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Refers to the increasing size of the physical structure of the body. It denotes quantitative change. It is measured by inches, centimeters, kilograms or pounds. Refers to the improvement in skill or ability to function. It denotes qualitative change. Defined as age in years. Refers to age based on functional behavior and ability to adapt to the behavior. Ability to combine simple movement or skills to achieve complex tasks. The nurse who works or cares for the children.
INTEGRATION OF SKILLS
A medical doctor who specializes in pediatrics. Development of traits carried through the genes. Means full or complete growth Physical Maturity – is normally complete by 20-25 years of age. Emotional and Intellectual Maturity – are not easily measured in normal individuals; generally attained by the age 25 years old.
HISTORY OF PEDIATRICS
It is believed that childcare was somewhat like that still found in isolated tribes living in the world today. Psychologist consider childcare during those times as almost ideal. Childhood is a period of relative freedom and preparation for adulthood.
ANCIENT CIVILIZATIONS (3000 BC TO 500 AD) In the ancients of Egypt, India and China, children were reared in the traditions passed down from the previous generations. The practice of medicine combined both medical knowledge and magic. In ancient Jews, hygienic measures greatly influenced the maternal and childcare. Widespread acceptance of infanticide.
MEDIEVAL WORLD (450 TO 1350 AD) Prevalent diseases – Influenza, Leprosy Death rate was high among children In 787 AD, the first known infant asylum or hospital was founded in Italy.
RENAISSANCE AND EARLY MODERN WORLD (1350-1800 AD)
2 books influenced the practice of pediatric medicine in 16th century. Thomas Phaer, the father of English Pediatrics wrote the “Broke of Children” and in Germany Felix Wurtz wrote the “Children’s Book”. St. Vincent de Paul, the “Patron Saint of Orphans” aroused the interest of the public in the care of children. In the early modern period – Industrial Revolution
Many advances in science, medicine and literature. In England, Edward Jenner developed the small pox vaccine. William Harvey discovered the circulation of blood. Rosseau wrote his famous book “Emile” which included a section on rights of children.
Remarkable changes happened 1. Scientifically gained knowledge
People are curious about themselves and the world around them. The scientific method was applied. Purification of water supplies and sanitary waste and sewage disposal. Pasteurization of commercial milk supplies. Testing of milk cows for tuberculosis. Immunization programs against communicable diseases. Development and mass production of antibiotics and other drugs. Maternal and child health programs that include free food and medical care. Laws to control child labor and childcare facilities. Counseling and recreation programs.
2. Humanitarianism - is the idea that all people are created with
an inherit dignity and value.
Childcare throughout the World
1946 – the chief international organization concerned with child welfare was established and was called United Nation International Children’s emergency Fund (UNICEF) Goal: to meet the distress of children caused by widespread disasters. Programs:
Training primary health workers Providing vaccines for immunizations, drugs, medical supplies and oral rehydration salts for supplemental nutrition. Assists with water and sanitation projects and indigenous food procurement.
1948, the World Health Organization (WHO) was established as the major international organization.
Various organizations and individuals within nations have initiated projects to assist other people to the world such as: - Peace Corps: technical advisors, educators and medical personnel are sent to underdeveloped countries to work with people to improve their lives. - Project Hope: is devoted to medical teaching and treatment and is staff entirely by volunteers. Other milestone in child welfare - 1959: Declaration of the Rights of the child adopted by the UN General Assembly. - 1979: International Year of the Child - 1985: International Youth Year designated by the UN
FACTORS INFLUENCING G& D
Heredity Life Experiences Health Status Cultural Expectations
PRINCIPLES OF GROWTH AND DEVELOPMENT
Development occurs in cephalocaudal (head-to-toe) direction. Development occurs in a proximodistal manner. Development occurs in an orderly manner from simple to complex and from general to specific. The pattern of G & D is continuous, orderly and predictable. However, G & D do not proceed at a consistent rate. Every person proceeds through stages of G & D at an individual rate. Every stage of development has specific characteristics. G & D may temporarily be stalled or regress during critical periods. Each stage of development has certain tasks to be achieved or acquired during that specific time. Tasks of one developmental stage become the foundation for tasks in subsequent stages. Some stages of G & D are more critical than others.
