PEDS/ SCHOOL AGE; CHAP. 28

Television, Video Games, and the Internet ObjectiveNursing Significance Increase the proportion of children and adolescents who do not exceed recommended limits for screen time • Assist families to identify activities other than television or video games for the child to participate in Increase the proportion of children and adolescents aged 2 years through 12th grade who view television or videos or play video games for no more than 2 hours a day • Praise craft, music, and sports participation

Take Note! According to the AAP age-based guidelines, school-age children need supervision and monitoring when using the internet to ensure they are not exposed to inappropriate material or content (AAP, 2015). Encourage parents of children in this age group to utilize internet safety tools that limit access to content and websites and that provide information on internet activities.

Bullying ºIn general, about 10% of all children attending school are frightened and afraid most of the day (American Academy of Child and Adolescent Psychiatry, 2011). ºAbout 25% of children have been bullied (Robinson & Segal, 2014). Most of the bullying occurs at school (Augustyn & Zuckerman, 2011). Both boys and girls are bullied and can bully others; however, boys are twice as likely to be bullies and victims of bullying (Augustyn & Zuckerman, 2011). ºBeing bullied can have negative results on children throughout life. These children often have increased episodes of headaches, stomachaches, sleep problems, anxiety, loneliness, depression, and suicidal tendencies (Schuster & Bogart, 2013). ºAfter 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

Tobacco and Alcohol Education ºSchool-age children are eager to grow up and be independent. Peers and acceptance are very important at this time. ºSchool-age children may be exposed to messages that are in conflict with their parents' values regarding smoking and alcohol. ºPeers often exert pressure for children to experiment with tobacco and alcohol

Emotional and Social Developmental Issues (School-Age Child) ºTemperament- described as the way individuals behave. ºVariations 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. ºFor 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. ºThe 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

ºTemperament º 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. ºThe 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. ºThese children require patience, firmness, and understanding to make the transition into a new situation or experience such as school. ºAssessment of temperament by a professional would include a combination of interview, observation, and a standardized questionnaire. ºBetter 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

Developmental Concerns (School-Age Child) ºTelevision and video games ºSchool phobia ºLatchkey children ºStealing, lying, cheating ºBullying ºThe developmental task (according to Erikson) of the school-age child is industry (Erikson, 1963; Feigelman, 2011a). ºThe school-age child is busy learning, achieving, and exploring. ºAs 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.

ADDRESSING COMMON DEVELOPMENTAL CONCERNS Television, Video Games, and the Internet ºLimit total screen time, which includes television watching, video game playing, and internet-connected devices to 1 to 2 hours per day ºMonitor television programs and internet activity ºProhibit television or video games with violence ºDo 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 ºProvide a schedule of accepted television programs for viewing each week

ADDRESSING COMMON DEVELOPMENTAL CONCERNS Television, Video Games, and the Internet ºCo-view television, video games and internet content with the child ºEncourage sports, interactive play, and reading ºTeach 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. ºNever respond to a message that hurts your feelings or makes you uncomfortable. Never send mean messages over the internet

ADDRESSING COMMON DEVELOPMENTAL CONCERNS- OBESITY ºProvide healthy meals and snacks ºSchedule and encourage daily exercise ºEncourage involvement in sports ºRestrict TV and computer-game use ºLimit the amount of fast-food intake ºProvide education about healthy nutrition ºNever use food as a reward ºBe a good role model

ADDRESSING COMMON DEVELOPMENTAL CONCERNS- SCHOOL REFUSAL ºReturn child to school ºInvestigate cause of the fear ºSupport child ºCollaborate with teachers ºPraise success in school attendance ADDRESSING COMMON DEVELOPMENTAL CONCERNS-LATCHKEY ºProvide rules to follow and expectations, such as: ºNot answering the door or phone ºNo friends in the house when parents are not home ºNo playing with fire

ADDRESSING COMMON DEVELOPMENTAL CONCERNS-LATCHKEY ºTeach child to call a trusted neighbor when help is needed and 911 in the event of emergency ºPost all resource numbers (even numbers you think your child may have memorized), including after-school help lines if available, in a clearly viewable spot. Include pediatrician's number and preferred hospital ºPurchase caller ID for the phone system ºEnroll the child in an after-school program if available ºDiscuss limitations of outside play ºDiscuss limitations of television viewing and video game use ºMake sure the child knows how to contact the parent

ºThe 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. ºIt 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. ºIf 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

Benefits of Physical Activity for the School-Age Child ºCardiovascular fitness ºWeight ºEmotional tension release ºDevelopment of leadership and following skills ºfollowing skills are enhanced through physical activity and team sports.

