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Pre-school, School age and Adolescent

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Pre-school, School age and Adolescent Elisa A. Mancuso RNC, MS, FNS Professor of Nursing Autism Spectrum Disorder ASD Complex neurodevelopmental disorders Core ... – PowerPoint PPT presentation

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Title: Pre-school, School age and Adolescent


1
Pre-school, School age and Adolescent
  • Elisa A. Mancuso RNC, MS, FNS
  • Professor of Nursing

2
Growth and Development Preschool 3-5 years
  • Biological
  • Growth slows and stabilizes during preschool
  • Average weight gain 2.2 kg (5lbs)/yr
  • Height 7.5 cm (3)/yr
  • 3 yr 32 lbs 37
  • 4 yr 37 lbs 40
  • 5 yr 42 lbs 43
  • Growth occurs in legs rather than trunk.
  • No longer resemble the pot belly toddler!

3
Psychosocial Development
  • Erickson Initiative vs Guilt
  • Ability to learn play.
  • Development of can do attitude
  • Behavior becomes goal directed, competitive and
    imaginative.
  • Imitate parents gender roles.
  • Proud when accomplish new goals.
  • When criticized show feelings of guilt.
  • Conscience develops along with moral
  • development

4
Psychosocial Development
  • Freud Phallic Stage
  • ? Focus on genitals
  • masturbation and exploration common
  • Oedipal conflict
  • Possessive love for opposite sex parent
  • Super-ego conscience develops
  • guilt feelings emerge

5
Psychosocial Development
  • Piaget
  • Pre-operational Stage 2-7 years
  • Readiness for school
  • ? physical activities loud
  • vivid imagination and curious
  • Limited attention span
  • Time- recognizes past and future
  • Idiosyncratic system for organizing events
  • Egocentric
  • See the world via me
  • Fear of Bodily harm
  • Ban-aids keep everything in place!

6
Piaget
  • Centering
  • one characteristic of an object
  • Concrete thought process
  • Literal
  • Magical thinking
  • Animism
  • Ascribe human characteristics to objects

7
Developmental Skills
  • 3 years
  • Walking, running and jumping well _at_ 36
  • 900 word vocabulary/3-4 word sentence
  • Copy a circle and cross
  • Builds a tower of 9 blocks
  • Ride tricycle, walk stairs alternating feet
  • Pour from pitcher
  • Asks a lot of questions!!

8
Developmental skills
  • 4 years
  • 1,500 word vocabulary/4-5 word sentence
  • Can copy a square
  • Very noisy, talkative
  • Exaggerates stories
  • Loves Rhymes songs
  • Names 3 colors
  • Hop on one foot
  • Catch a ball with both hands, throws overhand
  • ? Self-Care Brushes teeth
  • Gets dressed ? Cooperation

9
Developmental skills
  • 5 year old
  • 2,100 word vocabulary/6-8 sentence
  • Copy diamond and triangle
  • Prints name
  • Draw person with 6 parts
  • Head, body, 2 arms 2 legs
  • Talk constantly
  • Names 4 colors
  • Skip Hop on alternating feet
  • Walks backwards
  • Hits a ball
  • Ties shoes manage big zippers

10
Socialization
  • ? Peer interaction communication
  • Learn to relate to others
  • Increased cooperation Sharing
  • Conform to expectations
  • Enjoy games with simple rules
  • PreSchool play-
  • dramatic creative
  • Recognizes sociocultural
  • differences

11
Developmental Tasks
  • Large and small muscle coordination
  • Uses initiative with a conscience
  • Becomes a participating family member
  • Settles into a daily routine
  • Dental personal Hygiene
  • Sleep

12
Health Concerns
  • Safety
  • MVA 1 cause of injury
  • Being struck by car is ? risk
  • Drowning and falls
  • Doesnt fully understand danger
  • Magical thinking cartoons minimize the danger
  • Integrate safety education
  • Puppets, songs, rhymes and games

13
Health Concerns
  • ? Exposures to germs
  • Frequent colds and ear infections
  • Girls ? UTIs
  • RT anatomy and poor hygiene
  • Stress hand washing and proper hygiene
  • No sharing of utensils, pencils or pens!

