28 Growth and Development of the School-Age Child Notes

Addressing Common Developmental Concerns

Cheating • Educate parents that the child must be mature enough to understand the concept of rules. • Handle cheating situations openly. • Help parents to understand why their child is cheating and to modify the trigger. • Develop appropriate punishment; inappropriate punishment could undermine the child. • Educate parents that their behavior should reflect what they expect from their child. • Seek professional help if cheating persists in the older school-age child, to rule out underlying problems.

Developmental theories freud

Freud Latency A time of tranquility between the oedipal phase of early childhood and adolescence—focuses on activities that develop social and cognitive skills Develops social skills in relating to same-sex friends through joining clubs like Brownies, Girl Scouts, Boy Scouts

Musculoskeletal System

Musculoskeletal growth leads to greater coordination and strength, yet the muscles are still immature and can be injured easily. Bones continue to ossify throughout childhood, but mineralization is not complete until maturity.

Addressing Common Developmental Concerns

Obesity • Provide healthy meals and snacks. • Schedule and encourage daily exercise. • Encourage involvement in sports. • Restrict TV, digital media, and video game use. • Limit the amount of fast-food intake. • Provide education about healthy nutrition. • Never use food as a reward. • Be a good role model.

Addressing Common Developmental Concerns

Stealing • Educate parents about the possibility of stealing. • Discuss ways to teach concept of ownership and property rights. • Handle situation openly. • Assist child in developing and enacting a plan to return what was stolen. • Make sure the punishment is appropriate for the action.

Addressing Common Developmental Concerns

School Refusal • Return child to school. • Investigate cause of the fear. • Support child. • Collaborate with teachers. • Praise success in school attendance.

Addressing Common Developmental Concerns

The Bullying Child • Educate parents on reasons why it is important to correct the behavior. • Discuss ways the child can appropriately show his or her anger and feelings. • Have parents help the child to see how it feels to be bullied. • Do not allow fighting at home. • Reward settling of conflicts without violence.

Addressing Common Developmental Concerns

Tobacco and Alcohol Education • Inquire about tobacco and alcohol use. • Discuss the physical and social dangers of tobacco and alcohol use. • Urge parents to be good role models. • Limit reading and media materials about alcohol and tobacco use. • Discuss the influences of tobacco and alcohol use by peers. • Educate the child on spit tobacco. Let them know it is just as dangerous as smoking tobacco. • Educate the child on e-cigarettes and the dangers associated with them. • Advocate for a smoke-free environment in the home and other places frequented. • Avoid having tobacco and alcohol products readily available in the home.

Latchkey Children

With the increasing incidence of both parents in the workforce and many children living with just one parent, often times, children return home alone without adult supervision for a number of hours. Most young children are not capable of handling stress or making decisions on their own before 11 or 12 years of age. However, some school-age children are more mature and can be left alone by 8 to 10 years of age; maturity is the key, not the age. Parents not only need to consider their child's maturity and readiness to be home alone but also must comply with legal requirements if present. Many states offer guidelines of when it is OK to leave a child at home alone and a few states have laws with a minimum age but these vary by State; therefore, the nurse needs to be familiar with the state and local laws in order to assist parents in making decisions about when it is appropriate for their child to be home alone (American Academy of Child and Adolescent Psychiatry, 2017; Child Welfare Information Gateway, 2013). The AAP recommends that a school-age child should come home to a parent or another responsible adult (AAP, 2018). Despite the level of maturity, children who are unsupervised are more likely to participate in risky behaviors such as smoking, drinking, and doing drugs (AAP, 2015). In addition, latchkey children may feel anxiety, stress, fear, boredom, loneliness, they miss more days of school, and have lower academic scores (AAP, 2015). If children come home to no supervision, they should know the names, addresses, and phone numbers of parents and a neighbor, as well as emergency numbers. They should be given rules about answering the door and the phone. They should tell anyone who comes to the door or who calls that mom or dad is home but busy at this time. Directions as to the handling of the house key and fire safety should be taught and demonstrated (see Teaching Guidelines 28.2).

Abuse in Children

Abuse in Children Child abuse, including physical abuse and sexual abuse, is a common crime of violence against children. An estimated 3.5 million reports of child abuse are made annually to child protective services in the United States (U.S. Department of Health & Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children's Bureau, 2020). Over 678,000 cases were substantiated in 2018, with 60.8% being victims of neglect, 10.7% victims of physical abuse, 7% victims of sexual abuse, and 6.9% were victims of other abuse, such as drug or alcohol addiction, emotional or psychological abuse (U.S. Department of Health & Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children's Bureau, 2020). The abusers of children are family, friends, and strangers. It is important for parents to teach children the concept of "good touch" versus "bad touch" prior to school-age years. Whenever the school-age child's behavior yields suspicion of physical or sexual abuse, the nurse should report to the appropriate authorities in his or her state.

SENSORY DEVELOPMENT

All senses are mature early in the school-age years. Good vision is essential to the physical development and educational progression of school-age children. Vision screening programs conducted by school nurses identify problems with vision and result in appropriate referrals when warranted. Some problems frequently identified include amblyopia (lazy eye), uncorrected refractive errors or other eye defects, and malalignment of the eyes (called strabismus). Amblyopia is reduced vision in an eye that has not been adequately used during early development. Inadequate use can result from conditions such as strabismus, one eye being more nearsighted, farsighted, or astigmatic than the other eye. If untreated in childhood it can persist into adulthood causing permanent visual impairments (American Association for Pediatric Ophthalmology and Strabismus [AAPOS], 2017). This condition is correctable with glasses or patching which forces the child to use the weaker eye. Recent clinical trials by the National Institutes for Health have suggested that older children (7 to 14 years) may benefit from these treatments, but success remains higher when started at a younger age (AAPOS, 2017). Proper screening and referral, as well as notification to parents of the existing condition, are essential to the education and socialization of the school-age child. Hearing deficits that are severe are usually diagnosed in infancy, but the less severe may not be diagnosed until the child enters school and has difficulty learning or with speech. It is important to screen children for hearing deficits to ensure proper educational and social progression. The sense of smell is mature and can be tested in the school-age child by using scents that children are familiar with, such as chocolate or other familiar odors. In addition, the school-age child may be tested for the sense of touch with objects to discriminate cold from hot, soft from hard, and blunt from sharp.

