1

LABORATIUM &
TUMBUH KEMBANG
Growth & Development

Kuliah Ilmu Patologi Klinik
Fakultas Kedokteran
UKRIDA
Blok 13
Desember 2012

Sanarko Lukman Halim

Dominant and Recessive
Genes
Genotypeunderlying genetic makeup
Phenotypetraits that are expressed
Dominant geneswill always be
expressed if present
Codominant
Recessive geneswill not be expressed
unless they are in a pair
What is Epigenetics?
Heritable changes in phenotype or gene
expression caused by mechanisms other
than changes in DNA sequence.

Epigenetics causes the organism's genes
to behave differently, such as the changes
seen when cells differentiate or become
malignant.

Sex Linked Traits
Traits linked to the X or Y (sex)
chromosomes (46,X,Y)
Usually recessive and carried on the X
chromosome
Appear more frequently in one sex than
another
Color blindness, baldness, hemophilia,
Fragile X
Physical and Psychological
Development Related
Physical development begins at conception
Physical maturity sets limits on
psychological ability
visual system not fully functional at birth
language system not functional until much later
Prenatal environment can have lifetime
influence on health and intellectual ability
6
Tumbuh Growth
KembangDevelopment
Tumbuh:Ingin Tumbuh Sempurna
Pra-nikah
Janin (infeksi, herediter, Kongental)
Kelahiran
Neonatus/Bayi (Neonatal Screening)
Anak
Dewasa (Anemia, Hiperlipidemia,
Diabetes,kelainan organ)
Tua (Keganasan, degeneratif)


7
Penyebab2
Tobacco 12
High blood pressure 11
Alcohol 9
High cholesterol 8
High BMI 8

Conclusions
Few major risk factors - several multi-factorial
disorders
Treatment important but prevention under-used and
under-valued


8
Chronic disorder 1
Chronic disorder 2
Complication
Age
Birth
Health
QoL
Wellbeing
etc.
Ideal ageing
Intervention
Well-being perspective
Participation
Preconception
Obstetrics
CHC
Prevention &
cure
9
Elderly perspective Newcastle 85+ cohort
High prevalence and complexity age related disorders (many
undiagnosed)
Hypertension 58%
Osteoarthritis 52%
Atherosclerosis 47%
Cataract 47%
At least 3 of above 90%
Hearing loss, visual imp., falls, ui 66, 33, 40, 20%
High health care use 94% GP previous y
Self rated health good or better 78%

Yet clearly frail, and considerable unmet needs!

Collerton et al. BMJ 2009
10
Healthy perspective?
11
Barker-Hypothesis
Hertfordshire study (early 1990s)
Link between low birth weight
Glucose intolerance at adult age
Cardiovascular disease at adult
age

Molecular mechanism?


AGEING STARTS IN UTERO


12
Perkembangan
Faktor faktor yang mempengaruhi:
Genetik Talasemia, def G6PD, Sindroma
Down
Kelainan kongenital Hipotiroidi Kongenital
Lingkungan kebersihan, suasana rumah
Gizi nilai protein, malnutrition, albumin
Penyakit Infeksi mikroba, kultur, IgG, IgM, ELISA
Sosio-ekonomi keuangan, pendidikan

13
Keinginan:Tumbuh Sempurna
Fisik otot, tulang, growth curve pertumbuhan
Intelektual pendidikan
Kejiwaan emosional stabil
14
Persiapan pra-nikah
Penentuan Golongan Darah ABO
Penentuan faktor Rhesus Rh inkomp
Hemolytic Disease of the Newborn (HDN)
Darah Lengkap
Deteksi adanya penyakit:
Sifilis
Hepatitis B, C
HIV
Bila ada indikasi: Talasemia ,



15
Janin
Pemeriksaan wanita hamil
Darah Lengkap Anemia
Golongan Darah, faktor rhesus HDN
Kadar glukosa puasa, 2 jam pp
gestational diabetes
Infeksi kelainan kongenital pada janin
Toksoplasma
Sifilis
HIV
Analisis cairan amnion, bila terindikasi
Sindroma Down, Kordosentesis, bila ibu
hamil & suami trait talesemia sama



16
Neonatus
Darah Rutin
Glukosa darah
Neonatal Screening (NS)
Hipotiroidi Kongenital (HK) IQ rendah. kretin
Phenylketonuria (PKU) IQ rendah
def G6PD anemia hemolitik
Congenital Adrenal Hyperplasia (CAH)
kesulitan penentuan seks bayi, salt losing
Monitoring bilirubin indirek HDN
Bila ibu sifilis, tes sifilis kongenital
Bila ibu HIV positif, cek apakah bayi terinfeksi
Bila ibu toksoplasmosis, cek apakah bayi terinfeksi



17
Anak
Perhatikan perkembangan dan
nutrisi
Cek Hemoglobin
Cek ada tidaknya malnutrisi
protein Tes Albumin Darah
Imunisasi
Tes HBsAg. Negatif imunisasi

18
Kuliah Neonatal Screening NS
Hipotiroidi Kongenital HK
Phenylketonuria PKU
Congenital Adrenal Hyperplasia CAH
G-6-PD defisien

19
Basic Ethical Principles of
Neonatal Screening
The genetic disorder is serious
The test is accurate
There is available therapy
The cost is proportional to the benefit
No unreasonable burden was to fall on
those falsely identified as ill or on those
individuals who were screened but were
found not to be affected
20
Galaktosemi

