Developmental Tasks of the Infant

Erikson identified eight crises that must be resolved at major stages of human development.²⁷ He theorized that the developing infant, child, or young adult leaves each crisis with both positive and negative aspects. The developmental crisis of infancy is to acquire a sense of basic trust while overcoming a sense of mistrust. To acquire a sense of trust, the infant must develop a sense of physical safety and confidence that physical needs will be met. The quality of the parent-infant interaction and the parents’ ability to interpret the infant’s cues are important to the development of trust. When an infant is frustrated repeatedly in attempts to make needs known and have them met, distrust and pessimism can develop. Once a sense of trust is achieved, unfamiliar or unknown situations can be tolerated with minimal fear.

Both Erikson²⁷ and Freud³¹ have identified infancy as the oral phase of development. Sucking is of primary importance to the infant, because it is the infant’s major source of gratification and tension release.

When an infant is hospitalized in a critical care unit, the potential for frustration is high. Illness disrupts many of the infant’s physiologic processes and normal routines and rhythms, such as eating, sleeping, and exercise. The infant is in an unfamiliar environment, with care provided by strangers who are not as sensitive as the parents were to the infant’s cues. The presence of an endotracheal tube or restraints can prevent the infant from sucking, eliminating a major source of gratification and comfort.

The infant’s affective experience is determined largely by the emotional reactions of significant caregivers. This social referencing can be seen, for example, in a situation in which an infant looks to the mother after a surprise event to determine by her reaction whether to laugh or cry. This example further indicates the important role that parents play in their infant’s life.⁴² Because the parents typically know the infant very well, they can to teach the nurse about the infant’s unique cues, needs, and responses; their presence during the infant’s hospitalization is essential to help meet the baby’s needs.

Although infants are unable to express their feelings and needs with language, they can indicate their need for more attention or stimulation in other ways.^76,93,99 Perhaps more important, they communicate when they are becoming overstimulated and need rest. It is crucial that nurses constantly assess the infant’s tolerance during planning and provision of nursing care. In older children, it may be useful to group procedures and then to allow longer periods of uninterrupted rest, but this approach may not be optimal for infants. Too much stimulation at one time can diminish the infant’s coping resources, resulting in adverse physiologic reactions such as vomiting, respiratory distress, apnea, or bradycardia. Gaze aversion is a behavioral cue of fatigue or overstimulation that nurses and parents sometimes miss.

Because the nurse was not sensitive to early indications that Jamie was becoming overstimulated and could not tolerate eye contact at that point in time, the stimulation continued and led to a more extreme response.

States of Consciousness in the Infant

The infant’s state of consciousness exerts a powerful influence on the infant’s response at any given time. Two sleep states (deep and light) and four awake states have been identified in full-term infants (drowsy, quiet alert, active alert, and crying).^10,14,89

During deep sleep the infant is motionless except for occasional startles or twitches. There are no eye or facial movements except for occasional sucking movements at regular intervals. The infant’s threshold to stimuli is high; only intense and disturbing stimuli will arouse infants in this state. Although it is possible to arouse the infant with gentle shaking or stimulation, usually the infant will return to sleep. Generally, the nurse will be frustrated in attempts to feed an infant in this state or to arouse the infant to an alert state. It is more effective to wait until the baby cycles to a more responsive state. It is important for the nurse to be aware that this deep sleep state exists normally. Although inability to arouse an infant can result from neurologic abnormalities, it requires strong stimuli to arouse infants from this normal deep sleep state.

Light sleep accounts for the highest proportion of an infant’s sleep. During this state, the infant may demonstrate some body movement, rapid eye movements (fluttering of eyes beneath closed eyelids), and irregular breathing. Infants are more responsive to stimuli and more easily aroused during this period.

During the drowsy state, the infant has a variable activity level, irregular breathing, and delayed response to sensory stimuli. The infant’s eyes appear heavy-lidded and have a dull, glazed appearance. Infants in this state can often be aroused to the more interactive quiet alert state by providing visual or auditory or oral stimulation. Such intervention can be helpful in facilitating parent-infant interaction in the critical care unit.

