Fundamental Guidelines
DEVELOPMENTAL STAGES
The outlines of developmental tasks are drawn from several classic developmental theorists, such as Erik Erikson and Jean Piaget, and newer theorists, such as Urie Bronfenbrenner and Lev Vygotsky. Erik Erikson, an American psychoanalyst who studied the influence of family, culture, and society, has made major contributions to our understanding of early childhood and adolescent development. For an understanding of intellectual development, we turn to Swiss psychologist Jean Piaget, who has had a profound impact on the fields of psychology and learning. Through years of study and experimentation, Piaget asserted that it is through interaction with one’s world that human intelligence develops. Children, by constantly exploring and interacting with their expanding environment, create their own cognitive (intellectual) concepts, redefining reality based upon their experiences. Urie Bronfenbrenner posited an ecological model of development, which emphasizes the interaction of the various systems such as the macrosystem of the larger society, the exosystem, to which the family is exposed, the microsystem, which includes the home and school environments, and the mesosystem, which interacts between elements. Vygotsky studied cognitive development and discussed the impact of language, social and cultural influences on the actual achievements of individuals.
Understanding the principles of Erikson’s theories of the stages of child development can be a guide to help us realize that a child’s actions can be predicted from observing the environment in which he or she is living. For example, a supportive, thoughtful, gentle, and consistent environment will generally lead to a happy, energetic, affectionate, and cooperative child, whereas a child who is constantly criticized and harshly treated often develops negative and aggressive thoughts about the world.
Although each child develops at his or her own pace, Erikson emphasizes that each stage must be fairly well-established before the next stage can begin. Failure to master the developmental tasks at one stage will inevitably interfere with successful completion of the subsequent stages.
Birth to 24 Months
Stage one, Trust vs. Mistrust, will define for the infant through the care he or she receives whether the world is safe, kind, and supportive or uncaring, harsh, and dangerous. Erikson theorized that through early experiences, the infant develops trust or mistrust, and in the following years permanent attitudes of optimism or pessimism
are established (i.e., the ability to look after self and others versus helplessness, doubt of self and others, and mistrust in the world).
are established (i.e., the ability to look after self and others versus helplessness, doubt of self and others, and mistrust in the world).
It takes only a few months before the baby begins to experience that activities have consequences. Some activities bring hugs and kisses, while other activities bring frowns and words of disapproval, scolding, and sometimes even isolation. Because hugs and praise are much preferred, the baby will tend to repeat those activities and be more likely to abandon the others.
Starting from 8 months, so much physical and emotional development is taking place that it is imperative that there be a vigilant, consistent caregiver to keep the growing infant safe from injury and to provide understanding support as the baby explores his or her expanding world. During this second stage of development, Autonomy vs. Doubt, Shame, the caregiver will need to guide the infant or toddler lovingly to develop self-confidence.
Three major tasks face the infant. First, muscle strength and coordination must be developed. Second, memory must be established. Language development is third. As the infant develops muscle coordination and control, this leads to many new adventures and demands, such as learning to walk and starting toilet training. A consistent caregiver and firmly established daily schedule help the infant to remember and anticipate a pattern of activities upon which he or she can depend. Thus, when the loving caregiver leaves, the baby is able to remember that the caregiver will return and will know that he or she is not being abandoned. Through babbling and imitating sounds, the infant learns to say words. It does not take long to discover that those words can have an effect on others, particularly the caregiver.
The toddler’s mobility and handling of bodily functions, along with a developing memory and growing vocabulary, adds to feelings of security and more control over the world. It is important to recognize the range of emotions these developing skills can bring. Note the joy when a favorite adult returns. Frustration and anger are clearly displayed if a pleasurable activity is interrupted or a desired object is taken away. Watch the excitement when the toddler finally walks alone.
Year Two
As these accomplishments become better developed and integrated, the toddler’s psychosocial personality is forming. Pride in his or her new abilities brings selfconfidence and helps to establish feelings of value and autonomy. The toddler is cheerful, energetic, curious, and demanding of self and others. As the third year approaches, the process of learning impulse control starts as the toddler discovers how to modify his or her actions to gain the desired attention and affection, and for safety.