Pedestrian Safety ºEvery year 51,000 children are injured as pedestrians and 900 pedestrian children are killed (AAP, 2013b). ºChildren younger than 10 years of age should not be unsupervised pedestrians (AAP, 2013b). ºYoung 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.

Bicycle and Sport Safety ºBicycling, riding scooters, skateboarding, and inline skating or roller skating are common activities of school-age children. ºLaws 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. ºIt 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. ºIt is important for the child to have a bicycle that is appropriate for his or her size and age.

Self-esteem development ºSelf-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). ºBy 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. ºChildren 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). ºIf 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.

Body image ºBody 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. ºSchool-age children are very interested in peers' views and acceptances of their body, body changes, and clothing. ºThis 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 life-long effects.

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

Bullying The Bullied Child Educate parents whose children are at risk for being bullied, such as: ºChildren who appear different from the majority ºChildren who act different from the majority ºChildren who have low self-esteem ºChildren 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 ºImpress upon the child that he or she did not cause the bullying ºDevelop ways to increase the child's self-esteem at home ºDiscuss the situation with the teacher and develop a plan of care

STEALING, LYING AND CHEATING ºIn 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. ºTherefore, 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. ºSecondly, parents must directly confront any stealing, lying, or cheating behaviors and discuss (and follow through consistently with) the consequences of such behaviors

Bullying ºBullying, which is inflicting unwanted, repeated verbal, emotional, or physical abuse upon others, is on the rise (Schuster & Bogart, 2013). ºUtilizing email, text messages, social networking, and instant messaging, often referred to as cyberbullying, is a growing concern. ºBullies often look for victims who appear shy, weak, and defenseless. Children with health issues, such as disabilities, obesity, and food allergies, are at an increased risk of being bullied

COGNITIVE DEVELOPMENT ºPiaget's stage of cognitive development for the 7- to 11-year-old is the period of concrete operational thoughts (Feigelman, 2011a). In developing concrete operations, the child is able to assimilate and coordinate information about his or her world from different dimensions. ºThe 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. ºThe 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.

COGNITIVE DEVELOPMENT ºIt 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. ºAlso, 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. ºFor 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

Promoting Safety ºSchool-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. ºSchool 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. ºUnintentional injuries are the leading cause of death in children between 1 and 19 years of age (Gilchrist, Ballesteros, & Parker, 2012). Each year, 9.2 million children seek medical attention for nonfatal unintentional injuries (Centers for Disease Control and Prevention [CDC], 2012b). ºSchool-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. ºSchool-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.

Car Safety ºMotor 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. ºThe 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 ºSchool-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 feet 9 inches) or taller, usually between 8 and 12 years of age (AAP, 2013a). ºThe 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 (AAP, 2013a).

Developmental Milestones ºCoordination, balance, and rhythm improve facilitating the opportunity to ride a two-wheel bike, jump rope, dance, and participate in a variety of other sports ºMyelination of the central nervous system is reflected by refinement of fine motor skills in the school-age child. Sensory Development of the School-Age Child ºAll senses are mature. ºTypical child has 20/20 vision acuity. ºOcular muscular control, peripheral vision, and color discrimination are developed by age 7. Vision Problems Frequently Identified in School-Age Children

Cultural Influences on Growth and Development (School-Age Child) • Habits • Beliefs • Language • Values Culture influences habits, beliefs, language, and values. ºSchool-age children thrive on learning the music, language, traditions, holidays, games, values, gender roles, and other aspects of culture. ºNurses must be aware of the effects on children of various groups' family structures and traditional values. ºThe 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. ºCultural implications must be considered for all children and families in order to provide appropriate care.

ºAt 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. ºThe 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, 2011a) ºDuring 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. ºThey are comforted by the rituals of their religion, but are just beginning to understand the differences between natural and supernatural. Incorporating religious practices in their lives can assist school-age children in coping with different stressors.

