustrates the pattern and timing of dental shedding and eruption.

FIGURE 20-6 Sequence of eruption of secondary teeth.

From Hockenberry MJ, Wilson D 2011 Wong’s Nursing care of infants and children, ed 9. St Louis, Mosby.

Cognitive changes

Cognitive changes provide the middle school-age child with the ability to think in a logical manner about the here and now, but not about abstraction. The thoughts of middle school-age children are no longer dominated by their perceptions, and thus their ability to understand the world greatly expands. As highlighted in Chapter 19, Piaget identifies that during this period of development middle school-age children have a maturing cognitive ability. This stage of development is known as ‘concrete operational’, in which they are able to use symbols to carry out operations (mental activities) in thought rather than in action. They begin to use logical thought processes with concrete materials (objects, people and events they can touch and see). With this stage of development in mind, Taylor (2009) suggests that with the use of pictures and props the nurse may negotiate with the child in relation to their care.

Middle school-age children can use their newly developed cognitive skills to solve problems. Some children are better than others at problem solving because of native intelligence, education and experience. The nurse can help middle school-age children improve their problem-solving abilities and assume responsibility for their general health by helping them to articulate any problems and plan care around their healthcare needs (Glasper and Richardson, 2010). For example, when a child is newly diagnosed with type 1 diabetes, the nurse will play an integral part in assisting the child and their family to meet the new demands and challenges of this chronic illness.

• CRITICAL THINKING

Can you think of strategies you might use in caring for the child and their family described above?

Language development is rapid during the middle school-age years, with the average 6-year-old child having a vocabulary of approximately 3000 words which quickly expands with the introduction to formal reading, exposure to peers and contact with adults. With this exposure children understand the use of language and realise that words have arbitrary, rather than absolute, meanings. Children within the middle years can use different words for the same object or concept, and they understand that a single word may have many meanings. In the clinical setting, middle school-age children are able to use their understanding of language to articulate their health problem and understand the consequences of that articulation. For example, a child complaining of pain might receive pain relief in the form of an injection; as a consequence of that experience, the child might not verbalise when they are next in pain due to the negativity experienced with that injection. Therefore, the nurse cannot always rely on the use of language for accurate clinical assessment when caring for middle school-age children.

Psychosocial changes

In Chapter 19, you read about Erikson who identified the developmental task for middle school-aged children as ‘industry versus inferiority’. During this time, children strive to acquire the competence and skills necessary for them to function as adults. School-age children in the middle years who are positively recognised for success feel a sense of worth. Those faced with failure can feel a sense of mediocrity or unworthiness, which may result in withdrawal from school and peers.

The need for a moral code and social rules becomes more evident as the cognitive abilities and social experiences of school-age children in the middle years increase. For example, 12-year-old children are able to consider what society would be like without rules because of their ability to reason logically and their experiences with group play. They view rules as necessary principles of life, not just dictates from authorities. In the early school years, children strictly interpret and adhere to rules. As they develop, they make more flexible judgments and evaluate rules for applicability to a given situation. Middle school-age children consider motivations and the actual behaviour when making judgments about the way that their behaviours affect themselves and others. The ability to be flexible when applying rules and to take the perspective of others is essential in developing moral judgments. These abilities are present at times in earlier years but are more consistently displayed in middle and later school years.

Group and personal achievements become important to the middle school-age child. Success in physical and cognitive activities is important. Play involves peers and the pursuit of group goals. Although solitary activities are not eliminated, they are overshadowed by group play. Learning to contribute, collaborate and work cooperatively towards a common goal becomes a measure of success. The middle school-age child prefers same-sex peers to opposite-sex peers. The close network of same-sex companions that a child maintains evidences strong gender identity. In general, girls and boys view the opposite sex negatively. Peer influence becomes quite diverse during this stage of development. Conformity is evidenced in mannerisms, clothing styles and speech patterns, which are reinforced and influenced by contact with peers. During this time period, clubs and peer groups become prominent. Group identity increases as the middle school-age child approaches adolescence.

FIGURE 20-7 School-age children gain a sense of achievement when playing with peers.

Image: iStockphoto/Photo_Concepts

In Chapter 19 you also read about Freud’s description of middle childhood as the latency period as, in his opinion, children of this period had little interest in their sexuality. Today many researchers believe that middle school-agers have a great deal of curiosity about their sexuality. Some may experiment, but this play is usually transitory. Emotional consequences are a result of how the parents deal with the behaviour or how the child believes the action would be interpreted from the parental point of view. Children’s curiosity about adult magazines or meanings of sexually explicit words is an example of their interest in sexuality.

The middle school-age child goes through many adjustments during this stage. The nurse’s role is more likely to involve health promotion through assisting parents and children to identify potential stressors and designing interventions to minimise the child’s stress response. Box 20-7 provides an overview of stressors commonly encountered by middle school-age children, and appropriate nursing interventions.

BOX 20-7 POTENTIAL SOURCES OF STRESS IN MIDDLE CHILDHOOD*

SOURCES OF STRESS FOR THE 6-YEAR-OLD

Expectations—parents, teachers and other adults begin to demand more

School—first year introduces the child to the more formal academic setting; it may be the child’s first experience away from home all day

Activity level—may find it difficult to sit still for long periods of time; may have frequent accidents, such as spilling milk

Competition—the child wants to be ‘first’ or best

Shyness—may initially be shy in a new situation but usually recovers quickly

Aggression—may become hostile or aggressive; temper tantrums peak

Sensitivity—begins to read body language or facial expressions and becomes upset when disapproval is sensed

Teasing—engages in teasing, but becomes upset when on the receiving end

Decisions—has difficulty coping with increasing independence

Jealousy—sibling rivalry is common

Fears—usually centre around newly found independence and might include fear of getting lost or fear of making an embarrassing social blunder

SOURCES OF STRESS FOR THE 7-YEAR-OLD

Moodiness—is often moody, unhappy or pensive

Approval—continues to need praise and approval from peer group and parents

Modesty—demands privacy when in the bathroom or dressing

Organisation—is comfortable with rules, regulations, routines and order; becomes upset when they are disrupted

Interruptions—hates to be disturbed when intensely involved in an activity

Idols—has a desire to be more like an admired idol

Friendship—becomes more selective about playmates

SOURCES OF STRESS FOR THE 8-YEAR-OLD

Self-criticism—is very critical of personal ability and performance

Parental authority—is beginning to resent parental authority

Loneliness—likes frequent interaction with friends; may hate to miss school

Praise—continues to seek approval but can identify when praise is not genuine

Independence—many begin to stay alone for brief periods of time while parents run errands; with resulting feelings of uneasiness

SOURCES OF STRESS FOR THE 9-YEAR-OLD

Rebelliousness—Occasionally tests independence by rebelling

Opposite sex—Engages in sex-segregated play, expresses an aversion to the opposite sex

Fair play—Has a keen sense of what is fair and is vehement in demanding personal rights when a situation is perceived as unfair

Interruptions—continues to dislike interruptions but will usually resume an activity after an interruption

Propriety—has a sense of propriety and will often be upset if siblings or parents offend the child’s notion of decorum or dignity

SOURCES OF STRESS FOR THE 10–12-YEAR-OLD

Sexual maturation—girls, in particular, may become self-conscious regarding obvious signs of development

Social issues—a new level of awareness can generate concern regarding pressing societal problems

Size—both boys and girls may be upset by the fact that the girls are taller; the extremely small or extremely large child may be concerned about their size

Shyness—if the child already has a problem in this area, it is likely to become more pronounced at this stage

Opposite sex—may become interested, yet shy, around members of the opposite sex

Confusion—too much freedom can cause the child to flounder

Health—it is not uncommon for a child to become a hypochondriac during this period of development

Money—child is anxious to earn and handle money, but often uses poor judgment

Competition—continues to be highly competitive and looks to peer group for prestige

Burnout—child may become vigorously involved in so many activities that he or she finally becomes exhausted

Self-concept—may engage in teasing, scapegoating or vicious attacks to temporarily boost their self-image; guilt often ensues; may be self-conscious about attempting a new skill

Parents—often becomes highly critical or intolerant of parents

Idols—continues hero worshipping

Fair play—continues to have a highly developed sense of fair play

Drugs and sex—may be tempted to experiment with drugs or sex because ‘everyone’ is doing it

Peer pressure—becomes a powerful motivating force

Self-criticism—child may be highly critical of personal performance

From Kuczen B 1982 Childhood stress: don’t let your child be a victim. New York, Delacorte Press.

