LAURA E.

BERK
Physical growth during the school years continues at the slow, regular pace of early childhood. At
age 6, the average North American child weighs about 45 pounds and is 3½ feet tall. Over the next
few years, children will add about 2 to 3 inches in height and 5 pounds in weight each year (see
Figure 9.1). Between ages 6 and 8, girls are slightly shorter and lighter than boys. By age 9, this
trend reverses as girls approach the dramatic adolescent growth spurt, which occurs two years
earlier in girls than in boys. Because the lower portion of the body is growing fastest, Joey and
Lizzie appeared longer-legged than they had in early childhood. They grew out of their jeans more
quickly than their jackets and frequently needed larger shoes. As in early childhood, girls have
slightly more body fat and boys more muscle. After age 8, girls begin accumulating fat at a faster
rate, and they will add even more during adolescence (Hauspie & Roelants, 2012). During middle
childhood, the bones of the body lengthen and broaden. However, the ligaments are not yet firmly
attached to the bones. This, combined with increasing muscle strength, gives children the unusual
flexibility needed to perform cartwheels and handstands. As their bodies become stronger, many
children experience a greater desire for physical exercise. Nighttime “growing pains”—stiffness
and aches in the legs—are common as muscles adapt to an enlarging skeleton (Uziel et al., 2012).
Between ages 6 and 12, all 20 primary teeth are lost and replaced by permanent ones, with girls
losing their teeth slightly earlier than boys. For a while, the permanent teeth seem much too large.
Gradually, growth of facial bones causes the child's face to lengthen and mouth to widen,
accommodating the newly erupting teeth.Children from economically advantaged homes, like
Joey and Lizzie, are at their healthiest in middle childhood, full of energy and play. Growth in
lung size permits more air to be exchanged with each breath, so children are better able to exercise
vigorously without tiring. The cumulative effects of good nutrition, combined with rapid
development of the body's immune system, offer greater protection against disease. Not
surprisingly, poverty continues to be a powerful predictor of ill health during middle childhood.
Because economically disadvantaged US families often lack health insurance (see Chapter 7),
many children do not have regular access to a doctor. A substantial number also lacks such basic
necessities as a comfortable home and regular meals.
Nutrition
Children need a well-balanced, plentiful diet to provide energy for successful learning in school
and increased physical activity. With their increasing focus on friendships and new activities,
many children spend little time at the table, and the number who eat dinner with their families
drops sharply between ages 9 and 14. Family dinnertimes have waned in general, yet eating an
evening meal with parents leads to a diet higher in fruits, vegetables, grains, and milk products
and lower in soft drinks and fast foods (Burgess-Champoux et al., 2009; Hammons & Fiese,
2011). School-age children report that they “feel better” and “focus better” after eating healthy
foods and that they feel sluggish, “like a blob,” after eating junk foods. In a longitudinal study of
nearly 14,000 US children, a parent-reported diet high in sugar, fat, and processed food in early
childhood predicted slightly lower IQ at age 8, after many factors that might otherwise account for
this association were controlled (Northstone et al., 2012). Even mild nutritional deficits can affect
cognitive functioning. Among school-age children from middle- to high-SES families, insufficient
dietary iron and folate are related to poorer concentration and mental test performance (Arija et
al., 2006; Low et al., 2013). As we saw in earlier chapters, many poverty-stricken children in
developing countries and in the United States suffer from serious and prolonged malnutrition.
Unfortunately, malnutrition that persists from infancy or early childhood into the school years
usually results in permanent physical and mental damage (Grantham-McGregor, Walker, &
Chang, 2000; Liu et al., 2003). Government-sponsored supplementary food programs from the
early years through adolescence can prevent these effects.

