School-age + Adolescent

School-Age Child

6-12

Adolescent

10-21

Middle childhood is defined by competence:

the child wants to make things, master skills, and be good at something.

Physical maturity in school-aged children

•Maturity increases steadily through the period

•COORDINATION, BALANCE, and STRENGTH improve

•Participation in organized clubs and sports becomes important

•Growth spurts may temporarily decrease coordination — reassure the child and family that this is expected

Logical thinking development in school-aged children

•Thinking becomes logical and concrete

•Middle childhood is characterized by play that embodies the need for RULES and STRUCTURE

•Interest in how things are made and how they work

•This is why board games, collections, and team sports appeal so strongly at this age

Peers & self-confidence in school-aged children

•FRIENDS AND PEERS become increasingly important

•Self-confidence develops through successful experience

•The child needs CONSISTENT RULES, POSITIVE ATTENTION, and CLEAR EXPECTATIONS

•Parents should encourage independence and AVOID a power struggle — offer a choice of two or three acceptable options (coordinated outfits, meal items, drink options)

Approach to the interview with a school-aged child

•Direct questions TO THE CHILD, then verify answers with the caregiver

•Assess development through questions about the child’s life — school, friends, activities, chores

•Explain in CONCRETE TERMS what is going to happen; this age group thinks literally

•Parents should REMAIN in the examination room during the assessment

•Ask the child to SIT ON THE EXAMINATION TABLE rather than the caregiver’s lap — this supports independence

Examination & screening for the school aged child

•Perform the examination in a HEAD-TO-TOE manner

•Use the SNELLEN eye chart to assess vision

•Begin HYPERLIPIDEMIA SCREENING at 11 years old

•Begin plotting BODY MASS INDEX to determine risk for obesity

•Screen for scoliosis, blood pressure, hearing, and dental health per schedule

•Immunizations reviewed and updated at every visit

FRONTAL SINUSES- school age

are fully developed at 7 years old. Facial structures become elongated.

TONSILS HYPERTROPHY- school aged

during this period. The child is oriented to person, place, and time.

The respiratory system is FULLY DEVELOPED at

10 years old.

Tonsillar hypertrophy may contribute to

partial airway obstruction or sleep-disordered breathing.

in school aged- The POINT OF MAXIMUM IMPULSE moves to the

5th intercostal space at the midclavicular line — landmark for auscultation changes from the earlier position.

GI of school aged children

Stomach capacity increases, permitting retention of food for longer periods. Bowel movements are affected by diet and physical activity. Caloric needs per kilogram are LOWER than in earlier years.

MSK and skin on school aged children

LEGS AND ARMS GROW FASTER than the rest of the body, which contributes to the coordination changes of this period. ACNE may begin to develop toward the end of the stage.

Female puberty onset

•ages 8 to 13

female puberty first sign

•breast budding (THELARCHE)

The female GROWTH SPURT occurs

EARLIER than in males

MENARCHE occurs approximately

2 YEARS AFTER thelarche — average age about 12.8 years

Menstrual irregularity is

common during the first year or two after menarche

Breast development is often

ASYMMETRICAL. Once examination confirms no mass or disease, reassure the child that this is normal

A tender nodule beneath the nipple signals

the onset of puberty

PRECOCIOUS PUBERTY

onset before the expected window

Male puberty onset

•ages 9 to 14

Male puberty first sign

•TESTICULAR ENLARGEMENT, in response to testosterone secretion (Tanner stage 2)

As testosterone rises,

• the penis and scrotum enlarge, hair distribution increases, and scrotal skin texture changes

ANY secretions causing VULVAR IRRITATION

— this suggests infection and requires evaluation

SUPERNUMERARY (accessory) NIPPLES

respond to hormones like other breast tissue. Teach the child so enlargement at puberty or in a future pregnancy is not frightening

Tanner stage 1- female

Prepubertal; elevation of papilla only

Tanner stage 2 female

Breast bud; areolar diameter enlarges (THELARCHE — first sign)

Tanner stage 3 female

Further enlargement of breast and areola, no separation of contours

Tanner stage 4 female

Areola and papilla form a SECONDARY MOUND above the breast

Tanner stage 5 female

Mature; areola recedes to breast contour, papilla projects

Tanner stage 1 male

Prepubertal; testes, scrotum, penis of childhood size

Tanner stage 2- male

Testicular enlargement; scrotal skin reddens and changes texture (FIRST SIGN)

