AGE	PHYSICAL	GROSS-MOTOR	FINE-MOTOR	VOCALIZATION	SOCIALIZATION
3 years	Usual weight gain of 1.8 to 2.7 kg (4 to 6 pounds) Average weight of 14.6 kg (32 pounds) Usual gain in height of 7.5 cm (3 inches) Average height of 95 cm (37.25 inches) May have achieved night-time control of bowel and bladder	Rides tricycle Jumps off bottom step Stands on one foot for a few seconds Goes up stairs using alternate feet; may come down using both feet on step Broad jumps May try to dance; balance may not be adequate	Builds tower of 9 to 10 cubes Adeptly places small pellets in narrow- necked bottle Copies a circle, imitates a cross, names what has been drawn; cannot draw a stick figure but may make circle with facial features	Has vocabulary of approximately 900 words Uses complete sentences of 3 to 4 words Repeats sentence of 6 syllables Asks many questions Begins to sing songs	Dresses self almost completely Has increased attention span Feeds self completely; can prepare simple meals, such as cold cereal and milk Can help to set table May have fears (of dark or going to bed) Knows own gender and gender of others Play is parallel and associative; begins to learn simple games but often follows own rules; begins to share
4 years	Growth rate is similar to that of previous year Average weight of 16.7 kg (36.75 pounds) Average height of 103 cm (40.5 inches) Length at birth is doubled Maximum potential for development of amblyopia	Skips and hops on one foot Catches ball; throws ball overhand Walks down stairs using alternate footing	Uses scissors successfully Can lace shoes Copies a square, traces a cross and diamond, adds 3 parts to stick figure	Has vocabulary of 1500 words or more Uses sentences of 4 to 5 words Questioning is at peak Tells exaggerated stories Knows simple songs May be mildly profane if associates with older children Names one or more colors	Very independent Tends to be selfish and impatient Aggressive physically and verbally Takes pride in accomplishments Has mood swings Shows off dramatically, enjoys entertaining others Still has many fears Play is associative; imaginary playmates are common Sexual exploration and curiosity shown through play, such as being “doctor” or “nurse”
5 years	Average weight of 18.7 kg (41.25 pounds) Average height of 110 cm (43.25 inches) Eruption of permanent dentition may begin Handedness is established (approximately 90% are right-handed)	Skips and hops on alternate feet Throws and catches ball well Jumps rope Skates with good balance Walks backward with heel to toe Jumps from height of 12 inches Balances on alternate feet with eyes closed	Ties shoelaces Uses scissors, simple tools, and pencil well Copies a diamond and triangle; adds 7 to 9 parts to stick figure; prints a few letters, numbers, or words, such as first name	Has vocabulary of approximately 2100 words Uses sentences of 6 to 8 words Names coins Names 4 or more colors Knows names of days of week, months, and other time- associated words	Less rebellious and quarrelsome More settled and eager to get down to business Independent but trustworthy; not foolhardy; more responsible Has fewer fears; relies on outer authority to control world Eager to do things right and to please; tries to “live by the rules”; has better manners Cares for self with only occasional assistance Play is associative; tries to follow rules but may cheat to avoid losing

Modified from Hockenberry, M., and Wilson, D. (2007). Wong’s nursing care of infants and children (8th ed.). St. Louis: Mosby.

Preschool children have good control of their muscles and participate in vigorous play activities. As each year passes, they become more adept at using old skills. They can swing and jump higher. Their gait resembles that of an adult. They are quicker, and compared with toddlers, they have more confidence in themselves. Although preschool children may seem more or less quiet and steady with respect to physical development, certain difficulties do arise from an increase in independence, social participation, interaction, and cognitive ability.

Theories of Development

The thinking of the preschool child is unique. Piaget called this period the preoperational phase. This phase comprises the ages of 2 to 7 years and is divided into two stages: the preconceptual stage, from 2 to 4 years; and the intuitive thought stage, from 4 to 7 years. The increasing development of language and symbolic functioning is important in the preconceptual stage. Symbolic functioning can be seen when children play and pretend that an empty box is a fort; this creates a mental image, which stands for something that is not there.

Preoperational thinking also implies that children cannot think in terms of operations, or the ability to logically manipulate objects in relation to each other. They base their reasoning on what they see and hear. They also believe they have magical powers that can cause events to occur. For example, a child might wish that someone or something would die. If the death does occur, the child feels at fault because of the “bad” thought that made it happen.