Without a consistent supportive caregiver, few infants can adequately master the required tasks of this stage. With no one to turn to for guidance and encouragement, failure to succeed inevitably leads to self-doubt, shame, and despair.
Year Three
The third year can be a pleasant period of settling in following the successful integration and strengthening of the previous tasks. The older toddler, with the vibrant
good health that can be expected at this age, enthusiastically enjoys his or her increasing strength, agility, and body control. A growing vocabulary and increased memory help the toddler to better understand, predict, and cooperate with an expanding world. The toddler also begins to enjoy a growing imagination and hopes the “make believe” world will magically protect him or her and influence family and peers to grant all wishes. The young toddler eagerly embarking on new adventures will require loving support and protection while learning that actions have consequences. The ability to separate from one’s parents is important as children are often in preschool or day care by this age.
good health that can be expected at this age, enthusiastically enjoys his or her increasing strength, agility, and body control. A growing vocabulary and increased memory help the toddler to better understand, predict, and cooperate with an expanding world. The toddler also begins to enjoy a growing imagination and hopes the “make believe” world will magically protect him or her and influence family and peers to grant all wishes. The young toddler eagerly embarking on new adventures will require loving support and protection while learning that actions have consequences. The ability to separate from one’s parents is important as children are often in preschool or day care by this age.
Years Four and Five
During these years, a new stage of development, Initiative vs. Guilt, commences. A 4-year-old’s investigations into new activities with little or no regard for the consequences may result in disappointment, pain, and disapproval. He or she may become fearful of this new world. Nightmares can be expected, as well as a period of developmental regression. The child will surely need loving patience and understanding when struggling to deal with the unpleasant consequences of his or her actions. Providers need to be alert to the need to identify high-risk factors indicating that the child is not ready to take on the demands of the years to come.
Attention to school readiness is particularly important during these years as the child prepares for kindergarten and later school years. The ability to get along with other children should be developed enough for the child to succeed in school settings. Also critical are screening for sensory and language deficits.
By age five, the child must give up the fantasy of a protective world of makebelieve. Experience forces the child to accept reality as it is, not as one wants it to be. Understanding that things cannot happen by mere wishes—no matter how strong the wishes might be—can be a harsh blow to self-esteem. It is vital to make the child feel loved and appreciated as he or she continues to work on developmental tasks. The child’s egocentricity leads to the belief that peers should “do” just as he or she does. By the age of 5 years, the child is learning to be a better playmate, but until 6 or 7 years still finds it difficult to compromise and is stubborn about playing by the rules. Rewarding the child’s efforts to modify behavior will reduce feelings of frustration and guilt and teach the child how to gain some control over his or her world.
Positive reinforcement as the child continues to master day-to-day needs will strengthen feelings of autonomy and allow the child to say, “I am okay. I enjoy starting new activities. I can most often leave my caregiver and be okay. I learn by watching my friends. I don’t like changes and every new experience, but I will try them out, if my caregiver is there to back me up.” It is important to make a careful evaluation of the child’s emotional well-being. If it reveals that he or she is a shy, fearful, or aggressive youngster about to enter the sixth year, the caregiver must seek guidance on how to provide better support to ensure successful and happy school years.
Year Six
Proof that the school-age child has successfully integrated the many lessons of the preceding years is demonstrated by a healthy and vibrant enthusiasm. Self-confidence,
cooperation, a greater ability to express thoughts and ideas, and a growing list of accomplishments show how far the child has come on the road to adolescence. As the child enters yet another new developmental stage, Industry vs. Inferiority, he or she should now be able to manage a daily routine away from home, maintain appropriate behavior, make new friends, and be able to accept and return affection.
cooperation, a greater ability to express thoughts and ideas, and a growing list of accomplishments show how far the child has come on the road to adolescence. As the child enters yet another new developmental stage, Industry vs. Inferiority, he or she should now be able to manage a daily routine away from home, maintain appropriate behavior, make new friends, and be able to accept and return affection.
This period can be established without much difficulty if the child is given the freedom to try out new ideas, see how they work, and explain his or her conclusions. The child is able to cope with greater clarity when his or her fantasy world clashes with reality. Although still trying, through language, to persuade friends to do things his or her way and play by his or her rules, the 6-year-old is more able to cooperate, finding this a better way to form enduring friendships.
