Community
and Public Health Nursing
PRACTICUM
HEALTH PROBLEMS OF SCHOOL-AGE
CHILDREN.
HEALTH SERVICES FOR SCHOOL-AGE
CHILDREN AND ADOLESCENTS. ROLE OF THE SCHOOL NURSE.
Upon mastery of this
chapter, you should be able to:
●
Identify major health problems and concerns for
school-age and adolescent populations in the United States.
●
Describe types of programs and services that promote
health and prevent illness and injury of school-age and adolescent
populations.
●
State the recommended immunization schedule for
school-age children and give the rationale for the timing of each immunization.
●
Describe some common roles and functions of school
nurses.
●
Evaluate the potential benefits of school-based health
centers, and discuss possible parental or community objections.
Children and adolescents are important population
groups to community health nurses because their physical and emotional health
is vital to the future of society and because they require guidance and
direction. Mortality rates for children and adolescents have decreased
dramatically since the early 1900s, but morbidity rates remain high. Children
and adolescents are vulnerable to many illnesses, injuries, and emotional
problems, often as a result of a complex and stressful environment. Violence
against children and deaths due to homicide occur in the United States at
alarming rates. Unintentional injuries, suicide, and homicide are the leading
threats to life and health for adolescents. Other health problems include
alcohol and drug abuse, unplanned pregnancies, STDs and HIV/AIDS, and poor
nutrition. All of these problems create major challenges for the community
health nurse who seeks to prevent illness and injury among children and
adolescents and to promote their health. Chronic illnesses such as asthma and
diabetes are important to monitor. Irritating, somewhat common problems, such
as head lice and acne, can respond to treatment and education. Health services
for children and adolescents span three categories: prevention, health
protection, and health promotion. The community health nurse plays a vital role
in each. Preventive services include immunization programs, parental support
services, family planning programs, services for those with STDs, and alcohol and
drug abuse prevention programs. Health protection services include accident and
injury control, programs to reduce environmental hazards, control of infectious
diseases, and services to protect children and adolescents from child abuse and
neglect. Health promotion services include programs in nutrition and weight
control; exercise and physical fitness; smoking, alcohol, and drug abuse
education; and stress control. Schoolbased health centers provide a convenient
place for the provision of primary health care as well as health education and
mental health counseling. The role of school nurses includes three basic
interventions. With educational interventions such as nutrition teaching,
nurses provide information and encourage clients to act responsibly on behalf
of their own health. Nurses employ persuasive tactics to move clients toward
more positive health behaviors by engineering interventions, such as
encouraging consistent use of contraceptives by adolescents. With enforcement
interventions, such as reporting and intervening in child abuse, nurses
practice a form of coercion to protect children from threats to their health.
Nursing of the school-age population involves providing health services and
health education and ensuring a healthful school environment. School nurses may
provide these services as part of their roles within health departments, or
they may be hired by the school district full-time. The increasingly complex
needs of the school-age population and the collective accessibility for delivery
of primary health care services to children in the school setting are prompting
schools to hire nurses with advanced preparation as nurse practitioners and
credentialed school nurses expand their services to this aggregate.
Development
of Children
Understanding human development is an essential
part of the nursing process.
Knowledge of normal behavior for specific age
groups allows for individualizing assessments and care plans. Emphasis on
promoting and maintaining health, anticipatory guidance related to human
development, and assisting children and families to achieve optimal development
are all important aspects of pediatric nursing. Knowledge of several
principles, issues, and theories help us to understand holistic optimal
development and care. This chapter will describe the various principles and
issues that are interwoven within the major developmental theories discussed.
Each theoiy will be fully explained and analyzed. The discussion will also
include ideas on how the nurse can apply the theories to practice.
GROWTH,
MATURATION, AND DEVELOPMENT
Growth, maturation, and
development are common terms used to describe human development. An explanation
of these terms and of the age ranges associated with child development is
needed before principles, issues, and theories can be understood. Growth refers
to a physiologic increase in size through cell multiplication or
differentiation. This is most obviously seen in weight and height changes
occurring during the first year of life. Maturation refers to changes
that are due to genetic inheritance rather than life experiences, illness, or
injury.
These changes allow children
to function at increasingly higher and more sophisticated levels as they get
older. Development refers to the physiological, psychosocial, and
cognitive changes occurring over one's life span due to growth, maturation, and
learning, and assumes that orderly and specific situations lead to new
activities and behavior patterns (Figure 1).