Promoting Appropriate Discipline

Because of the increasing ability of the school-age child to view situations from different angles, the school-age child should be able to see how his or her actions affect others. The school-age child is aware of the cause and effect of his or her behaviors and realizes that his or her behaviors have consequences. School-age children should be able to express emotions without using violence. Discipline techniques with consequences have both natural and logical consequences. Natural consequences allow the child to learn the results of his or her actions. For example, if the child throws a toy out of the window, then he or she cannot play with the toy anymore. In logical consequences, if the child does not put away his or her bike, he or she does not get to ride the bike for the rest of the day. In disciplining children, parents should teach children the rules established by the family, values, and social rules of conduct. Rules should provide the school-age child with guidelines about behavior that is acceptable and unacceptable. School-age children look to their parents for guidance and as role models. Parents should role model appropriate expressions of feelings and emotions and allow the child to express emotions and feelings. Discuss the effects of the child's temperament on his or her behavior, as well as what constitutes age-appropriate behavior. Include how the parents' temperament can influence the child's temperament. Effective guidance and discipline focus on the development of the child. They can preserve the child's self-esteem and dignity. Discuss with parents guidelines regarding discipline. Explain to parents that they should never belittle the child. Children may view parents and caretakers negatively if they are consistently belittled or insulted. These negative actions can inhibit learning and teach the child to react unkindly to others. Instead, parents should discipline with praise. Positive acknowledgements of progress are likely to encourage healthy development and appropriate behavior (AAP, 1998, reaffirmed 2014). Discuss with parents how to be realistic when planning activities so as to not overwhelm the child, resulting in misbehavior. Encourage parents to say "no" only when they mean it, to avoid a negative atmosphere in the home, and to avoid inconsistency. When misbehaviors occur, the type and amount of discipline are based on different factors: Developmental level of both the child and the parents Severity of the misbehavior Established rules of the family Temperament of the child Response of the child to rewards Keep in mind that school-age children should participate in developing a plan of action for their misbehavior. Whatever methods of discipline are chosen, it is important that parents are consistent in providing discipline in a nurturing environment.

Bicycle and Sport Safety

Bicycling, riding scooters, skateboarding, and inline skating or roller skating are common activities of school-age children. Laws in some states require helmets for riding bicycles and scooters. In addition, when skating or skateboarding, school-age children should wear a helmet, kneepads, and elbow pads. Research has shown that head injuries due to bicycle accidents have reduced by 48% to 60% by wearing a well-fitting helmet (Gill, 2019) (see Healthy People 2030). It is important for children to wear helmets that fit and that do not obstruct their vision or hearing. Because school-age children have completed most of their skull growth, a helmet can be worn into adolescence. It is important for the child to have a bicycle that is appropriate for his or her size and age. The child should be able to plant both feet on the ground when sitting on the seat of the bike (Fig. 28.8). It is important to stress to parents the importance of appropriate size and not to get a bike for the child to "grow into." If older school-agers are using the bike for transportation on busy streets, they should be taught to use bike lanes and to give appropriate hand signals for turning. Nonmotorized and motorized scooters also place children at risk for injury, so counsel families about the use of protective gear, including helmets, elbow pads, and kneepads. Bike safety: general • Child should know to wear a properly fitted, Consumer Product Safety Commission (CPSC) or Snell-approved helmet every time he/she rides a bike. • Proper-fitting helmet should sit level, not tilted, and firmly and comfortably on the head; have strong wide Y-shaped straps and when you open your mouth it should pull down a bit; not move with sudden pulling or twisting; never be worn over anything else (hat, scarf, etc.). • Bikes should be well maintained and appropriately sized. • Child should be oriented to bike and demonstrate ability to ride bike safely before being allowed to ride on street. • Safe areas for bike riding should be established as well as routes to and from area of activities. • Riding bike barefoot, with someone else on bike, or with clothing that might get entangled in the bike should be prohibited. • Child should know to wear sturdy, well-fitting shoes. • Bike should be inspected often to ensure it is in proper working order. • A basket should be used to carry heavy objects. Bike safety in traffic • All traffic signs and signals must be observed. • Avoid riding at night but if riding at night occurs, the bike should have lights and reflectors and the rider should wear light-colored clothes. • Child should know to ride on the side of the road traveling with traffic, and keep close to the side of the road in single file. • Child should learn to watch and listen for cars, to stop and check for traffic in both directions when leaving driveways, alleys, or curbs. • Headphones should not be used while riding a bike. • Never hitch a ride on any vehicle.

Genitourinary System

Bladder capacity increases, but varies among individual children. Girls generally have a greater bladder capacity than boys. Urination patterns vary with the amount of fluids ingested, the time they were ingested, and the stress level of the child. The formula for bladder capacity is age in years plus 2 oz. Therefore, the bladder capacity of the 7-year-old would be 9 oz. The larger capacity of the bladder allows for the child to experience longer periods between voiding.

Body Image

Body image is how the school-ager perceives his or her body. School-age children are knowledgeable about the human body but may have different perceptions about body parts. School-age children are very interested in peers' views and acceptances of their body, body changes, and clothing. This age group may model themselves after parents, peers, and persons in movies or on television. It is important for late school-agers to feel accepted by peers. If they feel different and are teased, there may be lifelong effects.

Addressing Common Developmental Concerns

Bullying The Bullied Child • Educate parents whose children are at risk for being bullied, such as: • Children who appear different from the majority • Children who act different from the majority • Children who have low self-esteem • Children with a mental or psychological problem • Teach parents to role-play different scenarios the child may face at school; show the child different ways to react to being bullied. • Impress upon the child that he or she did not cause the bullying. • Develop ways to increase the child's self-esteem at home. • Discuss the situation with the teacher and develop a plan of care.

Bullying

Bullying, which is inflicting unwanted, repeated verbal, emotional, or physical aggression upon others and involving a power imbalance, is widespread and negatively impacts all parties involved (CDC, 2018). Utilizing email, text messages, social media, and instant messaging, often referred to as cyberbullying, is a growing concern. Bullies often look for victims who appear shy, weak, and defenseless. Concept Mastery Alert Bullying Children who bully most often have low self-esteem, poor grades, and poor interpersonal skills. Both boys and girls are bullied but boys tend to bully other boys and more often show force when bullying. In general, about 10% of all children are bullied on a regular basis with surveys revealing about 50% of children reporting being bullied at some point during their school-age years (American Academy of Child and Adolescent Psychiatry, 2016). Most of the bullying occurs at school (Augustyn & Zuckerman, 2016). Both boys and girls are bullied and can bully others; however, boys are 2.5 times as likely to be bullies (Augustyn & Zuckerman, 2016). Being bullied can have negative results on children throughout life. These children often have increased episodes of headaches, stomachaches, sleep problems, anxiety, loneliness, depression, substance use, lower academic achievement, and suicidal tendencies (Augustyn & Zuckerman, 2016; CDC, 2018). After the problem of either being bullied or being the bully has been identified, parents must work with the child, the school, and the physician or nurse practitioner to solve the problem

PHYSICAL GROWTH

From 6 to 12 years of age, children grow an average of 6 to 7 cm (2.5 in) per year, increasing their height by at least 1 foot. An increase of 3 to 3.5 kg (7 lb) per year in weight is expected (Feigelman, 2016a). In the early school-age years, girls and boys are similar in height and weight and appear thinner and more graceful than in previous years. In later school-age years, most girls begin to surpass boys in both height and weight

Promoting Growth and Development Through Play

Cooperative play is exhibited by the school-age child. Play for the school-age child includes both organized cooperative activities (such as team sports) and solitary activities. School-age children have the coordination and intellect to participate with other children of their age in sports such as soccer, baseball, football, and tennis. The school-age child comprehends that his or her cooperation with others will lead to a unified whole for the team. In addition, the child learns rules and the value of playing by the rules. School-age children also enjoy solitary activities including board, card, video, and computer games, and dollhouse and other small-figure play (Fig. 28.5). Many school-agers start collections of stamps, cars, or other valuable or not-so-valuable items. During the school-age years, children may also begin a scrapbook or keep a diary. They may participate in activities such as dance or karate. Girls and boys may join clubs, gangs, or special interest groups (Fig. 28.6). Active play has decreased in recent years as television viewing, multimedia device use, and video games have increased. This trend has resulted in health risks such as obesity, type 2 diabetes, and cardiovascular problems.