14
Health Concerns
  • Eyes
  • Visual acuity and depth perception fully
    developed by age 7
  • Vision testing begun at 3 years
  • Objective screening using appropriate chart
  • 3 years- Allen cards-images
  • gt4 years utilize E chart
  • indicate direction of E
  • 4 year 20/30-20/40
  • 5 year 20/20-20/30

15
Common Eye Disorders
  • Strabismus
  • ? Coordination of EOM
  • Eyes are not aligned
  • One or both eyes can turn
  • In (Esotropia)
  • Out (Exotropia)
  • Up (Hypertropia)
  • Down (Hypotropia)

16
Eye
  • Amblyopia- Lazy Eye
  • Only uses 1 eye for vision
  • No binocular vision
  • ? vision in the deviated eye
  • Distorted visual field
  • Can develop if strabismus is not treated early
  • If left untreated ? Blindness in deviated eye
  • Therapy
  • Patch normal eye x 24 hours/day
  • Deviated eye must work
  • Surgery

17
Hearing
  • Early detection better outcome
  • Mandatory newborn hearing screenings
  • Routine Audiometry screening by age 3
  • Various tones _at_ various frequencies
  • Standard volume (usually 20 db)
  • Normal hearing ranges from 10 ? 15
  • By age 5 hearing is fully developed

18
Hearing Impairments
  • Sensorineural (Nerve deafness)
  • Damage or malformation of structures of
  • inner ear/and or auditory nerve
  • Causes
  • Infections CMV, Rubella, Herpes, Meningitis
  • Heredity
  • Prematurity (Hypoxia)
  • Ototoxic meds
  • Hearing Loss is usually permanent
  • Therapy
  • Hearing Aids- worn ASAP to help facilitate
    language development
  • Cochlear implants Controversy
  • American sign language ? communication

19
Hearing Impairments
  • Conductive
  • Middle hearing loss affected by
  • inflammation, obstruction or damage
  • OME/OM
  • Cerumen impaction
  • Perforation
  • Temporary restores to prior hearing level
  • Therapy
  • Antibiotics for infection
  • Myringotomy Tympanostomy tubes

20
Biological Development School Age 6-12 years
  • Growth slows down
  • Weight 5 - 6 lbs/year
  • Height 1 - 2 inch/year
  • Average 6 year old
  • 46 lbs 45 inches
  • Lose baby teeth _at_ 6 years.
  • First permanent teeth _at_ 6yrs (6 year molar)
  • Ugly Duckling Stage
  • Distorted facial proportions
  • Wide range of physical differences
  • Age 7 could look like 10-years or 5-years
  • Treat according to their age not appearance!

21
Psychosocial
  • Erickson- Industry vs Inferiority
  • Industry
  • Interest in doing work
  • Learn and solve problems
  • ? accomplishment RT ? motivation
  • Desire to master do well in everything
  • If they dont they will feel inferior.
  • Reinforce that they cannot do well in everything
  • Perseverance
  • Self-control
  • Compromise

22
Psychosocial
  • Juvenile Stage 6-9 years
  • ? need for peers, friends
  • Stage of Accomplishment
  • Work concept chores, schoolwork
  • Carry tasks to completion
  • ? skill and coordination
  • Develop self esteem
  • Greater intellectual capacity
  • Role models teachers/coaches
  • Manipulate environment
  • Reinforcement via grades with material reward
  • Move to external focus and socialization
  • Parents needed in times of stress

23
Psychosocial
  • Preadolescent Stage 9-12 years
  • Ability to love (same sex) best friend
  • Pre Pubescence
  • 2 years before onset of puberty.
  • Puberty
  • Period of rapid growth
  • Development of primary and secondary sex
    characteristics
  • girls _at_ 12yrs
  • boys _at_ 13 ½ yrs )

24
Psychosocial
  • Freud - Latency period
  • Sexuality
  • plays less prominent role
  • Best friend same sex
  • Usually do not want to play with opposite sex
    (icky!)

