Introduction
In this family and child developmental case study, I have chosen a family close to my residence. As required by the syllabus, I have been able to stay with the family and enquire deeply into Jessica’s development. Prior to the stay, I had read a few articles and books on developmental milestones. Mary Sheridan’s book “From birth to five years” and an article on the Child Development Programme by the Centre for Child and Adolescent Services Research Centre provided me all the necessary information to make suitable inquiries with the family. I was already armed with a set of questions to be asked when I reached for the stay.
The Family structure
Jessica Ray is an infant of one year and nine months of age. She has an elder brother, Ryan, of age four years and six months. They have their mother Cathy and father, Peter, with them at home. The maternal grandparents, John and Louise are also living with them. They are a close-knit extended family with plenty of bonding with each other and the children. Peter and Cathy have full-time jobs. Peter is aged 31 and is a software engineer in the Wachovia Bank. Cathy is 30 and a staff nurse in the Hayes Hospital in town.
Ryan, the elder child, is 3 years and 6 months of age. He is attending a day-care center close to his house. Louise takes him to and from it. Jessica is just 1 year and nine months.
The older Rays are essentially farmers who had moderate holdings. Now the two brothers work there. The McKennas are also middle-class and held Government jobs. Both have accepted voluntary retirement and are living with Peter and Cathy to help them.
Louise has Non-Insulin-dependent diabetes mellitus which is well controlled and she enjoys fairly good health as she conforms strictly to her diet and exercises apart from her medicines. John is absolutely healthy, jovial, and keeps the atmosphere bonhomie. The grandchildren are really fond of him.
Both John and Louise understand that their grandchildren need their attention and guidance badly as Cathy and Peter are busy. Louise is the carer and child rearer. John is a disciplinarian and maintenance person. He makes sure that groceries and baby food are always sufficient. Peter is the decision-maker and plays the role of the primary breadwinner. Cathy is the person who looks after the health of the children and family members. She always is on the dot where her children’s immunizations are due. Both Cathy and Peter are ardent workers and responsible parents.
Relationship with family members
William and Marie, the paternal grandparents, live just around the corner and visit this family frequently. The grandchildren are lucky to have two sets of doting grandparents. Cathy’s sister Anne’s family lives twenty miles from them. Her two girls are extremely fond of the children here and insist on seeing them almost every weekend if they had their way. Peter’s unmarried brothers live together in the countryside where they have a fruit orchard. Their visits are few and far between but they are there when an occasion arises.
Relationship with others
The family is religious and attends Church on Sundays no matter what happens. They have good relationships with the neighbors and there is a community hall where they meet for various purposes, charitable and otherwise. Elaine and her child come over once in a while. Louise, Cathy, and Jessica return these visits. Father Richard visits them occasionally. Religion may not be the only matter discussed on these visits.
The parents and grandparents (McKennas) have interactions at the mother-baby clinic where the children are taken for immunizations and the ‘Littlebabes’ day-care center which Ryan goes to.
Cathy’s pregnancy with Jessica
Cathy had an uneventful pregnancy. She availed of the regular antenatal services provided by the hospital where she works. Antenatal care in Australia is frequently reviewed and the evidence-based approach to develop guidelines has been promoted (Hunt and Lumley, 2002). Cathy made visits every four weeks till she reached the 28th week, every two weeks till she reached 36 weeks and every week till her delivery at the 42nd week. This is the regime followed in her hospital and reflects the standard protocol.
(Hunt and Lumley, 2002). The World Health Organisation after a systematic review has pointed out that reduced schedules of visits are ‘not associated with worse outcomes for mothers or babies’ (Carroli, 2001)
She was checked for gestational diabetes at her first visit, at 24 weeks, 26 weeks, and at 28 weeks. Gestational diabetes usually presents between the 26th and 28th weeks of gestation (Hunt and Lumley, 2002). Cathy had the glucose challenge and tolerance tests, the HbA1c, and the random blood sugar tests. She was normal for all.