Figure 1 (A)
Toddlers are developing their gross motor skills. (B) School-aged children
often become involved in physical activities and team sports.
The five stages and age ranges
of human development relating specifically to pediatric nursing are
found in Table 1.
Table 1. Stages, Age Ranges, and Characteristics of
Human Development
Related to
Pediatric Nursing
Principles of Growth and
Development
At least eight principles providing a framework
for studying human development are embedded within the issues and theories
discussed in the following pages. Although not all of these principles are
proven by research, they are often observed in children and generally assumed
to be true (Hetherington & Parke, 1993; Murray & Zentner, 2001).
1. Development is orderly
and sequential. This principle suggests that maturation follows a
predictable and universal timetable. For example, children learn to crawl
before they learn to walk, and they learn to walk before they learn to run.
These changes occur rapidly during the first year of life and slow during
middle and late childhood. Even though the onset and length of each
developmental change vary among children, the basic sequence is the same,
allowing comparison to norms.
2. Development is
directional. Skill development proceeds along two different pathways:
cephalocaudal and proximodistal. Cephalocaudal development proceeds from
the head downward. Therefore, areas closest to the brain or head develop first,
followed by the trunk, then legs and feet. For example, head control is
followed by sitting, then crawling, and then walking. Proximodistal development
proceeds from the inside out. Controlled movements closest to the body's center
(trunk, arms) develop before controlled movements distant to the body (fingers).
For example, grasping changes from using the entire hand to just the fingers as
infants get older.
3. Development is unique
for each child. Ever)' child has a unique timetable for physiological,
psychosocial, cognitive, and moral development. For example, some children can
name four colors by the time the y are 3 years old, whereas others cannot name
four colors until they are 4V2 years old. Some children walk well at 11 months;
others do not walk well until they are 14 months old.
4. Development is
interrelated. Physiological, psychosocial, cognitive, and moral aspects of
development affect and are affected by one another. For example, central
nervous system maturation is necessary for cognitive development. Children
cannot be independent in toileting if they are not aware of the urge to void
and cannot independently remove clothing.
5. Development becomes
increasingly differentiated. This means responses become more specific and
skillful as the child grows. Young infants respond to stimuli in a generalized
way involving the entire body, whereas older children respond to specific
stimuli in a more refined and specialized way. For example, infants will react
with their entire body to pain by crying and withdrawing, whereas a child is
able to localize the pain, can often identify its source, and may only withdraw
the extremity experiencing the pain. An infant will use the entire hand to grab
a toy before developing the fine motor ability necessary for the pincer grasp.
6. Development becomes
increasingly integrated and complex. This means, as new skills are gained,
more complex tasks are learned. For example, learning to drink from a cup
initially requires eye-hand coordination, then grasping, and then hand-mouth
coordination. Infants' cooing is followed by babbling, before these sounds are
refined into the understandable speech of a child.
7. Children are competent. They
possess qualities and abilities ensuring their survival and promoting their
development. For example, newborns can cough, sneeze, suck, swallow, digest,
breathe, and elicit caretaking responses from adults. Children make their needs
known to caregivers in increasingly sophisticated ways so that others know if
they are cold, hungry, or in pain.
8. New skills predominate. This occurs because of the
strong drive to practice and perfect new abilities, especially early in life,
when the child is not capable of coping well with several new skills
simultaneously. For example, when children are learning to walk, talk, or feed
themselves with utensils, their attention and effort is focused on developing
that one skill; they do not usually learn to walk, talk, and feed themselves at
the same time.
Issues
of Human Development
Theories on growth and development are often considered
from the perspective of seven issues. These issues help explain how development
occurs and what humans are like and can be applied to theories of human
development. These issues answer questions related to the importance of biology
or the environment on development, whether children are inherently good, bad,
or actively involved in their own development, if development occurs gradually
or abruptly, if children are more similar than different from one another, or
if one's personality or way of interacting with others remains stable
throughout life. The issues discussed include nature versus nurture, continuity
versus discontinuity, passivity versus activity, critical versus sensitive
periods, universality versus context specificity, assumptions about human
nature, and behavioral consistency.
Nature versus
Nurture
One of the more important and
oldest issues discussed in human development is the nature/nurture controversy.
