Gross and Fine Motor Skills

Walking, running, climbing, and jumping are well established by age 36 months. Refinement in eye-hand and muscle coordination is evident in several areas. At age 3 the preschooler rides a tricycle, walks on tiptoe, balances on one foot for a few seconds, and broad jumps. By age 4 the child skips and hops proficiently on one foot (Fig. 33-1) and catches a ball reliably. By age 5 he or she skips on alternate feet, jumps rope, and begins to skate and swim.

Fine motor development is evident in the child’s increasingly skillful manipulation such as in drawing and dressing. These skills provide readiness for learning and independence for entry into school.

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, and the phase of intuitive thought, ages 4 to 7. 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.

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 the young child’s thinking through other, nonverbal approaches. For children in this age-group, the most enlightening and effective method is play, which becomes the child’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 right and left, 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 right and left.

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 an illness or 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 that he or she is a bad person; thus it is better to say that the actions were bad (e.g., “That was a bad thing to do”).

Language

During the preschool years language becomes more sophisticated and complex and the major mode of communication and social interaction (Fig. 33-2). 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, grammatic 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, et al., 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. Preschoolers also benefit from “reading” picture books with a parent or adult figure; this provides immediate feedback to the child and helps develop vocabulary as he or she hears the pronunciation of words from an adult (Feigelman, 2011). There is evidence that reading and speaking to a child in early life programs words into the child’s memory bank for use at a later time.

From ages 4 to 5 years preschoolers use longer sentences of four or five words and more parts of speech to convey a message (e.g., prepositions, adjectives, and a variety of verbs). They can 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’re 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. Preschoolers also are incapable of understanding figurative speech and are very literal in their understanding of the meaning of words (Feigelman, 2011). For example, saying that an IV cannula to be inserted for hydration is a straw is interpreted by the preschooler as literally a drinking straw because that is his or her common frame of reference for that object.

By 6 years of age 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. 33-3). They can be trusted to obey warnings of danger, although 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 32).

Play

Various types of play are typical of this period, but preschoolers especially enjoy associative play (i.e., 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. 33-4). Activities such as swimming and skating teach safety and 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 that 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. 33-5). 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). Prolonged television viewing by young children has been linked to an increase in psychologic distress and decreased time spent in active playing, which increases the risk for obesity among certain children (Hamer, Stamatakis, and Mishra, 2009). Fast-paced television cartoons have been linked to a temporary decrease in executive functioning in 4-year-olds (self-regulation and working memory) (Lilard and Peterson, 2011).

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 co-viewing 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 2½ and 3 years of age, 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 more often tend to impersonate characters (Trionfi and Reese, 2009).

Imaginary companions serve many purposes: they become friends in times of loneliness, accomplish what the child is still attempting, and experience what the child wants to forget or remember. It is not unusual for the “friend” to have myriad vices and 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. They 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 33-1 summarizes the major developmental achievements for children 3, 4, and 5 years of age.

Sex Education

Preschoolers have assimilated a tremendous amount of information during their short lifetimes. Although their thinking may not be mature, they search constantly for explanations and reasons that are logical and reasonable to them. The word “why” seems to supplant the word “no,” which was common in toddlerhood. It is only natural that, as they learn about “me,” they will also want to know “why me” and “how me.” Questions such as, “Where do babies come from?” are as casual as, “What makes it rain?” or “Who is that?” It is the way in which questions about procreation are answered that conditions children, even the youngest, to separate these questions from others about their world.

Two rules govern answering sensitive questions about topics such as sex. The first is to find out what children know and think. By investigating the theories that children have produced as a reasonable explanation, parents can give correct information and help them understand why their explanation is inaccurate. Another reason for ascertaining what the child thinks before offering any information is that the “unasked for” answer may be given. For example, 4-year-old Sally asked her father, “Where did I come from?” Both parents quickly took this inquiry as a clue for offering sex education. After the explanation Sally exclaimed, “I don’t know about all that! All I know is that Mary came from New York, and I want to know where I was born.”