It is during the quiet-alert state that the infant can be the most interactive and provide the most positive feedback to parents or other caretakers. Infants in this state have wide, bright eyes, regular breathing, and minimal body activity. They are interested in their environment and focus attention on their caretakers, moving objects, or other stimuli. It can be gratifying and comforting for parents to be able to smile at and talk to the baby in this state.

Infants in a critical care unit may spend a large portion of their awake time in an active-alert state. This state is characterized by significant body activity with periods of fussiness. Breathing is irregular. The infant’s eyes are open but are not as bright as in the quiet alert state, and there is frequent facial movement. The infant can become sensitive to and upset by disturbing stimuli such as hunger, background noise in the critical care unit, and excessive handling. As the infant becomes more active and upset, intervention is often necessary to bring the infant to a lower (i.e., quiet-alert) state and avoid escalation to a crying state. Many critical care units have attempted to reduce excessive background noise and other auditory and visual stimulation.

Crying is one of the infant’s major methods of communication.¹⁰ Crying is associated with increased body activity, grimaces, wide-open or tightly closed eyes, and irregular breathing. Although the infant’s color can change to bright red, very sick patients or those with cyanotic heart disease may demonstrate peripheral or more generalized cyanosis. Infants may be able to bring themselves to a quieter state by instituting self-consoling behaviors such as sucking on their fingers, fist, or endotracheal tube or by paying attention to voices or faces nearby. However, ill infants often need consolation from their caregivers and are often unable to provide self-consoling maneuvers, or such maneuvers may be ineffective. The nurse should attempt soothing maneuvers such as changing the infant’s diaper, feeding the infant, moving close to the infant, making eye contact, or talking to the infant in a calm, soft voice. The infant may also be comforted if held closely, swaddled, or rocked with a pacifier. Infants frequently are highly upset when uncovered or wrapped loosely, but become calm and drowsy when they are swaddled. A combination of verbal and tactile stimuli, such as patting, stroking, holding, or rocking is generally more effective in alleviating distress in hospitalized infants than verbal stimuli alone. Rocking seems to bring comfort and build trust and may relax the parent or nurse as well as the patient.

Touch is extremely important to infants, who need to be caressed, stroked, cuddled, held, hugged, and loved to feel secure and develop normally, and detrimental long-term effects from lack of tactile stimulation during infancy have been documented.^92,99 Therapeutic touch is a potentially useful therapeutic modality to relax the patient and enhance recovery.^43,46 However, premature and severely stressed infants can exhibit negative responses to excessive handling and stimulation.⁹⁹ The nurse must identify a therapeutic balance between too much and too little handling for each infant and modify the nursing approach based on the infant’s cues (e.g., gaze aversion, respiratory effort).

Cognitive Development in the Infant

Cognitive or intellectual development in normal children has been observed and described in detail by the Swiss psychologist Jean Piaget, who identified five major phases in a child’s development of logical thought.^69,71,72 The nurse is more likely to communicate effectively with children by understanding these phases and the basis of the child’s perceptions, fears, and misunderstandings.

Piaget named the period of infancy and early toddlerhood, from birth to approximately 2 years, the sensorimotor phase. There are six stages in this phase of intellectual development. From birth to 1 month, the infant generally uses reflexes such as sucking, grasping, and crying. The infant is completely self-centered and cannot differentiate self from others. Infants in this stage show little or no tolerance for frustration or delayed gratification.

In the second stage, approximately 1 to 4 months, the use of reflexes is gradually replaced by voluntary activity. Infants begin to recognize familiar faces and objects such as a bottle, and they show awareness of strange surroundings. They begin to differentiate themselves from others and discover parts of their own bodies. Young infants delight in playing with their fingers, hands, and feet. These infants seem to believe that an object or person exists only while within their sight. If an object falls to the floor or is hidden, the infant immediately loses interest and will not search for it. If a person leaves the room or moves out of sight, the infant acts as if that person no longer exists. Infants in this stage show no anxiety around strangers and may become bored when left alone for more than a few minutes.

