Developmental Management of School-Age Children

7 Developmental Management of School-Age Children



Bonnie Gance-Cleveland, Yvonne Yousey


School-age children are busy, active, curious, and creative. With guidance and encouragement they eagerly apply the skills they learned as toddlers and preschoolers as they move into more structured school environments, home schooling, or community settings. Their physical abilities advance, and they join organized sports activities and engage in casual play with friends or siblings. Cognitively and emotionally, school-age children face daunting challenges. They must master the intellectual skills of reading, writing, mathematics, science, and other academic work. They are expected to become skilled socially, separating from home and family, establishing friendships, negotiating with siblings and other family members, and developing a sound sense of who they are as unique members of the community.


School-age children pass through several phases on their way from preschool innocence to the complexity of adolescence. The school-age years are divided into early childhood (5 to 7 years), middle childhood (8 to 10 years), and late childhood (11 to 12 years). Children in each of these phases demonstrate different developmental goals and achievements. Each school-age child is unique, and patterns of “normal” development have broad parameters. The goals of school-age children’s development include laying the groundwork for achievement, creating a sense of self-worth, developing the ability to contribute to the group, and, ultimately, gaining satisfaction with life.


Primary health care providers who care for school-age children must be familiar with psychosocial theoretical models of development in this age group as well as physical growth parameters. Parents often turn to their health care provider for understanding and guidance. Some authors characterize the school-age period as one of quiescence, but a remarkable amount of growth takes place, and the route is not always smooth. Providers support children and their families to successfully achieve during these important years.



image School-Age Child Development



Physical Development


School-age children gain strength and coordination and become more physically capable, setting the stage for participation in sports, dance, gymnastics, and other activities. Success and enjoyment of physical activities establishes healthy patterns for a lifetime. Social status among children is often based on physical competence; therefore, the child’s feelings about physical development can be as important as the physical growth itself.


The growth rate of school-age children increases significantly from that of the toddler and preschooler and occurs in “spurts.” The child literally “grows out of his or her clothes” in a matter of weeks. Children from this age group need height, weight, and body mass index (BMI) evaluation. Head circumference increases slowly, although it is not routinely measured. By middle childhood the brain is about 90% of its adult size. Full adult brain size is reached by about 12 years old. Myelination of the brain, which is necessary for information processing, is not complete until early adulthood. The cerebral cortex (responsible for intelligence) and the frontal lobe (responsible for problem-solving, judgment, and decision-making) are the last to fully develop. The increasing maturation of the brain allows children to complete increasingly complex skills and have greater control over their bodies (see Chapter 2). Organ development is complete. Most school-age children sleep about 10 hours per night (range 8 to 14 hours) without naps, particularly during the school year. Night terrors or sleepwalking may emerge (see Chapter 14).


Traditionally, school-age children are lean; however, recent national data indicate a steady increase in overweight school-age children. National Health and Nutrition Examination Survey data indicate that in 2007 to 2008, 35.5% of children 6 to 11 years old were overweight or obese, up from 29.8% in 1999 to 2000; 19.6% of all children and adolescents were obese. The number of overweight girls, 6 to 11 years old, increased from 13.8% in 1999 to 2000 to 18% in 2007 to 2008. For boys the increase was from 14% overweight in 1999 to 2000 to 21.2% in 2007 to 2008. Although these data represent a significant increase, even more alarming is the fact that in 1980, only 5% to 6% of children were overweight (Ogden et al, 2010). In less than 25 years, the number of overweight children in the U.S. has more than tripled, and the trend continues.


Table 7-1 includes a description of the significant physical changes that occur in school-agers. Discussion of school-age health issues and disease processes is found in Units 3 and 4 of this text.


TABLE 7-1 Physical Development of School-Age Children






























Body System Developmental Change
Skin and lymph

• At about 6 yr, tonsils and adenoids are their largest.


• Prepubescence is characterized by more active sebaceous glands and vasomotor instability that can lead to uncontrolled blushing.

Head, eyes, ears, nose, and mouth

• By early childhood, head size becomes smaller in proportion to body size.


• Developing frontal sinus cavities contribute to increased susceptibility to upper respiratory infections, sinus irritation, and sinus headaches.


• By 6 to 7 yr, the retinas are fully developed, and visual acuity is 20/20.


• By middle childhood, the Eustachian tubes grow longer, narrower, and more slanted.


• By 5 to 6 yr, first primary teeth are shed, and first permanent teeth erupt, usually the central incisors.