Overweight and Obesity

Mona, a very heavy child in Lizzie's class, often watched from the sidelines during recess. When
she did join in games, she was slow and clumsy, the target of unkind comments: “Move it, Tubs!”
Most afternoons, she walked home from school alone while her schoolmates gathered in groups,
talking, laughing, and chasing. At home, Mona sought comfort in high-calorie snacks. Mona
suffers from obesity, a greater-than-20-percent increase over healthy weight, based on body mass
index (BMI)—a ratio of weight to height associated with body fat. A BMI above the 85th
percentile for a child's age and sex is considered overweight, a BMI above the 95th percentile
obese. During the past several decades, a rise in overweight and obesity has occu rred in many
Western nations, with large increases in Canada, Germany, Greece, Ireland, Israel, New Zealand,
the United Kingdom, and the United States. Since the 1970s, US childhood obesity has tripled.
Today, 32 percent of US children and adolescents are overweight, more than half of them
extremely so: 17 percent are obese (Ogden et al., 2014; World Health Organization, 2015g).
Obesity rates have also recently been in developing countries, as urbanization shifts the population
toward sedentary lifestyles and diets high in meats and energy-dense refined foods (World Health
Organization, 2015g). In China, for example, where obesity was nearly nonexistent a generation
ago, today 20 percent of children are overweight and 8 percent obese, with two to three times as
many boys as girls affected (Sun et al., 2014). In addition to lifestyle changes, a prevailing belief
in Chinese culture that excess body fat signifies prosperity and health—carried over from a half-
century ago, when famine caused millions of deaths—has contributed to this alarming upsurge.
High valuing of sons may induce Chinese parents to offer boys especially generous portions of
energy-dense foods. Overweight rises with age, from 23 percent among US preschoolers to 35
percent among school-age children and adolescents to an astronomical 69 percent among adults
(Ogden et al., 2014). Overweight preschoolers are five times more likely than their normal-weight
peers to be overweight at age 12, and few persistently overweight adolescents attain a normal
weight in adulthood (Nader et al., 2006; Patton et al., 2011). Causes of Obesity. Not all children
are equally at risk for excessive weight gain. Identical twins are more likely than fraternal twins to
resemble each other in BMI, and adopted children tend to resemble their biological parents (Min,
Chiu, & Wang, 2013). Although heredity clearly contributes to children's risk, the importance of
environment is apparent in the consistent relationship of low SES to overweight and obesity in
industrialized nations, especially among ethnic minorities—in the United States, African-
American, Hispanic, and Native-American children and adults (Ogden et al., 2014). Factors
responsible include lack of knowledge about healthy diets; a tendency to buy high-fat, low-cost
foods; and family stress, which can prompt overeating. Recall, also, that children who were
undernourished in their early years are at risk for later excessive weight gain (see page 129 in
Chapter 4). Parental feeding practices also contribute to childhood obesity. Overweight children
are more likely to eat sugary and fatty foods, perhaps because these foods are plentiful in the diets
offered by their parents, who also tend to be overweight (Kit, Ogden, & Flegal, 2014). Frequent
eating out—which increases parents' and children's consumption of high-calorie fast foods— is
linked to overweight. And eating out likely plays a major role in the relationship between mothers'
employment hours and elevated BMI among school-age children (Morrissey, Dunifon, & Kalil,
2011). Demanding work schedules reduce the time parents have for healthy meal preparation.
Furthermore, some parents anxiously overfeed, interpreting almost all their child's discomforts as
a desire for food—a practice common among immigrant parents and grandparents who, as
children themselves, may have survived periods of food deprivation. Still other parents are overly
controlling, restricting when, what, and how much their child eats and worrying about weight gain
(Couch et al., 2014; Jansen et al., 2012). In each case, parents undermine children's ability to
regulate their own food intake. Because of these experiences, obese children soon develop
maladaptive eating habits. They are more responsive than normal-weight individuals to external
stimuli associated with food—taste, sight, smell, time of day, and food-related words—and less
responsive to internal hunger cues (Temple et al., 2007). Furthermore, a stressful family life
contributes to children's diminished self-regulatory capacity, amplifying uncontrolled eating (see
the Social Issues: Health box above). Another factor implicated in weight gain is insufficient sleep
(Hakim, Kheirandish-Gozal, & Gozal, 2015). Reduced sleep may increase time available for
eating while leaving children too fatigued for physical activity. It also disrupts the brain's
regulation of hunger and metabolism. The rise in childhood obesity is due in part to the many
hours US children devote to screen media. In a study that tracked children's TV viewing from ages
4 to 11, the more TV children watched, the more body fat they added: By age 11, children who
devoted more than 3 hours per day to TV accumulated 40 percent more fat than those devoting
less than 1¾ hours (Proctor et al., 2003). TV and Internet ads encourage children to eat unhealthy
snacks: The more ads they watch, the greater their consumption of high-calorie snack foods.
Children permitted to have a TV in their bedroom—a practice linked to especially high TV
viewing—are at even further risk for overweight (Borghese et al., 2015; Soos et al., 2014). And
heavy viewing likely sub-tracts from time spent in physical exercise.
Consequences of Obesity.
Obese children are at risk for lifelong health problems. Symptoms that began to appear in the early
school years—high blood pressure, high cholesterol levels, respiratory abnormalities, insulin
resistance, and inflammatory reactions—are powerful predictors of heart disease, circulatory
difficulties, type 2 diabetes, gallbladder disease, sleep and digestive disorders , many forms of
cancer, and premature death. Furthermore, obesity has caused a dramatic rise in cases of diabetes
in children, sometimes leading to early, severe complications, including stroke, kidney failure, and
circulatory problems that heighten the risk of eventual blindness and leg amputation (Biro &
Wien, 2010; Yanovski , 2015). Unfortunately, physical attractiveness is a powerful predictor of
social acceptance. In Western societies, both children and adults stereotype obese youngsters as
lazy, sloppy, ugly, stupid, self-doubting, and deceitful (Penny & Haddock, 2007; Tiggemann &
Anesbury, 2000). In school, obese children and adolescents are often socially isolated. They report
more emotional, social, and school difficulties, including peer teasing, rejection, and consequent
low self-esteem (van Grieken et al., 2013; Zeller & Modi, 2006). They also tend to achieve less
well than their healthy-weight agemates (Datar & Sturm, 2006). Persistent obesity from childhood
into adolescence predicts serious psychological disorders, including severe anxiety and
depression, defiance and aggression, and suicidal thoughts and behavior (Lopresti & Drummond,
2013; Puhl & Latner, 2007). As we will see in Chapter 13, these consequences combine with
continuing discrimination to further impair physical health and to reduce life chances in close
relationships and employment. Treating Obesity. In Mona's case, the school nurse suggested that
Mona and her obese mother enter a weight-loss program together. But Mona's mother, unhappily
married for many years, had her own reasons for overeating and rejected this idea. In one study,
nearly 70 percent of parents judged their overweight or obese children to have a normal weight
(Jones et al., 2011). Consistent with these findings, most obese children do not get any treatment.
The most effective interventions are family-based and focus on changing weight-related behaviors
(Seburg et al., 2015). In one program, both parent and child revised eating patterns, exercised
daily, and reinforced each other with praise and points for progress, which they exchanged for
special activities and times together. The more weight parents lost, the more their children lost.
Follow-ups after 5 and 10 years showed that children maintained their weight loss more
effectively than adults—a finding that underscores the importance of early intervention (Epstein,
Roemmich, & Raynor, 2001; Wrotniak et al., 2004). Monitoring dietary intake and physical
activity is important. Small wireless sensors that sync with mobile devices, enabling
individualized goal-setting and tracking of progress through game-like features, are effective
(Calvert, 2015; Seburg et al., 2015). But these interventions work best when parents' and
children's weight problems are not severe. Children consume one-third of their daily caloric intake
at school. Therefore, schools can help reduce obesity by serving healthier meals and ensuring
regular physical activity (Lakshman, Elks, & Ong, 2012). Because obesity is expected to rise
further without broad prevention strategies, many US states and cities have passed obesity-
reduction legislation. Among the measures taken are weight-related school screenings for all
children, improved school nutrition standards that include food and beverages sold outside of
meals, additional school recess time and physical education, and obesity awareness and weight-
reduction programs as part of school curricula. A review of these school-based efforts reported
impressive benefits (Waters et al., 2011). Obesity prevention in schools was more successful in
reducing 6- to 12-year-olds' BMIs than programs delivered in other community settings, perhaps
because schools are better able to provide long-term, comprehensive intervention.

