FREUD’S THEORY

Sigmund Freud (1856–1939) founded the psychoanalytical approach to, or theory of, development. Freud’s theory stresses the formative years of childhood as the basis for later psychoneurotic disorders, primarily through the unconscious repression of instinctual drives and sexual desires. His theory emphasises the drives of sex and aggression, which he saw as motivating much human behaviour.

According to Freud, an individual’s personality is composed of the ‘id’, the ‘ego’ and the ‘superego’ (Sigelman 2003). The id is that part of the psyche that is the source of instinctive energy, impulses and drives. Based on the pleasure principle, it directs behaviour towards self-gratification. The ego represents the conscious self and is that part of the psyche that maintains conscious contact with reality and tempers the primitive drives of the id and the demands of the superego with the physical and social needs of society. The superego is the individual’s conscience, which is formed as the result of internalisation of societal demands and restrictions (Carel 2006).

Freud’s theory of development is based on a series of psychosexual stages through which a person must pass. Successful completion of each stage is necessary before the next stage can be entered without detrimental effects on future development. According to Freud, specific body areas are the primary sites for expression and achievement of needs, and these sites change from stage to stage. Table 15.1 outlines the stages of development according to Freud’s theory.

TABLE 15.1 Developmental stages according to Freud

Anal

1–3 years

THE PLACENTA

The outer cells of the trophoblast develop projections (villi), which project into the maternal capillaries to allow the exchange of oxygen, nutrients and waste products. The villi eventually join with an area of uterine tissue to form the placenta. The placenta continues to grow throughout the pregnancy, with one surface (maternal surface) attached to the lining of the uterus, and the other (fetal surface) with the umbilical cord arising from its centre. The fully formed placenta is disc-shaped, about 2.5 cm thick in the centre, and weighs about 500 g. The functions of the placenta are nutritional, respiratory, excretory and hormonal (Marieb 2004).

THE MEMBRANES

The two fetal membranes — the amnion and the chorion — are derived from part of the trophoblast and attached to the placenta. The inner membrane (amnion) encloses the fetus and liquor and covers the fetal surface of the placenta and the cord. The outer membrane (chorion) is continuous with the margin of the placenta and adheres to the wall of the uterus (Marieb 2004).

LIQUOR

The liquor (amniotic fluid) is the pale straw-coloured liquid that surrounds the fetus in the amniotic sac. Derived mainly from the secretions of the cells in the amniotic membrane, liquor is 99% water plus mineral salts. The functions of liquor include protection of the fetus, and maintenance of an even intrauterine temperature (Marieb 2004).

THE UMBILICAL CORD

The umbilical cord extends from the fetal umbilicus to the fetal surface of the placenta. It contains two umbilical arteries, which transport deoxygenated blood from the fetus, and one umbilical vein, which transports oxygenated and nutrient-rich blood from the placenta to the fetus. The vessels in the cord are embedded in a thick jelly-like substance and the cord is covered by amniotic membrane. At 40 weeks of pregnancy the cord is about 1.25 cm in diameter and 60 cm long (Leifer 2007).

FETAL CIRCULATION

The fetal circulation is designed so that the major blood flow bypasses the fetal lungs. Oxygen and nutrients move from the maternal blood into the fetal blood, and fetal wastes move in the opposite direction. As blood from the umbilical vein flows towards the fetal heart, most of it bypasses the fetal liver through the ductus venosus and enters the inferior vena cava. Some of the blood entering the right atrium is shunted into the left atrium through the foramen ovale, a temporary opening in the septum between the atria. Blood that enters the right ventricle is pumped out through the pulmonary artery, where it meets the ductus arteriosus, a short vessel connecting the pulmonary artery to the aorta (see Figures 15.2 and 15.3). Because the fetal lungs are collapsed, blood enters the systemic circulation through the ductus arteriosus. The aorta transports blood to the fetal tissues and, ultimately, back to the placenta through the umbilical arteries (Marieb 2004).

Figure 15.2 Ovulation, fertilisation and implantation

(reproduced from Leifer 2007, with permission)

Figure 15.3 Fetal circulation

(reproduced from Leifer 2007, with permission)

PHYSICAL DEVELOPMENT

At birth the spinal cord and lower brain centres are well developed and, while not capable of coordinated movement, the infant exhibits a range of reflexes:

After several months these basic reflexes disappear and are gradually replaced by conditioned reflexes.

