MODULE: CHILDREN’S HEALTH (MED 7710)

LECTURE:
GROWTH AND DEVELOPMENT II
 OBJECTIVES
• To differentiate growth from development
• Discuss the different aspects of development
in pediatrics (per age group) – School Age,
Adolescence
• Integrate the developmental milestones of
pediatric patients
School-Age
School Age (Middle Childhood)
❑period between the age of 6 to 12 years.
❑characterized by gradual growth
• period in which children increasingly separate
from parents and seek acceptance from
teachers, other adults, and peers.
School Age (Middle Childhood)
• Children begin to feel under pressure to conform to
the style and ideals of the peer group.
• Self-esteem becomes a central issue, as children
develop the cognitive ability to consider their own
self-evaluations and their perception of how others
see them.
• For the first time, they are judged according to their
ability to produce socially valued outputs, such as
getting good grades, playing a musical instrument, or
hitting home runs.
 Physical Development
• Growth occurs discontinuously, in 3-6
irregularly timed spurts each year, but varies
both within and among individuals.
• Growth during the period averages 3-3.5 kg
(6.6-7.7 lb) and 6-7 cm (2.4-2.8 in) per year
• The head grows only 2 cm in circumference
throughout the entire period, reflecting a
slowing of brain growth.
 Physical Development
• Myelinization continues into adolescence, with
peak gray matter at 12-14 yr.
• Loss of deciduous (baby) teeth is a more dramatic
sign of maturation, beginning around 6 yr of age.
• Replacement with adult teeth occurs at a rate of
about 4 per year, so that by age 9 yr, children will
have 8 permanent incisors and 4 permanent
molars. Premolars erupt by 11-12 yr of age
• Physical fitness has declined
• Sedentary habits at this age are associated
with increased lifetime risk of obesity,
cardiovascular disease, academic
achievement, and lower self-esteem
• Prior to puberty, the sensitivity of the
hypothalamus and the pituitary changes,
leading to increased gonadotropin synthesis.
• Interest in gender differences and sexual
behavior increases progressively until puberty.
• Sexual drives are limited, masturbation is
common, and children may be interested in
differences between genders.
 Physical growth

Weight:
• School–age child gains about 3.8kg/year.
• Boys tend to gain slightly more weight
through 12 years.
• Weight computation for 7 - 12 yrs:
= (age in yrs x 7 )– 5
2
Height:
• The child gains about 5cm/year.
• Body proportion during this period: Both
boys and girls are long-legged.
Dentition
• Permanent teeth erupt during school-age
period, starting from 6 years, usually in the
same order in which primary teeth are lost.
• The child acquires permanent molars, medial
and lateral incisors.
Motor development
At 6–8 years, the school–age child:
• Rides a bicycle.
• Runs Jumps, climbs and hops.
• Has improved eye-hand coordination.
• Prints word and learn cursive writing.
• Can brush and comb hair.
 School Years: Fine Motor
• Writing skills improve
• Fine motor is refined
• Fine motor with more focus
• Building: models – logos
• Sewing
• Musical instrument
• Painting
• Typing skills
• Technology: computers
 At 8–10 years, the school–age child:
• Throws balls skillfully.
• Participates in organized sports.
• Uses both hands independently.
• Handles eating utensils (spoon, fork, knife)
skillfully.
At 10–12 years, the school–age child:
• Enjoys all physical activities.
• Continues to improve his motor coordination.
 School Age: Gross Motor

