week3
Primary Care of Children and Adolescents
Chyrise E. Taylor, DNP-BC
Introduction to School Age Children in Primary Care
Welcome to this week’s lecture!
This PowerPoint is designed to supplement your reading for this week.
It is NOT designed to take the place of the readings.
Please make sure you complete all the assignments due this week to prepare for the mid-term and final exams.
This week we are examining the School Age and Adolescent populations.
What makes these age groups unique? What are their specific developmental needs?
How do we as their PCP help their parent(s) to adapt to a new life as their child enters these stages?
What is our responsibility to foster their developmental needs in our care of these age groups?
Growth and Development of School Age Children
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Growth and Development of School Age Children
The growth and development of this age group is divided into 3 distinctive stages:
Early childhood 5-7 years old
Middle childhood 8-10 years old
Late childhood 11-12 years old
At school age children undergo rapid changes of growth. These changes can be difficult for both the child and the parents as the child goes through them.
Psychological growth also occurs at this time. The child begins to make friends independent of parents.
By late childhood may engage in semi-Independent social activities (e.g. “drop me off at Laura’s house for a slumber party”).
Growth and Development of School Age Children Areas of Developmental Growth
| Area of Development | 5-7 | 8-10 | 11-12 |
| Motor Skills | Fine motor skills with increased dexterity. | Children can run, jump, hop, skip. | Gross motor skills controlled and purposeful. |
| Communication and Language | Receptive language ability is strong. | Correctly uses pronouns and comparisons. | Can discuss and understand metaphors |
| Social and Emotional Development | Child learns to separate from parents. | Building peer relationships and value role models | Define role within family. Achieve social acceptance. |
| Social Skills | Very concrete understanding of right vs wrong. | Actions need to be rewarded to adhere to rules. | Respect for and understanding of morality. |
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Comparison of Developmental Theories of School Age Children
| Early Childhood 5-7 | Middle Childhood 8-10 | Late Childhood 11-12 |
| Freud: Phallic | Latency | Genital Stage |
| Attaches to parent of opposite sex | Acquiring social skills | Reemergence of sexual impulses |
| Erikson: Initiative vs. guilt | Industry vs. Inferiority | Industry vs. Inferiority |
| Begins to learn appropriate behaviors | Seeks to become a successful member of group | Socialization with peers and groups. |
| Piaget: Preoperational | Early Concrete | Formal Operational |
| Problem solving is not logical. | Understands size and shape of objects relative to one another | Begins to think in abstracts. |
| Kohlberg Preconventional Stage 1 Reasoning is based on Rewards/Punishment | Conventional Stage 3 Acts to Please Others | Post conventional Stage 5: Begins to see their behavior benefits society. |
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How Do These Changes Effect Our Professional Relationship with the Child?
FNPs enjoy this group because their job is easier to understand “where it hurts.” This is the age where most of our patients are fully able to express how they feel.
They can share in the history gathering of the present illness.
They can answer questions regarding symptoms and help you to complete the LOCATES information.
Make sure you ask the parent(s) who are present if they concur with the information the patient is giving. They may want to add, subtract or correct the child’s information.
Bottom line, trust the child but always validate with the adult present.
Anticipatory Advice for School Age Children Ages 5-12
Parents must understand that young child are learning social norms. Therefore, they are not able to readily understand complex rules of a game.
School Age children are learning societal norms and acceptable behavior. Aberrant behavior should be corrected, but this does not indicate a lifelong pattern.
Children can exhibit nervousness or anxiety as they grow in this role. This is normal and to be expected.
All children less than age 13 should be in a booster seat or seat belt in the rear seat of the car: whichever is appropriate for age/weight of the child.
Parents should begin to speak to the child about puberty and sexual maturity as soon as the child indicates interest in the opposite sex.
Screening Tools for School Readiness and Developmental Assessment
Although there are many screening tools available for use with this population, we are going to focus on 3.
PHQ: An easy, effective, and quick screening to determine if the patient is suffering from depression.
M-CHAT: A screening tool for children who may have developmental delays and/or ASD/
Vanderbilt Assessment Scale: Used to screen children for ADHD.
Developmental Red Flags
| 5-7 | 8-10 | 11-12 |
| Problems making friends | Lack of a best friend | Risk taking behaviors |
| Withdrawn, flat affect, depression | Cruelty to animals and others | Inappropriate sexual behavior |
| Poor language skills | Unable to add, subtract | Lack of understanding cause and effect |
| Unable to draw a picture of them self | Unable to read simple sentences. Unable to tell left from right | Poor peer influences or interest in gangs |
| Unable to catch a ball | Unable to print name | Difficulty holding a writing instrument |
| Unable to sit still in class | Poor coordination | Cannot throw or catch |
Psychosocial Needs of the School Age Child
It is a sad fact that bullying has been the cause of suicides in this age group.
School age children who are confronted with bullying often find it occurs during non structured hours at school.
During your examination it is important to ask if the child is experiencing bullying, and how they feel about this.
If the child expresses they are being bullied, it is imperative to act! Bullied children are depressed and need to be referred to a trained mental health professional ASAP!
Due to the shortage of trained mental health professionals most depressed children receive their first treatment from their PCP (YOU).
Remind parents their child is closely watching their behavior. This is the age when the child is often mimicking behaviors of role models.
Psychosocial Needs of the School Age Child
In early ages of the school age child, ADHD is treated first with behavioral modification techniques. Methylphenidate and other medications are not indicated for use in children until age 6.
Due to increased pressure, school phobias may form. These are often connected with depression and anxiety. These phobia manifest with vague physical problems which cause numerous absences from school to accumulate. This child needs the care of a mental health professional.