In sensorimotor stage three, approximately 4 to 8 months, causality, time, deliberate intention, and appreciation of separateness from the environment are beginning to develop. During this stage the infant begins to develop the concept of object permanence—that is, objects and people still exist even when they cannot be seen. The infant will search for partially hidden objects and will look for objects that have disappeared from view, realizing that parents are present even when they are not in sight. Once the infant develops object permanence, attachment to parents or primary caretakers is obvious and strong. The baby demonstrates stranger anxiety and will likely protest when the parents depart. In this stage, infants begin to be able to postpone gratification and await anticipated routines with eager expectation. The baby develops an association between objects and events. For example, an infant may cry in response to nursing interventions related to insertion of an intravenous catheter, but may not yet be able to take constructive action, such as withdrawal, to try to prevent the painful event.

During the fourth sensorimotor stage, approximately 9 to 12 months, the infant’s concept of object permanence develops further. The baby learns that hidden objects still exist, and that he or she can take action, such as retrieving an object from under a blanket, to make the object reappear. This is the beginning of intellectual reasoning. The infant begins to understand the meaning of some words and simple commands and begins to associate gestures with events. For example, waving means someone is leaving. The presence of the infant’s mother is extremely important to the infant’s sense of security, and the threat of her departure is met with protest. The infant is developing a sense of independence in feeding and locomotion and begins to venture away from the mother for short periods to explore the surroundings. The infant now responds when addressed by name and inhibits behavior when told “no.” By the end of this stage, the infant is jabbering expressively, verbalizing words that refer to the parents, and saying a few other simple words.

During this period the infant may adopt a favorite blanket, pillow, or stuffed animal as a transitional object¹⁰¹ that provides comfort and a sense of security during the parents’ absence. Absence of the transitional object, particularly during times of stress, will increase the infant’s anxiety. Thumb sucking, genital play, and transitional objects are all potential mechanisms of self-consolation when parents are absent. The last two stages in the sensorimotor phase are discussed in the section, Emotional and Psychosocial Development of Toddlers, in The Critically Ill Toddler part of this chapter, below.

The Infant in the Critical Care Environment

Young infants admitted to a critical care unit may be most affected by the strange environment and disruption of normal routines. The infant’s usual sleep-wake cycles are interrupted by procedures, lights, alarms, or other noxious stimuli. Providers often attempt to arouse the infant regardless of the infant’s sleep state. Ironically, the critical care unit may also produce sensory deprivation with a lack of meaningful stimulation. Some characteristics of a stress-enhancing intensive-care environment—one that adds to the demands placed on the ill infant or child—and those of a more growth-enhancing unit are shown in Box 2-1.

The nurse must maintain a soothing and reassuring environment. Providers should attempt to interrupt constant, rhythmic sounds (e.g., the whooshing of a ventilator or beeping of a cardiac monitor) by introducing more meaningful, varying sounds such as talking, humming, or singing to the infant or by playing soft, soothing music. Providers should be aware that noises such as loud laughing or talking at the nurses’ desk, loud music, music with a rapid beat or uninterrupted music can be highly disturbing. Infants and children who receive pharmacologic paralytic agents are hypersensitive to bright lights, loud music, and voices. Because they are not able to move, they may become extremely anxious.

The often stark, sterile environment of the critical care unit can be made more comforting by the use of natural lighting, colorful walls and curtains, and bright mobiles. Pictures, blankets, or toys from home can help make the environment more attractive. The infant’s parents can personalize the environment by mounting pictures of themselves or other family members on the crib in the infant’s line of sight to give the infant something to look at.

From approximately 6 months of age through the preschool period, separation anxiety is the infant’s major source of fear. Separation from parents is extremely stressful.^12,87 Because separation is so traumatic, it is helpful for a parent to stay with the hospitalized infant as much as possible. Most hospitals have facilities for parents to stay with young children. If it is not possible for a parent to remain with the child throughout the hospitalization, it is beneficial to maintain flexible visiting opportunities at all hours for parents.

