1.THEORIES & FACTORSAFFECTING GROWTH AND DEVELOPMENT (KOHLBERGS AND FOWLERS THEORY) Submitted to :Mrs. B. Padmavathi madamDept. of Pediatrics M.sc(N)CON-NIMS

2. INTRODUCTION: The period of growth and development extendsthroughout the life cycle. Changes occur is from conception to the adolescence. Growth and development is a process where theperson thinks normally, eventually & takes aresponsible place in society. It is important for a nurse to understand the earlyperiods as well as the total life cycle of an individual tobetter understand the behaviour of parents and otherswho provide care of the child. 3. WHY IT IS IMPORTANT ?Knowledge of growth and development is important to the nurse for the following reasons: To know the expected growth of a child at a given ageand certain kinds of behaviors. The nurse uses thisknowledge to observe and assess each child in terms ofnorms or specific levels of development. To plan for the nursing management and to help informulating the plan of total care of the child 4. To better understand the reason for particular condition & illness those occur in various age groups. To teach parent how to observe and to use their knowledge so that they may help their children achieve optimal growth & development. This seminar presents information helpful for adapting care to the needs of the children, factors affecting growth and development, types of classification of development and theories 5. TERMINOLOGY AND DEFINITIONS: GROWTH: Growth refers to an increase in physical size of wholeor any of its part and can be measured in inches/centimeters and in pounds/ kilograms.-According to the text book ofMarlow; 6th edition- Growth of full size or maturity, as in the progress of anegg to the adult stage-Tabers cyclopedia 20th edition- 6. DEVELOPMENT: Development refers to progressive increase in skill andcapacity. -According to the text book of Marlow; 6th edition- Development, maturation or expansion of physicalstructures or cognitive & psychological abilities. Theprocess may be normal, as in the development of afetus or a child, or pathological, as in a cyst or amalignant tumor -Tabers cyclopedia 20th edition-MATURATION: The term maturation is the synonym for developmentin reference to the development of traits carriedthrough genes. 7. CHARACTERISTICGROWTH & DEVELOPMENTS 8. CHARACTERISTICS OF GROWTHAND DEVELOPMENT INDIVIDUAL DIFFERENCES READINESS FOR CERTAIN TASKS(CRITICAL PROCESS) RATE OF DEVELOPMENT SEQUENCE OF GROWTH AND DEVELOPMENT IRRELATEDNESS OF GROWTH AND DEVELOPMENT CHANGING IN GROWTH RATES OVER THE YEARS 9. PRINCIPLESOFGROWTH &DEVELOPMENT 10. PRINCIPAL OF GROWTH ANDDEVELOPMENT: Growth proceeds from the head down to the tail, or in a cephalocaudal direction. particularly evident during the period of first year of life after the birth, the head end of the child enlarge and develops before the tail end 11. Growth proceeds from the center, or midline, of the body to the periphery, or in a proximodistal direction. During the prenatal period, the limb buds develop before the rudimentary fingers and toes. During infancy, the large muscles of the arms and legs are subject to voluntary control earlier than the fine muscles of the hands and feet. This proximodistal development is bilateral and symmetric, for most of the parts and on both sides of the body. 12. As the child matures, general movements become more specific. Generalized muscle movements occur before fine muscle control is possible. At first, infants can make only random movements of the arms. Gradually they learn to use the whole hand in picking up a small object, than learn to pick it up with a pincer grasp i.e. between thumb and forefinger. As development progresses, the child can eventually learn to move just one finger or a thumb at a time. 13. STAGES OF GROWTH &DEVELOPMENT 14. STAGES OF GROWTH ANDDEVELOPMENT:- Prenatal period: Conception to birth, encompassingthe embryonic period (conception to 8 weeks) and thefetal period(8 weeks -ending in birth). Newborn(Neonatal) period: from birth to 2 to 4 weeks Infancy: from 2-4 weeks to one year. Toddler: from 1-3 years of age. Early child hood (Preschool): From 3 to 6 years. Late child hood (School): From the puberty to thebeginning of the adult life is called adolescence. 15. FACTORSAFFECTINGGROWTH &DEVELOPMENT 16. Factors affecting growth anddevelopment are 1. Hereditary 2. Sex 3. Race 4. Nationality 5. Environment 17. FACTORS INFLUENCING GROWTHAND DEVELOPMENT: HEREDITY: The heredity of a man and a woman determines that of their children. Embryonic life begins with the cytoplasm and nucleus of the fertilized ovum, genetically determine by both parents. The rate of growth is more alike among siblings than among unrelated persons. Some children are small not because of endocrine or nutritional disturbances but because of their genetic constitution. 