Glucose + galactose lactose + H
2
O
Glucose + fructose sucrose + H
2

Monosaccharides Disaccharide
Glucose + glucose
maltose + H
2
O
Glucose + galactose
lactose + H
2
O Glucose +
fructose sucrose + H
2
O
21
Important Disaccharides
A disaccharide
Consists of two monosaccharides.
Monosaccharides Disaccharide
Glucose + glucose maltose + H
2
O
Glucose + galactose lactose + H
2
O
Glucose + fructose sucrose + H
2
O



22
23
Uji Tapis Hipotiroidi
1. Aim of Screening
2. Causes of primary hypothyroidism
3. Screening Parameter: TSH
4. Timing; cut off
5. atypical hypothyroidism with delayed
elevation of TSH
6. Conclusions and recommendations


24
Tujuan Uji Saring Kelenjar
Tiroid
early diagnosis of
primary hypothyroidism

[Frequency 1 in 3500]
[to optimize mental development]

25
Penyebab hipotiroidi primer
15% hereditary
1. inborn errors of thyroxine
synthesis.
2. mutations in the genes coding for the
sodium/iodide symporter,
thyroid peroxidase and
thyroglobulin
26
Penyebab Acquired pr.. hypothyroidism
Iodine deficiency
Iodine excess
antiseptica, or other iodine
contained agents
27
Parameter Uji Saring CHT: TSH
in the screening for primary
hypothyroidism

an elevated TSH is much more
sensitive than a low T4 level


28
Timing for screening blood sample
independent of gestational age
day 3 p.p.(>48h)
in all newborns


29
Sampling &Metodologi
Capillary spotted blood on filter paper
Cave:high hematocrit >falsely low
values
Fluorometric assay

30
Fungsi tiroid janin & neonatus
Thyroxine (T4)
levels are higher in full term than in
premature newborns.
TSH
dose not change during the second
half of gestation
31
TSH cut off
Cord blood 40 U TSH/ml
Day 3-6 20
Day >7 10
Valid for all newborns
independently from gestational age
32
Kesimpulan
(Perhatikan khusus (Rapaport 2003):
1. VLBW infants
2. infants requiring intensive neonatal care
3. infants exposed to iodine-containing
solution, especially in low iodine endemic
regions
4. dopamine, amiodarone, or other agents that
affect thyroid functions, and
5. infants with congenital anomalies, especially
cardiac defects and chromosomal
abnormalities.
33
Figure 15-11. (Left panel) Infant with severe, untreated
congenital hypothyroidism diagnosed prior to the advent of
newborn screening. (Right panel) Infant with congenital
hypothyroidism identified through newborn screening. Note
the striking difference in the severity of the clinical features.
34
Figure 15-12. Ten year old female with severe 1 hypothyroidism due to
primary myxedema before (A) and after (B) treatment. Presenting
complaint was poor growth. Note the dull facies, relative obesity and
immature body proportions prior to treatment. At age 10 years she had
not lost a single deciduous tooth. After treatment was initiated (indicated
by the arrow in Panel C), she lost 6 teeth in 10 months and had striking
catch up growth. Bone age was 5 years at a chronologic age of
10 years. TSH receptor blocking antibodies were negative.
35
Uji Tapis/Skrinig
Phenylketonuria/ PKU
All published studies show that PKU
screening and treatment represent a net
direct cost savings to society
Phenylketonuria: Screening and
Management NIH Consensus Statement
Online 2000
36
Overview
What is PKU?
Diagnosis of PKU
Discovery of PKU
PKU Diet
Women (pregnant) with PKU
Quiz/Questions



37
Apakah Phenylketonuria?
Inherited metabolic disease
Autosomal recessive disease
Phenylalanine is not metabolized to
tyrosine due to deficiency or inactivity of
phenylalanine hydroxylase (PAH).
PKU is caused by a mutation in a gene on
chromosome 12.
There are three different ways PAH
enzyme can affect the conversion of
phe to tyr.

38
Phenylketonuria
Most common inborn error in amino acid
metabolism
High phe can cause neurologic damage
Unusual compounds: phenylpyruvate;
phenyllactate; phenylacetate
Brain toxicity: reduced uptake of other aromatic
amino acids
Tyrosine deficiency may lead to
hypopigmentation
Cofactor processing can also be defective
39

Living with PKU
40
Cara Diagnosis PKU
Tested for at birth in all 50 states (AMERICA)
Guthrie bacterial inhibition assay is most common
test done.
If positive test, have to retest to determine if it
is defect in BH4 (cofactor to PAH) or PKU.
If blood concentration of phe exceeds 6 mg/dl
and tyr levels are less than 3 mg/dl test is
positive for PKU.
There are different levels of severity for PKU:
mild PKU= >6 mg/dl and PKU= >20 mg/dl.
http://www.pkunews.org/
41
Pentingnya Diagnosis Dini PKU
individuals without early diagnosis develop
complications such as severe mental
retardation/low IQ, heart defects
Early diagnosis is important to prevent
these complications as soon as possible.
If PKU is caught and treated early, children
are healthy and grow up with normal IQ
levels.
42
Tujuan diet PKU
To decrease phenylalanine levels
Between 2-6 mg/dl are considered
safe levels.
To increase tyrosine
Because the bodys PAH gene does
not work properly, tyrosine
synthesis is compromised


