Community and Public Health Nursing

PRACTICUM

HEALTH PROBLEMS OF ADOLESCENTS.

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.

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.