THEORIES OF G & D
THEORY A systematic statement of principles that provides a framework for explaining some phenomenon. Developmental theories provide road maps for explaining human development. DEVELOPMENTAL TASK – a skill or a growth responsibility arising at a particular time in an individual’s life, the achievement of which will provide a foundation for the accomplishment of future tasks.
FREUD’S PSYCHOANALYTIC THEORY
Freud based his theory on his observations of mentally disturbed adults. He described adult behavior as being the result of instinctual drives that have a primarily sexual nature (LIBIDO) from within the person and the conflicts that develop b/w these instincts. Three components of personality:
ID – the unconscious mind EGO – the conscious mind SUPEREGO – the conscience
FREUD’S STAGE OF CHILDHOOD
STAGES/AGE INFANT (Birth to 18 months) TODDLER (18 months to 3 years) PRESCHOOLER ( 3 to 6 years) PSYCHOSEXUAL STAGE Oral Stage: Child explores the world by using mouth especially the tongue. Anal Stage: Child learns to control urination and defecation. Phallic Stage: Child learns sexual identity through awareness of genital area. Latent Stage: Child’s personality development appears to be non-active or dormant. Genital Stage: Adolescent develops sexual maturity and learns to establish satisfactory relationships with the opposite sex.
SCHOOL-AGE (6 to 12 years)
ADOLESCENT (12 years to adulthood)
ERIKSON’S THEORY OF PSYCHOSOCIAL DEVELOPMENT
His theory stresses the importance of culture and society in personality development. Main tenet of his theory – person’s social view of himself/herself is more important than instinctual drives in determining behavior, allows for a more optimistic view of the possibilities for human growth. While Freud looked at ways mental illness develops, Erikson looked at actions that lead to mental health. Erikson describes eight developmental stages covering the entire life span.
ERIKSON’S STAGES OF CHILDHOOD
STAGES/AGE INFANT (Birth to 18 months) TODDLER (18 months to 3 years) PRESCHOOLER (3 to 6 years) SCHOOL-AGE (6 to 12 years) ADOLESCENCE (12 to 20 years) DEVELOPMENTAL TASK Sense of trust vs mistrust. Child learns to love and be loved. Autonomy vs shame. Child learns to be independent and make decisions for self. Initiative vs guilt. Child learns how to do things (basic problem solving) and that doing things is desirable. Industry vs inferiority. Child learns how to do things well. Identity vs role confusion. Adolescents learn who they are and what kind of person they will be by adjusting to a new body image, seeking emancipation from parents, choosing a vocation and determining a value system. Intimacy vs isolation. Develop commitments to others and to a life work (career) Generativity vs self-absorption/Stagnation Establish a family and become productive Ego integrity vs disgust and despair View one’s life as meaningful and fulfilling
YOUNG ADULT (20 to 25 years) ADULTHOOD (25 to 45 years) SENESCENCE (45+ years)
JEAN PIAGET’S COGNITIVE THEORY
He used several terms to describe cognitive development like: Schema
Interactions with the environment caused people to organize patterns of thought which they used to interpret or make sense of their experience. Example – Young children who believed the sun is alive because it moves – are operating on the schema that moving things are alive.
Interpreting new information in terms of existing information. As they get older, children continually encounter animate and inanimate objects and learn all objects are not alive. Example: Trees do not move from one area of the yard to another even though they are alive. Adequate understanding of differences b/w nonliving and living objects. Revising, readjusting or realigning existing schema to accept this new information. Results in equilibrium or harmonious relationship b/w thought processes and the environment.