The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) however does not recommend routine screening for diabetes (Hunt and Lumley, 2002). Screening for and managing gestational diabetes has not been demonstrated to have improved the outcomes of mothers and babies (Walkinshaw, 2001; Wen et al, 2000). Also, labeling them as high risk and managing them with diet, exercise and insulin may have adverse effects (Enkin, 2000; Wen et al, 2000 😉
Screening for syphilis and HIV was done routinely at her first visit. Her hospital does routine HIV screening for antenatal whereas many in Australia do not (Hunt and Lumley, 2002). RANZCOG has included syphilis screening as routine but recommends HIV screening after appropriate counseling.
Cathy was earlier found to be positive for Hepatitis B surface antigen. However, she tested negative for the Hepatitis C test done at her first visit. The risk of transmission vertically is 6% if a woman is HCV RNA positive. There are no interventions to prevent or reduce the mother-to-baby transmission (Hunt and Lumley, 2002).
The inquiry was made about smoking but Cathy did not smoke. Many hospitals advise quitting smoking however only very few actually give written advice (Hunt and Lumley, 2002). No national guidelines are provided for smoking.
Cathy was strict about her diet and kept close to it with Louise’s help. She had a well-balanced and healthy diet with complex carbohydrates and protein. In the first trimester, she reduced the nausea of morning sickness by frequent small meals rich in B group vitamins and low in spice and fat (Morning Sickness, Baby Center). Her mother Louise advised her to sniff a cut lemon when feeling nauseous (Morning Sickness, Baby Center)
She took 400 micrograms of folic acid from before her pregnancy all through the first trimester in order to ensure that her child does not get any neural defects or spina bifida. (10 steps to a healthy pregnancy, Babycentre). Cathy had calcium supplements too. Louise made sure that Cathy would have fish frequently in her meals but ensured that it would be of the smaller variety and preferably canned (so that it contains lesser mercury). Fish helps the birth weight of the child to be normal and also helps in the development of the baby’s brain and nerves in the 3rd trimester (10 steps to a healthy pregnancy, Babycentre).
Cathy avoided iron supplements as she was not anemic. Her exercise program included mild exercise and pelvic floor exercises to help her carry the baby and to handle distress in labor (10 steps to a healthy pregnancy, Babycentre). Cathy gained about 12 kgs during her pregnancy (10 steps to healthy pregnancy, Babycentre). She went through labor fairly fast and had a normal delivery.
Jessica as a newborn
Jessica was born in normal labor after 42 weeks of gestation and she was assessed as AGA (10-90th percentile). She weighed 4.0 kgs and her APGAR score was 8 at one minute and nine at 5minutes. Her length was 52.5cms.and head circumference 37 cms. ‘A lively, kicking child bawling out loudly’ was how her gynaecologist described the newborn Jessica.
From the table above, we may assume that Jessica had a very normal life till now. Her results for the 3 parameters coincide with the normal charts of the three (Revised Growth Charts, 2005). She maintains the 90th percentile for all three parameters.
Head circumference is thought to correlate with brain volume (Mannerkoski, 2008). Increased head circumference is associated with autism and Asperger. Developmental problems and lower cognitive ability are seen in a child with 2 lesser or more than the normal head circumference. Normal head circumference is related to high IQ more than a height difference (Mannerkoski, 2008).
The length-for-age percentiles Jessica’s changes from birth to 21 months.
The weight for age percentiles Jessica’s changes from birth to 21 months.
The head circumference-for-age percentiles Jessica’s changes from birth to 21 months.
Jessica’s Immunisations
Jessica’s immunisations have all been taken at timely intervals. As Cathy was positive for Hepatitis B surface Antigen, Jessica received her HepB and 0.5 ml.of Hepatitis B immunoglobulin about five hours after her birth (Recommended Immunization Schedules, US). She has had the 3 doses of Rota, the 3 doses of DTaP and its 1st booster , the 3 doses and 1st booster of Hib (Hemophilus influenza type B), Inactivated Poliovirus (3 doses), Pneumococcal conjugate vaccine (3 doses), MMR, Varicella vaccine and the Meningococcal vaccine. Her parents have been vigilant in this respect. Her schedule was as follows.
Jessica’s Immunization schedule (National Immunisation Schedule, Immunise Australia Programme).
Her next immunization would be at the age of 4 when she would receive the boosters for DTPa, Inactivated Poliovirus and MMR.