• CRITICAL THINKING

Take a minute to reflect on your own journey through school and the stressors you may have encountered. How did you manage them?

Other middle childhood health considerations

MAJOR HEALTH PROBLEMS

Injuries, poisonings and cancer (leukaemia and solid brain tumour) are the major health problems affecting Australian middle school-age children (Australian Bureau of Statistics, 2004). It is therefore crucial that those caring for children in the middle years understand the relationship between developmental abilities related to risk of injury and appropriate prevention strategies (see Table 20-11).

TABLE 20-11 INJURY PREVENTION DURING SCHOOL-AGE YEARS

DEVELOPMENTAL ABILITIES RELATED TO RISK OF INJURY	INJURY PREVENTION
MOTOR VEHICLES
Is increasingly involved in activities away from home Is excited by speed and motion Is easily distracted by environment Does not always perceive injury risk Can be reasoned with	Educate child regarding proper use of seatbelts while a passenger in a vehicle Maintain discipline while a passenger in a vehicle (e.g. keep arms inside, do not lean against doors or interfere with driver) Remind parents and children that no one should ride in the back of a ute or truck Emphasise safe pedestrian behaviour Insist on wearing safety apparel (e.g. helmet) where applicable, such as when riding a bicycle or motorcycle
DROWNING
Is apt to overdo May work hard to perfect a skill Is cautious, but not fearful	Teach child to swim Teach basic rules of water safety Select safe and supervised places to swim Check sufficient water depth for diving Swim with a companion Use an approved flotation device in water or boat Adhere to legislation requiring fencing around pools Learn cardiopulmonary resuscitation (CPR)
BURNS
Has increasing independence Enjoys trying new things	Make sure smoke detectors are in homes Set hot-water temperatures to 50°C to avoid scald burns Instruct child in behaviour in areas involving contact with potential burn hazards (e.g. petrol, matches, bonfires or barbecues, lighter fluid, firecrackers, cigarette lighters, cooking utensils, chemistry sets); avoid climbing or flying kites around electricity wires Instruct child in proper behaviour in the event of fire (e.g. fire drills at home and school) Teach child safe cooking (use low heat, avoid frying, be careful of steam burns, scalds or exploding foods, especially from microwaving)
SUBSTANCE ABUSE AND POISONING
May be easily influenced by peers Has strong allegiance to friends	Educate child regarding hazards of taking non-prescription drugs and chemicals, including aspirin and alcohol Teach child to say ‘no’ if offered illegal or dangerous drugs or alcohol Keep potentially dangerous products in properly labelled receptacles—preferably locked and out of reach
BODILY DAMAGE
Has increased physical skills Needs strenuous physical activity Is interested in acquiring new skills and perfecting attained skills Is daring and adventurous, especially with peers Frequently plays in hazardous places Confidence often exceeds physical capacity Desires group loyalty and has strong need for friends’ approval Attempts hazardous feats Accompanies friends to potentially hazardous facilities Delights in physical activity Is likely to overdo Growth in height exceeds muscular growth and coordination	Help provide facilities for supervised activities Encourage playing in safe places Keep firearms safely locked up except during adult supervision Teach proper care of, use of and respect for devices with potential danger (power tools) Teach children not to tease or surprise dogs, invade their territory, take dogs’ toys or interfere with dogs’ feeding Stress eye, ear or mouth protection when using potentially hazardous objects or devices or when engaged in potentially hazardous sports (e.g. football) Teach safety regarding use of corrective devices (glasses); if child wears contact lenses, monitor duration of wear to prevent corneal damage Stress careful selection, use and maintenance of sports and recreation equipment such as skateboards and inline skates Emphasise proper conditioning, safe practices and use of safety equipment for sports or recreational activities Caution against engaging in hazardous sports, such as those involving trampolines Use safety glass and stickers on large glassed areas, such as sliding glass doors Use window guards to prevent falls Teach name, address and phone number and to ask for help from appropriate people (cashier, security guard, policeman) if lost; have identification on child (sewn in clothes, inside shoe)
	Teach stranger safety: —avoid personalised clothing in public places —caution child to never go with a stranger —have child tell parents if anyone makes child feel uncomfortable in any way —always listen to child’s concerns regarding others’ behaviour —teach child to say ‘no’ when confronted with uncomfortable situations

Modified from Hockenberry MJ, Wilson D 2011 Wong’s Nursing care of infants and children, ed 9. St Louis, Mosby.

Long-term conditions do occur in the middle school-age years and are most commonly allergy-related conditions such as asthma, hayfever, sinusitis and eczema. Otitis media and eyesight problems are the next most common long-term conditions. While these long-term conditions are certainly present, children in this age group are more likely to experience colds, coughs, sore throats or influenza (Australian Bureau of Statistics, 2004).

Certain groups of middle school-age children are more prone to disease and disability, such as those with an intellectual disability, mental health disorder, learning disorder or sensory impairment. There is also a well-known strong correlation between poverty and prevalence of illness. Children living in impoverished circumstances are often malnourished and have limited access to healthcare, health promotion or health prevention initiatives. A search of the relevant government’s health website will help you see some of the major health challenges that are experienced by disadvantaged families and some Aboriginal and Māri and Pacific Islander communities. Involvement with social reform, environmental change and methods of healthcare delivery is necessary if the nurse wants to positively influence the health of children and their families.

HEALTH PERCEPTIONS

During the middle school-age years, identity and self-concept become stronger and more individualised. Perception of wellness is based on readily observable facts, such as the presence or absence of illness and adequacy of eating or sleeping. Functional ability is the standard by which personal health and the health of others are judged. The middle school-age period is a crucial period for the acquisition of behaviours and health practices for a healthy adult life. Since cognition is advancing during the middle years, effective health education must be developmentally appropriate.

Promotion of good health practices is a nursing responsibility, with programs frequently organised and conducted within the school environment. During these programs, the nurse is involved in the planning, implementation and evaluation of health-promoting activities, working within a primary healthcare framework. Nurses support curriculum planning, teaching and learning. They provide advice and information on health matters, conduct individual consultations and are advocates for young people. Age-appropriate input on topics such as alcohol, drugs, tobacco, HIV, menstruation, sexual intercourse, reproduction, relationships and identity are all-important aspects of nursing work with middle school-age children. Nurses are also involved in the coordination of immunisations, screenings and dental care.