CULTURAL INFLUENCES ON GROWTH AND DEVELOPMENT

Culture influences habits, beliefs, language, and values. School-age children thrive on learning the music, language, traditions, holidays, games, values, gender roles, and other aspects of culture. Nurses must be aware of the effects on children of various groups' family structures and traditional values. The school-age child's cultural and ethnic backgrounds must be considered when assessing growth and development, including differences in growth in children of different racial and cultural backgrounds. Cultural implications must be considered for all children and families in order to provide appropriate care.

Promoting Healthy Teeth and Gums

Dental caries remains a leading chronic disease in the United States (CDC, 2016b); the incidence declined from the 1970s to the early 1990s, mostly due to the introduction of fluoride (National Institute of Dental and Craniofacial Research, National Institutes of Health, 2018). Since then, there has been a small but significant increase in the incidence of dental caries. Recent statistics show that 42% of children between the ages of 6 and 11 have dental caries in their primary teeth, 21% have dental caries in their permanent teeth, and 23% of children 2 to 11 years of age have untreated dental caries (National Institute of Dental and Craniofacial Research, National Institutes of Health, 2018). Dental care with emphasis on prevention of caries is important in this age group. School-age children need to brush their teeth two to three times per day for 2 to 3 minutes each time with fluoridated toothpaste (Fig. 28.9). Parents should replace the toothbrush (soft) every 3 to 4 months. Flossing the teeth at least once daily is recommended along with limiting the intake of sugar to aid in the prevention of cavities and improved oral health. Parents must monitor teeth brushing, observe for abnormal alignment of their child's teeth, and schedule regular dental examinations every 6 months to ensure good dental health and prevent dental problems. Children will need help with brushing teeth until they are between 7 and 10 years of age. Dental sealants are an easy way to protect a child's primary or permanent teeth. The sealant is a plastic coating applied to biting surfaces to seal out tooth decay on back teeth and sometimes to cover deep pits or grooves. In addition, parents should give a fluoride supplement (as directed by the dentist) to their children if fluoride is not in the town's water supply (American Academy of Pediatric Dentistry, 2018). The school-age child should have an established dental home; if not, provide appropriate resources to establish one. See Healthy People 2030. Proper alignment of teeth is important to tooth formation, speech development, and physical appearance. Many school-age children need braces or other orthodontic devices to correct malocclusion, a condition in which the teeth are crowded, crooked, or misaligned. Bruxism or teeth grinding while asleep may continue in the school-age years. Bruxism may result in grinding away of tooth enamel. Teeth grinding may be due to malalignment. A dental evaluation should be scheduled if consistent teeth grinding occurs. Children wearing braces are more prone to cavities; encourage them to brush their teeth after meals and snacks. School nurses can assist these children with brushing after lunch. In addition, the school nurse should promote dental health through education on dental care and gum problems that result from lack of proper dental care. Diet can play a part in dental health. Limiting sticky, high-sugar, and high-carbohydrate foods will decrease the possibility of cavities.

Gastrointestinal System

During the school-age years, all 20 primary deciduous teeth are lost, replaced by 28 of 32 permanent teeth, with the exception of the third molars (commonly known as wisdom teeth). The school-age child experiences fewer gastrointestinal upsets compared with earlier years. Stomach capacity increases, which permits retention of food for longer periods of time. In addition, the caloric needs of the school-age child are lower than in the earlier years.

Gross Motor Skills

During the school-age years, coordination, balance, and rhythm improve, facilitating the opportunity to ride a two-wheeled bike, jump rope, dance, and participate in a variety of other sports (Fig. 28.3). Older school-age children may become awkward due to their bodies growing faster than their ability to compensate. School-age children between the ages of 6 and 8 enjoy gross motor activities such as bicycling, skating, and swimming. They are enthralled with the world and are in constant motion. Sometimes fear is limited due to the strong impulses of exploration. Children between 8 and 10 years of age are less restless, but their energy level continues to be high with activities more subdued and directed. These children exhibit greater rhythm and gracefulness of muscular movements, allowing them to participate in physical activities that require longer and more concentrated attention and effort, such as baseball or soccer. Between the ages of 10 and 12 years (the pubescent years for girls), energy levels remain high but are more controlled and focused. Physical skills in this age group are similar to those of adults, with strength and endurance increasing during adolescence. Jumping rope is an example of the increased development of gross motor skills of the school-age child. School-age children improve their fine motor skills so they can play musical instruments well. All school-age children should be encouraged to engage in physical activities and learn physical skills that contribute to their health for the rest of their lives. Cardiovascular fitness, weight control, emotional tension release, and development of leadership and following skills are enhanced through physical activity and team sports.

Promoting Nutrition

Growth, body composition, and body shape remain constant during late school-age years. Needed calories decrease while the appetite increases. In preparation for adolescence, the body fat composition of school-age children increases. This tendency toward increased body fat occurs earlier in girls than in boys, with the amount of increase greater in girls. Boys have more lean body mass per inch of height than girls. Diet preferences established in the preschool years continue during the school-age period. As the child grows older, influences of family, media, and peers can impact the eating habits of this age group. Some of these influences are parents' work schedule, outside activities, and exercise level of the child. Decreased exercise levels and poor nutritional choices lead to the mounting problem of obesity seen in this age group. See Box 28.2 for appropriate questions to ask the child and parent regarding nutritional status. Healthy People 2030 provides objectives and actions to improve the nutritional health of children.

MORAL AND SPIRITUAL DEVELOPMENT

During the school-age years, the child's sense of morality is constantly being developed. According to Kohlberg, the school-age child is at the conventional stage of moral development (Kohlberg, 1984). The 7- to 10-year-old usually follows rules out of a sense of being a "good" person. He or she wants to be a good person to parents, friends, and teachers and to himself or herself. The adult is viewed as being right. This is stage 3: interpersonal conformity (good child, bad child), according to Kohlberg. The 10- to 12-year-olds progress to stage 4: the "law and order" stage. At this stage, the child can determine if an action is good or bad based on the reason for the action, not just on the possible consequences of the action. The older school-age child's behavior is guided by his or her desire to cooperate and by his or her respect for others. This leads to the school-age child's ability to understand and incorporate into his or her behavior the concept of the "golden rule," to treat others how you would like to be treated (Feigelman, 2016a). See Table 28.1 for additional information about the moral development of school-age children. During school age, children may develop a desire to understand more about their religion (Ford, 2007). They are still concrete thinkers and are guided by their family's religious and cultural beliefs. They are comforted by the rituals of their religion, but are just beginning to understand the differences between the natural and supernatural. Incorporating religious practices in their lives can assist school-age children in coping with different stressors.