Another characteristic of this period is egocentrism, a type of thinking in which children have difficulty seeing any point of view other than their own. Children’s knowledge and understanding are restricted to their own limited experiences, and, as a result, misconceptions arise. One of these misconceptions is animism. This is a tendency to attribute life to inanimate objects. Another is artificialism, the idea that the world and everything in it is created by human beings (Table 8-2).

Table 8-2

The Nature of Early Childhood Thought

SAMPLE QUESTION	TYPICAL ANSWER
Ecocentrism
Why does the sun shine?	To keep me warm.
Why is there snow?	For me to play in.
Why is grass green?	Because that is my favorite color.
What are television sets for?	To watch my favorite shows and cartoons.
Animism
Why do trees have leaves?	To keep them warm.
Why do stars twinkle?	Because they are happy and cheerful.
Why does the sun move in the sky?	To follow children and hear what they say.
Where do boats go at night?	They sleep like we do.
Artificialism
What causes rain?	Someone emptying a watering can.
Why is the sky blue?	It has been painted.
What is the wind?	A man blowing.
What causes thunder?	A man grumbling.

From Helms, D., and Turner, J. (1978). Exploring child behavior: basic principles (p. 447). Philadelphia: Saunders, with permission.

Evolving from preconceptual thinking to intuitive thinking involves a shift from egocentric thought to a social awareness and ability to consider another’s point of view. This is considered to be closely associated with superego or conscience development.

Another distinctive characteristic of intuitive thinking is centering, the tendency to concentrate on a single outstanding characteristic of an object while excluding its other features. With time and experience, more mature conceptual awareness is established. The process is highly complex, and the implications for practical application are numerous. In addition, through intuitive thinking, play becomes more socialized and words are used to express ideas and thoughts.

According to Erik Erikson’s theories, preschoolers acquire a sense of initiative. They believe learning is fun and try new activities and experiences. Conflict arises when initiative is criticized or punished; then they develop a sense of guilt. This guilt can carry over later in life and affect their ability to make decisions or solve problems.

It is important to provide preschoolers exposure to a wide variety of experiences and play materials to enhance their learning. They need to be allowed to play with finger paints, build sand castles, play with clay, and engage in activities that enhance their imaginations.

Preschoolers enjoy dressing up and pretending to be real and make-believe characters (Figure 8-1). They love to imitate people around them and often mimic what they see their parents doing. Playing “store” or “office” or doing household chores such as “lawn mowing” or “doing the dishes” are activities that preschoolers enjoy. Toy companies manufacture many toys that encourage the preschooler to engage in this domestic mimicry.

FIGURE 8-1 The preschooler has a vivid imagination and enjoys playing “dress-up.”

Lawrence Kohlberg emphasized moral development and moral judgment. Preschoolers are at a preconceptual stage of moral development. Young children learn whether an action is good or bad depending on whether the action is rewarded or punished. Preschool children progress to a stage where they can carry out actions to satisfy their own needs but not society’s in general. They do something for another if that person does something for them.

Children at this age are just beginning to learn right from wrong. Spiritual development is strongly linked to development of the conscience (Hockenberry and Wilson, 2007). The preschooler is just beginning to understand spiritual matters. Rudimentary knowledge is provided by parents or significant others. Their concrete thinking allows them to perceive God as an imaginary friend. Children this age enjoy hearing Bible stories and reciting simple prayers. If hospitalized, saying prayers as part of their routine can actually help with the stressors of hospitalization.

Sigmund Freud developed a psychosexual theory with the concept that sexual energy is focused on certain body parts at certain ages. He felt that unmet needs in stages of development could cause later conflicts. While there is criticism of his theory, it does explore emotional development and has provided the basis for other theorists such as Erikson. Freud felt that during the preschool age, the child’s focus is on the genital area. The child also is working out emotional relationships with the parent, which is the foundation for the child learning to relate to the opposite sex.

Physical, Psychosocial, and Cognitive Development

The 3-Year-Old

Most 3-year-olds are a delight to their parents. They are helpful and can participate in simple household chores. They obtain articles on request and return them to the proper place. Three-year-olds come very close to the ideal picture that parents have in mind of their child. They are living proof that their parents’ guidance during the “terrible twos” has been rewarded. Temper tantrums are less frequent, and, in general, the 3-year-old is a pretty good youngster. Of course, they are still their individual selves, but they seem to be able to direct and control their primitive instincts better than before. They can help dress and undress themselves, use the toilet, and wash their hands. They eat independently, and their table manners have improved.