• Each year after 6 yr, approximately four teeth are replaced, one set in the upper jaw, one set in the lower jaw.

Pulmonary

• Through childhood, the lungs gradually descend into the thoracic cavity.


• By 8 yr, alveolar development is complete.


• During middle childhood, tidal volume increases; normal adult respiratory rate is achieved, 18 to 30 breaths per minute.


• Increased maturation of macrophagocytic activity of mucus and ciliary function in lungs make child more resistant to respiratory infections.

Cardiovascular

• By 5 yr, the heart is four times larger than at birth.


• By 7 yr, the left ventricle thickens and is two to three times greater in size than the right; blood pressure increases to 90 to 108/60; cardiac volume increases; heart rate declines to 60 to 100 beats per minute.


• Atherosclerosis begins in childhood.

Gastrointestinal

• By middle childhood, the gastrointestinal system is of adult size and function.

Genitourinary

• By 6 yr, elimination patterns are established; greater than 90% of children are toilet trained.


• Bladder capacity continues to expand.


• Between 10 and 14 yr, puberty begins but can be normal in any child after 8 yr.


• Delayed puberty is diagnosed as no secondary sex changes (e.g., breast budding; penis or testicle growth) at 13 yr in girls and 14 yr in boys.

Musculoskeletal

• Long bones grow, leading to taller, thinner appearance.


• Spine becomes straighter; legs become straighter.


• Facial bones are actively changing, as nasal accessory sinuses grow.

Immune system

• Rapid maturation of immune system during middle childhood.


• Allergic conditions may appear.



Motor Skills Development


In middle childhood gross motor skills continue to be refined, allowing children to hop, skip, tandem walk, alternate their foot patterns, and use an overhand motion. Activities that require balance and coordination such as riding a bicycle, swimming, roller skating, and skateboarding demonstrate children’s expanding skills. In late childhood, gross motor skills become more controlled and purposeful. Skills are perfected with practice. A sense of competition is high as children try to outlast or outperform one another. Consequently, school-age children enjoy participating in competitive sports.


Mastery of fine motor skills includes finer dexterity and better control of scissors and writing tools such as crayons and pencils. In early childhood, children become adept at dressing themselves, including being able to tie knots and manage buttons and zippers. Their drawings become more recognizable, showing details of eyes, ears, and other body parts. Self-care skills (e.g., combing hair, brushing teeth) improve. In late childhood, hand-eye coordination improves, and the child uses each hand independently with speed and smoothness. During this time skill in playing musical instruments emerges.



Communication and Language Development


The child’s language patterns provide insight into the neurologic system’s status because the maturing brain is capable of increasingly complex language skills. Both receptive and expressive language skills improve. Six-year-olds have a well-developed vocabulary and retrieve words quickly. They have simple syntactic abilities and follow more complex directions than preschoolers. The language demands of school can be challenging for 6-year-olds. First, they may not be accustomed to attending to total auditory stimuli as in the classroom environment. Second, they are still mastering connotative and semantic skills such as understanding the concepts “before” and “after,” relative clauses (e.g., “the cat was chased by the dog”), and the structures of sentences. These factors can make it difficult for some to follow complicated directions or to cope with the increased demand to recall information within a specific time frame. Narrative skills can be poor, and reading may be difficult. The expressive language of 6-year-olds should be fully intelligible. Stuttering usually resolves by school age but may be seen if young children are overly eager to express themselves. Stuttering should be ignored at this age as long as it does not involve repetition of syllables or cause distress for the child.


Seven-year-olds’ receptive language is strong as they move from the ability to simply decode language to the more complex process of encoding information. They can organize previous knowledge and express it verbally or in writing. They solve word problems. Articulation mastery of the sounds of “l” and “th” may not be achieved until 7 or 8 years of age.


Eight- to 9-year-old children demonstrate significant syntactic growth with better use of pronouns, allowing them to understand convoluted sentences. Comparatives are learned, and the child distinguishes qualities such as more or less, near or far, and heavy or light. By 8 years old, children follow complex directions. They begin to tell jokes because they understand different meanings of words. In their expressive language, children have better narrative abilities and significantly improved storytelling and summarization skills needed for such activities as explaining a task to other children. Vocabulary grows, and there are gradual improvements in grammar (e.g., noted by the use of past and future tenses and plural forms of nouns, particularly irregular nouns and verbs).