Reading

Encouraging reading is an excellent way to promote learning in the school-age child. Trips to the library and purchasing books help to promote a love of reading. School-age children enjoy being read to as well as reading on their own. Younger school-age children (6 to 8 years) enjoy books that are simple to read with few words on a page, such as the Dr. Seuss books. They enjoy books about animals and trains and simple mysteries. Children 8 to 10 years of age have more advanced reading skills and enjoy those books from early childhood, plus more classic novels and adventures such as the Harry Potter series. Older children enjoy horror stories, mysteries, romances, and adventure stories as well as classic novels. School-age children of all ages benefit from books on topics related to things they may be experiencing, such as a visit to the hospital for a surgical procedure

school age developmental theories erikson

Erikson Stage Industry versus inferiority Activities *Interested in how things are made and run *Success in personal and social tasks *Increased activities outside home—clubs, sports *Increased interactions with peers *Increased interest in knowledge *Needs support and encouragement from important people in child's life *Needs support when child is not successful *Inferiority occurs with repeated failures with little support or trust from those who are important to the child

PSYCHOSOCIAL DEVELOPMENT

Erikson (1963) describes the task of the school-age years to be a sense of industry versus inferiority (Feigelman, 2016b). During this time, the child is developing his or her sense of self-worth by becoming involved in multiple activities at home, at school, and in the community, which develops his or her cognitive and social skills. The child is very interested in learning how things are made and work. The school-age child's satisfaction from achieving success in developing new skills leads him or her to an increased sense of self-worth and level of competence. It is the role of the parents, teachers, coaches, and nurses of the school-age child to identify areas of competency and to build on the child's successful experiences to promote mastery, success, and self-esteem. If the expectations of adults are set too high, the child will develop a sense of inferiority and incompetence that can affect all aspects of his or her life.

Pedestrian Safety

Every year, 40,000 children are injured as pedestrians and 456 pedestrian children are killed (Safe Kids Worldwide, 2016). Children younger than 10 years of age should not be unsupervised pedestrians (Safe Kids, Worldwide). Young school-age children therefore should walk to school or the bus with an older friend, sibling, or parent. Darting out into the street without looking both ways or from between cars is a common occurrence in the school-age years. Teach children safe street and pedestrian practices. Pedestrian safety • Child should be instructed to stop at the curb and look right, left, then right again before crossing the street; and crossing only at safe crossings. • Older children and adults should provide supervision of younger children. • Walking should only be done on sidewalks. • Phones, headphones, and devices should be put away when crossing the street. • In parking lots, children should know to watch for cars backing up and not dart out between parked cars. • If children are playing outside, drivers should be aware of their presence before backing up.

MOTOR SKILL DEVELOPMENT

Gross and fine motor skills continue to mature throughout the school-age years. Refinement of motor skills occurs, and speed and accuracy increase. To assess the motor skills of school-age children, ask questions about participation in sports and after-school activities, band membership, constructing models, and writing skills.

THE NURSE'S ROLE IN SCHOOL-AGE GROWTH AND DEVELOPMENT

Growth and development in the school-age child occurs in irregular spurts with a wide variation of sizes, shapes, and abilities seen. Nurses must be aware of the usual growth and development patterns for this age group so that they can assess school-age children appropriately and provide guidance to the child and his or her family. This is a time when children compare themselves to peers and self-esteem is a central issue. The school-age child is separating from his or her parents and seeks acceptance from peers and adults outside of his or her family. Health care visits throughout the school-age period continue to focus on expected growth and development and anticipatory guidance. Visits are more infrequent during the school-age years; therefore, the nurse needs to assess the child's functioning not only at home but also at school and within the community. If the school-age child is hospitalized, growth and development may be altered. The school-age child is able to understand the reason for hospitalization and what will happen. He or she is often worried about pain or changes that may occur to his or her body. It is important for health care providers and family members to be honest and open with the school-age child. The school-age child may miss school and the interactions with his or her peers. The school-age child may regress and exhibit behaviors of a younger child, such as needing special comfort toys or demanding attention from his or her parents. Hospitalization for the school-age child can bring with it a loss of control. The school-age child is used to controlling his or her self-care and making choices about his or her meals and activities. When caring for the hospitalized school-age child, the nurse must use knowledge of normal growth and development to recognize potential delays, promote continued appropriate growth and development, and interact successfully with the school-age child. Provide opportunities for the school-age child to maintain independence, gain control, and increase self-esteem.

Developmental Theories kohlberg theories

Kohlberg Stage Conventional Stage 3: interpersonal conforming, "good child, bad child," age 7-10 years Stage 4: "law and order," age 10-12 years Activities *An act is wrong because it brings punishment Behavior is completely wrong or right Does not understand the reason behind rules If child and adult differ in opinions, the adult is right Can put self in another person's position Begins to exercise the "golden rule" Acts are judged in terms of intention, not just punishment

COMMUNICATION AND LANGUAGE DEVELOPMENT

Language skills continue to accelerate during the school-age years and vocabulary expands. Culturally specific words are used, with bilingual children speaking English in school and a second language at home. The school-age child learns to read and reading efficiency improves language skills. Reading skills are improved with increased reading exposure. School-age children begin to use more complex grammatical forms such as plurals and pronouns. Also, they develop metalinguistic awareness—an ability to think about language and comment on its properties. This enables them to enjoy jokes and riddles due to their understanding of double meanings and play on words and sounds. They are also beginning to understand metaphors such as "a stitch in time saves nine." School-age children may experiment with profanity and dirty jokes if exposed. This age group tends to imitate parents, family members, or others. Therefore, role modeling is very important.

Addressing Common Developmental Concerns

Latchkey Kids • Provide rules to follow and expectations, such as: • Not answering the door or phone • No friends in the house when parents are not home • No playing with fire • Teach child to call a trusted neighbor when help is needed and 911 in the event of emergency. • Post all resource numbers (even numbers you think your child may have memorized), including after-school helplines if available, in a clearly viewable spot. Include pediatrician's number and preferred hospital. • Enroll the child in an after-school program if available. • Discuss limitations of outside play. • Discuss limitations of television viewing and video game use. • Make sure the child knows how to contact the parent. • Set clear homework expectations. • DO NOT keep guns in the home. • Teach the child where first-aid supplies are located. • Teach the child household emergency procedures such as circuit breakers and water shut off valves. • Practice with your child. Have a trial run by leaving for a short time but staying close and role-playing situations that may occur. • Always check in with your child while you are away.

Addressing Common Developmental Concerns

Lying • Help parents in understanding why the child is lying. • When the child lies, calmly confront the child and explain why the behavior is not acceptable. • Educate parents that their behavior should reflect what they teach and expect from their child. • Educate parents that too-rigid or severe punishments can decrease the child's sense of worth. • Seek professional help if lying persists in the older school-age child, to rule out underlying problems.

Immune System

Lymphatic tissues continue to grow until the child is 9 years old; immunoglobulins A and G (IgA and IgG) reach adult levels at around 10 years of age. Due to the lymphatic system becoming more competent in localizing infections and producing antibody-antigen responses, school-age children may have fewer infections. They may experience more infections during the first 1 to 2 years of school due to exposure to other children who may have infections.

PHYSIOLOGIC CHANGES

Maturation of organs may differ with age or gender. Maturation of organs remains fairly consistent until late school age. In the late school-age years (10- to 12-year-olds), boys experience a slowed growth in height and increased weight gain, which may lead to obesity. During this time, girls may begin to have changes in the body that soften body lines. Preadolescence is a period of rapid growth, especially for girls.