Erikson's Theory ºIndustry versus inferiority ºDeveloping 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 ºDeveloping cognitive and social skills

Factors Determining Type and Amount of Discipline ºEffective guidance and discipline focus on the development of the child. They can preserve the child's self-esteem and dignity. ºDiscuss 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. ºThese 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, 2012). ºDiscuss 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.

Factors Determining Type and Amount of Discipline When misbehaviors occur, the type and amount of discipline are based on different factors: ºDevelopmental level of both the child and the parents ºSeverity of the misbehavior ºEstablished rules of the family ºTemperament of the child ºResponse 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.

Piaget's Stage of Cognitive Development of Concrete Operational Thoughts (7 to 11 Years) ºAssimilates and coordinates information about the world from different dimensions ºSees things from another person's point of view ºThinks through an action, anticipates consequences and the possibility of having to rethink the action ºStores memories of past experiences to evaluate present situations ºDivides things into different sets and identifies relationships to each other ºUnderstands the principle of conservation: matter does not change when its form changes

Kohlberg's Theory Moral/Spiritual Development ºInterpersonal concordance ºGood child versus bad child ºLaw and order ºconventional stage of moral developmen ºThe 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. ºThe 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.

Factors Determining Type and Amount of Discipline ºDevelopmental level of both the child and the parents ºSeverity of the misbehavior ºEstablished rules of the family ºTemperament of the child ºResponse of the child to rewards ºThe 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. ºSchool-age children should be able to express emotions without using violence. Discipline techniques with consequences have both natural and logical consequences. ºNatural consequences allow the child to learn the results of his or her actions. ºFor example, if the child throws a toy out of the window, then he or she cannot play with the toy anymore. ºIn 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.

Factors Determining Type and Amount of Discipline ºIn disciplining children, parents should teach children the rules established by the family, values, and social rules of conduct. ºRules should provide the school-age child with guidelines about behavior that is acceptable and unacceptable. ºSchool-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. ºDiscuss 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.

Teacher and school influences ºTo 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. ºEven though the teacher's responsibilities are primarily to stimulate and guide intellectual development, they must share in shaping the child's attitudes and values. ºThe system of awards and punishment administered by teachers affects the self-concept of children and influences their response to school. ºTeachers and school are important in shaping the socialization, self-concept, and intellectual development of children.

Family influences ºThe school-age years are a time for peer relationships, questioning of parents, and the potential for parental conflict but continued respect for family values. ºSchool-age years are the beginning of the time of peer-group influence, with testing of parental and family values. ºAlthough the peer group is influential, the family's values usually predominate when parental and peer-group values come into conflict. ºEven though the school-age child may question the parents' values, the child will usually incorporate the values from parents into his or her values. ºMany 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. ºThis 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. ºThe school-ager is beginning to strive for independence, but parental authority and controls continue to impact choices and values.

Bicycle and Sport Safety ºThe 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." ºIf 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. ºNonmotorized 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. Reduce fatal and nonfatal traumatic brain injuries. • Provide education to children and their parents about avoiding head injury through helmet use. • Encourage child to choose a helmet that appeals to him or her (one that looks "cool").

Fire Safety ºSchool-age children are eager to help parents with cooking and ironing. ºThey are curious about fire and are drawn to play with fire, matches, and fireworks. ºSerious burns can occur from any exposure to fire. ºEducate children about the hazards of fire. In addition, teach children proper behavior around fires at home and outdoors. ºAlways 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. ºIn the school setting, children should be aware of the appropriate response to fire drills and fire drills should be conducted on a regular basis. ºWater Safety Teach school-age children swim and water safety. An adult should always supervise children when they are swimming to prevent water-related accidents.

Organ System Maturation (School-Age Child) Neurologic system: brain and skull grow very slowly; shape of head is longer; growth of facial bones changes facial proportions; Brain growth is complete by the time the child is 10 years of age Respiratory system: continues to mature with development of lungs and alveoli; fewer respiratory infections ; respiratory rates decrease; respirations diaphragmatic in nature ; abdominal breathing disappears; 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: blood pressure increases and 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. Immune system: Lymphatic tissues continue to grow until the child is 9 years old; immunoglobulins A and G (IgA and IgG) reach matures to adult level around 10 years old; fewer a experienced ºDue 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.