Friends and teachers continue to be important to the child, but family support and encouragement are still critically needed. The family must set reasonable expectations for appropriate behavior. Family discussions can help the child develop and strengthen his or her own standards and moral values. At the same time, the child begins to measure peer group values against the end of this busy and important year, the 6-year-old is confident enough in his or her own skills and abilities to work on new ideas, and is increasingly free to let his or her natural ability flourish in the academic years ahead.
It is imperative for parents and the school to remember that children develop at their own pace. Close monitoring of achievements is necessary. Careful evaluation must be made of physical health, environment, and, in particular, of each child’s support system. In order to learn, children need special attention and stimulation so that they will not lose their enthusiasm to boredom. Children who are still working on consolidating the tasks of the preceding years need to be given time and support to complete these on their own timetable. Without adequate family support and selfesteem, children will become insecure and feel inferior because of their inability to perform as well as peers. Such feelings of inferiority can begin early in life, and they are hard to ever completely overcome. The school years will continue to require industry, concentration, and high adventure. They must be started from a firm base.
Because the child needs to be ready to learn at this time, the provider must be alert to high-risk factors indicating that a youngster is not yet ready to take on the demands of this period. Inappropriate behavior, lack of concentration, and poor language skills will hinder success at school. Poor ability to anticipate and accept the consequences of actions, careless health practices, and accident-proneness are further indications that professional evaluation and intervention are needed.
Years Seven and Eight
These 2 years should be a pleasurable time for the child. Building on the many skills developed in previous years, the child is now able to set appropriate goals and reach them with enthusiasm and ingenuity. He or she is becoming less ego-centered and can expect and instigate responsible behavior from self and others. Family discussions should be augmented by group discussions at school and with peers to further reinforce and maintain the behavior and moral standards set earlier by the child and his or her family. This period is characterized by successful endeavors at school and
a satisfying involvement in outside activities. It is important to provide an appropriate environment for children of this age and to make accommodations for their special abilities or needs. A caring support group of family, school, and community members can help develop a positive self-identity as they approach the unsettling years of adolescence.
a satisfying involvement in outside activities. It is important to provide an appropriate environment for children of this age and to make accommodations for their special abilities or needs. A caring support group of family, school, and community members can help develop a positive self-identity as they approach the unsettling years of adolescence.
Years Nine, Ten, and Eleven
As the child approaches adolescence, he or she must now seek to answer, “Who am I?” These 3 years will be filled with many challenges as the preadolescent grapples with multiple physical and intellectual changes. Thus commences the stage of Identity vs. Role Confusion, which will continue through the teen years and into young adulthood. As the preadolescent further develops self-identity, independent of family and peers, he or she faces an upsetting period of emotional and physical instability.
Physical changes can be expected and predicted. Girls, on average, mature earlier than boys, which can be confusing to childs as their interactions begin to change. Discussing these expected changes with appropriate adults can be reassuring and help preadolescents to appreciate their uniqueness.
The intellectual changes can be exciting to observe as concrete thinking becomes more abstract. Language is now a very important tool as the adolescent evolves into a questioning, self-hypothesizing child who needs lot of time to talk and be heard. The preadolescent will begin to question the concerns and values of family, peers, and society, while seeking to define his or her own. Discussions and activities with peers and adults within the community become important as the preadolescent moves toward independence. It is important, however, that parents continue to uphold family behavioral limits, values, and standards, while allowing their children to question and challenge at every point. Successful completion of this period is demonstrated by appropriate handling of school and family responsibilities. Accepting physical body changes, taking responsibility for their own health and safety, and being able to discuss sex and drug knowledge and concerns with appropriate adults and peers can be expected. Children at this stage will take pride in their developing intellectual skills, which help them to deal with their schoolwork and to further explore other people’s ideas, particularly those of appropriate role models. Greater participation in community activities can be expected.
High-risk factors indicating the need for a careful evaluation and additional support include the following: unhappiness and rejection of physical changes; inability to make or retain friends; anger and isolation; or choice of inappropriate role models. Poor language skills and study habits are reflected in school grades and perhaps an inappropriate school environment. These are critical issues that must be addressed before the preadolescent can meet the challenges of the teen years and beyond.
