* INFANCY * Prenatal Visit * Newborn Visit * 3-5 Day Visit * 1 Month Visit * 2 Month Visit * 4 Month Visit * 6 Month Visit * 9 Month Visit * EARLY CHILDHOOD * 12 Month Visit * 15 Month Visit * 18 Month Visit * 2 Year Visit * 2 1 2 Year Visit * 3 Year Visit * 4 Year Visit * MIDDLE CHILDHOOD * 5 Year Visit * 6 Year Visit * 7 Year Visit * 8 Year Visit * 9 Year Visit * 10 Year Visit * ADOLESCENCE * 11 Year Visit * 12 Year Visit * 13 Year Visit * 14 Year Visit * 15 Year Visit * 16 Year Visit * 17 Year Visit * 18 Year Visit * 19 Year Visit * 20 Year Visit * 21 Year Visit Does she enjoy her subjects? Middle Childhood 5–10 Years We need to do a better job of weaving a safety net of understanding, appreciation and guidance in the family, in the community and school. We need to start thinking of health and education as interlocking spheres. —C. Everett Koop, M.D. Former Surgeon General U.S. Public Health Service MIDDLE CHILDHOOD 171 What images do we have of school- age children? One image is of energetic children running through a playground, laughing as they happily pursue their friends in a game of tag. Safe, strong, resilient, well-nourished, and self- confident, they are able to interact with peers on an equal basis. These children are becoming more aware of the outside world—its opportunities, challenges, and fun. Yet, for other children, middle childhood may present a distinctly different picture. Some travel home through unsafe neighborhoods and let themselves into an empty apartment at the end of the school day. Once inside, they sit alone in front of the television, snacking on soda and chips. For these children, life presents few opportunities to participate in healthy activities with friends after school, to learn new skills, or to gain self- confidence. These two contrasting worlds of middle childhood highlight the differing effects of social inequality on child health and well-being. To be successful, health supervision must be grounded in a solid base of knowledge about the physical, cognitive, emotional, social, and moral development of the child. In each of these areas, there is a known progression during the middle childhood years. There also needs to be an appreciation of the family, the school, and the community as the context within which children grow and develop. Children of school age should be active participants in health supervision. Whether this happens depends, in part, on the structure of the child’s family, the cultural context, and the extent to which the child and the family are encouraged to form a health-promoting partnership with the health professional. Physical Development During the middle years, the child’s growth rate is somewhat slower than in previous years, and certainly less rapid than the growth anticipated during adolescence. Nonetheless, major increases in strength and improvements in motor coordination do occur. These changes contribute to the child’s growing sense of competence in relation to his physical abilities and enhance his potential for participating in sports, dance, gymnastics, and other physical pursuits. Monitoring the child’s growth patterns and conducting periodic physical examinations to assess growth and development are important components of health supervision. Families can provide enormous support for healthy physical development. They can also work with communities to ensure that children have access to safe play areas, recreation centers, and parks, in addition to well-supervised play activities. For children to flourish, communities must value children’s physical growth and provide carefully maintained play facilities to help their bodies develop in a healthy way. Health professionals can augment their guidance on physical activity by advocating for such community facilities. Middle childhood is a critical time for children with physical disabilities or chronic illness to adapt successfully to their condition. During this period, they acquire a more defined sense of self and a MIDDLE CHILDHOOD • 5 – 10 YEAR S Page 4 172 greater ability to care for their own health. Children adapt best to chronic illness when health professionals, families, and communities work together to foster their emerging independence. Full inclusion in school and community life allows children with challenges to feel valued and to integrate their disabilities with other aspects of their lives. Cognitive Development Children’s readiness to learn in school depends on their experience. The synthesis of basic language, perception, and abstraction allows the child to read, write, and communicate thoughts of increasing complexity and creativity. Progress may appear subtle from month to month, but it is dramatic from one school year to the next. As the child’s cognitive skills grow, he matures in his ability to understand the world and people around him and to function independently. The major developmental achievement of this period is self-efficacy—i.e., the knowledge of what to do and the ability to do it. Success at school is most likely to occur when such achievement is valued by families. Parental encouragement of learning is essential. Families who reward children with enthusiasm and warmth for putting forth their best effort ensure their steady educational progress and prepare them to use their intelligence and knowledge productively. Moreover, by being aware of individual learning styles, parents and teachers can adapt materials and experiences to each child. Social/Emotional Development As children become more independent, they develop their own sense of personhood. They begin to discern where they “fit” in their family, school class, neighborhood, or community. When the “fit” is good and comfortable, children see themselves as effective and competent members of their family, group, team, school, or community. But when the “fit” is tenuous or poor, the dissonance may be a source of distress and may predispose children to emotional disorders with long-term consequences. The promotion of good mental health requires active participation and support by families, health professionals, educators, and all who care for and teach children. Children need both the freedom of personal expression and the structure of expectations and guidelines that they can understand and accept. Opportunities to interact with other children in MIDDLE CHILDHOOD • 5 – 10 YEAR S play environments without excessive adult inter- ference are important, although some neighbor- hoods or living arrangements restrict these chances. At the same time, children need to have positive interactions with adults, reinforcing their sense of self-esteem, self-worth, and belief in their capability of personal success. The child’s “self” evolves in a social context. Health professionals can help families understand this dynamic and encourage specific roles for their children within the family. Parents who consciously assess their child’s emotional maturity and role in the family at each birthday will appreciate the changes that have occurred subtly over time. As a result, they will be able to celebrate the child’s evolving autonomy by granting new privileges. Parents who match each new entitlement with a new responsibility signal their respect for the child’s growing capability to contribute to the family and the community. Moral/Spiritual Development Part of the child’s development as an individ- ual includes an emerging understanding of the life cycle—of birth, growth, aging, and death. There is an increasing awareness that life fits into a larger scheme of relationships among individuals, groups of people, other living creatures, and the earth itself. School-age children become keenly interested in these topics, especially when confronted with personal experiences such as the birth of a sibling or the death of a grandparent. As children experience these events and learn to view their personal encounters as part of a larger whole, families and communities provide important structure. They define value systems that provide children with basic principles and encourage them to examine their personal actions in light of their impact on those around them. Children’s ability to understand their place in the larger world leads to greater self-esteem and competence. The close link between competence and self-esteem is strength- ened when a child is recognized for working hard in school; successfully completing chores and special projects; and participating in school, church, or community activities. The relationship between values, competence, self-esteem, and personal responsibility needs to be modeled and affirmed by the child’s parents, teachers, and community. Parents also need to support maintaining a balance between responsibilities at school and home, time spent with family and friends, extracurricular and community activities, and personal leisure. Achieving this balance is essential for healthy development. Health Behaviors As a child’s sense of competence emerges in the middle childhood period, a shift in responsibility needs to occur in health supervision. At the beginning of the period, it is the parent who buys the food, clothing, toys, and other materials. It is the parent who makes the rules about how to cross the street, where a bike can be ridden, and what the child can eat. By the end of the period, the child has begun to learn how to be a consumer, perhaps handling a small or moderate allowance and deciding on snacks, games, TV programs, and other types of activities or entertainment. Although the child is not making the safety rules, he is undoubtedly negotiating for a more independent role in determining his bedtime, selecting activities and opportunities, and choosing friends. As this MIDDLE CHILDHOOD • 5 – 10 YEAR S Page 6 174 shift occurs, children who are active and eager learners are ready to hear, consider, and respond to health promotion messages. The middle childhood period therefore offers an excellent opportunity to introduce information on health promotion and disease prevention, including discussions on the consequences of smoking and the use of alcohol, drugs, and inhalants. If the child feels that he has a role in determining his future, these interventions will make a difference in his life. Although most children do not have the emotional need, cognitive understanding, or independence to experiment with lifestyles the way adolescents and young adults do, they are watching, listening, learning, and mapping their own view of the outside world. They are beginning to create their own framework for life’s experiments and experiences. It is the role of families and the health professional during health supervision to help children build this structure solidly so that it can be expanded during adolescence. With the knowledge and understanding provided by their families and health professionals, children can develop the responsibility needed to achieve good personal health practices and to avoid unhealthy habits. MIDDLE CHILDHOOD • 5 – 10 YEAR S MIDDLE CHILDHOOD • 5 – 10 YEAR S 175 Page 8 MIDDLE CHILDHOOD • 5 – 10 YEAR S 176 Achievements During Middle Childhood ■ Responsibility for good health habits ■ Ability to play in groups ■ Development of one or more close friendships ■ Identification with peer groups ■ Competence as member of family, community, and other groups ■ Ability to express feelings ■ Belief in capacity for success ■ Understanding of right and wrong ■ Awareness of safety rules ■ Ability to read, write, and communicate increasingly complex and creative thoughts ■ Responsibility for homework ■ School achievement Tasks for the Child ■ Maintain healthy eating habits ■ Practice good oral hygiene ■ Participate in athletic programs, physical activities ■ Maintain appropriate weight ■ Use vehicle safety belt ■ Wear protective gear for physical activities (e.g., bicycle helmet, mouth guard, knee pads) ■ Avoid alcohol, tobacco, and other drugs ■ Resist peer pressure to engage in risk-taking behaviors ■ Control impulses ■ Resolve conflict and manage anger constructively ■ Assume responsibility for belongings, chores, homework, and good health habits ■ Play with and relate well to siblings and peers ■ Communicate well with parents, teachers, and other adults ■ Work hard in school and develop good study habits Health Supervision Outcomes ■ Sense of personal competence ■ Sense of self-efficacy and self-confidence ■ Optimal growth and development ■ Active role in health supervision and promotion ■ Optimal nutrition ■ Good health habits ■ Injury prevention ■ Personal safety ■ Social competence ■ Promotion of developmental potential ■ Prevention of behavioral problems ■ Promotion of family strengths ■ Enhancement of parental effectiveness ■ Success in school MIDDLE CHILDHOOD DEVELOPMENTAL CHART Health professionals should assess the achievements of the child and provide guidance to the family on anticipated tasks. The effects are demonstrated by health supervision outcomes. Page 9 MIDDLE