Jessica as she was
Cathy has a record of the developmental milestones of Jessica. Jessica recognized her mother early and thoroughly enjoyed breastfeeding. Cathy did not introduce a pacifier to her. She believed that breast feeding led to effective mother-infant bonding and that human milk is the best nutrition for all infants (Joanna Briggs Institute, 2005). Pacifiers are known to cause Sudden Infant Death Syndrome and studies have associated the two. Gastro-intestinal infection and dental caries are also associated but effective research has still to connect them with the pacifier (Joanna Briggs Institute, 2005). The use of the pacifier is considered a barrier to effective breast feeding. Jessica was lucky in that Cathy breastfed her till she was one.
At six weeks she started smiling at her mummy. By then she held up her head too. Cathy fed her at regular intervals and in between Jessica was a contented baby. Her cooing and other sounds thrilled the elders galore. Louise always used to sing her favourite lullabies for Jessica. The soft music of which John is crazy about also used to evoke some interest in Jessica. She never used to wake up at night after her 10 o’clock feed. She sat with support at 6 months of age (Sheridan, 2007).
By then she was also focusing her eyes. At this time she would search for the toys and stretch out to grasp them, very close to her palm (Sheridan, 2007). This indicated the development of fine movements. The sound of her family approaching her resulted in her chuckling and
sometimes squealing aloud. She used both hands to play. Playing with even unfamiliar and new visitors was not a problem to her (Sheridan, 2007).
Her first tooth appeared at 7 months of age. Louise recalls how Jessica used to put something in her mouth frequently to chew. Her family had to go on watching to see that she did not put anything into her mouth (Sheridan, 2007). Solid foods were introduced at the eighth month. Her behaviour developed a shyness to strangers.
At nine months she was crawling. Toys would be handled with both hands and transferred to and fro. She was also using the pincer grasp for holding the strings which were attached to some toys, an improvement in fine movements (Sheridan, 2007). Sometimes she threw the toys afar and then went crawling to look for them. Slowly she pulled herself to standing position (Sheridan, 2007). She had started dressing and needed help only at times. Granny and Jessica used to play peek-a-boo frequently. Louise remembers that she used to hide her face from strangers (Sheridan, 2007).
She started walking at age 1. In fact she took her first step on her first birthday (Childhood Development, CASRC). The family had come together to celebrate it. She was on all fours and moving towards her mummy when her daddy held out a toy. She held onto her mummy’s chair and rose up. On reaching out for the toy, she inadvertently took a step forward and clutched her toy, simultaneously dropping down to sit. Peter gave a whoop of joy. He had missed capturing that first step on video. Her milestones of development were well within normal limits. This gives her a chance to do well in her education (Mannerkoski, 2008). Her dolls were frequently carried and used to be cast off afar when she got angry.
Jessica as she is now
Jessica is 1 year and nine months now. Her locomotor milestones are within the normal range. She walks fairly well still with a broad base but her legs are closer now than before. Her arms are no longer held extended to balance her walk (Sheridan, 2007). The first 5 years of infant life are packed with extraordinary physical growth and increasing complexity of function. Jessica is no different. She walks and fairly well now at this age (Childhood Development, CASRC).
Both Ryan and Jessica love climbing the stairs and then coming down. Stair climbing is considered a major milestone in the motor development literature (Berger, 2007). Jessica wants help but she still enjoys it (Sheridan, 2007). Louise remembers when she crawled upstairs the first time and gleefully called her from the fourth step (Berger, 2007). Ryan jumps from the third stair now. It is difficult to keep him still. John has attached baby gates at the bottom of the stairs to prevent Jessica and Ryan from climbing without the elders’ supervision (Childhood Development, CASRC). Stair climbing illustrates how multiple factors contribute to the acquisition of milestones (Berger, 2007).
Jessica, I notice, is a contented child but has begun showing independence in selecting the color of the cereal which she wants to consume for a meal which she has sometimes. She usually joins the family at the table for all their 3 meals. Her special penchant for ‘cheeky chikin fly’ is a point of humor for the family. Louise makes a preparation of it so that Jessica can chew it easily and swallow. A bread-spread using butter and yoghurt is another favorite of hers (Childhood Development, CASRC).
