Health Promotion of the School-Age Child and Family

Health Promotion of the School-Age Child and Family

Cheryl C. Rodgers


Promoting Optimal Growth and Development

The segment of the life span that extends from age 6 to approximately age 12 has a variety of labels, each of which describes an important characteristic of the period. These middle years are most often referred to as school-age or the school years. This period begins with entrance into the school environment, which has a significant impact on development and relationships.

Physiologically the middle years begin with the shedding of the first deciduous tooth and end at puberty with the acquisition of the final permanent teeth (with the exception of the wisdom teeth). Before 5 or 6 years of age, children have progressed from helpless infants to sturdy, complicated individuals with an ability to communicate, conceptualize in a limited way, and become involved in complex social and motor behaviors. Physical growth is also rapid during the preschool-age years. In contrast, the period of middle childhood, between the rapid growth of early childhood and the prepubescent growth spurt, is a time of gradual growth and development with more even progress in both physical and emotional aspects.

Biologic Development

During middle childhood, growth in height and weight assumes a slower but steady pace as compared with the earlier years. Between ages 6 and 12 years, children grow an average of 5 cm (2 inches) per year to gain 30 to 60 cm (1–2 feet) in height and almost double their weight, increasing 2 to 3 kg (4.5–6.5 pounds) per year. The average 6-year-old child is about 116 cm (45.7 inches) tall and weighs about 21 kg (46 pounds); the average 12-year-old child is about 150 cm (59 inches) tall and weighs approximately 40 kg (88 pounds). During this period, girls and boys differ little in size, although boys tend to be slightly taller and somewhat heavier than girls. Toward the end of the school-age years, both boys and girls begin to increase in size, although most girls begin to surpass boys in both height and weight, to the acute discomfort of both girls and boys.

Proportional Changes

School-age children are more graceful than they were as preschoolers, and they are steadier on their feet. Their body proportions take on a slimmer look, with longer legs, varying body proportion, and a lower center of gravity. Posture improves over that of the preschool period to facilitate locomotion and efficiency in using the arms and trunk. These proportions make climbing, bicycle riding, and other activities easier. Fat gradually diminishes, and its distribution patterns change, contributing to the thinner appearance of children during the middle years.

Accompanying the skeletal lengthening and fat diminution is an increase in the percentage of body weight represented by muscle tissue. By the end of this age period, both boys and girls double their strength and physical capabilities, and their steady and relatively consistent development of coordination increases their poise and skill. However, this increased strength can be misleading. Although strength increases, muscles are still functionally immature when compared with those of adolescents, and they are more readily damaged by muscular injury caused by overuse.

The most pronounced changes that indicate increasing maturity in children are a decrease in head circumference in relation to standing height, a decrease in waist circumference in relation to height, and an increase in leg length in relation to height. These observations often provide a clue to a child’s degree of physical maturity and have proved useful in predicting readiness for meeting the demands of school. There appears to be a correlation between physical indications of maturity and success in school.

Specific physiologic and anatomic characteristics are typical of children in middle childhood. Facial proportions change as the face grows faster in relation to the remainder of the cranium. The skull and brain grow very slowly during this period and increase little in size. Because all of the primary (deciduous) teeth are lost during this age span, middle childhood is sometimes known as the age of the loose tooth (Fig. 15-1). The early years of middle childhood, when the new secondary (permanent) teeth appear too large for the face, are known as the ugly duckling stage.

Maturation of Systems

Maturity of the gastrointestinal system is reflected in fewer stomach upsets; better maintenance of blood glucose levels; and an increased stomach capacity, which permits retention of food for longer periods. School-age children do not need to be fed as promptly or as frequently as preschool-age children. Caloric needs are less than they were in the preschool years.

Physical maturation is evident in other body tissues and organs. Bladder capacity, although differing widely among individual children, is generally greater in girls than in boys. The heart grows more slowly during the middle years and is smaller in relation to the rest of the body than at any other period of life. Heart and respiratory rates steadily decrease, and blood pressure increases from ages 6 to 12 years (see Appendix E and inside back cover).

The immune system becomes more competent in its ability to localize infections and to produce an antibody–antigen response. However, children have several infections in the first 1 to 2 years of school because of increased exposure to other children.

