Peds Ch 34 School Age

School age is how old

6-12 years

Vast majority of childhood

School age is a period of gradual

growth and development, they have really learned all of the skills they are going to learn and just kind of refining a lot of what the already started mastering, so they just continue to master this stuff and start becoming more emotionally mature

•Losing first primary tooth à getting final permanent teeth

•Period of more gradual growth and development

•Continued progress with physical and emotional maturity

At the very beginning boys and girls are very much the same, until they

hit puberty girls and boys look very similar aside from like how they dress and how they cut their hair. Towards the end as we start getting to the prepubescence getting ready to hit puberty girls start to go through their growth spurt first and they start to be taller and heavier then boys at the end of this childhood period but they are more graceful, more steady, don’t have as much baby fat. A lot more muscle so they don’t fall as often or hurt themselves as often

This is the period that would classify as the ugly duckling because we are

physically kind of like a baby but also might be getting adult teeth or their head is still kind of little and may need to grow into a lot of their features still because they are not going to hit the last 20% of the growth spurt until adolescence

Physical maturity does not equal

emotional/social maturity

Its important to remember that what they look like, does not equal their emotional or social maturity, so some kids may hit puberty or enter into prepubescence a lot earlier, the might even still be considered school age and start developing secondary sex characteristics but remember they still have the thought, the Erickson and Piaget of being a school aged child.

Prepubescence starts around what age in girls

10 years

Prepubescence starts around what age in boys

12 years

Anytime after what age is considered normal for kids to begin puberty?

after 8 is considered normal for either age group if they start having pubertal changes after 8 we would say that is a normal time to start experiencing these changes.

This stage is industry V. Inferiority which in the sense of industry means

they want to be productive and show their worth. Show that they can do things. They do these things beyond their family because majority of their day is spent outside the home at school with someone other than their family. They have to learn these social skills, how to talk and communicate and be away from their family for an extended period of time. They want to accomplish things and do useful skills, these kids are so proud when the bring home like a spelling test or a little craft they made, because when we reward them it encourages their self worth and makes them feel better about themselves when they are industrious when they can make things. So we reward them with grades, with stickers, with material things like candy. This is the proof of industry.

School age kids have to learn cooperation because

They are no longer just spending time with their family, they are having to learn to cooperate. They have to learn to compete with other kids. If an only child and just was home with the parents, they don’t have to learn cooperation, they don’t cooperate with the parents because parents are the lead hierarchy and the kid just did but now that they are in school they have to learn how to cooperate with others and how to compete with others and how to work and apply social skills to our peers. The peers are taking on a much more important effect, they are not the most important yet though, family still has a little but of control. For a lot of the day though, they learn the rules because of the other kids they are around, peer approval tells them what is okay and what is not okay. Like if a kid was smelly and dirty and mean they would not have any friends, so learning that peer approval that those things are not okay and knowing that if they don’t follow these social rules, kids wont like me or hangout with me. They will get bullied out of behaviors that aren’t socially acceptable. They learn these things by being modeled by other kids around.

These school age kids are starting to understanding cause and

and effect and the relationships between things

They can start reasoning about things rather than just what they can see

They can now understand others perspective and reason and rationalize

Piaget stage here is concrete operations where:

we are still kind of thinking of things as concrete but we are starting to get more abstract because eventually as an adolescent we are going to be able to think much more abstractly.

•Ability to relate a series of events to mental representations that can be expressed verbally and symbolically

Concrete is

things are true what is it, is what it is. They are still literal and concrete and don’t really love metaphors and similes. They start to as they progress through this stage but now they can start remembering things and use these mental representations that now they can express verbally. They can read, write, and explain themselves a lot better then our younger kids who are very egocentric.