Robertson⁷⁷ has identified three distinct phases in the crisis of separation: protest, despair, and denial. Although shorter length of stay and more liberal visiting hours have reduced the separation of children from parents during hospitalization, some aspects of this crisis of separation may still be observed. During the protest phase the child cries loudly and screams for the parents while visually searching for them. The infant will tightly cling to the parent if the parent shows signs of leaving. Attention from others is rejected and may even intensify the protest of a child who is experiencing stranger anxiety. The child may seem inconsolable, sometimes quieting only when exhausted. This anxiety, which can last from hours to days depending on the child’s energy and degree of illness, adds to the child’s stress in the critical care unit. It can be frustrating to care for the infant who is protesting, but the nursing staff should still attempt to provide comfort, with consoling gestures, conversation, and objects (such as a pacifier or transitional object). If the nurse takes the time to interact with the infant while the parent is present, that nurse may seem safe to the infant, and the infant may be more receptive to that nurse’s interactions. It can also be helpful to attempt to distract the infant with a colorful toy or musical mobile.

The second phase of the separation crisis is the phase of despair. In this phase the child continues the mourning process, but becomes more passive and withdrawn. The child seems disinterested in play, food, or the environment and looks lonely, apathetic, or even depressed. Some of the child’s activities during this phase may be thumb sucking, head banging, rocking, sitting quietly and sadly, or clutching objects. The child continues to watch for the parents’ return. When they do come, the child may ignore them or act angry, but will usually cling ferociously to them if they show signs of leaving again.

The last phase of the separation crisis is denial, or detachment. The child seems to have adjusted at last, appearing friendly and interested in the environment and other people. More receptive to strangers, the child accepts caretaking from many people. This phase may be interpreted by inexperienced staff as a positive sign that the child is adjusting and is no longer anxious. This behavior may not be a sign of contentment, however, but of resignation. The child detaches from the parent to escape the pain of separation and denies longing for the parent’s presence.⁷⁷ The child may react with indifference when the parent returns or may seem to prefer the nurse or another staff member.

If the parents do not understand the basis of the child’s distress, they can become extremely upset. They may restrict their time with the child in an attempt to minimize the child’s distress; however, this will only reinforce the child’s fears. It is important for the nurse to explain the child’s behavior to the parents and encourage them to spend as much time as they can with their child. The nurse should assure the parents that they are helping their child to cope effectively with the frightening environment in the critical care unit. By minimizing the parents’ distress, the nurse will be helping to maintain the child’s best support system.

Preparation of the Infant for Procedures and Surgery

Older infants react intensely to potentially painful situations (Box 2-2). They are uncooperative and may refuse to lie still, attempting to push the threatening person away or to escape. Distraction is not as effective as it is with younger infants. The best technique to decrease fear and resistance is to familiarize the older infant with some of the equipment beforehand (e.g., let the older infant play with a stethoscope), to perform the procedure as quickly as possible, and to maintain parent-child contact. Advance warning of a painful procedure is essential. Painful procedures should never be initiated while the child is asleep, unless the child is anesthetized.

The Infant and Play

Play is critical for development, providing an important opportunity for infants to learn about themselves and the world.⁴⁷ Six features differentiate play from other behaviors⁵³:

Three types of infant play have been described. The earliest type of play, appearing at a young age, is social-affective play. The infant interacts with people, imitating adult actions, such as coughing or sticking out his tongue. The second type is sense-pleasure play, during which the infant derives pleasure from objects in the environment such as lights and colors, tastes and odors, textures and consistencies. Body motion—such as rocking, swinging, or bouncing— and pleasant sounds also provide pleasurable experiences. Sensorimotor activity is the third category of infant play. Infants initially play with body parts, bringing hands and feet into their mouths; oral testing is an important means of exploration. Motor activity is highly enjoyable for infants, and they take great pleasure in kicking their feet and waving their arms. Between 7 and 10 months of age, infants are able to enjoy throwing things out of the crib onto the floor. This game seems to be an endless source of fun. At approximately 9 months old, infants show a newly developed sense of object permanence. Games such as peek-a-boo and toys that go away and come back, such as a jack-in-the-box, provide enjoyable ways for the infant to work through fears associated with separation anxiety.⁵³

Infants can become highly frustrated if their feet and arms are restrained, particularly if they are accustomed to being active. Restraints should be used in the critical care unit only when medically necessary. When restraints are necessary for safety, they should still allow the infant as much movement as possible.