Bones continue to ossify throughout childhood but yield to pressure and muscle pulls more readily than with mature bones. Children need ample opportunity to move around, but they should observe caution in carrying heavy loads. For example, they should shift books or tote bags from one arm to the other. Backpacks distribute weight more evenly than tote bags.

Wider differences between children are observed at the end of middle childhood than at the beginning. These differences become increasingly apparent and, if they are extreme or unique, may create emotional problems. The associated characteristics of height and weight relationships, rapid or slow growth, and other important features of development should be explained to children and their families. Physical maturity is not necessarily correlated with emotional and social maturity. Seven-year-old children who look like 10-year-old children will, in fact, think and act like 7-year-old children. To expect behaviors appropriate for the older age is unrealistic and can be detrimental to their development of competence and self-esteem. Conversely, to treat 10-year-old children who look young physically as though they were younger is an equal disservice to them.


Preadolescence is the period of approximately 2 years that begins at the end of middle childhood and ends with the thirteenth birthday. Because puberty signals the beginning of the development of secondary sex characteristics, prepubescence typically occurs during preadolescence.

Toward the end of middle childhood, the discrepancies in growth and maturation between boys and girls become apparent. On the average, there is a difference of approximately 2 years between girls and boys in the age of onset of pubescence. This is a period of rapid growth in height and weight, especially for girls.

There is no universal age at which children assume the characteristics of prepubescence. The first physiologic signs appear at about 9 years of age (particularly in girls) and are usually clearly evident in 11- to 12-year-old children. Although preadolescent children do not want to be different, variability in physical growth and physiologic changes among children of the same sex and between the two sexes is often striking at this time. This variability, especially in relation to the onset of secondary sexual characteristics, is of great concern to preadolescents. Either early or late appearance of these characteristics is a source of embarrassment and uneasiness to both sexes.

Preadolescence is a period of considerable overlapping of developmental characteristics of both middle childhood and early adolescence. However, several unique characteristics set this period apart from others. Generally, puberty begins at 10 years in girls and 12 years in boys, but it can be normal for either sex after the age of 8 years. Boys experience little visible sexual maturation during preadolescence.

Psychosocial Development: Developing a Sense of Industry (Erikson)

Freud described middle childhood as the latency period, a time of tranquility between the Oedipal phase of early childhood and the eroticism of adolescence. During this time, children experience relationships with same-sex peers following the indifference of earlier years and preceding the heterosexual fascination that occurs for most boys and girls in puberty.

Successful mastery of Erikson’s first three stages of psychosocial development is important in terms of development of a healthy personality. Successful completion of these stages requires a loving environment within a stable family unit. These experiences prepare the child to engage in experiences and relationships beyond the intimate family group.

A sense of industry or a stage of accomplishment is achieved somewhere between age 6 years and adolescence. School-age children are eager to develop skills and participate in meaningful and socially useful work. They acquire a sense of personal and interpersonal competence; receive the systematic instruction prescribed by their individual cultures; and develop the skills needed to become useful, contributing members of their social communities.

Interests expand in the middle years, and with a growing sense of independence, children want to engage in tasks that can be carried through to completion (Fig. 15-2). They gain satisfaction from independent behavior in exploring and manipulating their environment and from interaction with peers. Often the acquisition of skills provides a way to achieve success in social activities. Reinforcement in the form of grades, material rewards, additional privileges, and recognition provides encouragement and stimulation.

A sense of accomplishment also involves the ability to cooperate, to compete with others, and to cope effectively with people. Middle childhood is the time when children learn the value of doing things with others and the benefits derived from division of labor in the accomplishment of goals. Peer approval is a strong motivating power.

The danger inherent in this period of development is the occurrence of situations that might result in a sense of inferiority. Children with physical and mental limitations may be at a disadvantage in the acquisition of certain skills. When the reward structure is based on evidence of mastery, children who are incapable of developing these skills risk feeling inadequate and inferior. Even children without chronic disabilities may experience feelings of inadequacy in some areas. No child is able to do everything well, and children must learn that they will not be able to master every skill they attempt. All children, even children who usually have positive attitudes toward work and their own abilities, will feel some degree of inferiority when they encounter specific skills that they cannot master.

