M. M.

COLLEGE OF NURSING
MULLANA, AMBALA

SUBJECT: PEDIATRIC NURSING

TOPIC: HISTORY TAKING OF CHILDREN AND

DEVELOPMENTAL ASSESSMENT

SUBMITTED TO: Submitted by:

Ms. Jyoti Bala Janet
Chaudhary
Lecturer M. Sc Nursing
1st Year
 1909719

HISTORY TAKING OF CHILDREN AND

DEVELOPMENT ASSESSMENT

INTRODUCTION: -
History taking in paediatrics is different from that in adults. Experienced paediatrician do extremely
well because mothers are very good historians and older children can contribute to the case
history. Observation of the child’s behaviour and feeding can give useful clues about the
diagnosis. The format used for history taking may (1) Direct – the nurse asks for information via
direct interview with the informant. (2) Indirect – the informant supplies the information by
completing some type of questionnaire. During history taking these must be observed – the
consulting room should be attractive, colourful and there should be some toys, different kinds of
toys to appeal to the children of different age groups. The physicians should greet the child and
parents and should make them feel comfortable. The infant should be allowed to sit in the
mother’s lap. The child should be observed while listening to the history.

The history should be taken in detail and suitably edited and presented under the following
headings: -

1. Personal data
2. Chief complaints
3. History of present illness
4. History of past illness

(a) Birth history

(b) Previous illness, injuries or operations
(c) Allergies
(d) Current medications
(e) Immunization
(f) Growth and development
(g) Habits

5. Family medical history

6. Psychosocial history
7. Sexual history
8. Family history
9. Nutritional assessment
10. Summary
1. PERSONAL DATA: -
 Name
 Age
 Sex
 Address
 Telephone
 Birth date and place
 Race/ ethnic
 Religion
 Date of interview
 Informant

These may give clues for the diagnosis of certain conditions prevalent in certain age groups, sex
or geographical areas. Mothers and primary caregivers give a good history, even when someone
else has given the history, it is better to get the mother’s view about the illness. It is mandatory to
record about the informant e.g. the informant is the mother and the history is reliable.

Informant: One of the important elements of identifying information is the person(s) who furnished
the information. Record: -

 Who the person is (child, parent or other).

 An impression of reliability and willingness to communicate
 Any special circumstances such as the use of an interpreter or conflicting answers by more
than one person.

2. CHIEF COMPLAINTS: -
The chief complaint is the specific reason for the child’s visit to the clinic or hospital. It may be
viewed as the theme with the present illness as the description of the problem. The chief
complaints should be listed in chronological order. It is elicited by asking open- ended neutral
questions such as “what seems to be the matter?” “How may I help you?” avoid labelling- type
questions such as “how are you sick?” or “what is the problem?”In a disease starting in the
perinatal period, the complaints should be listed from the time of birth. It is also worth mentioning
whether it is a previously well child or an ill child who has come with the present complaints .

3. HISTORY OF PRESENT ILLNESS: -

The history of the present illness is a narrative of the chief complaint from its earliest onset through
its progression to the present. Its four major components are: -

 The details of onset.

 A complete interval history.
 The present status.
  The reason for seeking help now.

The focus of the present illness is on all factors relevant to the main problem even if they have
disappeared or changed during the onset, interval and present. The description about pain should
include the site, radiation, severity, duration timing, character, aggravating factors and relieving
factors.

4. HISTORY OF PAST ILLNESS: -

The past history contains information relating to all previous aspects of the child’s health status
and concentrates on several areas that are ordinary detailed in the history of an adult such as birth
history, detailed feeding history, immunizations and growth and development. Since a great deal
of information is included in this section, use a combination of open- ended and fact- finding
questions e.g. statements such as “tell me about your child’s birth” to provide the informants with
the opportunity to relate what they think is most important.

 Birth history: - The birth history includes all data concerning: -

(1) The mother’s health during pregnancy,
(2) The labour and delivery,
(3) The infant’s condition immediately after birth.

Since prenatal influences have significant effects on a child’s physical and emotional
development, a thorough investigation of birth history is essential. Because parents may
question what relevance pregnancy and birth have on the child’s present condition.
Emotional factors also affect the outcome of pregnancy and the subsequent parent- child
relationship, investigate

1. Concurrent crises during pregnancy

2. Prenatal attitudes toward the fetus

Asking parents if the pregnancy was planned is a leading statement because they may
respond affirmatively for fear of criticism if the pregnancy was unexpected. Rather
encourage parents to disclose their true reactions by referring to specific facts relating to
the pregnancy such as the spacing between offspring, an extended or short interval
between marriage and conception or the concurrent experience of pregnancy and
adolescence. If the parent remains silent, refocus on this topic later in the interview.

 Previous illness, injuries and operations: - When inquiring about past illnesses, begin
with a general statement such as “What other illnesses has your child had?” Since parents
are most likely to recall serious health problems, ask specifically about colds; earaches and
childhood diseases such as measles, rubella, chickenpox, mumps, pertussis etc. Also ask
about injuries that required medical intervention, operations and any other reason for
hospitalization including dates of each incident.

 Allergies: - Ask about common known allergic disorders such as hay fever, asthma,
unusual reaction to drugs, foods or latex products and reaction to other contact agents such
as poisonous plants, animals, household products or fabrics.
 Current medication: - Inquire about the current drug regimens including vitamins,
antipyretics (especially aspirin), antibiotics, antihistamines or antitussives. List all
medications including name, dose, duration and reason for administration. Often parents
are unaware of the drug’s actual name, ask parents to bring the containers with them to the
next visit.

 Immunization: - A record of all immunization is essential. Since many parents are unaware
of the exact name and date of each immunization, the most reliable source of information is
a hospital, clinic or private practitioner’s record. All immunizations are “boosters” are listed,
stating:-
1. The name of the specific disease
2. The number of injections
3. The dosage (sometimes lesser amounts are given if a reaction is anticipated
4. The ages when administered
5. The occurrence of any reaction following the immunization.