CHILDHOOD • 5 – 10 YEAR S 177 ■ Be prepared to give updates on the following at your next visit: Illnesses and infectious diseases Injuries Visits to other health professionals or facilities Use of the emergency department Hospitalizations or surgeries Immunizations Food and drug allergies Eating habits Medications Supplementary fluoride and vitamins Oral health care Vision and hearing Chronic health conditions ■ Be prepared to provide the following information about your family: Health of each significant family member Occupation of parent(s) Three-generation family health and social history, including congenital disabilities and genetic disorders Depression or other mental health problems in the immediate or extended family Alcoholism or other substance abuse (including use of tobacco) in the immediate or extended family Family transitions (e.g., birth, death, marriage, divorce, loss of income, move, frequently absent parent, incarceration, change in child care arrangements) Home environment/pets/neighborhood Exposure to hazardous conditions or substances (e.g., tuberculosis, asbestos, carbon monoxide) Exposure to violence ■ Be prepared to discuss your questions, concerns, and observations about issues affecting your child, such as Achievements Stressors (school, friends, family, community) School (learning style and peer interaction) Physical changes (sports readiness, aches and pains, injuries, oral health status, approach of puberty) ■ Bring in school reports and results of parent-teacher conferences. Bring in the Individualized Education Program (IEP) if your child has special needs. ■ Provide updates on your child’s extracurricular activities. ■ Complete and bring in psychosocial or developmental questionnaires (if indicated). ■ Fill out and bring in health forms (school entry, sports participation) for the health professional to complete. ■ Help prepare your child to discuss issues, concerns, and achievements with the health professional and to learn about the health supervision process. ■ When you get home, update your child’s health and immunization records. FAMILY PREPARATION FOR MIDDLE CHILDHOOD HEALTH SUPERVISION Health professionals can help families prepare for health supervision visits. This preparation supports a partnership in which the health professional and the family share responsibility. Page 10 MIDDLE CHILDHOOD • 5 – 10 YEAR S 178 Child ■ Has good physical health and nutrition ■ Has good eating habits ■ Is developing a sense of responsibility for personal health ■ Has regular oral health care ■ Engages in physical activities ■ Has positive attitude ■ Feels loved and valued by parents and other adults ■ Has one or more close friends ■ Is developing social competence ■ Expresses feelings ■ Enjoys life and has joyful experiences ■ Participates in social activities ■ Has personal sense of competence ■ Has high self-esteem and expects personal success ■ Has opportunities for new challenges ■ Feels comfortable asking questions of parents and teachers ■ Works hard in school ■ Has positive role models Family ■ Meets child’s basic needs (food, shelter, clothing, safety, health care) ■ Provides strong, nurturing family ■ Provides safe environment (e.g., smoke alarms, car booster seat or safety belt) ■ Enjoys child ■ Responds to child‘s developmental needs ■ Encourages good communication ■ Spends individual time with child ■ Praises and takes pride in child’s achievements ■ Affirms child‘s feeling of being loved ■ Helps child develop social competence ■ Possesses working knowledge of child health and development ■ Serves nutritious family meals regularly ■ Reinforces health as a family priority ■ Allows age-appropriate autonomy ■ Protects child against excessive stress ■ Provides value system, good parental role models ■ Promotes cooperation among siblings ■ Has support of extended family and others ■ Encourages participation in community Community ■ Provides quality schools and educational opportunities for all families ■ Provides supervised programs for children (recreational, sports, educational, social, cultural) ■ Provides activities for families ■ Promotes physical activity (e.g., safe playgrounds, parks) ■ Encourages participation of children in organized groups ■ Provides support for families with special needs (school meal programs, educational programs, community outreach) ■ Provides outreach to identify uninsured or underinsured children and facilitates enrollment in health insurance programs and access to care ■ Provides neighborhood/school settings with supervised before- and after-school activities ■ Provides an environment free of hazards ■ Ensures that neighborhoods are safe ■ Provides affordable housing and public transportation ■ Develops integrated systems of health care ■ Fluoridates drinking water ■ Promotes community interactions (neighborhood watch programs, support groups, community centers) ■ Promotes positive ethnic/cultural environment STRENGTHS DURING MIDDLE CHILDHOOD Health professionals should remind families of their strengths during the health supervision visit. Strengths and issues for child, family, and community are interrelated and interdependent. Page 11 179 MIDDLE CHILDHOOD • 5 – 10 YEAR S Child ■ School concerns (learning disabilities, underachievement, difficulty completing homework, frequent school absence or tardiness/school avoidance, lack of motivation) ■ Behavioral concerns (hyperactivity, inability to concentrate, temper outbursts, lying, aggression, fighting, stealing, vandalism, fire-setting, cruelty, violence) ■ Peer concerns (inability to get along with other children, lack of friends, excessive shyness) ■ Emotional concerns (separation problems, depression, anxiety, low self-esteem, threat of suicide) ■ Risk-taking behavior (sexual activity, use of alcohol, drugs, or tobacco) ■ Weight and height concerns (short stature, obesity, eating disorders) ■ Physical inactivity ■ Chronic illness ■ Physical complaints ■ Tics ■ Developmental delays Family ■ Parents or other family members with serious problems (depressed, mentally ill, abusive, lacking interest, overly critical, overprotective, incarcerated) ■ Severe marital problems ■ Domestic violence (verbal, physical, emotional, or sexual abuse) Frequently absent parent ■ Rotating “parents” (parents’ male or female partners) ■ Inadequate child care arrangements ■ Family health problems (illness, chronic illness, or disability) ■ Substance use (alcohol, drugs, tobacco) ■ Financial insecurity ■ Homelessness ■ Family transitions (move, divorce, remarriage, incarceration, death) ■ Lack of knowledge about child development ■ Lack of parental self-esteem and self-efficacy ■ Poor family communication ■ Social isolation and lack of support ■ Neglect or rejection of child Community ■ Poverty ■ Inadequate housing ■ Environmental hazards ■ Unsafe neighborhood ■ Discrimination and prejudice ■ Community violence, gangs ■ Few opportunities for employment ■ Inadequate or unsafe schools ■ Lack of supervised programs before and after school ■ Lack of programs for families with special needs (e.g., school meal programs) ■ Inadequate outreach to uninsured and underinsured children and failure to facilitate enrollment in health insurance programs and access to care ■ Lack of social support ■ Isolation in a rural community ■ Lack of social, educational, cultural, and recreational opportunities ■ Lack of access to immunizations and to medical and oral health services ■ Inadequate public services (lighting, transportation, garbage removal) ■ Inadequate fluoride in drinking water ISSUES DURING MIDDLE CHILDHOOD Health professionals should address problems, stressors, concerns, and other issues that arise during health supervision. Strengths and issues for child, family, and community are interrelated and interdependent. Page 12 The health professional should talk directly with the child about her family, her friends, and her excitement or fears about going to school. Page 13 FIVE YEAR VISIT 181 S tarting school is a major milestone for the 5-year-old and for her family. As she prepares to enter elementary school, key developmental issues emerge, such as her readiness for school and her ability to separate from her parents. The 5-year-old who has experienced preschool or child care may be able to separate more easily. How do her parents react to the idea of her starting school? Should a child who will not turn 5 until October start school or wait until the following year? By observing how the child responds to new situations, the parents, teacher, and health professional can anticipate how the child’s temperament will affect school entry and performance. If a child is “slow to warm up,” it is crucial to allow enough time for her to adjust to a new school, new people, and new experiences and expectations. School activities require greater impulse control. Children are expected to obey rules, get along with others, and avoid disruptive behavior. Paying attention to teachers, the principal, and other adults may be difficult. Acquiring skills in listening, reading, and math challenges some children and excites others. Children entering kindergarten will have many opportunities to make friends and meet other families. There may be occasions for school field trips or after-school activities. Some children manage these new challenges gracefully, while others struggle to learn appropriate behaviors. Parents should be encouraged to listen to their child’s feelings, to reassure her, and to praise her efforts and accomplishments. As the 5-year-old becomes more independent and begins to explore the neighborhood, new safety and injury prevention issues arise. The health professional should emphasize how essential it is for parents to teach their child to be safe at home, at school, on the playground, and in the neighborhood. Parents need to teach and frequently review with their child the safety rules for crossing the street, playing on the playground, riding a bicycle in the neighborhood, and interacting with strangers. Since 5-year-olds are often fascinated by matches and cigarette lighters, parents should be advised to keep these items out of reach, and children should be reminded that matches and lighters are not toys. Parents should be cautioned specifically about the dangers of keeping guns and other weapons in the home. As the 5-year-old’s cognitive skills continue to develop, her ability to understand and to communicate becomes more sophisticated. The health professional should talk directly with the child about her family, her friends, and her excitement or fears about going to school. MIDDLE CHILDHOOD • 5 YEAR S HEALTH SUPERVISION: 5 YEARS The following questions are intended to be used selectively to invite discussion, to gather information, to address the needs and concerns of the family, and to build partnerships. Use of the questions will vary from visit to visit and from family to family. Questions can be modified to match the health professional’s communication style. 182 Questions for the Parent(s) ■ How are you? ■ How are things going at home? ■ What questions or concerns do you have today? ■ What makes you especially proud of Nora? ■ Have there been any major changes or stresses in your family since your last visit? ■ How did Nora enjoy preschool? ■ How does she get along with others? ■ How are you feeling about Nora’s starting school? ■ How does she feel about going to school? ■ Is there anything you would like to discuss or have checked before Nora goes to school? ■ Is there anything the school or teacher should know? ■ What have you done to prepare Nora for crossing the street on the way to school or for taking a school bus? Is her bus stop safe? ■ Will you visit the school with Nora before school starts? ■ What are your plans for before- and after- school care? ■ Do you make sure that Darryl wears a bike helmet when bike riding or skating? ■ Does Darryl ride in a booster seat securely fastened in the back seat of the car? ■ Does Darryl usually eat what you fix for dinner? ■ How many hours a day does Darryl sleep? Is it hard to get him out of bed in the morning? ■ How do you and your partner handle disagreements about discipline? Do you know how to reduce your child’s risk of exposure to lead hazards if you live in an older home or one that has been renovated recently? ■ Have you ever been in a relationship where you have been hurt, threatened, or treated badly? ■ Have you ever been worried that someone was going to hurt your child? Has your child ever been abused? ■ Does anyone in your home have a gun? Does a neighbor or family friend? If so, is the gun unloaded and locked up? Where is the ammunition stored? Have you considered not owning a gun because of the danger to children and other family members? MIDDLE CHILDHOOD • 5 YEAR S Page 15 183 Questions for the Child ■ What do you do for fun? ■ Do you have a best friend? ■ Tell me some of the things you are good at. ■ Did you enjoy going to child care (or