The Preschooler and Family

Chapter 33

The Preschooler and Family

David Wilson

Promoting Optimal Growth and Development

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

Biologic Development

The rate of physical growth slows and stabilizes during the preschool years. The average weight is 14.5 kg (32 lbs) at 3 years, 16.7 kg (36.8 lbs) at 4 years, and 18.7 kg (41.5 lbs) at 5 years. The average weight gain per year remains approximately 2 to 3 kg (4.5 to 6.5 lbs). Growth in height also remains steady, with an annual increase of 6.5 to 9 cm (2.5 to 3.5 inches), and generally occurs by elongation of the legs rather than the trunk. The average height is 95 cm (37.5 inches) at 3 years, 103 cm (40.5 inches) at 4 years, and 110 cm (43.5 inches) at 5 years.

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

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

Psychosocial Development

Developing a Sense of Initiative (Erikson)

After preschoolers have mastered the tasks of the toddler period, they are ready to face the developmental endeavors of the preschool period. Erikson (1963) maintained that the chief psychosocial task of this period is acquiring a sense of initiative. Children are in a stage of energetic learning. They play, work, and live to the fullest and feel a real sense of accomplishment and satisfaction in their activities. Conflict arises when they overstep the limits of their ability and inquiry and experience a sense of guilt for not having behaved appropriately. Feelings of guilt, anxiety, and fear may also result from thoughts that differ from expected behavior.

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

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

Cognitive Development

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

Preoperational Phase (Piaget)

Piaget’s cognitive theory does not include a period specifically for children who are 3 to 5 years old. The preoperational phase covers the age span from 2 to 7 years and is divided into two stages: the preconceptual phase, ages 2 to 4, 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”).

Moral Development

Preconventional or Premoral Level (Kohlberg)

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

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

Spiritual Development

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

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

In many religious faiths cultural practices and religion are closely intertwined (McEvoy, 2003) and are an important part of the child’s and family’s life.

Development of Body Image

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

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

Development of Sexuality

Sexual development during these years is an important phase in the formation of a person’s overall sexual identity and beliefs. Preschoolers are forming strong attachments to the opposite-sex parent while identifying with the same-sex parent. Sex-typing, or the process by which an individual develops the behavior, personality, attitudes, and beliefs appropriate for his or her culture and sex, occurs through several mechanisms during this period. Probably the most powerful mechanisms are childrearing practices and imitation. Gender identification is a result of complex prenatal and postnatal psychologic factors and biologic or genetic factors. Most children are aware of their gender and the expected sets of related behaviors by 1.5 to 2.5 years of age.

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

Sexual exploration may be more pronounced now than ever before, particularly in terms of exploring and manipulating the genitalia. Questions about sexual reproduction may come to the forefront in the preschooler’s search for understanding (see Chapters 34 and 35).

Social Development

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


During the preschool years language becomes more sophisticated and complex and 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).


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.