Children need and want real achievement. Children achieve a sense of industry when they have access to tasks that need to be done and they are able to complete the tasks well despite individual differences in their innate capacities and emotional development.

Cognitive Development (Piaget)

When children enter the school years, they begin to acquire the ability to relate a series of events to mental representations that can be expressed both verbally and symbolically. This is the stage Piaget describes as concrete operations, when children are able to use thought processes to experience events and actions. The rigid, egocentric view of the preschool years is replaced by mental processes that allow children to see things from another’s point of view.

During this stage, children develop an understanding of relationships between things and ideas. They progress from making judgments based on what they see (perceptual thinking) to making judgments based on what they reason (conceptual thinking). They are able to master symbols and to use their memories of past experiences to evaluate and interpret the present.

One cognitive task of school-age children is mastering the concept of conservation (Fig. 15-3). At an early age (5–7 years), children grasp the concept of reversibility of numbers as a basis for simple mathematics problems (e.g., 2 + 4 = 6 and 6 – 4 = 2). They learn that simply altering their arrangement in space does not change certain properties of the environment, and they are able to resist perceptual cues that suggest alterations in the physical state of an object. For example, they recognize that changing the shape of a substance such as a lump of clay does not alter its total mass. They no longer perceive a tall, thin glass of water as containing a greater volume than a short, wide glass; they can distinguish between the weight of items regardless of their size. They recognize that size is not necessarily related to weight or volume. There is a developmental sequence in children’s capacity to conserve matter. Conservation of mass usually is accomplished first, weight some time later, and volume last.

School-age children also develop classification skills. They can group and sort objects according to the attributes they share, place things in a sensible and logical order, and hold a concept in mind while making decisions based on that concept. Another characteristic of middle childhood is that children derive enjoyment from classifying and ordering their environment. They become occupied with collections of objects, such as stickers, shells, dolls, cars, cards, and stuffed animals. They may even begin to order friends and relationships (e.g., best friend, second best friend).

They develop the ability to understand relational terms and concepts, such as bigger and smaller; darker and paler; heavier and lighter; to the right of and to the left of; and more than and less than. They view family relationships in terms of reciprocal roles (e.g., to be a brother, one must have a sibling).

School-age children learn the alphabet and the world of symbols called words, which can be arranged in terms of structure and their relationship to the alphabet. They learn to tell time, to see the relationship of events in time (history) and places in space (geography), and to combine time and space relationships (geology and astronomy).

The ability to read is acquired during the school years and becomes the most significant and valuable tool for independent inquiry. Children’s capacity to explore, imagine, and expand their knowledge is enhanced by reading.

Moral Development (Kohlberg)

As children move from egocentrism to more logical patterns of thought, they also move through stages in the development of conscience and moral standards. Young children do not believe that standards of behavior come from within themselves but that rules are established and set down by others. During the preschool years, children adopt and internalize the moral values of their parents. They learn standards for acceptable behavior, act according to these standards, and feel guilty when they violate them. Although children 6 or 7 years of age know the rules and behaviors expected of them, they do not understand the reasons behind them. Rewards and punishments guide their judgment; a “bad act” is one that breaks a rule or causes harm. Young children believe that what other people tell them to do is right and that what they themselves think is wrong. Consequently, children 6 or 7 years old may interpret accidents or misfortunes as punishment for “bad” acts.

Older school-age children are able to judge an act by the intentions that prompted it rather than just its consequences. Rules and judgments become less absolute and authoritarian and begin to be founded on the needs and desires of others. For older children, a rule violation is likely to be viewed in relation to the total context in which it appears. The situation, as well as the morality of the rule itself, influences reactions. Although younger children judge an act only according to whether it is right or wrong, older children take into account different points of view. They are able to understand and accept the concept of treating others as they would like to be treated.

Spiritual Development

Children at this age think in concrete terms but are avid learners and have a great desire to learn about their God. They picture God as human and use adjectives such as “loving” and “helping” to describe their deity. They are fascinated by the concepts of hell and heaven, with a developing conscience and concern about rules. They may fear going to hell for misbehavior. School-age children want and expect to be punished for misbehavior and, when given the option, tend to choose a punishment that “fits the crime.” However, they may view illness or injury as a punishment for a real or imagined misdeed. The beliefs and ideals of family and religious persons are more influential than those of their peers in matters of faith.