preschool)? ■ How do you feel about going to school? ■ Will you ride the bus to school? ■ How will you get to and from school safely? ■ Do you sit on a booster seat and use a safety belt every time you ride in the car? Do you sit in the back seat? ■ What is your address? Your phone number? ■ What chores do you do to help your parents around the house? ■ How do you get along with your brothers and sisters? With your parents? ■ Do you brush your teeth every day? When? ■ If you had three wishes, what would they be? MIDDLE CHILDHOOD • 5 YEAR S Page 16 MIDDLE CHILDHOOD • 5 YEAR S Developmental Surveillance and Milestones Questions and Possible Responses ■ Do you have any specific concerns about Robin’s development or behavior? ■ How does Robin communicate what she wants? Uses words (uses future tense) Uses complete sentences of five words or more Speaks in short paragraphs Is able to recall parts of a story Has fluent speech Speaks intelligibly to others (all of the time) ■ What do you think Robin understands? Concept of numbers Two- or three-step instructions Her address and telephone number ■ How does Robin get from one place to another? Walks, climbs, runs Goes up and down stairs (alternating feet without support) Skips ■ How does Robin act around others? Responsive or withdrawn Friendly or hostile/aggressive Cooperative or defiant Dependent or self-reliant ■ To what extent has Robin developed independence in eating, dressing, and toileting? Uses eating utensils Dresses herself (except for tying shoelaces) Has bladder and bowel control ■ Does Robin show an ability to understand the feelings of others? ■ Tell me about Robin’s typical play. Plays with favorite toys (describe play) Listens to stories Engages in elaborate fantasy play Plays interactive games with peers (follows rules of games) Has manual dexterity Milestones Dresses self without help Knows address and telephone number Can count on fingers Copies a triangle or square Draws a person with a head, a body, arms, and legs Recognizes many letters of the alphabet Prints some letters Plays make-believe and dress-up May be able to skip Page 17 MIDDLE CHILDHOOD • 5 YEAR S Observation of Parent-Child Interaction Does the child sit with the parent or in her own chair? When the health professional asks the child a question, does the parent answer or does the child? Is the child active in the reception room or the examination room? How does the parent respond to this activity? How does the parent discipline the child? What is the child’s reaction to the discipline? Physical Examination Measure the child’s height and weight, and calculate body mass index (BMI). Plot these on the CDC growth charts (see Appendix C and the back pocket of this publication). Share the information with the family. As part of the complete physical examination, the following should be particularly noted: • Early childhood caries, developmental dental anomalies, malocclusion, pathologic conditions, or dental injuries • Evidence of possible neglect or abuse Additional Screening Procedures Vision: Examine eyes; screen vision with an objective method (see Appendix E). Hearing: Screen with an objective method (see Appendix D). Lead: Assess risk of lead exposure and screen as needed (see Appendix G). Anemia: Assess risk of anemia and screen as needed (see Appendix F). Hyperlipidemia: Assess risk of hyperlipidemia (see Appendix H). Blood pressure: Conduct blood pressure screening (see Appendix I). Urinalysis: Perform urinalysis. Tuberculosis: Administer tuberculin test (PPD) if child meets any of the following risk criteria: 1 Exposure to tuberculosis Radiographic or clinical findings Immigration from areas with high prevalence Residence/travel in areas with high prevalence Homelessness HIV infection, or living with person who has HIV Other medical risk factors Immunizations Please see Appendix C and refer to the current recommended childhood immunization schedule in the back pocket of this publication. Be sure that immunizations are up to date. Discuss possible side effects, what to do about them, and when to call the health professional. Page 18 ANTICIPATORY GUIDANCE FOR THE FAMILY In addition to providing anticipatory guidance, many health professionals give families handouts at an appropriate reading level or a videotape that they can review or study at home. 186 Promotion of Healthy and Safe Habits Be a role model for your child by living a healthy life. Be sure that your child gets adequate sleep. For children through 5 years of age, the suggested bedtime is 7–8 p.m.; for those ages 6–10, it is 8–9 p.m. (This may vary depending on families’ schedules.) Encourage family participation in regular physical activities. Limit television viewing to an average of 1 hour per day. Check television ratings and choose appro- priate programs. Watch programs together and discuss them. Teach your child about personal care and hygiene. Remind your child to wash her hands after toileting and before meals. Injury Prevention Continue to use a belt-positioning booster seat. Be sure the vehicle lap and shoulder belt are positioned across the child in the back seat of the car. Never place your child in the front seat of a vehicle with a passenger air bag. The back seat is the safest place for children of any age to ride. Establish and enforce firm, clear, and consistent rules for safe behavior. Teach your child how to swim and reinforce water safety rules. Children should be supervised by an adult whenever they are near water. Be sure that swimming pools in your community, apartment complex, or home have a four-sided fence with a self-closing, self-latching gate. Continue to put sunscreen (SPF 15 or higher) on your child before she goes outside to play or swim. Continue to keep your child’s environment free of smoke. Test smoke alarms to be sure that they work properly. Change batteries yearly. Conduct fire drills at home. Teach your child emergency phone numbers and safety rules for the home. Lock up poisons, matches, and electrical tools. Be sure that guns, if kept in the home, are unloaded and locked up and that ammunition is stored separately. A trigger lock is an additional important precaution. Teach your child safety rules for getting to and from school. Teach pedestrian and neighborhood safety skills. Teach your child safety rules for biking and skating. Teach the correct hand signals for traffic safety (e.g., right turn, left turn, stop). Be sure that your child always wears a helmet when riding a bicycle or skating. Emphasize playground safety with your child. Be sure that your child is supervised before and after school in a safe environment. Choose caregivers carefully. Talk with them about their attitudes and behavior in relation to discipline. Do not permit corporal punishment. MIDDLE CHILDHOOD • 5 YEAR S Page 19 187 Teach your child rules for how to be safe around strangers (e.g., never opening the door to strangers, never getting into a stranger’s car). Be sure that your child’s school curriculum includes information on how to be safe when interacting with strangers. Nutrition Model and encourage healthy eating habits. Serve your child three nutritious meals a day and include a variety of healthy foods. Share family meals together regularly. Make mealtimes pleasant and companionable. Encourage conversation. Serve your child a balanced breakfast or be sure that the school provides one. Be sure that your child eats a nutritious lunchtime meal at school by packing a balanced lunch or participating in the school lunch program. Provide two planned nutritious snacks that are rich in complex carbohydrates. Limit high-fat or low- nutrient foods and beverages, such as candy, chips, or soft drinks. Oral Health Be sure that your child brushes her teeth twice a day with a pea-size amount of fluoridated toothpaste, and regularly supervise tooth brushing. Ask the oral health professional when and how to floss between your child’s teeth. Give your child fluoride supplements as recommended by your dentist, based on the level of fluoride in your drinking water. Learn how to prevent dental injuries and how to handle dental emergencies. If your child regularly sucks her fingers or thumb, begin to intervene gently to help her stop. Schedule a dental appointment for your child every 6 months or as indicated by your child’s individual needs or susceptibility to disease. As your child’s permanent molars erupt, be sure that your dentist evaluates them for placement of dental sealants. Sexuality Education Recognize that your child’s sexual curiosity and exploration are normal. Use correct terms for all body parts, including genitals. Begin to teach your child about sexuality through the use of picture books suitable for family reading. Check with your local library for approved resources. Explain to your child that certain parts of the body (those areas normally covered by a bathing suit) are private and should not be touched without his permission. MIDDLE CHILDHOOD • 5 YEAR S Page 20 188 Promotion of Social Competence Praise your child for her cooperation and accomplishments. Encourage your child to talk with you about her school or friends. Encourage her to express her feelings. Read interactively with your child. Spend individual time with your child, doing something you both enjoy. Expand your child’s experiences through trips and visits to parks, libraries, and other places of interest. Provide opportunities for your child to interact with other children. Help your child learn how to get along with her peers. Promote physical activity in a safe environment. Set limits. Use “time out” and establish con- sequences for unacceptable behavior (e.g., limit television viewing time). Encourage self-discipline and impulse control. Expect your child to follow family rules, such as those for bedtime, television and video viewing, computer time, and chores. Assign age-appropriate chores. Teach your child to respect authority. Begin to teach your child the difference between right and wrong. Help your child to manage anger and resolve conflicts without violence. Promotion of Constructive Family Relationships and Parental Health Serve as a positive ethical and behavioral role model. Show affection in your family. Listen to and respect your child. Show interest in your child’s school and after- school activities. Set reasonable expectations. Spend some individual time with each child in your family. Participate in games and other activities with your child. Encourage the development of good sibling relationships. Acknowledge conflicts between siblings. When possible, attempt to resolve conflicts without taking sides. Do not allow hitting, biting, or other violent behavior. Handle anger constructively in the family. Create opportunities for your family to share time together and for family members to talk and play with your child. Talk with the health professional about your own preventive and health-promoting practices. MIDDLE CHILDHOOD • 5 YEAR S Promotion of Community Interactions If you need financial assistance to help pay for health care expenses, ask about resources or referrals to the state Medicaid programs or other state health insurance or medical assistance programs. Ask about resources or referrals for food and/or nutrition assistance (e.g., Commodity Supplemental Food Program, Food Stamp Program, WIC), housing, or transportation if needed. Talk with the health professional about possible programs for your child, such as school, recreational, or other community programs. Participate as a family in school and community organizations and activities. Volunteer regularly for school or community activities that require adult supervision. Explore or continue to participate in social, religious, cultural, volunteer, and recreational organizations or programs. Find out what you can do to make your community safer. Advocate for and participate in a neighbor- hood watch program. Advocate for adequate and safe play spaces and playgrounds. Recommend that schools provide early and regular comprehensive health education and services that encourage healthy lifestyles. Promotion of Successful School Entry Meet with your child’s teachers. Prepare your child for school. Talk about new opportunities, friends, and activities at school. Tour your child’s school with her. Become involved with your child’s school, perhaps as a volunteer. MIDDLE CHILDHOOD • 5 YEAR S Page 22 Is the Family Prepared for Health Supervision? 