Gastrointestinal system: all 20 primary deciduous teeth replaced by 28-32 permanent teeth with the exception of the third molars (commonly known as wisdom teeth) ;fewer gastrointestinal upsets ;stomach capacity increases-which permits retention of food for longer periods of time; -caloric needs are lower Genitourinary system: bladder capacity increases (age in years plus 2 oz); Girls generally have a greater bladder capacity than boys; prepubescence occurs ºUrination 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 ounces. Therefore, the bladder capacity of the 7-year-old would be 9 ounces. The larger capacity of the bladder allows for the child to experience longer periods between voiding.

LATCHKEY CHILDREN ºWith 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. ºHowever, 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. ºMany 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 ºState and local laws in order to assist parents in making decisions about when it is appropriate for their child to be home alone (Child Welfare Information Gateway, 2013). The AAP recommends that a school-age child come home to a parent or another responsible adult (AAP, 2013f).

LATCHKEY CHILDREN ºDespite the level of maturity, children who are unsupervised are more likely to participate in risky behaviors such as smoking, drinking, and doing drugs (AAP, 2013g). ºIn addition, latchkey children may feel anxiety, stress, fear, boredom, loneliness, they miss more days of school, and have lower academic scores (AAP, 2013g). ºIf 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. ºThey should tell anyone who comes to the door or who calls that mom is home but busy at this time. Directions as to the handling of the house key and fire safety should be taught and demonstrated

ADDRESSING COMMON DEVELOPMENTAL CONCERNS-LATCHKEY ºSet clear homework expectations ºDO NOT keep guns in the home ºTeach the child where first aid supplies are located ºTeach the child household emergency procedures such as circuit breakers and water shut off valves ºPractice with your child. Have a trial run by leaving for a short time but staying close and role playing situations that may occur ºAlways check in with your child while you are away Stealing ºEducate parents about possibility of stealing ºDiscuss ways to teach concept of ownership and property rights ºHandle situation openly ºAssist child in developing and enacting a plan to return what was stolen ºMake sure the punishment is appropriate for the action

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

Nurse's role ºGrowth and development in the school-age child occurs in irregular spurts with a wide variation of sizes, shapes, and abilities seen. ºNurses 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. ºThis 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. ºHealth 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. ºIf 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.

Nurse's role ºHe 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. ºThe 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. º 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. ºWhen 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.

Promoting Healthy Teeth and Gums ºDental sealants are an easy way to protect a child's primary or permanent teeth as children with dental sealants have 60% less decay (CDC, 2013b). ºThe 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 . ºThe school-age child should have an established dental home; if not, provide appropriate resources to establish one (AAP, 2014). See the Healthy People 2020 chart.

Objective Nursing Significance Reduce the proportion of children and adolescents who have dental caries in their primary or permanent teeth • Encourage appropriate tooth brushing and flossing • Educate child and family about fluoride use Reduce the proportion of children and adolescents with untreated dental decay • Refer school-age children to dentist for regular check-ups and interventions such as molar sealants Increase the proportion of children who have received dental sealants to their molar teeth • Assist families lacking dental insurance to find resources for the provision of dental care

GROWTH & DEVELOPMENT OVERVIEW ºThe 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. ºTheir 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. ºThe nurse uses knowledge of normal growth and development of the school-age child to assist the child with coping with disruptions and changes during this time period.

PHYSICAL GROWTH ºIn the early school-age years, girls and boys are similar in height and weight and appear thinner and more graceful than in previous years. ºIn later school-age years, most girls begin to surpass boys in both height and weight. (See Appendix A for growth charts.) ºPreadolescent boys and girls do not want to be different from peers of the same sex or the opposite sex, although there are differences in physical and physiologic growth during the school-age years. ºThese differences, especially secondary sexual characteristics, are concerning and often a source of embarrassment for both sexes.

Promoting Healthy Teeth and Gums ºProper alignment of teeth is important to tooth formation, speech development, and physical appearance. ºMany school-age children need braces or other orthodontic devices to correct malocclusion, a condition in which the teeth are crowded, crooked, or misaligned. ºBruxism 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.