School-age children begin to learn the difference between the natural and the supernatural but have difficulty understanding symbols. Consequently, religious concepts must be presented to them in concrete terms. Prayer or other religious rituals comfort them, and if these activities are a part of their daily lives, they can help them cope with threatening situations. Their petitions to their God in prayers tend to be for tangible rewards. Although younger children expect their prayers to be answered, as they get older, they begin to recognize that this does not always occur, and they become less concerned when their prayers are not answered. They are able to discuss their feelings about their faith and how it relates to their lives (see Cultural Considerations box).

Social Development

One of the most important socializing agents in the school-age years is the peer group. In addition to parents and schools, the peer group conveys a substantial amount of information to its members. Peer groups have a culture of their own with secrets, traditions, and codes of ethics that promote feelings of solidarity and detachment from adults. Through peer relationships, children learn how to deal with dominance and hostility, how to relate to persons in positions of leadership and authority, and how to explore ideas and the physical environment.

Peer group identification is an important factor in gaining independence from parents. The aid and support of the group provide children with enough security to risk the moderate parental rejection brought about by small victories in the development of independence.

A child’s concept of the appropriate sex role is also influenced by relationships with peers. During the early school years, few gender differences exist in the play experiences of children. Both girls and boys share games and other activities. However, in the later school years, the differences in the play of boys and girls become more marked.

Social Relationships and Cooperation

Daily relationships with peers provide important social interactions for school-age children. For the first time, children join group activities with unrestrained enthusiasm and steady participation. Previous interactions were limited to short periods under considerable adult supervision. With increased skills and wider opportunities, children become involved with one or more peer groups in which they can gain status as respected members.

Valuable lessons are learned from daily interaction with age mates. First, children learn to appreciate the numerous and varied points of view that are represented in the peer group. As children interact with peers who see the world in ways that are somewhat different from their own, they become aware of the limits of their own point of view. Because age mates are peers and are not forced to accept each other’s ideas as they are expected to accept those of adults, other children have a significant influence on decreasing the egocentric outlook of the child. Consequently, children learn to argue, persuade, bargain, cooperate, and compromise to maintain friendships.

Second, children become increasingly sensitive to the social norms and pressures of the peer group. The peer group establishes standards for acceptance and rejection, and children are often willing to modify their behavior to be accepted by the group. The need for peer approval becomes a powerful influence toward conformity. Children learn to dress, talk, and behave in a manner acceptable to the group. A variety of roles, such as class joker or class hero, may be assumed by individual children to gain approval from the group.

Third, the interaction among peers leads to the formation of intimate friendships between same-sex peers. The school-age period is the time when children have “best friends” with whom they share secrets, private jokes, and adventures; they come to one another’s aid in times of trouble. In the course of these friendships, children also fight, threaten each other, break up, and reunite. These relationships, in which the child experiences love and closeness with a peer, may be important as a foundation for relationships in adulthood (Fig. 15-4).

Clubs and Peer Groups

One of the outstanding characteristics of middle childhood is the formation of formalized groups, or clubs. A prominent feature of these groups is the rigid rules imposed on the members. There is exclusiveness in the selection of persons who have the privilege of joining. Acceptance in the group is often determined on a pass–fail basis according to social or behavioral criteria. Conformity is the core of the group structure. There are often secret codes, shared interests, and special modes of dress, and each child must abide by a standard of behavior established by the members. Conforming to the rules provides children with feelings of security and relieves them of the responsibility of making decisions. By merging their identities with those of their peers, children are able to move from the family group to an outside group as a step toward seeking further independence. Peer groups and clubs allow children to substitute conformity to a peer group for conformity to a family at a time when children are still too insecure to function independently.

During the early school years, groups are usually small and loosely organized, with changing membership and no formal structure. The clubs and groups usually do not display elements of cooperation and order that are seen in groups of older children. In general, girls’ groups are less formalized than boys’ are, and although there may be a mixture of both sexes in the early school years, the groups of later school years are composed predominantly of children of the same sex. Common interests are the basis around which the group is structured.