190 M ichelle is about to turn 5. Her mother makes an appointment with the pediatrician because the school has sent home a note explaining that Michelle must have a second immunization for measles, mumps, and rubella before starting school in the fall. She will also be attending a day camp this summer, and the camp requires a physical exam. During the health supervision visit, Dr. Hillborough asks Michelle about her interests, how she likes her child care provider, and how she gets along with her little brother. Michelle has not been prepared for the health supervision visit and seems bewildered by the questions. Michelle’s mother assures the doctor that things are fine but provides little specific information about Michelle. The visit is short, and Michelle and her mother leave with little more than an immunization and a completed physical exam form for camp. L in Shu is also about to turn 5. His parents make an appointment with Dr. Gomez. The day before the visit, Lin Shu’s father and mother do a few things in preparation. They ask Lin Shu if he has any questions for the doctor. Lin Shu’s parents spend time thinking about their own questions and concerns and write them on a list to bring to the doctor’s office.They also bring Lin Shu’s health record, which they have had since his birth, as well as his latest progress report from preschool. During the visit, Dr. Gomez asks Lin Shu how things are going and asks his parents if they have any questions. Lin Shu’s parents ask several questions: Is it time to help Lin Shu stop sucking his thumb, and how can they help? How much “silly behavior” is appropriate for a 5-year-old? What can be done about the constant fighting between Lin Shu and his older sister? Can Lin Shu play soccer even though he has asthma? Dr. Gomez addresses these concerns during the health supervision visit and gives Lin Shu and his parents some tips on how to handle the changes elementary school will bring. Lin Shu and his parents leave half an hour later feeling satisfied and encouraged. Lin Shu’s mother and father have learned some strategies for handling behaviors that have concerned them and have also received the informa- tion they need to feel comfort- able enrolling Lin Shu in a soccer program. MIDDLE CHILDHOOD • 5 YEAR S Page 23 191 MIDDLE CHILDHOOD • 5 YEAR S Page 24 A 6-year-old is interested in testing the limits of his body. How fast can he run? How far can he throw? Page 25 SIX YEAR VISIT 193 A 6-year-old is eager to act independ- ently but is not yet able to make good decisions consistently. He likes to climb trees or fire escapes and to play in the yard or on the sidewalk with other children. He is learning about safety—crossing streets, riding a bicycle, and interacting with strangers. Before he is ready to start exploring the community on his own, he must be able to remember and understand safety rules well enough to interpret them and adapt them for different situations. His family should continue to set appropriate boundaries and other limits while encouraging and promoting his growing independence. A 6-year-old is interested in testing the limits of his body. How fast can he run? How far can he throw? As he learns how his body works, he gains the confidence and skills needed to enjoy physical activities or to participate in individual or team sports. Adult supervision is needed for swimming and other water sports. If the child has a bicycle, it should be suited to his size and level of ability. He should always wear an approved helmet when riding and should wear appropriate protective equipment when playing organized sports. Parents should be sure that coaches’ demands are reasonable and should avoid overscheduling their child’s after-school activities. The 6-year-old spends increasing amounts of time with friends and others outside the home, and it is important for parents to meet these new friends and their families. Parents need to encourage their child’s friendships and respect the growing influence of new peers, but family rules should remain consistent. Discussing the child’s progress in school is an important part of health supervision. School systems are required by law to evaluate children who are experiencing learning or developmental difficulties. The health professional can remind parents of their child’s right to an appropriate public education, help them understand special education programs and services, and identify community resources to assist the family. As his social maturity and intellectual skills continue to develop, the 6-year-old may look forward to being included in discussions with the health professional. Health supervision visits provide the primary opportunity for the health professional to develop a partnership directly with the child and to encourage him to assume responsibility for his clothes, toys, or other belongings; selected chores; and good health habits. His self-reliance will help promote autonomy, independence, and a sense of competence. MIDDLE CHILDHOOD • 6 YEAR S Page 26 HEALTH SUPERVISION: 6 YEARS The following questions are intended to be used selectively to invite discussion, to gather information, to address the needs and concerns of the family, and to build partnerships. Use of the questions will vary from visit to visit and from family to family. Questions can be modified to match the health professional’s communication style. 194 Questions for the Parent(s) ■ How are you? ■ How are things going at home? ■ What questions or concerns do you have today? ■ What are you especially proud of about Justin? ■ Have there been any major changes or stresses in your family since your last visit? ■ What do you and Justin like to do together? ■ How is school going for Justin? ■ Does Justin talk to you about what’s happening in school? ■ What does Justin eat for an after-school snack? ■ When is Justin’s next dental appointment? ■ How many hours a day does Justin sleep? Does he seem rested when he wakes up? ■ What have you done to prepare Justin for crossing the street on the way to school or for taking a school bus? Is his bus stop safe? ■ Does Maegan ride in a booster seat securely fastened in the back seat of the car? ■ Does Maegan participate in any after-school sports or other activities? ■ What are the child care arrangements for Maegan before and after school? ■ Do you know how to reduce your child’s risk of exposure to lead hazards if you live in an older home or one that has been renovated recently? ■ Have you ever been in a relationship where you have been hurt, threatened, or treated badly? ■ Have you ever been worried that someone was going to hurt your child? Has your child ever been abused? ■ Does anyone in your home have a gun? Does a neighbor or family friend? If so, is the gun unloaded and locked up? Where is the ammunition stored? Have you considered not owning a gun because of the danger to children and other family members? MIDDLE CHILDHOOD • 6 YEAR S Page 27 195 Questions for the Child ■ How is school going? What do you like the most about school? The least? ■ Tell me some of the things you are good at. ■ If you had three wishes, what would they be? ■ What do you like to do after school? ■ Do you like to read or have someone read to you? What is your favorite book? ■ What are your favorite TV shows? Toys? Movies? Food? ■ Do you have a best friend? Tell me about your best friend. ■ Draw me a picture of your family. Tell me a story about them. ■ Do you wear a helmet when you ride your bike or skate? ■ Do kids you know get into trouble at school sometimes? Do you ever get into trouble? ■ When you have a problem, who do you talk to about it? ■ What chores do you do to help your parents around the house? ■ How do you get along with your brothers and sisters? With your parents? ■ Do you use a car booster seat and a safety belt when you ride in the car? Do you sit in the back seat? MIDDLE CHILDHOOD • 6 YEAR S MIDDLE CHILDHOOD • 6 YEAR S 196 Developmental Surveillance and School Performance Review a copy of the child’s report card. Review a copy of the Individualized Education Program (IEP) if the child has special needs. ■ Do you have any specific concerns about Jackson’s development or behavior? ■ How do you think Jackson is progressing in school? ■ How is his attendance? ■ Does Jackson seem to be able to follow the rules at school? ■ When he plays with other children, can he keep up with them? ■ Is he proud of his achievements at school? ■ How do you acknowledge and praise Jackson’s achievements at school? ■ Have you visited Jackson’s classroom? ■ Do you participate in activities at his school? ■ Does Jackson talk to you about what goes on in school? ■ What did the teacher say about Jackson during your parent-teacher conference? Page 29 MIDDLE CHILDHOOD • 6 YEAR S 197 Observation of Parent-Child Interaction Does the child sit with the parent or in his own chair? When the health professional asks the child a question, does the parent answer or does the child? Is the child active in the reception room or the examination room? How does the parent respond to this activity? How does the parent discipline the child? What is the child’s reaction to the discipline? Physical Examination Measure the child’s height and weight, and calculate body mass index (BMI). Plot these on the CDC growth charts (see Appendix C and the back pocket of this publication). Share the information with the family. As part of the complete physical examination, the following should be particularly noted: • Caries, developmental dental anomalies, malocclusion, pathologic conditions, or dental injuries • Evidence of possible neglect or abuse Additional Screening Procedures Vision: Examine eyes; screen vision with an objective method (see Appendix E). Hearing: Screen with an objective method (see Appendix D). Lead: Assess risk of lead exposure and screen as needed (see Appendix G). Hyperlipidemia: Assess risk of hyperlipidemia (see Appendix H). Blood pressure: Conduct blood pressure screening (see Appendix I). Tuberculosis: Administer tuberculin test (PPD) if child meets any of the following risk criteria: 1 Exposure to tuberculosis Radiographic or clinical findings Immigration from areas with high prevalence Residence/travel in areas with high prevalence Homelessness HIV infection, or living with person who has HIV Other medical risk factors Immunizations Please see Appendix C and refer to the current recommended childhood immunization schedule in the back pocket of this publication. Be sure that immunizations are up to date. Discuss possible side effects, what to do about them, and when to call the health professional. ANTICIPATORY GUIDANCE FOR THE FAMILY In addition to providing anticipatory guidance, many health professionals give families handouts at an appropriate reading level or a videotape that they can review or study at home. 198 Promotion of Healthy and Safe Habits Be a role model for your child by living a healthy life. Be sure that your child gets adequate sleep. For children 6–10 years of age, the suggested bedtime is 8–9 p.m. (This may vary depending on families’ schedules.) Encourage regular physical activity. Limit television viewing to an average of 1 hour per day. Check television ratings and choose appropriate programs. Watch programs together and discuss them. Continue to teach your child personal care and hygiene. Remind your child to wash his hands after toileting and before meals. Injury Prevention Continue to use a belt-positioning booster seat. Be sure the vehicle lap and shoulder belt are positioned across the child in the back seat of the car. Never place your child in the front seat of a vehicle with a passenger air bag. The back seat is the safest place for children of any age to ride. Enforce firm, clear, and consistent rules for safe behavior. Teach your child how to swim and reinforce water safety rules. Children should be supervised by an adult whenever they are near water. Be sure that swimming pools in your community, apartment complex, or home have a four-sided fence with a self-closing, self-latching gate. Teach your child how to put on sunscreen (SPF 15 or higher) before going outside to play or swim. Continue to keep your child’s environment free of smoke. Test smoke alarms to be sure they work properly. Change batteries yearly. Conduct fire drills at home. Be sure your child knows emergency phone numbers and safety rules for the home. Lock up poisons, matches, and electrical tools. Be sure that guns, if kept in the home, are unloaded and locked up and that ammunition is stored separately. A trigger lock is an additional important precaution. Teach your child safety rules for getting to and from school. Reinforce child pedestrian and neighbor- hood safety skills. Review safety rules for biking and skating, including correct use of hand signals in traffic. Be sure that your child always wears a helmet when riding a bicycle or skating. Continue to emphasize playground safety with your child. Be sure that your child is supervised before and after school in a safe environment. MIDDLE CHILDHOOD • 6 YEAR S Page 31 199 Continue to teach your child rules for how to be safe around strangers (e.g., never opening the door to strangers, never getting into a stranger’s car). Be sure that your child’s school curriculum includes information on how to be safe when interacting with strangers. Teach your child the importance of sports safety, including the need to wear protective gear (mouth guard, helmet, knee pads). Nutrition Model and