MOVEMENT

Locomotion proceeds in stages. First, the infant learns to position the head in space, then to crawl on hands and knees, later to move about while sitting upright, and, finally, to stand, balance and walk. Thus, motor development occurs in the cephalocaudal direction.

At birth an infant is about 50–55 cm long and weighs about 2.8–4.5 kg. During the first 12 months the infant increases in length by more than one-third, and mass almost triples (see Figure 15.5). As the infant grows in height and mass, internal organs also grow and develop to cope with the increasing demands made on them. Growth is influenced by hormones, especially thyroxine and growth hormone.

Figure 15.5 Growth charts — newborn to infant boys

(Centers for Disease Control and Prevention: www.cdc.gov/nchs — reproduced with permission from the National Center for Health Statistics)

At birth the infant will follow a moving person with their eyes; binocular vision begins at 6 weeks and is established by 4 months. At about 6 months the infant can move the head and eyes in every direction. By 12 months they are able to recognise familiar people and objects at a distance.

Infants can hear at birth and by 1 month they are able to move their eyes towards a sound. The brain is not sufficiently developed initially for any meaning to be attached to sounds, but by 5 to 6 months the infant turns immediately to the sound of their mother’s voice even when she is quite a distance away.

Speech develops from vocalising at birth and crying as a means of communication, until at 12 months the infant is able to say one or two recognisable words. With time the number of words spoken increases and they become clearer. The rate of vocabulary gain varies and is related to factors such as the amount and type of speech the infant hears (Leifer 2007).

INTELLECTUAL DEVELOPMENT

The process of acquiring intellectual skills is often referred to as cognitive development. Cognitive activities, such as reasoning, thinking and problem solving, involve two main processes — perception and conceptualisation. Perception is the sensory process by which a person obtains information about themself and their environment. Through the senses, an infant perceives many stimuli, such as pressure, pain, warmth, cold, sound, taste and visual images. Conceptualisation is the process of concept formation and is an intellectual activity that facilitates reasoning, thinking and problem solving. Concepts allow sense to be made of the information received through the senses.

EMOTIONAL DEVELOPMENT

Emotion is the term used to describe a feeling. Anger, fear, joy and sorrow are typical emotions. Emotional development depends on a variety of factors such as maturation, heredity, socialisation and the environment. Most emotional expressions appear to be learned, and emotional development is related to age. While some forms of emotional expression appear to be inborn or develop through maturation, learning is important in modifying emotional expression to conform to the patterns approved by a specific culture.

At birth infants are able to exhibit distress and pleasure; by 3–6 months they can express anger, distrust and fear; and by about 8–10 months they can exhibit anxiety, surprise, dissatisfaction, obstinacy, anticipation and frustration.

PERSONALITY DEVELOPMENT

Personality may be defined as the ‘characteristic patterns of behaviour and modes of thinking that determine a person’s adjustment to his environment’ (Bolander 1994). An individual’s personality encompasses many factors: intellectual abilities, motives, emotional reactivity, attitudes, beliefs and moral values. An infant is born with certain potentialities, the development of which depend upon maturation and experiences encountered in growing up. Therefore, personality is the product of heredity and environment, and personality development is a complicated process involving all aspects of the individual and the environment.

The theories of personality development of Sigmund Freud and Erik Erikson are outlined at the start of this chapter. Although various theories provide a simple way of looking at personality, in actuality development of personality is far more complex. Broadly, personality development can be viewed as a process that begins in infancy, continues into adulthood, and is the way in which a person relates to his environment and circumstances. Personality is shaped by inborn potential as modified by experiences that affect the person as an individual.

SOCIAL DEVELOPMENT

Social development refers to how a person learns to interact with others and begins early in an infant’s life; smiling, for example, can be considered a social response. Initially a smile can be elicited in response to strangers but after about 6 months the infant’s smile becomes more selective. As the infant begins to vocalise and later to speak, social interaction is increased.

The family is the first, and most important, social institution for the infant. Later on, other people become significant in a child’s social network, for example, those at kindergarten and school. Social roles such as brother or sister or playmate are gradually acquired during social development in infancy. Play provides the opportunity for social development, whereby the infant learns the social expectations that accompany relationships.