This debate concerns the influence that biology (nature) and the environment (nurture)
have on an individual. Nature describes genetically inherited traits
such as eye color or body type, or disease such as cystic fibrosis or
hemophilia. This view sees development as predetermined by genetic factors and
not altered by the environment. A person believing in the principle of nature
would suggest that all normal children achieve identical developmental
milestones at a similar time due to maturational forces. If children differed
in achieving these milestones, it would be because of differences in their
genetic makeup. Nurture refers to the influences that the environment
has on development, and includes the influences that child-rearing methods,
culture, learning experiences, and society have on development. A person
believing in the principle of nurture would suggest that development can take
different paths depending on the experiences that an individual has over a
lifetime.
Today, most developmentalists
believe that both nature and nurture are important, and that the relative
contribution of each depends on the aspect of development studied.
Developmentalists today are also more concerned about how biological and
environmental factors interact to produce developmental differences and
changes, rather than the importance of one over the other .
Continuity
versus Discontinuity
This issue addresses the
nature of change across development. Continuity suggests that change is
orderly and built upon earlier experiences. Development is a gradual and smooth
process without abrupt shifts; the course of development looks like a smooth
growth curve. This issue also suggests early and late development are
connected; aggressive toddlers become aggressive adults, curious infants become
creative adolescents, and shy preschoolers become introverted adults. Finally,
continuity proposes that changes occur quantitatively, or in degrees. For
example, when children grow older, they become taller, run faster, and learn
more about the world around them.
Discontinuity
suggests development is a series of discrete steps or
stages that elevate the child to a more advanced or higher level of functioning
with increased age. The course of development looks like a flight of stairs.
There is no connection between early and later development; behavior seen later
in life has replaced behavior seen earlier in life. For example, infants once
comfortable around strangers may come to fear them as they get older; a shy and
introverted preschooler may become an outgoing, extroverted adolescent.
Discontinuity would also argue that adult behavior cannot be predicted by
knowing what the person was like as a child. Finally, discontinuity implies
qualitative change, or changes that make the individual different as growth
occurs, as when a nonverbal infant becomes a toddler using language, or when a
prepubertal child becomes a mature adolescent.
Passivity
versus Activity
This issue views the child as
either a passive recipient shaped by external environmental forces, or as
internally driven and actively participating in development. The passive view
suggests that child-rearing beliefs, practices, and behaviors cause children to
be either shy or assertive. Children become delinquent because of their
association with an antisocial peer group. Talented and creative teachers
deserve credit for a child's interest in mathematics or literature. Those
disagreeing with this view believe children purposefully, creatively, and
actively seek experiences to control, direct, and shape their development.
Active children also modify caregiver, peer, and teacher behavior (Figure 2).
Figure 2 Active
children are interested in learning about other children's projects and art
work.
For example, an inquisitive,
friendly child may encourage that same behavior in an otherwise indifferent or
unfriendly peer or adult.
Critical
versus Sensitive Period
This issue concerns the
importance of different time periods in development, and asks if some phases
are more important than others in developing particular abilities, knowledge,
or skills. The critical period refers to a limited time span when a
child is biologically prepared to acquire certain behaviors, but needs the
support of a suitably stimulating environment. Indeed, there are some periods
during development when children need to experience certain sensory and social
input if their development is to proceed normally. The first 3 years of life
are important for developing language, social, and emotional responsiveness. If
there is little or no opportunity for these experiences during this time,
children may have difficulty learning language, developing close friendships,
or having an intimate emotional relationship later in life.
The sensitive period, on
the other hand, is a time span that is optimal for certain capacities to emerge
when the individual is especially receptive to environmental influences
(Bornstein, 1989). Supporters of this view believe some behaviors can be
modified during early development. For example, infants reared in an
impoverished orphanage grew up without identifiable intellectual deficits if they
were placed in a stimulating and nurturing adoptive home (Skeels, 1966). The
fact that early experiences can be modified suggests humans are malleable and
adaptable and, for some areas of development, there are sensitive rather than
critical periods.
Universality versus Context Specificity
The importance of culture to development is
embedded within this issue. Some theorists believe an individual's culture has
a profound influence on development. Others suggest there are culture-free laws
of development that apply to all children in all cultures. For example,
universality would say humans follow similar developmental pathways regardless
of their culture: language is acquired and used at 11-14 months of age,
cognitive changes preparing children for school or higher learning occur during
5-7 years of age, and sexual maturity is reached during the preteen or teenage
years. Context specificity on the other hand, would suggest there are differences
in children related to cultural values, beliefs, and experiences. For example,
some societies encourage early walking by providing opportunities to exercise
and practice these new skills, whereas in other societies carrying or swaddling
infants is the norm, thereby reducing the chance of walking until older.