At 10 years, children discuss ideas and understand inflections and metaphors. Their ability to understand ambiguities of sentence structure, word meaning, and language contributes to their increasing ability to enjoy jokes and riddles. Using concrete operational thinking, they analyze and interpret language and become more aware of the inconsistency in spoken languages. Children in late childhood understand that the literal meaning of words may not be the only meaning. By 12 years old, children should be able to answer questions involving sophisticated concepts. Expressively, their sentences should be grammatically correct, and they have more detail in their verbal skills. The ability to express emotions also develops. Language has become a means of socializing, and fewer gestures are used. Language can become a game as children make up words and participate in storytelling using proper sequence and pronouns.


Language impairment is linked with motor coordination disorders. Forty to 90% of children with specific language impairment meet criteria for developmental coordination delay. In addition, the overlap between language impairment and attention-deficit/hyperactivity disorder is estimated as high as 90%. Fifty-one percent of children with a language learning disability met the criteria for another developmental disorder (Campbell and Skarakis-Doyle, 2007).


The development of speech and auditory skills is crucial to long-term literacy skills in children. It is necessary to assess these skills throughout the school years to determine the need for remedial efforts with those children who demonstrate literacy difficulties (Shapiro et al, 2009).



Social and Emotional Development


The psychosocial development of school-age children puts to rest the notion that childhood is a “quiescent” period. Challenges that school-age children face are especially difficult because the child’s skill and ultimate success are dependent on abilities that are only just evolving. Gaining social acceptance from one’s peers, for example, depends on skills such as being socially responsive, understanding the group “rules,” using the group jargon, being appropriately assertive, and being empathic. Children who do not yet have those skills can experience a sense of failure when they are compared with their peers who do. Erikson stated that school-age children are eager to learn and internally motivated to achieve mastery and recognition (see Chapter 4). They need to be given experiences in an environment that recognizes, adjusts for, and supports their maturing set of skills, where they can explore creatively, learn actively, and be recognized for their successes.


The stages through which children progress as they become more socially and emotionally mature are sequential and build on earlier skills (Table 7-2) (see Table 4-1 and discussion in Chapter 4 of the theoretical models of development). In particular, school-age children must develop social interactional skills including how to:



• Understand meaning in social situations and interpret the social cues of others


• Initiate interactions


• Terminate interactions positively


• Gain impulse control and manage emotions


• Resolve conflicts



TABLE 7-2 Developmental Characteristics of School-Age Children

image

Mastering these skills enables children to:



• Refine their role within the family system


• Separate self from family


• Develop and maintain peer friendships


• Develop positive relationships with adults outside the family


• Achieve social acceptance


• Strengthen a sense of self


The earliest school-age milestone in the psychosocial area occurs when children learn to separate easily from family, allowing them to go to school. As they move into the community, children maintain their role and feelings of belonging to a family, but also develop secondary attachments with other adults outside the home. Having good relationships with adults outside the home and supports within the community are especially important when the family is not wholly functional—not responsive and supportive—to the child (Vanderbilt-Adriance and Shaw, 2008).



Peer Relationships


A major task of school-age children is to develop competence in social relationships. Friendships are an important part of the school-ager’s life. They allow children to practice learned social skills, provide emotional support, and help children identify a healthy self-image. Social acceptance is especially important at this age. Friends are generally chosen because of shared skills, interests, personality, and loyalty. Children come to see themselves in the eyes of their friends. As early as 7 years old, some children are more concerned about a friend’s opinion than about adults’ opinions. They develop “best friends” and dress and talk like their peers. A special-friend phase should occur at around 10 years old. This is an intense attachment to a same-sex child. With that friend, the child expands the self, learns altruism, shares feelings, and learns how others manage problems. Talking on the telephone and sleepovers become more common. These early friendships are the basis for later relationships. Family conflicts can arise when peer activities and expectations conflict with family rules and values.


Children’s temperaments affect the way they interact with peers, teachers, family, and others in their environment. Emotional problems during these years often follow frustrations, losses, and situations in which the child’s self-esteem is threatened or the child is faced with adversity.



Morality


Although there is variability in moral development, moral reasoning in early childhood is usually determined by the consequences of behavior: to avoid punishment, receive rewards, or meet one’s needs. There is some consideration of the feelings of others, but only as it serves one’s needs. By 7 years old, most children name a site for their conscience (heart or brain), and, consistent with concrete thinking, school-age children tend to be rather rigid in their views of right and wrong. They can understand the relationships between responsibility and privileges and realize that choices between right and wrong behaviors are within their control. Some children at this age act appropriately to get a direct reward, whereas others view moral behavior as following the rules of higher authority (see Table 20-2). In late childhood children begin to move into Kohlberg’s postconventional stage (Kohlberg, 1981), where respect for authority and social norms develops.