This age of kids can’t be egocentric or

they would not thrive in this stage, they loose egocentrism here. They wouldn’t have any friends if they couldn’t think of others or know how to share or think beyond just what they feel. They are starting to master cause and effect and the relationship between things, and because of that they can start reasoning about things rather than just what they see. Like remembering that one time they got hurt when they jumped off the slide, so now they think oh I will not jump off the slide. Where as the egocentric preschooler or toddler would think I want to jump off the slide so I am going to do that, they are only thinking about what they are going to do. This reasoning now help them be safe because they can learn and remember things.

School age they now know like if they hit their brother, even if no one sees it they still think that was a

bad idea and they know they shouldn’t have done that and they can reason with it and remember that is not a great idea and they can understand the brothers perspective. Young kids cant, they are so black and white they think if they hit the brother and no one sees it, its okay. If no one sees it or it isn’t punished that must mean its okay.

They also develop conceptual thinking where they are

Able to make judgments based on reason rather then only on what they see

Conservation is

volume doesn’t change based in the size of container, a smaller container completely full seems more to them a bigger container that has the same amount of water but is less full.

School aged has mastered conservation

The size determines the weight to kids who have not mastered conservation yet.

Kids also learn to conserve numbers, that is why we do not use 0-10 pain scale until

8 years. This is because they have now mastered the conservation of numbers so they know that 1 is smaller then 2. Everything is the same as 1 weather 1 marble or whatever it might be, the appearance of it does not necessarily change the amount of it. Because of this they love classifying things, they understand these relational terms and know when I say something is bigger or smaller, when we say to the right or more than less than, they can understand how this works in order and they can categorize based on the order.

As a toddler, they go around flipping all the light switches to categorize that every light switch has the same general characteristics. Where as a school age kid we can rely on our

memories and we can reason that every room we go into is going to have a light switch that looks pretty similar. They start to reason what is bigger than, what is smaller than, and like to classify by ordering these things.

When we want to enhance a skill in younger kids we would give toys that improve development. This is where reading comes in with

school age kids, they will get fascinated by a certain type of book or an author because it enhances their knowledge and understanding and they can apply things from a different book and it helps them understand certain concepts. Really helps them connect and make sense of all the things they are learning, they can enhance this through reading.

These cognitive skills becomes how they are entertained and how they enhance their development.

At school age they can now tell

time and understand it

A lot of their play is focused on

interacting with kids their age.

Play becomes much more important, they are no longer egocentric and are spending much more time with other kids. Their play is focused on interaction with their peers. Important to know that the rules are the rules in this play. In order to belong to the club you need to know the rules. You can not stray from the rules.

They like to be on teams and do more sophisticated sports because this is how they learn and practice

cooperation and competition so they can understand doing something better means they win. Learning to asses other peoples weaknesses or strengths in order to win the game, they can start cognitively understanding that stuff.

They also enjoy quiet games and activities like collections and reading.

Their creative skill, they might learn they like to cook or garden whatever activity they are in to at the time is supporting their

cognitive development and often times the social development as well because they do these things with other kids.

We aren’t as worried about safety in these kids because they are much safer. First most influential thing in life is still

the family.

Second most influential thing or person in the life is the

school, they like worship the teacher and think of them as a parent because the teacher helps them. They love them like they love their parents. All of the roles previously played by caregiver, are taken over by teacher at school.

Industry stage we know the teacher is giving them the self esteem the good boy or the sticker or the reward. The teacher is helping form that self confidence in who they are and that sense of self.

Latch key kid is like

after school care. When no one is there to care for the child after school for the period of time until the caregiver gets home from work. Risk here in this time is injury because they are fully caring for themselves in this gap time.

The reason injuries are less is because of

limit setting discipline because kids can reason and use their memories we can start applying penalties and reasoning as to why you shouldn’t do things. They might not listen to this all the time but cognitively they understand it and are going to try to avoid those penalties generally.

Dishonest behaviors like

lying, cheating, and stealing are really common in this age group because, if you know the rules you are cool and in the club. If you loose you are not cool and your out so these social concepts make it really damaging to not win. These kids naturally turn to these dishonest behaviors to help them win, not because they are being little assholes. They drive to be industrious and have those social connections is so much higher than the criminality or wrongness of these dishonest behaviors. Winning is their highest priority because its how they confirm that sense of industry.