encourage healthy eating habits. Serve your child three nutritious meals a day and include a variety of healthy foods. Share family meals together regularly. Make mealtimes pleasant and companionable. Encourage conversation. Serve your child a balanced breakfast or be sure that the school provides one. Be sure that your child eats a nutritious lunchtime meal at school by packing a balanced lunch or participating in the school lunch program. Provide two planned nutritious snacks a day that are rich in complex carbohydrates. Limit high-fat or low-nutrient foods and beverages, such as candy, chips, or soft drinks. Help your child learn to choose appropriate foods, including five servings of fruits and vegetables a day. Oral Health Be sure that your child brushes his teeth twice a day with a pea-size amount of fluoridated toothpaste and regularly supervise tooth brushing. Ask your oral health professional when and how to floss between your child’s teeth. Give your child fluoride supplements as recommended by your dentist, based on the level of fluoride in your drinking water. Learn how to prevent dental injuries and handle dental emergencies, especially the loss or fracture of a tooth. If your child regularly sucks his fingers or thumb, begin to intervene gently to help him stop. Schedule a dental appointment for your child every 6 months or as indicated by your child’s individual needs or susceptibility to disease. As your child’s permanent molars erupt, be sure that your dentist evaluates them for placement of dental sealants. Sexuality Education Answer questions at a level appropriate to your child’s understanding. Have age-appropriate sex education books in your home that provide answers to some of your child’s questions, and encourage him to feel comfortable asking additional questions. MIDDLE CHILDHOOD • 6 YEAR S Page 32 200 Promotion of Social Competence Praise your child for his cooperation and accomplishments. Encourage your child to talk with you about his school, friends, or observations. Encourage your child to express his feelings. Read interactively with your child. Listen as he begins to read out loud. Spend individual time with your child, doing something you both enjoy. Expand your child’s experiences through family trips and outings to parks, museums, libraries, and other sites. Provide opportunities, including team or group activities, for your child to interact with other children. Help your child learn how to get along with his peers and to follow group rules. Promote physical activity in a safe environment. Continue to set limits and establish consequences for unacceptable behavior (e.g., limit television viewing time). Encourage self-discipline and impulse control. Expect your child to follow family rules, such as those for bedtime, chores, television and video viewing, and computer time. Assign age-appropriate chores, including responsibility for personal belongings. Foster your child’s ability to communicate with family members, teachers, and other adults. Continue to teach your child the difference between right and wrong. Help your child manage anger and resolve conflicts without violence. Provide personal space (even if limited) for your child at home. Promotion of Constructive Family Relationships and Parental Health Serve as a positive ethical and behavioral role model. Show affection in your family. Listen to and respect your child. Contribute to your child’s self-esteem by being affectionate and by praising his efforts and accomplishments. Show interest in your child’s school and after- school activities. Set reasonable expectations. Promote self-responsibility. Spend some individual time with each child in your family. Participate in games and other activities with your child. Encourage the development of good sibling relationships. Handle anger constructively in your family. Create opportunities for your family to share time together and for family members to talk with and enjoy each other. Know your child’s friends and their families. Talk with the health professional about your own preventive and health-promoting practices. MIDDLE CHILDHOOD • 6 YEAR S Page 33 201 Promotion of Community Interactions If you need financial assistance to help pay for health care expenses, ask about resources or referrals to the state Medicaid programs or other state health insurance or medical assistance programs. Ask about resources or referrals for food and/or nutrition assistance (e.g., Commodity Supplemental Food Program, Food Stamp Program, WIC), housing, or transportation if needed. Talk with the health professional about possible programs for your child: school programs, before- and after-school programs, and recreational or other community programs. Participate as a family in school and community organizations and activities. Volunteer regularly for school or community activities that require adult supervision. Explore or continue to participate in social, religious, cultural, volunteer, and recreational organizations or programs. Advocate for community programs and facilities for children (recreational, athletic, artistic, and educational activities). Promote social connections with friends and neighbors and ties with extended family members. Participate in activities that reflect cultural diversity. Find out what you can do to make your community safer. Recommend that schools provide early and regular comprehensive health education and services that encourage healthy living. Promotion of Successful School Entry Meet with your child’s teachers. Prepare your child for school. Talk about new opportunities, friends, and activities at school. Tour your child’s school with her. Be involved with your child’s school, perhaps as a volunteer. MIDDLE CHILDHOOD • 6 YEAR S Page 34 MIDDLE CHILDHOOD • 6 YEAR S I Am Mommy’s Best Friend 202 P enny, a first-grade student, has not been participating in class activities all morning. Walking around the room and staring out the window, Penny is obviously preoccupied. After trying several times to get Penny to join her classmates, the teacher takes her to see the school nurse, Ms. Goldstein. “Please find out what is going on,” she asks. “Penny has come to the health room often and she trusts you. Something isn’t right.” Ms. Goldstein has seen Penny four times in the past month. Each time Penny had a vague complaint, and Ms. Goldstein determined that the complaint did not indicate a serious physical illness. Now the nurse begins to ask Penny questions to encourage her to talk about her life. Penny talks about her little sister, Wanda; her dog, Kiki; and her favorite television show. Ms. Goldstein senses that something is troubling Penny. After chatting with Penny for a few minutes, Ms. Goldstein asks her directly, “Are you worried about something?” Penny replies, “I’m supposed to be taking care of Mommy. I’m her best friend and Daddy hurts her when I’m not home.” The nurse, questioning Penny further, finds out that Penny’s mother was treated in the emergency room the night before and then released. Penny is terrified by the violence at home and feels that she must protect her mother. Ms. Goldstein arranges a meeting right away with the principal and Penny’s mother, who confirms the story. Ms. Goldstein helps Penny’s mother contact the local social services department. Penny, her mother, and her sister are able to stay in a safe shelter temporarily. Ms. Goldstein’s trusting rela- tionship with Penny, her gentle questioning, and her knowledge of community resources were essential in getting help for Penny’s family. Ms. Goldstein senses that something is troubling Penny. After chatting with Penny for a few minutes, Ms. Goldstein asks her directly, “Are you worried about something?” MIDDLE CHILDHOOD • 6 YEAR S Page 36 The growing influence of peers may present a challenge to the family, and the child now begins to view her parents as ordinary people. Page 37 EIGHT YEAR VISIT This material is also appropriate for a Seven or Nine Year Visit. 205 T he 8-year-old who takes responsibility for making her own bed, bathing herself, picking up her clothes, or setting the table develops a sense of personal competence. Her sense of accomplishment and pride helps her become confident in attempting activities that require more responsibility. The 8-year-old is able to use logic and to focus on multiple aspects of a problem. Busy with school projects, book reports, and collections, she is interested in learning how things work and has many questions. She is also beginning to recognize that others’ viewpoints may differ from her own. The 8-year-old increasingly looks outside the family for new ideas and activities. Her peer group becomes more important; she identifies with children of the same gender who have similar interests and abilities. She may have a best friend, a milestone in interpersonal development. The growing influence of peers may present a challenge to the family, and the child now begins to view her parents as ordinary people. During the health supervision visit, the health professional should speak directly with the 8-year- old. How does she feel about her school work and friends? What are her other interests? How and when does she expect her body to change? Does she have a best friend, and what do they like to do together after school? This is an opportunity for the health professional to build a trusting relationship with the child; as she continues to grow and develop, she will need to feel comfortable asking questions and discussing concerns with the health professional. Parents should be encouraged to talk with the health professional about their own perceptions of their child’s school progress, other activities and accomplishments, and friends. What are their attitudes regarding family life education? What aspects of maturation and sexuality have they discussed with their child? Since the 8-year-old is developing health habits—including those related to nutrition, physical activity, and safety—this is an excellent time to foster self-responsibility for health behaviors. Individ- ualized health education should help the child make good choices. Both the family and the health professional need to continue encouraging the child to eat a variety of healthy foods rather than “junk” foods, brush her teeth twice a day, participate in physical activities rather than watching television, and make safety a priority (e.g., using a safety belt when riding in a car and wearing a helmet when biking). As the 8-year-old gains confidence in making good choices, she is also developing the sense of personal competence that will help her make sensible decisions and withstand peer pressures during adolescence. MIDDLE CHILDHOOD • 8 YEAR S Page 38 HEALTH SUPERVISION: 8 YEARS The following questions are intended to be used selectively to invite discussion, to gather information, to address the needs and concerns of the family, and to build partnerships. Use of the questions will vary from visit to visit and from family to family. Questions can be modified to match the health professional’s communication style. 