Keywords

FormalPara Chapter Objectives

At the end of this chapter, you will be able to:

  • Demonstrate a basic understanding of the key milestones associated with the development of school-aged children 5–13 years.

  • Describe Erikson’s fourth stage of psychosocial development, industry verse inferiority, and how this applies to the school-aged child.

  • Consider the use of therapeutic play techniques to engage the school-aged child in a developmentally sensitive manner in the health care setting.

Introduction

The school-age years are an important stage of development where a child’s social world expands. Understanding how children present based on typical developmental expectations is essential knowledge for health care practitioners. This chapter will focus on school-aged children 5–13 years. Incorporating Erikson’s fourth stage of psychosocial development, industry verse inferiority, the chapter will explore several key elements that contribute to healthy development and instilling competence in the school-aged child. The use of therapeutic play techniques within the health care setting will also be explored.

Child Development and Assessment

Physical Development

Children reach many physical milestones during the school years as their understanding of themselves and the world around them develops. It is important to acknowledge that some children may progress at a different rate than others depending on individual circumstances, including genetics, environmental factors and early childhood experiences. Some of the common physical milestones children may reach at this stage include the ability to distinguish between their left and right, independence in self-care tasks such as bathing and dressing, the ability to ride a bicycle, jump, skip and chase, as well as an increased ability to use tools, such as eating utensils [1]. Children of school age need plenty of opportunities for physical activity to assist in building strength, coordination and confidence in themselves and their physical abilities. Physical activity can also enhance a child’s academic performance, increase their self-esteem and prevent obesity and serious illnesses in the future, such as diabetes [2].

During this stage of development, children will have an increased body awareness which may lead to an increase in physical complaints, which may be related to their physical development, illness or injury. Regardless of the nature of a physical complaint, it should not be dismissed, so that any underlying health condition or emotional concerns can be explored. For children who have experienced significant trauma, it is not uncommon for these children to complain of physical ailments. Whilst these complaints may not have a physical cause they may reflect an unmet emotional need. No matter how small or big, health care professionals should always check and tend to these ‘hurts’ giving the message that ‘you are important, I want to help you with your hurts, and I care about you’.

Psychosocial Development

Developmental psychologists have theorised about the psychosocial processes involved in development. Psychologist Jean Piaget identified four stages of cognitive development. Piaget’s theory explains how the child not only acquires knowledge as they develop but also create a mental model of the world [3]. During the school years, a child is said to be at the Concrete Operational Stage. During this stage, children become less egocentric and begin to understand that not everyone shares their thoughts, beliefs or feelings [4]. Piaget believed that a child’s cognitive development was dependent on changes in a child’s cognitive processing ability. Piaget observed that children learn and develop in sequence. However, Piaget’s theory did not extend to the child in relation to their social context, which in the school years, becomes significant. Alternatively, Lev Vygotsky focused on a child’s community and believed that it held a critical role in how children learn to make sense of the world. He believed that a child’s observations and experiences of the community around them will make meaning out of everything they see, learn, feel and hear [5]. Unlike other developmental psychologists, Erikson not only examined child development but the whole human lifespan, from birth to death [6]. The school-age years are known as Erikson’s fourth stage of psychosocial development, industry verse inferiority. Successful resolution of the crisis that accompanies this stage of development results in the virtue of competence. The developmental stages before the school years focus on the influence of caregivers and family members. From the school years the focus widens to include the greater social network around the child, including peers. These new social interactions influence a child’s confidence, self-esteem and self-concept.

By the school-age years, children can understand emotions in a more complex way. They understand that someone else can feel differently and be able to operate recursively on this understanding [7]. At this age, children are also more likely to make comparisons between themselves and others. A child observing their peers completing tasks may discover that they are more or less able than their peers. This experience is likely to influence how the child perceives themselves in relation to others. In other words, the child may increase in confidence and self-esteem if they experience a sense of achievement compared to another child, especially if their abilities receive praise and validation from others. Here they gain a sense of industry—they feel competent in their ability. However, a child may decrease in confidence and experience feelings of inadequacy and low self-esteem if they feel their abilities are less than those of their peers, here they may experience feelings of inferiority.