Jessica loves her pink toothbrush and so brushing her tiny teeth is a pleasure to her for the time being and she does it in the morning and before sleeping. Louise helps out. The child got compliments from the dentist at her last visit. Cathy has given her a pretty spoon ‘specially made’ (that is what she has told her) for her to consume her food. She is learning to handle it (Sheridan, 2007). Her fingers hold it a little distance from the broader scooped end.
Nevertheless she is able to spoon her bowl contents into her mouth, of course spilling some of it. In the corner of her play room, there is a bucket which holds her toys which range from plastic spoons to picture postcards. Louise has taught her how to drop things in her bucket but she does not always bother (Childhood Development, CASRC). A favorite hobby of hers is to ‘draw’ with the crayons that her cousin left for her.
She makes criss-cross marks on the drawing paper and the wall when her granny is not looking. Ryan meanwhile manages to make pictures of cats and dogs and houses more successfully. Jessica likes to arrange her playthings one on top of each other (Sheridan, 2007). I joined in her game and I could understand that she was well in the path of development. She could arrange six layers of cubes before they get toppled. Her gleeful laughter when the whole stack tumbles down is indicative of her healthy disposition. Ryan sometimes helps her build towers and they have great fun watching the tower topple (Childhood Development, CASRC).
Jessica wears her squeaky shoes when she is taken ‘for a walk’ in the lawn outside for some exercise. Pink is the color of her dress and it needs to have frills. Both grandparents are receptive to the idea that talking frequently and teaching Jessica and Ryan as and when they communicate. Jessica keeps pointing at things or articles which catch her attention (Sheridan, 2007). One of them names it and says some more or tells a nonsense tale attached to it.
Jessica looks at herself in the mirror and points to her body parts and John would be ready to help her name them (Childhood Development, CASRC). Her vocabulary has reached around 30 words by her granny’s assessment (Sheridan, 2007). She has recently started waving good bye to her parents every morning after climbing on the sofa outside on the verandah and wishing them ‘ave a nice day’ (Sheridan, 2007).. It thrills them a lot.
Every day after breakfast, she has a bath. Now her granny is having a problem soaping her as she wants to do it herself and she wheels some toys into her bath too(Sheridan, 2007). She soaps her toy doggie and ‘bathes’ him. Dressing has become a tedious affair with Jessica selecting her own dress, a pink one with frills almost daily. On top of that she keeps changing her selection at least twice (Childhood Development, CASRC).
Louise has to be patient and slowly ‘wean’ her away. Then she slowly turns the pages of her picture book which Cathy got for her. She does not allow Louise to do it. She compares the colors of her dress or Louise’s with the colors in her book and keeps shrieking in delight (Childhood Development, CASRC).. Another favourite pastime is tending to her ‘Barbie’ doll which she has named Lucy.
She feeds her with a spoon, combs her hair, changes her clothes and what not. The other day she dipped her in the bucket of water saying she is ‘smelly’. This is symbolic play (Goldson, 2007). Play is a significant means of learning. It is a very complex process which involves the practice and rehearsal of roles, skills, and relationships. It is a way to integrate the child’s life experiences. There is emotional development, cognitive development and social/motor development. Play has a developmental progression. If last year, peek-a-boo was her favourite game, this year she is playing by herself or with her imaginary friends (Goldson, 2007). Next year she would have her pre-school friends. It is all social development.
Jessica has a habit of making monosyllable answers to the parents’ and grandparents’ queries. Sometimes several ‘nos’ make things difficult (Childhood Development, CASRC). Cathy commented to her mother that the word ‘no’ needs to be removed from their family dictionary till Jessica forgets it. Now she asks for ‘sumthin to dink’ and ‘I thirsty or ‘wanna eat’. Cathy’s neighbor Elaine brings her two and a half year old child over occasionally.
Jessica immediately runs close to her granny and sits on her lap till the other child leaves (Childhood Development, CASRC). Maybe she is worried that she may lose the attention of her granny in the presence of others or it is that she is not that social yet. This is definitely normal going by the milestones. Cathy recites nursery rhymes to her just before she sleeps. She loves ‘Mary had a little lamb’. Louise keeps asking her to show the doggie, kitty etc from her picture books and Jessica happily obliges.