 Growth and development: - The most important previous growth patterns to record are:
1. Approximate weight at 6 months, 1 year, 2year and 5 year
2. Approximate length at ages 1 and 4 years
3. Dentition, including age of onset, number of teeth and symptoms during teething

Development milestones include: -

1. Age of holding up head steadily.

2. Age of sitting alone without support.
3. Age of walking without assistance.
4. Age of saying first words with meaning.

Use specific questions when inquiring about developmental milestones. The area of
developmental or intellectual performance can be delicate one for parents especially if
there is concern for child’s progress. Therefore, approach such questioning with broad
questions, such as “How is jimmy doing in school?” rather than with qualifying statements
such as “Does Jimmy do well in school?”

 Habits: - Habits are an important area to explore. Parents frequently express concerns
during this part of the history. Encourage their input by saying, “Please tell me any
concerns you have about your child’s habits, activities or development.” One of the most
common concerns relates to sleep. Many children develop a normal sleep pattern; however
a number of children also develop sleep problems. When sleep problem occur, a more
detailed sleep history is required in order to guide appropriate interventions.

Habits related to use chemicals apply primarily to older children and adolescents. If a
youngster admits to smoking, drinking or drug use, ask about the quantity and frequency.
Clarify that “drinking” includes all types of alcohol such as beer and wine.
5. FAMILY MEDICAL HISTORY: -
The family history is used primarily for the purpose of discovering the potential existence of
hereditary or familial diseases in the parent and child, as well as family habits that may affect the
child’s health such as smoking and other chemical use. It is confined to first degree relatives and
is easily recorded using a pedigree chart or genogram. Information about each family member
includes age, marital status, state of health if living, cause of the death if deceased and any
evidence of conditions like hypertension, diabetes mellitus, obesity etc. In case of genetic
diseases, inquire about the pattern of family transmission of the disorders. Confirm the accuracy of
the reported disorders by inquiring about the symptoms, course, treatment and sequelae of each
diagnosis. Details of temporary and permanent methods of family planning adopted by the family
also should be included.

6. PSYCHOSOCIAL HISTORY: -
In the traditional health history a personal and social section is included that concentrates o
children’s personal status, such as school adjustment and any unusual habits and on the family
and home environment. Obtain a general idea of how children handle themselves in terms of
confidence in dealing with others and ability to answer questions. Watch the parent- child
relationship for the types of messages sent to children about their self- worth. Do the parents treat
the child with respect, focusing on strengths or the emphasis on child’s weakness and faults?
Messages about the body image are also conveyed through the parent- child interaction. Does the
parent label the child and body parts such as “bad boy”, “skinny legs” or ugly scars”.

7. SEXUAL HISTORY: -
The sexual history is an essential component of an adolescent health assessment and requires a
professional sensitivity when inquiring about personal information. The history uncovers the areas
of concern related to sexual activity, alerts the nurse to circumstances that may indicate screening
for sexually transmitted diseases or test for pregnancy and provides information related to the
need for sexual counselling such as safe sex practice. One approach toward initiating a
conversation about sexual concerns is to begin with a history of peer interaction. Open- ended
statements such as “Tell me about your social life,” or “Who are your closest friends?” In any
conversation regarding sexual history, be aware of the language that is used in either eliciting or
conveying sexual information.

8. FAMILY HISTORY: -
Family assessment is the collection of data about the composition of the family and the
relationships among its members. Family structure refers to the composition of the family who
lives in the home and those social, cultural, religious and economic characteristics that influence
the child’s and family’s overall psychobiologic health. The most common method of eliciting
information on family structure is interviewing family members. The genogram (family tree) uses
symbols to dramatically record data about family structure. Since the genogram is also concerned
with the strength of the family relationships, attachments symbols are often added as additional
information on family functioning is obtained.

9. NUTRITIONAL ASSESSMENT: -
A nutritional assessment is an essential part of a complete health appraisal. Knowledge of the
child’s dietary intake is a useful and practical component of a nutritional assessment. The exact
questions used to elicit a dietary history vary with the child’s age. The dietary history is concerned
with financial and cultural factors that influence food selection food and preparation. Because
cultural practices are very prevalent in food preparation, it is important to consider carefully the
kinds of questions that are asked and the judgements made in regard to counselling. The most
common and easiest method of assessing daily intake is the 24- hour recall. Some of the
difficulties with a daily recall are the family’s inability to remember exactly what was eaten and
inaccurate estimation of portion size. To improve the reliability of the daily recalls have the family
complete a food dairy by recording every food and liquid consumed for a certain number of days.
A food frequency questionnaire or record provides information about the number of times in a day,
week, or month a child consumes items from the food groups e.g. bread, cereal, rice, milk,
cheese, yogurt, vegetables, fruits, juices, other protein foods, fats , oils, sweets etc.

10. SUMMARY: -
It is a good practice to summarise the relevant points in the history e.g. a two year old
unimmunised male child from a low socio- economic status with a history of contact with an open
case of TB is presenting with fever, altered sensorium and convulsions. The summary can also be
presented after completing the physical examination.
 DEVELOPMENT ASSESSMENT

INTRODUCTION: -
The period of growth and development extends throughout the life cycle, however the period in
which the principal changes occur is from conception to the end of adolescence.

GROWTH- Growth refers to an increase in physical size of the whole or any of its parts and can
be measured in inches or centimetres and in pounds or kilograms.

DEVELOPMENT- Development refers to a progressive increase in skill and capacity to function. It

causes a qualitative change in the child’s functioning.

Growth and development are continuous and orderly processes that have predictable sequences.
Although the rate of progress vary, all human beings go through the same stages on their way to
their physical increase in size and the maturation of neuromuscular functions.