Assumptions
about Human Nature
The doctrine of original sin used by
Thomas Hobbes (1588-1679) to describe a child's nature, suggests children are
inherently evil and selfish egotists who must be controlled by society. The
doctrine of innate purity, proposed by Jean Jaques Rousseau (1712-1778),
suggests children are inherently good and born without an intuitive sense of
what is right and wrong. The doctrine of tabula rasa, proposed by John
Locke (1632-1704), suggests children are neither good nor evil, but rather
enter the world as a blank slate without inborn tendencies, and are molded
through life experiences. These assumptions are based on 17th and 18th century
social philosophers and rarely addressed directly in theories of human
development today. However, emphasis on positive or negative aspects of a
child's character and a particular theorist's belief reflect an individual's
orientation and assumptions about human nature. For example, if one believes
children are inherently caring and helpful, or on the other hand, innately
selfish, child-rearing practices would vary. Permissive parents may believe
children should be allowed to develop without interference (innate purity),
whereas authoritarian parents may take an approach that would combat and
control their child's selfish and aggressive impulses so they would develop
positive behaviors.
Behavioral
Consistency
This issue addresses whether or not a child's
basic behavioral traits change according to the setting (school, neighborhood,
family). Some theorists suggest individual personality characteristics and
predispositions cause children to behave similarly no matter the setting.
Others suggest children's behavior changes from one setting to another. Those
supporting the former view would say a particular child can always be described
as honest, helpful, aggressive, or independent, no matter the situation. The
latter view would argue children's behavior shifts according to the situation
and who/what is present—friend in need, angry caregiver or teacher, competitive
game, or a difficult test.
THEORIES OF HUMAN
DEVELOPMENT
The following theoretical views present various ways
of examining human development during childhood and adolescence (Figure 3).
Figure 3. The
Eclectic Nature of Human Development
Freud
and Psychosexual Development
Sigmond
Freud (1856-1939), a Viennese physician, originated the psychosexual theory
emphasizing the importance of unconscious motivation and early childhood
experiences in influencing behavior, and describing concepts related to
personality and stages of development (Freud, 1933). His ideas, considered
radical when proposed early in the twentieth century, became popular in the
United States during the 1930s and continue to influence thinking about human
development today.
Central to Freudian theory is the notion that two
basic biological instincts (life and death) motivate behavior, must be satisfied,
and compete for supremacy (Freud, 1933). The life instinct aims for survival
and is responsible for such life sustaining activities as eating, breathing,
copulation, and behavior that expresses self preservation, love, and
constructive conduct. The death instinct on the other hand, is a destructive
force expressed by self centered and cruel behavior, hate, aggression, and
destructive conduct. These instincts, the source of psychic energy that drives
human behavior, have three components: id, ego, and superego. As the child
matures, these components of personality become more rational and reality bound
(Freud, 1933).
During infancy, all psychic energy resides in the id,
the inborn element of personality that is driven by selfish urges. The id
obeys the "pleasure principle," oriented toward maximizing pleasure
and immediately satisfying needs, even when biologic needs cannot be
appropriately or realistically met. The id is manifest as the irrational,
selfish, impulsive part of personality (Freud, 1933).
As the infant develops, the ego or rational and
controlling part of the personality emerges. The ego operates according to the
"reality principle" as realistic ways of gratifying instinctual
drives are discovered. Ego functions allow individuals to be successful and
include memory, cognition, intelligence, problem solving, compromising,
separating reality from fantasy, and incorporating experiences and learning
into future behavior. Ego development continues during childhood and throughout
the life span (Freud, 1933).
The third component of personality is the superego or
conscience, which emerges when the child internalizes caregiver or societal
values, roles, and morals. Superego development begins in infancy, and becomes
apparent in the preschool and school-aged years when the child learns socially
acceptable behavior. The superego strives for perfection rather than for
pleasure or reality. After the superego emerges, children have a conscience
that tells them the difference between right and wrong, and which behaviors are
socially acceptable outlets for the id's undesirable impulses. The superego
also serves as a disciplinarian by creating feelings of remorse and guilt for
transgressing rules, and self praise and pride for adhering to rules (Freud, 1933).
