Piaget identifies this first stage as characterised by the links formed between the infant and the environment as the infant comes to understand the relationship between actions, sensation and movement. Piaget divided the stage into six subsections (for more detail see Piaget & Inhelder 1969 pp 4–12). These stages characterise the infant’s development from being primarily reflexive/reactive (stage 1) through processes of trial and error, experiment and reinforcement (stages 2–5), to finally being able to actively understand and manipulate aspects of his or her world (stage 6). In other words, the infant has a gradually increasing awareness of the relationship between action and effect.

Piaget saw a key concept within this stage as something he called ‘object permanence’. This means that for the younger infant ‘out of sight’ is also ‘out of mind’. In contrast, older infants (Piaget argued from around 8 months) realise that an object exists even when it cannot be seen. Also, throughout this first stage the child is described as egocentric, i.e. ‘the child’s initial universe is entirely centred on his [sic] own body’ (Piaget & Inhelder 1969 p 13).

Piaget viewed the next two stages as a vital period of transition. At the beginning of this second stage, Piaget argued that the child’s behaviour is characterised by actions; by its end the child will have reached the level of operations, summarised by Santrock (1999 p 203) as ‘internalised sets of actions that allow the child to do mentally what was done physically before’. Piaget regarded achieving this as of pivotal importance and saw the preoperational period as dominated by organisation and preparation towards becoming ‘operational’ (Piaget & Inhelder 1969 p 96). Consequently, the stage tends to be characterised negatively, by what children are not yet able to do, rather than what they can. Examples include their perceived inability to classify objects into groups, to think logically and to engage in moral reasoning. A key skill not yet achieved is that of conservation, i.e. the ability to realise that something might ‘stay the same’ despite a change in appearance. For example, a preoperational child would think the amount of juice in a short, fat glass becomes ‘more’ when poured into a tall, thin glass (see also Channel 4 Television, 2001 and Santrock, 2009).

Also within this stage is a continued focus on the child’s egocentricity, characterised particularly by the inability to be able to see the world from another’s point of view or to distinguish another’s point of view from their own (both visually and intellectually). Closely linked to this is Piaget’s belief that these children could not conceptualise a world beyond their direct experience, i.e. what he or she had actually seen or experienced. Practically applied, it can be seen how such beliefs can limit perceptions of the preoperational child’s abilities in a whole variety of conceptual domains. Piaget also noted that these children display animism, the attribution of ‘life’ to non-live objects.

Piaget saw this stage as characterised by children becoming ‘operational’, and thus being able to do many of the activities that they were working towards in the preoperational stage. He argued that operational children are capable of logical, systematic thought, and able to ‘conserve’ concepts such as number, mass, length, weight and volume. They are also able to classify and seriate objects/items, and to understand logical relationships between them. However, Piaget felt at this ‘concrete’ stage that children could only understand problems related to direct experience; they are not seen as capable of abstract or hypothetical thought, or the manipulation of variables.

Piaget used the term ‘propositional operations’ to describe this final stage. He regarded these skills as congruent with preparation for adolescence, with the child able to think in abstract terms and capable of ‘the handling of hypotheses and reasoning with regard to propositions removed from concrete and present operation’ (Piaget & Inhelder 1969 p 131). Thus young people are able systematically to explore the solutions to an abstract or hypothetical problem, including everything from algebra to decisions concerning their future! An important extension of this is described as ‘reflective abstraction’ – self-awareness in relation to one’s own strategies and thoughts.

These four stages are the centre-piece of Piaget’s theories of childhood but many other important concepts also exist within his works. Those with particular relevance for child health practitioners can be summarised as follows:

(See also Bee and Boyd, 2008, Santrock, 2009 and Taylor et al., 1999)

Within Piaget’s theories three additional key concepts underpin a child’s emergent understanding of the world (derived from Meadows 2006, Piaget, 1929, Piaget, 1930, Piaget and Inhelder, 1969, Santrock, 2009 and Vacik et al., 2001):

To illustrate these somewhat abstract concepts, it might be helpful to consider an example. Imagine for a moment the child seeing a picture of a zebra for the first time.