PRINCIPLES OF GROWTH AND DEVELPMENT: -

1. Growth proceeds from the head down to the tail or in a cephalocaudal direction.
2. Growth proceeds from the centre or midline of the body to the periphery or in a
proximodistal direction.
3. As the child matures, general movements become more specific. Generalized muscle
movements occur before fine motor control is possible.

MAJOR THEORIES OF DEVELOPMENT: -

1. PSYCHOSEXUAL DEVELOPMENT (FREUD -1933) : -

Freud considered the sexual instincts to be significant in the development of the

personality. He used the term psychosexual to describe any sexual pleasure. During
childhood certain regions of the body assume a prominent psychologic significance as the
source of new pleasures and new conflicts gradually shifts one part of the body to the
another at particular stages of development.

 Oral stage (birth to 1 year): - During infancy the major sources of pleasure seeking is
centred on oral activities such as sucking, biting, chewing and vocalizing. Children may
prefer one of these over the others and preferred method of oral gratification can provide
some indication of the personality.
 Anal stage (1 to 3 years): - Interest during the second year of life centres in the anal
region as sphincter muscle develops and children are able to withhold or expel faecal
material at will. At this stage the climate surroundings toilet training can have lasting effects
on children’s personalities.
  Phallic stage (3 to 6 years): - During the phallic stage the genitals become an interesting
and sensitive area of the body. Children recognize differences between the sexes and
become curious about the dissimilarities. This is the period around which the controversial
issues of the Oedipus and Electra complexes, penis envy and castration anxiety are
centred.
 Latency period (6 to 12 years): - During the latency period children elaborate on
previously acquired traits and skills. Physical and psychic energy are channelled into
acquisition of knowledge and vigorous play.
 Genital stage (age 12 and older): - The last significant stage begins at puberty with
maturation of the reproductive system and production of sex hormones. The genital organs
become the major sources of sexual tensions and pleasures but energies are also invested
in forming friendships and preparing for marriage.

LIMITATIONS OF THE THEORY: -

 The theory was difficult to test, too narrow and simple.

 It is based on primarily on biological drivers rather than socio- cultural influences and
learning.
 It depends on instincts, defence memories of maladjusted adult clients.
 There is minimal information on the exact factors responsible for changes in an individual’s
life.
 The theory produces a variety of new questions about human development, probably
because it is so complex.
 The theory did not describe the concept of unconscious motivation for behaviour and the
importance of early family experience and later development.

2. PSYCHOSOCIAL DEVLOPMENT (ERIKSON): -

The most widely accepted theory of personality development is that advanced by Erikson
(1963). It is known as psychosocial development and emphasizes a healthy personality as
opposed to a pathologic approach. Each psychosocial stage has 2 components- the
favourable and unfavourable aspects of the core conflict and progress to the next stage
depends on resolution of this conflict.

 Trust vs. mistrust (birth to 1 year): - The first and most important attribute to develop for
a healthy personality is a basic trust. Establishment of basic trust dominates the first year
of life and describes all of a child’s satisfying experience at this stage. Mistrust develops
when trust- promoting experiences are deficient or lacking or when basic needs are
inconsistently or inadequate met. Although shreds of mistrust are sprinkled throughout the
personality, from a basic trust in parents stems trust in the world, other people and oneself.
 Autonomy vs. Shame and doubt (1 to 3 years): - Corresponding to Freud’s anal stage,
the problem of autonomy can be symbolized by the holding on and letting go of the
sphincter muscles. Negative feelings of doubt and shame arise when children are made to
feel small and self- conscious, when their choices are disastrous, when others shame them
or when they are forced to be dependent in areas in which they are capable of assuming
control. The favourable outcomes are self- control and willpower.

 Initiative vs. Guilty (3 to 6 years): - The stage of initiative corresponds to Freud’s phallic
stage and is characterized by vigorous, intrusive behaviour, enterprise and a strong
imagination. Children sometimes undertake goals or activities that are in conflict with those
 of parents or others and being made to feel that their activities or imaginings are bad
produces a sense of guilt.
 Industry vs. Inferiority (6 to 12 years): - The stage of industry is the latency period of
Freud. Children learn to compete and cooperate with others and they learn the rules. It is a
decisive period in their social relationships with others. Feeling of inadequacy and inferiority
may develop if too much is expected of them or if they believe that they cannot measures
up to the standards set for them by others. The ego quality developed from a sense of
industry is competence.
 Identity vs. role confusion (12 to 18 years): - Adolescence struggle to fit the roles they
played and those they hope to play with the current roles and fashions adopted by their
peers, to integrate their concepts and values with those of society and to come to a
decision regarding an occupation. Inability to solve the core conflict results in role
confusion. The outcome o successful mastery is devotion and fidelity to others and to
values and ideologies.

LIMITATIONS OF THE THEORY: -

 Erikson believes he is biased against women and does not consider the difference between
men and women in relation to social and cultural influences.
 Imprecise about the cause of psychosocial development.
 The theory was not able to articulate specifically how outcomes of one stage impact
development at another stage or specify the kinds of experiences needed to resolve or
cope with conflicts.
 The theory describes development socially and emotionally, but does not explain well how
or why development occurs.
 The theory does not discuss observable behaviours indicating that trust, autonomy,
initiative or identity has been achieved.