A child’s early attachment experiences also impact on the development of a child’s sense of competence. A child’s strategy of attachment will influence how the child responds in relationships. Bowlby [8] believed that if a child experiences a secure attachment with a caregiver, they take this security with them into the tasks of life. They are less dependent on external validation, less devastated by failure and less in need of status to reassure themselves of their own worth. These children carry with them a stable, measured and secure sense of who they are. When it comes to the school-aged child these early attachment experiences will shape a child’s ability to regulate their level of emotional arousal. A school-aged child who has experienced a complex and emotionally challenging environment with an unavailable or unpredictable caregiver is likely to respond differently to a child who has experienced an available and consistent caregiver. If the stages before act as a blueprint for what is to come next in relation to the self and others, children with difficult attachment experiences may also have difficulty forming positive peer relationships which may impact on their capacity to develop a sense of industry at this stage of development. Children who have difficulty interacting with peers are at risk for social difficulties [9]. Some of these difficulties may include an inability to recognise emotions in oneself and others, respond appropriately and communicate effectively. This may then lead to future problems with mental health, maintaining friendships or low academic performance. A child’s eligibility for play and group activities enables them to meet their social needs and provides opportunities for genuine personality development and the creation of healthy peer relationships [10].

Neurological Development

Two important brain growth spurts occur during the school-age years [11]. Between the age of 6 and 8 years, there are significant improvements in fine motor skills and eye–hand coordination. A second growth spurt occurs between 10 and 12 years, where the frontal lobes become more developed leading to an increased capacity for logic, planning and memory (Molen & Molenaar 1994). School-age children are also better able to plan and coordinate activity using both left and right hemispheres of the brain, and to control emotional outbursts. Attention is also improved as the prefrontal cortex matures [12].

During this stage the emotional brain also develops considerably. Siegel [13] explores the link between social interactions and how the mind develops meaning. He describes how meaning making and relationships appear to be mediated via the same neural circuits responsible for initiating emotional processes. Emotion can therefore be seen as an integrating process that links the internal and interpersonal worlds of the human mind [13]. Essentially at this stage, the brain is molded by learning and social influences. It is an optimal time for learning because children are developing critical and abstract thinking skills. They are becoming more skilled in reading, writing and linguistics [14]. In play, they may now be able to create their own games with complicated rules. At this age, children need opportunities to practice and repeat skills such as bike riding, swimming and cleaning their teeth.

Trauma, abuse or neglect can have a negative impact on the developing brain. These changes can have lifelong physical and psychological consequences. Perry [15] observes the brain’s sensitivity to adverse experiences in early childhood and how this has the potential to impact on brain development and emotional, behavioural, cognitive, social and physiological functioning.

Play Development

The power of play is incredibly profound and is crucial to a child’s development. Frequently in the school-age years, there is an emphasis on intellectual development which can overshadow social and emotional development. Play can allow children to freely express themselves, it is not dependent on how well a child is doing in science or how skilled they are at remembering mathematical equations. Play not only aids the development of the self but also the development of relationships with others. For example, children can learn about turn taking through games with simple rules. Learning how to play fairly and equally can help a child develop skills in making and maintaining friendships. Games with rules and simple structures can also help a child to develop skills that assist them in managing timetables and learning frameworks at school. According to Vygotsky [16], efficient learning occurs in a social context, where learning is scaffolded into meaningful contexts that resonate with children’s active engagement and previous experiences. Children learn through the enjoyment of the play and increase their confidence, self-worth and sense of industry through the achievements they experience whilst playing. Older children tend to become increasingly interested in play involving risk and challenge. For example, a child might want to ride their bike down a steep hill or reach the highest point of the climbing frame in the playground. As well as learning about their physical limits, they are developing their problem-solving skills as they negotiate risk through play.

Jennings [17] has developed two interweaving developmental paradigms for play, Neuro-Dramatic-Play (NDP) and Embodiment-Projection-Role (EPR). NDP begins in infancy and continues until 6 months, whilst EPR follows the progression of dramatic play from birth to 7 years. By the school-age years, the child is in the ‘role stage’. The child’s play becomes increasingly dramatised including stories and scenes being enacted. At this stage, children build confidence and increase skills in communication through being able to play roles in superhero and fantasy stories, improvise with new ideas to set a scene and create masks and costumes to develop characters. EPR addresses the physical, cognitive, emotional and social developmental stages of the young child. Children can experience EPR through play, dance, games, singing, movement, stories and sensory experiences. With myths and fairy tales, the child can experience different roles and identities, relationships as well as explore risk and resolution. Jennings [18] suggests that competence in NDP and EPR are essential to maturity due to their influence on early attachment, formation of emotional intelligence, problem solving and conflict resolution. In the school-age child, role play will also contribute to the development of the skills needed to navigate the social world.