Years Twelve Through Sixteen
Erikson describes this period as a slow coming together of the preadolescent’s sense of self, both in the present and in the future, which he or she develops while adjusting
to the pressures of family, school, and society. He or she is still concerned with working through Erikson’s first question, “Who am I?” and is not yet ready to answer the next question, “Where am I going?” Erikson states that making this decision too early may rob the adolescent of his or her potential future. Attempting to answer this question, the teenager will need to spend a prolonged period of time and much effort trying out many different roles.
to the pressures of family, school, and society. He or she is still concerned with working through Erikson’s first question, “Who am I?” and is not yet ready to answer the next question, “Where am I going?” Erikson states that making this decision too early may rob the adolescent of his or her potential future. Attempting to answer this question, the teenager will need to spend a prolonged period of time and much effort trying out many different roles.
Many important tasks still face the adolescent and parents during these years. Now more than ever, there is a critical need for an adult to listen consistently. Listening and discussing ideas, and not arguing with the youngster, are the key ingredients. This will help the adolescent to learn to listen and understand other viewpoints and to appreciate considering mature ideological issues, such as morals and ethics.
Both parent and adolescent need to work together in establishing realistic behavior standards and setting limits on school and outside activities. Physical changes need to be acknowledged and appreciated. Such health habits as sleep, diet, exercise, and personal grooming need to be evaluated and maintained. Safety practices should become more firmly established, with special evaluation and help given to accident-prone children. The growing adolescent requires continued ageappropriate sex education, making certain that differences and similarities of the opposite sex are understood and appreciated. More intense alcohol and drug education is necessary during these years. It is very helpful to have family discussions on these topics, as well as issues of ethics, reinforced outside the home through school- and community-sponsored peer group discussions.
Part of the parents’ role is to make certain that the school provides a safe and healthy environment, with an appropriate academic program and ongoing measurement of achievement for their adolescents. In addition to the academic curriculum, hands-on exposure to music, art, sports, and physical education must be available. The school should offer opportunities for the interchange of ideas and values of other cultures and the larger community. Care must be given to be sure that the child’s activities are realistic and that a balance is sought between out-of-school activities, school work and the needed time to relax.
In our changing society, parents may have to give even more input and exert more effort to help the school and community in reinforcing adolescents’ efforts to refine answers and maintain moral values and ethics. Ideally, the school and community should provide a protected environment for adolescent activities and help meet their need to be together as they struggle to work through the many dilemmas of growing into adulthood. Fortunate is the adolescent who lives in a community where he or she can participate in protecting and improving the environment or offer help to neighbors in need. If the community does not sponsor “helping” activities, parents must seek out such opportunities for their children. Service to the community and its people provides fertile ground for adolescents to develop ego strength and leads to optimism and high expectations for themselves and the world. Every effort must be made to help adolescents develop a positive attitude about themselves and others, for them to reach their fullest potential and begin to find a satisfactory answer to Erikson’s question, “Where am I going?” Society will pay a high price indeed if our adolescents do not receive this support.
References
Altmann, T. R. (Ed.). (2006). The wonder years. Chicago, IL: The American Academy of Pediatrics.
Brazelton, T. B., & Sparrow, J. (2006). Touchpoints: 0-3. Cambridge, MA: DaCapo Press.
Sears, W., & Sears, M. (2003). The baby book: Everything you need to know about your baby from birth to age two. Boston, MA: Little Brown.
Theis, K., & Travers, J. (2006). Handbook of human development for health care professionals. Sudbury, MA: Jones and Bartlett.
INITIAL HISTORY
The initial history is obtained at the child’s initial health care visit. Because taking the history is time-consuming, allow sufficient time for that visit. When the appointment is scheduled, the office assistant should advise the parent or child of the extended visit and request that he or she have immunization, birth, developmental, and illness records available.
Informant’s relationship to patient
Family history
Parents
Age
Health status
Chronologic listing of mother’s pregnancies, including miscarriages and abortions. The list should contain the names, ages, sex, health, and consanguinity of children.