We don’t really see regression here with these kids like we do with toddlers when they have too much stress because their skills are so developed. When there is too much demand or stress for these kids they will have

somatic complaints. My head hurts or my stomach hurts to get them out of doing whatever causes them that stress. This is a good tine to teach them coping skills, how stress feels in their body and how to manage it moving forward.

They now have larger and stronger muscles they can start competing in

competitive sports, sports to win. It is important to find out what they like to do, this is the time they will identify their sport and maybe stick with it. Kids like competition and this time with their peers. This is not the time to be looking for the next NFL star but just teaching them basics and important skills.

This is the time to teach them basic skills, how to work with peers, how to stay safe so like wearing pads or stretching and rest, teach them how to take care of themselves and mastery their skills and a healthy attitude rather than being perfect or emphasizing winning the sport.

A lot of sports are Coed playing together because there is not much difference

between boys and girls size before puberty. Then after when puberty hits they will split up and do girls only or boys only team because the muscular difference will show at that time.

They love reading, drawing, beads, bracelets, artwork and giving them to people and love to reward of giving someone something or drawings hung up.

Kids at this age will preform chores that are more

responsible and keep the house going so feeding the dog, picking up around the house, or maybe doing laundry. Those formal chores is what we will see here the things that help keep the family running.

A lot of kids at this age spend 8-11 hours a day on some sort of media, some sort of screen. Depending on how much other influence they have in their lives, that media can cause

the family to bump down to becoming the third influence because they spend less time with family then they do using media or at the school. Could be a healthy combination but can very quickly become unhealthy where they are desensitized to violence, exposed to bulling, etc.

Less injuries because they can think

about things and can reason.

Most common cause of injury in this group is related to

motor vehicle accidents either as a pedestrian or as a passenger. These kids spend time outside of school riding bikes or walking to the park without parents with them because they do not need constant supervision. In preschool age we teach them safety, now as a school aged kid we can really focus on the teaching doing its job and they really know how to keep themselves safe. We still teach new rules for like maybe a new toy they got like an ATV here are rules for being safe so its constant education that they will learn to keep them safe.

Enuresis

After 5 years old if still wetting the bed, after we rule out there is NO physiological reason they are still wetting the bed it is termed enuresis. It tends to run strongly in families. We have to rule out constipation, UTIs, diabetes, kidney issues, neurologic deficits all has to be ruled out before we diagnose enuresis.

•Repeated urination into bed or clothing at least 2x weekly for at least 3 months, not due to a physiologic condition or substance

•At least 5 years old

Treatment for enuresis

We can start doing behaviors modifications but when appropriate. It is no appropriate to restrict the fluids of a 3 year old because they keep wetting the bed because it is developmentally normally for a 3 year old to still do this and we hardly ever restrict fluids in kids because they dehydrate so easily. This is one situation however though that if a kid truly has enuresis that we can start doing some of that behavior modification like restricting fluids, avoiding caffeine, avoiding sugar fluids, and if really severe they can wake up the child to void in the night. Regardless this is considered a pathological condition that needs to be treated.

Encopresis is

pooping pants and in the bed. We can diagnosis this a little earlier because poop is a routine thing that happens more often. If you are 4 and you are having these problems with pooping it is considered encopresis.

Repeated bowel movements into bed or clothing at least 1x per month for at least 3 months, not due to a physiologic condition or substance

•At least 4 years old

•Rule out constipation; cycle of holding and pain

•May need bowel clean out

When you get constipated and don’t poop for a while the poop is

stuck in your butt and belly, the poop feels hard. When kids have hard ball of poop and it is sticking right in the sphincter where the nerves are, the kid feels that. When the do things like wont poop at school and hold it for so long, sphincter gets paralyzed it wont move after holding it for so long. It gets stretched and paralyzed so they will have liquid stool because it comes and leaks down the big ball of poop. After holding poop so long and final decide to go, it actually hurts really bad that the next time they have to poop they wont want to go do it because it hurt so bad last time. Parents will say like oh my kid has diarrhea but the sphincter is just stretched at that point its paralyzed and just letting everything come out except the big ball of poop. It’s a lot of times related to kids not pooping at school.