206 Questions for the Parent(s) ■ How are you? ■ How are things going at home? ■ What questions or concerns do you have today? ■ Have there been any major changes or stresses in your family since your last visit? ■ What are some of the things you do together as a family? ■ How is Kim doing in school? ■ How many hours a day does Kim sleep? Does she seem rested when she wakes up? Does Kim bring friends home? Does she go to friends’ homes? ■ What does Kim do when she is stressed, angry, or frustrated? ■ Is Kim involved in sports? If so, does she wear protective sports gear? ■ How would you handle a dental emergency? ■ Do you talk to your child about sensitive subjects such as sex, drugs, or drinking? What have you discussed with her? ■ What are the rules at home in relation to food, movies, games, and language? ■ Do you make Max’s lunch or does he buy lunch at school? ■ Do you enforce the use of bike helmets and safety belts? ■ What are the child care arrangements for Max before and after school? ■ Have you ever been in a relationship where you have been hurt, threatened, or treated badly? ■ Have you ever been worried that someone was going to hurt your child? Has your child ever been abused? ■ Does anyone in your home own a gun? Does a neighbor or a family friend? If so, is the gun locked up? Where is the ammunition stored? Have you considered not owning a gun because of the danger to children and other family members? MIDDLE CHILDHOOD • 8 YEAR S Page 39 207 Questions for the Child ■ How is school going? ■ What are some of the things you are good at? What are you really proud of? ■ Tell me about your friends. ■ What do you do for fun? What is your favorite game? ■ What kinds of clubs are there at your school? ■ What kinds of school and after-school activities are you involved in? ■ Do you know how to swim? ■ Do you stay home by yourself, either before or after school? If so, how do you feel when you are alone? ■ Tell me about your neighborhood. Do you feel safe there? ■ Does your school/neighborhood have gangs? ■ Do you get picked on by other kids at school? ■ Have you ever been pressured to do things you didn’t want to do? Have you ever been tempted to do things you knew you shouldn’t do? ■ Has anyone ever touched you in a way you didn’t like? ■ Has anyone ever tried to harm you physically? ■ Have you ever been bullied? ■ Do you wear a helmet when you ride your bike or skate? ■ Do you use a car booster seat and a safety belt when you ride in the car? Do you sit in the back seat? ■ If you could change your life, school, family, or home, what changes would you make? ■ Do you brush your teeth every day? When? MIDDLE CHILDHOOD • 8 YEAR S Page 40 MIDDLE CHILDHOOD • 8 YEAR S 208 Developmental Surveillance and School Performance Review a copy of the child’s report card. Review a copy of the Individualized Education Program (IEP) if the child has special needs. Do you have any specific concerns about Claire’s development or behavior? ■ Do you have any specific concerns about Claire’s school work or behavior? ■ How is her attendance? ■ Is she reading at grade level? Doing math at grade level? ■ Is she in any special classes? ■ Is she proud of her achievements at school? ■ How do you acknowledge and praise Claire’s efforts and achievements at school? ■ Have you visited Claire’s classroom? ■ Do you participate in activities at her school? ■ Does Claire talk to you about what goes on in school? ■ What did the teacher say about Claire during your parent-teacher conference? Page 41 MIDDLE CHILDHOOD • 8 YEAR S 209 Observation of Parent-Child Interaction Do both the parent and the child ask questions? Does the parent let the child speak directly to the health professional, or does the parent interrupt? Is the child playful or serious with the health professional? Do the parent and child make eye contact with each other and with the health professional? Physical Examination Respect the child’s privacy by using appropriate draping during the examination. Measure the child’s height and weight, and calculate body mass index (BMI). Plot these on the CDC growth charts (see Appendix C and the back pocket of this publication). Share the information with the family. As part of the complete physical examination, the following should be particularly noted: • Early puberty (girls) • Caries, developmental dental anomalies, malocclusion, pathologic conditions, or dental injuries • Evidence of possible neglect or abuse Additional Screening Procedures Vision: Examine eyes; screen vision with an objective method (see Appendix E). Hearing: Screen with an objective method (see Appendix D). Hyperlipidemia: Assess risk of hyperlipidemia (see Appendix H). Blood pressure: Conduct blood pressure screening (see Appendix I). Tuberculosis: Administer tuberculin test (PPD) if child meets any of the following risk criteria: 1 Exposure to tuberculosis Radiographic or clinical findings Immigration from areas with high prevalence Residence/travel in areas with high prevalence Homelessness HIV infection, or living with person who has HIV Other medical risk factors Immunizations Please see Appendix C and refer to the current recommended childhood immunization schedule in the back pocket of this publication. Be sure that immunizations are up to date. Discuss possible side effects, what to do about them, and when to call the health professional. Page 42 ANTICIPATORY GUIDANCE FOR THE FAMILY In addition to providing anticipatory guidance, many health professionals give families handouts at an appropriate reading level or a videotape that they can review or study at home. 210 Promotion of Healthy and Safe Habits Be a role model for your child by living a healthy life. Supervise your child’s activities with peers. Be sure that your child gets adequate sleep. For children 6–10 years of age, the suggested bedtime is 8–9 p.m. (This may vary depending on parents’ schedules.) Encourage regular physical activity. Limit television viewing to an average of 1 hour per day. Check television ratings and choose appropriate programs. Watch programs together and discuss them. Supervise your child’s personal care and hygiene. Continue to emphasize the importance of hand washing. Counsel your child about avoiding the use of alcohol, tobacco, drugs, and inhalants. Be sure that your child’s school curriculum includes information on substance abuse. Injury Prevention Continue to use a belt-positioning booster seat with the lap and shoulder belt as long as needed (until your child can sit upright against the back seat cushion and bend her knees over the edge of the seat without slouching). Be sure the safety belt fits correctly. The lap belt should fit low and snugly across your child’s thighs and the shoulder belt should rest across the center of her chest. Never place your child in the front seat of a vehicle with a passenger air bag. The back seat is the safest place for children of any age to ride. Continue to emphasize the importance of safety and injury prevention. Anticipate that your child may make errors in judgment because she is trying to imitate peers. Anticipate providing less direct supervision as your child demonstrates more maturity. Teach your child to swim and reinforce water safety rules. Children should be supervised by an adult whenever they are near water. Be sure that swimming pools in your community, apartment complex, or home have a four-sided fence with a self-closing, self-latching gate. Be sure that your child puts on sunscreen (SPF 15 or higher) before going outside. Continue to keep your child’s environment free of smoke. Test smoke alarms to be sure they work properly. Change batteries yearly. Conduct fire drills at home. Be sure that your child understands safety rules for the home, including the use of emergency phone numbers and what to do in case of fire or other emergencies. Lock up poisons, matches, and electrical tools. Be sure that guns, if kept in the home, are unloaded and locked up and that ammunition is stored separately. A trigger lock is an additional important precaution. Review neighborhood safety rules with your child. MIDDLE CHILDHOOD • 8 YEAR S Page 43 211 Reinforce safety rules for biking and in-line skating, including correct use of hand signals in traffic. Be sure that your child always wears a helmet when riding a bicycle or skating. Be sure that your child is supervised before and after school in a safe environment. Review with your child the rules for how to be safe around strangers (e.g., never opening the door to strangers, never getting into a stranger’s car). Be sure that your child’s school curriculum includes information on how to be safe when interacting with strangers. Reinforce the importance of safety in sports and other physical activities, emphasizing the need for wearing protective gear (mouth guard, helmet, knee or elbow pads). Do not allow your child to operate power tools or machinery (e.g., lawn mower or motorized farm equipment). Nutrition Model and encourage healthy eating habits. Encourage your child to eat three nutritious meals a day, including a variety of healthy foods. Share family meals together regularly. Make mealtimes pleasant and companionable. Encourage conversation. Teach your child the importance of eating a balanced diet. Help her choose plenty of fruits and vegetables; breads, cereals, and other grain products; low-fat dairy products; lean meats, chicken, fish, and other sources of protein; and foods prepared with little or no fat. Serve your child a balanced breakfast or be sure that the school provides one. Be sure that your child eats a nutritious lunch at school by packing a balanced lunch or participating in the school lunch program. Help your child choose nutritious snacks that are rich in complex carbohydrates. Limit high-fat, high- sugar, or low-nutrient foods and beverages, such as candy, chips, or soft drinks. Oral Health Be sure that your child brushes her teeth twice a day with a pea-size amount of fluoridated toothpaste. Ask the oral health professional when and how to teach your child to floss her teeth. Give your child fluoride supplements as recommended by your dentist, based on the level of fluoride in your drinking water. Schedule a dental appointment for your child every 6 months or as indicated by your child’s individual needs or susceptibility to disease. As your child’s permanent molars erupt, be sure that your dentist evaluates them for placement of dental sealants. Teach your child how to handle dental emergencies, especially the loss or fracture of a tooth. Counsel your child not to smoke or use smokeless tobacco. Sexuality Education Have age-appropriate sex education books in the home that will answer some questions, and encourage your child to ask additional questions. If your child receives family life education at school or in the community, discuss the information with her. Answer questions at a level appropriate to your child’s understanding. For parents of girls: Prepare your daughter for menstruation. MIDDLE CHILDHOOD • 8 YEAR S Page 44 212 Promotion of Social Competence Praise your child for personal efforts and accomplishments, especially in school. Encourage your child to talk with you about her school, friends, and feelings. Encourage your child to read and to develop hobbies. Spend individual time with your child, doing something you both enjoy. Expand your child’s experiences through family trips and outings (e.g., parks, museums, libraries). Promote your child’s interactions with peers through participation in social activities, community groups, and team sports. Help your child learn to get along with peers. Discuss awareness of and respect for differences among peers. Help your child learn appropriate and reasonable behavior. Continue to set limits and establish consequences for unacceptable behavior (e.g., grounding, limited television viewing time, less time with friends). Expect your child to follow family rules, such as those for bedtime, homework, and chores. Assign age-appropriate chores and explain the importance of each family member contributing to family life. Promote positive interactions between your child and her teachers and other adults. Help your child develop an ability to deal constructively with conflict and anger in the family, at school, and in the neighborhood. Provide personal space (even if limited) for your child at home. Promotion of Constructive Family Relationships and Parental Health Serve as a positive ethical and behavioral role model. Show affection in your family. Contribute to your child’s self-esteem by being affectionate and by praising her efforts and accomplishments. Show interest in your child’s school performance and after-school activities. Set reasonable but challenging expectations. Promote self-responsibility. Spend some individual time with each child in your family. Participate in games and other activities with your child. Create opportunities for your family to share time together. Handle anger constructively in the family. Acknowledge conflicts between siblings. Whenever possible, attempt to resolve conflicts without taking sides. Do not allow violence. Become acquainted with your child’s friends and their families. Talk with the health professional about your own preventive and health-promoting practices. MIDDLE CHILDHOOD • 8 YEAR S Page 45 213 Promotion of Community Interactions If you need financial assistance to help pay for health care expenses, ask about resources or referrals to the state Medicaid programs or other state health insurance or medical assistance programs. Ask about resources or referrals for food and/or nutrition assistance (e.g., Commodity Supplemental Food Program, Food Stamp Program, WIC), housing, or transportation if needed. Discuss with the health professional possible programs for your child: before- and after-school programs, recreational programs, or other community programs. Participate as a family in school and community activities. Volunteer regularly for school or community activities that require adult supervision. Explore or continue to participate in social, religious, cultural, volunteer, and recreational organizations or programs. Advocate for community programs and facilities for children (recreational, athletic, artistic, and educational activities). Encourage your child to participate in organized groups. Discuss current events and social responsibility with your child. Promote social connections with neighbors and ties with extended family members. Participate in activities that reflect cultural diversity. Find out what you can do to make your community safer. Encourage peer-mediated conflict management in schools from third grade through high school. Recommend that schools provide early and regular comprehensive health education and services that encourage healthy living. MIDDLE CHILDHOOD • 8 YEAR S Page 46 Can the Dentist Fix My Broken Tooth? 