Tanner stage 3- male

Penis lengthens; testes and scrotum continue to grow

Tanner stage 4 - male

Penis widens and glans develops; scrotal skin darkens

Tanner stage 5 - male

Adult size and shape

Pubic hair- tanner stage 1

Prepubertal; vellus hair only

Pubic hair- tanner stage 2

Sparse, lightly pigmented, straight hair

Pubic hair- tanner stage 3

Darker, coarser, curlier hair spreading sparsely

Pubic hair- tanner stage 4

Adult-type hair, area smaller than adult; no spread to thighs

Pubic hair- tanner stage 5

Adult in quantity and type, spreading to medial thighs

Younger than 7- pain assessment

FACES scale

•A series of faces ranging from smiling to crying; the child selects the face that matches how they feel

•This is a SUBJECTIVE evaluation — the child rates their own pain, not the nurse

•Do not tell the child which face to pick or interpret their expression for them

Older than 7- pain rating

Numerical Rating Scale

•A straight line with numbers spaced evenly

•0 to 10 scale; the HIGHER number indicates MORE pain

•Requires the ability to understand rank order and proportion — which develops with concrete operational thought

•Ask questions to determine pain QUALITY, not just intensity

Nonpharmacological methods- pain in school aged children

•DISTRACTION is particularly effective for the school-age child with chronic pain

•Guided imagery, music, video, conversation, and counting

•Relaxation and controlled breathing techniques

•Give the child a JOB during a procedure — holding the tape, counting, choosing the arm — which supports the sense of competence

•Include CULTURAL CONSIDERATIONS in every pain assessment: expression of pain, family involvement, and beliefs about medication all vary

•Combine with pharmacological management rather than substituting for it

Height in school age

•Grows 2.5 to 3 inches (6.3 to 7.3 cm) PER YEAR

•Growth occurs in INTERMITTENT SPURTS rather than steadily

•GIRLS ARE TALLER THAN BOYS at 12 years old — the female growth spurt comes earlier

Weight in school age

•Gains 6.5 to 7.5 pounds (2.9 to 3.4 kg) PER YEAR

•Weight varies with diet, physical activity level, and home environment

•Begin plotting BODY MASS INDEX to determine risk for obesity

•Stomach capacity increases; caloric needs per kilogram are LOWER than in earlier childhood

Approaching weight with the family of school aged

•Involve the ENTIRE FAMILY in the plan, with emphasis on long-term permanent changes — not rapid weight loss

•Promote moderate exercise for everyone, 60 MINUTES PER DAY

•Encourage MEAL PLANNING and DISCOURAGE SKIPPING MEALS

•Maintain a healthy eating approach in the home rather than singling the child out

•A weight-management group with other preteens can help

•Avoid framing goals around specific weight numbers — that raises the risk of eating disorders, nutritional deficiency, and poor body image

Erikson- school aged

INDUSTRY vs. INFERIORITY

•Builds competence through realistic, ACHIEVABLE tasks

•Values productivity, perseverance, and mastery

•Confidence grows through successful work and peer feedback

•If adult expectations are set TOO HIGH, the child develops a sense of INFERIORITY that can affect all aspects of life

Piaget- school aged

CONCRETE OPERATIONS

Sequences, reversibility, time, and cause and effect

•Learns the principle of CONSERVATION

•Thinking is logical but tied to concrete, tangible things

•Abstract reasoning has not yet developed — explain in literal terms

Kohlberg- school aged

CONVENTIONAL REASONING'

•Follows rules and considers family and societal expectations

•“Good” means meeting the expectations of people who matter

•This is why rules and fairness feel so urgent at this age

Freud- school aged

LATENCY

•Sexual energy is channeled into school, sports, and skills

•Relationships with SAME-SEX peers are prominent

•Peer groups tend to be same-sex, often with clubs, passwords, and exclusions

Conservation

The ability to appreciate that a CHANGE IN SHAPE does not necessarily mean a change in size or amount. The child understands that the same amount of medicine in a taller, thinner cup is still the same dose.

Decentering

The ability to project oneself into other people’s situations and see the world FROM THEIR VIEWPOINT rather than focusing only on one’s own — for example, considering an injection from the nurse’s point of view.

Accommodation

The ability to ADAPT THOUGHT PROCESSES to fit what is perceived — such as understanding that there can be more than one reason for another person’s actions.

Class inclusion

The ability to understand that objects can belong to MORE THAN ONE CLASSIFICATION — a nurse can be a woman, a mother, and a nurse at the same time.