43
Transisi ke makanan padat
Childs rate of growth and development must
be closely monitored
Effective management requires cohesive
team
child, parents, social worker, registered
dietitian, pediatrician, psychologist, and
nurse work together
Goal is to maintain biochemical control,
and provide an atmosphere for normal
mental and emotional development
44
Diet PKU seumur hidup
Current Recommendations
Effective management of blood phenylalanine
concentrations should be done throughout life
Some studies have found a correlation
between prolonged and significant elevation of
blood phe levels, and declining intellectual
capabilities in adults.
Regular testing should be done to make sure the
PKU diet is effective in disease maintenance.
If phenylalanine and tyrosine levels are unsafe,
appropriate adjustments in diet should be made.
45
Ibu Hamil dengan PKU 1/2
High Maternal blood phenylalanine levels are
extremely toxic to the developing embryo/fetus:
Severe mental retardation
Small head size (microcephaly)
Heart defects
Low birth weight
Characteristic facial features/defects
These complications are a result of high blood phe
levels in mother the baby is affected even if
he/she does not inherit PKU.
46
Ibu Hamil dengan PKU 2/2
Special diet is essential to help prevent birth
defects
Special PKU diet and regular screening for
phenylalanine levels should begin at least three
months prior to becoming pregnant.
Continuing the diet and regular screening during
pregnancy can decrease chance of complications
Blood tests need to be done at least once a week.
Even a mother who follows the special diet may
still have a baby with birth defects
47
G6PD Deficiency

G6PD Deficiency is also called Glucose-6-
phosphate Dehydrogenate.
It is a common enzyme deficiency. There are
about 400 million people do have G6PD
Deficiency.
In Africa, theres one G6PD Deficient person
per four people.
48
Percent of people who have
G6PD Deficiency
49
G6PD Deficiency
G6PD enzyme is located on sex ` enzyme is
X-linked gene.
Males are more likely to have defective
gene than females do because G6PD
deficiency will only manifest itself in females
when there are two defective copies of the
gene in the genome. As long as there is one
good copy of the G6PD gene in a female, a
normal enzyme will be produced and this
normal enzyme can then take over the
function that the defective enzyme lacks.
50

G6PD deficiency cause red blood cells
no longer transport oxygen effectively
throughout the body. This condition is
called Hemolytic Anemia Arises.
There are other conditions that also
caused by G6PD deficiency- neonatal
jaundice, abdominal back pain,
dizziness, headache, irregular breathing,
and palpitations.
51
Congenital adrenal hyperplasia (CAH)
The commonest cause of
genital ambiguity at birth
21-Ohas deficiency is most
common form
Autosomal reccessive
Salt wasting form may be
lethal in neonates
SERUM 17OH-
progesterone
(21OHase)
SERUM
deoxycorticosterone, 11-
deoxycotisol (11- OHase)
Treatment : cortisol
replacement and ? Surgery

52
21-hydroxylase deficiency
congenital adrenal hyperplasia
Pituitary
ACTH
Adrenal cortex

Androgens
Cortisol
Cholesterol
Pregnenolone
Progesterone
17-OH progesterone
21-hydroxylase
Androgens Cortisol
53
Congenital Adrenal Hyperplasia/CAH
Cause
Most common form of CAH is complete
absence of 21 hydroxylase activity
Severe renal sodium wasting due to
deficient aldosterone production and
inhibition of sodium absorption in the distal
nephron
Symptoms
Ambiguous genitalia, hyponatremia,
hyperkalemia, and metabolic acidosis
54
Heel-prick neonatus
55
Dewasa Pria, Wanita
Diabetes?
Tes Glukosa puasa dan 2 jam pp
Hiperlipidemia ?
Tes kadar kolesterol
Keganasan
Elderly Development
Generally over 60 years
Feel integrity vs. despair
accomplishment or failure
Weakened immune system leaves them
susceptible to dangerous diseases
Due to a lifetime of having antibodies the
elderly rarely get the common cold
Mental disintegration may occur leading to
Alzheimer's
Dementia
57
Lansia
Dibicarakan terpisah
Keganasan
Penyakit degeneratif

58
Buku Wajib:
McPherson RA., Pincus MR., Editors Henrys Clinical Diagnosis and Management by
Laboratory Methods 21st edition, ISBN-13:978-1-4260-0287-1 Saunders Elsevier 2007
Daftar Kepustakaan
Gaw A, Clinical Biochemistry, ISBN 0-443-04481-3 Churchill Living Stone New York 1995,
92-93
Churchill Living Stone New York
ISBN 0-443-04481-3. 1995

Abraham P. editor, Physiology, ISBN-13: 978-1-905704-64-4, Amber Books London 2007
6

Thompson MW et al., Thompson & Thompson: Genetics in Medicine. Fifth Edition. ISBN 0-
7216-2817- WB Saunders Philadelphia, USA 1991
McPherson RA., Pincus MR., Editors Henrys Clinical Diagnosis and Management by
Laboratory Methods 21st edition, ISBN-13:978-1-4260-0287-1 Saunders Elsevier 2007
Daftar Kepustakaan
Gaw A, Clinical Biochemistry, ISBN 0-443-04481-3 Churchill Living Stone New York 1995,
92-93
Churchill Living Stone New York
ISBN 0-443-04481-3. 1995

Abraham P. editor, Physiology, ISBN-13: 978-1-905704-64-4, Amber Books London 2007
6

Thompson MW et al., Thompson & Thompson: Genetics in Medicine. Fifth Edition. ISBN 0-
7216-2817- WB Saunders Philadelphia, USA 1991

Federman DD., The Biology pf Human Sex Differences. N Engl J Med 2006; 354:1507-14

What is Epigenetics?
Heritable changes in phenotype or gene
expression caused by mechanisms other
than changes in DNA sequence.

Epigenetics causes the organism's genes
to behave differently, such as the changes
seen when cells differentiate or become
malignant.