3. COGNITIVE DEVELOPEMNT (PIAGET): -

Cognitive development consists of age-related changes that occur in mental activities. A

more comprehensive developmental theory than those already described, has been
developed by the Swiss psychologist Jean Piaget (1969). According to Piaget, intelligence
enables individuals to make adaptations to the environment that increase the probability of
survival and through their behaviour individuals establish and maintain equilibrium with the
environment. Piaget proposed three stages of reasoning: (1) Intuitive, (2) concrete
operational, (3) formal operation. The course of intellectual development is both maturation
and invariant and is divided into the following stages: -

 Sensorimotor (birth to 2 years): -

The sensorimotor stage of intellectual development consists of six sub stages that are
governed b y sensation in which simple learning takes place. Children develop a sense of
 “cause and effect” as they direct behaviour toward objects. They display a high level of
curiosity, experimentation and enjoyment of novelty and begin to develop a sense of self as
they are able to differentiate themselves from their environment. The sensorimotor stage is
divided into six sub- stages: -

 The reflexive phase (birth to 1 month) is characterized by predictable, innate

survival reflexes (sucking, grasping) becoming more efficient and generalized.

 The primary circular reaction phase (1- 4months) the infant performs more
complex, repetitive behaviours that appears to be responses to initial chances
events centering on the infant’s own body. Infants during this phase commonly look
and reach for objects in their environment.

 The secondary circular reaction phase (4 – 8 months) the infant learns from
intentional behaviour usually explores the world from a sitting position and begins to
show some understanding of objects. Motor skills and vision become further
coordinated and interest in the environment increases.

 The coordination of secondary phase (8- 12 months) occurs when the infant
understands concepts of space and object, learns to direct actions toward an
intended goal and anticipates actions of others.

 The tertiary circular reaction phase (12- 18 months) is characterized by interest in

novelty and repetition, awareness that objects which are out of sight continue to
exist, understand causality. Solution to the problems will be discovered, objects will
be increasingly explored to learn how they work and new behaviours developed.

 The mental combinations phase (18- 24 months) young children are able to think
before acting and use memory for simple trial and error problem solving. They can
name and locate familiar objects predict effects when observing causes, imitates
behaviour and demonstrate symbolic and ritualistic play.

 Preoperational(2 to 7 years): -
The predominant characteristics of the preoperational stage of intellectual development is
egocentrism, which in this sense does not mean selfishness or self- centeredness, but the
inability to put oneself in the place of another. Preoperational thinking is concrete and
tangible. Through imaginative play, questioning and other interacting, they begin to
elaborate concepts and to make simple associations between ideas. In the latter stage of
this period their reasoning is intuitive. Reasoning is also transductive- because two events
occur each other or knowledge of one characteristic is transferred to another.

 Concrete operations (7 to 11 years): -

At this age thought becomes increasingly logical and coherent. Children are able to
classify, sort, order and otherwise organize facts about the world to use in problem solving.
 They solve problems in a concrete, systematic fashion based on what they can perceive.
Reasoning is inductive. They can consider points of view other than their own. Thinking has
become socialized.

 Formal operations (11 to 15 years): -

Formal operational thought is characterized by adaptability and flexibility. Adolescents can
think in abstract terms, use abstract symbols and draw logical conclusions from a set of
observations.

LIMITATIONS OF THE THEORY: -

 The theory pays little attention to the influences of emotions and motivation on learning.
 The theory does not fully explain how children progress from one stage to another
 The theory focus is on cognitive development rather than on other areas of development.
 The theory requires ore explanation than the behavioural theories but less explanation than
the psychodynamics theory.

4. KOHLBERG’S THEORY OF MORAL DEVELOPMENT: -

Moral development is based on the cognitive developmental theory and consists of three
major levels, each with two stages. Kohlberg’s theory (1968) allows for prediction of
behaviour but pays little attention to individual differences.

 Preconventional (4 to 7 years): -
At this level morality is external because children conform to rules imposed by authority
figures. Culturally oriented to the labels of good and bad/ right and wrong, children integrate
these labels in term of the physical or pleasurable consequences of their actions. Decisions
are based on the desire to please others and to avoid punishment.

 Conventional (7 to 11 years): -
Children are concerned with conformity and loyalty, actively maintaining, supporting and
justifying the social order. Conscience or an internal set of standards becomes important.
Rules are important and must be followed to please other people and “be good”. This level
correlates with the concrete operational stage in cognitive development.

 Postconventional (12 years and older): -

Children have reached the cognitive formal operational stage and they endeavour to define
moral values and principles that are valid and applicable beyond the authority of the groups
and persons holding these principles. The individual has internalized ethical standards on
which to base decisions. Social responsibility is recognized. The value in each of two
differing moral approaches can be considered and a decision made.

LIMITATIONS OF THE THEORY: -

  The theory is important and offers a detailed stage sequence for moral thinking.
 The theory seems more helpful in describing the moral reasoning of adolescents and adults
rather than young children.
 The theory is bias against women because his subjects were all male. Gilligan argues
women develop a different moral orientation than men because of how they are raised.
 There is scientific evidence women emphasize morality of care more than men do and they
travel different moral paths.

GROWTH AND DEVELOPMENT MILESTONES: -

AGE PHYSICAL GROSS MOTOR FINE MOTOR SENSORY NUTRITION
GROWTH MOTOR

Birth to 1  Gain 140-  Inborn reflexes  Holds hand  Prefer to  Eats every
month 200 g/ week such as startle in fist. look at 2- 3 hours,
 Head and rooting are  Draws arms faces and breast or
circumferenc predominant and leg to black and bottle feed
e increases active. body when white (60- 90 ml)
1.5cm/  May lift head crying. geometric per feeding
month briefly if prone. designs.
 Alerts to high-  Follows
pitched voices. objects in
 Comforts with line of
touch. vision.