25
Cognitive Development
  • Concrete operations and Systematic reasoning
  • Conservation
  • Change shape but still has same volume
  • Classification
  • Group according to attributes 1st friend, 2nd
    friend
  • Seriation
  • Putting things in order or series smallest
    ?largest
  • Nesting
  • How one concept fits into another puzzles
  • Reversibility
  • Opposite function Addition Subtraction
  • Use thought process to experience events and
  • actions see things from another point of
    view.

26
Developmental Skills
  • 6 years
  • Period of Transition
  • Self centered
  • Normal to cheat at board games
  • Impulsive
  • ?Activity RT ?coordination
  • ?Dexterity drawing writing

27
Developmental Skills
  • 7 years
  • Quiets down
  • Solitary play
  • Attentive
  • Sensitive listener
  • Modest (Need Privacy)
  • Companionable

28
Developmental Skills
  • 8 years
  • Fluctuating Behavior
  • ?Graceful movements
  • ?Interest in nature
  • Very self-critical

29
Developmental Skills
  • 9 years
  • ? Independence
  • Refined eye-hand control
  • Musical instruments
  • Best friend
  • Collections
  • Well organized
  • ?Physical complaints with stress
  • May have boy/girl relationship
  • but wont admit

30
Development Skills
  • 10 years
  • ? Stamina
  • Budgets time
  • ? Energy
  • Enjoys family activities
  • ? Appetite

31
Development
  • 11 years
  • Moody
  • Strict superego-conscience
  • Strong morals/values
  • Best behavior is away from home

32
Development
  • 12 years
  • ? Personality integration
  • ? Self discipline
  • ? Self control
  • Tactful
  • Mutual understanding with parents

33
Developmental Tasks
  • ? Dependence on family
  • ? Neuromuscular skills
  • Must adjust to changes in body image
  • Develop positive attitude
  • Multicultural
  • Social
  • Economic groups

34
Health Problems
  • Generally not a sick age
  • Injury Prevention
  • Unintentional accidents/injury are the leading
    cause of death in any age group
  • MVC remains 1
  • No Seat belts, air bag injuries or hit as
    pedestrian/riding bike
  • Sports-
  • skateboards, bikes, all-terrain vehicles need
    helmets!!
  • Burns-
  • cooking, firecrackers, matches, candles
  • Guns
  • Access to loaded guns

35
Attention Deficit Hyperactivity Disorder ADHD
  • Most common chronic behavioral disorder
  • Affects 6-9 school age children
  • 40 persist into adult
  • ADHD has 3 cardinal signs
  • Inattention
  • Impulsiveness
  • Hyperactivity
  • Unable to self regulate inhibit behaviors
  • ? Academic Performance
  • RT ? Distractible ? Task completion
  • ? Self Esteem ? Peer relationships
  • ? Risky Behavior ? Substance Abuse MVA
  • Sequela Conduct, Mood Anxiety Disorders

36
ADHD Etiology
  • Familial Tendency with 1st degree relative
  • Males 3x more than females
  • Environment
  • Toxins (Pb), meds, food allergies, lead, smoking,
    alcohol, sugar???
  • ?Neurotransmitters ? NE, ? DA and ? 5-HT
  • NE - attention, impulsivity and control
  • DA - motivation/reward.
  • Needed for prioritizing and learning
  • 5-HT mood, aggressive/impulsive behavior
  • Other neurological disorders can impact
  • Fragile X, Turner or Klinefelter

37
Diagnosis
  • ADHD is an all day all domain disorder
  • Based on report of parent, teacher and child
  • Onset by age 7
  • symptoms persist for gt6 months
  • Behavior Rating Scale
  • Have 6/9 characteristics listed in DSM-IV
  • Affect 2 - 3 areas
  • school, home or social situations
  • Complete multidisciplinary evaluation
  • Medical, developmental and behavioral history
    R/O
  • Absence seizures,
  • Learning Disability
  • ?Hearing