Formal Education

Most children are excited about starting school and making new friends. They like the notion of getting books, having book bags, and having homework assignments. The reality of the work involved with school and homework may decrease the enthusiasm about school. Peers are very important within this age group. Both peers and teachers influence children. Attending school may be their first experience interacting with a large number of children of their own age. Through this interaction, children learn cooperation, competition, and the importance of following the rules. Peer approval and influences grow as the child matures. Teachers have significant influences on children. They help to guide the child's intellectual development by rewarding successes and helping the child deal with failures. The student-teacher relationship is a key to success. Teachers play a role in fostering feelings of industry and preventing feelings of inferiority (Fig. 28.7). School-age children also learn skills, rules, values, and other ways to work with peers and other authority figures. Parental support is important for school adjustment and achievement. Parents must collaborate with teachers and school personnel to ensure that the child is fulfilling the expectations and requirements for this age group in school. Parents must monitor the child's homework assignments and friends, and observe for any changes in behavior that would indicate school or behavioral problems.

PROMOTING HEALTHY GROWTH AND DEVELOPMENT

The family plays a critical role in promoting healthy growth and development of the school-age child. Respectful interchange of communication between the parent and child will foster self-esteem and self-confidence. This respect will give the child confidence in achieving personal, educational, and social goals appropriate for his or her age. The nurse should study interactions between parents and school-age children to observe for this respect or lack of respect ("putting the child down"). The nurse can model appropriate behaviors by listening to the child and making appropriate responses. The nurse can be a resource for parents and an advocate for the child in promoting healthy growth and development.

Car Safety

Motor vehicle accidents are a common cause of injury in the school-age child. While traveling in the car, school-age children should always sit in the rear seat. The front seat is dangerous because of passenger-side airbags in most new-model cars. A school-age child over 18.1 kg (40 lb) (generally 4 to 8 years of age) should use a belt-positioning, forward-facing booster seat using both lap and shoulder belts (American Academy of Pediatrics [AAP], HealthyChildren, 2020). School-age children who outgrow the convertible restraint can sit in a booster seat until the vehicle seat belt restraint fits properly over the hips and shoulder, typically when they are 144.8 cm (4 ft 9 in) or taller, usually between 8 and 12 years of age (AAP, HealthyChildren, 2020). The seat belt needs to lie low and flat over the hip bones and across the shoulder not the neck or face. Children younger than 13 years of age should not ride in the front seat of a vehicle with an airbag Car safety • Seat belt or age- and weight-appropriate booster seat should be used at all times. The lap belt should lie low and flat on the hips and the shoulder belt should lie on the shoulder not the neck or face (usually when the child is about 144.8 cm [57 in] tall). • Seat belts should be fastened before car is started. • Children under 13 years must sit in the back seat. • Childproof locks should be used in the back seat. • Rules of conduct for car rides must be established.

Fine Motor Skills

Myelinization of the central nervous system is reflected by refinement of fine motor skills. Eye-hand coordination and balance improve with maturity and practice. Hand usage improves, becoming steadier and independent and granting an ease and precision that allows these children to write, print words, sew, or build models or other crafts. The child between 10 and 12 years of age begins to exhibit manipulative skills comparable to adults. School-age children take pride in activities that require dexterity and fine motor skills such as playing musical instruments (Fig. 28.4). Talent and practice become the keys to proficiency.

Preventing the Development of Overweight and Obesity

Obesity and being overweight remains a serious health concern for children in the United States, with 18.4% of school-age children being obese (CDC, 2019). Overweight is classified as a body mass index (BMI) greater than 85% and obese is classified as a BMI greater than 95% (U.S. Department of Agriculture and U.S. Department of Health & Human Services, 2015) (see Healthy People 2030 proposed objectives). Obesity occurs when the intake of calories and food exceeds the expenditures. Some factors linked to causing obesity include family role modeling, lack of exercise, unstructured meals, consumption of sugar- sweetened beverages, large portion sizes, television viewing, and video gaming as well as cultural, genetic, environmental, and socioeconomic factors. Some factors that influence lack of exercise include the decreased number of days that school systems offer, physical education programs, and recess. Also, some children live in unsafe neighborhoods or in a community that lacks sidewalks or parks and have no safe place to play outside; therefore, they spend time doing sedentary activities such as watching TV or playing video or computer games. Obese children are at risk for cardiovascular diseases such as high cholesterol and hypertension, type 2 (non-insulin-dependent) diabetes, respiratory complications such as obstructive sleep apnea, mental health issues such as depression, anxiety and eating disorders, and orthopedic problems (U.S. Department of Agriculture and U.S. Department of Health & Human Services, 2015). When parents do not have knowledge of nutrition, do not monitor snacks or meals, and have unstructured meals, habits are established that lead to obesity. Preventing obesity in childhood is important because the fat cells of childhood are carried into adulthood obesity and contribute to disease. Due to the risk of obesity, encourage parents to never use food as a reward. To prevent obesity, establish regular mealtimes and offer healthy foods and snacks. Encourage parents to praise their child's good food choices and to role model appropriate eating and exercise.

emotional and social development

Patterns of temperamental traits identified in infancy may continue to influence behavior in the school-age child. Analyzing past situations may provide clues to the way a child may react to new or different situations. Children may react differently over time due to their experiences and abilities. Self-esteem is the child's view of his or her individual worth. This view is impacted by feedback from family, teachers, and other authority figures.

KEY CONCEPTS

Physical growth is slow and steady, with social and cognitive development progressing rapidly, during the school-age years of 6 to 12. Height increases approximately 6 to 7 cm (2.5 in) per year and weight gain is 3 to 3.5 kg (7 lb) per year. Boys are taller and heavier than girls during this time period (Feigelman, 2016a). With entrance into the school system, school-age children have the influences of peers and teachers. With the development of gross motor skills and involvement in sports at school and in the community, safety education and practices are required. Also, with the participation in cooperative sports, injuries occur. Increased independence leads to increased exposure to safety hazards. The school-age child develops the cognitive ability to classify objects and to identify relationships among objects. Dental care is very important to prevent dental caries, malocclusion, and other problems. In early school age, the first primary teeth will be lost. The onset of puberty may occur by the later school-age years. Erikson's (1963) developmental task for the age group is the development of a sense of industry. Peers are very important, especially peers of the same sex. School-age children usually have a best friend and belong to clubs. They have collections of nonvaluable items such as rocks, clips, and so forth. School-age children are capable of concrete operations, solving problems, and making decisions. They continue to need guidance, rules, and direction from parents. The school-age child develops a conscience and knows cultural and social values. He or she can understand and obey rules. The school-age child incorporates religious practices into his or her life, which may be a source of comfort during stressful times. The nurse's role includes educating parents and school-age children in promoting health and safety. Nurses should inform the school-age child about expected developmental changes in the body to promote self-esteem and self-confidence.

COGNITIVE DEVELOPMENT

Piaget's stage of cognitive development for the 7- to 11-year-old is the period of concrete operational thoughts (Feigelman, 2016b). In developing concrete operations, the child is able to assimilate and coordinate information about his or her world from different dimensions. The child is able to see things from another person's point of view and think through an action, anticipating its consequences and the possibility of having to rethink the action. He or she is able to use stored memories of past experiences to evaluate and interpret present situations. The school-age child also develops the ability to classify or divide things into different sets and to identify their relationships to each other. The school-age child is able to classify members of four generations on a family tree vertically and horizontally, and at the same time see that one person can be a father, son, uncle, and grandson. It is at this time that the school-age child develops an interest in collecting objects. The child starts out collecting multiple objects and becomes more selective as he or she gets older. Also, during concrete operational thinking, the school-age child develops an understanding of the principle of conservation—that matter does not change when its form changes. For example, if the child pours a half cup of water into a short, wide glass and into a tall, thin glass, she still only has a half cup of water despite the fact that it looks like the tall, thin glass has more (Fig. 28.2). She learns about conserving matter in a sequence ranging from the simplest to the more complex. See Table 28.1 for further information about cognitive development of school-age children.