In late childhood, the curiosity of items such as cigarettes, alcohol, and prescription drugs increases.
Therefore early experimentation with alcohol, cigarettes and prescription medications, all of which are easily accessible in the home, may begin.
Alcohol is the #1 most common substance abuse in the late childhood age group due to easy accessibility within the home.
Section 2
Growth and Development of Adolescents
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Growth and Development of Adolescents 10-19
The World Health Organization (WHO) defines “adolescence as a transitional phase between childhood and adulthood” In their world view the WHO considers “adolescents as those between the age of 10 and 19.”(WHO, 2019)
Our textbook concurs with this definition of the adolescent period with the addendum that adolescence begins in a child when puberty starts (Burns, et al, 2017).
Puberty begins individually but generally between age 10-13. Each person varies as to the start of puberty, but once it begins the child is considered an adolescent.
Each state in the U.S. has a law which determines what age and/or under which circumstances a child is to be considered an adolescent. You MUST know the law(s) of your states to treat these patients.
Treating adolescents in primary care has a different set of rules.
Growth and Development of Adolescents 10-19
Adolescent patients have rights which patients who are children do not have:
Parents do not have the right to order any test, examination, or treatment on an adolescent patient without the adolescent’s express permission.
Parents do not have the right to be in the examining room, or present during the taking of the HPI with an adolescent.
In most states reproductive decisions are to be made without input or permission of the parent. But some states require a parent to be told.
Once again, it is imperative you understand the laws of your state when examining an adolescent patient!
Parental education MUST be a part of your practice. YOU must educate the patient regarding the legal rights of their adolescent.
Puberty
In order to clarify and standardize the physical changes of adolescents, in 1969 these development of the adolescent body were categorized in a chart by Dr. James Tanner. This chart is known as the Tanner Scale.
The Tanner scale is used universally as it gives a stratified and standardized manner to describe sexual development of any child, adolescent or adult in the world.
The Tanner scale is arranged in 5 stages: Stage I (pre-adolescence)-Stage V (adult).
The left side of the scale is girls. The right side of the scale is boys.
The chart is arranged in columns for Breast development: Pubic Hair growth: Changes in genitalia and distribution of hair.
Age ranges are given for each stage. Some revisions of the scale include pictures. But the basic Tanner scale stages remain unchanged.
Tanner Stages of Development
©The World Health Organization
Psychosocial Needs of Adolescents in Your Practice
Establish trust with the patient.
Adolescent questions generally ask “am I normal?”
Answer their question fully and directly. If you are asked about sexual development answer that question directly and fully.
If the trust bond has been established you will easily be able to ask about sexual activity, drugs, tobacco and alcohol use.
Ask about tobacco use in all forms: cigarettes, chewing and vaping. Tobacco is the #1 abused substance in adolescents.
Remember to ask about depression and other psychosocial issues annually.
Adolescents who attempt to commit suicide need to be evaluated by specialized mental health professionals (psychologist, psychiatrist) ASAP.
If an adolescent has suicidal ideation it must be reported IMMEDIATELY.
Normal Growth Patterns of the Adolescent Patient
As the body grows and changes occur it is time to start annual screening for the development of DM2, hyperlipidemia and hypertension.
Have open communication at least annually regarding the physical development including adolescent’s BMI. Screen for body dysmorphia.
Screen for self-esteem issues. Ask about friends, academic progress, participation in extra curricular activities. Refer to counseling if needed.
Openly discuss sexual tendencies, preferences, and activity. Discuss birth control options if sexually active.
Openly discuss protection against STIs.
Openly discuss perceived issues with parents with your adolescent patient.
Parental Needs of Adolescent Patients
Parents of adolescents are learning to let go of their child. Yet they harbor fear for their child as their adolescent ventures out into the world.
Acknowledge and validate their fears. Validation lets the parent know their fears are normal.
Encourage the parents to encourage their adolescent’s strive toward independence, but to also provide family structure which teaches responsibility within the unit.
Acknowledge “the mood swings of their adolescent can put a strain of familial relationships”, but they adolescent requires “boundaries, limits and consistent discipline”( Burns, et al, 2017 p 129 p 2).
Encourage the parent to offer advice on issues that are important to their adolescent.
Encourage the parent to allow the adolescent to ask them “the hard questions” and have them answered openly and honestly. This helps to build a trusting bond.
Anticipatory Guidance for Adolescents
Physical changes to expect to their body. Address concerns.
Adolescents generally see themselves as immortal, unbreakable and indestructible. Therefore, they engage in risky behaviors. Teach to avoid them.
Safe use of motor vehicles, and emphasize the need to use seat belts, wear helmets when engaged in motor sports, or on skateboards, on ATVs, biking, etc.
To avoid date rape and emphasize the need to not drink from any container that has not been in their possession the entire time.
To use social media platforms wisely and safely.
Do not engage in cyberbullying, and to report such behavior when it occurs.
To be sexually responsible. Even though physically they can have a child, they are not emotionally or financially prepared to care for a child.
Conflict resolution strategies that do not include weapons.
Conclusion
As you can see the primary care of school age and adolescents has its own challenges. You may long for the day when the child just cooed and smiled!
But, as FNPs we have a great deal of influence in how our school age and adolescent patients grow, mature and develop into stable adults.
Remember you hold a great deal of authority in the lives of these patients. What YOU say and do can make a tremendous difference in their life.
Best wishes on your midterm and final exams!
~Dr. Taylor
Reference:
In preparation for your mid-term and final exams, all material contained herein, unless specified otherwise, is obtained form the following:
Burns, C., Dunn, A., Brady, M., Starr, N.B., Blosser, C.G., & Garzon, D.L. (2017) Pediatric Primary Care (6th ed) St. Louis: Elsevier.