Early Childhood 1 Through 4 Years

Physical Development. After

1 year of age, the rate of physical growth slows to half that of infancy. After age 2 years, toddlers gain about 2 to 3 kg and grow 5 cm per year. Growth can proceed in spurts. Physical changes are impressive, and during a few short years, children are transformed from chubby, clumsy toddlers into leaner, more muscular preschoolers. Even more significant are the changes in motor and cognitive development.

Gross motor skills develop quickly during this period. Most children walk by 15 months, run well by

2 years, and pedal a tricycle and jump around by 3 years. These new skills make the world a dangerous place for toddlers and pose inherent challenges during your examination. Fine motor skills develop through neurologic maturation and experience with manipulation of the environment. The 18-month-old who scribbles fleetingly, develops into a 2-year-old who imitates lines, and a 4-year-old who draws and copies circles.

Children are the keys of paradise.

—Richard Stoddard

Cognitive and Language Development. Intellectually, a toddler makes the transition from learning about the environment through touching and looking (sensorimotor learning), to symbolic thinking, simple problem-solving, remembering songs, and imitating through play. Take advantage of these changes by making your examination seem like you are playing.

Language develops at extraordinary speed. An 18-month-old with 10 to 20 words emerges as a 2-year-old with two- to three-word sentences, and then a 3-year-old who converses well, asks "why" repeatedly, and entertains you with songs and often uproariously illogical symbolic stories. By 4 years of age, preschoolers form complex sentences. Recall that these ambitious and creative youngsters are still preoperational in thinking and lack sustained logical thought processes.

Social and Emotional Development. The toddler's march to new intellectual pursuits is only surpassed by a new drive for independence. Expect a struggle during parts of your examination. Because toddlers are impulsive, temper tantrums are common. Don't get into a battle of wills with a 2-year-old! Also, don't ask a toddler "May I listen to your chest?" After all, what will you do when the toddler emphatically says "No!"? Just tell the toddler gently what you will do. Note interactions between toddlers and caregivers, assessing both strengths and areas of concern.

Dresses self Plays games

Copies figures Defines words Some numbers

Skips and balances Imaginative well Sings, talks about experiences

Feeds self

Speech all understandable

Sentences Imitates activities

Balances on each foot Hops, pedals tricycle


Plays simple games

(peek-a-boo) Two or three Jumps in place ,

Balances on one foot

Cognitive/Language .. .

g g g three words Throws

Physical/Motor Walks

1 yr

2 yr

3 yr

4 yr

5 yr

H Middle Childhood: 5 Through 10 Years_

Despite Freud's viewpoint, the middle childhood years are certainly not latent. Rather, this period is marked by goal-directed exploration of the world, increasing physical and cognitive abilities and achievements, and trials and errors. The physical examination is more straightforward in this age group, but keep in mind the developmental stages and tasks facing these school-age children.

Physical Development. Physically, children in this age group grow steadily but at a slower rate than during the preschool and adolescent periods. Nevertheless, you will see major improvements in strength and coordination, leading to increasing participation in activities. This is also a time when children with physical disabilities or chronic illnesses begin to face their limitations.

Cognitive and Language Development. Children become "concrete operational"—capable of limited logical thinking and increasingly complicated learning, yet still rooted in the present, with little ability to understand consequences or abstract issues. A tremendous amount of learning from school and family takes place, and this is greatly influenced by environmental factors. A major developmental task is the achievement of self-efficacy, or the knowledge and ability to thrive in different situations. Moral development remains simple, with a clear sense of "right and wrong." Language becomes increasingly complex during this age period.

You know children are growing up when they start asking questions that have answers. —-John Plomp

Social and Emotional Development. School-age children become progressively more independent, initiating their own activities and enjoying their own accomplishments. This is a period of achievements and a crit-

Middle Childhood

Developmental Task


Health Care Needs


Enhanced strength and coordination Competence on a variety of tasks and activities

Screening for strengths, assessing problems Involvement of parents in competence Support for disabilities or problems Anticipatory guidance about safety


"Concrete operational":

focus on the present Achievement of knowledge and skills, self-efficacy

Emphasis on short-term consequences Support; screening about skills


Achieving good "fit" with family, friends, school Sustained self-esteem Reconciling individuality with conformity Evolving self-identity

Assessment, support, advice about interactions Support

Confidentiality, understanding, advice Understanding, support

ical time for developing self-esteem and an appropriate "fit" within the child's major social structures—the family, the school, and peer activity groups. Guilt and poor self-esteem can also appear. The child's family and environment are crucial to the achievement of a positive self-image. Moral and value systems mature, though they remain relatively simple and concrete.

H Adolescence: 11 Through 20 Years_

Adolescence can be divided into three stages: early, middle, and late, as shown in the table on p. 633. You need to understand the physical, cognitive, and social/emotional stage of each adolescent, because your interview and examination techniques will vary widely depending on the adolescent's level of development.

Physical Development. Adolescence is the period of transition from childhood to adulthood. The physical transformation generally occurs over a period of years, beginning at an average age of 10 in girls and 11 in boys. On average, girls end pubertal development with a growth spurt by age 14 and boys by age 16. The age of onset and duration of puberty varies widely, although the stages are predictable. Early adolescents are preoccupied with these physical changes.

A boy becomes an adult three years before his parents think he does, and about two years after he thinks he does.

Cognitive Development. Although not as obvious, cognitive changes during adolescence are as dramatic as changes in physique. Most adolescents progress from concrete to formal operational thinking, acquiring an ability to reason logically and abstractly and to consider future implications of current actions. Although the interview and examination resemble those of adults, keep in mind the wide variability in cognitive development of adolescents and their often erratic and still limited ability to see beyond simple solutions. Moral thinking becomes sophisticated, with lots of time spent debating issues.

Social and Emotional Development. Adolescence is a tumultuous time, marked by the transition from family-dominated influences to increasing autonomy and peer influence. The struggle for identity, independence, and eventually intimacy leads to much stress, many health-related problems, and, often, high-risk behaviors. This struggle also provides you with an important opportunity for health promotion.


Developmental Task


Health Care Needs

Early Adolescence (10-14-year-olds)


Puberty (F: 10-14; M: 11-16) variable

Confidentiality; privacy


"Concrete operational": focus on the present

Emphasis on immediate consequences


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