The ability to reason through difficult situations with a variety of factors operating depends on cognitive development; however, school-age children do not have the cognitive maturity to cope with all situations. The school environment, where rules and values differ from those of the immediate family, must be confronted and negotiated daily. This presents a challenge to the child’s concepts of right and wrong. Social pressures may make it difficult to choose actions that the child believes are right. The pressures of gangs, drugs, and peers push many children to make decisions about their activities and behaviors before they are developmentally ready. Furthermore, family values are challenged as the child learns that other families make decisions and have beliefs that differ from their own.



Body Image


School-age children can appear to be totally unaware of their bodies (e.g., the 9-year-old who does not change his shirt for 3 days), perhaps because they are so busy with their daily lives. In fact, children at this age are extremely curious about changes happening to them as they grow, and they are sensitive to others around them. Highly literal in their thinking, they can be very frank with questions to people they trust (e.g., “Grandma, why are you growing a mustache?”). At the same time, they learn the importance of social politeness—what is appropriate in certain situations and how to behave themselves—so they may be uncomfortable or shy about new or unusual situations. Modesty is characteristic of school-age children.


Sexual exploration, including masturbation, is common. Children in early childhood, 5 to 7 years old, often play “doctor.” In middle childhood, children compare their bodies with friends of the same sex.


Physical growth and neurologic maturation give children the ability to master many new physical skills. Young swimmers, runners, skateboard enthusiasts, soccer players, musicians, and artists all emerge at this time. Their achievements—and failures—help them define who they are and are the basis for their evolving self-image. The images they have about their bodies come from the experiences they have and from the feedback from family, peers, teachers, and others in the community. This feedback clarifies their understandings and allows the child to gain in self-confidence and feelings of worth (see Chapter 16).



Coping Skills


As a part of the process of developing relationships with others, school-age children refine their ability to identify, label, and manage their feelings. However, their experiences are limited and their cognitive abilities are still expanding. They continue to need help labeling complex emotions such as sadness, depression, worry, and envy. They also need help to consciously manage feelings in acceptable ways.


Impulse control is an important coping skill learned by school-age children. Without impulse control, random behavior occurs; on the other hand, overly controlled children appear hostile, uncreative, or both. By 7 years old, children develop sufficiently to function in a variety of settings (e.g., home, school, playground) with increasing competence.


School-age children face a variety of stressors in society today, including violence, parental divorce, substance abuse in the family, early responsibilities, and lack of support in school. Violence is a constant problem for many, not only in neighborhoods where they live and play but also within their families and schools. Anxiety disorders are one of the most common mental disorders seen in children, with most cases being diagnosed before age 12 years (Beesdo et al, 2009).


Based on the Substance Abuse and Mental Health Services Administration’s (SAMHSA) National Survey on Drug Use and Health in 2008, 8.3 million parents of children less than 18 years old reported drug abuse in the past year. More than 11.9% of all parents stated they abused drugs (USDHHS and SAMHSA, 2008). Substance abuse by parents has led to many children being placed in foster care. In some states, 60% to 70% of all foster care placements are drug related, and many directly connected to methamphetamine use (Smith et al, 2007).


Some children are given heavy responsibility at a young age. When parents work, many children must care for themselves after school. Latchkey children remain alone, housebound and unsupervised, until adults return at the end of the day. Some also have the responsibility of caring for younger siblings.


Many schools lack resources to maintain small class sizes or offer special programs for children with learning difficulties. As a result, children with learning problems are passed on from grade to grade without remediation and with the stigma of failure. Children with chronic illnesses or disabilities may have trouble adapting during the school-age years and may need special help to foster independence and a sense of self-esteem. The child’s physical differences may lead to isolation and rejection by peers. Academic success may be difficult if the child is also cognitively impaired, or if the condition limits exposure to opportunities for cognitive development. Latchkey children with chronic illnesses are especially vulnerable because they may need to make decisions about a health care situation without adult advice. Such children need to understand their illness, medications, where to go for emergency care, how to write down instructions or messages, and how to follow important rules. Children mature at different rates in their ability to manage their self-care throughout the school-age years. A child’s capacity for self-care of chronic illnesses depends on the illness, its stability, the child’s age and cognitive skills, and the child’s support network.