Vision and Hearing

The most common vision problem in middle childhood is myopia, or nearsightedness. By the end
of the school years, it affects nearly 25 percent of children—a rate that rises to 60 percent by early
adulthood (Rahi, Cumberland, & Peckham, 2011). Heritability estimates based on comparisons of
twins and other family members reveal a moderate genetic influence (Guggenheim et al., 2015).
And worldwide, myopia occurs far more frequently in Asian than in white populations (Morgan,
Ohno-Matsui, & Saw, 2012). Early biological trauma can also induce myopia. School-age children
with low birth weights show an especially high rate, believed to result from immaturity of visual
structures, slower eye growth, and a greater incidence of eye disease (Molloy et al., 2013). When
parents warn their children not to read in dim light or sit too close to the TV or computer screen,
their concern (“You'll ruin your eyes!”) is well-founded. In diverse cultures, the more time
children spend reading, writing, using the computer, and doing other close work, the more likely
they are to be myopic. In school-age children who spend more time playing outdoors, the
incidence of myopia is reduced (Russo et al., 2014). Myopia is one of the few health conditions to
increase with SES. Fortunately, it can be overcome easily with corrective lenses. During middle
childhood, the Eustachian tube (canal that runs from the inner ear to the throat) becomes longer,
narrower, and more slanted, preventing fluid and bacteria from traveling so easily from the mouth
to the ear. As a result, middle-ear infections, common in infancy and early childhood, become less
frequent. Still, about 3 to 4 percent of the school-age population, and as many as 20 percent of
low-SES children, develop persistent hearing loss as a result of repeated untreated infections
(Aarhus et al., 2015; Ryding et al., 2002). With regular screening for both vision and hearing,
defects can be corrected before they lead to serious learning difficulties.