SAFETY

Since accidents are a leading cause of death and injury in the middle school-age period, safety is a priority health teaching consideration. Nurses can contribute to the general health of children by educating them about safety measures to prevent accidents. At this age, children should be encouraged to take responsibility for their own safety.

NUTRITION

Nurses can contribute to meeting national policy goals by promoting healthy lifestyle habits, including nutrition. Middle school-age children should participate in educational programs that enable them to plan, select and prepare healthy meals and snacks. Box 20-8 outlines several learning activities appropriate for this age group.

BOX 20-8 SCHOOL-BASED INTERVENTIONS TO PROMOTE NUTRITION EDUCATION

• Have young children collect pictures of healthy foods and make a poster for display in the school cafeteria

• Make healthy foods (fruits, vegetables, whole grains, low-fat snacks) available in school vending machines and at school sporting events

• Discourage the use of high-fat foods (lollies and chocolates) as part of school fund-raising projects

• Avoid the use of food as rewards for behaviour; use verbal praise and token gifts to reinforce healthy eating and physical activity

• Have teachers and school personnel model healthy eating habits

• Ask children to select foods from a fast-food restaurant menu and to identify those foods high in fat, cholesterol and sodium

• Ask each child to keep a diary of foods eaten in 1 day; using the food pyramid, evaluate these foods

• Incorporate nutrition education into other classes (such as using a computer to analyse the nutritional content of foods)

• Have students keep a diary to identify cues for their eating behaviour (e.g. hunger, stress, other people, social situations)

• Teach students how to read and discuss the nutrition labels on foods

• Ask students to examine television commercials, magazine advertisements and billboards to identify social influences on eating and physical activities

• Use role-playing to help students learn to cope with social and peer pressures to eat specific foods

• Have students identify environmental barriers to healthy eating

• Have students prepare nutritious foods, plan menus and develop a recipe book of healthy foods

• Involve parents in nutrition education through homework assignments or by inviting parents to attend student-led nutrition fairs

Modified from Center for Communicable Diseases 1996 Guidelines for school programs to promote lifelong healthy eating, J Sch Health 67:9.

Although actual growth may slow down during the middle school-age period, the body is preparing for a pubescent growth spurt, with a build-up of weight occurring at this time. Additional weight should not be a concern if the child has moderate eating habits in place. Obesity may become a problem because children often rush into the home after school or play and eat the most easily obtainable and appealing foods. Unfortunately, these foods are often nutritionally poor and kilojoule-laden. Providing access to fresh fruit, raw vegetables, cheese and high-protein, nutritious snacks is often the best way for a parent to ensure good nutritional intake. Children can learn a great deal about the food pyramid and a balanced diet by helping to prepare their own lunches and snacks. Activity levels vary from day to day, and children’s appetites and consumption of food vary accordingly. When children are overweight, they should be encouraged to increase their expenditure of kilojoules through exercise and vigorous play. Children who become overweight have lower self-esteem, have difficulty keeping up with other children in physical activities and are often rejected by their peers. Nurses can help families and children prevent obesity through promoting proper nutrition and exercise. Obesity in middle childhood is very much on the Australian health agenda.

• CRITICAL THINKING

What do you know about current initiatives in the area of childhood obesity?

Preadolescence

Professionals in behavioural science often refer to the transitional period between middle childhood and adolescence as preadolescence. Others have referred to this period as late childhood, early adolescence and pubescence. Physically it refers to the beginning of the second skeletal growth spurt, when physical changes such as the development of pubic hair and female breasts begin. These physical changes that announce the approach of puberty begin about 2 years earlier in girls than in boys. In addition, children become much more social, and their behavioural patterns become much less predictable. Development of close social networks of both same and opposite sexes commences during the period of preadolescence. This expanded network may progress to new intimate relations and is likely to influence the beliefs, perceptions and actions of this age group. These newly acquired social relations extend beyond their immediate peers to individuals older than their parents. This may provide the preadolescent with an opportunity to gain information regarding the attributes necessary for social and emotional maturity.

Adolescence

Adolescence is the period of development during which the individual makes the transition from childhood to adulthood, usually between 13 and 20 years. The term adolescent usually refers to psychological maturation of the individual, whereas puberty refers to the point at which reproduction becomes possible. The hormonal changes of puberty result in changes in the appearance of the young person, and mental development results in the ability to hypothesise and deal with abstractions. Adjustments and adaptations are needed to cope with these simultaneous changes and the attempt to establish a mature sense of identity. Adaptations required push the adolescent to develop coping mechanisms and styles of behaviour that will be used or adapted throughout life. Table 20-12 provides you with an overview of three sub-phases which are said to exist during the period of adolescence.

TABLE 20-12 GROWTH AND DEVELOPMENT DURING ADOLESCENCE

EARLY ADOLESCENCE (11–14 YEARS)	MIDDLE ADOLESCENCE (14–17 YEARS)	LATE ADOLESCENCE (17–20 YEARS)
GROWTH
Rapidly accelerating growth reaches peak velocity Secondary sex characteristics appear	Growth decelerating in girls Stature reaches 95% of adult height Secondary sex characteristics well advanced	Physically mature Structure and reproductive growth almost complete
COGNITION
Explores newfound ability for limited abstract thought Clumsy groping for new values and energies Comparison of ‘normality’ with peers of same sex	Developing capacity for abstract thinking Enjoys intellectual powers, often in idealistic terms Concern with philosophical, political and social problems	Established abstract thought Can perceive and act on long-range operations Able to view problems comprehensively Intellectual and functional identity established
IDENTITY
Preoccupied with rapid body changes Trying-out of various roles Measurement of attractiveness by acceptance or rejection of peers Conformity to group norms	Modifies body image Very self-centred; increased narcissism Tendency towards inner experience and self-discovery Has a rich fantasy life Idealistic Able to perceive future implications of current behaviour and decisions; variable application	Body image and gender-role definition nearly secured Mature sexual identity Phase of consolidation of identity Stability of self-esteem Comfortable with physical growth Social roles defined and articulated
RELATIONSHIPS WITH PARENTS
Defining independence–dependence boundaries Strong desire to remain dependent on parents while trying to detach No major conflicts over parental control	Major conflicts over independence and control Low point in parent–child relationship Greatest push for emancipation; disengagement Final and irreversible emotional detachment from parents; mourning	Emotional and physical separation from parents completed Independence from family with less conflict Emancipation nearly secured
RELATIONSHIPS WITH PEERS
Seeks peer affiliations to counter instability generated by rapid change Upsurge of close, idealised friendships with members of the same sex Struggle for mastery takes place within peer group	Strong need for identity to affirm self-image Behavioural standards set by peer group Acceptance by peers extremely important—fear of rejection Exploration of ability to attract the opposite sex	Peer group recedes in importance in favour of individual friendship Testing of male–female relationships against possibility of permanent alliance Relationships characterised by giving and sharing
SEXUALITY
Self-exploration and evaluation Limited dating, usually socialises with a group Limited intimacy	Multiple plural relationships Decisive turn towards heterosexuality (if homosexual, knows by this time) Exploration of ‘self-appeal’ Feeling of ‘being in love’ Tentative establishment of relationships	Forms stable relationships and attachment to another Growing capacity for mutuality and reciprocity Dating as a male–female pair Intimacy involves commitment rather than exploration and romanticism
PSYCHOLOGICAL HEALTH
Wide mood swings Intense daydreaming Anger outwardly expressed with moodiness, temper outbursts and verbal insults and name-calling	Tendency towards inner experiences; more introspective Tendency to withdraw when upset or feelings are hurt Vacillation of emotions in time and range Feelings of inadequacy common; difficulty in asking for help	More constancy of emotion Anger more apt to be concealed

Modified from Hockenberry MJ, Wilson D 2011 Wong’s Nursing care of infants and children, ed 9. St Louis, Mosby.