TABLE 33-1


Age 3 Yr
Usual weight gain of 1.8-2.7 kg (4-6 lbs)
Average weight of 14.5 kg (32 lbs)
Usual gain in height of 7.5 cm (3 inches) per year
Average height of 95 cm (37.5 inches)
May have achieved nighttime 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 still come down using both feet on step
Broad jumps
May try to dance, but balance may not be adequate
Builds tower of 9-10 cubes
Builds bridge with three cubes
Adeptly places small pellets in narrow-necked bottle
In drawing, copies a circle, imitates a cross, names what has been drawn; cannot draw stick figure but may make circle with facial features
Has vocabulary of about 900 words
Uses primarily telegraphic speech
Uses complete sentences of three or four words
Talks incessantly regardless of whether anyone is paying attention
Repeats sentence of six syllables
Asks many questions
Dresses self almost completely if helped with back buttons and told which shoe is right or left
Pulls on shoes
Has increased attention span
Feeds self completely
Can prepare simple meals such as cold cereal and milk
Can help to set table; can dry dishes without breaking any
May have fears, especially of dark and 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
Is in preconceptual phase
Is egocentric in thought and behavior
Has beginning understanding of time; uses many time-oriented expressions, talks about past and future as much as about present, pretends to tell time
Has improved concept of space, as demonstrated by understanding of prepositions and ability to follow directional command
Has beginning ability to view concepts from another perspective
Attempts to please parents and conform to their expectations
Is less jealous of younger sibling
Is aware of family relationships and sex-role functions
Boys tend to identify more with father or other male figure
Has increased ability to separate easily and comfortably from parents for short periods
Age 4 Yr
Pulse and respiration rates decrease slightly
Growth rate is similar to that of previous year
Average weight of 16.7 kg (36.8 lbs)
Average height of 103 cm (40.5 inches)
Birth length has doubled
Maximum potential for development of amblyopia
Skips and hops on one foot
Catches ball reliably
Throws ball overhead
Walks down stairs using alternate footing
Uses scissors successfully to cut out picture following outline
Can lace shoes but may not be able to tie bow
In drawing, copies a square, traces a cross and diamond, adds three parts to stick figure
Has vocabulary of 1500 words or more
Uses sentences of four or five words
Questioning is at peak
Tells exaggerated stories
Knows simple songs
May be mildly profane if associates with older children
Obeys four prepositional phrases such as under, on top of, beside, in back of, or in front of
Names one or more colors
Comprehends analogies such as, “If ice is cold, fire is _______.”
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
Tells family tales to others with no restraint
Still has many fears
Play is associative
Imaginary playmates are common
Uses dramatic, imaginative, and imitative devices
Sexual exploration and curiosity demonstrated through play such as being “doctor” or “nurse” (see text)
Is in phase of intuitive thought
Causality is still related to proximity of events
Understands time better, especially in terms of sequence of daily events
Unable to conserve matter
Judges everything according to one dimension such as height, width, or order
Immediate perceptual clues dominate judgment
Is beginning to develop less egocentrism and more social awareness
May count correctly but has poor mathematic concept of numbers
Obeys because parents have set limits, not because of understanding of right or wrong
Rebels if parents expect too much such as impeccable table manners
Takes aggression and frustration out on parents or siblings
Do’s and don’ts become important
May have rivalry with older or younger siblings; may resent older sibling’s privileges and younger sibling’s invasion of privacy and possessions
May “run away” from home
Identifies strongly with parent of opposite sex
Is able to run simple errands outside the home
Age 5 Yr
Pulse and respiration rates decrease slightly
Average weight of 18.7 kg (41.2 lbs)
Average height of 110 cm (43.5 inches)
Eruption of permanent dentition may begin
Handedness is established (about 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 and lands on toes
Balances on alternate feet with eyes closed
May begin to tie shoelaces but still needs some help
Uses scissors, simple tools, or pencil very well
In drawing copies a diamond and triangle; adds seven to nine parts to stick figure; prints a few letters, numbers, or words such as first name
Has vocabulary of about 2100 words
Uses sentences of six to eight words, with all parts of speech
Names coins (e.g., nickel, dime)
Names four or more colors
Describes drawing or pictures with much comment and elaboration
Knows days of week, months, and other time-associated words
Knows composition of objects, such as “A shoe is made of _____.”
Can follow three commands in succession
Less rebellious and quarrelsome than at age 4 yr
More settled and eager to get down to business
Not as open and accessible in thoughts and behavior as in earlier years
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 totally, occasionally needing supervision in dress or hygiene
Not ready for concentrated close work or small print because of slight farsightedness and still unrefined eye-hand coordination
Play is associative; tries to follow rules but may cheat to avoid losing
Begins to question what parents think by comparing them with age-mates and other adults
May notice prejudice and bias in outside world
Is more able to view other’s perspective but tolerates rather than understands differences
May begin to show understanding of conservation of numbers through counting objects regardless of arrangement
Uses time-oriented words with increased understanding
Cautious about accepting or believing information
Gets along well with parents
May seek out parent more often than at age 4 yr for reassurance and security, especially when entering school
Begins to question parents’ thinking and principles
Strongly identifies with parent of same sex, especially boys with their fathers
Enjoys activities such as sports, cooking, and shopping with parent of same sex



Coping with Concerns Related to Normal Growth and Development

Preschool and Kindergarten Experience

Some children are home schooled, but many attend some type of early childhood program, usually preschool or a day care center. Group care has become commonplace with the large number of parents currently employed outside the home (see Alternate Child Care Arrangements, Chapter 31). The effects of early education and stimulation on children have increasingly gained recognition. (For a discussion of the effects of day care on young children, see Working Mothers, Chapter 27.) Because social development widens to include age mates and other significant adults, preschool provides an excellent vehicle for expanding children’s experiences with others. It is also excellent preparation for entrance into elementary school.