Peer-group identification and association are essential to a child’s socialization. Poor relationships with peers and a lack of group identification can contribute to bullying. Bullying is any recurring activity that intends to cause harm, distress, or control towards another in which there is a perceived imbalance of power between the aggressor(s) and the victim (Lamb, Pepler, and Craig, 2009). Although bullying can occur in any setting, it most often occurs at school during unstructured times such as recess (Arseneault, Bowes, and Shakoor, 2010). Children who are targeted for bullying often have internalizing characteristics such as withdrawal, anxiety, depression, low self-esteem, and reduced assertiveness that may make them an easy target for bullying (Arseneault, Bowes, and Shakoor, 2010). Bullies are generally defiant toward adults, antisocial, and likely to break school rules. They have dominant personalities, may come from homes where parental involvement and nurturing are lacking, and may experience or witness violence or abuse at home (Bowes, Arseneault, Maughan, and others, 2009). Boys who bully tend to use physical force, referred to as direct bullying, but girls usually use indirect bullying methods, such as exclusion, gossip, or rumors (Arseneault, Bowes, and Shakoor, 2010). Cyberbullying is a new form of bullying and involves the use of cellular telephones, digital cameras, or social networking Internet sites to cause distress on an individual (American Academy of Pediatrics [AAP], Committee on Injury, Violence, and Poison Prevention, 2009).

The long-term consequences of bullying are significant. Chronic bullies seem to continue their behaviors into adulthood, negatively influencing their ability to develop and maintain relationships. Victims of bullying often experience psychological distress such as worry, sadness, anxiety, depression, and nightmares and can have increased self-harm behaviors, social isolation, suicidal ideation, and violent behaviors (Arseneault, Bowes, and Shakoor, 2010). School personnel play an important role in implementing antibullying interventions in schools; however, research has recognized that involving the whole family in antibullying programs greatly increases success (Arseneault, Bowes, and Shakoor, 2010).

There are also dangers in peer group attachments that are too strong. Peer pressures force some children to take risks or engage in behaviors that are against their better judgment. A child’s membership in a gang is associated with marked increases in serious delinquent behavior (Fisher, Montgomery, and Gardner, 2008). Peer group activities that result in unlawful or criminal gang violence are increasing in the United States. An integration of family-centered and school-based programs is needed to reduce the influences for children to become affiliated with gangs.

Relationships with Families

Although the peer group is influential and necessary for normal child development, parents are the primary influence in shaping their children’s personalities, setting standards for behavior, and establishing value systems. Family values usually take precedence over peer value systems. Although children may appear to reject parental values while testing the new values of the peer group, ultimately they retain and incorporate into their own value systems the parental values they have found to be of worth.

In the middle school years, children want to spend more time in the company of peers, and they often prefer peer group activities to family activities. This can be disturbing to parents. Children become intolerant and critical of their parents, especially when their parents’ ways deviate from those of the group. They discover that parents can be wrong, and they begin to question the knowledge and authority of their parents, who were previously considered to be all-knowing and all-powerful.

Although increased independence is the goal of middle childhood, children are not prepared to abandon all parental control. They need and want restrictions placed on their behavior, and they are not prepared to cope with all of the problems of their expanding environment. They feel more secure knowing there is an authority figure to implement controls and restrictions. Children may complain loudly about restrictions and try to break down parental barriers, but they are uneasy if they succeed in doing so. They respect adults who prevent them from acting on every urge. Children view this behavior as an expression of love and concern for their welfare.

Children also need their parents to be adults, not friends. Sometimes parents, hurt by their children’s rejection, attempt to maintain their love and gratitude by assuming the role of “pals.” Children need the stable, secure strength provided by mature adults to whom they can turn during troubled relationships with peers or stressful changes in their world. With a secure base in a loving family, children are able to develop the self-confidence and maturity needed to break loose from the group and stand independently.


Play takes on new dimensions that reflect a new stage of development in the school years. Play involves increased physical skill, intellectual ability, and fantasy. In addition, children develop a sense of belonging to a team or club by forming groups and cliques.