214 K evin is 8 years old, and he isn’t happy. He broke his front tooth playing baseball with his friends. Now his dad is taking him to see Dr. Wilson, his dentist. Kevin is really upset about a lot of things. He won- ders if his tooth will ever look the same again. It is jagged and sharp and looks terrible. But even if it does look the same, his front teeth stick out and some of the boys in his third-grade class call him “Dracula.” Most of the time he doesn’t even want to smile and show his teeth in front of the other kids. He is afraid that it will hurt to have his teeth treated. At Dr. Wilson’s office, the dental assistant immediately takes Kevin and his dad back to the treatment room. Kevin has known Dr. Wilson for years. In fact, Kevin was barely walking when he came in for his first visit. Dr. Wilson has always been nice to him. Kevin has had his teeth cleaned many times, has had fluoride treatments, and has even had dental sealants placed on his back teeth. But coming to the dentist has always been easy for Kevin because he has never had any decayed teeth. Kevin is worried that it might be harder today. Kevin is surprised at how upset his father is now that they are in the treatment room. But he begins to feel better when Dr. Wilson comes in and calmly asks him about the injury. How did it happen? Does he have any other injuries? Dr. Wilson puts them both at ease by answering their questions and telling them exactly what he is going to do. First, he will take an x-ray of Kevin’s tooth to make sure it is not injured beneath the gum. Then he will put the tooth to sleep and use a tooth-colored material to make it look like new again. The best part is that it won’t hurt. The visit lasts about 45 minutes and doesn’t hurt a bit. Not only does Kevin’s tooth look great, but Dr. Wilson talks to his dad about braces to align his teeth. This will help him look and feel better and will reduce the risk that his teeth will be injured again. Next month, at Kevin’s follow-up visit, Dr. Wilson will make him a mouth guard to wear every time he plays baseball. Kevin leaves the office feeling much better. MIDDLE CHILDHOOD • 8 YEAR S Page 47 215 MIDDLE CHILDHOOD • 8 YEAR S Page 48 Children who feel good about themselves are better equipped to withstand peer pressure. Page 49 TEN YEAR VISIT This material is also appropriate for a Nine Year Visit. 217 B y age 10, children have informally become a member of their peer group, whether playing sports, competing at video games, or listening to their favorite CD. Ten-year-olds have primarily same-sex friends, and their friends assume greater importance. The child’s growing independence from the family is now obvious. For some families, conflict arises if the parents misinterpret the normal realignment of allegiance toward peers as a rejection of family values, past support, and guidance. Parents can acknowledge their child’s desire for independence by offering increasing responsibility. For example, parents may identify certain tasks as appropriate chores, while allowing the child to decide when to complete them. Injury prevention should be emphasized during this stage of development. The 10-year-old may engage in dangerous risk-taking behaviors (e.g., dares, drinking, smoking, inhaling) as a result of peer pressure. Some children are able to influence their peers to engage in dangerous or illegal activities against their better judgment. If the peer group includes older children, the child may encounter pressure to perform acts and take risks for which he is not developmentally prepared. Recognizing this possibility may help parents teach their children about dealing with peer pressure. Supporting and enhancing the child’s self- esteem and self-confidence are critical during this period. Children who feel good about themselves are better equipped to withstand peer pressure. Families need to spend time with the child, talking with him and showing affection, and praising his efforts and accomplishments. The health professional can help by identifying the child’s strengths and promoting communication between him and his family. School progress, achievements, or problems may become an issue for many children and families during this period. Learning problems may not become evident until the later elementary school years, as expectations for class performance increase. Some children and parents are apprehensive about the transition into middle school. The health professional can help families prepare for the major changes that will take place during adolescence. Parents have concerns about issues that might arise during adolescence, and the child needs to feel comfortable enough to talk about the growth he is experiencing and the challenges he is likely to face. With puberty approaching—and already present for some children—providing information about physical and emotional development and pubertal changes is a crucial component of health supervision. MIDDLE CHILDHOOD • 10 YEAR S Page 50 HEALTH SUPERVISION: 10 YEARS The following questions are intended to be used selectively to invite discussion, to gather information, to address the needs and concerns of the family, and to build partnerships. Use of the questions will vary from visit to visit and from family to family. Questions can be modified to match the health professional’s communication style. 218 Questions for the Parent(s) ■ How are you? ■ How are things going at home? ■ What questions or concerns do you have today? ■ What makes you most proud of Sanjay? ■ Have there been any major changes or stresses in your family since your last visit? ■ What are some of the things you do together as a family? ■ How is Sanjay doing in school? ■ Tell me about Sanjay’s relationships with other children. ■ Does Sanjay share his feelings and his school experiences with you? ■ How does Sanjay express his feelings? ■ How much television does Sanjay watch? ■ What is his bedtime? ■ Is Sanjay involved in sports? If so, does he wear protective sports gear? ■ Do you always use a safety belt in the car? Do you make sure that everyone in your family always uses a safety belt? ■ Do you talk to your child about sensitive subjects such as sex, drugs, or alcohol? What have you discussed with her? ■ What family life education has Nancy received? Does she know about menstruation? ■ What have you discussed with her about her changing body? ■ Does Sanjay know about wet dreams? ■ What are the rules at home in relation to food, movies, games, language, and makeup? ■ What do you and your partner do when you disagree about limits for Nancy? ■ Have you ever been in a relationship where you have been hurt, threatened, or treated badly? ■ Have you ever been worried that someone was going to hurt your child? Has your child ever been abused? ■ Does anyone in your home own a gun? Does a neighbor or a family friend? If so, is the gun locked up? Where is the ammunition stored? Have you considered not owning a gun because of the danger to children and other family members? MIDDLE CHILDHOOD • 10 YEAR S Page 51 219 Questions for the Child ■ How is school going? How are your grades? ■ What are you good at? What are you really proud of? ■ Tell me about your friends. Do you have a best friend? What do you like to do together? ■ Do your friends pressure you to do things you don’t want to do? If so, what do you do? ■ What education have you had about sex? What are some of the questions that I can answer for you? ■ Have you ever been pressured to have sex? ■ If you could, how would you change your life? Your home? Your family? ■ How are you getting along with your parents? Your brother(s)? Your sister(s)? ■ What kind of activities are you involved in at school? After school? ■ Do you wear protective gear when you ride your bike, skate, or participate in other sports? ■ Do you get any of your own meals? What do you like to eat? ■ Are you concerned about your weight? Are you trying to change it? ■ How much time do you spend watching television every day? ■ Do you or your friends smoke? Drink? Take drugs? Use inhalants? Have sex? ■ Do you stay home by yourself, either before or after school? If so, how do you feel when you are alone? ■ Is there anyone in the family whose health worries you? ■ What are some of the things that make you happy? ■ What do you do to have fun? ■ What are some of the things that make you sad? Angry? Worried? ■ How do you handle that? Who do you talk to? ■ Has anyone ever touched you in a way you didn’t like? ■ Has anyone ever tried to harm you physically? ■ Have you ever been bullied? ■ Do you know what to do if someone threatens you? MIDDLE CHILDHOOD • 10 YEAR S Page 52 MIDDLE CHILDHOOD • 10 YEAR S 220 Developmental Surveillance and School Performance Review a copy of the child’s report card. Review a copy of the Individualized Education Program (IEP) if the child has special needs. ■ Do you have any specific concerns about Pablo’s grades? ■ How is his attendance? ■ Is he reading at grade level? Doing math at grade level? ■ Is he in any special classes? ■ Does Pablo follow the rules at school? ■ Is he proud of his achievements at school? How do you acknowledge and praise Pablo’s efforts and accomplishments at school? ■ Where and how does Pablo do his homework? ■ Have you visited Pablo’s classroom? ■ Do you participate in activities at his school? ■ Does Pablo talk to you about what goes on in school? ■ Has he identified certain interests he wants to pursue or talents he would like to develop? ■ What did the teacher say about Pablo during your parent-teacher conference? ■ How does Pablo feel about going to middle school? Page 53 MIDDLE CHILDHOOD • 10 YEAR S 221 Observation of Parent-Child Interaction Do both the parent and the child ask the questions? Does the parent let the child speak directly to the health professional, or does the parent interrupt? Is the child playful or serious with the health professional? Do the parent and child make eye contact with each other and with the health professional? If the health professional speaks with the child alone, how comfortable is the child? Physical Examination Respect the child’s privacy by using appropriate draping during the examination. Measure the child’s height and weight, and calculate body mass index (BMI). Plot these on the CDC growth charts (see Appendix C and the back pocket of this publication). Share the information with the child and family. Evaluate for Sexual Maturity Rating (SMR) or Tanner stage (see Appendix K). As part of the complete physical examination, the following should be particularly noted: • Caries, developmental dental anomalies, malocclusion, pathologic conditions, or dental injuries • Evidence of possible neglect or abuse • Scoliosis 2 (screen females initially at 10 year visit) Additional Screening Procedures Vision: Examine eyes; screen vision with an objective method (see Appendix E). Hearing: Screen with an objective method (see Appendix D). Hyperlipidemia: Assess risk of hyperlipidemia (see Appendix H). Blood pressure: Conduct blood pressure screening (see Appendix I). Tuberculosis: Administer tuberculin test (PPD) if child meets any of the following risk criteria: 1 Exposure to tuberculosis Radiographic or clinical findings Immigration from areas with high prevalence Residence/travel in areas with high prevalence Homelessness HIV infection, or living with person who has HIV Other medical risk factors Immunizations Please see Appendix C and refer to the current recommended childhood immunization schedule in the back pocket of this publication. Be sure that immunizations are up to date. Discuss possible side effects, what to do about them, and when to call the health professional. Page 54 ANTICIPATORY GUIDANCE FOR THE FAMILY In addition to providing anticipatory guidance, many health professionals give families handouts at an appropriate reading level or a videotape that they can review or study at home. 222 Promotion of Healthy and Safe Habits Be a role model for your child by living a healthy life. Be sure that your child gets adequate sleep. For children 6–10 years of age, the suggested bedtime is 8–9 p.m. (This may vary depending on families’ schedules.) Encourage regular physical activity. Enforce reasonable television/music standards. Supervise your child’s personal care and hygiene. Reinforce the importance of handwashing. Counsel your child about avoiding the use of alcohol, tobacco, drugs, and inhalants. Be sure that your child’s school curriculum includes information on substance abuse. Injury Prevention Continue to ensure that your child wears a lap/shoulder safety belt in the back seat of the car. The lap belt should rest low and snugly across your child’s upper thighs, and the shoulder belt should rest across the shoulder and chest area. Never place your child in the front seat of a vehicle with a passenger air bag. The back seat is the safest place for children of any age to ride. Reinforce important safety rules. Anticipate