In preschool or day care centers children are exposed to opportunities for learning group cooperation; adjusting to sociocultural differences; and coping with frustration, dissatisfaction, and anger. If activities are tailored to provide mastery and achievement, children increasingly have feelings of success, self-confidence, and personal competence. Whether structured learning is imposed is less important than the social climate, type of guidance, and attitude toward the children that is fostered by the teacher or leader. With a teacher who is aware of preschoolers’ developmental abilities and needs, children learn from the activity that is provided. Most programs incorporate a daily schedule of quiet play, active outdoor activity, group activities such as games and projects, creative or free play, and snack and rest periods. Preschool is particularly beneficial for children who lack a peer-group experience such as only children and for children from impoverished homes.

One of the issues that parents face is their children’s readiness for preschool or kindergarten. There are no absolute indicators for school readiness; but children’s social maturity, especially attention span, is as important as their academic readiness. Using a developmental screening tool that addresses cognitive (especially language), social, and physical milestones can identify children who may benefit from diagnostic testing and early-intervention programs before starting school. Parents play an integral role in their children’s school readiness. They should promote a positive attitude toward learning, read to their children, encourage their children to participate in a variety of activities to explore their talents and interests, and choose appropriate child care or preschool programs (Hagan, Shaw, and Duncan, 2008).

Nurses and other health care workers can guide parents in selecting enriched social and educational early-intervention programs, schools, and child care centers. Careful selection of early-childhood education is intrinsic to future learning and development. Licensed and regulated programs are mandated to abide by established standards, which represent minimum requirements and safeguards. Regulation is important to protect children from harm and promote the conditions essential for a child’s healthy development and learning. The National Association for the Education of Young Children (NAEYC) serves as the model for optimal care of small children.*

Areas for parents to evaluate include the daily program of the facility, teacher qualifications, staff-to-student ratio, discipline policy, environmental safety precautions, provision of meals, sanitary conditions, adequate indoor and outdoor space per child, safety and injury prevention, and fee schedule. A plan for emergency response in case of fire or other hazard [flooding, tornado] should also be well established (with evacuation drills) by the program. References from other parents help in evaluating a facility, but personal observation of the facility is recommended. Encourage parents to meet the director and some of the employees at a few facilities to make an informed choice.

Evaluation of the health practices of the facility is extremely important. Children in day care centers have more illnesses than those not in day care centers, especially gastrointestinal tract infections; respiratory tract infections; and hepatitis A, varicella-zoster virus, and cytomegalovirus infections (Nesti and Goldbaum, 2007). Nurses play an important role in infection control. Not only can they advise parents regarding the evaluation of the sanitary practices of a facility, but they can also take an active part in educating staff in measures to minimize transmission of infection (Fig. 33-6). Proactive infection control measures and education of staff have been effective in reducing the incidence of upper respiratory tract infections, diarrhea, and rotavirus (Kotch, Isbell, Weber, et al., 2007). Day care staff should also have updated routine immunizations according to the adult immunization recommendations, including the annual influenza vaccine, to protect the children in the center (AAP Committee on Infectious Diseases, 2012). Parents should inquire about the policy of the center regarding the attendance and care of sick children.

The American Academy of Pediatrics’ 2012 Red Book: Report of the Committee of Infectious Diseases (2012) contains additional infection control guidelines regarding day care hand washing; cleaning sleep equipment, toys, and food; care of pets; and conditions or illnesses for which children should be kept out of day care to prevent the spread of illness.

Children need preparation for the preschool or kindergarten experience. For young children it represents a change from their usual home environment and prolonged separation from their parents. Before children begin school, parents should present the idea as exciting and pleasurable. Talking to children about activities such as painting, building with blocks, or enjoying swings and other outdoor equipment allows children to fantasize about the forthcoming event in a positive manner. When the first day of school arrives, parents should behave confidently. Such behavior requires them to have resolved their own feelings regarding the experience.