Pediatric critical care nurses should be creative when facilitating the play of these very ill patients. Toys that are appropriate for the baby’s age should be available, and the nurse should encourage the parents to bring toys from home. The older infant may benefit from observing as the nurse plays with puppets or dolls or punches a balloon. This form of passive play can provide the infant with a pleasant distraction from discomfort and fear.

The Infant and Death

The infant’s reactions to fatal illness and dying will be based on the degree of discomfort involved and on the parents’ reactions. Emotional expression in an infant is at a primitive level that is directly linked to impulse and sensation.⁴⁴

Emotional empathy exists between parents and children; this enables special communication that makes the feelings of each transparent to the other. Parents serve as the frame of reference for the child, and parental attitudes and feelings are clearly transmitted, even when the child does not fully understand the words being used. If the parents are helped to cope with their anxiety, they will be more calm and supportive and can decrease the infant’s anxiety. Because separation from parents is the most stressful event that can happen, even highly anxious parents should not be kept away from their child; instead they should be supported to promote effective coping.

Emotional and Psychosocial Development of Toddlers

The major developmental task for toddlers is beginning the development of autonomy and self-control,²⁷ so toddlers typically become more independent as the months pass. They can be a bountiful source of enjoyment and satisfaction as they take delight in exploring and discovering new things. They are often liberal with expressions of affection such as engaging smiles, hugs, and kisses. However, the reputation of this period as the “terrible twos” is well deserved, and caregivers must have a great deal of patience and understanding.

This is the “no” stage, and toddlers often adamantly state this newly learned word even when the toddler may want to say “yes”—a concept not learned until later. Parents and caregivers see resistive behavior as the toddler struggles to assert independence and gain control of the environment. Frequent temper tantrums can result from the toddler’s low frustration tolerance and need to test the limits of acceptable behavior. Dawdling behavior is common, particularly at mealtimes.

The toddler is extremely attached to and dependent on the parents. Parents represent safety and security. The toddler is typically more aware of separation from the mother and seeks more attention and greater closeness to her. The child forms relationships with the parents, rather than simply requiring their presence. Although a toddler can tolerate some physical distance from a parent and ventures away to explore and play, the toddler needs to find the parent or call to the parent at short intervals. Separation from the parents for prolonged or unexpected periods is difficult, especially when other stresses are present. Older toddlers are more able to accept symbols, such as a parent’s keys, as an indication that the parent will return. The toddler also may be more able to accept care and consolation from another caregiver if given an opportunity to become familiar with that caregiver over a period of time, particularly if the toddler sees that the caregiver has the parents’ approval.

Freud refers to the toddler years as the anal stage, because elimination and retention are important skills developed during this period.³¹ Toilet training begins during these years. Because bowel and bladder control are newly acquired skills, they may be lost when the toddler is stressed. Toddlers who have been toilet trained find it distressing to be placed in diapers. They also may find it confusing and anxiety-provoking to be told that it is acceptable to wet in their diaper or go to the bathroom in their bed after being told the opposite so frequently during toilet training. Toddlers require sensitivity and reassurance from parents and staff to help them feel less anxious. If possible, the child should be allowed to use a bedside potty chair.

Cognitive Development of the Toddler

The toddler makes massive strides in intellectual development, beginning to think and reason, although in a way that is different from adult cognition. During Piaget’s fifth sensorimotor stage of intellectual development, from approximately 13 to 18 months, the toddler further differentiates the self from other objects and will search for an object where it was last seen.⁶⁹ Early traces of memory also begin to develop during this period.

The child in this stage is beginning to be aware of causal relationships and can understand that flipping one switch will cause a machine to make noise, and flipping another switch may turn on a light. However, the child is not able to transfer that knowledge to new situations; for example, may not be aware that turning a switch of another machine may cause it to make noise. The toddler must continuously examine the same object every time it appears in a new place or under changed conditions. For this reason the toddler is likely to want to examine each stethoscope brought to the bedside by a different person.