• 8 to 10 years: team sports

• Age ten: match sport to the physical and

emotional development
 School performance
• Ask about favorite subject
• How they are doing in school
• Do they like school
• By parent report: any learning difficulties,
attention problems, homework
• Parental expectations
 School Age: Cognitive Development
• thinking of early elementary school-age
children differs qualitatively from that of
preschool children.
• In place of magical, egocentric, and
perception-bound cognition, school-age
children increasingly apply rules based on
observable phenomena, factor in multiple
dimensions and points of view, and interpret
their perceptions using physical laws
 School Age: cognitive development
Child now is in the concrete operational stage
of cognitive development.
He is able to function on a higher level in his
mental ability.
Greater ability to concentrate and participate in
self-initiating quiet activities that challenge
cognitive skills, such as reading, playing
computer and board games.
Social and Emotional Development
• energy is directed toward creativity and productivity
• Changes occur in 3 spheres: the home, the school, and
the neighborhood. (home and family remain the most
influential)
• Increasing independence: first sleepover at a friend’s
house and the first time at overnight camp
• Parents should make demands for effort in school and
extracurricular activities, celebrate successes, and offer
unconditional acceptance when failures occur.
• Regular chores, associated with an allowance, provide
an opportunity for children to contribute to family
functioning and learn the value of money.
Social and Emotional Development
• Social groups: same-sex, with frequent changing
of membership, contributing to a child’s growing
social development and competence.
• Popularity and self-esteem → possessions (latest
electronic gadgets, clothes), personal
attractiveness, accomplishments, actual social
skills
• Racial differences, racial groups that impact their
relationships.
Social and Emotional Development
• Children who adopt individualistic styles or
have visible differences may be teased.
• Children with deficits in social skills may go to
extreme lengths to win acceptance, only to
meet with repeated failure.
• Attributions: funny, stupid, bad, or fat →
child’s self-image and affect the child’s
personality, as well as school performance
 Moral Development
• By age 6 yr most children will have a
conscience (internalized rules of society)
• For the younger youth: rules are established
and enforced by an authority figure (parent or
teacher) and decision-making is guided by
self-interest (avoidance of negative and
receipt of positive consequences).
• Decision-making: needs of others are not
strongly considered
 Moral Development
• As they grow older, most will recognize not only
their own needs and desires, but also those of
others, although personal consequences are still
the primary driver of behavior.
• Social behaviors that are socially undesirable are
considered to be wrong.
• By age 10-11 yr the combination of peer
pressure, a desire to please authority figures as
well as an understanding of reciprocity (treat
others as you wish to be treated) shapes the
child’s behavior.
• Unconditional support (daily query over dinner/
bedtime)
• Allowing independence, excessive pressure to
achieve
• Stressors (divorce, domestic violence, substance
abuse)
• Gangs: self-protection, attain recognition
• Bullying
• Media exposure: limit to 2hrs/day
Adolescence: 13 to 18 year old
 ADOLESCENCE
• Hormonally driven physiologic changes and
ongoing neurologic development occur in the
setting of social structures that foster the
transition from childhood to adulthood.
• which is divided into 3 phases—early, middle,
and late adolescence—each marked by a
characteristic set of biologic, cognitive, and
psychosocial milestones
 PHYSICAL DEVELOPMENT
• Maturation of the gonadotropin-releasing hormone
pulse generator is among the earliest neuroendocrine
changes associated with the onset of puberty.
• Under the influence of gonadotropin-releasing
hormone, the pituitary gland secretes luteinizing
hormone and follicle-stimulating hormone; initially
this occurs in a pulsatile fashion primarily during sleep,
but this diurnal variation diminishes throughout
puberty.
• Luteinizing hormone and follicle-stimulating hormone
stimulate corresponding increases in gonadal
androgens and estrogens.
Sexual Development: Tanner Staging
Sexual Development: Tanner Staging
• In males, the first visible sign of puberty and the
hallmark of SMR 2 is testicular enlargement,
beginning as early as 9.5 yr → development of pubic
hair → penile growth (SMR 3)
• Peak growth occurs when testis volumes reach
approximately 9-10 cm3 during SMR 4.
• Under the influence of LH and testosterone:
enlargement of seminiferous tubules, epididymis,
seminal vesicles, prostate
• Sperm may be found in the urine by SMR 3; nocturnal
emissions may be noted at this time as well.
• In females, typically the first visible sign of puberty and
the hallmark of SMR 2 is the appearance of breast buds
(thelarche), (8 to 12 yr)
• Enlargement of the ovaries, uterus, labia, and clitoris, and
thickening of the endometrium and vaginal mucosa
• A clear vaginal discharge may be present prior to menarche
(physiologic leukorrhea).
• Menses typically begins 2.5 yr after the onset of puberty,
during SMR 3-4 (average age: 12.5 yr; normal range: 9-15
yr)
• Timing of menarche is determined largely by genetics;
contributing factors likely include adiposity, chronic illness,
nutritional status, and the psychosocial environment.
 Somatic Growth
• Females attain PHV of 8-9 cm/yr at SMR 2-3,
approximately 6 mo before menarche.
• Males typically begin their growth acceleration at a
later SMR stage, achieve a PHV of 9-10 cm/yr later, at
SMR 3-4, and continue their linear growth for
approximately 2-3 yr after females have stopped
growing
• Growth spurt begins distally, with enlargement of the
hands and feet → arms and legs → trunk and chest last
• This growth pattern imparts a characteristic “awkward”
appearance to some early adolescents
Physiologic growth:

Pulse: Reaches adult value 60–100 beats/min

Respiration: 16–20/min
The sebaceous glands of face, neck and chest
become more active. When their secretion
accumulates under the skin, acne will
appear.
Secondary sex characteristics

Secondary sex characteristics in girls:

• Increase in transverse diameter of the pelvis.
• Development of the breasts.
• Change in the vaginal secretions.
• Growth of pubic and axillary hair.
• Menstruation (first menstruation is called
menarche, which occurs between 12 to 13
years).
Body image
Secondary sex characteristics
Secondary sex characteristics in boys:
• Increase in size of genitalia.
• Swelling of the breast.
• Growth of pubic, axillary, facial and chest hair.
• Change in voice.
• Rapid growth of shoulder breadth.
• Production of spermatozoa (which is sign of
puberty).
 Adolescents

• As teenagers gain independence they begin to

challenge values
• Critical of adult authority
• Relies on peer relationship
• Mood swings especially in early adolescents
 Psychosocial Development
• subject to greater environmental and cultural
influences
• Some late adolescents move immediately from
high school into marriage, childbearing, working,
and financial independence; others remain
dependent on the parents while pursuing their
own education for several more years, in a period
sometimes referred to as emerging adulthood.
• Separation from the parents is a hallmark of
adolescent development.
 Psychosocial Development
• Increasing importance of the peer group
• Sexual awareness and interest (sexual talk
and gossip, focus on sexual anatomy,
masturbation, sexual exploration)
• Body image (distorted body image, eating
disorders)
 REFERENCES
• Kliegman, Robert et al., Nelson Textbook of
Pediatrics 20th edition, 2015.
• Brown, Lloyd et al., Board Review Series (BRS)
Pediatrics 2nd edition, 2018.
 SUPPLEMENTAL READINGS
• Introduction to Growth and Development
https://www.msdmanuals.com/professional/pe
diatrics/growth-and-
development/introduction-to-growth-and-
development?query=growth%20and%20devel
opment
 INSTRUCTIONAL VIDEO
• Pediatrics - Growth and Development
Milestones Review
https://www.youtube.com/watch?v=ZG60nC3RJ
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