Breast Cancer

Pathology
Grade of tumor
Protein & gene
expression
Stage of a tumor
Squamous Cell
Carcinoma
Ductal Carcinoma

Epigenetic Biology of Normal Cells
The methylation of cytosines in DNA is the most widely
studied epigenetic modification with 36% of all
cytosines methylated in normal human DNA. The
methylation of DNA is located in regions known as CpG
islands.

Repetitive genomic sequences are highly methylated to
protect chromosomal integrity by preventing the
reactivation of transposable elements such as LINES,
SINES, HERVS.

The healthy cell regulates genes and tissue-specific
genes in the germ line through DNA methylation, such
as genomic imprinting and X-chromosome inactivation.
Epigenetic Biology of Normal Cells
Lysine methylation at H3K9, H3K27, and H4K20 gene silencing

Lysine methylation at H3K4, H3K36, and H3K79 gene activation.

Functional Interactions between
DNA and Histones

Chapter 7 64
Conception to Full Term
First Trimester
Begins with conception, when 1
sperm penetrates the ovum (egg) in
the outer third of the fallopian tube.
The zygote (fertilized ovum) travels
through the fallopian tube toward the
uterus, dividing along the way.
At the back of the group of cells, or
morula, is a rootlike projection that
will eventually become the placenta.
Chapter 7 65
Conception to Full Term (cont.)
Chapter 7 66
Conception to Full Term (cont.)
By 21 to 25 days from conception,
a rudimentary heart is beating and
a nervous system is forming.
At 4 weeks, the embryo is about
inch long and has arm buds, a
head, body, and tail. Eyes can be
discerned.
At 5 weeks, the nose can be seen.
Chapter 7 67
Conception to Full Term (cont.)
At 6 weeks, the embryo is a little
less than inch long and leg
buds can be seen.
Chapter 7 68
Conception to Full Term (cont.)
At 7 weeks, the embryo is about
inch long and can move its hands.
At 8 weeks the embryo is almost 1
inch long, has a large liver, and
bones are forming.
At 10 weeks, the fetus is about 1
to 2 inches long, the kidneys are
making urine, and lower trunk
muscles are developing.
Chapter 7 69
Conception to Full Term (cont.)
Second Trimester
At 12 weeks, the head of the
fetus is about one-third the size
of its outstretched length and
the ribs can be seen. Soft,
downy hair begins to appear.
Chapter 7 70
Conception to Full Term (cont.)
At 16 weeks, the fetus is about
4 inches long and weighs 3 to 4
ounces.
At 20 to 24 weeks, the fetus is
about 12 inches long, major
systems continue to develop, and
bones continue to form.
Chapter 7 71
Conception to Full Term (cont.)
Third Trimester
At 26 weeks, the pregnancy
begins the third trimester.
At 28 weeks, the fetus is about
14 inches long and weighs
about 2 pounds. Survival is
possible if born at this stage.
38 to 40 weeks labor begins.
Chapter 7 72
The Neonate:
Birth to One Month
Physical
Development
weight usually 7 to 9
pounds, and length
18 to 22 inches.
The newborns head is
large in comparison
with rest of body.
Chapter 7 73
The Neonate:
Birth to One Month (cont.)
Bones in skull are
not fixed, but can
slide over one
another. This is
called molding.
Head has 2 soft
spots, or fontanels,
which are tough
cartilage.
Chapter 7 74
The Neonate:
Birth to One Month (cont.)
The Skin of the Newborn
Loose, wrinkled, and red.
At birth, hands and feet may be bluish, but
will pinken after a few breaths.
Activity, temperature, and circulatory
changes during the first few days can affect
skin color.
Peeling during the first week is not unusual
or harmful.
Vernix caseosa, a white waxy substance, may
be found in the folds of the skin.
Chapter 7 75
The Neonate:
Birth to One Month (cont.)
Milia, small white bumps on
the chin and nose may
appear, but go away naturally.
The remaining part of the
umbilical cord is about 1 to
1 inches long and usually
falls off after the 10
th
day of
life.
Neonatal jaundice, a yellowish
color of the skin caused by an
accumulation of bilirubin, can
occur.
Chapter 7 76
The Neonate:
Birth to One Month (cont.)
Other Physical Characteristics of the
Newborn:
Eyes may appear swollen, due to the
passage through the birth canal.
Lips may have blisters from thumb
sucking in the uterus.
Breast tissue and genitalia may
appear swollen.
Fists tightly closed.
Chapter 7 77
The Neonate:
Birth to One Month (cont.)
Reflexes blinking, a normal reflex.
Some other reflexes are due to an
immature nervous system.
Crying may be from hunger or other
reasons.
Eating 7 or 8 times a day for the first
few weeks.
Sight infants can see objects within
8 inches of their eyes.
Hearing seem to prefer high-pitched
tones.
Chapter 7 78
The Neonate:
Birth to One Month (cont.)
Intellectual-Cognitive Development
Newborns will become calm when picked
up and held firmly.
Disturbing stimulation is tuned out by
sleeping.
Social Development
Infants respond to a soft, gentle voice.
Newborns can show excitement and
distress.
Chapter 7 79
The Neonate:
Birth to One Month (cont.)
Aspects of Care:
Keep warm, especially right after birth.
Vitamin K shot given to prevent
bleeding.
Medicated eye drops to prevent
infection.
Umbilical cord is painted with
antibacterial.
Give small amounts of water to ensure
swallowing.
Blood sample checks metabolic
disorders.
Tepid water sponge baths until the
umbilical cord has fallen off.
Chapter 7 80
The Neonate:
Birth to One Month (cont.)
Feeding by breast, bottle, or
both. Parents must be told about
the frequency and duration of the
feedings.
Chapter 7 81
The Neonate:
Birth to One Month (cont.)
Treatment of jaundice make
sure the infant is well hydrated
with breast or bottle milk.
Ultraviolet light may be used,
but make sure to protect the
infants eyes. Blood tests
should be done frequently.
Arrange follow-up care.
Chapter 7 82
The Infant:
One Month to One Year
Physical Development
Weight triples in the first year.
3 weeks the infant can focus on
objects.
4 weeks the infant can follow a
bright object with eyes and make
eye contact.
2 months an infant can follow
objects with eyes, listen to
sounds, bat at objects, and
respond to sound.
Chapter 7 83
The Infant:
One Month to One Year (cont.)
Physical Development (cont.)
3 months infants may raise head and
shoulders while on abdomen.
4 months infant can roll from stomach
to back, may play with rattle placed in
the hand. Teething may begin.
5 months may transfer rattle hand to
hand.
6 months may roll back to stomach,
may be able to sit momentarily, can
transfer objects hand to hand. Can
retrieve dropped object. Two bottom
teeth are probably visible.