She has learnt the left-to-right technique of going through her pictures. Jessica has her tantrums when Louise restricts her running out of the front door or wishing to play under the tap in the bathroom. Jessica has been introduced to her potty training (Childhood Development, CASRC). She likes it because there are some musical sounds coming from her potty. Brain maturation permits infants to sense full rectum or bladder
and also controls the bowel and bladder sphincters (Goldson, 2007). Jessica for one feels proud when she has been able to inform her granny in time for her to use her potty. Louise makes it a point to praise her ‘accomplishment’. Cathy has specifically advised her parents not to be too strict over this (Goldson, 2007). Jessica was to decide when to go. She reminds them about her son who used to make a big issue due to frequent restrictions by the grandparents.
Sleep is a restful period for Jessica. Though it is accepted that 17% of infants have moderate sleep problems, Jessica is not affected. This is probably because Jessica’s parents are both mentally and physically healthy (Fauroux et al, 2008). Jessica lies on her side (prone position) while sleeping. The supine position is associated with delays in motor development and thereby a delay in the motor milestones (Fauroux et al, 2008). There is a hypothesis that says that children who have greater activity during the night in their sleep and increased sleep disturbances tend to show a delay in the onset of locomotor milestones (McKay, 2006). Thankfully Jessica does not fall in this category.
In the recent times, evidence has emerged which says that earlier motor development is associated with better scholastic performance, better educational outcomes in adulthood and better cognitive functions (Murray et al, 2006). Murray’s study found that “infant motor development was an independent predictor of adult cognition” in some aspects like adolescent behavioural problems.
Jessica’s Colic
Jessica has colic occasionally. She would cry incessantly holding onto her abdomen. It has been estimated that 40% of male and female infants suffer from colic (Joanna Briggs Institute, 2008). Food allergies, gastrointestinal causes, behavioural symptoms, change in bowel or urine excretion patterns, dietary patterns should be taken into consideration. Jessica has only very few colic episodes after Louise reduced cow’s milk from her diet and tried a soy-based formula and then a fibre-enriched formula both of which failed to provide relief to Jessica.
Then at the advice of the paediatrician, Jessica has been started on the hypoallergenic formula (Joanna Briggs Institute, 2008).. Special attention is taken to give sufficient fresh fruit and juices to Jessica so that she does not have constipation. When her symptoms are severe enough she is taken to Cathy’s hospital where the paediatrician advises some antispasmodic injection for relief. However such visits are few and far between now that Jessica is growing up and her diet is well adjusted.
Analysis of Jessica’s development
Jessica is healthy child conforming to the changes of weight, length and head circumference to the 90th percentile of each parameter in the Revised Growth Charts of Victoria. Her mother had a normal pregnancy which terminated in a normal delivery.
Jessica had no congenital or other abnormalities. She had a fairly normal neonatal and infant period. Her milestones of development were all within normal limits. She has been immunized to most childhood illnesses as indicated in the immunization schedule of Australia. Her mental, locomotor and social developments are appropriate. Her IQ is normal and she is expected to do well in her education. Her warmth reflects the strong interactions among the family members and with the rest of the world.
Reflections
I visited the Ray family on the 25th of August, 2008 and spent about two days in their home. They welcomed me warmly into the family and permitted me to stay in their guest room. I was surprised that they allowed me to move fairly freely with them and also to join in looking after Jessica. Jessica too took to me and invited me to play with her. I had no difficulties. All my qualms about family nursing practice flew away at their response. I was lucky to get a good start. This has confirmed my option to choose family nursing. I am aware that this may not be the situation in all families. However my mind is made up.
Conclusion
Having never directly faced the clients before, I was a little apprehensive of things. However, I was lucky to get a warm family. The questions that I had prepared came in handy and I could extract plenty of information for my case study. I was able to do the genogram and ecomap of the family and include the maximum information that I gathered. The Calgary Family Assessment Model guided me in putting on paper what I had learned.
I have attempted to include many facets of Jessica’s developmental milestones but I had to limit my findings to stay within the length of paper allowed. I realized that assessing the family as a whole is essential in assessing a child. My confidence has been lifted with this assignment. I have also been able to look for good references. With sufficient preparation, I should be able to face clients and really be efficient in getting the maximum information for study. Interacting with the family has changed my outlook and I expect to go through my study with flying colours.
Appendix A
Appendix B
References
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