Cognitive Development


In early childhood, children transition from preoperational thinking that uses intuitive problem-solving to early concrete operational thinking. One of the signs of school readiness at this age is the presence of logical thought processes (Box 7-1). Magical thinking and egocentric logic fade, and concepts of conservation, transformation, reversibility, decentration, seriation, and classification emerge. Children’s ability to mentally manipulate the world, relationships, and viewpoints of others is facilitated when they have the opportunity to physically manipulate concrete materials (e.g., using paints, paper, and glue; building things; making dams and forts of mud, snow, or rocks).



BOX 7-1 Screening and Assessment



Screening Tests to Evaluate School Readiness





















Test Source Content
Beery Visual-Motor Integration, Fifth Edition (VMI-5)

Pro-Ed Inc.


www.proedinc.com

 Test of visual motor integration
Denver Developmental Screening Test II

Denver Developmental Materials, Inc.


www.denverii.com

Divided into four areas:


Gross motor


Language


Fine motor


Personal and social



Pediatric Examination of Educational


Readiness (PEER-2) and Pediatric


Examination of Educational


Readiness at Middle Childhood (PEERAMID-2)

Educators Publishing Service, Inc.


www.epsbooks.com

 Combined neurodevelopmental, behavioral, and health assessment


Screening and Assessment Tools for the School-Age Child




image image

By middle childhood, children need to understand relationships of mass and length and multiple variables relating to objects. School-age children normally classify or group materials in relation to other information they have. By late childhood, children have well-developed concrete operational thinking. They should be able to focus on more than one aspect of a problem and use logical thinking. For effective cognitive work, young people must process information, recognize salient cues in the environment, organize their thoughts, consider relationships with other information, use short- and long-term memory retrieval and storage skills, make decisions based on the analysis of information, take action, and use feedback to further their learning.


Concrete operational abilities allow children to read, write, and communicate thoughts effectively. It is now possible to learn about the world, its people, and the views and values of others. Logical thinking and new social skills appear with the ability to understand the viewpoints of others and the decline of egocentricity. Empathy, or the ability to share and understand another’s feelings, emerges and with it the capacity for making deep friendships.



image Developmental Assessment of School-Age Children


Health promotion ensures physical, cognitive, and social emotional health and protects children from infectious diseases and injuries (intentional and unintentional) (Hagan et al, 2008). The real value of preventive health visits may be in the monitoring, screening, and anticipatory guidance related to developmental, behavioral, and emotional issues. It is by reviewing the child’s progress, offering suggestions, and validating parent’s efforts that providers best assist families as they move through the school-age years.


Developmental surveillance (see Chapter 4) is an essential aspect of each contact with the school-age child because visits are less frequent during the school years. Most visits are for minor acute illnesses rather than health maintenance. Data must be collected on the child’s physical, nutritional, neurodevelopmental, psychosocial, behavioral, and emotional status during these visits. As with all children, assessment of the family system is crucial. For the school-age child, it is particularly important to evaluate how well the family nurtures the child while supporting the child’s efforts to separate, become more independent, and create a unique self in the community.


The assessment process begins by building rapport with the parents and the child. Ask direct questions first to the child, encouraging him or her to share aspects of daily routines, family experiences, school activities, and sensitive developmental concerns. Parents can then be invited to expand on data collected, providing information not only about the child’s abilities but also about interactions between child and parents.



Screening Strategies for School-Age Children


Formal developmental screening tools and/or questionnaires should be used with all children (Hagan et al, 2008). These tools allow the child, parent, and teachers to provide specific information about a child’s development, behaviors, and emotional status. They also document a baseline status, highlight potential need for referrals, and evaluate the effectiveness of intervention strategies. Differing parental, school, and child perceptions about specific issues may be noted. Parental reports of skills and concerns about language, fine motor, cognitive, and emotional-behavioral development are highly predictive of true problems. The information gives the provider insights into areas needing further investigation and those that may require counseling, therapy, or other intervention strategies. In addition, the Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents (3rd edition) recommends annual routine health visits for children from 5 through 12 years (Hagan et al, 2008).