PHYSICAL DEVELOPMENT

During early childhood there is a steady increase in growth so that by about 30 months the birth mass is quadrupled. Physical growth slows and stabilises during the preschool years so that by age 5 years the child is about 18.6 kg in mass and about 109 cm tall.

During the toddler years (12–24 months) chest circumference continues to increase in size and exceeds head circumference. After the 2nd year the chest circumference exceeds the abdominal measurement, the lower extremities grow and the child assumes a taller, leaner appearance.

By the end of toddlerhood most of the body systems are relatively mature. The internal structures of the ear and throat continue to be short and straight, and the lymphoid tissue of the tonsils and adenoids remains large. (These circumstances account for a high incidence of ear, throat and upper respiratory tract infections during this stage of development.) In later childhood most systems are mature and can adjust to moderate stress and change.

TABLE 15.7 Growth chart — infant to younger child

Motor development continues rapidly during early childhood so that the toddler is able to walk up and down stairs, kick a ball, and jump. By the end of the 3rd year, most children can run well and ride a tricycle. Drawing progresses from spontaneous scribbling to drawing stick-people, circles and other recognisable objects. Improving motor skills allow more intricate manipulations during later childhood.

Towards the end of childhood, a child grows on average 2.5–5 cm/year and increases in mass by about 1.5–3 kg/year. The average 12-year-old is about 150 cm tall and weighs about 38 kg. Body proportions take on a slimmer appearance, as fat gradually diminishes and its distribution patterns change. Cardiovascular functioning is refined and stabilised so that the heart rate averages 70–90 beats/minute, ventilations average 16–18 breaths/minute, and blood pressure normalises at about 110/70 mmHg. Development of all body systems continues during middle childhood to become more efficient and adult-like in function.

Bones continue to ossify, but ossification of small and long bones is not completed during this stage of development. By about age 10, all temporary teeth have been shed and most permanent teeth have erupted.

The school-age child gains increasing control over his muscular coordination and fine motor coordination (Cameron 2002).

INTELLECTUAL DEVELOPMENT

The major cognitive achievement of early childhood is the acquisition of language, and verbal language skills are further developed with an increased vocabulary and fluency of speech.

By the beginning of the 2nd year, the child is able to think and reason, and the concepts of time, space and causality (cause and effect) begin to have meaning.

By about age 5, egocentric thinking is replaced partially by intuitive thought. The child begins to acquire the ability to use thought processes to make sense of experiences, events and actions. Piaget describes this stage of development as concrete operational. The ability to read becomes a valuable means of increasing knowledge. During the ages of 6–12 years the ability to think abstractly and to solve problems develops and improves (Mitchell & Ziegler 2007).

EMOTIONAL AND PERSONALITY DEVELOPMENT

As a child learns to be more specific in the expression of emotions, they begin to learn the effects of their own behaviour on others. New motives appear that are learned by interacting with other people. While an infant’s early behaviour is largely determined by basic biological needs, such as crying when hungry, much of the later behaviour is involved with meeting psychological needs such as security, acceptance, approval and feelings of self-worth. Emotions can activate and direct behaviour in the same way as biological drives.

Relationships with others play an important role in emotional and personality development. As the child interacts with other people they learn to cope more effectively with them, and an ability to co-operate or compete with others involves a sense of accomplishment. The more positive a child feels about themself the more confident they will feel about trying for success. Every small success increases the child’s self-image, and a positive self-image makes the child feel likeable and worthwhile. If a child is incapable of, or unprepared for, assuming the responsibilities associated with a sense of accomplishment, they may develop a sense of inadequacy or inferiority.

It is generally recognised that if a child’s need for love and security is not met they may become insecure and unable to relate effectively to others in later life. Therefore, throughout childhood, emotional and personality development depend largely on having psychological needs met. Emotional deprivation results in developmental retardation. Young children especially do not thrive if their main carer is hostile or indifferent to them and their needs (Mitchell & Ziegler 2007).