Conflict among the id, ego, and superego is inevitable
throughout life. Mature, healthy personalities, however, are in a dynamic
balance, with the id communicating its basic needs, the ego restraining the id
until realistic ways are found to satisfy these needs, and the superego
determining whether or not the ego's problem-solving strategies are morally
acceptable. Freud believed defense mechanisms, such as regression,
displacement, projection, and sublimation were created as escape valves to
repress painful experiences or threatening thoughts coming from the id's
unsatisfied needs that were not managed by the ego or superego (Freud, 1933).
To Freud, the most important life instinct was the sex
instinct, which changed its character and focus according to biological
maturation. (Freud's concept of sex and sexuality was broader than what is
implied in the use of these words today, and indicates sexuality in its genital
manifestations as well as any kind of pleasure seeking.) As the sex instinct's
psychic energy (libido) shifts from one part of the body to another, the
child passes through five stages of development: oral, anal, phallic, latency,
and genital (Table 2). Each stage is related to a specific body part (erogenous
zone) that brings primary pleasure to the child during that stage. According to
Freud, adult personality is profoundly impacted by how each stage is managed.
Table 2. Stages of Freud's Psychosexual
Development
Application
Freud provides insight into human
actions, and helps us understand others by realizing all behavior is meaningful
and may hide inner needs or conflicts. Therefore, it is especially important to
teach this information as well as normal behavior for the various stages to
parents. Since during infancy comfort and pleasure are obtained through the
mouth, it is important to offer babies a pacifier if they are NPO, or a bottle,
pacifiers, or the breast after painful procedures. When hungry, they should be
promptly fed (if not NPO). Providing plastic or rubber rings or other toys
suitable for teething infants are also appropriate.
Toddlers are gratified by
controlling body excretions. Therefore, when caring for children between 1 and
3 years of age, asking about the status of toileting and words and rituals used
for elimination is important. It is wise to provide a child-sized potty chair
and avoid starting toilet training during periods of illness or stress. In
addition, toddlers should be reprimanded carefully if toilet training is
difficult or if the child has accidents. Finally, parents need to be flexible
and patient in toilet training and begin when the toddler indicates readiness.
Preschool children are
concerned about sexuality and initially identify with the parent of the
opposite gender. Nurses should teach parents that curiosity about gender
differences and masturbation is normal. In addition, nurses should be aware of
preschoolers who appear more comfortable with a particular nurse (no matter the
gender), attempt to accommodate that situation, and encourage parents to
participate in the care of their child. School-aged children and adolescents
should be encouraged to have contact with friends, and their questions answered
honestly. Privacy for both school age and adolescent clients should be ensured
during physical examinations or when they are changing clothes or showering in
gym class.
Erikson and Psychosocial Development
Erik Erikson (1902-1994)
acknowledged the contribution of biologic factors to development, but felt that
the environment, culture, and society were also important. His psychosocial (epigenetic)
theory of development stresses the complexity of interrelationships
existing between emotional and physical variables during one's lifetime
(Erikson, 1963).
Erikson agreed with many of
Freud's ideas regarding basic instincts and the three components of personality
(id, ego, superego). In addition, he believed development was stagelike, and
conflict resolution was necessary at each stage in order for the individual to
successfully advance to the next stage. In fact, Erikson's first five stages of
development and the approximate ages of each stage correspond closely with
those outlined by Freud (Table 3). Erikson differs from Freud, however, in that
he believes children actively adapt and explore their environment instead of
being passively controlled and molded by caregivers and society. Erikson also
assumes humans are rational creatures whose actions, feelings, and thoughts are
controlled primarily by the ego instead of the id, superego, or conflicts
between the three components of personality.
Table 3. Comparison of Stage Theories of Human
Development
For Erikson, lifespan
development consisted of eight sequential stages. Five of these stages describe
infants through adolescents (Table 4). Each stage is dominated by major
developmental conflicts or crises related to societal demands and expectations
that must be addressed or resolved before the individual can progress to the
next stage.
Table 4. Stages of Erikson's Psychosocial Theory of
Development
The resolution of each
conflict or crisis might be positive (favorable and growth enhancing), or
negative (unfavorable, frustrating, and making later development difficult).
Erikson believed major conflicts occurring during each stage are rarely
completely resolved. Instead, they are of primary or dominant importance during
a particular stage and then become less important or dominant as other
conflicts arise in later stages. In addition, he suggests conflict is rarely
completely resolved positively. Rather, the positive resolution predominates
over the negative resolution during a particular stage. Failure to successfully
master a crisis or developmental task does not destine the child to failure
since delayed mastery is possible. It is true, however, that difficulty at one
stage may affect progress through later stages (Erickson, 1963).