The 3-year-old talks in longer sentences and can express thoughts such as “What are you doing?” or “Where is Daddy?” They also provide more company to their parents because they can verbally share their experiences with them. They are imaginative, talk to their toys, and imitate what they see about them. Soon they begin to make friends outside the immediate family. They can now converse with playmates and find satisfaction in joining with their activities. Three-year-olds do not play cooperatively for long periods of time, but at least it’s a start. Through associative play, they begin to share with other children; playing with other children their own age teaches them socialization skills. Much of their play still consists of watching others, but now if they have the need, they can offer verbal advice. They can ask others to “come out and play.” If 3-year-olds are placed in a strange situation with children they do not know, they commonly revert to parallel play because it is more comfortable.

At this time, there is a change in the relationship between the child and the family. Preschoolers begin to find enjoyment away from Mom and Dad. However, they want them to be right there when needed. They begin to lose some of their interest in their mother, who up to this time has been more or less their total world. Their father’s prestige begins to increase. Romantic attachment to the parent of the opposite gender is seen during this period. Johnny wants to “marry Mommy” when he grows up. They also begin to identify themselves with the parent of the same gender. This behavior reflects Freud’s beliefs.

Preschool children have more fears than the infant or the older child. Some of the many causes of this are increased intelligence, which enables them to recognize potential dangers; the development of memory; and graded independence, which brings them into contact with many new situations. While toddlers are not afraid of walking in the street because they do not know any better, preschool children realize that trucks can injure them, and therefore they worry about crossing the street. This type of fear is well founded, but many others are not. The fear of bodily harm is particularly peculiar to this stage. They have poorly defined body boundaries and become fearful with intrusive procedures. They are fearful that a minor cut will allow their “insides to spill out.” Band-Aids become a necessity to prevent everything from coming out. The little boy who discovers that his baby sister is made differently worries that perhaps she has been injured. He wonders if this will happen to him. Masturbation is common during this stage as children attempt to reassure themselves that they are all right. Other common fears include fear of animals, fear of the dark, and fear of strangers.

Preschool children become angry when others attempt to take their possessions. They grab, slap, and hang on to them for dear life. They become very distraught if toys do not work the way they should. They resent being disturbed from play. They are sensitive, and their feelings are easily hurt. It is good to bear in mind that much of the disturbing social behavior seen during this time is normal and necessary to the children’s total pattern of development.

Communication

Preschool children sometimes believe that they are being punished for something they thought or did. Thus when a painful procedure is performed on the child, the nurse might say, “I am sorry that it hurt when I put the needle in your arm. I did that so we can give you medicine to make you feel better, not to hurt or punish you.”

The 4-Year-Old

Four is a stormy age. Children are not as eager or willing as they were at 3 years of age. They also are more aggressive and like to show off. They are eager to let others know that they are superior and are prone to pick on their playmates. They often take sides and make life difficult for any child who does not measure up to their standards. Four-year-olds are boisterous, tattle on others, and may begin to swear if they are around children or adults who use profanity. Personal family activities are repeated with an amazing sense of recall, but they still forget where they left their bicycle. At this age, children become interested in how old they are and want to know the exact age of each playmate. It bolsters their ego to know that they are older than someone else in the group. Their ego is also bolstered by being a “big brother” or “big sister” to a younger sibling. They are able to help care for and protect them. The relationship of one person to another interests them as well. For example, Timmy is not only a brother but also is Daddy’s son.

Four-year-olds can use scissors successfully. They can lace their shoes and do simple buttons (Figure 8-2). Vocabulary has increased to about 1500 words. They run simple errands and can play with others for longer periods of time. Many feats are done for a purpose. For instance, they no longer run just for the sake of running. Instead, they run to get someplace or to see something. They are imaginative and like to pretend they are firefighters or cowboys. Much of their play time is spent pretending. They may even have an imaginary friend. The friend may “exist” until the child starts school. They also begin to prefer playing with friends of the same gender rather than with those of the opposite gender.

FIGURE 8-2 The child progressively achieves mastery of fine-motor skills and cognitive abilities, such as **(A)** buttoning clothes and **(B)** stacking blocks.

The preschool child enjoys simple toys. They love to color pictures and have mastered the use of large crayons (Figure 8-3). Raw materials are more appealing than toys that are ready-made. An old cardboard box that can be moved about and climbed into is more fun than a dollhouse with tiny furniture. A box of sand or colored pebbles can be made into roads and mountains. A small mirror becomes a lake. “Dress up” becomes more dramatic, especially with the 4-year-old. Parents should avoid showering their children with ready-made toys. Instead they can select materials that are absorbing and that stimulate the child’s imagination.