24.1 Principles of Growth and Development

CPHON Test Content Outline (TCO) VI.B tests principles of growth and development as a procedure-and-teaching toolkit, not as a generic pediatrics lecture. Erikson's psychosocial stages and Piaget's cognitive levels matter because they change who stays in the room, which words you use, how you offer control, and which pain tool you pick. A 7-month-old with infant acute lymphoblastic leukemia (ALL) who screams at isolation garb, a 2-year-old who shouts no to a lumbar puncture (LP), a 4-year-old who believes chemotherapy is punishment for hitting a sibling, a 9-year-old who wants to hold the flush syringe, and a 16-year-old who will not undress with a parent watching are the same domain at different ages.

This section does not restage the full analgesic ladder (that is TCO IV.B.1). It uses developmental tools to choose teaching methods and procedure support. The Oncology Nursing Certification Corporation (ONCC) does not mandate one branded scale for every age.

Infant: trust, stranger anxiety, sucrose, parent presence

Trust versus mistrust (Erikson) and sensorimotor cognition (Piaget) mean the infant's teaching plan is the parent or consistent caregiver. You do not explain protocol names to a 6-month-old. You keep a familiar adult at the bedside, limit how many strangers hold the child, and treat stranger anxiety—typically emerging in the second half of the first year—as expected, not as failed bonding.

Parental presence during port or Broviac access, LP, and dressing change is the default, not a privilege you grant if the unit is quiet. Oral sucrose, nonnutritive sucking, swaddling, and a parent's voice are interventions. Pain tools are behavioral: Neonatal Infant Pain Scale (NIPS) for neonates and young infants; Face, Legs, Activity, Cry, Consolability (FLACC) for older infants and nonverbal children. Do not demand a 0–10 number. Cluster care so the infant is not poked hourly. A 9-month-old with a tunneled Broviac who arches when you approach still needs the parent in the chair and sucrose for a stick—not exile to the waiting room "so staff can work."

Toddler: autonomy, negativism, play, real choices

Autonomy versus shame and doubt produces negativism. The toddler's favorite word is no. Early preoperational thought is concrete and here-and-now. Do not ask "Can I do your spinal tap now?" if the tap is not optional. That question is a setup for shame. Offer forced choices that are actually choices: which arm for the blood pressure, which stuffed animal holds the other hand, lap versus table with the parent holding. Play is the teaching method: a doll with a central-line dressing, a syringe of water to "flush" a toy, Child Life rehearsal.

Transitional objects and rituals (same chair, same song) protect autonomy. Toilet-trained toddlers who wet the bed in the hospital are not being defiant. Regression is expected; name it, keep the diaper without humiliation, and restore the skill when the crisis eases. Pain is usually FLACC if they cannot self-report. A 2-year-old with neuroblastoma who screams "no needle" still gets topical anesthetic, a parent hold, Child Life, and a choice of bandage color—not a debate about whether port access is happening.

Preschool: magical thinking and "not your fault"

Initiative versus guilt plus preoperational thought produces magical thinking. Preschoolers connect events that are not connected. Illness, isolation, hair loss, and a sibling's death can be read as punishment. The sentence they need, repeated, is that the cancer is not their fault and the medicine is not a punishment. They fear body mutilation and believe a needle hole stays open; bandages and honest concrete words ("a small straw to look at the liquid around the spine") beat percentages.

Do not say "put to sleep" for anesthesia—that terrorizes bedtime. Do not bargain with false promises ("this will not hurt"). Medical play lets them give a shot to a doll and master initiative. Parents stay. Pain: Wong-Baker FACES for many preschoolers who can point to a face. A 4-year-old starting ALL induction who whispers "I was bad" needs that guilt named and corrected before you launch into cell biology.

School-age: industry, simple explanations, participation

Industry versus inferiority and concrete operational thought mean school-age children want a simple why and a job. They can sequence: first numbing cream, then the stick, then a bandage, then the playroom. Give a concrete explanation ("these cells are growing too fast; this medicine slows them") without a graduate lecture. Let them hold the flush, choose the finger, watch the pump, and keep school packets so industry is not only hospital failure.

Pain: FACES or numeric 0–10 once they can rank. Participation is the intervention. A 9-year-old with osteosarcoma who is allowed to count flush milliliters is using industry. A child told nothing and then blamed for "not cooperating" is being set up for inferiority.

Adolescent: identity, privacy, peers, assent, body image, fertility

Identity versus role confusion and emerging formal operational thought make privacy, peers, and body image non-optional. Seek assent for procedures and research even though the parent or guardian gives legally effective consent (signpost the trials chapter for the legal consent process). Examine and teach without an audience. Talk about fertility, contraception, and sexual function in a private conversation—not in a hallway with siblings, and not only to the parent while the 16-year-old sits silent. Hair loss, amputation, Cushingoid change, scars, and central lines collide with identity. Peers matter more than a visiting-hours slogan; facilitate video contact and let the adolescent choose what classmates hear.

Pain: numeric self-report; patient-controlled analgesia (PCA) when they understand the button (no PCA-by-proxy unless a protocolized pathway exists). A 16-year-old starting cyclophosphamide who has not had a private sperm-banking conversation has had incomplete developmental care, even if a parent "already decided."

Pain tools, regression, delay versus treatment effect

Regression—thumb-sucking, enuresis, wanting the crib, baby talk, a school-age child who needs a parent in the bed—is an expected stress response. Document it. Do not shame it. Distinguish it from a new neurologic finding (unequal pupils, new weakness) that belongs to the emergency chapters.

Developmental delay versus treatment effect is a CPHON discrimination, not a shrug. Prolonged hospitalization and isolation steal practice of speech and motor skills. Cisplatin and other ototoxins can drop hearing and look like "not listening." Vincristine neuropathy slows motor milestones. Steroids change mood and sleep. Central nervous system (CNS) therapy—high-dose methotrexate, cranial radiation, brain-tumor surgery—changes processing speed and school performance. Do not label a toddler who lost words after months of isolation as "just delayed" without developmental screening, audiology when ototoxic drugs were used, and early-intervention or school referral. Do not assume every slow milestone is lifelong delay, and do not assume every change will "bounce back" without a plan. Plot development the way you plot height.

The CPHON product is a procedure plan that matches the stage in front of you: parent and sucrose for the infant, a real choice for the toddler, a not-your-fault sentence for the preschooler, a job for the school-age child, and a private assent-and-fertility conversation for the adolescent—plus a pain tool they can actually use.