38
Meds
  • Psychostimulants (? DA and NE)
  • stimulates inhibitory CNS
  • 1st line medication ? efficacy ? response
  • Methylphenidates (MPH) gt 6 years
  • Concerta- 12H duration
  • Adderal XR- 10-12H duration
  • Ritalin- 4H Duration Ritalin LA 8H duration
  • Daytrana patch- 12H duration (remove after 9H)
  • SEv Tics, ? appetite, sleep disruption,
  • H/A, slight ? BP HR
  • Contraindications
  • TIC disorders Tourette Syndrome,
  • Anxiety Disorder
  • Risk for Abuse Potential

39
Meds
  • Non-stimulant
  • Inhibits NE (NE Reuptake Inhibitor)
  • Better for pts who cant tolerate MPH
  • atomoxetine (Strattera)
  • 24H Duration
  • SE N V ?appetite wt.
  • Tricyclic antidepressents TCAs
  • Blocks re-uptake of NE and 5-HT
  • imipramine (Tofranil) nortryptyline (Pamelor)
  • SE anticholinergic- dry mouth,
  • Urinary Retention, orthostatic ? BP

40
Behavior Therapy
  • Education Psychosocial
  • Consistent approach by family school
  • Follow rules
  • Complete tasks
  • ? Self control
  • Positive Reinforcement
  • Time Out
  • Modify Environment
  • ? Distractions
  • Predictable
  • clearly define acceptable behavior consequences
  • Diet Therapy?? Not EB (evidence Based)
  • Limit sugar, aspartame (NutraSweet), Chocolate,
    Cows milk eggs

41
Autism Spectrum Disorder ASD
  • Complex neurodevelopmental disorders
  • Core deficits in 3 areas
  • Social Interaction
  • Verbal nonverbal communication
  • Restricted interests, repetitive behaviors
    resistant to change
  • Male 3-4x gt Female
  • Genetic Predisposition
  • Affects prenatal postnatal brain development
  • NO correlation with MMR vaccine
  • Related Disorders
  • Pervasive Developmental Disorder (PDD)
  • Aspergers Syndrome,
  • Childhood Disintegrative Disorder
    (CDD)
  • Rhetts Syndrome

42
ASD Clinical Signs
  • Inappropriate social behavior
  • Unable to maintain eye contact
  • Avoid body contact
  • Lack emotional reciprocity
  • Impaired expressive receptive language skills
  • Delayed echolalia
  • Inability to sustain or initiate conversation
  • Repetitive behaviors
  • Opening closing doors, flipping light switches,
  • H2O play, shredding paper, prefer item movements
    ritualistic behaviors
  • Insist on sameness
  • Self-Stimulatory behaviors
  • Finger licking, hand flapping, body rocking, run
    in circles
  • Deep pressure stimulation-crawl into tight
    spaces
  • Self-injury RT ?? Pain Threshold, aggressive
    behaviors
  • GI Symptoms- Constipation ? Mega rectum

43
Treatment
  • Developmental Screening
  • DDST, Modified Checklist for Autism in Toddlers
    (M-CHAT)
  • Childhood Autism Rating Scale (CARS)
  • Physical Exam
  • Hearing Vision screening, Neuro, EEG, Metabolic
    studies (Pb), Genetic testing
  • Multidisciplinary approach
  • Early intervention programs
  • Highly structured and intensive behavior
    modification programs
  • Promote positive reinforcement
  • Increase social awareness of others
  • Increase verbal communication skills
  • Decrease unacceptable behavior
  • Use brief, concrete communication
  • Minimal holding eye contact to avoid outbursts
  • Gradually introduce new
    situations
  • Medications
  • Atypical antipsychotic- Risperidone
  • ? behavioral symptoms only

44
Scoliosis
  • Abnormal lateral curvature
  • gt10 of the spine
  • Severe type can ? thoracic capacity
  • ? risk for osteopenia
  • Develops in preadolescent growth spurt
  • Higher risk in females 85

45
Functional/Idiopathic/Secondary
  • Most common
  • Rapid growth Poor posture
  • Unequal leg
  • Therapy
  • Exercises
  • PT for posture
  • Shoe Lifts

46
Structural/Congenital/Neuromuscular
  • Muscle or bone deformity
  • congenital or result of neuromuscular disorders
  • S shaped curved with vertebral rotation
  • Asymmetric
  • thoracic cavity
  • scapula, breasts, shoulders and hips
  • ? deformity during periods of growth

47
Therapy
  • Depends on degree of curve
  • 10-20 degree
  • observe and follow-up X-Rays q 4-6months
  • Exercises and improving posture
  • gt20-40 degrees
  • Milwaukee brace-worn 23 hours/day
  • ? compliance (15)
  • ? comfort and body image
  • Prevents disease progression
  • will not resolve current distortion.