Promoting Healthy Teeth and Gums ºChildren wearing braces are more prone to cavities; encourage them to brush their teeth after meals and snacks. ºSchool nurses can assist these children with brushing after lunch. ºIn addition, the school nurse should promote dental health through education on dental care and gum problems that result from lack of proper dental care. ºDiet can play a part in dental health. Limiting sticky, high-sugar, and high-carbohydrate foods will decrease the possibility of cavities.

School-age fears ºSchool-age children are less fearful of harm to their body than in their preschool years, but fear being kidnapped or undergoing surgery. ºThey continue to fear the dark and worry about their past behaviors. They fear death and are fascinated by death and dying. They are less fearful of animals, such as dogs and noises. ºThe school-age child needs reassurance that his or her fears are normal for this developmental age. Parents, teachers, and other caretakers should discuss the fears and answer questions posed by the child (Child Development Institute, 2013). ºRecognize the child's fears but do not cater to them. 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

Peer relationships ºThe school-age child's concept of self is shaped not only by his or her parents but also by relationships with others. ºPeer relationships influence children's independence from parents. Peers play an important role in the approval and critiquing of skills of school-age children. ºPreviously, only adults such as parents and teachers have been 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. ºSchool-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.

Physiologic Growth of the School-Age Child 6-12 YEARS OLD ºGrow an average of 2.5in (6- 7 cm) in per year ºIncrease in height by at least 1 ft ºIncrease weight by 4 to 6 lb (3 to 3.5kg) ºSecondary sexual characteristics appear *engage in meaningful projects *need to have freedom to develop a strong sense of industry or accomplishment in learning how to do things well *need rewards or they can develop feeling of inferiority •need frequent Reassurance to make sure they are doing things right *interested in new ideas/ they ask lots of questions *speaking at there language or setting up scenarios that they can relate too

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. ºThe 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 HEALTHY GROWTH AND DEVELOPMENT ºRespectful 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. ºThe nurse should study interactions between parents and school-age children to observe for this respect or lack of respect ("putting the child down"). ºThe 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.

Promoting Growth and Development Through Play ºCooperative 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. ºSchool-age children have the coordination and intellect to participate with other children of their age in sports such as soccer, baseball, football, and tennis. ºThe 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.

Promoting Healthy Teeth and Gums ºDental caries (tooth decay) remains a leading chronic disease in the United States (CDC, 2012b; ºThe incidence declined from the 1970s to the early 1990s, mostly due to the introduction of fluoride . ºSince then, there has been a small but significant increase in the incidence of dental caries. ºRecent statistics show that 51% 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

Promoting Healthy Teeth and Gums ºDental care with emphasis on prevention of caries is important in this age group. ºSchool-age children need to brush their teeth two to three times per day for 2 to 3 minutes each time with fluorinated toothpaste (Fig. 28.9). ºParents 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. ºParents 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. ºChildren will need help with brushing teeth until they are between 7 and 10 years of age.

Promoting Growth and Development Through Play ºSchool-age children also enjoy solitary activities including board, card, video, and computer games, and dollhouse and other small-figure play (Fig. 28.6). ºMany 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. ºThey may participate in activities such as dance or karate. Girls and boys may join clubs, gangs, or special interest groups. ºActive play has decreased in recent years as television viewing and computer games have increased. This trend has resulted in health risks such as obesity, type 2 diabetes, and cardiovascular problems.

Promoting Learning ºSchool 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. Formal Education ºMost 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. ºPeers 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.

BOX 28.1 PROMOTION OF READING IN SCHOOL-AGE CHILDREN ºRead to and with your children ºAsk teachers and librarians for advice on books appropriate for your child ºChoose stories that the child can relate to if the child has difficulty reading ºChoose books with movement if the child has a short attention span ºTake advantage of all reading opportunities (cereal boxes, road signs) ºProvide choices for the child to select a book of interest ºTalk about the text and ask questions to improve understanding ºKeep a record of what the child is reading ºVisit a library, get a library card, and check out books ºDemonstrate role modeling through reading books

Promoting Sleep and Rest (School-Age Child) ºAges 6-8 =12 hours of sleep required 8-10= require 10-12 hours 10-12= 9-10 hours ºYoung school-age children may need an occasional brief nap for an energy boost after being in school for most of the day. ºShould have bedtime expectations and wake-up times º quiet time before bed ºBedtime is a special time for parents and children to read together, listen to stories or soothing music, share events of the day, and exchange expressions of affection ºNight terrors and sleepwalking may occur but should resolve by age 8 to 10 years ºin 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.