Gross motor

•Muscle coordination, rhythm, and balance improve

•Can ride a bicycle by age 7 to 8

•GROWTH SPURTS MAY DECREASE COORDINATION temporarily — normalize this for the child and family

•Organized sports, dance, and gymnastics are popular activities

Fine motor

•Improved hand-eye coordination and finger dexterity

•Playing an instrument, braiding string for bracelets, and building models are popular

•The child MAY BECOME FRUSTRATED as skills develop

•Children should be encouraged to try new things — but when they face something they are not good at, pressure can be COUNTERPRODUCTIVE if they feel they are disappointing parents or others who matter to them

METALINGUISTIC AWARENESS

the ability to think about language and how it is used

communication and speech- school age

•METALINGUISTIC AWARENESS — the ability to think about language and how it is used

•Increased use of JOKES AND HUMOR during this stage

•READING SKILLS increase markedly

•Ability to think about and TALK THROUGH thoughts and feelings — which makes therapeutic communication possible in a way it was not earlier

SIX YEARS:

•talks in full sentences, using language easily and with meaning

SEVEN YEARS:

•can tell time in hours, but may struggle with “half past” and “quarter to,” especially given digital clocks

NINE YEARS:

•discovers “dirty” jokes and tells them to friends; may use swear words to express anger or to show other children they are growing up. A short period of intense fascination with bathroom language is common, as in the preschool years

TWELVE YEARS:

can carry on an adult conversation, although stories are limited by lack of experience

Peers and self-esteem- school age

•Begins to SEPARATE from parents and develop peer relationships

•Develops POSITIVE OR NEGATIVE SELF-ESTEEM through interactions with others

•Identifies a BEST FRIEND by 7 years old

•Wants to be accepted by peers and is subject to PEER PRESSURE

•Children with NEGATIVE self-esteem are more likely to give in to peer pressure — which is why building competence is also a safety intervention

•Peer groups tend to be SAME-SEX

By TEN YEARS,

•children take the values of their peer group seriously and seek peers of like mind

Clubs, values & fears- school aged

•By TEN YEARS, children take the values of their peer group seriously and seek peers of like mind

•CLUBS are formed with specific exclusions, typically with a secret password and meeting place, and are usually all girls or all boys

•These groups reflect normal development — they are not evidence of immaturity, sexism, or bullying in themselves

•FEARS AND ANXIETY to a degree are NORMAL. Encourage the child to work through them

•Acknowledge fears but AVOID CATERING to them; teach positive self-talk and relaxation techniques

•Allowing a child to stop an activity they dislike does not make them “a quitter”

They understand rules and consequences- school age

This age group can genuinely grasp why a rule exists. Teach SOCIETAL rules alongside household rules.

Role model desired behaviors

Children calibrate to what adults do, not what adults say. Model the emotional regulation you are asking for.

Teach emotional expression

Teach the child to express emotions in a CALM MANNER rather than suppressing or exploding.

Establish clear consequences and remain consistent

Consistent rules, positive attention, and clear expectations are what build self-confidence. Inconsistency teaches the child that rules are negotiable.

Keep the dialogue open- discipline

Encouraging the child to explore their feelings is therapeutic communication. Helping the child identify the REASONS behind a parent’s rules is more effective than simply being told why.

Sports

•Wear protective gear appropriate to the sport

•Prevent DEHYDRATION — scheduled fluid breaks

•Match the activity to the child’s size and skill

Water

•NEVER allow children to swim alone

•Teach children to swim

•Constant, undistracted supervision around any water

Bicycle & pedestrian

•ALWAYS wear a helmet that fits securely

•Look both ways before crossing the street

•Reflective clothing and lights at dusk

Home safety

•Store FIREARMS in locked cabinets, unloaded, with ammunition stored separately

•Develop and practice a FIRE SAFETY PLAN

•Store medications and chemicals securely

Media use

•Media use has increasingly DISPLACED other activities — reading, exercising, and playing with friends

•The average child or adolescent watches 3 to 4 hours of television per day

•Major concerns: GLAMORIZATION OF VIOLENCE, increased weight with screen hours, and promotion of RISKY BEHAVIORS

•Educate caregivers about content as well as duration

Booster seats and vehicle restraint

•A child should use a BOOSTER SEAT until the adult seat belt fits correctly

•That means reaching 4 feet 9 inches (1.45 m) in height, and being between 8 and 12 years of age, before stopping booster use

•When an adult belt is used, BOTH the lap and shoulder belt are worn

•The LAP BELT is worn LOW AND SNUG ACROSS THE THIGHS — not across the stomach

Why sleep matters

•School-age children require 9 TO 12 HOURS of sleep per night

•Adequate sleep is associated with a HEALTHY IMMUNE SYSTEM

•Improved ACADEMIC PERFORMANCE

•Overall BETTER MOOD

•Improved BEHAVIOR — sleep deficit frequently presents as irritability or inattention rather than sleepiness in this age group