The second rule for giving information is to be honest. It is true that the preschooler will forget or misunderstand much of the correct information, but the correct information can be restated until the child absorbs and comprehends the facts. Even though the correct anatomic words may be hard to pronounce or even more difficult to remember, they become foundational content for explaining other concepts at a later time.

Honesty does not imply imparting to children every fact of life or allowing excessive permissiveness in sexual curiosity. When children ask one question, they are looking for one answer. When they are ready, they will ask about the other “unfinished” parts of the story. Sooner or later they will wonder how the “sperm meets the egg” and “how the baby gets out,” but during this period it is best to wait until they ask.

Regardless of whether or not children are given sex education, they will engage in games of sexual curiosity and exploration. At about 3 years of age children are aware of the anatomic differences between the sexes and concerned with how the other “works.” This is not really “sexual” curiosity because many children are still unaware of the reproductive function of the genitalia. Their curiosity is for the eliminative function of the anatomy. Little boys wonder how girls can urinate without a penis, so they watch girls go to the bathroom. Because they cannot see anything but the stream of urine coming out, they want to observe further. “Doctor play” is often a game invented for just such investigation. Little girls are no less curious about boys’ anatomy. It is intriguing to closely inspect this “thing” that girls do not have.

One question that parents often have is how to handle such sexual curiosity. A positive approach is to neither condone nor condemn it but to express that if children have questions, they should ask the parents; the parents should then encourage them to engage in some other activity. In this way children can be helped to understand that there are ways to satisfy their sexual curiosity other than through investigative games. This in no way condemns the act but stresses alternate methods to seek solutions and answers. Allowing children unrestricted permissiveness only intensifies their anxiety and concern, since exploring and searching usually yield little evidence to satisfy their curiosity.

Many excellent books on sex education are available for preschool children at public libraries. The Sexuality Information and Education Council of the United States (SIECUS)* and the AAP† have bibliographies of suggested reading material. Parents should read the book themselves before giving or reading them to their children.

Another concern for some parents is masturbation, or self-stimulation of the genitalia. This occurs at any age for a variety of reasons and, if not excessive, is normal and healthy. It is most common at 4 years of age and during adolescence. For preschoolers it is a part of sexual curiosity and exploration. If parents are concerned about their children masturbating, it is essential for nurses to investigate the circumstances associated with the activity because it may be an expression of anxiety, boredom, or unresolved conflicts. Children who openly and publicly masturbate are inviting a reaction such as discipline, punishment, or criticism. They may be overwhelmed by their sexual feelings and are asking others to help channel them into more constructive outlets. Like other forms of sex play, masturbation is a private act, and parents should emphasize this to children when teaching them socially acceptable behavior.

Fears

A great number and variety of real and imagined fears are present during the preschool years, including fear of the dark, being left alone (especially at bedtime), animals (particularly large dogs), ghosts, sexual matters (castration), and objects or persons associated with pain. The exact cause of children’s fears is often unknown. Parents often become perplexed about handling the fears because no amount of logical persuasion, coercion, or ridicule sends away the ghosts, boogeymen, monsters, and devils. Inappropriate television viewing by preschoolers may increase fears and anxieties because of the inability to separate reality-based experiences from fantasy portrayed on television.

The concept of animism (i.e., ascribing lifelike qualities to inanimate objects) helps explain why children fear objects. For example, a child may refuse to use the toilet after watching a television commercial in which the toilet bowel is portrayed as turning into a monster.

Preschoolers also experience fear of annihilation. Because of poorly defined body boundaries and improved cognitive abilities, young children develop concerns related to loss of body parts. They fear losing body parts with certain medical procedures such as an intravenous insertion or cast application on a limb and may see these procedures as real threats to their existence. Preschoolers are often fearful when approaching the health care environment (office or hospital) and are especially fearful of pain. Because of their inability to sometimes discern reality from the imagined, a painful procedure such as a vaccination may be perceived as the end of existence (death) to the child; the preschooler is often unable to see beyond that experience. It is helpful to discuss the child’s fears but maintain honesty and openness when working with preschoolers in the health care setting.