Illnesses
Children experience a somewhat higher rate of illness during the first two years of elementary
school than later because of exposure to sick children and an immune system that is still
developing. About 20 to 25 percent of US children have chronic diseases and conditions
(including physical disabilities) (Compas et al., 2012). By far the most common—accounting for
about one-third of childhood chronic illness and the most frequent cause of school absence and
childhood hospitalization—is asthma, in which the bronchial tubes (passages that connect the
throat and lungs) are highly sensitive (Basinger , 2013). In response to a variety of stimuli, such as
cold weather, infection, exercise, allergies, and emotional stress, they fill with mucus and
contracts, leading to coughing, wheezing, and serious breathing difficulties. The prevalence of
asthma in the United States has increased steadily over the past several decades, with nearly 8
percent of children affected. Although heredity contributes to asthma, researchers believe that
environmental factors are necessary to spark the illness. Boys, African-American children, and
children who were born underweight, whose parents smoke, and who live in poverty are at
greatest risk (Centers for Disease Control and Prevention, 2015a). The higher rate and greater
severity of asthma among African-American and poverty-stricken children may be the result of
pollution in inner-city areas (which triggers allergic reactions), stressful home lives, and lack of
access to good health care. Childhood obesity is also related to asthma (Hampton, 2014). High
levels of blood-circulating inflammatory substances associated with body fat and the pressure of
excess weight on the chest wall may be responsible. About 2 percent of US children have more
severe chronic illnesses, such as sickle cell anemia, cystic fibrosis, diabetes, arthritis, cancer, and
AIDS. Painful medical treatments, physical discomfort, and changes in appearance often disrupt
the sick child's daily life, making it difficult to concentrate in school and separating the child from
peers. As the illness worsens, family and child stress increases (Marin et al., 2009; Rodriguez,
Dunn, & Compas, 2012). For these reasons, chronically ill children are at risk for academic,
emotional, and social difficulties. A strong link exists between good family functioning and child
well-being for chronically ill children, just as it does for physically healthy children (Compas et
al., 2012). Interventions that foster positive family relationships help parent and child cope with
the disease and improve adjustment. These include health education, counseling, parent and peer
support groups, and disease-specific summer camps, which teach children self-help skills and give
parents time off from the demands of caring for an ill youngster.

Unintentional Injuries
As we conclude our discussion of threats to school-age children's health, let's return to the topic of
unintentional injuries (discussed in detail in Chapter 7). As Figure 9.2 shows, injury fatalities
increase from middle childhood into adolescence, with rates for boys rising significantly above
those for girls. Motor vehicle accidents, involving children as passengers or pedestrians, continue
to be the leading cause of injury, followed by bicycle accidents (Bailar-Heath & Valley-Gray,
2010). Pedestrian injuries most often result from midblock dart-outs, bicycle accidents from
disobeying traffic signals and rules. When many stimuli impinge on young school-age children at
once, they often fail to think before they act. They need frequent reminders, supervision, and
prohibitions against venturing into busy traffic on their own. Effective school- and community-
based prevention programs use extensive modeling and rehearsal of safety practices, give children
feedback about their performance along with praise and tangible rewards for acquiring safety
skills, and provide occasional booster sessions. Targeting specific injury risks (such as traffic
safety) rather than many risks at once yields longerlasting results (Nauta et al., 2014). As part of
these programs, parents, who often overestimate their child's safety knowledge and physical
abilities, must be educated about children's age-related safety capacities. One vital safety measure
is legally requiring that children wear protective helmets while bicycling, in-line skating,
skateboarding, or using scooters. This precaution leads to a 9 percent reduction in head injuries, a
leading cause of permanent disability and death in school-age children (Karkhaneh et al., 2013).
Combining helmet use with other community-based prevention strategies is especially effective.
Highly active, impulsive, risk-taking children, many of whom are boys, remain particularly
susceptible to injury in middle childhood. Parents tend to be lax in intervening in the dangerous
behaviors of such children, especially under conditions of marital conflict or other forms of stress
(Schwebel et al., 2011, 2012). The greatest challenge for injury-control programs is reaching these
youngsters and reducing their exposure to hazardous situations . Visit a park on a pleasant
weekend afternoon, and watch several preschool and school-age children at play. You will see that
gains in body size and muscle strength support improved motor coordination in middle childhood.
And greater cognitive and social maturity enables older children to use their new motor skills in
more complex ways. A major change in children's play takes place at this time.