Piagetian theories influenced the delivery of child health care throughout much of the latter half of the 20th century and many of his views continue to be profoundly influential. For example, in the care of infants, Piaget’s theory of ‘object permanence’ suggests that under about 8 months a child does not realise an object still exists when it cannot be seen, a theory applied not only to inanimate objects but also to people. Thus it has been argued in some centres that younger infants will not be unduly distressed when separated from their parents. So although unrestricted parental visiting is now more or less universally accepted within child health care, the parents of infants continue to be excluded in some care settings from anaesthetic rooms, recovery rooms and a variety of other procedures, on the grounds that this age group of children won’t be unduly distressed by parental absence.

For the ‘pre-operational’ child, assumptions are often made about what the child is or is not able to understand about an illness, procedure or investigation. A Piagetian perspective would assume that children under the age of about seven were incapable of conceptualising their internal anatomy, and thus suggests that it may be pointless to attempt any realistic explanation of an internal procedure. As will be discussed in detail later, such guidelines were heavily influential during the 1970s and 1980s. A Piagetian stance would also contend that other misconceptions are inevitable and cannot be overcome until a child reaches a certain point of maturation. Examples include ‘immanent justice’ (Santrock 2009), which is the belief that pain or injury is a punishment, and ‘overgeneralising contagion’, e.g. believing cancer is ‘catching’.

Even as the child becomes ‘operational’, assumptions continue to be made. As Piaget asserts that the concrete operational child cannot hypothesise, look meaningfully into the future or make decisions based on abstract concepts, it is often suggested that, until mid to late adolescence, a child cannot make an informed decision about what might be in his or her ‘best interests’. Such beliefs have historically limited children being offered any meaningful involvement in decisions regarding their care – a situation which continues to exist in some care settings even today.

Thus it can be seen how important it is to gain an accurate picture of the extent to which Piaget’s beliefs represent ‘truth’. If there are doubts about some aspects of his theory, then such doubts must inevitably be extended to the application of Piagetian principles to care delivery. It is therefore important both to review the literature that takes a more critical view of Piaget’s work and also to consider different theoretical perspectives that might offer alternative tools to guide contemporary practice.

The 1970s and 1980s were characterised by a series of challenges to Piaget’s perspective on child development, with a whole range of authors suggesting that Piagetian theory unreasonably limited our beliefs in children’s abilities and that, in reality, children were capable of far more than Piaget gave them credit for.

In respect of the preoperational child, various studies have demonstrated the ability of young infants to visually recognise their parents and distinguish them from strangers (see Taylor et al 1999 pp 25–26). Similarly, Santrock, 1999 and Santrock, 2009 and Bee & Boyd (2008) describe studies where infants demonstrate learning at just a few weeks old, far younger than Piaget would have accepted that these infants could proactively manipulate their environment. In one example, Santrock (1999 p 153) cites the work of Rovee-Colyer (1987), who took infants at just a few months old and tied their foot to a ribbon that moved a mobile. Weeks later, when placed under the mobile, the infants will once again kick in an attempt to move the mobile, despite no ribbon being in place.

Similar critiques of Piagetian theory are found in respect of the preoperational child. For example, in his study of egocentricity, Piaget devised a test known as the ‘three mountains experiment’ (Piaget & Inhelder 1956). The child was shown a three-dimensional model of three differently coloured mountains, positioned so that clearly different views of the mountains were visible from each of the four sides of the model (see Piaget & Inhelder 1969 or Santrock 1999 p 205 for more detail). The child was given a series of four two-dimensional drawings representing the view from each side of the model, and asked to ‘work out’ which drawing represented the view of a doll positioned on the opposite side of the model to the child. The fact that most children aged under 7 were unable to do this was central to Piaget’s persistent belief in their egocentricity; their inability to see the world from another’s point of view.

Yet in contrast, Donaldson (1978), one of Piaget’s foremost critics, constructed another experiment where children were far more successful, using an intersection of two walls in a ‘cross shape’ (see Donaldson 1978 pp 21–22 or Taylor et al 1999 p 58 for more detail). Two policeman models were positioned in such a way that they could see behind most of the walls but not all. In this study, children who got the three-mountain test wrong were frequently able to position a naughty doll so that the policemen were unable to see her; clearly they had to understand what the world looked like from the policemen’s perspective to do this. Perhaps the key difference, Donaldson suggests, is that this experiment ‘made sense’ to the child and so was more readily understood. Clearly if children below 7 years are able to see another’s point of view there are major implications for beliefs regarding their egocentricity.