The best way to help children overcome their fears is by actively involving them in finding practical methods to deal with the frightening experience. This may be as simple as keeping a night-light on in the child’s bedroom for assurance that no monsters lurk in the dark. Exposing children to the feared object in a safe situation also provides a type of conditioning, or desensitization. For instance, children who are afraid of dogs should never be forced to approach or touch one, but they may be introduced gradually to the experience by watching other children play with the animal. This type of modeling, with others demonstrating fearlessness, can be effective if the child is allowed to progress at his or her own rate.

Usually by 5 or 6 years of age children relinquish many of their fears. Explaining the developmental sequence of fears and their gradual disappearance may help parents feel more secure in handling preschoolers’ fears. Sometimes fears do not subside with simple measures or developmental maturation. When children experience severe fears that disrupt family life, professional help is required.

Stress

Although for parents the preschool years generally are less troublesome than toddlerhood, this period of life presents children with many unique stresses. Some such as fears are innate and stem from preschoolers’ unique understanding of the world. Others such as beginning school are imposed. Although minimal amounts of stress are beneficial during the early years to help children develop effective coping skills, excessive stress is harmful. Young children are especially vulnerable because of their limited capacity to cope. Expression of frustration, fear, or anxiety is hampered by inadequate expressive language.

To help parents deal with stress in their child’s life, they must be aware of its signs (see Stress in Childhood, Chapter 28) and be helped to identify the source. Any number of stressors may be present such as the birth of a sibling, marital discord, divorce and separation, relocation, or illness.

The best approach to dealing with stress is prevention (i.e., monitoring the amount of stress in children’s lives so levels do not exceed their coping ability and informing them of anticipated changes on a short-term basis) and education. In many instances structuring children’s schedules to allow rest and preparing them for change such as entering school are sufficient measures.

Aggression

The term aggression refers to behavior that attempts to hurt a person or destroy property. Aggression differs from anger, which is a temporary emotional state, but anger may be expressed through aggression. Hyperaggressive behavior in preschoolers is characterized by unprovoked physical attacks on other children and adults, destruction of others’ property, frequent intense temper tantrums, extreme impulsivity, disrespect, and noncompliance. Aggression is influenced by a complex set of biologic, sociocultural, and familial variables. Factors that tend to increase aggressive behavior are gender, frustration, modeling, and reinforcement.

Evidence indicates that types of aggression differ between genders. Boys exhibit more physical aggression than girls during preschool years (Benzies, Keown, and Magill-Evans, 2009); however, preschool girls exhibit more relational aggression than preschool boys (Ostrov and Bishop, 2008). Frustration, or the continual thwarting of self-satisfaction by disapproval, humiliation, punishment, or insults, can lead children to act out against others as a means of release. Especially if they fear their parents, these children displace their anger on others, particularly peers and other authority figures. This type of aggression often applies to children who are well-behaved at home but have a discipline problem at school or are bullies among their playmates.

Modeling, or imitating the behavior of significant others, is a powerful influencing force in preschoolers. Children who see their parents as physically abusive are observing behavior that they come to know as acceptable and therefore may exhibit with others (Benzies, Keown, and Magill-Evans, 2009). Another aspect of modeling is the “double standard” for acceptable conduct. For example, in some families aggression is synonymous with masculinity, and boys are encouraged to defend themselves. Television is also a significant source for modeling at this impressionable age. Research indicates that there is a direct correlation between media exposure, both violent and educational media, and preschoolers exhibiting physical and relational aggression (Ostrov, Gentile, and Crick, 2006). Therefore parents should be encouraged to supervise television viewing. The AAP (2007) offers a list of recommendations for healthy television viewing.