2- 4  Gains 140-  Moro reflex  Holds rattle  Follows  Has

months 200 gm/ fading in when objects 180 coordinated
week strength placed in degree suck-
 Grows 1.5  Can turn side hand  Turns swallow
cm/ month to back and  Looks at head to look  Establishes
 Head then return and play for voices regular
circumferenc  Decrease in with own and sounds eating
e increases head lag when finger pattern of
1.5 cm/ pulled to sitting.  Readily 90- 120 ml
month  When prone, brings every 3-4
holds head and objects from hours.
support weight hand to
on forearms mouth

AGE PHYSICAL GROSS MOTOR FINE MOTOR SENSORY NUTRITION

GROWTH MOTOR
4- 6  Gains 140-  Head held Grasps rattle  Examines  Eats (100-
MONTHS 200 g/ week steady when and other complex 150 g) four
 Doubles birth sitting objects at will, visual or more
weight 5-6  No head lag drops them to images times/day
months when pulled to pick up  Watches the  Begins
 Grows 1.5 sitting another course of a baby food,
cm/ month  Turns from offered falling object usually rice
 Head abdomen to objects.  Responds cereals.
circumferenc back by 4 Mouths readily to
e increases months and objects sounds
1.5 cm/ then back to Hold feet and
month abdomen by 6 pulls to mouth
 Teeth may months  Holds bottle
be erupting  When held Grasp with
by 6 months standing whole hand
supports much Manipulates
of own weight objects

6- 8  Gains 85-  Most inborn  Bangs 2 Recognizes  Eats (160-

MONTHS 140g/week reflexes objects held name and 225 g) four
 Grows 1 cm/ extinguished in hands responds by times/ day
month  Sits alone Transfer looking and  Ears baby
 Growth rate steadily without objects from smiling food such
slower than support by 8 one hand to  Enjoys small as rice
first 6 months the other and complex cereal,
months  Like to bounce objects at fruits and
on legs when play vegetables
held in standing
position

8- 12  Gains 85-  Crawls or pull  Picks up  Understands  Eats (160-

MONTHS 140g/ week whole body small objects words such 225g) four
 Grows 1 cm/  Creeps by using  Uses pincer as “no” and times/day
month hands and grasp well “cracker”  Uses cup
knees to keep  May hold  May say 1 with lid and
trunk off floor crayon or word in attempts to
 Pulls self to pencil and addition to feed self
standing and mark on “mama” with spoon
sitting by 10 paper though
month spills often

AGE PHYSICAL GROSS MOTOR FINE MOTOR SENSORY NUTRITION

GROWTH MOTOR
8- 12  Stand alone  Places  Plays peek-  Eating
months  Walks holding objects into a-boo and most soft
onto furniture containers patty cake table foods
 Sits down from through with family
standing holes

1-2 years  Gains 227 g  Run stiffly, often  Builds a Visual acuity  Eats three
or more per falls tower of 6-7 20/40 meals per
month  Walks up and cubes Binocular day with
 Grows 9-12 down stairs,  Open boxes vision fully snacks
cm this year both feet on  Pokes finger developed  Drinks
 Anterior one step. in hole Identifies regular milk
fontanel  Likes push and  Turns pages various or follow up
closes pulls toys in a book 1 at shapes formula
 Climb on a time Inserts  Use cup
furniture  Transfer square and spoon
 Throws ball objects hand object into but often
overhead to hand at will its prefers
without falling  Opens door appropriate finger foods
 Pushes light by turning the place or
furniture around knob hole.
the room.  Unscrews lid
 Explores of jar
drawers,  Folds paper
closets etc. once
 Seats self in imitatively
small car  Makes cubes
 Kicks large ball into train, one
without falling. behind the
 Picks up object other
from floor
without losing
balance.

2-3 years  Gains 1.4-  Jumps  Draws a Visual acuity May begin
2.3Kg/year  Kicks ball circle and 20/20 to use fork
 Grows 5-6.5  Throws ball other Recalls visual but still
cm/ year over hand rudimentary images needs food
forms cut into bite
 Learns to size pieces.
pour
 Learning to
dress self

AGE PHYSICAL GROSS MOTOR FINE MOTOR SENSORY NUTRITION

GROWTH MOTOR
  Stands on one  Builds tower
foot alone of 9-10
 Walks up and cubes
down stairs,  Holds crayon
one foot on a with fingers
step, alternate instead of
feet entire hand
 Jumps from  Self- feeding
step or low with
chair occasional
 Walks on spilling
straight line  Gets a drink
 Walks on tiptoe without
for few steps assistant
upon request  Chews with
 Rides a walker mouth closed
or pedal car  Puts arms
through the
arm hole
 Buttons one
large front
button
 Toileting and
grooming
skills

3- 6 years  Gain 1.5-  Walks on  Copies a  Visual acuity  Eats bread,

2/5 Kg/ straight line circle, 20/20 vegetables,
year.  Walks square, fruits, milk.
 Grows 4-6 backward triangle
cm/ year.  Catches ball  Puts beads
with extended on string
arms and hands  Can pulls
 Runs on tiptoe pant up and
 Climbs ladder, down
trees,  Draws
playground simple face,
equipment vertical lines
 Balance on one  Can put
foot 8- 10 socks with
seconds help
 Roller skates  May be able
to lace shoes

AGE PHYSICAL GROSS MOTOR FINE MOTOR SENSORY NUTRITION

GROWTH MOTOR
6- 12 Gains 1.4- Rides two- Print words,  Visual acuity Eat three
years 2.2 Kg/ Year wheelers learns cursive 20/20 meals per
Grows 4- 6 Jump rope writing  Can read day
cm/ Year Roller skates or Draws a Concentrate  Enjoys
ice skates person with for longer preparing
Coordination 18- 20 parts periods on own food
improving Uses both activities by
Throws ball hands filtering out
skilfully independentl surrounding
Enjoys all y sounds
physical activity

12- 18  During  New sports  Skills are well  Fully  Large

years growth spurt- activities developed developed appetite
girls gain 7- attempted and which
25 Kg and muscle increases
grow 2.5- 20 development during
cm continues. growth
 Boys gain  Some lack of spurt.
approximatel coordination  Eats many
y 7- 29.5 Kg common during meals with
and grows growth spurt. friends,
11- 30 cm food
choices
influenced
by peers.