Chapter 7 84
The Infant:
One Month to One Year (cont.)
9 months infant can sit
well, creep, build tower
with 2 blocks. Infant uses
pincer grasp, can put
consonants with vowels
and make repetitive
sounds.
12 months child can
cruise by holding onto
the edge of a piece of
furniture and moving
around. Infant can begin
self-feeding.
Physical Development (cont.)
Chapter 7 85
The Infant:
One Month to One Year (cont.)
Intellectual-Cognitive Development
1 month eye contact.
4 to 5 months makes faces.
6 months makes babbling sounds.
9 months can play peek-a-boo games.
12 months can follow simple directions.
Chapter 7 86
The Infant:
One Month to One Year (cont.)
Psycho-Emotional Development
1 month smiles at another smiling
face.
3 months smiles spontaneously
and displays pleasure in making
sounds.
4 months vocalizes moods.
6 months abrupt mood changes.
9 months displays pleasure
playing simple games.
12 months can express many
emotions.
Chapter 7 87
The Infant:
One Month to One Year (cont.)
Social Development
1 month smiles.
3 months responds to voices.
6 months babbles and is
interested in own voice.
9 months begins to develop
words.
Chapter 7 88
The Infant:
One Month to One Year (cont.)
Aspects of Care: One Month to One
Year
Regular health check-ups and
immunizations.
Tactile stimulation, such as physical
contact and cuddling, as well as
attention to needs, is required for
appropriate growth and development.
Food breast milk or formula is
sufficient for the first 6 months. Obtain
guidance from health care provider
about solid foods.
Chapter 7 89
The Infant:
One Month to One Year (cont.)
Safety must be considered at all
times. Take the following safety
measures:
Keep emergency phone numbers
available.
Ensure the crib meets federal safety
standards.
Use an appropriate car seat.
Do not allow pillows, comforters, or
plush toys in bed with the child.
Chapter 7 90
The Infant:
One Month to One Year (cont.)
Prevent falls.
Prevent choking.
Remove hanging toys from the crib
when the child begins to reach, pull,
and roll over.
Never leave the child unattended in
the car.
Secure and keep out of reach all cords
on window blinds, lamps, and
electrical equipment.
Safety (cont.)
Chapter 7 91
The Toddler:
One to Three Years
Physical Development
Arms and legs grow faster
than the trunk.
Most walk by 15 months,
run by 2 years.
At 3 years, they are very
agile and active. They can
throw a ball, draw simple
shapes, and use childs
scissors.
Chapter 7 92
The Toddler:
One to Three Years (cont.)
Intellectual-Cognitive
Development
Child tries to imitate actions like
raking, sweeping, etc.
Speech
12 to 15 months speaks single
words.
Second year makes sentences of 6
to 20 words.
Third year repeats nursery rhymes.
May always ask Why?
Chapter 7 93
The Toddler:
One to Three Years (cont.)
Psycho-Emotional Development
1 year many emotions available.
1 to 3 years child gains some
control over ways to express feelings.
18 months to 2 years temper
tantrums become an issue, child
begins to resist authority.
3 years child becomes sensitive to
the feelings of others and may be
characterized as affectionate.
Chapter 7 94
The Toddler:
One to Three Years (cont.)
Social Development
1 to 2 years child unable to
play well with others, may be
aggressive.
2 to 3 years child learns
sharing and becomes aware of
appropriate behavior when
playing with others.
Chapter 7 95
The Toddler:
One to Three Years (cont.)
Aspects of Care
Work on motor skills with crayons.
Patient explanations and patience
provide a positive environment for
growth.
Health care monitoring and
vaccinations are needed.
Toilet training may be encouraged
when child demonstrates signs of
readiness.
Chapter 7 96
The Preschooler:
Three to Five Years of Age
Physical Development
Height heredity becomes
apparent in variations among
children.
Respiratory and heart rates begin
to slow.
Bones begin to ossify. Activity
and calcium are important in
developing strong bones.
Chapter 7 97
The Preschooler:
Three to Five Years of Age (cont.)
Nighttime bladder and
bowel control achieved
by 3 to 4 years of age.
Large muscle
development should
enable the child to
navigate stairs using
alternating steps.
At 5 years a child can
hop, skip, and
participate in team
sports.
Physical Development
Chapter 7 98
The Preschooler:
Three to Five Years of Age (cont.)
Intellectual-Cognitive
Development
Nervous system many
connections, called synapses,
are made, enabling more skillful
play.
Language great strides are
made. Vocabulary may reach
900 words by 3 years, and 1600
by 4 years. At age 5, vocabulary
exceeds 2000 words.
Chapter 7 99
The Preschooler:
Three to Five Years of Age (cont.)
Psycho-Emotional
Development
3 years usually pleasant, enjoys
music, has a sense of self.
4 years child tests limits,
becomes more negative.
5 years child should be more
self-assured, adjusted, and home-
centered. Child can accept some
responsibility.
Chapter 7 100
The Preschooler:
Three to Five Years of Age (cont.)
Social Development
3 years children know what
gender they are; they like to
help.
4 years very social. Enjoy
games.
5 years enjoy games with more
rules.
Chapter 7 101
The Preschooler:
Three to Five Years of Age (cont.)
Aspects of Care
Maintain regular checkups,
including a complete preschool
physical.
Immunizations must be kept up to
date.
Nighttime routines help a child feel
secure.
Chapter 7 102
The Elementary School Child:
Six to Ten Years
Physical Development
Girls tend to be taller and heavier
than boys at this stage.
