1. Toddler (1-3 years)
    1. Erikson’s theory of personality development
      1. Central task: autonomy vs. shame and doubt; central persons: parents
      2. Behavioral indicators
        1. Does not separate easily from parents.
        2. Negativistic.
        3. Prefers rituals and routine activities.
        4. Active physical explorer of environment.
        5. Begins attempts at self-assertion.
        6. Easily frustrated by limits.
        7. Temper tantrums.
        8. May have favorite “security object.”
        9. Uses “mine” for everything - does not understand concept of sharing.
      3. Parental guidance/teaching
        1. Avoid periods of prolonged separation if possible.
        2. Avoid constantly saying “no” to toddler.
        3. Avoid “yes/no” questions.
        4. Stress that child may use “no” even when he or she means “yes.”
        5. Establish and maintain rituals, e.g., toilet training, going to sleep.
        6. Offer opportunities for play, with supervision.
        7. Allow child to feed self.
        8. Offer only allowable choices.
        9. Best method to handle temper tantrums: ignore them.
        10. Keep security object with child, if so desired.
        11. Do not force toddler “to share.”
    2. Physical growth (by 3 years)
      1. Height
        1. Slow, steady growth at 2-4 inches per year, mainly in legs rather than trunk.
        2. Adult height is roughly twice child’s height at 2 years of age.
      2. Weight
        1. Slow, steady growth at 4-6 Ib/year.
        2. Birth weight quadruples by 2.5 years of age.
      3. Vital signs
      4. Cardiac system
        1. Heart begins to function more efficiently.
        2. Decreased heart rate, slight increase in blood pressure from infant values.
      5. Pulmonary system
        1. Mainly abdominal breathing.
        2. Lumina of bronchial vessels in size —> decrease in lower respiratory system infections.
        3. Decreased respiratory rate from infant values.
      6. Gastrointestinal system
        1. Increased capacity —> three meals a day feeding schedule.
        2. Gastric juices increase in acidity —> decrease in GI infections.
        3. Possible voluntary control of anal sphincter.
      7. Genitourinary system
        1. Bladder capacity increases; to determine bladder capacity in ounces, add 2 to the child’s age (e.g., 2-year-old has a bladder capacity of 4 oz or 120 mL).
