Health Promotion of the Preschooler and Family

Health Promotion of the Preschooler and Family

Rebecca A. Monroe


Promoting Optimal Growth and Development

The combined biologic, psychosocial, cognitive, spiritual, and social achievements during the preschool period (3–5 years of age) prepare preschoolers for their most significant change in lifestyle: entrance into school. Their control of bodily functions, experience of brief and prolonged periods of separation, ability to interact cooperatively with other children and adults, use of language for mental symbolization, and increased attention span and memory prepare them for the next major period: the school years. Successful achievement of previous levels of growth and development is essential for preschoolers to refine many of the tasks that were mastered during the toddler years.

Biologic Development

The rate of physical growth slows and stabilizes during the preschool years. The average weight is 14.5 kg (32 pounds) at 3 years, 16.7 kg (36.8 pounds) at 4 years, and 18.7 kg (41.5 pounds) at 5 years. The average weight gain per year remains approximately 2 to 3 kg (4.5–6.5 pounds).

Growth in height also remains steady, with a yearly increase of 6.5 to 9 cm (2.5–3.5 inches), and generally occurs by elongation of the legs rather than of the trunk. The average height is 95 cm (37.5 inches) at 3 years, 103 cm (40.5 inches) at 4 years, and 110 cm (43.5 inches) at 5 years.

Physical proportions no longer resemble those of the squat, pot-bellied toddler. Preschoolers are slender but sturdy, graceful, agile, and posturally erect. There is little difference in physical characteristics according to gender except as dictated by such factors as dress and hairstyle.

Most organ systems can adjust to moderate stress and change. During this period, most children are toilet trained. For the most part, motor development consists of increases in strength and refinement of previously learned skills, such as walking, running, and jumping. However, muscle development and bone growth are still far from mature. Excessive activity and overexertion can injure delicate tissues. Good posture, appropriate exercise, and adequate nutrition and rest are essential for optimal development of the musculoskeletal system.

Psychosocial Development

Developing a Sense of Initiative (Erikson)

After preschoolers have mastered the tasks of the toddler period, they are ready to face the developmental endeavors of the preschool period. Erikson maintained that the chief psychosocial task of this period is acquiring a sense of initiative. Children are in a stage of energetic learning. They play, work, and live to the fullest and feel a real sense of accomplishment and satisfaction in their activities. Conflict arises when children overstep the limits of their ability and inquiry and experience a sense of guilt for not having behaved appropriately. Feelings of guilt, anxiety, and fear may also result from thoughts that differ from expected behavior.

A particularly stressful thought is wishing one’s parent dead. As a sense of rivalry or competition develops between the child and same-sex parent, the child may think of ways to get rid of the interfering parent. In most situations, this rivalry is resolved when the child strongly identifies with the same-sex parent and peers during the school years. However, if that parent dies before the identification process is completed, the preschooler may be overwhelmed with feelings of guilt for having wished and therefore “caused” the death. Clarifying for children that wishes cannot and do not make events occur is essential in helping them overcome their guilt and anxiety.

Development of the superego, or conscience, begins toward the end of the toddler years and is a major task for preschoolers (see Cultural Considerations box). Learning right from wrong and good from bad is the beginning of morality (see Moral Development).

Cognitive Development

One of the tasks related to the preschool period is readiness for school and scholastic learning. Many of the thought processes of this period are crucial for achieving such readiness, and it is intentional that children begin school between ages 5 and 6 years rather than at an earlier age.

Preoperational Phase (Piaget)

Piaget’s cognitive theory does not include a period specifically for children who are 3 to 5 years old. The preoperational phase covers the age span from 2 to 7 years and is divided into two stages: the preconceptual phase, ages 2 to 4 years, and the phase of intuitive thought, ages 4 to 7 years. One of the main transitions during these two phases is the shift from totally egocentric thought to social awareness and the ability to consider other viewpoints. However, egocentricity is still evident. (For a review of the characteristics of preoperational thought, see Chapter 12.)

Language continues to develop during the preschool period. Speech remains primarily a vehicle of egocentric communication. Preschoolers assume that everyone thinks as they do and that a brief explanation of their thinking makes the entire thought understood by others. Because of this self-referenced, egocentric verbal communication, it is often necessary to explore and understand young children’s thinking through other, nonverbal approaches. For children in this age group, the most enlightening and effective method is play, which becomes children’s way of understanding, adjusting to, and working out life’s experiences.