Application
Erikson's theory provides us
with a means of assessing and gaining insight into five developmental crises children
and adolescents face, and allows us to use this knowledge to teach caregivers
behaviors they can expect to see in their children. It also helps us realize
the importance of societal influences on health and behavior, and that
psychosocial development is a lifelong process. Erikson's theory is easy to
apply to practice. Health care provides a variety of situations and
opportunities where a child's progression through stages can be facilitated,
and caregivers taught how to encourage positive resolution of each
developmental crisis. Since meeting basic needs (feeding, bathing, changing) in
a timely and appropriate fashion during infancy results in the development of
trust, it is critical that feeding and hygiene needs be met promptly. When an
infant is ill, parents should be encouraged to spend as much time as possible
with their infant.
Figure 4. Letting toddlers feed themselves is important.
For toddlers, independence is
increasing and self control gained by maintaining familiar daily routines.
Allowing opportunities for the child to independently dress, feed, and do
self-hygiene care is important (Figure 4). If restraint for procedures or treatments is necessary,
explanations and comfort should be provided and caregivers encouraged to
participate. Love, approval, and praise are important for toddlers and children
in all stages.
Preschoolers like to initiate
activities and remain curious and interested in the world around them.
Opportunities to explore, ask questions, and create should be provided. Nurses
should accept children's choices and negative expression of feelings, answer
their questions, and allow them to play with medical equipment so their
curiosity is satisfied and their knowledge about experiences broadened.
For school-aged children,
involvement and success in a variety of activities provide a sense of
self-worth and value. Nurses should provide the school-aged child with
opportunities for continuing school work if hospitalized or ill, maintaining
hobbies or activities, interacting with their peers, and adjusting to
limitations imposed by illness or hospitalization.
Primary care nurses need to be
in touch with school nurses when a child with a chronic condition is
hospitalized and when this child is ready to return home and to school.
Adolescents are searching for
who they will become independent from their parents. Nurses should allow
adolescent clients to be as autonomous as possible, encourage them to take
responsibility for their own actions, support their life choices, introduce
them to other teens, and provide them with a separate recreation or activity
area if in an acute care setting. Parental involvement in the care of
adolescents is still important.
Sullivan
and Interpersonal Development
Harry Stack Sullivan
(1892-1949) focused on interpersonal relations as important behavioral
motivators and the source of psychological health. His interpersonal theory posits
that the self concept is the key to personality development.
He acknowledged the importance
of the environment (especially the home), and also emphasized the role of
social approval and disapproval in forming a child's self concept. Sullivan
believed personality development was largely the result of childhood
experiences, interpersonal encounters, and the mother-child relationship. How
well physiological needs were met in an interpersonal situation affected not
only one's sense of satisfaction and security, but also allowed anxiety to be
avoided. Poor environmental interactions caused anxiety and tension; a positive
social relationship resulted in security, a major life goal (Sullivan, 1953).
Stages of
Interpersonal Development
Sullivan describes seven
stages of interpersonal development (Sullivan, 1953); six relate specifically
to infants through adolescents (Table 5). Sullivan believed each stage prepared
the personality for the next stage and failure to successfully achieve stage activities limited
personality development and opportunities for a successful life. Refer to Table 3 for a comparison of
Sullivan's first six stages with Freud's and Erikson's stages.
Table 5. Stages of Sullivan's Interpersonal Theory of
Development
Application
Sullivan also has relevance to
the nursing care of children. Perhaps the two most important points he
made is to emphasize the significance of interpersonal relations with others on
personality development, and meeting the child's basic needs in a timely and
appropriate fashion. This does not mean, however, that caregivers protect
children from all discomforts or meet needs before they are expressed. The key
is to relieve unpleasant feelings associated with basic needs so feelings of
security and attachment result in a "good me" rather than a "bad
me." Sullivan also has helped us realize the important place chums have in
a school-aged child's life, and how this experience is critical for developing
interpersonal relationships later in life.
Behavioral Perspective
The behavioral perspective posits
that human actions and interactions come from learned responses to environmental
stimuli. Behavioral theorists study human behavior in a laboratory setting and
then apply this information to the general population, and look for ways to
alter or control the environment to change, modify, or teach desired behaviors.