The nurse that demonstrates a good understanding of development can provide a unique perspective for helping teenagers and parents anticipate and cope with the stresses of adolescence. Nursing activities, particularly education, can promote healthy development. These activities occur in a variety of settings and can be directed at adolescents, parents, or both.

• CRITICAL THINKING

Can you think of an example where you might provide health promotion to the adolescent? For example, the nurse can provide practical suggestions for solving various problems of concern such as making responsible decisions about drug or alcohol use.

Physical changes

Physical changes occur rapidly in adolescence. Sexual maturation occurs with the development of primary and secondary sexual characteristics. Primary characteristics are physical and hormonal changes necessary for reproduction. Secondary characteristics externally differentiate males from females. The four main aspects of physical development are:

• increased growth rate of skeleton, muscle and viscera

• sex-specific changes, such as changes in shoulder and hip width

• alteration in distribution of muscle and fat

• development of the reproductive system and secondary sex characteristics.

Wide variation exists in the timing of physical changes associated with puberty between sexes and within the same sex. In general, girls tend to begin their physical changes earlier than boys, with variations more pronounced in boys. The sequence of growth changes in puberty is the same in most individuals (see Table 20-13).

TABLE 20-13 AVERAGE SEQUENCES OF PHYSIOLOGICAL CHANGES IN ADOLESCENCE

CHARACTERISTICS	GIRLS^*	BOYS^*
Beginning of skeletal growth spurt	8–14½ (peak: 12)	10–16½ (peak: 14)
Beginning of breast development	8–13
Enlargement of testes and scrotal sac		10–13 ½
Appearance of straight, pigmented pubic hair, which gradually becomes curly	8–14	10–15
Early voice changes (cracks)		11–14½
Enlargement of penis and prostate gland		11–14½
Menarche	10–18 (average: 12¼)
Spermatogenesis (ejaculation of sperm)		11–17 (average: 13½)
Ovulation and completion of breast development	14–18 (average: 15½)
Appearance of downy facial hair		12–17
Appearance of axillary (underarm) hair and increased output of oil and sweat-producing glands, which may lead to acne	10–16	12–17
Widening and deepening of female pelvis, with deposition of subcutaneous fat that gives rounded appearance to body	10–18
Increase in shoulder width		11–21
Deepening of voice in males, with appearance of coarse and pigmented facial hair and appearance of chest hair		16–21

^*Age ranges are in years.

The various physical changes which occur during the period of adolescence are caused by hormonal changes within the body; that is, when the hypothalamus begins to produce gonadotropin-releasing hormones which signal the pituitary to secrete gonadotropic hormones. Gonadotropic hormones stimulate ovarian cells to produce oestrogen and testicular cells to produce testosterone. These hormones contribute to the development of secondary sex characteristics such as hair growth and voice changes, and play an essential role in reproduction. The changing concentrations of these hormones are also linked to acne and body odour. Understanding these hormonal changes enables the nurse to reassure adolescents and educate them about body care needs.

As with increases in height and weight, the pattern of sexual changes is more significant than their time of onset. Large deviations from normal frames require investigation. Being like peers is extremely important for adolescents. Any deviation in the timing of the physical changes can be extremely difficult for them to accept. The nurse should therefore provide emotional support for adolescents undergoing assessment of early or delayed puberty. Even adolescents whose physical changes are occurring at the normal times may seek confirmation of and reassurance about their normalcy.

Height and weight increases usually occur during the prepubescent growth spurt. The growth spurt for girls generally begins between 8 and 14 years of age; height increases 5–20 cm, and weight increases by 7–25 kg. The male growth spurt usually takes place between 10 and 16 years of age; height increases by 10–30 cm, and weight increases by 7–30 kg. The final 20–25% of adult height and final 50% of adult weight is gained during this time period (Hockenbury and Wilson, 2009). Girls attain 90–95% of their adult height by menarche (the onset of menstruation) and reach their full height by 16–17 years of age, whereas boys continue to grow taller until 18 to 20 years of age. Fat is redistributed into adult proportions as height and weight increase, and gradually the adolescent torso takes on an adult appearance.

FIGURE 20-8 Interacting with peers helps to increase self-esteem during puberty.

Image: Getty Images/David Malan.

Although there are individual and sex differences, growth follows a similar pattern for both sexes. Growth in the length of the extremities occurs earliest, making the hands and feet appear very large and the legs very long; the individual often appears awkward and clumsy. At the same time the lower jaw and nose become longer and the forehead higher and wider, as the baby face of childhood disappears. Next the thighs widen; then the shoulders broaden, and growth of the trunk proceeds. Widening of the female hips and broadening of the male shoulders continue throughout adolescence.

Personal growth curves help the nurse assess physical development. An individual’s sustained progression along the curve, however, is more important than a comparison against the norm. The nurse charts growth measurements during routine health assessments to evaluate changes. Adolescents are sensitive about physical changes that make them different from peers. For this reason they are generally interested in the normal pattern of growth and their personal growth curves. Consequently, the nurse should share this information to reassure adolescents that their own patterns are normal.

Cognitive changes

The widening social environment of the adolescent continues to shape cognitive capacity resulting in the highest level of intellectual development, which in Chapter 19 is described by Piaget as ‘formal operations’. Without an appropriate educational environment, young people who possess sufficient neurological development to reach this stage may not attain it, and those who are guided towards rational thinking may reach this stage early. During the period of adolescence, behavioural changes may be noticed. Indeed, Swartz (2009) noted that individuals in this age group are more likely to initiate ‘multiple risk taking behaviours’. Behaviours that involve risk ‘may inevitably lead to health status becoming compromised or threatened and contribute to the potentially preventable health problems associated with cigarette smoking, drug and alcohol use, and abuse, unintended pregnancies, sexually transmitted illnesses and sedentary lifestyle’ (Swartz, 2009).

The adolescent develops the ability to solve problems through logical operations. The adolescent can think abstractly and deal effectively with hypothetical problems. When confronted with a problem, the adolescent can consider an infinite variety of causes and solutions. For the first time, the young person can move beyond the physical or concrete properties of a situation and use reasoning powers to understand the abstract. Middle school-age children think about what is, whereas adolescents can imagine what might be. These newly developed abilities allow the adolescent to have more insight and skill in playing games such as video games, computer games and board games that require abstract thinking and deductive reasoning about many possible strategies. An adolescent can even solve problems requiring simultaneous manipulation of several abstract concepts.

Development of these higher-level abilities is important in the pursuit of an identity. For example, newly acquired cognitive skills allow the adolescent to define appropriate, effective and comfortable sex-role behaviours and to consider their impact on peers, family and society. The ability to think logically about these behaviours and their outcomes encourages the adolescent to develop personal thoughts and means of expressing sexual identity. In addition, a higher level of cognitive functioning makes the adolescent receptive to more detailed and diverse information about sexuality and sexual behaviours. For example, sex education can include an explanation of physiological sexual changes and birth-control measures.

By mid-adolescence there is an introspective quality emerging with regard to cognition. At this time adolescents believe an ‘imaginary audience’ (Elkind, 1984) provides them with an evaluative means and a sense of being unique. This concept may account for some typical adolescent behaviour, including self-consciousness and the desire for privacy. Elkind (1984) also describes another characteristic of cognitive function, the personal fable. This is a story created by the adolescent that is not true. This concept may account for many undesirable risk-taking behaviours, since the adolescent believes they are immune from negative consequences.