Parents should introduce their child to the teacher and the facility. In some instances it is helpful for parents to remain with the child for at least part of the first day until the child is comfortable and at ease. Other specific actions that can help reduce separation anxiety include providing the school with detailed information about the child’s home environment such as familiar routines, favorite activities, food preferences, names of siblings or pets, and personal habits. Such information helps the child feel familiar in the strange surroundings. When schools automatically request this information, the parent has a valuable clue to evaluating the quality of the program because the request represents the staff’s awareness of each child’s needs. Transitional objects such as a favorite toy may also help the child bridge the gap from home to school.

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.


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.


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.


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.

Promoting Optimal Health During the Preschool Years


Healthy nutrition during childhood should include eating a variety of foods and consuming sufficient energy to promote growth and development while avoiding the development of obesity (AAP Committee on Nutrition, 2009). The 2010 Dietary Guidelines for Americans (U.S. Department of Agriculture, 2010) recommend an average intake of 1400 to 1600 calories per day for a moderately active child 4 to 8 years of age; these guidelines emphasize the reduction of sugar-sweetened beverages and excess intake of juices for young children and an overall increase in the amount of whole grains, vegetables, and fruits.* A daily intake of 16 oz/day of milk for preschoolers is recommended; this can be whole milk, 2%, or 1% milk. The Dietary Guidelines indicate that there is moderate evidence that consumption of milk and other dairy products does not contribute significantly to weight gain in young children. Fluid requirements may also decrease slightly to approximately 100 mL/kg/day but depend on the child’s activity level, climatic conditions, and state of health. Protein requirements increase with age, and the recommended intake for preschoolers is 13 to 19 g/day (0.45 to 0.67 oz/day) (Otten, Hellwig, and Meyers, 2006).

The AAP Committee on Nutrition (2009) recommends the following guidelines for children older than 2 years of age: saturated fatty acid consumption should be less than 10% of total caloric intake; total fat over several days should be 20% to 30% of total caloric intake; and cholesterol consumption should be less than 300 mg/day. Fiber intake for children 3 years of age should be 19 mg/day and 25 mg/day for children 4 to 8 years of age (AAP, 2009). Research supports the efficacy of following these recommendations, and negative health effects have not been reported (American Heart Association, Gidding, Dennison, et al., 2006). These efforts are important in preventing childhood obesity, cardiovascular disease, diabetes, and metabolic syndrome. There is now sufficient evidence that the incidence of coronary heart disease, obesity, and chronic health problems such as diabetes mellitus can be influenced by early eating patterns (Barlow and Expert Committee, 2007). Evidence suggests that children who participate in family meal times in the home (three or more meals together) have a decreased risk for obesity and unhealthy eating patterns that may contribute to overweight and subsequent cardiovascular disease (Dattilo, Birch, Krebs, et al., 2012).

In addition to limiting fat consumption, it is also important to ensure that diets contain adequate nutrients such as calcium. The recommendation for daily calcium intake for children 1 to 3 years of age is 500 mg; for children 4 to 8 years of age is it 800 mg (Otten, Hellwig, and Meyers, 2006). Milk and dairy products are excellent sources of calcium and vitamin D (fortified). Low-fat milk may be substituted; thus the quantity of milk may remain the same while limiting fat intake overall.

Excessive consumption of fruit juices and other sweetened beverages has been associated with adverse health effects such as dental caries, gastrointestinal conditions such as chronic diarrhea, and diets poor in nutritive value (Allen and Myers, 2006). The AAP recommends limiting the intake of 100% fruit juice to 4 to 6 oz/day for children 1 to 6 years of age (AAP, 2009). Parents should be educated regarding nonnutritious fruit drinks, which usually contain less than 10% fruit juice yet are often advertised as healthy and nutritious; sugar content is dramatically increased and often precludes an adequate intake of milk by the child. When counseling parents regarding moderation in fruit juice consumption, providers should offer suggestions for more appropriate sources of nutrients such as ascorbic acid, folate, and potassium. In young children intake of carbonated beverages that are acidic or contain high amounts of sugar is also known to contribute to dental caries; large amounts of nonnutritive calories in such beverages may also displace or preclude intake of nutrients necessary for growth.