Through play, school-aged children can feel competent and gain a sense of industry. Everyday play is not scored or graded. For the school-aged child, it can also help children escape the pressure and focus on academic achievement. An overemphasis on academic learning may lead a child to constantly compare themselves to their peers. There is a risk for school-age children to feel inferior when the focus weighs heavily on academic progression. Every child can be successful and feel competent at something if given the right opportunity. Broadening the horizon of what these opportunities look like can give every child a chance to experience a sense of industry. Play can offer every child a place to grow, learn, achieve and feel good about something.

Considerations for Nursing and Allied Health Care

Common Fears and Anxieties

Young school children are likely to feel afraid and anxious when engaging with services including health and therapeutic care. At this stage of self and social awareness, they may be worried about what is the matter with them or nervous about interacting with strange professionals. Children will often use behaviour to communicate how they feel, especially in situations of stress and uncertainty. A child may become aggressive or withdrawn. This may become problematic for assessment or medical procedures, so it is essential that appropriate therapeutic skills are applied to help create a safe space and foundation of trust for the child. For a particularly nervous child, allowing time for the child to relax into the appointment is important. They will need the support of their parent/caregiver and preparation for what to expect. As well as a nurturing and inviting physical environment. Building rapport and developing trust with the child will help ease anxieties and lessen the child’s fear and anxiety.

Grief and Loss/Death and Dying

Children have an awareness of death from a relatively young age, although they may not fully understand it. Children of school age have the capacity to understand the permanence of death [19]. It is therefore important they are provided with the facts in an age-appropriate way using developmentally sensitive language. A sensitive approach is needed to avoid overwhelming children with too much information that may scare or confuse them. Overly complicated terms and details may be hard for a child to understand. Not enough explanation, however, such as saying a person has ‘gone to sleep’, may lead to confusion and the false belief that the person is going to wake up again. It is best to listen and answer any questions that may arise sensitively and honestly, no matter how big or small.

However, loss does not always mean death and can refer to losses including the loss of a parent through severed relationships such as divorce, the loss of friendships in schools, the loss of a favourite teacher or the loss of an ability due to illness or injury. No matter what the loss is, grieving for that loss is important. Children grieve and cope differently than adults. They are likely to act out how they are feeling through their behaviour rather than verbalise it. They may become withdrawn or emotionally reactive. Although expressed differently, children still experience powerful feelings, so it is important their experiences are not minimised. Support needs to be developmentally appropriate. Children of school age need to be encouraged to grieve and be able to express their feelings both verbally and non-verbally through play, art and creativity. Children’s books about death, such as Badgers Parting Gifts by Susan Varley, can be read with a trusted adult to help start conversations about loss. We know how important play is at any stage of child development, especially when words are just too hard. Drawing pictures and telling stories are examples of the many ways to help a child express a feeling of loss.

Pain Management

When a child of school age is in pain, they may not always verbally communicate this. Some behaviours that may indicate distress include a loss of appetite, insomnia, crying, lack of play, increased sedentary behaviour, irritability and physical sensitivity. Therefore, observing how a child is behaving is as important as listening to what they are saying. Children will need comfort in times of pain through the presence of a caregiver. A transitional object may also provide comfort. The concept of a transitional object was introduced by Winnicott [20]. A transitional object is something which represents the mother–child bond. Common examples include soft toys, dolls or blankets. By having a familiar object, the child may feel a sense of psychological comfort and security in anxious times, such as when receiving medical care. This may also minimise distress for a child who may need to separate from their parents for a specific medical procedure.

Play can help distract a child during a painful medical procedure, for example a puppet could be used to shift the child’s focus from the pain of receiving an injection. Language considerations are also important. Young children may be prone to confuse fantasy and reality. When not provided with the appropriate facts, children tend to create a much worse fantasy about a situation than the actual reality. Piaget [21] suggested that children not only confuse fantasy and reality, but the mental and the physical, dreams and reality, and appearance and reality. A child may see someone dressed up as Spiderman and struggle to realise that the person behind the mask is in fact not Spiderman. When young children have been provided with accurate information, they can more accurately imagine it. Trust and respect need to be at the core of our relationships with children. If children are not provided with the truth about what is happening to them, in a developmentally sensitive way, they may feel lied to when they later experience it and then lack trust in professionals in the future.