Rules and Rituals

The need for conformity in middle childhood is strongly manifested in the activities and games of school-age children. In the preschool years, children’s games were either invented for them or played in the company of a friend or an adult. Now children begin to see the need for rules, and their games have fixed and unvarying rules that may be bizarre and extraordinarily rigid. Part of the enjoyment of the game is knowing the rules because knowing means belonging. Conformity and ritual permeate their play and are also evident in their behavior and language. Childhood is full of chants and taunts, such as “Eeeny, meeny, miney, mo,” “Last one is a rotten egg,” and “Step on a crack, break your mother’s back.” Children derive a sense of pleasure and power from such sayings, which have been handed down with few changes through generations.

Team Play

A more complex form of play that evolves from the need for peer interaction is team games and sports. A referee, umpire, or person of authority may be required so that the rules can be followed more accurately. Team play teaches children to modify or exchange personal goals for goals of the group; it also teaches them that division of labor is an effective strategy for attaining a goal. Children learn about competition and the importance of winning—an attribute highly valued in the United States.

Team play can also contribute to children’s social, intellectual, and skill growth. Children work hard to develop the skills needed to become team members, to improve their contribution to the group, and to anticipate the consequences of their behavior for the group. Team play helps stimulate cognitive growth because children are called on to learn many complex rules, make judgments about those rules, plan strategies, and assess the strengths and weaknesses of members of their own team and members of the opposing team.

Quiet Games and Activities

Although play at this age is highly active, school-age children also enjoy quiet and solitary activities. The middle years are the time for collections, which constitute another ritual. Young school-age children’s collections are an odd assortment of unrelated objects in messy, disorganized piles. Collections of later school years are more orderly; selective; and organized in scrapbooks, on shelves, or in boxes.

School-age children become fascinated with complex board, card, or computer games that they can play alone, with a best friend, or with a group. As in all games, adherence to the rules is fanatic. Disagreements over rules can cause much discussion and argument but are easily resolved by reading the rules of the game.

The newly acquired skill of reading becomes increasingly satisfying as school-age children expand their knowledge of the world through books (Fig. 15-5). School-age children never tire of stories and, as with preschool children, love to have stories read aloud. They also enjoy sewing, cooking, carpentry, gardening, and creative activities such as painting. Many creative skills such as music and art, as well as athletic skills such as swimming, karate, dancing, and skating, are learned during these years and continue to be enjoyed into adolescence and adulthood (Fig. 15-6).

Developing a Self-Concept

The term self-concept refers to a conscious awareness of self-perceptions, such as one’s physical characteristics, abilities, values, self-ideals and expectancy, and idea of self in relation to others. It also includes one’s body image, sexuality, and self-esteem. Although primary caregivers continue to exert influence on children’s self-evaluation, the opinions of peers and teachers provide valuable input during middle childhood. With the emphasis on skill building and broadened social relationships, children are continually engaged in the process of self-evaluation.

Significant adults can often manage to unobtrusively manipulate the environment so that children experience success. Each small success increases a child’s self-image. The more positive children feel about themselves, the more confident they will be in trying for success in the future. All children profit from feeling that they are in some way special to a significant adult. A positive self-concept makes children feel likeable, worthwhile, and capable of significant contributions. These feelings lead to self-respect, self-confidence, and happiness. Negative feelings lead to self-doubt.

Developing a Body Image

School-age children have a relatively accurate and positive perception of their physical selves, but in general, they like their physical selves less as they grow older. The head appears to be the most important part of the school-age child’s perceived image of self, with hair and eye color the characteristics used most frequently to describe the physical self.

Body image is influenced, but not solely determined, by significant others. The number of significant others that influences children’s perception of themselves increases with age. Children are acutely aware of their own bodies, the bodies of their peers, and those of adults. They are also aware of deviations from the norm. Physical impairments, such as hearing or visual defects, ears that “stick out,” or birthmarks, assume great importance. Increasing awareness of these differences, especially when accompanied by unkind comments and taunts from others, may cause a child to feel inferior and less desirable. This is especially true if the defect interferes with the child’s ability to participate in games and activities.

Table 15-1 summarizes the major developmental achievements of the school-age years.

TABLE 15-1


Age 6 Years      

Jan 16, 2017 | Posted by in NURSING | Comments Off on Health Promotion of the School-Age Child and Family
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