Healthy bedtime routines

•A CONSISTENT BEDTIME, including on weekends

•Use the bed ONLY FOR SLEEP — not homework, screens, or play

•NO ELECTRONIC DEVICES for 2 hours before bedtime. Blue light wavelengths INHIBIT natural melatonin production

•DAILY PHYSICAL ACTIVITY improves sleep quality

•Keep the routine predictable: the sequence matters as much as the timing

Teaching and involvement- nutrition

•Teach children about their specific CALORIC NEEDS

•Allow children to ASSIST WITH MEAL PLANNING AND COOKING — this builds competence and increases acceptance of the food

•Encourage families to EAT TOGETHER

•Explain the benefits of a HEALTHY BREAKFAST

•Monitor CALCIUM AND VITAMIN D intake — bone mineralization accelerates in this period

What to limit and where to help- nutrition

•AVOID sugary drinks and snacks

•ENERGY DRINKS are dangerous and should be avoided entirely in this age group

•Assist families experiencing FOOD INSECURITY or limited resources — connect them with school meal programs and community resources

•Nutrition teaching that ignores access is teaching that cannot be followed

•Discourage skipping meals; promote 60 minutes of moderate activity daily for the whole family

Recognizing school refusal

•Unwillingness to attend school, or difficulty remaining in school for an entire day

•MULTIPLE SHORT ABSENCES or one PROLONGED absence

•Associated with SEVERE EMOTIONAL DISTRESS related to school — this distinguishes it from truancy

•Behaviors: refusing to board the bus, remaining in bed, temper tantrums, chronic lateness, severe misbehavior before school, or attending with great fear

•VAGUE SOMATIC SYMPTOMS — stomachache, headache, nausea — typically absent on weekends and holidays

•May be associated with recent LIFE STRESSORS: a move, a loss, a change of school, bullying

Peak ages- school reffusal

•Most common at ages 5 TO 7 — school entry and early transitions

•And again at ages 12 TO 14 — the move to middle or junior high school

•Also called school phobia or school avoidance

Nursing approach- school reffusal

•A MULTIDISCIPLINARY approach to treatment — family, school, primary care, and mental health

•Rule out organic causes for the somatic complaints first

•The goal is RETURN TO SCHOOL, generally as soon as possible, with supports in place

•Assess for bullying, learning difficulty, and anxiety disorders as underlying contributors

STREPTOCOCCAL pharyngitis may also present with a

SANDPAPER-LIKE RASH

TONSILLITIS is more likely to be

VIRAL

TONSILLAR HYPERTROPHY may lead to

airway obstruction and/or sleep apnea — assess for snoring and daytime sleepiness

Treat STREPTOCOCCAL pharyngitis and tonsillitis with

ANTIBIOTICS

Viral pharyngitis is managed supportively

fluids, analgesics, antipyretics, rest

THE REASON ANTIBIOTICS MATTER:

RHEUMATIC FEVER, which causes heart valve disease, can follow a streptococcal infection — usually strep throat

Also assess for post-streptococcal

glomerulonephritis and peritonsillar abscess

Early adolescence

10 to 13 years

•Concrete thinking still predominates

•Body changes begin and dominate attention

•Same-sex peer groups remain central

•Beginning to question parental authority

Middle adolescence

14 to 17 years

•Abstract reasoning develops

•Peer group influence is at its strongest

•Risk-taking behaviors increase

•Dating and romantic relationships emerge

Health Assessment of the Adolescent

•Annual health promotion visits continue through adolescence

•PRIVACY IS IMPORTANT — perform the health history and assessment WITHOUT the caregiver present

•Then allow the caregiver an opportunity to ask questions

•Adolescents and parents should be allowed to CHOOSE who is present during the physical examination

•ESTABLISH RAPPORT first; direct questions to the ADOLESCENT, not the parent

•SITTING while taking the history promotes comfort between nurse and client

•Examine in a sequential, HEAD-TO-TOE manner and KEEP THE BODY COVERED as much as possible

HEADSS — completed away from the caregiver

• Home

• Education/Employment

• Activities

• Drugs

• Sexuality

• Suicide/Depression

The PREFRONTAL CORTEX is undeveloped until

adolescence or early adulthood. This is the region governing judgment, impulse control, and consequence anticipation — and it explains much of the risk-taking of this period.

WISDOM TEETH erupt during

Adolescence Assess for pain, crowding, and access to dental care.

GROWTH PLATES CLOSE in

in middle to late adolescence. SKELETAL growth occurs BEFORE muscle growth, which contributes to temporary awkwardness. MUSCLE DEVELOPMENT is greater in males.