48
Therapy
  • Boston Brace-
  • low profile (lowest angle)
  • Thoracolumbar -sacral orthosis
  • Most widely used
  • ? 61 compliance
  • Providence Brace-
  • -New shows promise
  • used only at night!!!!
  • ?? compliance

49
Therapy
  • Surgery- curvature gt40
  • Harrington Rod-
  • internal spinal fixation- flat back
  • post-op immobilization required
  • Lugue Segmental System-
  • flexible wires threaded through spine-
  • no post-op immobilization required,
  • ? risk for nerve damage
  • Spinal fusion for severe scoliosis
  • Iliac bone graft

50
Post-op Care
  • Log rolling
  • Neurovascular checks
  • Pain management
  • Skin care
  • Urinary retention
  • Mesenteric Artery Syndrome-
  • Shift of abdominal organs
  • Abdominal distension/emesis

51
Varicella
  • Contagious virus-
  • 1 day before eruption to 1 week after outbreaks
    of vesicles
  • until all vesicles have crusted over
  • Incubation
  • 2-3 weeks

52
Signs and Symptoms
  • Low grade temp
  • Anorexia
  • Rash
  • 1st Macular papular
  • 2nd Vesicular ? crusted lesions
  • Outbreaks occur in crops _at_?temp 104
  • Trunk ? face ? upper extremities
  • Very itchy (pruritic)

53
Therapy
  • Palliative
  • Antihistamines (benadryl)
  • Antipyretics (Calamine lotion)
  • Acyclovir
  • ? of lesions-when given within 24H of rash
  • mostly for high risk pts
  • Varicella zoster immune globulin (VZIG)
  • given within 96 hours for high risk pts
  • Strict isolation in hospital

54
Lice - Pediculosis Capitus
  • Highly contagious infestation of scalp
  • itchy from crawling mites and saliva
  • ? _at_ occipital area
  • ? _at_ night
  • v Environment
  • Stuffed animals
  • Bedding
  • Clothing (fur)

55
Therapy
  • Rid/Nix-Permethin 1
  • One application
  • Kills lice and nits.
  • Not for kids lt 2 years
  • Kwell- Lidane
  • Two applications
  • Repeat in 7-10 days after eggs hatch

56
Pinworms Enterobiais
  • Infects 1/3 of all children
  • Contagious
  • Inhalation, ingestion or contact
  • Worms (intestines) migrate lay eggs in anal
    area _at_ night
  • Very itchy anal area ? scratching
  • Spread fecal ? fingernails ? mouth
  • Tape test v eggs _at_ anus
  • mebendazole (Vermox) gt 2 years
  • 100mg repeat in 2 weeks
  • pyrantel (Pamoate pin-X) gt 2 years
  • 11mg/kg repeat in 2 weeks

57
Bites/Stings
  • Allergic response
  • May develop anaphylactic shock
  • Wheal formation
  • Raised reddened
  • Epi-pen Jr 0.01 mL/kg (11000) IM
  • Animal Bites Dogs/cats
  • 80 punctures/lacerations
  • Avulsions (tissue tears)
  • ? infection risk
  • Wash area
  • Moist cool compress dsg
  • v vaccination status (Rabies)
  • Plastic surgery

58
Obesity
  • Weight Body Mass Index (BMI) gt95
  • Compare to age, gender and height
  • Culturally induced
  • 30-40 ?incidence in 6-11 year olds
  • BMI wt (kg)/ht (m2)
  • Calculate yearly
  • v rate of ?? wt and ht