Bones continue to ossify.
Reproductive systems begin
developing slowly.
Postural habits are developed.
Chapter 7 103
The Elementary School Child:
Six to Ten Years (cont.)
Intellectual-Cognitive Development
Progresses from brief attention span
to being able to focus for extended
periods of time.
Moves from block letters to cursive
handwriting.
Speech may differ between peers and
adults.
Recognizes time concepts,
differentiates between fantasy and
reality, and develops a sense of right
and wrong.
Chapter 7 104
The Elementary School Child:
Six to Ten Years (cont.)
Psycho-Emotional Development
Parental influence decreases while
peer influences increase as child
approaches 10 years.
Concerns shift from self to others.
Child may become very sensitive
to criticism.
Chapter 7 105
The Elementary School Child:
Six to Ten Years (cont.)
Social Development
School becomes
very important to
the child, along with
group activities.
Appropriate social
behaviors are
learned.
Chapter 7 106
The Elementary School Child:
Six to Ten Years (cont.)
Aspects of Care
Structure, schedule, and consistent
daily activities are important.
Activities must be monitored to
prevent physical injury.
Health and dental care and
immunizations must be maintained.
Chapter 7 107
The Middle School Child:
Eleven to Thirteen Years
Physical Development
Puberty occurs in girls at 12 to
13 years, but may start as early
as 9. In boys, it starts around 14
years of age.
Fusion of some bones occurs.
Skin problems may begin, and
appetite increases.
Chapter 7 108
The Middle School Child:
Eleven to Thirteen Years (cont.)
Intellectual-Cognitive
Development
Physical and psychological changes
divert energy from academics.
Child begins to think abstractly and
critically.
Exaggeration and fibbing may occur.
Chapter 7 109
The Middle School Child:
Eleven to Thirteen Years (cont.)
Psycho-Emotional Development
Accurate information about their
changing bodies should be given
by a reliable source.
Child may be temperamental or
moody.
Chapter 7 110
The Middle School Child:
Eleven to Thirteen Years (cont.)
Social Development
Becoming part of a
group becomes
important.
Girls become
interested in male-
female relationships
earlier than boys.
Chapter 7 111
The Middle School Child:
Eleven to Thirteen Years (cont.)
Aspects of Care
Reassure the child that he or she is
loved.
Avoid being hypercritical. Dont make
too many demands.
Monitor friendships and associations.
Maintain immunizations and regular
health care checkups.
Allow some quiet time in the
schedule.
Chapter 7 112
The Adolescent:
Fourteen to Nineteen Years
Physical Development
Females attain their adult
height and weight, while
males continue to grow
until age 25.
Poor diet and exercise in
this stage can lead to
problems later in life.
Education about sexual
behavior should be
provided by trusted, well-
informed adults.
Chapter 7 113
The Adolescent:
Fourteen to Nineteen Years (cont.)
Cognitive-Intellectual
Development
Reasoning and critical and
abstract thinking are developing.
Psycho-Emotional
Development
Although aware of acceptable
behavior, teens are prone to
angry outbursts.
Adolescents can feel both alone
and conspicuous.
Often, teens feel immortal or
invulnerable.
Chapter 7 114
The Adolescent:
Fourteen to Nineteen Years (cont.)
Social Development
Teens should learn
effective interpersonal
skills, resolve conflicts and
become comfortable with
their style of
communicating.
They tend to get involved in
community service
projects.
They are more comfortable
relating to their parents.
Chapter 7 115
The Adolescent:
Fourteen to Nineteen Years (cont.)
Problems Faced by Teens
Eating Disorders
Anorexia nervosa self-starving,
more common in females.
Bulimia binge eating, followed by
purging through vomiting, excessive
use of laxatives, abuse of diuretics,
or excessive exercise.
Chapter 7 116
The Adolescent:
Fourteen to Nineteen Years (cont.)
Substance Abuse Signs
Change in personality, friends, health
habits, and appearance.
Withdrawal from family and group
activities.
Sliding school grades.
At-risk teens are those who have:
Family history of substance abuse.
Low self-esteem.
Depression.
A sense of not fitting in.
Chapter 7 117
The Adolescent:
Fourteen to Nineteen Years (cont.)
Violence
Poverty is considered a leading cause
of violence in teens.
Bullying in school is increasingly
recognized as a cause of violence.
Depressed students may harbor
resentment for a long time.
Chapter 7 118
The Adolescent:
Fourteen to Nineteen Years (cont.)
Sexually Transmitted Diseases
STDs that threaten long-term health
and well-being include:
Chlamydia.
Syphilis.
Gonorrhea.
Hepatitis B.
Herpes type II.
Papilloma virus.
HIV.
Chapter 7 119
The Adolescent:
Fourteen to Nineteen Years (cont.)
Pregnancy problems associated
with teen pregnancy include:
Low birth weight.
Prematurity.
Cesarean delivery.
Child abuse.
Growing up in poverty.
Chapter 7 120
The Adolescent:
Fourteen to Nineteen Years (cont.)
Suicide the third leading cause of
death for people 15 to 24 years of age.
Warning signs include:
Depression.
Anger, directed inward.
Alcohol and/or other substance abuse.
Changes in habits.
Giving away personal possessions.
Giving verbal hints about committing
suicide.
Chapter 7 121
The Adolescent:
Fourteen to Nineteen Years (cont.)
Actions to take if you suspect someone
is contemplating suicide:
Listen.
Take the person seriously.
Get help from a responsible adult.
Do not promise to keep the secret.
Never assume its just talk.