18. SEX: Sex is determined in some countries at conception but it is not practiced in India. After birth the male infants are longer and heavier than female infants. Boys maintain this superiority until about 11 Years of age. Girls Mature earlier than boys, and are than taller on the average. During the prepubertal stage of growth and development, boys are again taller than girls. Bone development is more advanced in girls than in boys. Advance in osseous development is also demonstrated by the earlier eruption of permanent teeth in girls. 19. RACE:- Distinguishing characteristics called racial or subracialdevelopment in prehistoric humans. As too height, tooshort, tall do examples exist among all the races andsubraces. 20. NATIONALITY:-Many of the recent immigrants arrivals and their descendants of families in whom short stature is normally seen in United States. Even with the influence of good nutrition and environment, these children may not achieve the same heights as their peers in growth patterns 21. ENVIRONMENTPRE NATALENVIRONMENT INTELLIGENCEINTERNAL HARMONAL INFLUENCE EMOTIONSPOSTNATALENVIRONMENT CULTURE SOCIO-ECONOMY NUTRITION CLIMATE & SEASONEXTERNAL ORDINAL POSITION EXERCISE DEVIATIONS FROM +VE HEALTH 22. The Harmful prenatal factors are:- The fetus may suffer from nutritional deficiencies when themothers diet is insufficient in quantity or quality,regardless of her socio-economic standards. Mechanical problems may be present leading tomalposition in utero. The mother may suffer from metabolic endocrinedisturbances, such as diabetes mellitus which affects thefetus. If the mother is suffering from infectious diseases the fetusmay also be affected but there is less scientific proof. The fetus may also be affected by the treatment of radiationfor cancer if the mother is undergoing. 23. The mother may suffer from any infectious diseases duringgestation like TORCH infections 1st, 2nd and 3rd trimestersadversely influence the fetus. Erythroblastosis fetalis due to Rh incapability of the bloodtypes of the mother and the fetus may have a seriousinfluence upon the developing child. Faulty placental implantation may lead to nutritionalimpairment and anoxia. 24. Research has shown that smoking or the use of certain drugs such alcohol and phenytoin by the mother may result in prematurity or deformity of the child. If the mother has good prenatal care, many of these conditions can be prevented or treated thus ensuring a better prenatal environment for the fetus. 25. EXTERNAL ENVIONMENT:CULTURAL ENVIRONMENT: The effects of a particular culture on a child begin beforebirth . The nutrients the mother is expected to eat duringpregnancy are culturally determined.Delivery of the baby is culturally determined. After child is born, the child is cared for according to theculturally sanctioned pattern of child rearing. The behaviour expected of the child at each stage ofgrowth & development is culturally defined. 26. EXTERNAL ENVIRONMENTSOCIO ECONOMIC STATUS OF THE FAMILY: The environment of the lower socio economic groupsmay be less favorable than that of the middle & uppergroups. Parents in unfortunate financial circumstances . However public health & health education programsare gradually assisting such parents to provide bettercare for their children 27. EXTERNAL ENVIRONMENTNUTRITION: Nutrition is related to both the quantitative & qualitativesupply of food elements such as proteins, fats, carbohydrates,minerals & vitamins.During periods of rapid growth such as prenatal period,infancy, puberty & adolescence need high amount of proteins& calories are needed 28. EXTERNAL ENVIRONMENT The effects of inadequate nutrition or the causes of undernutrition include: An inadequate nutrition intake both qualitatively &quantitatively.Physical hyper activity or lack of adequate rest.A physical illness that causes an increase in nutritionalneeds but at the same time results in poor appetite & poorabsorption.An emotional illness that causes decreased food intake orinadequate absorption because of vomiting or diarrhea. 29. EXTERNAL ENVIRONMENT DEVIATIONS FROM NORMAL HEALTH: This may be cause by hereditary or congenital conditions, illness or injury & may result in altered levels of growth & development. Hereditary or congenital conditions may contribute to growth impairment or to an increase in height. Examples of conditions causing increase in height above normal include Marfan syndrome & klinefelter syndrome. 30. Long term or chronic illnesses of any type may haveadverse effects on growth & development. Certainillnesses like cystic fibrosis or mal absorptionsyndrome, an inability to digest & absorb food maylead to growth retardation. Congenital diseases or anomalies or chronic infectionsthat are present during rapid growth periods & criticalperiods of development have a temporary orpermanent delaying effects on the achievement ofnormal growth & development. 