An additional resource for dietary counseling includes MyPlate,* recently developed by the U.S. Department of Agriculture to replace MyPyramid. This colorful plate shows the five main food groups—fruits, grains, vegetable, protein, and dairy—with the intended purpose to involve children and their families in making appropriate food choices for meals and decrease the incidence of overweight and obesity in the United States. MyPlate provides an online interactive feature that allows the individual to select an individual food group and see choices for foods in that group. Approximate serving sizes are suggested, and vegetarian substitutions are also provided. This system is comprehensive and provides information for developing a healthy lifestyle at an early age. Parents can use this information to help their children make healthy lifestyle choices and prevent adverse health conditions secondary to poor nutrition. The importance of role-modeling by parents cannot be overemphasized in regard to food intake and dietary habits; if parents will not eat a particular food or if their dietary habits are poor, children are likely to develop the same habits.

Some preschoolers still have food habits that are typical of toddlers such as food fads and strong taste preferences. When they reach 4 years of age, they seem to enter another period of finicky eating, which is generally characteristic of the more rebellious behavior of children in this age-group. As with toddlers, small portions of each item being served should be offered. The practice of having children remain at the table until the “plate is clean” should be avoided because this may contribute to overeating and the development of poor eating habits that contribute to poor health later in life. By 5 years of age children are more agreeable to trying new foods, especially if they are encouraged by an adult who allows them to help with food preparation or experiment with a new taste or different dish (Fig. 33-7). Mealtimes can become battlegrounds if parents expect perfect table manners. Usually 5-year-old children are ready for the “social” side of eating, but 3- or 4-year-old children still have difficulty sitting quietly through long family meals.

The amount and variety of foods consumed by young children vary greatly from day to day. Consequently parents sometimes worry about the quantity and quality of food that preschoolers consume. In general the quality is much more important than the quantity, a fact that should be stressed during nutrition counseling. Eating habits are well established by 5 years of age, with the major contributing factor being the family, especially the parents.

One way to lessen parental concern is to advise parents to keep a weekly record of everything the child eats. In particular the parents can measure the amount of food such as setting aside a half cup of vegetables and serving the child from this premeasured amount to provide a more accurate estimate of food intake at each meal. When parents look at the food chart at the end of the week, they are usually amazed by how much the child has consumed. In general preschoolers consume only slightly more than toddlers, or about half an adult’s portion.

In addition to unhealthy eating habits, experts recognize that a sedentary lifestyle contributes to cardiovascular disease and obesity. Therefore the 2010 Dietary Guidelines also encourage 60 minutes of physical activity per day for children 6 years of age and older (U.S. Department of Agriculture, 2010). One program recommends that preschoolers be encouraged to be involved in at least 2 hours of cumulative activity per 8-hour day in day care, including unstructured free playtime (Larson, Ward, Neelon, et al., 2011).

Sleep and Activity

Sleep patterns vary widely, but the average preschooler sleeps about 12 hours a night and infrequently takes daytime naps. Waking during the night is common throughout early childhood and may be related to social and environmental factors rather than developmental or physiologic causes (Moore, Meltzer, and Mindell, 2008). Motor activity levels continue to be high and allow preschoolers to explore their environment, begin learning physical games and sports, and interact with others. Sedentary activities such as television and video or computer games are increasingly appealing and can become unhealthy substitutes for active play.

Preschoolers’ increased gross motor abilities and coordination allow them to engage in many physical activities, if only at a novice level. Whether young children should begin formalized training in an activity at this early age is controversial. Training programs must consider the child’s physical and psychologic immaturity, and readiness to participate in organized sports should be determined individually. The decision to participate should be based on the child’s, not the parent’s, motivation and enjoyment. The AAP Committee on Sports Medicine and Fitness and the AAP Committee on School Health (2006) encourages free play and a variety of physical activities; however, the AAP also supports organized play when it is developmentally appropriate and occurs in a nonthreatening, fun, and safe environment.

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.

Sep 16, 2016 | Posted by in NURSING | Comments Off on The Preschooler and Family
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