During the final stage of the sensorimotor period, from approximately 19 to 24 months, egocentric and magical thinking begin. Toddlers view themselves as the center of the universe and can appreciate no point of view but their own. As toddlers become aware of their thoughts, they believe that others must also be aware of them and that events happen because of their activity, thoughts, and wishes. For example, they may think that their parents went away or hospitalization occurred because they misbehaved.

The toddler is extremely ritualistic and takes comfort from consistency of environment and daily activities. The global organization of thought that is characteristic of this period causes the child to recognize experiences or events as parts of a whole. As a result, if even small changes in the environment or schedule are made, the child may require time for readjustment.

The toddler is beginning to develop a sense of time and understands some temporal terms and relationships, such as “in a minute” or “after lunch,” although specific time intervals, such as “3   hours” are meaningless. The toddler’s attention span, which is limited, is characterized by a sense of immediacy and concern for the present. Language abilities increase and the toddler can understand simple directions or requests.

From approximately 2 to 4 years of age, children demonstrate the preoperational or preconceptual phase of cognitive development. Vocabulary and language development markedly increase during this period. Magical thinking and egocentricity are still prevalent during this phase, giving the child feelings of omnipotence and supreme authority. This ideation also causes the child to feel guilty, assuming that bad thoughts are responsible for events. The child’s inability to reason the cause and effect of illness or injuries makes these events especially stressful.

The toddler will begin to demonstrate animism, a process in which lifelike qualities are attributed to inanimate objects. For example, the child may blame a glass of milk for falling or believe that an x-ray machine or elevator is a monster.

Toddlers do not use deductive reasoning (from the general to the particular) or inductive reasoning (from the particular to the general); instead they reason transductively (from the particular to the particular). Children frequently will believe that there is a causal relationship between any two events that occur at the same time or are contiguous to each other in time and space. For example, the color of a balloon can explain why it is floating, or the need for sleep makes it dark outside.

The Toddler in the Critical Care Environment

Toddlers can become terrified in a critical care unit. They are in a new place where they see, hear, smell, and feel frightening things. There are many strangers around who sometimes do scary and painful things, and the toddler is unable to freely move about. Gone is the security of familiar surroundings and routines. The toddler may be separated from parents, and may be uncomfortable or in pain. As a result of egocentric thinking, toddlers may think their bad behavior caused their illness or hospitalization. Because most of the direct contacts in the PCCU are intrusive instead of comforting, interactions with staff can create fear.

Parental presence and support are more crucial than ever to the toddler during this period. When a parent is not present, a toddler may believe that punishment through abandonment is occurring. The toddler is terrified of complete desertion, and fears that the parent is angry; therefore, cries of “I want my mommy; I be good!” may be heard. The toddler can exhibit the same three stages of protest, despair, and denial that the infant does, but is able to be more verbal and assertive in protest.⁷⁷ Toddlers may call for their parents and may verbally reject consolation and care from others. Physical aggression, hostility, fighting, kicking, hitting, pinching, and biting may be displayed during this period. If nurses are not familiar with a child’s particular rituals for comfort, provision of different comfort measures can add to the child’s confusion and distress.

The best way to minimize the toddler’s anxiety is to minimize separation from the parents. During the toddler years, perhaps more than any other, every effort should be made to arrange for one parent or another familiar adult to stay with the child as much as possible. It is important for the nurse to convey to the parents that they are welcome in the unit to provide necessary support for their child. The PCCU is no place for restrictive visiting hours that might benefit the staff but add to the anxiety of the child or parents.

Rooming-in or frequent regular visiting by the parent decreases the possibility that the child will enter the despair phase of separation crisis. Children who progress to the despair state may become listless, anorexic, uncommunicative, and withdrawn. Regression to an earlier stage of development usually is demonstrated as loss of sphincter control, reduced verbal communication, or passivity. When the parent returns, the toddler often cries or expresses anger, distrust, or rejection. If the parent attempts to depart again, however, the child may cling tightly, crying and begging the parent to remain. If toddlers progress to denial, they can appear to be more accepting and interactive, but might actually be more disturbed.