Dietary Questions

Questions for the Child • How often do you eat together as a family? • What are the usual mealtimes? • How often does the family eat out? • Do you eat breakfast regularly? • Where do you eat lunch? • What do you drink/how much? • What foods do you eat most often? • What is your favorite food? • How often do you eat fast foods? • What type of exercise do you do? Questions for the Parents • How would you describe your child's usual appetite? • Do you have any special cultural/religious practices regarding food? • Has your child gained or lost weight recently? • Do you have any concerns about his or her eating behaviors? • How does your child exercise? Your family? • Is there a family history of cancer, hypertension, diabetes, obesity, or heart disease?

what is the age range for school-age children?

School-age children, between the ages of 6 and 12 years, are experiencing a time of slow progressive physical growth, while their social and developmental growth accelerates and increases in complexity. The focus of their world expands from family to teachers, peers, and other outside influences (e.g., coaches, media). The child at this stage becomes increasingly more independent while participating in activities outside the home.

Promoting Learning

School attendance and learning are very important to the school-age child. Parent-child, child-teacher, and child-peer relationships and activities influence the school-age child's learning. This school-age girl enjoys solitary play with her dollhouse and dolls. School-age children like to join clubs. These children, in the acting club at school, are rehearsing for a play.

School Refusal

School refusal (also called school phobia or school avoidance) has been defined as a refusal to attend school or difficulty remaining in school for an entire day. Behaviors include frequent absences, skipping classes, chronically late for school, severe misbehavior before school, or attending school with great fear. School phobia needs to be defined both symptomatically and operationally as the cause for the anxiety. School avoidance occurs in approximately 5% of children (AAP, 2017). Some of the fears expressed by school-refusing children include separating from parents, riding the bus, tests, bullying, teacher reprimands, anxieties over toileting in a public bathroom, physical harm, or undressing in the locker room. Due to the emotional distress caused in these children when attending school, they are frequently classified as having school phobia. Young children may complain of stomachache or headache and older children may complain of palpitations or feeling faint. It is important to investigate specific causes of school refusal/school phobia and take appropriate actions. Many times, school phobia is a symptom of deeper problems. The physician or nurse practitioner should conduct a physical examination of the child to rule out any physical illness. After these measures are taken, the parent, teacher, school counselor, and school administrator may devise a plan to assist the student to overcome a specific fear. In uncomplicated cases, parents must return the child to school as soon as possible. There may be altered schedules (partial days or decreased hours) to help promote a successful transition back to school. Another idea to help desensitize the child may be to have him or her spend part of the day in the counselor's or school nurse's office.

Teacher and School Influences

School serves as a means to transmit values of society and to establish peer relationships. Secondary only to the family, school exerts a profound influence on the social development of the child. Often, school requires changes for the child and parent. The child enters an environment that requires conforming to group activities that are structured and directed by an adult other than the parent. The parent's attitude and support influence the child's transition into the school setting. Parents who are positive and supportive promote a smooth entry into school. Parents who encourage clinging behaviors may delay a successful transition into school. To facilitate the transition from home to school, the teacher must have the personality and knowledge of development that will allow him or her to meet the needs of young children. Even though the teacher's responsibilities are primarily to stimulate and guide intellectual development, they must share in shaping the child's attitudes and values. The system of awards and punishment administered by teachers affects the self-concept of children and influences their response to school. Teachers and school are important in shaping the socialization, self-concept, and intellectual development of children.

Tobacco and Alcohol Education

School-age children are eager to grow up and be independent. Peers and acceptance are very important at this time. School-age children may be exposed to messages that are in conflict with their parents' values regarding smoking and alcohol. Peers often exert pressure for children to experiment with tobacco and alcohol. School-age children are ready to absorb information that deals with drugs and alcohol. Information from parents or other adults who are major influences in the child's life is essential at this time to set clear rules and model behaviors for children to embrace. Discussions with children need to be based on facts and focused on the present. Some topics for discussion include: What alcohol and drugs are like and how they harm you Differences in medical use versus illegal use of drugs How to think critically to interpret messages seen in advertising, media, sports, and entertainment personalities

Fire Safety

School-age children are eager to help parents with cooking and ironing. They are curious about fire and are drawn to play with fire, matches, and fireworks. Serious burns can occur from any exposure to fire. Educate children about the hazards of fire. In addition, teach children proper behavior around fires at home and outdoors. Always supervise children in the use of matches. In the home setting, parents should develop a fire safety plan with their children, teach children what to do if their clothes catch on fire, and practice evacuating the house in the event of a fire. In the school setting, children should be aware of the appropriate response to fire drills and fire drills should be conducted on a regular basis. Fire safety • All homes should have working smoke detectors and fire extinguishers. Change the batteries at least twice a year. • Have a fire-escape plan. • Practice fire-escape plan routinely. • Nobody should smoke in the home especially in bed. • Teach what to do in case of a fire: use fire extinguisher, call 911, and how to put out clothing fire. • Use stove and other cooking facilities under adult supervision. • All flammable materials and liquids should be stored safely. • Fireplaces should have protective gratings. • Teach children to avoid touching wires they might encounter while playing.

Promoting Safety

School-age children become more independent with age. This independence leads to an increased self-confidence and decreased fears, which may contribute to accidents and injuries. School age is a time that the child may walk to school with peers who may influence his or her behavior. Increased independence may also increase exposure to dangerous situations such as the approach of strangers or unsafe streets. Promotion of safe habits during the school-age years is important for parents and nurses. Unintentional injuries are the leading cause of death in children between 1 and 14 years of age (Centers for Disease Control and Prevention (CDC)/National Center for Health Statistics, 2017). Each year, 13 million children seek medical attention for nonfatal unintentional injuries (Gill & Kelly, 2019). School-age children are very active at home, in the community, and at school. This increased mobility, activity, and time away from parents increase the risk for unintentional injuries. School-age children continue to need supervision and guidance. They need information and rules about car safety, pedestrian safety, bicycle and other sport safety, fire safety, and water safety.

Promoting Healthy Eating Habits

School-age children should choose culturally appropriate foods and snacks from the U.S. Department of Agriculture's MyPlate. MyPlate illustrates the five food groups and encourages children to make half of their plate fruits and vegetables, to make half of their grains whole grains, and to choose lean proteins and calcium-rich foods. The website https://www.choosemyplate.gov/kids offers many tools for the child to use including development of personalized goals and menus, online dieting, and physical activity assessment tools, games, activities, and tips for parents. School-age children need to limit intake of fat and processed sugars. A prudent diet limits the use of fatty meats, high-fat dairy products, eggs, and hydrogenated shortenings and promotes the consumption of fish and the substitution of polyunsaturated vegetable oils and margarines.