The complex development of thought during this period leads adolescents to question society and its values. Although adolescents have the ability to think as well as an adult, they do not have experiences on which to build. It is common for adolescents to consider their parents too narrow-minded or too materialistic. Cognitive abilities and performance vary greatly among adolescents. In fact, an adolescent may perform at different levels in different situations based on past experiences, formal education and motivation in the use of logic and effective deductive reasoning.

Language development is fairly complete by adolescence, although vocabulary continues to expand. The main focus becomes communication skills that can be used effectively in various situations. Adolescents need to communicate thoughts, feelings and facts to peers, parents, teachers and other persons of authority. The skills used in these diverse communication situations are varied. Adolescents must select the person with whom to communicate, decide on the exact message and choose the way to transmit the message. For example, the way adolescents tell parents about failing a subject is not the same as the way that they tell friends. Adolescents develop different skills and styles of communication and learn how and when to use them most effectively. These diverse communication skills are used and refined throughout life. Good communication skills are critical for adolescents to overcome peer pressure to participate in non-healthy behaviours.

Psychosocial changes

The search for personal identity is the major task of adolescent psychosocial development. Adolescents must establish close peer relationships or remain socially isolated. In Chapter 19 you read that Erikson sees identity (or role) confusion as the prime danger of this stage and suggests that the cliquishness and intolerance of differences seen in adolescent behaviour are defences against identity confusion. Adolescents work at becoming emotionally independent from their parents, while retaining family ties. In addition, they need to develop their own ethical systems based on personal values. Choices about vocation, future education and lifestyle must be made. The various components of total identity evolve from these tasks and compose an adult personal identity that is unique to the individual. Behaviours indicating negative resolution of the developmental task for this age are indecisiveness and the inability to make an occupational choice.

SEXUAL IDENTITY

Achievement of sexual identity is enhanced by the physical changes of puberty. In Freud’s view, these physiological changes of puberty reactivate the libido, the energy source that fuels the sex drive. This is evidenced by the adolescent’s interest in developing intimate relationships with partners outside of the family, and the practice of masturbation. The physical evidence of maturity encourages the development of masculine and feminine behaviours. If these physical changes involve deviations, the person has more difficulty developing a comfortable sexual identity. Adolescents depend on these physical clues because they want assurance of maleness or femaleness and because they do not wish to be different from peers. Without these physical characteristics, achieving sexual identity is difficult. Other influences are cultural attitudes and expectations of sex-role behaviour and available role models. The masculine and feminine behaviours that teenagers see affect the way that they express sexuality.

GROUP IDENTITY

Adolescents also seek a group identity because they need esteem and acceptance. Similarity in dress or speech is common in adolescent groups. Popularity is a major concern. Trends in the desire for popularity have not changed much in recent years. Peer groups provide the adolescent with a sense of belonging and approval and the opportunity to learn acceptable behaviour. Popularity with opposite-sex and same-sex peers is important. The strong need for group identity seems to conflict at times with the search for personal identity. It is as though adolescents require close bonds with peers so that they can later redefine themselves against this group identity.

FAMILY IDENTITY

The movement towards stronger peer relationships is contrasted with the adolescent’s movement away from parents. Although financial independence for adolescents is not the norm, many adolescents work part-time, using their income to bolster independence. When adolescents cannot have a part-time job because of studies, school-related activities and other factors, parents can provide allowances for clothing and incidentals, which encourages adolescents to develop decision-making and budgeting skills.

FIGURE 20-9 Adolescents acquire sexual identity during social interaction.

Some adolescents and families have more difficulty during these years than others. Adolescents need to make choices, act independently and experience the consequences of actions. This testing, however, is best done against a firm, supportive family foundation. The family needs to allow independence while providing a haven in which adolescents can contemplate actions. Families unable to provide this support complicate movement towards identity formation. Support for the family and the adolescent may be essential to their success. Nurses can help families to consider ways that are appropriate for them to foster the independence of their adolescents while maintaining family structure. Many of these discussions involve curfews, jobs and participation in family chores. Emancipation from the immediate family is most successful when accomplished gradually, resulting in separation from the family and family ties that last a lifetime.

VOCATIONAL IDENTITY

The selection of an occupation or a vocational direction in life provides a goal for adolescents. Because of society’s changing needs, adolescents must be future-oriented when making these choices. However, adolescents do not know which jobs will be available or which jobs will be rewarding 10 or 20 years in the future, so selecting a career is a complicated task. The nurse should provide emotional support during this process and should help adolescent clients select courses of action that promote self-satisfaction, identity and continued opportunity for growth.

MORAL IDENTITY

The development of moral judgment depends heavily on cognitive ability, communication skills and peer interaction. Although moral development begins in early childhood, it is consolidated in adolescence because of the presence of certain skills. Adolescents learn to understand that rules are cooperative agreements that can be modified to fit the situation, rather than absolutes. Regarding rules, adolescents learn to use their own judgment rather than use the rules to avoid punishment as in earlier years. As you read in Chapter 19, Kohlberg explains moral development in terms of stages, with the highest level derived from individual principles of conscience. Adolescents judge themselves by internalised ideals, which often lead to conflict between personal and group values. Group values become less significant in later adolescence.

Not all adolescents attain the same level of moral development. There is, however, a general forward movement through the stages of moral development, and the sequence of the stages is similar for all individuals even when their time of achievement varies. Kohlberg’s theory of moral development has a focus on justice based on reciprocity and equal respect. Females have been found to be more likely to give caring responses to moral problems. Males have been found to give more justice-oriented responses.

PSYCHOSOCIAL MORATORIUM

According to Erikson (1968), adolescence provides a time-out period when society allows the physically mature teenager to delay the assumption of adult responsibilities. This is a time for young people to try a variety of ideological and vocational roles before making a commitment. This psychosocial moratorium ends in the selection of values and a consolidation of identity.

HEALTH IDENTITY

Another component of personal identity is perception of health. This component is of specific interest to healthcare providers. Healthy adolescents evaluate their own health according to feelings of wellbeing, ability to function normally and absence of symptoms (Hockenberry and Wilson, 2009). Interventions to improve health perception might, therefore, concentrate on the adolescent period. The rapid changes during this period make health promotion programs especially crucial (see Research highlight). Adolescents try new roles, begin to stabilise their identity and acquire values and behaviours from which their adult lifestyle will evolve.

Other adolescent health considerations

There has been a significant amount of research concerned with adolescents that has been captured, interpreted and made available by governments, health and welfare groups and others interested in reducing adolescent risk-taking behaviours and their consequences. Specific statistics vary from place to place, and from time to time. You will be able to gather the most current statistics by accessing websites such as those of the Australian Bureau of Statistics, the Australian Institute of Health and Welfare, the Australian Department of Health and Ageing and the New Zealand Ministry of Health (see Online resources). The following section provides information about some of the most common areas of health risk.

ACCIDENTS

Accidents remain the leading cause of death in adolescents in Australia and New Zealand. Motor vehicle accidents, which are the most common cause of death, result in almost half of the fatalities from the mid-teen years. These accidents are often associated with alcohol intoxication or drug abuse. Adolescents are more likely than other age groups to never or rarely use a seatbelt, ride a motorcycle or a bicycle without a helmet, ride with someone who has been drinking alcohol, become involved in fights and seriously consider suicide (Australian Institute of Health and Welfare, 2010; Ministry of Health, 2010). The other frequent cause of accidental death in teenagers is drowning.