31. EXTERNAL ENVIRONMENT CLIMATE & SEASON: Climatic variations influence the infants health. It is important that parents may be unable to provideadequate refrigeration and extermination of flies & otherinsects The season of the year influences growth rates in height &weight, especially in older children. Weight gains are lowest in summer & autumn. Thegreatest gains in height among children occur in spring.The differences are mainly due to seasonal variations. 32. EXTERNAL ENVIRONMENTEXERCISES: Exercise, increases the circulation, promotes physiologicactivity & stimulates muscular development. Fresh air & moderate sun shine favor health & growth. Prolonged exposure to sunlight may cause tissue damageof the skin & even more consequences if the child isunprotected from the rays of the sun 33. EXTERNAL ENVIRONMENTORDINAL POSITION IN THE FAMILY: The first born child in the family is an only child in a familywho receives all the parental attention until the secondchild is born. The parents of the first born child are unusuallyinexperienced & may not know the successive stages ofgrowth & development. 34. INTERNAL ENVIRONMENTINTELLIGENCE: The child of high intelligence is likely to be taller &better developed than is the less gifted child. Also,intelligence influences mental and socialdevelopment. 35. INTERNAL ENVIRONMENTHARMONAL INFLUENCES:There is evidence that all the hormones in the body effect growth in some manner. Although 3 hormones are very important others also influence growth to an extent.a) Somatotropic harmone (STH) or growth hormone: Its major effect is on linear growth in height because it isessential in the proliferation of cartilage cells at theepiphyseal plates. The growth harmone stimulates skeletaland protein anabolism through the production ofsomatomedins or intermediary harmones. 36. HARMONAL INFLUENCE: An excess of growth harmone causes gigantism & lack results in dwarfism. 37. HARMONAL INFLUENCE:b) Thyroid harmone: Thyroxine (T4) & Tri Iodothyronine(T3)Thyrotrophic harmone(TH), produced byadenohypophysis stimulates the thyroid gland torelease T3,T4,TH. These thyroid harmones stimulatethe general metabolism & therefore are necessary foradvanced linear growth whereas a deficiency produces cretinism with stuntedphysical growth & mental retardation. 38. HARMONAL INFLUENCE:c) Harmones that stimulate the gonads. Theadenocorticotrophic harmone(ACTH): ACTH is produced by the adenohypophysis, stimulate the hypothalamus, which in turn causes the adenohypophyses to secrete gonadotrophic harmones. The gonadotrophic harmone stimulate the interstitial cells of the testes to produce testosterone & the interstitial cells of the ovaries produce estrogen. 39. Testosterone stimulates the development secondarysexual characteristics & the production ofspermatozoa in young man. Estrogen stimulates thedevelopment of secondary sexual characteristics & theresults in precocious puberty, whereas the deficiencyresults in delay in development. Other harmones that less directly influence theprocess of growth & development include insulin,parathormone, cortisol, & calcitonin. 40. INTERNAL ENVIRONMENT EMOTIONS: Relationships with significant other persons, mother,father, sibling, peers & teacher play a vital role in theemotional, social, & intellectual development of the child. If the child is given the necessary care & love thatpromotes healthy development, otherwise growth &development retardation may occur. emotionally deprived children may receive adequatenutrition but do not gain weight as expected & are pale &unresponsive. If emotional deprivation continues & lovingcare is not given over a period of time, the children mayhave repeated illness, become emotionally ill, or die at anearly age. 41. PHYSICAL GROWTH &DEVELOPMENT 42. PHYSICAL GROWTH& DEVELOPMENT Physical growth & development can be divided into 3 areas Biological growth Motor development Sensory development 43. BIOLOGICAL GROWTH changes in general body growth: Changes results from different rates of growth indifferent parts of the body during consecutive stages ofdevelopment eg :- the infants head constitutes 1/4th of the entirelength of the body at birth, where as the adults head isonly 1/8th of body length 44. BIOLOGICAL GROWTHLength or height: Some children reach adult heights in their early teens,but others continue to grow throughout lateadolescence. The periods of rapid growth are infancy & puberty. 45. BIOLOGICAL GROWTH Weight: Weight is influenced by all the increments in size & isprobably the best gross index of nutrition & health. Obesity may result from a glandular deficiency, but it is more likely due to over eating to a diet containing too much starch & fat and too little protein or lack of exercises. 46. BIOLOGICAL GROWTH Head circumference: The circumference of the head is an importantmeasurement since it is related to intracranial volume. An increase in circumference permits an estimation ofthe rate of brain growth. This measurement has arelatively narrow normal range of a particular agegroup. 