Gross-Motor Development
During the school years, running, jumping, hopping, and ball skills have become more refined.
Third to sixth graders burst into sprints as they race across the playground, jump quickly over
rotating ropes, engage in intricate hopscotch patterns, kick and dribble soccer balls, bat at balls
pitched by their classmates, and balance adeptly as they walk heel-to- toe across narrow leads.
These diverse skills reflect gains in four basic motor capacities:
Flexibility. Compared with preschoolers, school-age children are physically more pliable and
elastic, a difference evident as they swing bats, kick balls, jump over hurdles, and execute
tumbling routines.
Balance. Improved balance supports many athletic skills, including running, hopping, skipping,
throwing, kicking, and the rapid changes of direction required in many team sports.
Agility. Quicker and more accurate movements are evident in the fancy footwork of dance and
cheerleading and in the forward, backward, and sideways motions used to dodge opponents in tag
and soccer.
Force. Older youngsters can throw and kick a ball harder and propel themselves farther off the
ground when running and jumping than they could at earlier ages (Haywood & Getchell, 2014).

Along with body growth, more efficient information processing plays a vital role in improved
motor performance. During middle childhood, the capacity to react only to relevant information
increases. And steady gains in reaction time occur, including anticipatory responding to visual
stimuli, such as a thrown ball or a turning jump rope. Ten-year-olds react twice as quickly as 5-
year-olds (Debrabant et al., 2012; Kail, 2003). Because 5- to 7-year-olds are seldom successful at
batting a thrown ball, T-ball is more appropriate for them than baseball. Similarly, handball, four-
square, and kickball should precede instruction in tennis, basketball, and football. Children's
gross-motor activity not only benefits from but contributes to cognitive development. Physical
fitness predicts improved executive function, memory, and academic achievement in middle
childhood (Chaddock et al., 2011). Exercise-induced changes in the brain seem to be responsible:
Brain-imaging research reveals that structures supporting attentional control and memory are
larger, and myelination of neural fibers within them greater, in better-fit than in poorly-fit children
(Chaddock et al ., 2010a, 2010b; Chaddock-Heyman et al., 2014). Furthermore, children who are
physically fit—and those assigned to a yearlong, one-hour-per-day school fitness program—
activate these brain structures more effectively while performing executive function tasks
(Chaddock et al., 2012; Chaddock-Heyman et al. ., 2013). Mounting evidence supports the role of
vigorous exercise in optimal brain and cognitive functioning in childhood—a relationship that
persists throughout the life span.
Fine-Motor Development
Fine-motor development also improves over the school years. On rainy afternoons, Joey and
Lizzie experimented with yo-yos, built model airplanes, and wove potholders on small looms.
Like many children, they took up musical instruments, which demand considerable fine-motor
control. Gains in fine-motor skills are especially evident in children's writing and drawing. By age
6, most children can print the alphabet, their first and last names, and the numbers from 1 to 10
with reasonable clarity. Their writing is large, however, because they make strokes using the
entire arm rather than just the wrist and fingers. Children usually master uppercase letters first
because their horizontal and vertical motions are easier to control than the small curves of the
lowercase alphabet. Legibility of writing gradually increases as children produce more accurate
letters with uniform height and spacing. Children's drawings show dramatic gains in middle
childhood. By the end of the preschool years, children can accurately copy many two-dimensional
shapes, and they integrate these into their drawings. Some depth cues have also begun to appear,
such as making distant objects smaller than near ones (Braine et al., 1993). Around 9 to 10 years,
the third dimension is clearly evident through overlapping objects, diagonal placement, and
converging lines. Furthermore, as Figure 9.3 shows, school-age children not only depict objects in
considerable detail but also better relate them to one another as part of an organized whole (Case
& Okamoto, 1996).