PIAGET’S PHASES OF COGNITIVE DEVELOPMENT
PHASE Sensorimotor Stage 1: Use of reflexes Stage 2: Primary circular reaction Stage 3: Secondary circular reaction Stage 4: Coordination of secondary schemata Stage 5: Tertiary circular reaction Stage 6: Invention of new means AGE Birth to 2 yrs Birth to 1 mon 1 to 4 months DESCRIPTION Sensory organs & muscles become more functional Movements are primarily reflexive *Perceptions center around one’s body. *Objects are perceived as extensions of the self *Becomes aware of external environment *Initiates acts to change the environment Differentiate goals and goal-directed activities. *Experiments w/ methods to reach goals *Develops rituals that become significant *Uses mental imagery to understand the envi. *Uses fantasy (make-believe)
4 to 8 months 8 to 12 months 12 to 18 months 18 to 24 months
PIAGET’S PHASES OF COGNITIVE DEVELOPMENT
PHASE Preoperational Preconceptual stage Intuitive stage AGE 2 to 7 years 2 to 4 years 4 to 7 years DESCRIPTION Emerging ability to think *Thinking tends to be egocentric *Exhibits use of symbolism *Unable to break down a whole into separate parts. *Able to classify objects according to one trait
Concrete operations Formal operations
7 to 11 years Learns to reason about events in the here and now 11+ years Able to see relationships and to reason in the abstract
KOHLBERG’S STAGES OF MORAL DEVELOPMENT
Developed a theory on the way children gain knowledge of right and wrong or moral reasoning. He described changes in thinking about moral judgments and reflected social norms and values. He was interested in the underlying rationale for the moral decisions rather than the decision itself. He also believed the process of moral development was influenced by:
Internal factor includes: empathy, intelligence, impulse control, ability to judge. External factors includes: rewards, punishment, family structure, parent/perr contracts.
KOHLBERG’S STAGES OF MORAL DEVELOPMENT
LEVEL AND STAGE Level I: Preconventional Age 4 to 10 years Stage 1: Punishment & obedience orientation Stage 2: Hedonistic and instrumental orientation DESCRIPTION Authority figures are obeyed (self-centered orientation) Misbehavior is viewed in terms of damage done. A deed is perceived as “wrong” if one is punished; the activity is “right” if one is not punished. “Right” is defined as acceptable to and approved by the self. When actions satisfy one’s needs, they are “right”.
KOHLBERG’S STAGES OF MORAL DEVELOPMENT
Level II: Conventional Cordial interpersonal relationships are maintained. (able to see victim’s perspective) Approval of other’s is sought through one’s action. Authority is respected. Individual feels “duty-bound” to maintain social order. Behavior is “right" when it conforms to the rules.
Age 10 to 13, but can go into adolescence Stage 3: Good boy/girl orientation Stage 4: Law-and-order orientation
KOHLBERG’S STAGES OF MORAL DEVELOPMENT
Level III: Postconventional Individual understands the morality of having democratically established laws. (underlying ethical principles are considered that include societal needs)
Adolescence and beyond Stage 5: Social contract orientation Stage 6: Hierarchy of principles orientation It is “wrong” to violate others’ rights Judgments based on principles of justice, respect for dignity of human beings as individuals- do to others as you would have them do to you.
The Healthy Child: Stages of G & D
INFANT (1 month to 1year) B. Psychosocial Development Depends on the quality of relationship b/w caregiver and infant. If needs are met consistently, it results in feelings of physical comfort and emotional security. Infants to love and be loved.
INFANT (1 month to 1year) B. Physical Growth and Development – there is rapid gain in physical size & maturation.
Length – grows 20 inches at birth; 30 inches at 1 year (50% increase by 1 year): grows 1 inch every month for 6 months, then ½ inch every month during the last 6 months. Weight – gains 1 ½ Ibs/month; doubles body weight by 5-6 months; triples body weight by 1 year. Head Circumference – HC is greater than chest circumference until age 2. Vital Signs – PR=80-150/min (ave=100/min); RR=2050/min
Fontanels Anterior – diamond shaped; closes at 12-18 months Posterior – triangle shaped; closes at 2 months Teeth 4-8 months: central mandibular incisors By 1 year – has 8 teeth Sleep 0-6 months – sleeps thru the night 8-9 months – sleeps 10-12 hours at night Play Solitary – purpose is to stimulate sensorimotor development. Toys: safe, simple, stimulating, easily handled, washable Types: mobiles, musical, rattles, squeeze & sponge toys 9-12 months: activity box, balls, blocks, pots & pans Games: peek-a-boo
Nutrition: breast milk – 0-6 months
Caloric needs: NB needs 400 kcal/day; 1 year needs 1,200 kcal/day. Cereals/solids: introduced at 4-6 months; then at 6-7 months strained fruits and vegetables. Note: does not need solid food before 4 months because salivary enzymes and intestinal antibodies to aid digestion are not present until 4-6 months; extrusion reflex lasts until 3-4 months and chewing movement begin at 7-9 months. Ground/pureed meat: given at 8-9 months, chewable finger foods introduced when teething begins. Egg yolks: delay egg whites until 12 months due to allergies. At 10 months, baby can drink independently from a cup.