SOCIAL DEVELOPMENT

With increasing age, social development becomes less family dominated than in infancy. Not only do the quality and quantity of contacts with other people exert an influence on the growing child, but a widening range of contacts is essential to learning and to developing a healthy personality. Each group the child becomes involved with, such as school friends, provides a social relationship of varying strength and type. One of the most important socialising agents in a child’s life is the peer group with whom they explore ideas and the physical environment. Through peer relationships children learn ways in which to relate and deal with others, such as those in positions of authority.

As a child interacts with peers they become aware that there are views other than their own. As a result the child learns to persuade, bargain and co-operate to maintain friendships. The child becomes increasingly sensitive to the social norms and pressures of the peer group, and the need for peer approval becomes a powerful influence towards conformity. Peer relationships in which a child experiences love and closeness from a friend seem to be important as a foundation for close relationships in adulthood.

Although increased independence is the goal of middle to late childhood, children still feel secure knowing that there is someone, such as the parents, to implement controls and restrictions. With a secure base in a loving family, a child is able to develop self-confidence and independence (Mitchell & Ziegler 2007).

GENETIC FACTORS

Genetic factors influence many aspects of a person’s physical and psychosocial being. Research indicates that, as well as determining physical characteristics, genetic factors also influence parts of a person’s psychological make-up, such as temperament.

The central structure of a living cell is its complement of genes, which are located on the chromosomes within the cell nucleus. Many thousands of genes are carried on the chromosomes. In humans each cell normally contains 46 chromosomes. Human sperm and ova, however, each contain 23 chromosomes. When fertilisation occurs the sperm and the ovum unite, each contributing 23 chromosomes to the zygote, making a total of 46 chromosomes in 23 pairs, which are replicated in every cell of the body as the embryo develops. Because of the high number of genes in each chromosome, some of which are ‘shuffled’ during replication, and because during cell division each pair of chromosomes sorts randomly into the daughter cells with respect to other pairs, it is extremely unlikely that any two human beings would ever have identical genetic make-up, even with the same parents. One exception is identical (monozygotic) twins who, having developed from the same ovum, have exactly the same chromosomes and genes (Thibodeau & Patton 2004).

The single cell formed at fertilisation is capable of multiplying and developing into a fetus, with its sex and other characteristics, such as hair and eye colour, racial characteristics and physical stature predetermined. Each person’s genetic structure is unique and lifelong, so heredity affects all stages of development. While each person’s capacities are inherited, the extent to which they are used in development is influenced by the environment.

ENVIRONMENTAL FACTORS

The hereditary potential a person is born with is greatly influenced by the environment they encounter. Therefore, the environmental conditions to which an infant is exposed are a major influence on development. Environment refers to the people with whom an individual has contact, the experiences they have throughout life and the physical surroundings they are exposed to.

Attachment (bonding) is the process by which the parents and infant establish a relationship. Both parents and the infant have a role to play in the attachment process, whereby each establishes emotional ties with the other. As the parent responds to the infant, the infant responds to the parent, for example by cooing or eye contact. Creating a situation in which the parent’s and the infant’s eyes meet in visual contact is significant in the formation of emotional ties. Research has suggested that this early social attachment provides the security necessary for infants to explore their environment, and that it forms the basis for interpersonal relationships in later years.

Failure to form an attachment to one or a few primary persons in the early years has been related to an inability to develop close personal relationships in adulthood (Sanson 2003). Early stimulation is important in providing the background necessary to cope with the environment at a later stage. Stimulation is provided by handling the infant, allowing them to move about freely and assume different positions, and by providing conditions whereby the infant receives visual and auditory stimuli, such as coloured objects, mobiles and the sounds of voices and music. Many studies have been performed that indicate that a stimulating early environment is important for later intellectual development. Conversely, too much stimulation too soon could be upsetting for an infant, who may exhibit distress at being unable to respond to multiple stimuli (Sanson 2003).

The family and peer group are the most influential forces on a person’s psychosocial growth and development, as it is through these groups that an individual learns about themself, others and society.

Through its various functions, the family exerts a major influence on development. It is through the family environment that the individual first learns about self, the world and their place within a society. Initially the individual adopts the family’s values and belief systems. Family functions include providing love and security, meeting the basic needs such as food and warmth, facilitating emotional and social development, and helping the individual to learn about society, roles and behaviours (Sigelman 2003).