Preschoolers increasingly use language without comprehending the meaning of words, particularly concepts of left and right, causality, and time. Children may use the concepts correctly but only in the circumstances in which they have learned them. For example, they may know how to put on shoes by remembering that the buckle is always on the outside of the foot. However, if different shoes have no buckles, they cannot reason which shoe fits which foot. In other words, they do not understand the concept of left and right.

Superficially, causality resembles logical thought. Preschoolers explain a concept as they heard it described by others, but their understanding is limited. An example is the concept of time. Because time is still incompletely understood, the child interprets it according to his or her own frame of reference, such as “A long time means until Christmas.” Consequently, time is best explained in relationship to an event, such as “Your mother will visit you after you finish your lunch.” Avoiding words such as yesterday, tomorrow, next week, or Tuesday to express when an event is expected to occur and instead associating time with expected daily events help children learn about temporal relationships while increasing their trust in others’ predictions.

Preschoolers’ thinking is often described as magical thinking. Because of their egocentrism and transductive reasoning, they believe that thoughts are all-powerful. Such thinking places them in the vulnerable position of feeling guilty and responsible for bad thoughts, which may coincide with the occurrence of a wished event. Their inability to logically reason the cause and effect of illness or an injury makes it especially difficult for them to understand such events.

Preschoolers believe in the power of words and accept their meaning literally. An example of this type of thinking is calling children “bad” because they did something wrong. In the preschooler’s mind, calling them bad means they are a bad person; thus, it is better to say that their actions were bad by saying, for example, “That was a bad thing to do.”

Moral Development

Preconventional or Premoral Level (Kohlberg)

Young children’s development of moral judgment is at the most basic level. They have little, if any, concern about why something is wrong. They behave because of the freedom or restriction that is placed on actions. In the punishment and obedience orientation, children (ages about 2–4 years) judge whether an action is good or bad depending on whether it results in a reward or a punishment. If children are punished for it, the action is bad. If they are not punished, the action is good regardless of the meaning of the act. For example, if parents allow hitting, the child will perceive that hitting is good because it is not associated with punishment.

From approximately 4 to 7 years of age, children are in the stage of naive instrumental orientation in which actions are directed toward satisfying their needs and, less frequently, the needs of others. They have a concrete sense of justice and fairness during this period of development.

Spiritual Development

Children generally learn about faith and religion from significant others in their environment, usually from parents and their religious beliefs and practices. However, young children’s understanding of spirituality is influenced by their cognitive level. Preschoolers have a concrete concept of a God with physical characteristics, often similar to an imaginary friend. They understand simple Bible stories, memorize short prayers, and imitate the religious practices of their parents without fully understanding the significance of these rituals. Preschoolers benefit from concrete representations of religious practices, such as picture Bible books and small statues, such as those of the Nativity scene.

Development of the conscience is strongly linked to spiritual development. At this age, children are learning right from wrong and behaving correctly to avoid punishment. Wrongdoing provokes feelings of guilt, and preschoolers often misinterpret illness as a punishment for real or imagined transgressions. Observing religious traditions and participating in a religious community can help children cope during stressful periods, such as illness and hospitalization (Speraw, 2006).

Development of Body Image

The preschool years play a significant role in the development of body image. With increasing comprehension of language, preschoolers recognize that individuals have desirable and undesirable appearances. They recognize differences in skin color and racial identity and are vulnerable to learning prejudices and biases. They are aware of the meaning of words such as pretty or ugly, and they reflect the opinions of others regarding their own appearance. By 5 years of age, children compare their size with that of their peers and can become conscious of being large or short, especially if others refer to them as “so big” or “so little” for their age. Research indicates that girls as young as preschool age already show concern about appearance and weight (Skouteris, McCabe, Swinburn, and others, 2010). Because these are formative years for both boys and girls, parents should make efforts to instill positive principles regarding body image, give their children encouraging feedback regarding their appearance, and emphasize the importance of accepting individuals no matter their differences in appearance.

Despite the advances in body image development, preschoolers have poorly defined body boundaries and little knowledge of their internal anatomy. Intrusive experiences are frightening, especially those that disrupt the integrity of the skin, such as injections and surgery. They fear that if their skin is “broken,” all of their blood and “insides” can leak out. Therefore, bandages are critical to “keep everything from coming out.”

Development of Sexuality

Sexual development during these years is an important phase in a person’s overall sexual identity and beliefs. Preschoolers are forming strong attachments to the opposite-sex parent while identifying with the same-sex parent. Sex typing, or the process by which an individual develops the behavior, personality, attitudes, and beliefs appropriate for his or her culture and sex, occurs through several mechanisms during this period. Probably the most powerful mechanisms are childrearing practices and imitations. Gender identification is a result of complex prenatal and postnatal psychologic factors, as well as biologic, social, and genetic factors. Most children are aware of their gender and the expected sets of related behaviors by image to image years of age.

