CHILD HEALTH NURSING
Theme: Assessment and care of newborn and
infant.
Breastfeeding and weaning. Routine health screenings.
OBJECTIVES
Theoretical Approaches to the Growth and Development of Children
1. Principles of Growth and Development
a. Nature Versus Nurture
b.
Continuity Versus Discontinuity
c.
Passivity Versus Activity
d. Critical
Versus Sensitive Period
e.
Universality Versus Context Specificity
f.
Assumptions about Human Nature
g.
Behavioral Consistency
2. Theories of Human Development
a.
Psychoanalytic Perspective
b. Behavioral
Perspective
c.
Cognitive-Structural Perspective
d.
Contextual Perspective
Growth and Development of the Newborn
1. Identify the adaptive changes that occur
during the transition to extrauterine life.
2. Describe the normal physiological
development of the newborn.
3. Discuss the psychosexual, cognitive, and
psychosocial development of the newborn.
4. Identify and explain aspects of health
promotion and maintenance pertinent to the newborn.
5. Describe family educational needs regarding
health promotion of the newborn.
6. Explain the etiology and treatment of the
high-risk newborn.
7. Discuss the nurse's role in caring for
healthy and high-risk newborns.
Growth and Development of the Infant
1. Discuss physiological growth and
developmental milestones of infants.
2. Discuss the process of infant fine and
gross motor development, including the principles associated with them.
3. Describe infant psychosexual, cognitive, and
psychosocial development.
4. Describe health promotion and maintenance
activities for infants.
5. Discuss caloric and fluid requirements
for infants.
6. Describe play activities of infancy.
7. Discuss educational strategies for caregivers
of infants as related to nutritional needs, growth and development patterns,
stranger and separation anxiety, and safety.
Theoretical
Approaches to the Growth and 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,
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
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.
GROWTH AND DEVELOPMENT OF THE NEWBORN
The
neonatal or newborn period is defined as the first 28 days, or 4 weeks, of
life. This chapter will present the normal changes that occur during the
transition to extrauterine life and the normal physiological,
psychosexual, cognitive, and psychosocial development that occurs during the
newborn period as well as information related to the high-risk newborn. Nursing
care of the normal and high-risk newborn will also be presented.
EXTRAUTERINE TRANSITION
Fetal
circulation is different from neonatal circulation due to structural
differences that include the (1) placenta, (2) umbilical arteries and veins,
(3) ductus venosus, (4)
foramen ovale, and (5) ductus
arteriosus. The placenta provides oxygen and
nutrients for the fetus, and removes carbon dioxide and other waste products.
The umbilical cord connects the fetus to the placenta, and contains two
arteries and one vein. Blood from the placenta flows through
the umbilical vein to the abdominal wall of the fetus. The umbilical
vein then divides into two branches. A small portion of the blood flows through
one branch and to the liver, sinusoids, and hepatic vein before entering the
inferior vena cava. Sixty percent of the blood flows through the ductus venosus (a shunt in the
fetus that carries oxygenated blood from the umbilical veins) and directly
enters the inferior vena cava (Moller & Dwan, 1992a). The blood then enters the right atrium. Most
blood will bypass the fetal lungs via the foramen ovale
(an opening between the right and left atria) and enter the left atrium. From
the left atrium, the blood enters the left ventricle and is pumped into the
aorta to the hypogastric arteries. The small amount
of blood that does pass from the right atrium to the right ventricle will pass
into the pulmonary artery. From the pulmonary artery, a small amount will go to
the nonfunctional lungs into the pulmonary vein, left atrium, left ventricle,
and to the aorta. The remainder of the blood will pass through the ductus arteriosus (channel
between the main pulmonary artery and the aorta) to the aorta. The hypogastric arteries lead to the iliac arteries, which give
rise to the umbilical arteries, which then return the blood to the placenta.
Figure 7-1 represents fetal blood flow.
The
transition to extrauterine life begins with the loss of
the umbilical cord and the initiation of respirations. With the initiation
of respirations, the PaO2 levels are increased, and several changes
occur. Decreased pulmonary vascular resistance results in increased pulmonary
blood flow, causing an increase in the pressure of the left atrium, a
decrease in pressure of the right atrium, and closure of the foramen ovale. The foramen ovale closes
shortly after birth and then undergoes fusion of the tissue margins during
early childhood. Increased PaC>2 levels also lead
to an increase in systemic vascular resistance, a decrease in systemic venous
return, cessation of umbilical venous return, and closure of the ductus venosus. The closure of
the ductus venosus occurs
gradually over a period of about 2 weeks. Since systemic resistance is greater
than pulmonary resistance, a left-to-right shunt occurs within the heart,
resulting in closure of the ductus arteriosus (usually within 24 hours of birth) and gradual
obliteration over the next month (Moller & Dwan, 1992b). Figure 7-2 represents transition to extrauterine life.
The
average period of transition is 6—12 hours, but may be shorter or longer
depending on the neonate's ability to adjust to the stresses of labor,
delivery, and a new environment (Kelly, 1994). Therefore, during this
transition period, the neonate needs to be closely observed for any
difficulties so that appropriate interventions can be offered.
PHYSIOLOGICAL DEVELOPMENT
General Appearance
Most people
visualize a newborn as the baby seen in advertisements (Figure 7-3); however,
the actual appearance may be a surprise to caregivers. The newborn's head,
which is one-quarter of the total body size, may appear out of proportion to
the body and be misshapen due to the labor and delivery process (molding; Figure
7-4). A caput succedaneum may be present as well, especially after a
long labor. A caput is the swelling of the soft tissues of the scalp. The
swelling may extend across the suture lines, is evident within 24 hours after
birth, and usually resolves within a few days. The collection of blood between
the skull bone and the periosteum as a result of the
rupture of blood vessels secondary to head trauma from the birth process
may result in a cephalhematoma. A cephalhematoma develops 24-48 hours after birth and does
not cross the suture lines (Figure 7-5).
A cephalhematoma may take 2—3 weeks to resolve. Reassurance to
the caregivers is needed that many of these characteristics will change
over the future weeks and months and that the newborn will then begin to take
on the appearance of a "normal" baby. Eyelids may be puffy and eye
color indistinguishable. In addition, the newborn has a large, round abdomen
with an umbilical area that may protrude for several weeks until the cord stump
falls off. The caregiver should be instructed on appropriate umbilical cord
care.
The
extremities may appear short in comparison to the body, but hands should be
able to touch the upper thighs when extended. The legs may appear to be bowed
and the newborn typically remains in a position with the extremities flexed.
The skin is delicate, often mottled, or acrocyanosis
may be present. Acrocyanosis is the bluish
discoloration of the hands and feet caused by the instability of the peripheral
circulation system.
Many
caregivers are afraid to touch the baby's head or "soft spot" due to
the fear of causing damage. The soft spots, or fontanels, occur at
junctions or suture lines of the skull bones, allowing for adaptation to the pelvis
shape during delivery and growth of the brain over the coming year (Figure
7-6). The posterior fontanel typically closes by 3 months of age, while the
anterior fontanel closes around 8-18 months of age. Caregivers need reassurance
that many of these characteristics will change during these time periods and
the newborn will then begin to take on the appearance of a "normal"
baby.