It is helpful when a small number of nurses consistently care for the hospitalized toddler, to minimize the variety of schedules and personalities to which the child must adapt. In addition, the child who has the opportunity to build trust in a few nurses may be able to take comfort from them when a parent is not present.

Physical restraint or restriction, altered routines and rituals, and enforced dependency represent a loss of bodily control to the toddler who is striving for more autonomy. This loss can make the toddler frightened and resistant. By allowing toddlers as much movement and independence as possible, the nurse can increase their cooperation and decrease their fears and frustrations. The toddler often can be allowed to sit upright or remain on a parent’s lap during frightening procedures. Less physical restraint may be required if the child is given the opportunity to handle the equipment being used. For example, toddlers often enjoy listening to their chest (or to that of a toy or another person) with the stethoscope. When physical restraint is necessary, lost activity should be replaced with another form of activity whenever possible.

Loss of familiar rituals and routines decreases the toddler’s the sense of control, predictability, and security.

If the toddler’s mother or nurse can continue some home routines in the hospital, it will help the toddler’s sense of familiarity and security. Routines and rituals that are most important to the toddler must be recorded as part of the child’s history and incorporated into the plan of care, when possible.

All children need limits to feel secure and may be more frightened without them. This is particularly true of toddlers who have not yet mastered a great deal of control over their own impulses. They need to feel that there is someone close who will protect them from injuring themselves, others, or their environment. Setting limits can help children channel strong feelings into safe, socially acceptable, pleasurable activities. To prevent children from hurting themselves, others, or property, they should be restrained temporarily or removed from the situation with an explanation of why they cannot continue the behavior. Adults should acknowledge the child’s feelings and then direct the youngster into acceptable behavior for dealing with these strong emotions.

The immature thought processes of toddlers can contribute to their anxiety. Egocentricity, magical thinking, transductive logic, and animism can magnify fears of known events and make unknown or unfamiliar situations terrifying. Sinister characteristics may be attributed to machines and hospital personnel. Toddlers, thinking that their misbehavior caused their illness, might not understand their parents’ inability or unwillingness to rescue them. Toddlers need frequent reassurance that they are not bad, are not being punished, are loved, will get better (if true), and will be able to walk and talk and go home again. The toddler might not understand the concept of returning home, but will be comforted by gentle reassurance.

Preparation of the Toddler for Procedures and Surgery

Any real or perceived painful experience will be met with extreme emotional distress and physical resistance. Because toddlers have a poorly defined concept of body integrity, any intrusive procedures—even painless ones such as measuring body temperature or examining of the ears—can provoke an intense reaction. Toddlers can understand only very simple explanations. Prolonged or detailed explanations or explanations given too far in advance may create more anxiety (see Box 2-2, earlier in chapter). When it is necessary to perform painful procedures, lengthy discussions or provisions of choices are best avoided. It is best to provide a brief explanation, assure the child that you will be there, perform the procedure as quickly as possible, and then comfort the child. Offer choices when you are able to do so.

The Toddler and Play

Most of the toddler’s time is normally spent in some type of play activity. Play is a major component in learning about the world, communicating feelings, overcoming boredom, developing motor skills and independence, and working through anxieties.²³ The toddler’s need for play continues during periods of illness. Through play the toddler can find a constructive, acceptable outlet for fears, frustrations, anxieties, and anger. Familiar toys can be comforting and provide a sense of security. Play can serve as a diversion from pain and fear and can become a replacement for mobility. It also can provide some feeling of autonomy and independence by providing control over something.¹¹

Play might have to be passive when the child is critically ill; creativity is needed to find activities that are meaningful and provide positive sensory stimulation. Bright, colorful mobiles, posters, stuffed animals, and toys can provide visual stimulation. Musical mobiles, CDs, talking story books, radios, tape recordings made by the child’s parents or other family members, and visits from the music therapist can help substitute pleasant and meaningful sounds for hospital noises. Favorite television shows or movies can help bring a sense of familiarity into the critical care unit. A book of fabrics and other materials with various textures can be stimulating for the child. Any of these activities will be especially comforting when initiated by the child’s parents.