Language and Communication Skills (School-Age Child) ºVocabulary expands from 8,000 to 14,000 words. ºCulturally specific words are used. ºReading efficiency improves language skills. ºMore complex grammatical forms are used.- plurals and pronouns ºDevelopment of metalinguistic awareness occurs. - 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. ºThey 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. ºMetaphors are beginning to be understood.

Question Is the following statement True or False? The school-age child's peer group values usually dominate when parental and peer group values come into conflict. Answer False. The school-age child's family values usually dominate when parental and peer group values come into conflict. (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.)

Formal Education ºThrough this interaction, children learn cooperation, competition, and the importance of following the rules. Peer approval and influences grow as the child matures. ºTeachers have significant influences on children. They help to guide the child's intellectual development by rewarding successes and helping the child deal with failures. ºThe 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. ºParental 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.

Reading ºEncouraging reading is an excellent way to promote learning in the school-age child. ºTrips to the library and purchasing books help to promote a love of reading. ºSchool-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. ºChildren 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. ºOlder children enjoy horror stories, mysteries, romances, and adventure stories as well as classic novels. ºSchool-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. See Box 28.1for ideas for parents to promote reading in the school-age child.

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. ºBehaviors 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, 2013e). ºSome 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. ºDue 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.

SCHOOL REFUSAL ºIt is important to investigate specific causes of school refusal/school phobia and take appropriate actions. ºMany 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. ºAfter 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. ºThere 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.

SENSORY DEVELOPMENT ºAmblyopia 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. ºAmblyopia is the leading cause of visual impairment in children (National Eye Institute, 2013). If untreated in childhood it can persist into adulthood causing monocular visual impairments (National Eye Institute, 2013). ºThis condition is correctable with glasses or patching which forces the child to use the weaker eye. Recent clinical trials have suggested that older children (7 to 17 years) may benefit from these treatments, which are more commonly used on younger children (National Eye Institute, 2013).

SENSORY DEVELOPMENT ºProper 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 ºHearing 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. ºThe 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.

FINE MOTOR SKILLS ºMyelinization of the central nervous system is reflected by refinement of fine motor skills. ºEye-hand coordination and balance improve with maturity and practice. ºHand 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. ºThe 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.

SENSORY DEVELOPMENT ºAll senses are mature early in the school-age years. ºThe typical school-age child has 20/20 visual acuity (Jarvis, 2012). ºGood vision is essential to the physical development and educational progression of school-age children. ºVision 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).

STEALING, LYING AND CHEATING ºLying is more common in boys and in children between 5 and 8 years old (Roux, 2013). It is acceptable for these children to tell tall tales, but they should know what truth is and what make-believe is. ºThese 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 (Roux, 2013). ºIf lying persists in older school-age children, if it is accompanied by other behavior 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.

STEALING, LYING AND CHEATING ºThe concept of cheating is not well understood until the child is 7 years old. Before this age, the desire to "win" is most important and rigid rules are hard to understand. ºIn children between 8 and 12 years old, the concept of cheating is fully understood and following of rules becomes more important (Roux, 2013). ºCheating is usually done because of competition and strong pressure placed on the child to succeed (AAP, 2013h). If cheating persists in older school-age children, parents should discuss the matter with a physician because the behavior may indicate underlying problems.

STEALING, LYING AND CHEATING ºIt is during the school-age years that antisocial behaviors can emerge. Children who were previously well behaved may now exhibit behaviors such as stealing, lying, and cheating (Mannheim, 2012). ºParents are usually disturbed by this change in behavior. In turn, they have difficulty in addressing these issues and need help in providing appropriate interventions. ºChildren 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 (Roux, 2013).

STEALING, LYING AND CHEATING ºThe 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 (Roux, 2013). ºStealing becomes a concern if the child steals and does not have remorse or steals continuously, or if stealing is accompanied by other behavior problems

NURSING PROCESS OVERVIEW ºUpon completion of assessment of the school-age child's current growth and development status, problems or issues related to growth and development may be identified. The nurse may then identify one or more nursing diagnoses, including: -Risk for disproportionate growth -Imbalanced nutrition: more than body requirements -Delayed growth and development -Risk for caregiver role strain -Risk for injury ºNursing care planning for the school-age child with growth and development issues should be individualized based on the school-age child's and family's needs. The nursing care plan can be used as a guide in planning nursing care for the school-age child with a growth and development concern. The nurse may choose the appropriate nursing diagnoses from Nursing Care Plan 28.1 and individualize them as needed. The nursing care plan is intended to serve as a guide, not to be an all-inclusive growth and development care plan.