        2. Ability to “hold” urine increases.
        3. Possible voluntary control of urethral sphincter.
      8. Immune system
        1. Possible immunity from intrauterine life/maternal transfer disappears.
        2. Gradual increase in IgA, IgD, and IgE antibodies.
      9. Neurological system
        1. Anterior fontanel closed by 18 months.
        2. Brain increases to 90% of adult size.
        3. Progressive increase in intelligence.
        4. Myelinization of spinal cord is complete.
      10. Sensory system
        1. Hearing evidences basic auditory skills.
        2. Vision shows evidence of convergence and accommodation; full binocular vision developed; visual acuity: 20/40.
      11. Teething
        1. Introduce tooth brushing as a “ritual.”
        2. By 30 months: all 20 primary teeth present.
        3. First dental checkup should be between 12 and 18 months.
      12. Musculoskeletal system
        1. Lordosis: abdomen protrudes.
        2. Walks like a duck: wide-based gait, side-to-side.
    3. DDST
      1. 12-18 months
        1. Personal-social
          1. Imitates housework.
          2. Uses spoon, spilling little.
          3. Removes own clothes.
          4. Drinks from cup.
          5. Feeds doll.
        2. Fine motor-adaptive
          1. Scribbles spontaneously.
          2. Builds tower with two to four cubes.
        3. Language
          1. Three to six words other than mama, dada.
          2. Points to at least one named body part.
        4. Gross motor
          1. Kicks ball forward.
          2. Walks up steps.
      2. 19-24 months
        1. Personal-social
          1. Puts on clothing.
          2. Washes and dries hands.
          3. Brushes teeth with help.
        2. Fine motor-adaptive
          1. Builds tower with four to six cubes.
          2. Imitates vertical line.
        3. Language
          1. Combines two or three words.
          2. Speech partially understandable.
          3. Names picture.
        4. Gross motor
          1. Throws ball overhand.
          2. Jumps in place.
      3. 2-3 years
        1. Personal-social
          1. Puts on T-shirt.
          2. Can name a friend.
        2. Fine motor-adaptive
          1. Thumb wiggles.
          2. Builds tower of eight cubes.
        3. Language
          1. Knows two verbs and two adjectives.
          2. Names one color.
        4. Gross motor
          1. Balances on one foot briefly.
          2. Pedals tricycle.
    4. Nursing interventions/parental guidance:
      1. Play: toddler years - generally parallel.
      2. Toys - stimulate multiple senses simultaneously:
        1. Push-pull.
        2. Riding toys, e.g., straddle horse or car.
        3. Small, low slide or gym.
        4. Balls, in various sizes.
        5. Blocks - multiple shapes, sizes, colors.
        6. Dolls, trucks, dress-up clothes.
        7. Drums, horns, cymbals, xylophones, toy piano.
        8. Pounding board and hammer, clay.
        9. Finger paints, chalk and board, thick crayons.
        10. Wooden puzzles with large pieces.
        11. Toy record player with kiddie records.
        12. Talking toys: dolls, See ‘n Say, phones.
        13. Sand, water, soap bubbles.
        14. Picture books, photo albums.
        15. Nursery rhymes, songs, music.
      3. Safety
        1. Accidents are the leading cause of death among toddlers.
        2. Motor vehicles: most accidental deaths in children under age 3 are related to motor vehicles.
          1. Use only federally approved car seat for all car rides, through age 6 or 60 lb.
          2. Follow manufacturer directions carefully.
          3. Make car seat part of routine for toddler.
        3. Drowning
          1. Always supervise child near water: tub, pool, Jacuzzi, lake, ocean.
          2. Keep bathroom locked to prevent drowning in toilet.
        4. Burns
          1. Turn pot handles in when cooking.
          2. Do not allow child to play with electrical appliances.
          3. Decrease water temperature in house to avoid scald burns.
        5. Poisonings: most common in 2-year-old.
          1. Consider every nonfood substance a hazard and place out of child’s sight/ reach.
          2. Keep all medications, cleaning materials, etc. in clearly marked containers in locked cabinets.
          3. Instruct in use of syrup of ipecac.
        6. Falls
          1. Provide barriers on open windows.
          2. Avoid gates on stairs - child can strangle on gate.
          3. Move from crib to bed.
        7. Choking: avoid food on which child might choke:
          1. Fish with bones.
          2. Fruit with seeds or pits.
          3. Nuts, raisins.
          4. Hot dogs.
          5. Chewing gum.
          6. Hard candy.