SUICIDE

Suicide rates in Australian and New Zealand adolescent groups, especially males, have been the focus of attention since the early 1990s, when it became apparent that the rate had risen three-fold over the preceding 30 years. A recent review by Harrison and others (2009) showed that the rate of suicide in Australian males had declined from 29.8 per 100,000 in 1997 to 17.0 per 100,000 in 2006. Equivalent rates for females were 7.8 and 4.8 per 100,000, respectively. Data from the New Zealand Ministry of Health also shows that in 2008 the rate of suicide amongst youth (aged 15–24) decreased by 35.4% since the peak in 1995. However, the female youth suicide rate of 11.1 per 100,000 was the highest since 1999. Within these figures, however, Indigenous young people from both countries continue to have higher rates than other young people, and males continue to have higher rates than females (Harrison and others, 2009; Ministry of Health, 2010).

RESEARCH HIGHLIGHT

Research focus

The physical, social and cognitive needs of adolescents requiring inpatient health services is an important health promoting strategy, and one overlooked in health-service infrastructure. Supportive environments may help adolescents meet their developmental challenges and tasks.

Research abstract

The purpose of this study was to survey inpatient facilities concerning the provision of age-appropriate environments and activities for adolescents. Responses from 33 facilities in the United Kingdom were collated in order to ascertain what was provided. Physical activity was found to be supported in the provision of snooker tables, punching bags, gym equipment and space. Issues that relate to identity and self-esteem were not well provided. For example, facilities affording privacy were infrequent. There was an effort to promote independence and autonomy by encouraging joint decision making and consent with parents and responsibility for individual schedules, kitchen facilities and phones. Some facilities provided areas for social interaction such as lounge areas. The findings suggested a strong need for specific education for nurses working with adolescents, so that they may be well positioned to support adolescents’ developmental tasks.

Evidence-based practice

• Adequate and specialised education should be provided for nurses in psychosocial as well as physical developmental challenges and tasks of adolescents.

• There needs to be specific education and training for nurses in communication.

• Facilities need to be organised to promote age-appropriate physical, cognitive and social activity and behaviour for adolescents.

• Independence and autonomy need to be supported and guided by including adolescents in decision making and scheduling of daily activities and treatments when they are inpatients.

Reference

Russell-Johnson H. Adolescent survey. Paediatr Nurs. 2000;12(6):15–19.

Young males are more successful at suicide attempts than females, in part because of the methods they use, but it is unclear whether they are at greater risk than females. Depression and social isolation commonly precede a suicide attempt, but suicide probably results from a combination of several factors. Although suicide is a complex issue, there are warning signs which often occur for at least a month before suicide is attempted:

• decrease in school performance

• withdrawal

• loss of initiative

• loneliness, sadness and crying

• appetite and sleep disturbances

• talking about suicide.

Other associated suicide risk factors are listed in Box 20-9. Where nurses are working with youth, it is important they know the factors associated with adolescent suicide risk and how these interact with precipitating events. Immediate referrals to mental health professionals need to be made when assessment suggests that adolescents may be considering suicide. Guidance can help them focus on the positive aspects of life and strengthen coping abilities. The need for suicide intervention has been recognised, with the suggestion that ‘Recommendations for intervening to reduce the suicide rates include launching public awareness campaigns about the scope of the problem and warning signs … and training primary health providers to screen for suicide ideation, intent and risk’ (Yearwood and DeLeon Siantz, 2010).

BOX 20-9 SUICIDE RISK FACTORS

PAST HISTORY

• Previous suicide attempt

• Family member or friend has made a suicide attempt

• History of child abuse or neglect

• Past psychiatric hospitalisation

• Death of a parent when child was young

INDIVIDUAL FACTORS

• Hopelessness

• Marked, persistent depression

• Alcohol or drug abuse

• Impulsiveness

• Difficulty tolerating frustration

• Feelings of self-hatred or excessive guilt, feelings of humiliation

• Thinking disorder (wishes to join a deceased person, hears voices telling to kill self)

• Physical/body image problems (delayed puberty, chronic illness, disability, attention deficit hyperactivity disorder, learning disorders)

• Gender identity concerns; gay or lesbian in an unsupportive environment

• Sees self as totally helpless—a victim of fate

• A need to do things perfectly

FAMILY FACTORS

• Difficult home situation—long, bitter parent–child conflict

• Hostile parents

• Overt rejection by one or both parents

• Divorce or separation of parents

• Recent or impending move

• Family break-up or parental loss

• Exposure to unrealistically high parental expectations

• Parental indifference with very low expectations

SOCIAL/ENVIRONMENTAL FACTORS

• Firearms in the home

• Incarceration

• Lack of effective social support system

• Isolation

• Exposure to suicide of another

• Few social, vocational, educational opportunities

Adapted from Hockenberry MJ, Wilson D 2011 Wong’s Nursing care of infants and children, ed 9. St Louis, Mosby.

SUBSTANCE ABUSE

Substance abuse is a concern for those who work with adolescents. Adolescents may believe that mood-altering substances create a sense of wellbeing or improve level of performance. Most adolescents are at risk of experimental or recreational substance use, but those who have unconventional values or come from unstable homes are more at risk of chronic use and physical dependency. Some adolescents believe that substance use makes them more mature. The Australian Institute of Health and Welfare and the New Zealand Ministry of Health both publish current data concerning drug use in young people. The most recent reports are based on data collected during 2007–08, which you can access from the websites listed in Online resources.

EATING DISORDERS

Adolescent girls or young women form the largest group suffering from eating disorders, but males in the same age groups are certainly not immune, and the number of young people with eating disorders continues to increase. Such disorders are associated with the developmental challenges of identity and autonomy, and the social constructions of female identity, rather than with diet. Eating patterns and extreme weight changes may provide clues to the presence of an eating disorder. Areas to include in the assessment are past and present diet history, food records, eating habits, attitudes, health beliefs and socioeconomic and psychosocial factors (Friedman and others, 1998).

Although anorexia nervosa and bulimia are classified as separate disorders, there is significant overlap between the two eating disorders (Friedman and others, 1998). Anorexia nervosa is considered a clinical syndrome with both physical and psychosocial components. The majority of sufferers are adolescents and young women. Attending a highly competitive school and being from a professional, upper-middle-class family increases the risk of this disorder. People with anorexia nervosa have an intense fear of gaining weight and use their bodyweight and image to control their environment and identity. Bulimia nervosa is most identified with binge-eating and behaviours to prevent weight gain. Behaviours include self-induced vomiting, misuse of laxatives and other medications and excessive exercise. Because adolescents rarely volunteer information about behaviours to prevent weight gain, it is important to take a thorough dietary history. Bulimia is considered a biopsychosocial illness. Both anorexic and bulimic people have a strong awareness of society’s emphasis on being thin.

SEXUAL EXPERIMENTATION

Sexual experimentation is common among adolescents. Peer pressure, physiological and emotional changes and societal expectations contribute to early heterosexual and homosexual relations. The proportion of young people who are sexually active in their mid-teenage years continues to increase (Australian Institute of Health and Welfare, 2011). By about 14 years of age, 27% of Australian adolescents report being sexually active; that number increases to 56% by 18 years of age. New Zealand figures show that around 20% of adolescents report being sexually active by the age of 13 years; 54% by age 17 (Adolescent Health Research Group, 2007). Young people from Indigenous groups report becoming sexually active at an earlier age (Australian Institute of Health and Welfare, 2011; Ministry of Health, 2001). The two most challenging consequences of adolescent sexual activity are sexually transmitted disease and unwanted pregnancies.