that your child may make errors in judgment because of increased risk-taking behavior. Anticipate providing less direct supervision as your child demonstrates more maturity. Be sure that your child knows how to swim, and reinforce water safety rules. Be sure that your child puts on sunscreen (SPF 15 or higher) before going outside. Continue to keep your child’s environment free of smoke. Test smoke alarms to ensure that they work properly. Change batteri es yearly. Conduct fire drills at home. Review with your child the safety rules for the home, including the use of emergency numbers and what to do when home alone (e.g., rules about having visitors, what to do in case of fire or other emergencies). Be sure that guns, if kept in the home, are unloaded and locked up and that ammunition is stored separately. A trigger lock is an additional important precaution. Learn first aid and cardiopulmonary resuscitation (CPR). Review safety rules for biking and in-line skating. Be sure that your child always wears a helmet when riding a bicycle or skating. Reinforce the importance of safety in sports and other physical activities, emphasizing the need for wearing protective gear (mouth guard, helmet, knee or elbow pads). Teach your child to avoid high noise levels, especially when listening to music through earphones. MIDDLE CHILDHOOD • 10 YEAR S Page 55 223 Nutrition Model and encourage healthy eating habits. Encourage your child to eat three nutritious meals a day, including a variety of healthy foods. Share family meals together regularly. Serve your child a balanced breakfast, or be sure that the school provides one. Teach your child to eat a balanced diet. Help him to choose plenty of fruits and vegetables; breads, cereals, and other grain products; low-fat dairy products; lean meats, chicken, fish, and other sources of protein; and foods prepared with little or no fat. Help your child choose nutritious snacks that are rich in complex carbohydrates. Limit high-fat, high- sugar, or low-nutrient foods and beverages, such as candy, chips, or soft drinks. Share family meals together regularly. Make mealtimes pleasant and companionable. Encourage conversation. Encourage your child to eat a nutritious lunchtime meal at school by packing a balanced lunch or participating in the school lunch program. Oral Health Be sure that your child brushes his teeth twice a day with a pea-size amount of fluoridated toothpaste. Ask the oral health professional when and how to teach your child to floss her teeth. Give your child fluoride supplements as recom- mended by your dentist, based on the level of fluoride in your drinking water. Schedule a dental appointment for your child every 6 months or as indicated by your child’s individual needs or susceptibility to disease. As your child’s permanent molars erupt, be sure that your dentist evaluates them for placement of dental sealants. Review with your child how to handle dental emergencies, especially the loss or fracture of a tooth. Continue to emphasize the dangers of smoking and smokeless tobacco. MIDDLE CHILDHOOD • 10 YEAR S Page 56 224 Sexuality Education Prepare your child for puberty and sexual develop- ment. If your child receives family life education at school or in the community, discuss the information with him. Provide additional information as needed. For parents of girls: Prepare your daughter for menstruation. For parents of boys: Prepare your son for wet dreams. Begin to teach your child the importance of delaying sexual behavior. Explore your child’s understanding of sexually transmitted diseases, including HIV/AIDS and hepatitis. Promotion of Social Competence Praise your child for his efforts and accomplish- ments, especially in school. Help your child choose activities in which he can be successful. Encourage your child to talk with you about his school, friends, and feelings. Encourage your child to read and to develop hobbies. Spend individual time with your child, doing something you both enjoy. Expand your child’s experiences through family trips and outings (e.g., parks, museums, cultural events). Promote interaction and friendship with peers through participation in social activities, commu- nity groups, and team sports. Help your child learn to get along with his peers. Discuss awareness of and respect for differences among peers. Promote independence by encouraging developmentally appropriate decision-making. Help your child learn appropriate or reasonable behavior. Continue to set limits and establish consequences for unacceptable behavior (e.g., grounding, limited television viewing time, loss of privileges). Expect your child to follow family rules, such as those for bedtime, homework, and chores. Provide a well-lighted, quiet space for homework. Remove distractions such as television. Assign age-appropriate chores, including responsibility for some household or yard tasks. Promote positive interactions between your child and his teachers and other adults. Help your child develop an ability to withstand peer pressure. Discuss strategies and try role- playing. Help your child develop an ability to deal con- structively with conflict and anger in the family, at school, and in the neighborhood. Provide personal space (even if limited) for your child at home. Encourage a sense of social responsibility and promote acceptance of diversity. MIDDLE CHILDHOOD • 10 YEAR Promotion of Constructive Family Relationships and Parental Health Serve as a positive ethical and behavioral role model. Show affection in your family. Anticipate beginning to see the normal range of adolescent behaviors, including the pervasive influence of peers, a change in the communication pattern between adolescents and parents, sudden challenges to parental rules and authority, conflicts over issues of independence, refusal to participate in some family activities, moodiness, and risk- taking. Contribute to your child’s self-esteem by being affectionate and by praising his efforts and accomplishments. Show interest in your child’s school progress and after-school activities. Set reasonable but chal- lenging expectations. Promote self-responsibility. Spend some individual time with each child in your family. Participate in games and other activities with your child. Create opportunities for your family to share time together. Foster conversation and open communication in your family. Know your child’s friends and their families. Encourage the development of good sibling relationships. Acknowledge conflicts between siblings. Help them to resolve conflicts themselves without taking sides. Do not allow violence. Handle anger constructively in the family. Talk with the health professional about your own preventive and health-promoting practices. Promotion of Community Interactions If you need financial assistance to help pay for health care expenses, ask about resources or for referrals to the state Medicaid programs or other insurance or medical assistance programs. Ask about resources or referrals for food or nutrition assistance (e.g., Commodity Supplemental Food Program, Food Stamp Program, WIC), housing, or transportation if needed. Discuss with the health professional possible programs for your child: before- and after-school programs, recreational programs, or other community programs. Participate as a family in school and community activities. Volunteer regularly for school or community activities that require adult supervision. Encourage your child to participate in social, religious, cultural, volunteer, and recreational organizations. Advocate for community programs and facilities for children (recreational, athletic, artistic, and educational activities). Discuss current events and social responsibility as a family. Promote social connections with neighbors and ties with extended family members. Participate in activities that reflect cultural diversity. Find out how to make your community safer. Encourage peer-mediated conflict management in schools from third grade through high school. MIDDLE CHILDHOOD • 10 YEAR A Visit to the School Health Room 226 D ahlia Petrovic, a fourth grader, has recently moved to a new country, a new town, and a new home. Now she is entering a new school. As she walks down the hallways of the large elementary school building to the principal’s office, she clutches her father’s hand tightly. Mr. Petrovic discusses Dahlia’s previous schooling with the school principal and learns more about the new school. In the school health room, the principal introduces them to Ms. Maxwell, the school nurse, who has recently joined the school staff. Dahlia is surprised when she walks into the health room. The walls are painted a soft yellow with white trim, and are covered with pictures students have drawn about healthy foods, bicycle safety, how to be safe around strangers, and how to keep a healthy smile. In a corner of the room are posters, books, and games related to staying healthy. “It’s nice to meet you, Dahlia,” Ms. Maxwell says as she takes Dahlia’s hand. “Let me show you what we have here. There are books about how to brush your teeth and cookbooks for making healthy snacks.” Ms. Maxwell walks with Dahlia to an adjoining room. “Here is a scale you can step on so I can weigh you, and then I’ll measure your height.” The nurse leads Dahlia and Mr. Petrovic to her desk in the corner of the health room. She takes out a form from her desk and attaches it to a clipboard. She asks Dahlia and her father about her health history, including questions about whether Dahlia has any chronic conditions, uses medications, requires special treatments during the school day, or might need emergency care to manage any special health conditions. She verifies Dahlia’s address and records the emergency contact numbers for her family members, doctor, and dentist. Ms. Maxwell also receives Mr. Petrovic’s permission to contact Dahlia’s doctor for further information. Dahlia leaves the health room holding her father’s hand and carrying a sticker she received from Ms. Maxwell. Printed on the sticker are the words “I’m happy because I’m healthy!” MIDDLE CHILDHOOD • 10 YEAR S Page 59 227 Summarize Findings at the End of Each Visit ■ Emphasize the strengths of the child and the family. Praise the child’s efforts and achievements. Commend the parents on their efforts to care for their child. Provide suggestions, reading materials, and resources to promote health and reinforce good family health practices, and address any concerns. Arrange Continuing Care Before the Next Visit ■ Give the parents materials to prepare them for the next health supervision visit. ■ Recommend that the parents make an appointment for their child’s next regularly scheduled visit. ■ Ask the parents to make an appointment for a supplementary health supervision visit (if indicated). Other Care ■ Be sure that the parents schedule an appointment to return to the health facility for follow-up on problems identified during the health supervision visit, or refer the child for secondary or tertiary medical care. ■ With the parents’ permission, consult with the school as needed, especially if school progress is unsatisfactory or teacher evaluations are needed. ■ Refer the family to appropriate community resources for help with problems identified during the visit (e.g., food and/or nutrition programs, parenting classes, marital counseling, mental health services, special education programs). Arrange to follow up on referrals and to coordinate care. ■ Ask if the family has scheduled a dental visit for the child. BUILDING PARTNERSHIPS DURING MIDDLE CHILDHOOD WHAT ELSE SHOULD WE TALK ABOUT? MIDDLE CHILDHOOD • 5 – 10 YEAR S Page 60 228 Middle Childhood Endnotes For additional information, see the list of resource materials on middle childhood in the Bibliography (Appendix N). 1. American Academy of Pediatrics, Committee on Infectious Diseases. 1997. 1997 Red Book: Report of the Committee on Infectious Diseases (24th ed., p. 548). Elk Grove Village, IL: American Academy of Pediatrics. Centers for Disease Control and Prevention. TB facts for health care workers. In Centers for Disease Control and Prevention [Web site]. Cited June 15, 1999; available at http://www.cdc.gov.nchstp/tb/faqs/ tbfacts/tbfacts.htm. 2. When screening for scoliosis, view child from front, back, and side, in erect and forward-bending positions. Evaluate and refer as needed if any of the following conditions are present: • Prominent spinal curves, trunk rotation • Uneven shoulder blades or hips • Accentuated roundback or swayback • Unequal distance from arm to side of body • Lack of flexibility to touch upper shin or feet when bending forward Scoliosis Research Society. 1995. Screening Procedure Guidelines for Spinal Deformity: Recommendations for Examiners. Rosemont, IL: Scoliosis Research Society. MIDDLE CHILDHOOD • 5 – 10 YEAR S http://www.pediatriccareonline.org/pco/ub/view/Interactive-Periodicity-Schedule/253999/3.3/interactive_periodicity_schedule