DEVELOPMENTAL ASSESSMENT:

A developmental assessment has several purposes

1. Validation that a child is developing normally

2. Early detection of problems
3. Identification of concerns of caregivers and child
4. Provision of an opportunity for anticipating guidance and teaching about appropriate
expected behaviours.

Several screening test are currently available for developmental assessment.

DEVELOPMENTAL SCREENING AND ASSESSMENT TOOLS: -
DATA COLLECTION: -

An important goal of the nurse in the collection of data is to assess the development, including
functional abilities and adaptive behaviours of neonates, infants and children within the
environment. Screening procedure are used by the nurse for this purpose because they can be
accomplished quickly and reliably, can determine those children whose level of development for
their chronologic ages and can provide baseline data for comparison with future assessment.
Children are screened for their progress in all areas of development. When assessing the
development stages of children, the nurse looks for strength as well as weakness.

Both mother and father can assist the nurse in the making the developmental assessments. They
can observe their child daily and share valid data with the nurse. Parents can assist in planning
and evaluating nursing care practices.

Accurate determination of behaviour is made during each assessment. Developmental

assessments of children are done on a serial basis, because progress or regression can be
determined only over a period of time.

1. THE BAYLEY SCALE OF INFANT DVELOPMENT:

The BSID are used to describe the current developmental functioning of infants and to assist in
diagnosis and treatment planning for infants with developmental delays or disabilities. The test is
intended to measure a child's level of development in three domains: cognitive, motor, and
behavioural. The BSID were first published by Nancy Bayley in The Bayley Scales of Infant
Development (1969) and in a second edition (1993). The scales have been used extensively
worldwide to assess the development of infants. The test is given on an individual basis and takes
45–60 minutes to complete. This is used to evaluate children between 6 to 30 months age. The
test contains items designed to identify young children at risk for developmental delay. BSID
evaluates individuals along three scales:

 Mental scale: This part of the evaluation, which yields a score called the mental
development index, evaluates several types of abilities: sensory/perceptual acuities,
discriminations, and response; acquisition of object constancy; memory learning and
problem solving; vocalization and beginning of verbal communication; basis of abstract
thinking; habituation; mental mapping; complex language; and mathematical concept
formation.

 Motor scale: This part of the BSID assesses the degree of body control, large muscle
coordination, finer manipulatory skills of the hands and fingers, dynamic movement,
postural imitation, and the ability to recognize objects by sense of touch (stereognosis).

 Behaviour rating scale: This scale provides information that can be used to supplement
information gained from the mental and motor scales. This 30-item scale rates the child's
relevant behaviours and measures attention/arousal, orientation/engagement, emotional
regulation, and motor quality.
RESEARCH ABSTRACT: -

Heart rate characteristics and neurodevelopmental outcome in very low birth weight
infants

K Addison, M P Griffin, J R Moorman, D E Lake, T M O'Shea

Background:
Sepsis in very low birth weight (VLBW) infants has been associated with an increased risk of
adverse developmental outcome. We have identified abnormal heart rate characteristics (HRCs)
that are predictive of impending sepsis, and we have developed a summary measure of an infant's
abnormal HRCs during the neonatal hospitalization that we refer to as the cumulative HRC score
(cHRC).

Objective:
In this study, we tested the hypothesis that increasing cHRC is associated with an increasing risk
of adverse neurodevelopmental outcome in VLBW infants.

Method:
Data were collected on 65 VLBW infants whose HRCs were monitored while in the neonatal
intensive care unit and who were examined at 12 to 18 months adjusted age. Using the Bayley
Scale of Infant Development-II, we identified delays in early cognitive function (i.e., Mental
Developmental Index <70) and psychomotor development (i.e., Psychomotor Developmental
Index <70). Cerebral palsy (CP) was diagnosed using a standard neurological examination.

Result:
Increasing cHRC score was associated with an increased risk of CP (odds ratio per 1 standard
deviation increase in cHRC: 2.6, 95% confidence limits: 1.42, 5.1) and delayed early cognitive
development [odds ratio: 2.3 (1.3; 4.3)]. These associations remain statistically significant when
adjusted for major cranial ultrasound abnormality. There was an association of increasing cHRC
and delayed psychomotor development, which did not reach statistical significance [odds ratio: 1.7
(1.0, 3.0)].

Conclusion:
Among VLBW infants, the cumulative frequency of abnormal HRCs, which can be assessed non-
invasively in the neonatal intensive care unit, is associated with an increased risk of adverse
neurodevelopmental outcome.
 The Correlation of Sucking Behaviors and Bayley Scales of Infant Development at Six
Months Of Age in VLBW Infants

Medoff-Cooper, Barbara; Gennaro, Susan

Background: The purpose of this study was to identify early predictors of developmental
outcomes in infants of very low birth weight (≤ 1,500 g). The sample consisted of 19 infants with a
mean birth weight of 1,238 g and a mean gestational age at birth of 29.1 weeks.

Method: The instruments used were the Kron Nutritive Sucking Apparatus, the Neonatal Morbidity
Scale, and the Bayley Scales of Infant Development (BSID).

Result: Mean pressure generated by each suck and the length of sucking bursts were positively
correlated (p < .05) with the Psychomotor Scale of the BSID. As a predictor of developmental
outcomes at 6 months of age, nutritive sucking demonstrated a 78% specificity and an 80%
sensitivity, as compared with neonatal morbidity, 58% and 69%, respectively. In a small sample of
relatively healthy preterm infants, their ability to suck helped identify those with questionable early
development.

2. THE DENVER PRESCREENING DEVELOPMENTAL QUESTIANNAIRE (PDQ): -

The PDQ identifies those children who need a more thorough screening test with the Denver
Developmental Screening Test (DDST). It is easy and fairly quick to administer. The
questionnaire consists of 97 questions, divided according to child’s age. The parent is asked to
answer the questions from the appropriate age grouping. If a child shows delay in development a
complete Denver Developmental Screening test is done as a follow up.