A person’s peer group exerts a major influence on development, as it is through the peer group that an individual learns skills of socialisation and different ways of interacting with others. The peer group also places demands and expectations on peers to adapt their behaviour to achieve group purposes. It is often through the peer group that a person learns about success and/or failure, receives support or rejection and learns to question thoughts and feelings.

Experiences, which may promote learning, enable an individual to progress developmentally through the lifespan. At each developmental stage a person must learn to master a task or skill before progressing to the next stage. Gradually individuals use their accumulated skills and experiences to develop a range of effective behaviour.

Factors within the everyday environment, such as nutrition, housing and socioeconomic status, have been found to influence development. For example, the adequacy of nutrients in the diet influences how physiological needs are met, and subsequent growth and development. When a diet is lacking in adequate nutrients, deficits in height, weight and developmental progression occur (Clinical Interest Box 15.1).

PAEDIATRIC CARE

The term paediatric means of or pertaining to a child, and paediatric nursing is the area of nursing concerned with the care of infants and children. Paediatric nursing requires knowledge of normal growth and development as well as knowledge of the needs and health problems of individuals in these age groups.

The role of a paediatric nurse can be described as that of carer, coordinator, educator and emotional support and resource person. The nurse who is involved in paediatric care, together with other members of the paediatric team, needs to adopt a holistic attitude towards caring for the child and parent(s) as a family unit. Many health care facilities recognise the need for family-centred care and adopt a philosophy to meet the needs of the family as a unit.

It is important for the nurse to recognise that children are not small adults, and that their reactions are generally quite different from the adults’ reactions to illness, treatment, separation from family and admission to hospital.

CHILD HEALTH SERVICES

There are a variety of child health services whose broad aims are promoting the health of infants and children, providing parental support and care for the child who is ill. Many of the services are involved in preventing ill-health and are concerned with monitoring the health of children from birth. Preventive services include child health clinics and school health services.

Child health clinics play an important role in assessing growth and development — health education; screening for physical, metabolic and neuropsychiatric disorders; and providing immunisation against infectious diseases. The child health nurse aims to develop a close relationship with the mother and newborn infant as soon as possible after the birth. Advice is provided on infant hygiene, nutrition, growth and development, and preventive health measures such as recommended immunisation schedules. The nurse counsels and supports parents, consults with a paediatrician on health problems, refers children and families for supportive care as appropriate and keeps comprehensive records. These records include information on the child’s growth and development, immunisations and illnesses and are important tools for assessment and for detecting situations that require early intervention and preventive action.

School health services aim to promote health by providing health education programs, by ensuring that each child is as healthy as possible so that each may obtain the maximal benefit from educational programs; and by assisting in detecting and managing children with impairments, disabilities or learning difficulties. School health services perform routine medical services just before or soon after children enter school, and selective medical examinations during school life. The school nurse plays an important role in preventing and detecting illness and disabilities. Two of the tests performed on all children assess acuity of sight and hearing.

Child guidance clinics staffed by educational psychologists, social workers and psychiatrists are available to assess children and provide services to help children overcome any difficulties. The services assist children who show evidence of emotional instability or psychological disturbance to attain personal, social or educational readjustment.

Children with mental or physical impairments are provided for by health, education and social services. Integration in ordinary schools is promoted so that all children can receive education, irrespective of the degree of their disability. In some instances this may not be possible and it may be necessary to provide education at home or in a special school. Every effort is made to ensure that a mentally or physically impaired child can develop to their fullest potential.

NEEDS OF INFANTS AND CHILDREN

The needs of children throughout the various stages of development are both physical and psychosocial. Physical needs include the need for food, water, oxygen, elimination, warmth, safety and protection. Further information regarding the nutritional needs of children at various stages of development can be found in Chapter 31. Meal times in a hospital should be pleasant unhurried occasions and the environment should be one that enables children to enjoy meals. Psychosocial needs include the need for love and affection, security, dependence and independence, and self-development. When physical or psychosocial needs are not met, children experience disruptions to their biological, emotional, social or educational growth and development. When needs are not met there are a variety of effects on the child, such as a greater incidence of disease and accidents, failure to thrive, behavioural problems, delayed language skills, antisocial behaviour such as conflicts with the law or substance use and abuse, learning difficulties and social inadequacy.