SEXUALLY TRANSMITTED INFECTION

Education about the ways in which human immunodeficiency virus (HIV) and other diseases are associated with sexual intercourse has been only partially successful in reducing risk-taking behaviours. Knowledge of the symptoms and even the names of other sexually transmitted infections (STIs) is poor among this age group, and many adolescents remain unaware of the short- and long-term consequences of contracting even the most common sexually transmitted infections (Australian Institute of Health and Welfare, 2011). This high degree of incidence makes it imperative that sexually active adolescents be screened for STIs even when they have no symptoms. The annual physical examination of a sexually active adolescent should include a thorough sexual history and a careful examination of the genitalia. Recommended tests for women include Papanicolaou (Pap) smears. The healthcare provider can take the initiative by using the interview process to identify risk factors in the adolescent. Once identified, the risk factors should lead to a strong message of prevention and targeted screening. For the most current information about STIs, you can visit the family planning websites listed in Online resources.

HIV, which progresses to acquired immune deficiency syndrome (AIDS), is transmitted through unprotected sexual intercourse, the use of shared needles, and infected blood products. Therefore, the risk-taking behaviours of adolescent sexual activity and drug use make adolescents one of the vulnerable groups to acquiring AIDS. Adolescents who have placed themselves at risk of AIDS should be tested for HIV. Again, the family planning websites listed in Online resources will give you the most up-to-date information.

PREGNANCY

The rate of adolescent pregnancy has fallen in Australia as a result of education, the ready availability of contraception and, in most states, legal abortion. The birth rate in adolescents reached an all-time low in 1988 and has remained below 20 babies per 1000 female teenagers aged 15–19 years ever since. The most recent statistics from the Australian Bureau of Statistics show that the rate of teenage pregnancy for 2010 was 16 per 1000 in the 15–19 year age group (Australian Bureau of Statistics, 2010). Within the same age group in New Zealand, the rate was 51 per 1000 in 2008, again a rate that has remained stable since the early 1980s (Ministry of Youth Development, 2008).

Adolescent pregnancy occurs across socioeconomic class, in public and private schools, among all ethnic and religious backgrounds and in all parts of the country. Two factors believed to account for adolescent childbearing levels and trends are the adult childbearing levels and trends, and poverty. The Australian Bureau of Statistics, Australian Institute of Health and Welfare and family planning websites will give you more information related to these issues.

General health concerns

One area of concern is the formation of healthy habits of daily living. Emphasis on exercise, sleep, nutrition and stress-reduction habits is increasing. The nurse must recognise the importance of these habits and identify ways to adapt them to each adolescent. To do this, the nurse must assess the individual’s positive and negative habits and attitudes about health. Extensive and long-term follow-up is required if individualised interventions are to succeed. The nurse needs to be aware of the prevalence of health problems, and make assessments accordingly.

HEALTH EDUCATION

Community and school-based health programs for adolescents focus on health promotion and illness prevention. Nurses are involved in community health through screening and teaching programs. The services provided to adolescents must be easily accessed and confidential. Not surprisingly, adolescents are more likely to reveal intimate information about their risk-taking behaviours when they feel comfortable and respected within the interaction.

Nurses can play an important role in preventing injuries and accidental deaths. Stimulating adolescents to discuss alternatives to driving when under the influence of drugs or alcohol prepares them to consider alternatives when such an occasion arises. The nurse must identify those adolescents at risk of abuse provide education to prevent accidents related to substance abuse and provide counselling to those in rehabilitation. ‘Effective adolescent health care focuses on those areas of health promotion while also engaging with the adolescent to address the issues of role conflict, parental involvement, confidentiality, and the varied coping strategies that are common to this group’(Swartz, 2009).

Sex education and relationship counselling are also important topics where nurses can support adolescents. Nurses are in a good position to help adolescent mothers access support services and continue their education, by helping to organise flexible teaching and learning arrangements, uniforms and alterations in attendance schedules, as well as integration of an infant into the school environment.

RURAL ADOLESCENTS

The long distance between population centres and declining rural populations, together with the subsequent reduction of opportunities and services, are negative influences on rural adolescents. Areas of concern for these adolescents include limited access to healthcare, the limited privacy inherent in small towns, lack of transportation to healthcare, poverty and farm accidents. Nurses can play an important role in improving the health of adolescents. Decreasing barriers to care, health promotion education, development of coping strategies and assessment of health beliefs are important areas for nurses to confront.

INDIGENOUS ADOLESCENTS

Indigenous youth has a special set of challenges. Indigenous adolescents may feel alienated both from mainstream society and from traditional culture. They experience a greater percentage of health problems and barriers to healthcare than their non-Indigenous peers. Health issues involving these adolescents living in both urban and isolated areas include learning or emotional difficulties, violence, death from suicide, accidental injuries, poverty and high rates of adolescent pregnancy and STIs. The rate of alcohol and drug abuse is especially high within Australian Indigenous youth, with petrol sniffing of particular concern (Australian Indigenous HealthInfoNet, 2010). For Māri youth, alcohol, drugs and tobacco are connected to risk-taking behaviour (Te Puni Ko–kiri, 2006).

Nurses can make a significant contribution to improving access to appropriate healthcare for adolescents. Nurses can be helpful by identifying their own ethnocentrism, stereotypes and prejudices and learning about social group dynamics, in order to understand the issues and identify effective culturally sensitive coping strategies that enable Indigenous adolescents to overcome stresses inherent in their environment (Ryan-Wenger and Copeland, 1994). Health promotion initiatives must be based on topics of concern for these adolescents. Further, appropriate presentation in terms of methods and language is important in health promotion materials, not only for Indigenous youth but for all young people.

KEY CONCEPTS

• Growth and development are patterned, complex and interdependent processes that continue throughout life.

• A developmental perspective helps the nurse understand commonalities and variations in developmental tasks and challenges for infants, young children and adolescents and the impacts these have on the client’s health.

• The interdependence of physical, cognitive and psychosocial development means that each can affect infant, child or adolescent achievement of another at any particular stage.

• Growth and development are influenced by the inner forces of heredity and temperament, and the outer forces of family, peers, life experiences and environmental elements.

• Because the embryo and fetus grow and develop throughout the intrauterine period, genetic factors and environmental factors (teratogens) may affect body systems in-utero.

• Physiological, cognitive and psychosocial developmental challenges continue from conception to adolescence, and the nurse must be familiar with normal parameters to identify potential problems and promote optimal growth and development.

• Physical growth during the school years is slow and steady until the skeletal growth spurt just before puberty.

• The major psychosocial developmental task of the school-age child is the development of a sense of industry, which is gained through personal achievements and results in positive self-esteem.

• Cognitively, the young school-age child develops conservation, the mental operation that allows thought processes to become more logical.

• The prepubescent growth spurt usually occurs 2 years earlier in girls than in boys; during this time, development of secondary sexual changes begins.

• Adolescence begins with puberty, when primary sexual characteristics begin to develop and secondary sexual characteristics complete development.

• The adolescent is able to solve complex mental problems, use deductive reasoning and hypothesise about the future.

• The adolescent’s rapid change in physical appearance heightens self-consciousness and concerns regarding body image.