47. BIOLOGICAL GROWTHThoracic diameter: Chest measurements increase as the child grows & theshape of the chest changes. At birth the transverse &anteroposterior diameters are nearly equal. Thetransverse diameter increases more rapidly than doesthe anteroposterior diameter i.e the width becomesgreater than the depth. 48. BIOLOGICAL GROWTH Abdominal & pelvic measurements: The abdominal circumference is not fixed by a bonycage as in the chest; consequently it is affected by theinfants nutritional state, muscle tone, gaseousdigestion & even the phase of respiration. The pelvicbi-cristal diameter (the maximal distance between theexternal margins of the iliac crest) is not affected byvariations in posture & musculature & is a good indexof a childs slenderness or stockiness. 49. MOTOR DEVELOPMENTMotor development depends on the maturation of the muscular, skeletal & nervous systems. The sequences of skills follow the cephalocaudal & proximal direction.Motor development is termed as 1. Gross motor. 2. Fine motor 50. MOTOR DEVELOPMENTGross motor activities include turning, reaching, sitting,standing & walking.Fine motor development is the involvement of reflexes.The child learns to use hands & fingers for thumbapposition, palmer grasp, release, pincer grasp and soon.Motor development is not affected by sex, geographicresidence, or level of parental education, althoughadequate nutrition & good health exert a positiveinfluence. Motor development varies widely in youngchildren. 51. SENSORY DEVELOPMENTThe sensory system is functional at birth, the child gradually learns the process of associating meaning with a perceived stimuli. As myelination of the nervous system is achieved, the child is able to respond to specific stimuli. 52. THEORIES OF GROWTH &DEVELOPMENT TYPES OF THEORIES OF GROWTH &DEVELOPMENT: Intellectual development or Jean piaget theory or cognitivedevelopment. Moral development or Jean piaget & Lawrence Kohlbergtheory. Emotional development or Erik. H Erikson theory orpsychosocial development. Development of sexuality or Sigmund Freuds theory orpsycho-sexual theory or development. Spiritual development or James. W Fowlers theory. Language development. Development of self concept. 53. CATEGORIESCategories of development:Theoretical foundations of personality development:Psycho-sexual development (freud)Psycho-social development (Erickson)Theoretic foundations of mental development:Cognitive development (piaget)Language developmentMoral development (Kohlberg)Spiritual development(Fowlers)Development of self concept:Body image Self esteem 54. THEORY OF LAWRENCE KOHLBERG & JEAN PIAGET:(Motor development)Moral development described by Kohlberg(1963) is based on cognitive developmental therapy & consist of following three levels.Kohlberg postulates six stages of potential moraldevelopment organized in three levels. Pre-conventional morality. Conventional morality. Post-conventional morality. 55. Level-1: pre-conventional morality :- The pre-conventional level of moral developmentparallels the pre-operational level of cognitivedevelopment & intuitive thought. Culturally oriented to the labels of good/ bad & right/wrong, children integrate these in terms of physicalpleasurable consequences of their actions. They avoid punishment & obey without question The elements of fairness, give & take, and equalsharing are evident, they are interpreted in a verypractical, concrete manner without loyalty, gratitudeor justice. 56. Stage 0: the good is what I like & want (0-2 years ofage) The infants & younger toddlers are egocentric, likingor loving that which helps them and disliking orhating that which hurts them. Stage 1: punishment- obedience orientation (2-3years). The older toddlers & young pre-school childrenbelieve that if they are not punished, their acts areright. If they are punished their acts are wrong.Children therefore, act to avoid displeasing those whoare in power. This is the stage where mothersrepeatedly say NO-NO. 57. Stage 2 : Instrumental hedonism and concrete reciprocity (4 to 7 years of age). Children focus on the pleasure motive. They consider those actions right that meet their own needs or those of other. They carry out rules to satisfy themselves 58. Level II CONVENTIONAL MORALITY This level corrects the behaviour and the authority, ifthe behaviour not acceptable the children feel guilty. Stage 3: Orientation to interpersonal relations ofmutuality (7 or 8 to 9 years). Children of early schoolage are becoming socially sensitive and want to gainthe approval of others.If their actions help them gain the approval of theirfamily, peers, teachers they are right. Disturbedrelationships result their actions are wrong. 