Chapter 7 122
The Adolescent:
Fourteen to Nineteen Years (cont.)
Aspects of Care
Provide adequate calcium and weight-
bearing exercise.
Provide sex education and information
about sexually transmitted diseases.
Encourage friendships, sporting
events, and social events.
Listen to them.
Give them the facts.

Chapter 7 123
The Adolescent:
Fourteen to Nineteen Years (cont.)
Aspects of Care (cont.)
Trust them.
Provide them with firm and friendly
discipline.
Be consistent.
Educate them, with their independence
in mind.
Set limits and stick to them.
Set examples of good behavior and
taste.
Remember how it felt to be an
adolescent.
Chapter 7 124
Section 7-2
Apply Your Knowledge
List three suicide warning signs.
Answer:
Suicide warning signs are:
1. Depression.
2. Anger, directed inward.
3. Alcohol and/or other substance
abuse.
4. Changes in habits.
5. Giving away personal possessions.
6. Giving verbal hints about committing
suicide.
Chapter 7 125
The Adult Years
The Young Adult: Twenty to
Forty Years
The Middle-Aged Adult: Forty to
Sixty-Five Years
The Mature Adult Years: Sixty-
Five Years and Older

Chapter 7 126
The Young Adult:
Twenty to Forty Years
Physical Development
Growth has generally stopped, but
calcium and regular weight-bearing
exercise are still required.
Visual acuity begins to decline,
especially depth perception.
Hearing loss may be noted, although
it can begin as early as age 14.
Chapter 7 127
The Young Adult:
Twenty to Forty Years (cont.)
Intellectual-Cognitive Development
Knowledge acquired through both
formal training and on-the-job
training.
Critical thinking and reasoning skills
are refined.
Chapter 7 128
The Young Adult:
Twenty to Forty Years (cont.)
Psycho-Emotional
Development
Long-lasting relationships
are established.
Careers can lead to stress
and anxiety.
Chapter 7 129
The Young Adult:
Twenty to Forty Years (cont.)
Social Development
Young adults establish careers,
marriages, families, and homes.
Friendships and relationships
may be based more on interests
than age.
Contributing to the community
becomes important.
Chapter 7 130
The Young Adult:
Twenty to Forty Years (cont.)
Aspects of Care
Weight-bearing and aerobic
exercise should be continued to
reduce and prevent bone loss.
A balanced nutritional plan
should be in place.
The need for social contact
continues, and may be fulfilled
through church, school, and
community activities.
Chapter 7 131
The Young Adult:
Twenty to Forty Years (cont.)
Stress management techniques
are essential.
Regular health checkups are
important for preventive
maintenance.
Regular dental care is necessary,
including cleaning and checkups
twice a year.
Chapter 7 132
The Middle-Aged Adult:
Forty to Sixty-Five Years
Physical Development
Females may experience bone loss as
early as age 35. Men may not
experience it until age 65.
Muscle strength, endurance, and
stamina may begin to decline.
Hair may begin to turn gray and thin;
wrinkles appear in the skin.
Chronic health problems such as
hypertension, heart disease, and
diabetes may surface.
Chapter 7 133
The Middle-Aged Adult:
Forty to Sixty-Five Years (cont.)
Intellectual-Cognitive
Development
The brain begins to decrease in
size, due to water loss.
Information processing begins
to slow.
The individual is still capable of
multitasking, learning new
information, and retrieving old
information.
Chapter 7 134
The Middle-Aged Adult:
Forty to Sixty-Five Years (cont.)
Psycho-Emotional Development
Many feel a sense of pride and
accomplishment in their careers.
Some may experience a sense of
loss, known as the empty nest
syndrome.
An awareness of ones mortality
may be noted.
Chapter 7 135
The Middle-Aged Adult:
Forty to Sixty-Five Years (cont.)
Social Development
Caring for an aging
parent may lead to
stress.
Creative, social, and
enjoyable outlets are
important.
Chapter 7 136
The Middle-Aged Adult:
Forty to Sixty-Five Years (cont.)
Aspects of Care
Regular weight-bearing and aerobic exercise
should be continued.
A balanced nutritional plan should be in place.
Adequate rest is needed to be able to perform
daily tasks.
The need for social contact continues.
Stress-management techniques should be
applied.
Regular health and dental checkups should
continue.
Chapter 7 137
The Mature Adult Years:
Sixty-Five Years and
Older
Physical Development The body
begins to show physical signs of
aging.
Chapter 7 138
The Mature Adult Years:
Sixty-Five and Older (cont.)
Integumentary System
Thinning and wrinkling skin is caused by a
decrease in collagen and elastin in the dermis.
Atrophy, or degeneration, of the subcutaneous layer
of skin is caused by a decrease in adipose tissue.
Decrease in melanocytes, which produce pigment
and protect against ultraviolet light.
Graying, thinning hair and brittle nails.