Who is usually diagnosed with encopresis?

A lot of times autistic kids will have this. They become very ritualistic or they have sensory experiences like going to the bathroom is to loud or too cold and they don’t poop often enough so they get really constipated and its painful and the cycle starts and this is when we see encopresis.

Fear of pain when pooping after holding it for so long

After holding poop so long and final decide to go, it actually hurts really bad that the next time they have to poop they wont want to go do it because it hurt so bad last time.

Most common cause of encopresis is

constipation, even though they are having liquid stools and feels like diarrhea it is actually constipation.

Treatment for encopresis

To help we will do fiber, fluids, and trying to establish a schedule. Telling them they will poop after lunch or after recess, giving them a schedule of the have to sit on the toilet for a certain amount of time. If we can make the bathroom a scheduled routine thing, it takes away the pressure if having to ask to go to the bathroom or can take away the pressure of the encopresis

Usually not until school age that a kid gets diagnosed with ADHD because they will then be in school and needs to be in

2 different settings.

Definition of ADHD

Developmentally inappropriate degrees of inattention, impulsiveness, and hyperactivity, present in at least two settings

It also requires multiple people to diagnose this like

teachers, social workers, or a provider. First have to rule out anything physical going on like hypothyroidism, do the have other physical causes that may be causing them to be inattentive or impulsive. Have to do a true history and physical to make sure that something else isn’t going on.

To manage we use behavioral

therapy, task modification is trying to schedule things that they dislike in the morning so that it has their full attention when their medication is at its peak.

Stimulants stimulate the brain so we will give it in the

morning so the kid can sleep at night. One of the biggest complications of stimulants is that it decreases their appetite. If they increased the dose but now belly hurts because they aren’t eating, we will cut the dose in half over the day so we give some in the morning and some later maybe after lunch. To help the focus stretch over the whole school day.

Standard BID dosing in hospital is

9a and 9p, we would need to be super conscious of when dosing stimulant meds because they will not sleep if we gave a stimulant at 9p.

Consistency is everything and helping the kid to know what to expect. We can work with the teacher or the multi disciplinary team so everyone is on the same page in managing these symptoms so that they can still do the scholastic

learning that happens in this age group. An ADHD child should sit right in the front so they aren’t seeing what other kids are doing and distracting them. Give regular breaks so they have a chance to discharge some of the energy.

Stimulants are NOT

weight based! They are titrated for effect so a lot of times kids will have to come in and maintain checkups and weight checks because of the effect on the appetite but the medication is titrated for effect so when the medication stops loosing effectiveness that is when it needs to be increased.

Common stimulant used for ADHD

Ritalin

We often miss childhood depression and that is very common in this time. In this age its harder for them to

recognize a true pattern of depression or say like I'm irritable.

Like stress does, a lot of times this comes out as a

somatic complaint of like not feeling well, belly hurting. When the kid doesn’t feel right it requires a very detailed assessment of is this something physically wrong or physiologically wrong because even in this age group it is way more common now to see a 12 year old who has suicidal ideation.

Their age does not screen them out for suicidal ideation; it is

ALWAYS considered an emergency.

Kids diagnosed with depression usually are treated with

an SSRI and have some sort of counseling.

SSRI can cause more suicide thoughts at the start and gives them more energy to act on those things and get up and find things they previously didn’t.

Goal by 2030 is that 79.3% kids with a mental health disorder get treatment, healthy people goal.

How long does it take to see effect with SSRI?

2-4 weeks