Pavlov
and Classical Conditioning
Ivan Pavlov (1849-1936), a
Russian physiologist, initially discovered linkages between a stimulus and a
response while studying a dogs response to food. He learned a dog would respond
(salivate) not only when he saw food (unconditioned stimulus), but also when he
saw the person who fed him or heard a bell ring just before the food appeared
(conditioned stimulus), because the dog had learned that the bell or appearance
of the man meant food would follow. This learning to respond to a new stimulus
the same way a familiar stimulus was responded to is called classical
conditioning, and suggests learning occurs when a response that is already
part of the organism s normal activities (salivating) can be reproduced by an
associated stimulus that previously would not have produced it—for example, the
presence of a person or the sound of a bell (Crain, 2000; Murray & Zentner,
2001). Another example of classical conditioning would be when an infant,
seeing the spoon used for feeding, becomes excited (waving hands and arms,
kicking legs, making babbling sounds) because the spoon is associated with
being fed and the infant knows that feeding time is coming soon.
Skinner
and Operant Conditioning
Operant conditioning, a term originated by B. F.
Skinner (1904-1990), involves behavioral changes due to either negative
(punishment) or positive (reinforcers) consequences rather than just the
occurrence of a stimuli. If behavior is rewarded, the likelihood of it
reoccurring increases; if behavior is punished, chances are it will not
reoccur. Positive reinforcement includes friendly smiles, praise, or special
treats/privileges; punishment includes criticism, a frown, or withdrawal of privileges.
Skinner discovered behavioral change became more permanent when consequences
were provided intermittently rather than continuously, and believed the essence
of development involved constantly acquiring new behaviors or habits due to
reinforcing or punishing stimuli. He emphasized why behaviors occur rather than
simply describing the behavior seen (Skinner, 1953).
Bandura
and Social Learning
A third kind of behaviorism is social learning,
proposed by Albert Bandura (b. 1925). According to this view, children learn by
imitating and observing others (a model), as well as by classical and operant
conditioning. Social learning theorists also believe behavior is influenced by
the environment and learned through various experiences. However, they do not
believe behavioral change is a mindless response to stimuli. Rather, they
suggest personality, past experiences, relationships with the model, the
situation itself, and cognition also impact behavioral change (Bandura, 1977).
Cognition plays a part because to successfully imitate behavior, a child must
be capable of remembering, rehearsing, and organizing the behavior seen.
Children often will think about connections between behavior and consequences
and will likely be affected more by what they believe will be the consequences
rather than what the consequences actually are. For example, learning to play a
musical instrument is expensive for families, and demanding and time consuming
for children. However, children and their parents continually tolerate the cost
and inconvenience because they are anticipating rewards once the child learns
to play the instrument.
Bandura also believes modeled behavior can be
weakened or strengthened depending on whether it is punished or rewarded.
Bandura suggests observational learning (learning that results from merely
watching others), where children acquire a variety of new behaviors when
"models" are merely pursuing their own interests and not attempting
to teach, reward, or punish, is another important method of learning behaviors.
For example, research has shown children who watch television violence
frequently are more aggressive than those children who do not watch very much
television violence (Murray & Zentner, 2001). Finally, Bandura found
children tend to model behavior of children and adults of their same gender
more often than not, and males model behavior of others more often than females
do.
Application
Although behaviorism has been criticized for
denying the inherent capabilities of persons to willfully respond to
environmental situations and its relative elementary nature, it is useful in
health care. Positive behaviors can be reinforced by encouragement, praise, and
other rewards, and behaviors needing to be altered or removed from a child's
repertoire can be extinguished by either ignoring or punishing. Parents
commonly use these concepts when toilet training or teaching their children
cooperation, compromise, helpfulness, and empathy. Some academic and preschool
programs and parents use behavior modification and time-out activities to
modify and change undesirable behavior in children. Operant conditioning can
also help plan new or extinguish undesirable behavior by providing specific
guidelines, determining available reinforcers, identifying responses acceptable
for reinforcement, and planning how reinforcers will be scheduled so behavior
is repeated.
Social learning theory is also readily applicable
to health care. Children often will cooperate with procedures (blood draws, X rays)
if they see other children or adults they emulate cooperating for the same
procedure. Nurses can help parents realize that their appearance and behavior
is often imitated by their children, and determine who might be significant
role models for their children to emulate. Finally, nurses need to demonstrate
nurturing approaches or discipline methods so parents learn effective parenting
practices.