Reinforcement can also shape aggressive behavior. Sometimes the reward for aggression is negative (e.g., punishment) yet reinforcing because it brings attention. For example, children who are ignored by a parent until they hit a sibling or the parent learn that this act garners attention.

When children exhibit extreme behaviors such as aggression, parents may be concerned about the need for professional help. Generally the difference between “normal” and “problematic” behavior is not the behavior itself but its quantity (number of occurrences), severity (interference with social or cognitive functioning), distribution (different manifestations), onset (when behavior started), and duration (at least 4 weeks).*

Speech Problems

The most critical period for speech development occurs between 2 and 4 years of age. During this period children are using their rapidly growing vocabulary faster than they can produce the words. Failure to master sensorimotor integrations results in stuttering or stammering as children try to say the word about which they are already thinking. This dysfluency in speech pattern is common during language development in children 2 to 5 years of age (National Institute on Deafness and Other Communication Disorders, 2010). Stuttering affects boys more frequently than girls, has been shown to have a genetic link, and usually resolves during childhood (Prasse and Kikano, 2008). The National Institute on Deafness and Other Communication Disorders (2010) encourages parents and caregivers of children who stutter to speak slowly and relaxed, refrain from criticizing the child’s speech, resist completing the child’s sentences, and take time to listen attentively.

The best therapy for speech problems is prevention and early detection. Common causes of speech problems include hearing loss or impairment, oropharyngeal structural anomalies, developmental disorders such as autism, brain injuries and other neuromotor impairments, lack of a verbally stimulating environment, and change in language exposure as in international adoption (Sharp and Hillenbrand, 2008). Referral for further evaluation and treatment may be necessary to prevent a problem from interfering with learning. Anticipatory preparation of parents for expected developmental norms may allay caregiver concerns.

Children pressured into producing sounds ahead of their developmental level may develop dyslalia (articulation problems) or revert to using infantile speech. Prevention involves educating parents regarding the usual achievement of speech production during childhood. The Denver Articulation Screening Exam is an excellent tool for assessing articulation skills of a child and explaining to parents the expected progression of sounds.

Sleep Problems

The preschool years are a prime time for sleep disturbances. Such disturbances are typically related to increasing autonomy, negative sleep associations, nighttime fears, inconsistent bedtime routines, and lack of limit setting (Moore, Meltzer, and Mindell, 2008). Sleep disturbances may also be caused by nightmares and sleep terrors. Consequences of inadequate sleep include daytime tiredness, irritability and other negative behaviors, hyperactivity, difficulty concentrating, impaired learning ability, poor control of emotions and impulses, and strain on family relationships (Mindell, Kuhn, Lewin, et al., 2006).

Recommendations for handling sleep disturbances are offered only after a thorough assessment of the problem. Cultural traditions may dictate sleep practices that are contrary to certain well-accepted professional recommendations; therefore parents may not perceive a particular sleep practice to be a problem.

Interventions differ greatly; for example, nightmares (frightening dreams that are followed by full arousal) and sleep terrors (partial arousal from deep, nondreaming sleep) require different approaches (see Table 32-2).

For children who delay going to bed, a recommended approach involves counseling parents about the importance of a consistent bedtime ritual and emphasizing the normalcy of this type of behavior in young children. Parents should ignore attention-seeking behavior and not take the child into the parents’ bed or allow him or her to stay up past a reasonable hour. Other measures that may be helpful include keeping a light on in the room, providing transitional objects such as a favorite toy, or leaving a drink of water by the bed. Parental consistency is paramount to all treatment approaches.

Helping children slow down before bedtime also reduces the resistance to going to bed. One strategy is to establish limited rituals that signal readiness for bed such as a bath or story. Parents can reinforce the pattern by stating, “After this story it’s bedtime,” and consistently carrying out the routine. If anticipated extra stimulation such as having visitors arrive at bedtime disrupts this routine, it is advisable to settle children in bed beforehand. Television viewing before bedtime may cause bedtime resistance and delay sleep.