When the toddler is recovering, more active play can be introduced. Hammering or pounding boards, punching balloons, water play, and active toys such as a “busy box” are all meaningful outlets for toddlers who are immobilized or confined to bed rest. Peek-a-boo is still enjoyed at this age and reinforces the toddler’s learning that things and people go away but come back. The child may also enjoy “talking” puppets or dolls or listening to tapes of books read by parents or siblings.

The Toddler and Death

The toddler’s egocentrism, lack of a concept of infinite time, and inability to distinguish between fact and fantasy prevent comprehension of the absence of life and the permanence of death. The toddler is developing cognitive concepts of consistency and permanence, and presence and absence, and does so through games such as hide and seek and peek-a-boo. Although toddlers can repeat what sounds like a definition of death, such as “people who die go to heaven,” they are unable to comprehend what this means. Death may mean separation from the love objects and people the toddler needs and depends on.⁹ The most frightening aspects of hospitalization for the toddler usually include pain, anxiety, and separation from parents, but they do not include anxiety about death. Rather than fear of death, the dying toddler will respond to comforting support offered by the parents and will also respond with fear or sadness to the anxiety, sadness, depression, or anger expressed by parents.

Emotional and Psychosocial Development of the Preschooler

The preschooler, at 3 to 5 years old, has come a long way in the development of motor, verbal, and social skills. This is a time of enthusiastic and energetic learning and exploration. The chief developmental task of the preschooler is creating a sense of initiative.²⁷ Tolerance of frustration is still limited, but is better developed. Guilt feelings result when the child is not able to live up to the child’s own or other’s expectations of appropriate behavior. The preschooler’s conscience is fairly primitive, is likely to be overzealous and uncompromising, and can be unnecessarily cruel.^27,30 Thoughts about “being bad” or wishing for “bad things” to happen to other people can also lead to feelings of guilt and anxiety. Painful treatments, isolation, separation from parents, loss of autonomy, and immobilization are likely to be interpreted as deserved punishments for real or imagined wrongdoing.

During the preschool years, the child begins the process of sex-role identification. Freud has termed this period the phallic stage.³¹ Initially, in the oedipal phase, the child is drawn to the parent of the opposite sex. Late in the preschool period, the child begins to strongly identify with and seeks to imitate the parent of the same sex. It is during this time that children discover that boys and men have penises and girls and women do not. For some children, seeing another child naked in the critical care unit (however briefly) may be the child’s first experience with this discovery. During this period, boys have a fear of castration as punishment for real or imagined misdeeds. Urinary catheterization or other procedures near the genital area may cause a great deal of anxiety, provoking frantic resistance. It is important to provide careful explanation of exactly what will and will not happen during such procedures in order to decrease the child’s fear and increase cooperation. In addition, protecting modesty by keeping the genital area covered and asking permission to look, listen, and touch conveys respect for the child.⁷³

The development of the superego or conscience is also a major task for the preschooler. The child begins to learn right from wrong and good from bad. Although preschoolers cannot comprehend all of the reasons why something is acceptable or not acceptable, they learn appropriate behavior through reward and punishment and from examples set by parents or other adults. Preschoolers are more aware of danger and will usually obey simple limits or rules that have been explained to them.

The preschooler is generally able to tolerate brief separations from the parents if given explanations of where the parents will be and when they will return. The preschooler is also less frightened and more trusting of strangers and thus is often able to relate well to unfamiliar people. Serious illness is likely to cause regression in the preschooler, however, and the need for parents may once again become very strong. The preschooler can manifest some or all of the stages of separation anxiety experienced by the infant and toddler, but the older child’s protest behaviors are usually more passive and subtle than those of the infant or toddler. The preschool child may ask parents repeatedly when they will return, cry for them, refuse to eat, demonstrate sleeplessness, throw things, break toys, or refuse to cooperate in activities or care. The critical care staff must be alert to these signs and reassure the child regarding the parents’ return, providing other comforts and interventions as necessary.