• Accidents are the major cause of death in all age groups.

ONLINE RESOURCES

Australian Bureau of Statistics, www.abs.gov.au

Australian Breastfeeding Association, www.breastfeeding.asn.au

Australian immunisation schedule, http://immunise.health.gov.au/internet/immunise/publishing.nsf/Content/nips2

Australian Institute of Health and Welfare, www.aihw.gov.au

Australian Department of Health and Ageing, www.health.gov.au

Australian safety standards, www.standards.org.au

Cochrane Collaboration, www.cochrane.org

Dietary guidelines for children and adolescents, www.nhmrc.gov.au/_files_nhmrc/publications/attachments/n34.pdf

Family Planning New South Wales, www.fpnsw.org.au

Family Planning New Zealand, www.familyplanning.org.nz

National Health and Medical Research Council, www.nhmrc.gov.au

New Zealand Ministry of Health, www.health.govt.nzimmunisation schedule, www.health.govt.nz/our-work/preventative-health-wellness/immunisation/new-zealand-immunisation-schedule

SIDS Australia, www.sidsandkids.org

World Health Organization, www.who.int/en/

REFERENCES

Adolescent Health Research Group. Youth 2000 Project, Youth’07 – The Second National Health and Wellbeing Survey of New Zealand Secondary School Students. Auckland: University of Auckland, 2007. Online Available at www.youth2000.ac.nz/research-projects-and-surveys-national-survey-2007–/overview-of-youth-07-1130.htm 11 Apr 2012.

Als H. A synactive model of neonatal behavioral organization: a framework for the assessment of neurobehavior in the premature infant and for support of infants and parents in the neonatal intensive care environment. Phys Occup Ther Pediatr. 1986;6(3–4):3–53.

Australian Bureau of Statistics (ABS). Health of children, Cat. no. 4829.0.55.001. Canberra: ABS, 2004. Online Available at www.abs.gov.au/ausstats/abs@.nsf/productsbytitle/BFDEA1987337522ECA2572820014F0FF?OpenDocument 4 Apr 2012.

Australian Bureau of Statistics (ABS). Causes of death, Australia, Cat. no. 3303.0. Canberra: ABS, 2006. Online Available at www.abs.gov.au/AUSSTATS/abs@.nsf/ProductsbyTopic/2093DA6935DB138FCA2568A9001393C9?OpenDocument 21 Apr 2011.

Australian Bureau of Statistics (ABS). Births, Australia, 2010, Cat. no. 3301.0. Canberra: ABS, 2010. Online Available at www.abs.gov.au/ausstats/abs@.nsf/Products/55AC7A73A93B9694CA25793300167595?opendocument 6 Dec 2011.

Australian Dental Association. Infant dental care fact sheets. St Leonards: Australian Dental Association, 2010. Online Available at www.ada.org.au/app_cmslib/media/lib/0805/m128283_v1_oral%20hygiene_factsheet_.pdf 24 Apr 2011.

Australian Indigenous HealthInfoNet. Substance abuse. Online. Available at www.healthinfonet.ecu.edu.au/health-risks/substance-use?gclid=COrB28DzsK8CFWZMpgod3iWQGg, 2010. 11 Apr 2012.

Australian Institute of Health and Welfare (AIHW). A picture of children’s health. Canberra: AIHW, 2009.

Australian Institute of Health and Welfare (AIHW). Young Australians: their health and wellbeing 2011, Cat. no. PHE 140. Canberra: AIHW, 2011. Online Available at http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=10737419259 11 Apr 2012.

Beckett C. Child protection: an introduction. London: Sage Publications, 2003.

Berk LE. Development through the lifespan, ed 4. Boston: Allyn & Bacon, 2007.

Bowlby J. Attachment and loss. London: Hogarth, 1969.

Department of Health and Ageing, National Health, Medical Research Council. Australian immunisation handbook, ed 9. Canberra: Australian Government, 2008. 2008, Online. Available at www.health.gov.au/internet/immunise/publishing.nsf/content/handbook-home 26 May 2011.

Elias SL, Gibbons MJ. Nutritional foundation for pregnancy, childbirth and lactation. In Pairman S, et al, eds.: Midwifery: preparation for practice, ed 2, Sydney: Churchill Livingstone, 2010.

Elkind D. All grown up and no place to go. Reading, Mass.: Addison-Wesley, 1984.

Erikson EH. Identity: youth and crises. New York: Norton, 1968.

Friedman S, Schonberg K, Alderman EM, et al. Comprehensive adolescent health care, ed 2. St Louis: Mosby, 1998.

Glasper A, Richardson J, eds. A textbook of children’s and young people’s nursing, ed 2, London: Churchill Livingstone, 2010.

Grigg C. Working with women in pregnancy. In Pairman S, et al, eds.: Midwifery: preparation for practice, ed 2, Sydney: Churchill Livingstone, 2010.

Griffiths C, Thorogood C. Challenges in pregnancy. In Pairman S, et al, eds.: Midwifery: preparation for practice, ed 2, Sydney: Churchill Livingstone, 2010.

Harrison JE, Pointer S, Elnour AA. A review of suicide statistics in Australia. Canberra: Australian Institute of Health and Welfare, 2009.

Hockenberry MJ, Wilson D. Wong’s Essentials of pediatric nursing, ed 8. St Louis: Mosby, 2009.

Homer C. Challenges in women’s health. In: Pairman S, et al, eds. Midwifery: preparation for practice. Sydney: Churchill Livingstone, 2006.

Hunt CE, Hauck FR. Sudden infant death syndrome. Can Med Assoc J. 2006;174(13):1861–1869.

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The toddler

Physical changes

Cognitive changes

Psychosocial changes

Other health considerations during toddlerhood

Safety

Health Perceptions

Nutrition

The preschooler

Physical changes

Cognitive changes

Psychosocial changes

3-YEAR-OLD

4-YEAR-OLD

5-YEAR-OLD

Other preschooler health considerations

Safety

Health perceptions

Nutrition

Sleep

School-age children and adolescents

Middle childhood

Physical changes

Cognitive changes

Psychosocial changes

SOURCES OF STRESS FOR THE 6-YEAR-OLD

SOURCES OF STRESS FOR THE 7-YEAR-OLD

SOURCES OF STRESS FOR THE 8-YEAR-OLD

SOURCES OF STRESS FOR THE 9-YEAR-OLD

SOURCES OF STRESS FOR THE 10–12-YEAR-OLD

Other middle childhood health considerations

MAJOR HEALTH PROBLEMS

HEALTH PERCEPTIONS

SAFETY

NUTRITION

Preadolescence

Adolescence

Physical changes

Cognitive changes

Psychosocial changes

SEXUAL IDENTITY

GROUP IDENTITY

FAMILY IDENTITY

VOCATIONAL IDENTITY

MORAL IDENTITY

PSYCHOSOCIAL MORATORIUM

HEALTH IDENTITY

Other adolescent health considerations

ACCIDENTS

SUICIDE

Research focus

Research abstract

Evidence-based practice

PAST HISTORY

INDIVIDUAL FACTORS

FAMILY FACTORS

SOCIAL/ENVIRONMENTAL FACTORS

SUBSTANCE ABUSE

EATING DISORDERS

SEXUAL EXPERIMENTATION

SEXUALLY TRANSMITTED INFECTION

PREGNANCY

General health concerns

HEALTH EDUCATION

RURAL ADOLESCENTS

INDIGENOUS ADOLESCENTS

ONLINE RESOURCES