Therapeutic Play Approaches for Clinical Practice

Play is a universal language. Sadly, adults often forget they can speak the language of play. Play is something we should always tune in to when communicating with and helping children, especially in challenging and anxiety-provoking situations. Play techniques can regularly be incorporated into working with children within the medical arena. Dolls, puppets and figures can help children understand complex situations and help them explain or re-enact how they may be feeling. Medical procedures can be explained using dolls. A child may also use dolls to explain how and where they may be feeling pain or symptoms. By using a doll, puppet or figure provides emotional distance allowing the child to explain something difficult in a way that feels safe by projecting this onto the toy. Puppets can also be used in several ways: children may find it easier to answer difficult questions asked by a puppet than directly from a medical practitioner. A puppet may have its own life story that the child can also ask questions about, which can lead to the child talking about their own story with the puppet.

Having a small play kit in your practice that is inviting is essential. If you are working from an office space, consider a corner dedicated to play that will help a child to feel relaxed. Play will help engage the child and decrease their anxiety, which will lead to a more productive and successful assessment or examination. Helpful things to include in this kit for the school-age child could be Lego bricks, sensory toys such as play doh, bubbles, slime, paper, colouring pens/crayons, puppets, dolls, figures, simple non-competitive games (such as Story Cubes or Story Cards), cuddly toys and soft balls. Sandtrays can also be a great tool when working with children. The sensory nature of sand can help calm children and provide a space for them to play out scenarios and create words. A sandtray could be used to explain and aid the visualisation of a hospital setting. This could help prepare a child for a hospital visit or a medical procedure. You could describe the hospital setting by drawing in the sand and explaining where the children’s department is and what they may see when they are there. You could ask the child to pick a figure for themselves so they can walk through the sand in preparation for their upcoming visit. The child may want to choose a strong and courageous animal figure for themselves, like a lion, to help them feel brave towards their upcoming medical event. Alternatively, they may choose a timid creature, like a rabbit, to help externalise and express their fears. Where it may not be possible to use a sandtray, the same activities can be undertaken through drawing tasks or virtual sandtrays. For all children, play is their first language. The more we can use and understand play when communicating with children, the more we will understand them. When it comes to play, children are the professionals, and we must learn and be led by them so we can be the professionals they need.

Parents as Partners

Fostering a good working relationship with parents is vital. Bowlby recognised the importance of supporting parents for positive outcomes for children from the outset noting that ‘if a community values its children, it must cherish their parents’ [22, pp. 84]. A parent’s support for their child is key in supporting healthy development and supporting the child through the challenges that may come with medical care. Respect and authenticity with a nonjudgmental approach are advised when working with parents. Developing a trusting relationship will help activate the trust of the child towards the professional. When children observe positive interactions between their parents and the health professional, it indicates that they are safe.

Considerations for Referral

A child’s experiences in their early years will greatly influence their development and functioning in the school years. Identifying concerns as early as possible is key to supporting healthy development. An appointment in a health care setting may be the first opportunity to observe developmental signs that may indicate a need for further referral. A child may attend a medical appointment for a physical ailment where it is also reported that they are struggling with learning, reading, attention, or memory. In this instance the child may need to be referred for a further developmental assessment. Children who have experienced significant medical trauma may also present with feelings of depression, anger or anxiety, where a referral for counselling or therapy may be appropriate.

Chapter Summary

Many important milestones are reached during the school years. Ability, activity and the social world expand significantly. Successful completion of this stage of development results in the virtue of competence. The use of therapeutic play within the health care setting may aid children to develop a sense of industry and self-worth and provide each child with the opportunity to flourish and thrive in the school years, as they navigate the complex world of feelings and relationships.

Reflective Questions and Activities

  • Consider how nurturing environments can be created in the health care setting.

  • What therapeutic play activities might be appropriate for the school-aged child during a hospital stay?

  • How would you incorporate play into an assessment session with a highly anxious child in your practice? How would you ‘set the scene’? What therapeutic play techniques might you use?