As sexual identity develops beyond gender recognition, modesty may become a concern. Sex-role imitation and “dressing up” like Mommy or Daddy are important activities. Attitudes and the responses of others to role-playing can condition children to views of themselves and others. For example, comments such as “Boys shouldn’t play with dolls” can influence a boy’s self-concept of masculinity.

Sexual exploration may be more pronounced now than ever before, particularly in terms of exploring and manipulating the genitalia. Questions about sexual reproduction may come to the forefront in preschoolers’ search for understanding (see Sex Education, p. 415, and in Chapter 15).

Social Development

During the preschool period, the separation-individuation process is completed. Preschoolers have overcome much of the anxiety associated with strangers and the fear of separation of earlier years. They relate to unfamiliar people easily and tolerate brief separations from their parents with little or no protest. However, they still need parental security, reassurance, guidance, and approval, especially when entering preschool or elementary school. Prolonged separation, such as that imposed by illness and hospitalization, is difficult, but preschoolers respond to anticipatory preparation and concrete explanation. They can cope with changes in daily routine much better than toddlers, although they may develop more imaginary fears. Preschoolers gain security and comfort from familiar objects, such as toys, dolls, or photographs of family members. They are able to work through many of their unresolved fears, fantasies, and anxieties through play, especially if guided with appropriate play objects (e.g., dolls, puppets) that represent family members, health care professionals, and other children.


During the preschool years, language becomes more sophisticated and complex and becomes a major mode of communication and social interaction (Fig. 13-2). Through language, preschool children learn to express feelings of frustration or anger without acting them out. Both cognitive ability and environment—particularly, consistent role models—influence vocabulary, speech, and comprehension. Vocabulary increases dramatically, from 300 words at age 2 years to more than 2100 words at the end of 5 years. Sentence structure, grammatical usage, and intelligibility also advance to a more adult level. Language development during these early years predicts school readiness (Harrison and McLeod, 2010) and sets the stage for later success in school (Reilly, Wake, Ukoumunne, and others, 2010).

Children between the ages of 3 and 4 years form sentences of about three or four words and include only the most essential words to convey a meaning. Such speech is often termed telegraphic for its brevity. Three-year-old children ask many questions and use plurals, correct pronouns, and the past tense of verbs. They name familiar objects, such as animals, parts of the body, relatives, and friends. They can give and follow simple commands. They talk incessantly regardless of whether anyone is listening or answering them. They enjoy musical or talking toys or dolls and imitate new words proficiently.

From ages 4 to 5 years, preschoolers use longer sentences of four or five words and use more words to convey a message, such as prepositions, adjectives, and a variety of verbs. They follow simple directional commands, such as “Put the ball on the chair,” but can carry out only one request at a time. They answer questions such as “What do you do when you are hungry?” by describing the appropriate action. The pattern of asking questions is at its peak, and children usually repeat a question until they receive an answer.

By age 6 years, children can use all parts of speech correctly except for deviations from the rule. They can define simple things by describing their use, shape, or general category of classification, rather than simply describing their outward appearance. For example, they define a ball as “round,” “something you bounce,” or “a toy,” rather than only describing its color. They can give some opposites, such as “If Mommy is a woman, Daddy is a man.” They can also describe an object according to its composition, such as “A spoon is made of metal.”

Personal-Social Behavior

The pervasive ritualism and negativism of toddlerhood gradually diminish during the preschool years. Although self-assertion is still a major theme, preschoolers demonstrate their sense of autonomy differently. They are able to verbalize their request for independence and perform independently because of their much-refined physical and cognitive development. By 4 or 5 years of age, they need little if any assistance with dressing, eating, or toileting (Fig. 13-3). They can also be trusted to obey warnings of danger; however, 3- or 4-year-old children may exceed their boundaries at times.

They are also much more sociable and willing to please. They have internalized many of the standards and values of the family and culture. However, by the end of early childhood, they begin to question parental values and compare them with those of their peer group and other authority figures. As a result, they may be less willing to abide by the family’s code of conduct. Preschoolers become increasingly aware of their position and role within the family. Although this is a more secure age for experiencing the addition of another sibling, relinquishing the position of first or youngest is still difficult and requires appropriate preparation. (See Sibling Rivalry, Chapter 12.)


Various types of play are typical of this period, but preschoolers especially enjoy associative play—group play in similar or identical activities but without rigid organization or rules. Play should provide for physical, social, and mental development.