3. REVISED PRESCREENING DEVELOPMENTAL QUESTIONNAIRE (R-PDQ): -

The R- PDQ is a revision of the original PDQ. Advantages of the R-PDQ includes the addition
and arrangement of items to be more age – appropriate, simplified parent scoring and easier
comparison with DENVER II norms for professionals. The R- PDQ is a parent answered pre-
screen consisting of 150 questions, although only a subset of questions are asked for each age
group. Four different forms available e.g. Orange (0- 9 months), purple (9- 24 months), gold (2- 4
years), white (2- 6 years). Scoring is based on the number of delays. Children who have no
delays are considered to be developing normally. If the child shows delay DENVERII is
administered as soon as possible.
4. THE DENVER DEVELOPMENTAL SCREENING TEST (DDST): -

Developed originally by Frankenburg and Dodds (1967).The DDST is screening tool, not a
diagnostic procedure. It provides developmental profile of the individual child in four areas,
personal- social, fine motor- adaptive, language and gross motor skills. The Denver Development
Screening Test (DDST) is used in infancy and the preschool years. It has been standardized on
children of Denver. The DDST form is copyrighted. Forms, kits, manuals, and instructional films
and videos may be purchased through Denver Development Materials.

GENERAL INSTUCTIONS:

The parents should be told that the purpose is to obtain an estimate of the child’s level of
development and that the child will not be able to perform all test items. The test relies on the
observations of the child and on report by apparent who knows the child. Direct observation
should be used whenever possible. Every effort should be made to put the child at ease. The
younger child may be tested while on the parent’s lap in such a way that he or she can
comfortably reach the test materials on a table. One or two test materials may be placed in front of
the child while the parent is queried regarding personal-social items. The first test items chosen
should assure the child an initial successful experience. To avoid distractions it is best to remove
all the test materials from the table except those required for the test that is being administered.

STEPS IN ADMINISTERING THE TEST

1. Draw a vertical line on the examination sheet at the child’s chronologic age. Place the date
of the examination at the top of the age line. For children who were born prematurely,
subtract the month of the prematurity from the chronologic age. Adjust the age line
appropriately and note the amount of adjustment at the top of the line.

2. The items to be administered are those in the Personal-Social, Fine Motor-Adaptive.

Language and gross Motor sectors through which the child’s chronologic age line passes.
In each sector one should establish age levels at which the child [passes all the times and
at which all items are failed.

3. When the child refuses to do an item requested by the examiner, the parent may
administer the item, provided this is done in the prescribed manner.

4. If a child passes an item, a large letter “P” is written on the bar. “F” designates a failure and
“R” denotes a refusal.

5. Note is made on the child’s adjustment to the examination and relationship to parent,
examiner and to test materials.

6. The parent reports whether the child’s performance was typical. This is recorded.

7. For retesting, use the same form, with different colours for each scoring line and age.

8. Instructions for administering footnoted items are on the back of the test form.
INTERPRETATIONS: -

Each test item is designated by a bar. The left end of the bar, the hatch mark at the top of the bar,
the left end of the shaded area, and the left end of the bar designate respectively the ages at
which 25 percent, 75 percent and 90 percent of the reference population performed the item
successfully. Failure on an item achieved by 90 percent of the children of the same age should be
considered a “delay”. Performances are scored as abnormal if two or more sectors have two or
more delays and one other sector has one delay and in the same sector the age line does not
intersect the one item that is passed; as questionable if any one sector has two or more delays, or
if one or more sectors have one delay and in the same sectors the age line does not intersect an
item that is passed; as unstable if refusals occurs in numbers large enough to cause the test score
to be questionable or abnormal if the performance is not abnormal, questionable, or unstable.

Suspect performances should be evaluated. They may be due to temporary factors such as
fatigue, illness, hospitalisation, separation from parent, fear and so on; chronic unwillingness to do
things requested; general retardation; pathogenic factors such as deafness or neurogenic
impairment; or familial patterns of development.

If test results are abnormal, questionable or unstable, the child should be rescreened a month
later. Without improvement, the child should be evaluated with more extensive and refined
diagnostic studies.

CAUTION:

The DDST is not an intelligence test and does not establish a DQ or an IQ. It is a screening
instrument for use in clinical practice to identify children whose development may need critical
study.

DENVER DEVELOPMENTAL SCREENING TEST AND PRETERM INFANTS.

A M Elliman, E M Bryan, A D Elliman, P Palmer, L Dubowitz

The result of Denver developmental screening test and Griffiths mental developmental scales
examination performed on 198 preterm children during the first three years of life and compared.
Using real age the former identifies children with developmental delay, but labelled up to 42% of
babies as having questionable or abnormal development. Using corrected age very few children
ahowed less than normal development and in the first year those whose Grifiths scales results
showed delay were often assessed as normal by the Denver test. In view of its satisfactory
sentivity and selectivity it is suggested that both age lines should be drawn when using the Denver
test with preterm children so that undue anxiety can be allayed while appropriate action is taken to
ensure adequate follow- up.
5. THE DENVER ARTICULATION SCREENING EXAMINATION (DASE): -

Language and speech development can be evaluated through a history of child’s speech
development, through observation of child’s verbal ability and speech patterns and through testing.
A child’s articulation can be evaluated with the DASE, a tool that tests the child’s ability to initiate
work sounds. This test is easy to administer, since the child is only asked to repeat 30 different
sound elements. The person testing the child listens for errors in articulation. The level of
intelligibility is scored in one of four categories: easy to understand, understandable, and cannot
evaluate. The DASE can pinpoint normal variations in the acquisition of the speech sounds as well
as important delays or abnormalities in speech development. It is emphasised that the DASE is no
way evaluates language development. It is strictly an articulation screening tool.