MAJOR NEONATAL REFLEXES
REFLEX Rooting Sucking Swallowing Grasp Babinski Moro DESCRIPTION Turning the mouth and nose in the direction of any facial touch Using the tongue and mouth to take in liquid or food Movement of throat muscles to push food from mouth to esophagus Firm contraction of hand muscles around an object When foot stroked, toes fan upward and outward When startled, arms and legs swing quickly out, then immediately back and neonate curls up into a ball
REFLEX Smiling Blinking Sneezing Coughing Crying Tonic neck Extrusion Head turning
DESCRIPTION Turning lips upward; neonate looks “happy” Rapid closing and opening of eyelids A violent, spasmodic, sudden expiration of breath Explosively expelling air from the lungs Making a loud, wailing sound When head is turned to side, arm and leg on same side are extended in a fencing posture Tongue pushes outward when touched by an object at the tip Moving face to one side or the other when airway is blocked by a surface such as a bed or pillow
TODDLER (1 TO 3 YEARS OLD) B. Psychosocial
G & D is a period of exploration, negativism and ritualism All activities attribute to independence Birth weight – quadruples, general appearance: potbellied, wide-based gait Vital signs – pulse & respiration decrease, BP increases with size and age Teeth – all 20 deciduous teeth present by 2 ½ - 3 years.
Physical G & D
Child will play beside but not with another child. Purpose: stimulate motor development and help make transition from solitary to cooperative play. Types: should allow for self-play and be actionoriented. Ex: Push & pull toys, blocks, balls, dolls, stuffed toys, clay, paints, crayons, coloring, wood puzzles. Games: “rough and tumble play”, like to throw and retrieve objects.
Nutrition: needs an average of 1,300 kcal/day
Has “physiological anorexia” – eats a great deal one day & little the next. Growth slows, has ritualistic food preferences like finger foods. Prone to Iron Deficiency Anemia (IDA), dehydration, Upper Respi Infection (URI), tonsillitis & Otitis media. Guide to parents: recognize ritualistic needs (same utensils, chair); don’t force child to eat; don’t give bottle as a substitute for solid foods. 2 ½ to 3 years – first visit to dentist as soon as all primary teeth have erupted. Brush teeth 2x/day; limit concentrated sweets, don’t allow child to take a bottle containing milk or juice at night since bottle mouth caries may result.
Toileting Practices – learning bowel & bladder control is one of the major tasks of toddler hood. Uses toileting activities to control self & others.
18 months – has bowel control 2 to 3 years – has day time bladder control 3 to 4 years – has night time bladder control
Limit Setting & Discipline
Help child to learn self-control and socially appropriate behavior Discipline should occur immediately after wrongdoing; be firm and consistent when enforcing limits; disapprove of the behavior not the child. Positive approach is best Common Accidents – falls, poisonous ingestion, burns and drowning.
PRE-SCHOOLER (3-6 YEARS) b. Psychosocial development
A period of curiosity, discovery, imaginary fears and fantasies. Child learns to do things, derives satisfaction from activities. Imitates role models; has active imagination; may have imaginary friends; has exaggerated fears Gains 4-5 Ibs/year Thinner, taller, more erect
Physical G & D
Is fairly common among toddlers and pre-schooler. Parents should ignore stuttering so that the child does not become anxious. Requires 9 to 12 hours sleep each night. Sleep problems are most common. Child may awaken with nightmares and may have fears of the dark. Purpose – help child to share and play in small groups; learns simple games & rules, language concepts & social roles. Play maybe creative, imitative and dramatic Types: dolls, dress-up clothes, housekeeping toys, wagons, tricycle, picture books, jigsaw puzzles, materials for cutting, pasting and painting.
Needs an average 1700 kcal/day. A slow growth period, appetite remains decreased; has definite food preferences. Knows sex differences by 3 years Imitates feminine or masculine behavior Gender identity well established by 6 years Masturbation is normal – may increase in frequency when under stress. Answer questions – simple, honestly and matter of fact For masturbation – redirect child’s attention w/out punishing or verbally reprimanding.