Play activities for physical growth and refinement of motor skills include jumping, running, and climbing. Tricycles, wagons, gym and sports equipment, sandboxes, wading pools, and activities at water parks can help develop muscles and coordination (Fig. 13-4). Activities such as swimming and skating teach safety as well as muscle development and coordination. Children involved in the work of play do not require expensive toys and gadgets to keep them entertained but often enjoy playing with common household items such as a broom handle or even items adults consider junk (boxes, sticks, rocks, and dirt). The imaginative mind of the preschooler enjoys playing for play’s sake.

Manipulative, constructive, creative, and educational toys provide for quiet activities, fine motor development, and self-expression. Easy construction sets, large blocks of various sizes and shapes, a counting frame, alphabet or number flash cards, paints, crayons, simple carpentry tools, musical toys, illustrated books, simple sewing or handicraft sets, large puzzles, and clay are suitable toys. Electronic games and computer programs are especially valuable in helping children learn basic skills, such as letters and simple words.

Probably the most characteristic and pervasive preschool activity is imitative, imaginative, and dramatic play. Dress-up clothes, dolls, housekeeping toys, dollhouses, play store toys, telephones, farm animals and equipment, village sets, trains, trucks, cars, planes, hand puppets, and medical kits provide hours of self-expression (Fig. 13-5). Probably at no other time is the reproduction of adult behavior so faithful and absorbing as in 4- and 5-year-old children. Toward the end of the preschool period, children are less satisfied with make-believe or pretend objects and enjoy doing the actual activity, such as cooking and carpentry.

Television and other media also have their place in children’s play, although each should be only one part of children’s total repertoire of social and recreational activities. Parents and other caregivers should supervise the selection of programs, watch and discuss programs with their children, schedule limited time for television viewing, and set a good example of television viewing (American Academy of Pediatrics [AAP], 2007). Children enjoy and learn from educational programs; however, television viewing may limit time spent in other meaningful activities such as reading, physical activity, and socialization (AAP, 2007).

Although the potential negative effects of television viewing have been well documented in literature, research has also shown that prosocial behavior and later academic achievement can result from viewing educational media during the preschool years; however, positive effects depend on the media content, the age of the viewer, the length of viewing time, and the presence of a coviewing parent (Kirkorian, Wartella, and Anderson, 2008). When parents view media with their children, the activity can become interactive with parents and children discussing program content. Considering the significant increase in media accessibility through various portable electronic devices and cell phones, parents need to be aware of the potential positive and negative effects of media exposure.

Play is so much a part of young children’s lives that reality and fantasy become blurred. Make-believe is reality during play and only becomes fantasy when the toys are put away or the dress-up clothes are removed. It is no wonder that imaginary playmates are so much a part of this age period. The appearance of imaginary companions usually occurs between ages image and 3 years, and for the most part, such playmates are relinquished when the child enters school. Differences in birth order and gender have been noted in studies of imaginary companion play. Firstborn children have a higher incidence of imaginary companions, as do young girls; young boys tend to impersonate characters more often (Trionfi and Reese, 2009).

Imaginary companions serve many purposes: They become friends in times of loneliness, they accomplish what the child is still attempting, and they experience what the child wants to forget or remember. It is not unusual for the “friend” to have myriad vices and to be blamed for wrongdoing. Sometimes the child hopes to escape punishment by saying, “My friend George broke the glass.” At other times, the child may fantasize that the companion misbehaved and play the role of the parent. This becomes a way of assuming control and authority in a safe situation.

Parents often worry about the imaginary playmates, not realizing how normal and useful they are. Parents need to be reassured that the child’s fantasy is a sign of health that helps differentiate make-believe and reality. Parents can acknowledge the presence of the imaginary companion by calling him or her by name and even agreeing to simple requests such as setting an extra place at the table, but they should not allow the child to use the playmate to avoid punishment or responsibility. For example, if the child blames the companion for messing up a room, parents need to state clearly that the child is the only one they see; therefore, the child is responsible for cleaning up.

Children also benefit from play that occurs between them and a parent. Mutual play fosters development from birth through the school years and provides enriched opportunities for learning. Through mutual play, parents can provide tactile and kinesthetic experiences, maximize verbal and language abilities, and offer praise and encouragement for exploration of the world. In addition, mutual play encourages positive interactions between the parent and child, strengthening their relationship.

Table 13-1 summarizes the major developmental achievements for children 3, 4, and 5 years of age.

TABLE 13-1


Age 3 Years

Jan 16, 2017 | Posted by in NURSING | Comments Off on Health Promotion of the Preschooler and Family
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