  2. Preschooler (3-5 years)
    1. Erikson’s theory of personality development
      1. Central task: initiative vs. guilt; central persons: basic family unit.
      2. Behavioral indicators
        1. Attempts to perform activities of daily living (ADL) independently.
        2. Attempts to make things for self/others.
        3. Tries to “help.”
        4. Talks constantly: verbal exploration of the world (“Why?”).
        5. Extremely active, highly creative imagination: fantasy and magical thinking.
        6. May demonstrate fears: “monsters,” dark rooms, etc.
        7. Able to tolerate short periods of separation.
      3. Parental guidance/teaching
        1. Encourage child to dress self by providing simple clothing.
        2. Remind to go to bathroom (tends to "forget").
        3. Assign small, simple tasks or errands.
        4. Answer questions patiently, simply; do not offer child more information than he or she is asking for.
        5. Normal to have “imaginary playmates.”
        6. Offer realistic support and reassurance with regard to fears.
        7. Expose to a variety of experiences: zoo, train ride, shopping, sleigh riding, etc.
        8. Enroll in preschool/nursery school program; kindergarten at 5 years.
    2. Physical growth (by 5 years)
      1. Height and weight
        1. Continued slow, steady growth.
        2. Generally grows more in height than weight.
        3. Posture: appears taller and thinner; “lordosis” of toddler gradually disappears.
      2. Vital signs
      3. Cardiac system
        1. Increased heart size (4 times larger than at birth); heart function is comparable to a healthy adult (by 5 years).
        2. Heart assumes vertical position in thoracic cavity.
        3. May hear “splitting” of heart sounds, as well as innocent murmurs on auscultation
        4. Decreased heart rate, steady blood pressure from toddler values.
      4. Pulmonary system
        1. Increase in amount of lung tissue.
        2. Adult-like lung sounds heard on auscultation.
        3. Decreased respiratory rate from toddler
      5. Gastrointestinal system
        1. Continued increase in size.
        2. Position is straighter and more upright than adult stomach —> more rapid emptying (defecation, vomiting).
        3. Lining still sensitive to roughage and spices.
        4. Elimination controlled.
      6. Genitourinary systems
        1. Bladder remains palpable above symphysis pubis.
        2. Needs to void frequently, or "accidents" may occur despite sphincter control.
        3. Low-grade urinary tract infections common.
      7. Immune system
        1. Growth of lymphoid tissue (especially tonsils).
        2. Illnesses (especially respiratory) tend to be more localized.
        3. Continued increase in IgA and IgG.
      8. Neurological system
        1. “Handedness” (right or left) is established.
      9. Sensory
        1. Vision-far-sightedness is improving; visual acuity: 20/30.
        2. Vision and hearing screening should be conducted before kindergarten, and annually thereafter.
      10. Teeth
        1. All 20 primary or deciduous teeth (“baby teeth”) should be present.
        2. Annual dental checkups; continue daily brushing.

    3. DDST/developmental norms:
      1. 3 years
        1. Personal-social
          1. Dresses without help.
          2. Plays board/card games.
        2. Fine motor-adaptive
          1. Picks longer of two Unes.
          2. Copies circle, intersecting lines.
          3. Draws person, three parts.
        3. Language
          1. Comprehends “cold,” “tired,” “hungry.”
          2. Comprehends prepositions: “over,” “under.”
          3. Names four colors.
        4. Gross motor
          1. Pedals tricycle; hops, skips on alternating feet.
          2. Broad jumps, jumps in place.
          3. Balances on one foot.
      2. 4 years
        1. Personal-social
          1. Brushes own teeth, combs own hair.
          2. Dresses without supervision.
          3. Knows own age and birthday.
          4. Ties own shoes.
        2. Fine motor-adaptive
          1. Draws person with six body parts.
          2. Copies square.
        3. Language
          1. Knows opposite analogies (two of three).
          2. Defines seven words.
        4. Gross motor
          1. Balances on each foot for 5 secconds.
          2. Can walk heel-to-toe.
      3. 5 years
        1. Personal-social
          1. Interested in money.
          2. Knows days of week, seasons.
        2. Fine motor-adaptive
          1. Prints name.
        3. Language
          1. Counts to 10.
          2. Verbalizes number sequences (e.g., telephone number).
        4. Gross motor
          1. Attempts to ride bike.
          2. Rollerskates, jumps rope, bounces ball.
          3. Backward heel-toe walk.
    4. Nursing interventions/parental guidance:
      1. Play: preschool years - associative and cooperative.
        1. Likes to play house, “work,” school, firehouse.
        2. “Arts and crafts”: color, draw, paint dot-to-dot, color by number, cut and paste, simple sewing kits.
        3. Ball, rollerskate, jump rope, jacks.
        4. Swimming.
        5. Puzzles, blocks (e.g., Lego blocks).
        6. Tricycle, then bicycle (with/without training wheels).
        7. Simple card games and board games.
        8. Costumes and dress-up: “make-believe.”
      2. Safety: Emphasis shifts from protective supervision to teaching simple safety rules. Preschoolers are “the great imitators” of parents, who now serve as role models.
        1. Teach child car/street safety rules.
        2. Change to “child booster seat” in car at 6 years or 60 lb.
        3. Teach child not to go with strangers or accept gifts or candy from strangers.
        4. Teach child danger of fire, matches, flame: “drop and roll.”
        5. Teach child rules of water safety; provide swimming lessons.
        6. Provide adult supervision, frequent checks on activity/location. Despite safety teaching, preschooler is still a child and may be unreliable.