Guidelines for Caregivers
SCHOOL AGE (6 TO 12 YEARS)
A. Psychosocial Development – develops a sense of competency and esteem academically, physically & socially; assumes more responsibility. Gains competency in mastering new skills and tasks.>
More responsive to peers; has best friends; desire for accomplishment so strong that young school child may try to change rules of game to win. School phobias may occur as a result of increase competition and desire to succeed. Height: growth is slow & regular (1-2 inch gain in height per year); Females usually taller than males. Weight: 3 to 6 Ibs weight gain per year.
B. Physical G & D
Team, rule-governed; same sex together. Purpose – learn to cooperate, compromise, develop logical reasoning abilities, to bargain and increase social skills. Types – entertainment, play figures, trains, model kits, games and jigsaw puzzles, storybooks, adventure-mystery, riding a bike, sports, music, dancing lessons. needs an average of 2,400 cal/day. Appetite increases Breakfast is important for school performance and more likely to eat junk foods. 5 to 7 years – loss of deciduous teeth & eruption of permanent ones; dental caries are a major dental problems.
ADOLESCENT (12-20 YEARS OLD) Begins at puberty and ends when physical maturity is achieved. It is an essential period in sexual development and formation of personality. Asks, “Who am I?” “What do I want to do with life?”
Nutrition Girls need 2,200 cal/day. Boys need 2,700 cal/day Appetite increases with rapid growth; increased need for protein, iron, calcium & zinc Eating habits are easily influenced by peer group Intake of junk foods, fad diets can lead to obesity, bulimia, anorexia nervosa, iron deficiency anemia.
YOUNG AND MIDDLE ADULTHOOD Developmental state and function characterized by selfsufficiency in pursuit or occupation/vocation and defined interpersonal relationships. Physical/cognitive Stabilized growth rate (weight is variable) and functioning Refines formal operational abilities Undergoes menopause Begins physical degeneration Psychosocial Develops self-sufficiency Pursues vocation/occupation Has intense interpersonal relationships (most frequently marriage and children)
LATE ADULTHOOD Physical / cognitive Has general slowing of physical and cognitive functioning Psychosocial Needs to establish highest degree of independence (self-sufficiency) physically possible by adopting environment to ability. Reflects on life accomplishments, events and experiences Continues interpersonal relationships despite changes and loss.
PROMOTING HEALTHY G & D
Ensuring the health of the child, the growing years is accomplished in the following ways:
Providing adequate nutrition Providing for dental health Meeting basic emotional needs Immunizing against infectious diseases Protecting from harmful accidents Giving continuous health supervision
Health promotion during infancy
Feeding milestones: At birth, the full term infant has sucking, rooting and swallowing reflexes. Newborn feels hunger and indicates desire for food by crying, expresses satisfaction by contentedly falling asleep. At one month, has strong extrusion reflex By 5-6 months, can use fingers to eat, teething crackers. By 6-7 months is developmentally ready to chew solids. By 8-9 months, can hold a spoon and play with it during feedings. By 9 months can hold bottle. By 12 months can drink from a cup.
Guidelines for infant feeding
Breast milk is the most complete diet for the 1st 6 months of life. Iron fortified formula is an acceptable alternative to breastfeeding. Water or milk requirement is 125-150 ml/kg/day from 0-6 months. Solids are not recommended before 4-6 months because salivary enzymes are not present and chewing movements begins at 7-9 months. Rice cereals are given because of its low allergic potential. First solids are strained, pureed, mashed. Finger foods are toast, crackers; fruits are introduced at 6-7 months. Chopped table food can be started at 9-12 months. Fruit juices should be offered from a cup ASAP to reduce the development of nursing bottle carries.
Feed when the baby is hungry, hold or cuddle the baby when feeding. Introduce one food at a time usually at intervals of 47 days to allow for identification of food allergies. Use small spoon with straight handle, begin spoon feeding by placing food at the back of the tongue. Gradually reduce milk as solid food increases to prevent overfeeding. Never mix food with formula bottle.
Readiness develops during 2nd half of the first year because of pleasure from receiving food by a spoon and desire for more freedom and control over body and environment. Gradually replace one bottle at a time with cup and finally end with a nighttime bottle. After 6 months, wean directly to a cup.
Immunizations against diseases
Immunizations – the process whereby a person becomes immune or able to resist diseases. It serves to be the safest, most effective and least expensive, method of preventing illness. Active immunity – the person produces its own antibodies. Passive immunity – when readymade antibodies are injected into an individual to provide immediate immunity to some diseases, which is temporary.