59. Stage 4: Maintenance of social order, fixed rules, and authority (10-12 years of age). Children want to do what is right and what they consider to be their duty. They obey rules for their own sake. Children see justice as reciprocity between the individuals and the social system.For example they assume responsibility on the schoolsafety patrol and when carrying out their duties, showrespect for those in authority. They want to maintainorder among their peers. 60. LEVEL III POST CONVENTIONAL, AUTONOMOUS,(OR) PRINCIPLED LEVEL: Stage 5: Adolescence & adulthood. Adolescent make choices on the basis of principles thathave been thought about, accepted & internalized.What ever actions conform to these principles areconsidered right inspite of the praise or blame of others. 5(a) : Social contract, utilitarian law making prespective. 5 (b) : Higher law and conscience orientation. They areconcerned that good laws be created that will maximize theindividuals welfare. They do not want something withoutpaying for it, and if they belong to group they work towardsits goal. 61. Stage 6 : Universal ethical principle of orientation. This is the level of highest moral value, and period in which individual can motivate, evaluate themselves. They have reached the level of self-actualization. 62. FOWLERS THEORY (SPIRITUALDEVELOPMENT) Spiritual beliefs are closely related to the moral andethical portion of the childs self concept. Fowler(1974) has identified seven stages in the developmentof faith, four of which are closely associated with andparallel cognitive and psychosocial development inchild hood. 63. The stages of spiritual development are: stage 0 : Primal faith (undifferentiated infancy) : This stage of development encompasses the period of infancy during which children have no concept of right or wrong, no beliefs, and no convictions to guide their behaviour. 64. Stage 1 : Intuitive projective faith (early child hood): Toddler hood is primarily a time of imitating the behaviour of others. Children imitate the religious gestures and behaviors of others without comprehending any meaning or significance to the activities. During the preschool years children assimilate some of the values and beliefs of their parents. Parental attitude toward moral codes and religious beliefs convey to children what they consider to be good and bad. 65. Stage 2: Individuating Reflexive : Adolescents become more skeptical and begin to compare the religious standards of their parents with those of others. They attempt to determine which to adopt and incorporate into their own set of values. They also begin to compare religious standards with the scientific view point. It is a time of searching rather than reaching. 66. LANGUAGE DEVELOPMENT The rate of speech development varies from child tochild and directly related to neurologic competenceand cognitive development. Gestures precedes speech, and in this way a small childcommunicate satisfactorily. As speech develops,gestures recedes but never disappears entirely. At all the stages of language development, childrenscomprehension vocabulary is greater than theirexpressed vocabulary. And this development reflects acontinuing process of modification that involves boththe acquisition of new words and the expanding andrefining of word meanings previously learned. 67. Language development The first parts of speech used are nouns, sometimesverbs and combination words such as (bye-bye).Responses are usually structurally incomplete duringthe toddler period, although the meaning is clear. Next they begin to use adjectives and adverbs toqualify nouns and verbs. Later pronouns and genderwords are added (such as he and she). By the timechildren enter school, they are able to use simple,structurally complete sentences that average five toseven words. 68. DEVELOPMENT OF SELF CONCEPT The term self concept includes all the notions, beliefs, and convictions that constitute an individuals self knowledge and that influence that individuals relationships with others. It is not present at birth but develops gradually as a result of unique experiences with in the self, with significant others and with the realities of the world. 69. BODY IMAGE Body image refers to the subjective concepts and attitudes that individuals have toward their own bodies. It consists of the physiologic, psychological and social nature of ones image of self. Body image is a complex phenomenon that evolves and changes during the process of growth and development. 70. SELF ESTEEM Self esteem is the value that on individual places ononeself. Self esteem is described as the affectivecomponent of the self, where as self concept is thecognitive component. The term self-esteem refers to a personal, subjectivejudgment of ones worthiness derived-from andinfluenced by the social groups in the immediateenvironment and individuals perceptions. Self esteem changes with development. 71. SUMMARY 72. THANK YOU