  3. School age (6-12 years)
    1. Erikson’s theory of personality development
      1. Central task: industry vs. inferiority; central person: school, neighborhood friends.
      2. Behavioral indicators
        1. Moving toward complete independence in ADL.
        2. May be very competitive - wants to achieve in school, at play.
        3. Likes to be alone occasionally, may seem shy.
        4. Prefers friends and peers to siblings.
      3. Parental guidance/teaching
        1. Be accepting of the child as he or she is.
        2. Offer consistent support and guidance.
        3. Avoid authoritative or excessive demands on child.
        4. Respect need for privacy.
        5. Assign household tasks, errands, chores.

    2. Physical growth (by 12 years)
      1. Height and weight
        1. Almost double in weight from 6-12 years.
        2. Period of slow, steady growth.
        3. 1-2 in/yr.
        4. 3-6 Ib/yr.
        5. Girls and boys differ in size at end of school-age years.
      2. Vital signs
      3. Cardiac system
        1. Increased size of left ventricle (to meet demands for increased blood to growing structures).
        2. Decreased heart rate, increased blood pressure from preschool values.
      4. Pulmonary system
        1. Front sinuses develop (by 7 years).
        2. Lymphatic tissue completes growth (by 9 years).
        3. Remains well oxygenated on exertion.
        4. Continued decrease in respiratory rate from preschool values; using intercostal muscles more effectively for breathing.