Severe febrile illness Has an altered immune system Has a history of allergic response prior to vaccination Recently acquired passive immunity like blood transfusion, immunoglobulin (antibodies).
BCG – preliminary dose: 1-14 months; booster dose: school entry. Diphtheria, Pertusis, Tetanus (DPT) – P: 2, 4, 6 months / B1: 1 year after / B2: 4-6 years. Hepa B vaccine – P: 0,1,6 months / B: 5 years after. Polio – P: 2,4,6 months / B1 – 1 year after / B2 – 4-6 years. Measles – P: 9 months as order / B1 – 15 months / B2 – 5-12 years. Mumps, Rubella (German measles) – MMR – 12 months as order / B – 5 to 12 years after. Varicella (Chicken pox) – 1st dose: 9 months to 12 years / 2nd dose: 13 years. Meningococcemia Hemophilus Influenza B (HIB) – 2 months to 5 years.
Usually starts from lower front incisors at about 6 months of age. It’s normal to see teething begins as early as 3-4 months or as late as 1 year old. The child will experience some discomforts when teething like: crankiness, restlessness, temporary loss of appetite. Management: give the child something to chew on such rubber teething ring in order to relieve sore gums. During this period multivitamins containing fluoride maybe given.
THE IMPORTANCE OF PLAY
Play is an excellent stress reducer and tension reliever. Play provides a source of diversional activity, alleviating separation anxiety. Play provides the child with a sense of safety and security. Developmentally appropriate play fosters the child’s normal G & D, especially for children who are repeatedly hospitalized for chronic conditions. Play puts the child in the driver’s seat, allowing him to make choices and giving him a sense of control.
FUNCTIONS OF PLAY
1. 2. 3. 4. 5. 6.
Physical and motor development Social development Emotional expression Intellectual education Development of moral values Recreational
Criteria for judging the suitability of toys:
1. Safety – the most important 2. Compatibility or suitability to:
Child age Level of development Experience Challenge to the development of the child Enhancing personality, social and moral development Expressing emotions Achieving mastery Developing creativity Implementing therapeutic procedures Means to cope with fears
ILLNESS AND HOSPITALIZATION
A. REACTIONS TO ILLNESS There are no general findings regarding the response of preverbal children to illness or fear of bodily injury. Younger infants respond to pain with generalized body responses including, loud crying and some facial gestures. Older infants respond with generalized body responses and deliberate withdrawal of the stimulated area, loud crying, facial gestures and anger and physical resistance.
B. REACTIONS TO HOSPITALIZATION Infants under age 3 months tolerate short-term hospitalization well if provided with a nurturing person who meets their physical needs consistently. Between 4 and 6 months infants begin to recognize mother and father as separate from self (known as “stranger anxiety”); therefore, infants at this age may also experience separation anxiety when hospitalized.
1. Provide general interventions
Spend time with parents within the infant’s sight so the baby identifies you as safe person. Allow the parents to provide as much of the care as possible. Follow the infant’s home schedule (eg, feeding times and bedtime) as closely as possible. Provide sensorimotor stimulation Keep the infant warm and dry Meet hunger needs consistently Ensure safety
2. Provide physical comfort and safety interventions
3. Provide cognitive interventions
Provide a variety of stimulating toys (eg, mobiles, music boxes, busy boxes, rattles) Promote language development (eg, make sounds and talk to infants) Encourage learning through sensorimotor experience (eg, allow repetition of acts and a variety of toys and textures for manipulation) Maintain a good relationship with parents of children in all age groups, encouraging them to give care, hold the child, play with the child and room in with the child as appropriate. Maintain consistent staffing Promote a sense of security (eg, handle gently, cuddle, talk and respond to cues)
4. Provide psychosocial and emotional interventions
CONCEPTS OF DEATH IN CHILDHOOD
Developmental Stage Infancy Early childhood None Knows the words “dead” and “death” * Reactions are influenced by the attitudes of parents.
Concept of Death
*Understands universality and irreversibility of death *May have a fear of parents dying *Begins to incorporate family and cultural beliefs about death *Explores views of an afterlife *Faces the reality of own mortality *Adult perception of death, but still focused on the “here and now”
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