Physical Development


Physical development is assessed through history taking, physical examination, and documentation of findings (Table 7-3). Growth measurements (weight, height, BMI) and blood pressure should be evaluated and compared with age-appropriate norms at each visit. Hearing and vision should be screened at routine health visits. Hemoglobin or hematocrit is done during early childhood (between 15 months and 5 years) and again during late childhood (about 13 years); girls should be screened again after beginning menstruation. Perform fasting glucose, insulin, lipid analysis; total cholesterol, and liver function tests to assess for diabetes mellitus, hyperlipidemia, and metabolic syndrome in children 4 years or older with a BMI equal to or greater than 95% or if BMI is greater than 85% and other risk factors are present such as family history of diabetes or cardiovascular disease. Lead screening should be conducted if no previous screen has been done, if a previous screen was positive, or if there is a change in risk factors (see Fig. 41-5 for lead screening criteria). Likewise, a tuberculin skin test should be performed if screening indicates risk factors (see Chapter 23). Review immunization status at all visits and update immunizations as appropriate. Tanner staging should be done at all visits because school-age children can begin pubertal changes as early as 8 years old, and some endocrine problems may emerge in the school years (see Chapters 8 and 25). If a child does not have a regular dentist, oral health screening and referral to a dental home are indicated.


TABLE 7-3 Guidelines for the History and Physical Examination of the School-Age Child



























































Assessment Area Findings
Chief Complaint Main concern (e.g., school performance: inattention, fidgeting, difficulty completing tasks, stays on tasks forever, forgetful, angry, frustrated, poor academic performance, moody, irritable, talks excessively)
Subjective Data and History
Birth history Early development, including feeding, sleep-wake cycles, colicky or fussy baby, poor suck; Apgar scores; length of hospitalization; oxygen or phototherapy
Past medical history Illnesses that may explain the child’s problems (e.g., otitis media, chronic illness, vision problems, dental problems, food allergies, reflux, voiding and stooling issues, undiagnosed pain); chronic conditions such as asthma, congenital cardiac conditions, accidents, injuries, hospitalizations, or surgeries
Allergies Type of allergies and reactions
Past development Age attained early developmental milestones, especially language and social skills
Interim history Onset of problem; description of when it occurs; note child’s use of alcohol, drugs, and cigarettes; review of systems related to any chief complaint; any medications taken for acute or chronic conditions
Daily activities Daily sleep-wake pattern, routines and schedule, amount of passive activities (TV and computer) vs. active play and recreational activities; note family routines, family activities, family expectations of the child, and child’s ability to complete chores or jobs around the house
Temperament and personality Identify difficulty with change and transitions, establishing routines, or finishing tasks; difficulty with mood, new situations, making or keeping friends
School history School progress, subjects liked and disliked, peer relationships, match with teacher and school philosophy
Family history Family and home routines and environment, family support systems, activities, involvement in social and school activities, parent’s knowledge of child’s friends and involvement with child’s friends
Family review of systems Family history of medical problems, congenital anomalies, ADHD, learning problems, mental retardation, autism, emotional or psychiatric problems, sleep problems, drug or alcohol abuse, diabetes, obesity, asthma or allergies, domestic violence, criminal activities
Objective Data and Physical Examination
Measurements and vital signs Child’s growth percentiles, especially if below the 5th percentile or above the 85th percentile; note head circumference where appropriate; note BMI and blood pressure and compare with norms for age of child; hematocrit
General Child’s overall appearance, cooperation, parent-child interaction, parent’s responsiveness to the child, and the child’s responsiveness to the parent
Skin and lymph Rashes, lesions, edema, and shape of the nails, hemangiomas, hirsutism, fat tissue, and skinfolds; note enlarged lymph nodes, or mottling of the skin
Head, eyes, ears, nose, mouth Head: Unusual skull shape, hair swirls and unruly hair, and hairline; identify any problems with the temporomandibular joint
Face: Flat midface, short mandible, asymmetrical facial movements, and unusual facies, fetal alcohol syndrome facies


Eyes: Eye position (hypertelorism/hypotelorism), asymmetries, small epicanthal folds or palpebral fissures; lid: ptosis; conjunctiva: clarity; pupils: PERRLA and cover test, especially for strabismus;


EOM: visual fields, nystagmus; fundus: light reflex, vessels, disc, and macula, visual acuity

< div class='tao-gold-member'>

Related posts:

  1. Values and Beliefs
  2. Dental and Oral Disorders
  3. Respiratory Disorders
  4. Cardiovascular Disorders

Stay updated, free articles. Join our Telegram channel
Tags:
Jul 24, 2016 | Posted by in PEDIATRICS | Comments Off on Developmental Management of School-Age Children

Full access? Get Clinical Tree

 Get Clinical Tree app for offline access