Self-Esteem Development

Self-esteem mirrors the child's individual self-worth and consists of both positive and negative qualities. Children strive to achieve internalized goals of attainment, although they continually receive feedback from individuals they perceive as authorities (parent or teacher). By the school-age years, children have received feedback related to their performance or tasks. The direction of this feedback influences the child's opinion of self-worth, which influences self-esteem and self-evaluation. Children face the process of self-evaluation from a framework of either self-confidence or self-doubt. Children who have mastered the earlier developmental task of autonomy and initiative face the world with feelings of pride rather than shame (Erikson, 1963). If school-age children regard themselves as worthwhile, they have a positive self-concept and high self-esteem. Significant adults in school-age children's lives can manipulate the environment to facilitate success. This success impacts the self-esteem of the child.

Stealing, Lying, and Cheating

Stealing, lying, and cheating are inappropriate behaviors that may occur during the school-age years. In most cases, these behaviors will result in a good lesson learned and the child will outgrow them. In some cases, they may indicate a more severe psychological or behavioral problem. Parents are usually disturbed by these behaviors. In turn, they have difficulty in addressing these issues and need help in providing appropriate interventions. Children between 6 and 8 years old do not fully understand the concept of ownership and property rights. These children may steal things because they like the look of the item. By the age of 9, the child should respect others' possessions and property and understand that stealing is wrong (Johns Hopkins Medicine, n.d.). The school-age child may steal because he or she desires the item, feels peer pressure and is trying to impress his or her peers, or has a sense of low self-esteem (Johns Hopkins Medicine, n.d.). Stealing becomes a concern if the child steals and does not have remorse or steals continuously, or if stealing is accompanied by other behavioral problems (Johns Hopkins Medicine, n.d.). Stealing and lying are both more common in boys and in children between 5 and 8 years old (Johns Hopkins Medicine, n.d.). It is acceptable for these children to tell tall tales, but they should know what truth is and what make-believe is. These younger children typically lie to avoid punishment. However, they do not like others to lie and will tell on them if they lie. Children between 8 and 12 years old typically lie because they are unable to meet expectations of family and peers, they are testing the rules and limits placed on them, or they are unable to explain bad behavior (Johns Hopkins Medicine, n.d.). If lying persists in older school-age children, if it is accompanied by other behavioral problems, or if the child does not show remorse with lying, parents should discuss the matter with a physician because the lying may be evidence of underlying problems. The concept of cheating is not well understood until the child is about 6 to 7 years old. Before this age, the desire to "win" is most important and rigid rules are hard to understand. In children between 8 and 12 years old, the concept of cheating is fully understood and following of rules becomes more important (Johns Hopkins Medicine, n.d.). If cheating persists in older school-age children, parents should discuss the matter with a physician because the behavior may indicate underlying problems. In dealing with children who exhibit stealing, lying, or cheating behaviors, parents must first realize the importance of their own behaviors in those areas. Parents are role models to the school-age child. Therefore, when the child sees or hears that parents lie, steal, or cheat (e.g., parents bragging about cheating on their taxes), they think it is all right to mimic those behaviors. Secondly, parents must directly confront any stealing, lying, or cheating behaviors and discuss (and follow through consistently with) the consequences of such behaviors (see Teaching Guidelines 28.2). Bullying

Water Safety

Teach school-age children swim and water safety. An adult should always supervise children when they are swimming to prevent water-related accidents. Water safety • Teach children how to swim and to never play around or in water without adult supervision. • If swimming skill is limited, child must wear life preserver at all times. • Child should know never to swim alone—if at all possible, swim only where there is a lifeguard. • Understand basic CPR. • Teach child to never run or fool around at edge of pool. • Drains in pool should be covered with appropriate cover. • Life jackets should be worn when on a boat. • Make sure water is deep enough to support diving.

Addressing Common Developmental Concerns

Television, Video Games, and the Internet • Establish a consistent time limit for any media use and develop a Family Media Plan. Establish media-free times, such as mealtime. • Monitor television programs and internet activity. • Prohibit television or video games with violence. • Do not put television, video games, or internet-connected devices in children's bedrooms. Place computers in an open area that allows easy monitoring by an adult. • Co-view television, video games, and internet content with the child. • Encourage sports, interactive play, and reading. • Teach your child internet safety, such as to never share personal information or meet a friend you have only met online without parental permission. Never share passwords. Never respond to a message that hurts your feelings or makes you uncomfortable. Never send mean messages over the internet. • Teach proper social media use. • Be a good role model.

Temperament

Temperament has been described as the way individuals behave. Three commonly grouped temperaments are the child that is easy and adaptable, the child that is slow to warm up, or the child that is difficult and easily frustrated (Levine, 2019). Variations and combinations of these categories are seen. Not every child can be placed into one of these groups. Understanding a child's temperament can help care providers and parents to understand the child's behavior, actions, and how they relate to the world. For example, the child who is easy may adapt to school entry and other experiences smoothly and with little or no stress. The slow-to-warm child may be slow to adapt to changes. The slow-to-warm school-age child may exhibit discomfort when placed in different or new situations such as school. This child may need time to adjust to the new place or situation, and may demonstrate frustration with tears or somatic complaints. The slow-to-warm child should be allowed time to adjust to new situations and people (such as teachers) within his or her own time frame. All of these factors may impact the younger school-age child upon entering the school environment, with changes in authority and the introduction of many peers. The difficult or easily distracted child may benefit from an introduction to the new experience and people by role-playing, by visiting the site and being introduced to the teachers, and by hearing stories or participating in conversations about the upcoming school experience. These children require patience, firmness, and understanding to make the transition into a new situation or experience such as school. Assessment of temperament by a professional would include a combination of interview, observation, and a standardized questionnaire. Better understanding a child's temperament can assist parents with adjusting their parenting style to better fit their child and may help limit emotional and behavioral problems that occur when these areas are in conflict

Neurologic System

The brain and skull grow very slowly during the school-age years. Brain growth is complete by the time the child is 10 years of age. The shape of the head is longer and the growth of the facial bones changes facial proportions.

ADDRESSING COMMON DEVELOPMENTAL CONCERNS

The developmental task (according to Erikson) of the school-age child is industry (Erikson, 1963; Feigelman, 2016b). The school-age child is busy learning, achieving, and exploring. As the school-age child becomes more independent, forces other than the family such as television, video games, and peers influence him or her. Some of these influences are positive and others are negative. Some of the common developmental concerns for the school-age child are discussed in the following sections. Guidelines to assist the parents and nurses when encountering these concerns are included in Teaching Guidelines 28.2.

Television, Video Games, and the Internet

The influence of television, video games, digital media and the internet upon the school-age child is a growing concern for parents and child specialists. Today's world is surrounded by digital media. School-age children use digital media for education, communication, and entertainment. They have access to thousands of apps, live streaming, streaming movies and TV shows, videos, games, and social media, all on multiple devices from TVs and computers to smartphones and tablets. By the age of 18, a child will see 200,000 violent acts (Ben-Joseph, 2020). Although a school-age child can determine what is real from what is fantasy, research has shown that too much time in front of a screen—watching it or playing video games—can lead to risky behaviors (such as smoking and drinking) less physical activity, and obesity (Ben-Joseph, 2020) (see Healthy People 2030). Some television shows, video games, and internet activity can have positive influences on children, but parents should be taught guidelines on the use of TV, video games, digital media, and the internet. Parents should set limits on how much screen time the child can have. The AAP recommends parents place consistent limits on media time and type and there should be designated media-free times (AAP, Council on Communications and Media, 2016). Television watching, internet activity, or video gaming should not be used as rewards. The parents should be aware of what the child is watching and doing online. This can be accomplished by parents and children watching programs together and parents using that opportunity to discuss the subject matter with the child. There should be no TV during dinner and no TV or internet-connected devices in the child's room. The parents need to set an example for the child by reading instead of using digital media or by doing a physical activity together as a family. If the TV or digital media cause fights or arguments, they should be turned off for a period of time.