      5. Gastrointestinal system
        1. Higher metabolic rate requires adequate food and fluids to ensure nutrition and hydration.
        2. Food retained in stomach for longer periods of time.
      6. Genitourinary system
        1. Bladder capacity increase continues.
        2. Kidneys mature.
        3. Less likely to have fluid and electrolyte (F/E) imbalance as increased conservation of water occurs.
      7. Immune system
        1. Growth of lymphoid tissue increases, then plateaus, then decreases.
        2. Continued improvement noted with body’s increased ability to localize infections.
      8. Neurological system
        1. Central nervous system matures.
        2. Myelinization continues increase in both fine motor-adaptive and gross motor skills.
      9. Sensory
        1. Vision: 20/20 vision well established between 9 and 11 years.
        2. Should be screened for vision/hearing annually, usually in school.
      10. Teeth
        1. Begins to lose primary teeth around sixth birthday.
        2. Eruption of permanent teeth, including molars; 28 permanent teeth (by 12 years).
        3. Dental screening annually, daily brushing.
      11. Pubescence (preliminary physical changes of adolescence)
        1. Average age of onset: girls at 10, boys at 12.
        2. Beginning of growth spurt.
        3. Some sexual changes may start to occur.
    3. Developmental norms
      1. 6-8 years
        1. Dramatic, exuberant, boundless energy.
        2. Alternating periods: quiet, private behavior.
        3. Conscientious, punctual.
        4. Wants to care for own needs but needs reminders, supervision.
        5. Oriented to time and space.
        6. Learns to read, tell time, follow map.
        7. Interested in money - asks for “allowance.”
        8. Eagerly anticipates upcoming events, trips.
        9. Can bicycle, swim, play ball.
      2. 9-11 years
        1. Worries over tasks; takes things seriously, yet also developing sense of humor-likes to tell jokes.
        2. Keeps room, clothes, toys relatively tidy.
        3. Enjoys physical activity, has great stamina.
        4. Very enthusiastic at work and play; has lots of energy - may fidget, drum fingers, tap foot.
        5. Wants to work to earn money: mow lawn, babysit, deliver papers.
        6. Loves secrets (secret clubs).
        7. Very well behaved outside own home (or with company).
        8. Uses tools, equipment; follows directions, recipes.
        9. By twelfth birthday: paradoxical stormy behavior, onset of adolescent conflicts.
    4. Nursing interventions/parental guidance:
      1. Play
        1. Wants to win, likes competitive games.
        2. Prefers to play with same-sex children.
        3. Enjoys group, team play.
        4. Loves to do magic tricks and other “showoff” activities (e.g., puppet shows, plays, singing).
        5. Likes to collect things: cards, compact discs.
        6. Does simple scientific experiments, computer games.
        7. Has hobbies: needlework, woodwork, models.
        8. Enjoys pop music, musical instruments, radio, audiotapes, videos, posters.
      2. Safety - motor vehicles
        1. As passenger: teach to wear safety belt, not distract driver.
        2. As pedestrian: teach bike, street safety.
        3. Teach how to swim, rules of water safety.
        4. Sports: teach safety rules.
        5. Adult supervision still necessary; serve as role model for safe activities.
        6. Suggest Red Cross courses on first aid, water safety, babysitting, etc.

  4. Adolescent (12-18 years)
    1. Erikson’s theory of personality development
      1. Central task: identity vs. role confusion; central persons: peer group.
      2. Behavioral indicators
        1. Changes in body image related to sexual development.
        2. Awkward and uncoordinated in the beginning.
        3. Much interest in opposite sex: females become romantic.
        4. Wants to be exactly like peers.
        5. Becomes hostile toward parents, adults, family.
        6. Concerned with vocation, life after high school.
      3. Parental guidance, teaching
        1. Offer firm but realistic limits on behavior.
        2. Continue to offer guidance, support.
        3. Allow child to earn own money, control own finances.
        4. Assist adolescent to develop positive self-image.
    2. Physical growth (by 18 year)
      1. Height and weight
        1. Adolescent growth spurt lasts 24-36 months.
        2. b. Growth in height commonly ceases at 16-17 years in girls, 18-20 years in boys.
        3. Boys gain more weight than girls, are generally taller and heavier.
      2. Vital signs approximately those of the adult.
      3. Cardiac system
        1. Increased heart size and strength to near adult values.
        2. Decreased heart rate, increased blood pressure from school-age values.
      4. Pulmonary system
        1. Lungs increase in size to near-adult levels, but not as rapidly as other body systems (may explain lack of energy).
        2. System is “mature” by 12 years.
        3. Continued decreased respiratory rate from school-age values.
      5. Gastrointestinal system
        1. Continued need for increased calories.
      6. Genitourinary system
        1. Fully developed; bladder can hold 700 mL.
      7. Immune system
        1. Fully developed; infections become increasingly rare in a healthy adolescent.
        2. Lymphoid tissue matures and regresses.
      8. Neurological system
        1. Fully developed.
      9. Sensory
        1. Fully developed.
      10. Teeth: 32 permanent teeth by 18-21 years.
      11. Sexual changes
        1. Girls
          1. Changes in nipple and areola; development of breast buds.
          2. Growth of pubic hair.
          3. Change in vaginal secretions.
          4. Menstruation - 12.8 years (average); range 10.5-15 years
          5. Growth of axillary hair.
          6. Ovulation.
        2. Boys
          1. Enlargement of genitalia.
          2. Growth of pubic, axillary, facial, and body hair.
          3. Lowering of voice.
          4. Production of sperm; nocturnal emission (“wet dreams”).
    3. Developmental norms
      1. Motor development
        1. Early (12-15 years) - awkward, uncoordinated, poor posture, decrease in energy and stamina.
        2. Later (15-18 years) - increased coordination and better posture; more energy and stamina.
      2. Cognitive
        1. Academic ability and interest vary greatly.
        2. "Think about thinking" - period of introspection.
      3. Emotional
        1. Same-sex best friend, leading to strong friendship bonds.
        2. Highly romantic period for boys and girls.
        3. May be moody, unpredictable, inconsistent.
      4. Social
        1. Periods of highs and lows, sociability and loneliness.
        2. Turmoil with parents - related to changing roles, desire for increased independence.
        3. Peer group is important socializing agent - conformity increases sense of belonging.
        4. Friendships: same-sex best friend advancing to heterosexual “relationships.”
    4. Nursing interventions/parental guidance:
      1. Play
        1. School-related group activities and sports.
        2. Develops talents, skills, and abilities.
        3. Television - watches soap operas, romantic movies, sports.
        4. Develops interest in art, writing, poetry, musical instrument.
        5. Girls: increased interest in makeup and clothes.
        6. Boys: increased interest in mechanical and electronic devices.
      2. Safety - motor vehicles (cars and motorcycles) - as passenger or as driver
        1. Encourage driver education; serve as positive role model.
        2. Teach rules of safety for water sports.
        3. Wants to earn money but still needs guidance: advocate safe job, reasonable hours.