Family history (including history of parents, siblings, grandparents, aunts, and uncles)
Skin: Atopic dermatitis, cancer, birthmarks
Head: Headaches (migraine, cluster)
Eyes: Visual problems, strabismus
Ears: Hearing deficiencies, ear infections, malformation
Nose: Allergies, sinus problems
Mouth: Cleft palate, dental status
Throat: Frequent infections including beta-hemolytic strep infections
Respiratory: Asthma, chronic bronchitis, tuberculosis, cystic fibrosis
Cardiovascular: Cardiac disease, hypertension, high cholesterol in family members, early cardiac death, cardiac anomalies
Hematologic: Anemias, hemophilia
Immunologic deficiencies
Gastrointestinal: Ulcers, pyloric stenosis, chronic constipation or diarrhea
Genitourinary: Renal disease, enuresis
Endocrine: Type I and Type II diabetes, thyroid problems, abnormal pattern of sexual maturation
Musculoskeletal: Dislocated hips, scoliosis, arthritis, deformities
Neurologic: Convulsive disorders, learning disabilities, pervasive developmental disorders, craniosynostosis, mental retardation, mental illness
General: Obesity, unusual familial pattern of growth and other issues not already mentioned
Social history
Occupation and educational level
Mother
Father
Siblings
Housing
Ownership of home, rental, public housing, homelessness
Age and condition of home
Parents’ marital status
Duration of marriage
Marital relationship
Single parent, support system
Divorce or stepfamilies
Single sex couple
Parents’ source of medical care
Medical insurance
Financial status and source of support
Social outlets of parents and family
Pregnancy
Prenatal care
Location and duration
Prenatal classes
Mother’s health
Complications: Vaginal bleeding, excessive weight gain, edema, headaches, hypertension, glycosuria
Infection: Rubella, varicella, urinary tract infection, hepatitis, HIV status, other infections
Exposure to radiation, drugs (alcohol, illicit drugs, smoking)
Medications taken during pregnancy, including folic acid, prenatal vitamins, AZT if mother is HIV positive
Mother’s diet during pregnancy
Planning of pregnancy
Methods of contraception
When contraception was discontinued
Planned or unplanned pregnancy
Birth
Location
Gestational age in weeks
Labor
Delivery
Presentation: Vertex, breech, transverse
Method: Spontaneous, forceps, cesarean section (repeat, emergency)
Parents’ reaction to labor and delivery, including mother’s physical and mental recuperation; presence of postpartum depression; if applicable, ability to return to work; caregiver arrangements
Complications
Neonatal health
Birth weight
Condition at birth
Apgar score
Resuscitation, oxygen
Special care nursery
Congenital anomalies
Hospital course
Respiratory distress
Cyanosis
Jaundice: Physiologic, ABO, Rh, other
Difficulty sucking
Vomiting
Other complications
Infection
Seizures
Length of stay
Low weight and discharge weight
Baby home from hospital with mother
Nutrition
Feeding
Breast: Duration (see Breastfeeding Guidelines, p. 24)
Formula: Amount per feeding and per day, type, frequency, how prepared
Problems
Scheduling
Vomiting/spitting up: Frequency, amount, character of vomitus, relationship to feeding
Diarrhea
Urine: Color, odor, frequency, amount
Colic: Duration
Vitamins and fluoride
Solids
When introduced to cereal, vegetables, fruits, meats, eggs, juices
How prepared
Infant’s tolerance
Present diet
Appetite
Balanced
Relate to growth pattern
Food intolerances, allergies, and dislikes
Adequate diet of family
Growth and development
Physical
Height and weight at birth, 6 months, 1 year
Consistent growth rate (use growth charts including body mass index; see Appendices A and B)
Motor
Gross motor
Sits by 6 months
Turns to name by 6 months
Crawls by 9 months (some children do not crawl but instead progress to walking)
Stands alone by age 12 months
Walks by age 15 months
Undresses, dresses by 2.5 years
Pedals tricycle by 3 years
Ties shoes by 6 years
Fine motor
Reaches for objects by 4 months
Pincer grasp by 1 year of age
Holds and drinks from cup by 1.5 years of age
Feeds self by 2 years of age
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