In another of her critiques of Piaget’s work, Donaldson also challenged some of his conservation experiments. For example, Piaget had conducted a study where children are asked to view two identical rows of sweets and say whether the rows are the same. The experimenter then repositions the sweets in one row so they are further apart, but leaves the same number. When re-questioned in Piaget’s study, many children under seven insisted the row where the sweets have been moved now contained ‘more’. Yet when Donaldson (1978) replicated the study using a ‘naughty teddy’ to move the sweets, significantly fewer children got the answer wrong than in a control group where, like in Piaget’s original study, the researcher moved the sweets. Donaldson argued this was because the answer ‘still being the same’ now ‘made sense’, unlike the Piagetian version in which many children assumed the answer must now be different. Indeed, central to Donaldson’s (1978) theories about Piaget was a recurrent theme that his experiments were designed in such a way that the children were often set up to fail, and that as a consequence children’s abilities at a given age/stage were at significant risk of being underestimated.

For the concrete operational child, again, numerous studies challenge Piaget’s perspectives. One particular study with clear healthcare implications is by Alderson (1993). She interviewed 120 children, many of whom fell into Piaget’s concrete operational age group, and demonstrated the ability of several of these children to make carefully considered and informed choices about non-essential surgery.

It is beyond the scope of this chapter to illuminate the dozens of similar examples of experiments that call into question many of Piaget’s findings (see Bee and Boyd, 2008, Berger, 2008, Berk, 2006 and Berk, 2008, Donaldson, 1978 and Santrock, 2009 for more details). It is important to stress, however, that it is not Piaget’s fundamental assertions about the systematic way in which children develop cognitively that are necessarily being challenged; his model continues to offer extremely valuable insight into the sequential ways in which children develop. Rather it is the nativist domination in his theories that has become the key focus of his critics, i.e. the:

However, if these critiques of Piaget’s work cast doubt on his theories in this way, then there are also inevitably important implications for many of the traditional applications of his theory to care delivery. Thus it may no longer be safe to assume that a 4-month-old baby can go for surgery alone and not be adversely affected by parental separation before he or she is asleep. Similarly, it might be unsafe to assume that a 4-year-old cannot understand an explanation of his or her heart surgery, or that a 9-year-old is unable to contribute meaningfully to a decision to undergo leg lengthening. It is therefore vital that such assumptions are carefully considered in light of the research that casts doubt on aspects of Piagetian theory, and also in the light of the views of alternative theorists, who may offer a more positive interpretation of younger children’s cognitive development.

The significance of Vygotsky’s perspective in contrast to Piaget’s is considerable because it offers the possibility of enhancing and accelerating the child’s development by teaching. Unlike Carey, Vygotsky felt there were maturational limits on how far a child’s understanding could develop at a given point in time. However, although these limits are in many ways congruent with the stages Piaget describes, in Vygotsky’s theories the child can achieve understanding at a far earlier age than Piaget would suggest. Thus Vygotsky’s theory offers teachers and health practitioners the possibility of considerably enhancing children’s understanding through education.

Thus if a Vygotskian perspective rather than a Piagetian perspective influences our healthcare practice, the key difference is that a child’s developmental potential is not persistently viewed in negative terms but rather in positive ones. Piagetian ‘tools to guide practice’ are framed in terms of what children are unable to understand (e.g. Taylor et al 1999 p 64). By contrast, a Vygotskian perspective encourages the practitioner to find out what the child already knows and then to use this as a basis for working with the child and family to help the child to reach an enhanced level of understanding (Gaffney, 2000, Holaday et al., 1994 and Rushforth, 1999).

Vygotsky’s work was further developed by Bruner (1972), who used the analogous term ‘scaffolding’ to describe the role of teachers (both professionals and parents) within the ‘zone of proximal development’. Bruner saw this human scaffolding as a ‘supportive mechanism’, which was gradually withdrawn as the child strengthens in his or her own knowledge and understanding. Bruner believed that any topic could be meaningfully conveyed at some level to any child, provided it was appropriately individualised and congruent with what the child already knew and understood.