Prepubescence

The late school-age years are also referred to as preadolescence (the time between middle childhood and the 13th birthday). During preadolescence, prepubescence occurs. Prepubescence typically occurs in the 2 years before the beginning of puberty and is characterized by the development of secondary sexual characteristics, a period of rapid growth for girls, and a period of continued growth for boys. There is approximately 2 years' difference in the onset of prepubescence between boys and girls. Sexual development in both boys and girls can lead to a negative perception of physical appearance and lowered self-esteem. Early development in girls can lead to embarrassment, concern over physical appearance, and low self-esteem. Delayed development in boys can lead to a negative self-concept, resulting in substance abuse or reckless use of nonautomobile vehicles. Early development may lead to risk-taking behaviors in both boys and girls. It is important for the nurse and parents to educate the late school-age child about body changes to decrease anxiety and promote comfort with these body changes.

Promoting Healthy Sleep and Rest

The number of hours of sleep required for growth and development decreases with age. Children between the ages of 6 and 8 years require about 12 hours of sleep per night, children between 8 and 10 years of age require 10 to 12 hours of sleep per night, and children between 10 and 12 years of age need 9 to 10 hours of sleep per night. Young school-age children may need an occasional brief nap for an energy boost after being in school for most of the day. Bedtime rituals and consistent schedules continue to be important throughout the school-age years. Parents must facilitate a bedtime schedule and quiet time before bed. Bedtime is a special time for parents and children. They can spend time together reading, listening to soothing music, and discussing the day's events. This time continues to be important during the school-age years as the child gains independence from his or her parents. Children should have bedtime expectations as well as wake-up times and methods for waking up (alarm, calling by parent, and so forth). Night terrors or sleepwalking may occur in 6- to 8-year-olds, but should be resolved between the ages of 8 and 10 years. In the older school-age child (11 to 12 years), encourage parents to allow a variation in the sleep schedule on the weekends and a regular schedule on weekdays.

Respiratory System

The respiratory system continues to mature with the development of the lungs and alveoli, resulting in fewer respiratory infections. Respiratory rates decrease, abdominal breathing disappears, and respirations become diaphragmatic in nature. The frontal sinuses are developed by 7 years of age. Tonsils decrease in size from the preschool years, but they remain larger than those of adolescents. The adenoids and tonsils may appear large normally, even in the absence of infection.

Cardiovascular System

The school-age child's blood pressure increases and the pulse rate decreases. The heart grows more slowly during the middle years and is smaller in size in relation to the rest of the body than at any other development stage.

Nutritional Needs

The school-age child's calorie needs vary based on age, gender, and activity level. Boys and girls 4 to 8 years old who are moderately active will need about 1,400 to 1,600 calories a day (U.S. Department of Agriculture and U.S. Department of Health & Human Services, 2015). Boys 9 to 13 years old who are moderately active need about 1,800 to 2,200 calories a day, while girls this age who are moderately active need about 1,600 to 2,000 calories a day (U.S. Department of Agriculture and U.S. Department of Health & Human Services, 2015). Of these calories, 45% to 65% should come from carbohydrates, 10% to 30% from protein, and 25% to 35% from fat (U.S. Department of Agriculture and U.S. Department of Health & Human Services, 2015). The 4- to 8-year-old child needs 1,000 mg of calcium, while the 9- to 13-year-old needs 1,300 mg of calcium for maintenance of growth and good nutrition (U.S. Department of Agriculture and U.S. Department of Health & Human Services, 2015). Calcium is needed for the development of strong bones and teeth. Milk, yogurt, and cheese provide protein, vitamins, and minerals and are excellent sources of calcium. Meats, poultry, fish, and eggs provide protein, vitamins, and minerals.

Peer Relationships

The school-age child's concept of self is shaped not only by his or her parents but also by relationships with others. Peer relationships influence children's independence from parents. Peers play an important role in the approval and critiquing of skills of school-age children. Previously, only adults such as parents and teachers were authorities; now, peers influence school-age children's perceptions of themselves. Peer relationships help to support the school-age child by providing enough security to risk the parental conflict brought about when establishing independence. School-age children associate with peers of the same sex most of the time. Although games and other activities are shared by both boys and girls, the child's concept of the appropriate sex role is influenced by his or her relationship with peers. Continuous peer relationships provide the most important social interaction for school-age children. Valuable lessons are learned from interactions with children of their own age. Children learn to respect differing points of view that are represented in their groups. Peer groups establish norms and standards that signify acceptance or rejection. Children may modify behavior to gain acceptance. A characteristic of school-age children is their formation of groups with rules and values.

School-Age Fears

The school-age child's fears shift away from pretend things, like monsters, to things that could happen to them in real life, such as natural disasters, others hurting them, and the death of a loved one (Lyness, 2018). School-age children are less fearful of harm to their body than in their preschool years, but fear being kidnapped or undergoing surgery. They may continue to fear the dark but are less fearful of animals, such as dogs and noises. The school-age child needs reassurance that his or her fears are normal for this developmental age. Parents, teachers, and other caretakers should listen to the child's fears with sympathy and support. Recognize the child's fears but do not cater to them. Help the child face his or her fears and teach the child coping strategies such as positive self-statements such as "I can do this" and relaxation techniques such as deep breathing and visualization

Family Influences

The school-age years are a time for peer relationships, questioning of parents, and the potential for parental conflict but continued respect for family values. School-age years are the beginning of the time of peer-group influence, with testing of parental and family values. Although the peer group is influential, the family's values usually predominate when parental and peer-group values come into conflict. Even though the school-age child may question the parents' values, the child will usually incorporate the values from parents into his or her values. Many times in the late school age and preadolescent period, the child may prefer to be in the company of peers and show a decreased interest in family functions. This may require an adjustment for parents. Parents' awareness of this developmental trend and their continuing support for the child are important while they continue to enforce restrictions and control of behaviors. The school-ager is beginning to strive for independence, but parental authority and controls continue to impact choices and values. School-age children continue to need parenting. They do not need parents as pals.

Growth and Development Overview

The school-age years are a time of continued maturation of the child's physical, social, and psychological characteristics. It is during this time that children move toward abstract thinking and seek approval of peers, teachers, and parents. Their eye-hand-muscle coordination allows them to participate in organized sports in school or the community. The school-age child typically values school attendance and school activities. The nurse uses knowledge of normal growth and development of the school-age child to assist the child in coping with disruptions and changes during this time period.

Promotion of Reading in School-Age Children

• Parents, read to and with your children. • Ask teachers and librarians for advice on books appropriate for your child. • Choose stories that the child can relate to if the child has difficulty reading. • Choose books with movement if the child has a short attention span. • Take advantage of all reading opportunities (cereal boxes, road signs). • Provide choices for the child to select a book of interest. • Talk about the text and ask questions to improve understanding. • Keep a record of what the child is reading. • Visit a library, get a library card, and check out books. • Parents, demonstrate role modeling through reading books.