6. THE GOODENOUGH- HARIS DRAWING TEST: -

Originally called the Goodenough Draw-A-Man Test, this revised and re-standardised version of
an intelligence test is used for screening children between the ages of 3 and 12 years. Children
are requested to make three drawings: a man, a woman and a representation of self. The
interpretation of the test results is based on the fact that children generally include more detail in
their drawings of human figure as they become older.

This test is as culture free as possible, since it does not rely on verbal ability. The examiner
assumes that the children of this age have used drawing materials before. The level of fine motor
development may be a factor in a child’s ability to produce a picture

The Goodenough-Harris drawing Test is supposedly more accurate than the Goodenough Draw-
A-Man Test but is not as simple to score. The figures a child draws are scored according to
standards outlined in the instructional manual. It is useful for screening children with previous low
scores who may require follow-up of acceleration or retardation of intellectual functioning.

7. THE DENVER DEVELOPMENTAL SCRRENING TEST II (DDST-II): -

The DENVER II, published in 1992, was standardized on 2,036 children. Its interpretation was
slightly modified from the DDST. The Denver II designed for screening the child from birth through
6 years. It identifies a broad range of ages at which achievement of certain verbal, motor-
adaptive, gross motor, language and social skills is expected. Failure to meet these milestones by
the designated age range is labelled a delay. A child persists, referrals are initiated. Following
identification of a persistent delay, various tests may be performed in order to diagnose mental
retardation. This test requires 30 minutes to complete.
 ASSESSMENT OF RISK TO NEURO-PSYCHOMOTOR DEVELOPMENT: SCREENING
USING THE TEST DENVER II AND IDENTIFICATION OF MATERNAL RISKS

DA CUNHA HL, DE MELO AN.

PURPOSE: To identify a positive screening test for developmental delay in children by the Denver
Test II and their risk factors.

METHODS: A sample of 398 children was studied at 0 the 12 months of age regarding their
neurodevelopment. The Denver II Test was used. The children who failed in two or more items of
the test were suspected of having neurodevelopment delay. A set of independent variables was:
socioeconomic, reproductive and environmental, birth conditions children's care. Analyses were
performed using chi-square test and multivariate technique logistic regression.

RESULTS: At of 0 - 12 months of age, 45,73% (182) of the total of 398 children failed in the
screening test. After adjusting for possible confounding variables, failure was associated with
family lower income children, gestational age less than 38 weeks, socioeconomic status family,
schooling of the mother, mother's age, use of drug.

CONCLUSIONS: This study demonstrates: 1--The Denver Test permitted screening the delays
development; 2--Maternal risk factors may interfere in the child's neurodevelopment.

CONCLUSION: -
Screening procedure using these measures quickly and reliable identify children whose
development is below normal and may also be used to monitor developmental progress. Some
developmental assessment instruments can be administered in a variety of settings with a minimal
amount of preparation, whereas others require proper training and supervision. Caution should
always be taken to guarantee that administration is accurate, directions and explanation to the
caregivers and children need to be clear and concise. All results should carefully be
communicated to caregivers so that misunderstandings and misinterpretation are kept to a
minimum.
BIBLIOGRAPHY: - BOOKS
1. Potts. Nicki. L, Paediatric Nursing, 2nd Edition, Thomas Delmar Learning, 2007, Pp 387,
389-390.

2. Dorothy R Marlow, Text book of paediatric nursing, 6 th edition, Saunders and Elsevier,
2009, Noida, pp- 213-217

3. Jane Ball $ Ruth Binder, paediatric nursing, 2 nd edition, USA 1999, Pp 52-87, 1115.

4. Marylin J. Hockenberry, Wong’s Essential of Paediatric Nursing, 7 th edition, Mosby, 2007,

New Delhi, Pp153- 170.

5. K.E Elizabeth, Fundamentals Of Paediatrics, 2nd edition, Paras publishing, 2002,

Hyderabad, pp- 1-39.

WEBSITE

6. http://en.wikipedia.org/wiki/DENVER_II
7. www.ldonline.org/ld_indepth/early_identification/assessment_devareas.html

8. http://www.wiley.com/WileyCDA/WileyTitle/productCd-0471326518,descCd-authorInfo.html

9. http://www.answers.com/topic/bayley-scales-of-infant-development
10. http://www.denverii.com/DASE.html
11. http://findarticles.com/p/articles/mi_g2602/is_0002/ai_2602000277/
12. http://www.medterms.com/script/main/art.asp?articlekey=9719
13. http://www.denverii.com/PDQ.html
14. http://sciencestage.com/d/525202/a-new-developmental-screening-test-the-denver-ii-.html
15. http://spi.sagepub.com/cgi/content/abstract/10/3/205
16. http://www.citeulike.org/user/lboussou/article/2833624
17. http://www.babycenter.com/0_milestone-chart-1-to-6-months_1496585.bc
18. http://www.ncbi.nlm.nih.gov/pubmed/17768797
19. medind.nic.in/icb/t07/i9/icbt07i9p841.pdf
20. http://adc.bmj.com/content/60/1/20
21. http://journals.lww.com/nursingresearchonline/Abstract/1996/09000/The_Correlation_of_Su
cking_Behaviors_and_Bayley.7.aspx
22. http://pediatrics.aappublications.org/cgi/content/abstract/116/2/333
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24. http://www.babycenter.com/0_milestone-chart-1-to-6-months_1496585.bc

JOURNALS

25. Journal of the American academy of paediatrics (Indian edition), volume- 18, number- 2,
March 2008, Pp 164- 173, 230- 234.
26. Nightingale nursing times, volume- 1, number- 12, February 2006, Pp 21- 23.
27. Paediatric clinics of north America, volume- 54, number- 1, February 2007, Pp 469- 478.