59
Etiology of Obesity
  • Diet
  • Culturally based
  • Fast food/ Junk Food
  • ? fats ? carbs ? protein
  • ? Physical activity
  • Computer, video games TV
  • Genes Family Hx
  • Prader Willi Syndrome PWS
  • Obesity, hyperphagia, hypogonadism
  • Small hands feet
  • Mental Retardation
  • 70 paternal/30 maternal

60
Complications
  • HTN ? cholesterol _at_ age 5-10
  • ? incidence of Type II diabetes
  • Obstructive Sleep Apnea (OSA)
  • Cardiac disease
  • Gallstones
  • Orthopedic problems
  • ? Self-Esteem
  • Social Isolation

61
Therapy
  • Nutritional Counseling
  • Home School
  • change family eating patterns
  • Behavior Modification
  • Healthy lifestyle habits
  • ? physical activity q day 30 -90 minutes
  • ? computer/video time
  • ? H20 intake ? juice/soda
  • Recognize and monitor associated risks for
    chronic diseases
  • No Gastric Bypass surgery ltage 18

62
Adolescence 12-18 years
  • Until physically and psychologically mature
  • Self-sufficient
  • Puberty
  • Period of physiological changes.
  • Sex organs mature, menses, spermatoza
  • Growth spurt
  • Reach adult height by age 17
  • Increase in height 2.5 inch -5 inches
  • Girls _at_ 12 Boys _at_ 14-15
  • Need ? nutrition

63
Tanner stages
  • Sexual Maturity Rating Scale
  • Stages I-V
  • Male secondary sex characteristics
  • Androgen
  • ? muscle skeletal growth
  • Testosterone
  • ? facial/body hair
  • spermatogenesis
  • Female secondary sex characteristics
  • Estrogen
  • ? epiphysis ossification
  • ? adipose deposits
  • Ovum maturation

64
Psychosocial development
  • Identity Formation vs Role Confusion
  • Individuality
  • Internal Stability
  • Achieve Sense of Self
  • Occupation/Future Goals
  • Social Development
  • FRIENDS!! gtgt Family
  • Peer pressure
  • Recognition via group identity
  • Dating groups vs. individual
  • Sexual intimacy

65
Cognitive Development
  • Piaget - Formal Operations (11-15)
  • Abstract thinking
  • Future Oriented
  • Scientific Reasoning
  • ?? Range of Logic
  • Developmental Tasks
  • Accept body changes
  • Achieve satisfying sex-related role
  • Achieve independence warm relationship with
    parents
  • Develop mature set of values, work ethic
    occupation

66
Health Problems
  • ACNE
  • Inflammatory Disease ? _at_ age 17
  • Males gt Females
  • 17 million kids/year
  • clogged sebaceous glands
  • androgens stimulate secretions
  • bacteria inflammation
  • Therapy
  • Topical Antibiotics- Cleocin, EES
  • PO Antibiotics - Tetracycline
  • Antibacterial - Benzoyl Peroxide
  • Tretinoin (Retin A)
  • interrupts keratin formation
  • use _at_ night Sunshine ? efficacy
  • Isotretinoin Retinoic Acid (Accutane)
  • SE depression Teratogenic
  • ? congenital defects
  • Document if sexually active v HCG
    q month

67
Health Problems
  • Cardiac
  • ? Growth of heart ? SV
  • ? Ability to meet O2 needs ? BMR fatigue
  • v Sports physical
  • Drug use
  • ETOH, Marijuana, Coke, E, Special K, LSD, Heroin
  • Pregnancy STDs
  • Early pregnancy _at_ age 12-14
  • HPV (80), HIV
  • ? Chlymydia, genital warts, Hep B C
  • Depression and suicide
  • ? risk _at_ age 14
  • 25 feel sad/hopeless q day more than 2 weeks
  • 20 seriously consider suicide
  • 10 attempted suicide
  • Boys successful RT violent method

68
Anorexia Nervosa
  • Preoccupation with food
  • Distorted body image
  • ? Need for control
  • ? Pressure to be thin
  • ? Intense fear of being fat
  • Review from NUR 136
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