Decreasing inflammatory response, resulting in
slower healing.
Chapter 7 139
The Mature Adult Years:
Sixty-Five and Older (cont.)
Nervous System
Slower reaction time and thought processing.
Decreased blood flow to the brain, caused by
arteriosclerosis.
Shortened attention span and difficulty in multi-
tasking.
Shrinkage of temporal lobes, leading to weaker
signals to the brain for processing.
Impairment of fine motor activities.
Memory loss caused by changes in the brain.
Impaired vision and hearing.
Chapter 7 140
The Mature Adult Years:
Sixty-Five and Older (cont.)
Musculoskeletal System
Osteoporosis or decreased bone
density.
Osteoarthritis or joint disease.
Decreased numbers of
musculoskeletal fibers.
Chapter 7 141
The Mature Adult Years:
Sixty-Five and Older (cont.)
Cardiovascular System
Decreased cardiac output, especially
during exercise.
Arteriosclerosis.
Postural hypotension or loss of blood
pressure when standing or sitting up
abruptly.
Increased risk of heart disease.
Chapter 7 142
The Mature Adult Years:
Sixty-Five and Older (cont.)
Respiratory System
Some loss of elasticity of the lungs.
Calcification of the intercostal cartilage.
Increased shortness of breath, caused by
the physical changes listed above.
Chapter 7 143
The Mature Adult Years:
Sixty-Five and Older (cont.)
Immune System
General decline, giving rise to
susceptibility to infectious diseases
and autoimmune diseases such as
cancer and rheumatoid arthritis.
Chapter 7 144
The Mature Adult Years:
Sixty-Five and Older (cont.)
Digestive System
Constipation, caused by lack of
exercise and poor diet.
Fecal incontinence, caused by lack of
muscle tone.
Chapter 7 145
The Mature Adult Years:
Sixty-Five and Older (cont.)
Genitourinary System
Decreased number of nephrons, the
functional units of the kidney.
Reduced tolerance for stress, so the
kidneys may respond to disease in other
parts of the body.
Loss of voluntary control of urination.
Chapter 7 146
The Mature Adult Years:
Sixty-Five and Older (cont.)
Endocrine System
Decreased thyroid function.
Loss of estrogen production in females.
Decreasing levels of aldosterone, a hormone
that has a role in regulating blood pressure.
Increased delay in return of cortisol to
normal levels after stressful events.
Deficiencies in response to insulin by
various organs.
Chapter 7 147
The Mature Adult Years:
Sixty-Five and Older (cont.)
Intellectual-Cognitive Development
Although information is processed slowly,
mature adults can continue to learn.
Long-term memory seems to remain intact;
short-term memory may be less acute.
The wealth of knowledge accumulated
tends to make mature adults great
teachers.
Chapter 7 148
The Mature Adult Years:
Sixty-Five and Older (cont.)
Psycho-Emotional Development
Retirement can lead to a sense of
loss or grief.
Mature adults must increasingly
deal with death, as that of a
spouse or friends.
Chapter 7 149
The Mature Adult Years:
Sixty-Five and Older (cont.)
Social Development
Some mature adults
experience an increased
spirituality.
Many live in retirement
homes or communities.
Grandchildren may
become a source of
pleasure.
Chapter 7 150
The Mature Adult Years:
Sixty-Five and Older (cont.)
Aspects of Care
Regular weight-bearing and
aerobic exercise should be
continued to reduce and prevent
bone loss.
A balanced nutritional plan
should be maintained.
Chapter 7 151
The Mature Adult Years:
Sixty-Five and Older (cont.)
Aspects of Care (cont.)
The need for sleep may decrease, but
short periods of rest throughout the
day may offset the loss.
Social contact should persist.
Regular health and dental checkups
should continue.
Individuals should maintain active
interests.
Chapter 7 152
Section 7-3
Apply Your Knowledge
List some signs of aging.
Answers:
1. Thinning and wrinkling skin.
2. Graying and thinning hair.
3. Slower healing.
4. Slower reaction time.
5. Impairment of fine motor
activities.
6. Impaired vision and hearing.
7. Decreased bone density.
8. Increased risk of heart disease.
Chapter 7 153
Procedures in Student Text
7A Measuring the Infant
7B Measuring Head Circumference
7C Measuring the Toddler
7D Measuring the Adult
Chapter 7 154
Chapter 7 Credits
Slide 9 Neil Harding/Getty Images
Slide 10 Neil Bromhall/SPL/Photo Researchers
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Slide 21 Total Care Programming, Inc.
Slide 24 Nancy Durrell McKenna/Photo Researchers
Slide 29 Laura Dwight/Photo Edit (left) & PhotoDisc (right)
Slide 33 John Fortunato
Slide 40 Myrleen Ferguson Cate/Photo Edit
Slide 41 Paul Steel/CORBIS
Slide 46 Mark C. Burnett/Photo Researchers
Slide 54 Pictures Unlimited
Slide 59 CORBIS
Slide 61 Tony Freeman/PhotoEdit
Slide 63 Yang Liu/CORBIS
Slide 77 David J. Sams/Stock Boston
Slide 82 PhotoDisc
Slide 84 PhotoDisc
Slide 98 PhotoDisc