Safety Issues for the School-Age Child ºCar safety ºPedestrian safety ºBicycle and sport safety ºFire safety ºWater safety ºAbuse in children Promoting Appropriate Discipline (School-Age Child) ºChildren learn the natural and logical consequences of discipline. ºParents should teach children rules established by the family, values, and social rules of conduct. ºDiscipline should focus on the development of the child. ºParents should discipline with praise.

Peer relationships ºContinuous 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 (Fig. 28.5). ºPeer 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. Peer and peer-group identification are important to the socialization of the school-age child (Feigelman, 2011a).

Teacher and school influences ºSchool 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. ºOften, 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. ºThe parent's attitude and support influences 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.

Television, Video Games, and the Internet ºThe influence of television, video games, and the internet upon the school-age child is a growing concern for parents and child specialists. Children 8 to 10 years of age in the United States spend about 4 hours a day either watching TV or playing video games and another 2 hours on the computer outside of school work (Dowshen, 2011). ºDuring that time, a child by the age of 18 will see 200,000 violent acts (Dowshen, 2011). Although a school-age child can determine what is real from what is fantasy, research has shown that this amount of time in front of a screen—watching it or playing video games—can lead to aggressive behavior, less physical activity, and obesity (Dowshen, 2011) (see Healthy People 2020).

Television, Video Games, and the Internet ºSome 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, and the internet. Parents should set limits on how much screen time the child can have. ºThe AAP recommends 2 hours or less of screen time per day (Dowshen, 2011). The parent should establish guidelines on when the child can watch TV; for example, after homework or when chores are completed (Dowshen, 2011). Television watching, internet activity, or video gaming should not be used as a reward. The parents should be aware of what the child is watching and doing online. ºThis 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. ºThe parents need to set an example for the child by reading instead of watching TV or by doing a physical activity together as a family. If the TV causes fights or arguments, it should be turned off for a period of time.

The Bullying Child ºEducate parents on reasons why it is important to correct the behavior ºDiscuss ways the child can appropriately show his or her anger and feelings ºHave parents help the child to see how it feels to be bullied ºDo not allow fighting at home ºReward settling of conflicts without violence

Tobacco and Alcohol Education ºInquire about tobacco and alcohol use ºDiscuss the physical and social dangers of tobacco and alcohol use ºUrge parents to be good role models ºLimit reading and media materials about alcohol and tobacco use ºDiscuss the influences of tobacco and alcohol use by peers ºEducate the child on spit ºLet them know it is just as dangerous as smoking tobacco ºAdvocate for a smoke-free environment in the home and other places frequented ºAvoid having tobacco and alcohol products readily available in the home

Prepubescence ºThe late school-age years are also referred to as preadolescence (the time between middle childhood and the 13th birthday). During preadolescence, prepubescence occurs. ºPrepubescence 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. ºThere 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.

ºEarly 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. ºEarly 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. Musculoskeletal system: greater coordination and strength; muscle still immature and can easily be injured ºMusculoskeletal 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.

GROSS MOTOR SKILLS ºDuring the school-age years, coordination, balance, and rhythm improve, facilitating the opportunity to ride a two-wheel bike, jump rope, dance, and participate in a variety of other sports (Fig. 28.3). ºOlder school-age children may become awkward due to their bodies growing faster than their ability to compensate. ºSchool-age children between the ages of 6 and 8 enjoy gross motor activities such as bicycling, skating, and swimming. ºThey are enthralled with the world and are in constant motion. Sometimes fear is limited due to the strong impulses of exploration. ºChildren between 8 and 10 years of age are less restless, but their energy level continues to be high with activities more subdued and

ºThese 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. ºBetween the ages of 10 and 12 years (the pubescent years for girls), energy levels remain high but are more controlled and focused. ºPhysical skills in this age group are similar to those of adults, with strength and endurance increasing during adolescence.