Nursing Care of a Preschool Child PDF

15610_Ch31.qxd 7/6/09 6:43 AM Page 862 Chapter Nursing Care of a Family With a 31 Preschool Child K E Y T E R M S Cathy Edwar...

15610_Ch31.qxd 7/6/09 6:43 AM Page 862 Chapter Nursing Care of a Family With a 31 Preschool Child K E Y T E R M S Cathy Edwards is a broken fluency endomorphic body type 3-year-old girl. Her bruxism genu valgus father cares for her conservation intuitional thought ectomorphic body type Oedipus complex because her mother is Electra complex secondary stuttering hospitalized as a result of preterm labor for a second pregnancy. Her O B J E C T I V E S father tells you he is concerned be- After mastering the contents of this chapter, you should be able to: cause Cathy talks constantly with an 1. Describe normal growth and development as well as common parental concerns of the preschool period. imaginary friend named Emma. She 2. Identify National Health Goals related to the preschool period that makes up stories about events that nurses can help the nation achieve. cannot possibly be true. When 3. Use critical thinking to analyze methods of care for preschoolers to be certain care is family centered. corrected, Cathy stutters so badly no 4. Assess a preschooler for normal growth and developmental one can understand her. milestones. 5. Formulate nursing diagnoses related to preschool growth and The previous chapter described tod- development and common parental concerns. dler growth and development and the 6. Identify expected outcomes for nursing care of a preschooler. 7. Plan nursing care to meet a preschooler’s growth and development abilities children develop during that needs, such as planning age-appropriate play activities. period. This chapter adds information 8. Implement nursing care related to normal growth and development of a preschooler, such as preparing a preschooler for an invasive about the changes, both physical and procedure. psychosocial, that occur during the 9. Evaluate expected outcomes for achievement and effectiveness of care. preschool years. Such information 10. Identify areas related to care of the preschool-age child that builds a base for care and health could benefit from additional nursing research or application of teaching for the age group. evidence-based practice. 11. Integrate knowledge of preschool growth and development with nursing process to achieve quality maternal and child health Is Cathy’s father describing typical nursing care. preschool behavior, or does Cathy need a referral to a child guidance counselor? 862 15610_Ch31.qxd 7/6/09 6:43 AM Page 871 CHAPTER 31 Nursing Care of a Family With a Preschool Child 871 watching can help children develop motor skills as well as be Night Grinding. Bruxism, or grinding the teeth at night a step toward preventing childhood obesity (Kline, 2008). (usually during sleep), is a habit of many young children (Goddard, 2008). Teeth grinding may be a way of “letting Hygiene go,” similar to body rocking, that children do for a short time each night to release tension and allow themselves to fall Preschoolers can wash and dry their hands adequately if the asleep. Children who grind their teeth extensively may have faucet is regulated for them so they do not scald themselves greater-than-average anxiety. Children with cerebral palsy with hot water. Also, when possible, parents should turn may do it because of the spasticity of jaw muscles. If the down the temperature of the water heater in their home to grinding is extensive, the crowns of the teeth can become under 120° F to help prevent scalds. Preschoolers do not abraded. The condition can advance to such an extent that clean their fingernails very well, so these often need “touch- tooth nerves become exposed. If the problem seems to stem ing up” by a parent or older sibling. The child may also need from anxiety, identifying and relieving the source of anxiety the assistance of a parent or older sibling to clean the ears is essential for treatment. If some damage is evident, refer the during bath time. Hair washing can be a problem, as well. family to a pedodontist so the teeth can be evaluated, re- Preschoolers are too heavy for a parent to hold over the sink paired (capped), and conserved. to rinse their hair, and children may have difficulty keeping the eyes closed well enough or long enough to keep soap out Promoting Healthy Family Functioning because they insist on opening them to see whether the par- ent is finished. Hanging a mobile over the tub so they have Some parents who enjoyed maintaining a rhythm of care for a reason to look up for rinsing and using a nonirritating an infant and allowed for ritualistic behavior of a toddler may shampoo are good suggestions. Although preschoolers may have difficulty being the parents of a preschooler because sit well in bathtubs, they should still not be left un- more flexibility and creativity are required. Others come into supervised at bath time. Caution parents about not using their own as the parents of a preschooler; they delight in en- bubble bath with preschoolers as some girls develop vulvar couraging imaginative games and play. irritation (and perhaps bladder infections) from exposure to A major parental role during this time is to encourage vo- such products. cabulary development. One way to do this is to read aloud to a child; another is to answer questions so a child sees lan- Care of Teeth guage as an organized system of communication. Answering a preschooler’s questions can be difficult because the ques- If independent toothbrushing was not started as a daily prac- tions are frequently philosophical; for example, “Why is grass tice during the infant or toddler years, it should be started green?” A child may listen to an explanation of chlorophyll during the preschool years. A child should continue to drink but then repeat the question, regardless of the clarity of the fluoridated water or receive a prescribed oral fluoride supple- explanation, because the parent underestimated the extent of ment if fluoride is not provided in the water supply (Armfield the question: a child did not want to know what makes grass & Spencer, 2007). green, but why, philosophically, it is not red or blue or yel- One good toothbrushing period a day is often more effec- low. The obvious answer to that is, “I don’t know.” Parents tive than more frequent half-hearted brushings. Although who are confident can give this answer without feeling many preschoolers do well brushing their own teeth, parents threatened. Parents who are less sure of themselves may feel must check that all tooth surfaces are cleaned. They should extremely uncomfortable when they realize they do not know floss the teeth, because this is a skill beyond a preschooler’s the answers to a 4-year-old’s questions (Box 31.5). motor ability. Toothbrushing is generally well accepted by preschool- Discipline ers because it imitates adults. Electric or battery-operated toothbrushes are favorites because of the adult responsibil- Preschoolers have definite opinions on things such as what ity involved in handling them. Children must be supervised they want to eat, where they want to go, and what they want when using an electric toothbrush, however, and must be to wear. This may bring them into opposition with parents. A taught not to use it or any other electrical appliance near a major parental responsibility when this happens is to guide a basin of water. child through these struggles without discouraging the child’s Encouraging children to eat apples, carrots, celery, chicken, right to have an opinion. “Timeout” is a good technique to or cheese for snacks rather than candy or sweets is yet another correct behavior for parents throughout the preschool years way to attempt to prevent tooth decay. If a child is allowed to (see Chapter 30). This technique allows parents to discipline chew gum, it should be the sugar-free variety. without using physical punishment and allows a child to learn Children should have made a first visit to a dentist by a new way of behavior without extreme stress. 21⁄2 years of age for evaluation of tooth formation. Because this visit usually shows no cavities, this should have been a Parental Concerns Associated With the pain-free experience, so a child should not fear the dentist, Preschool Period and the idea that dentists like to help rather than hurt should A number of common health problems and fears usually arise have been implanted. If parents did not take a child for this during the preschool years. visit previously, it should be done during the preschool pe- riod. Deciduous teeth must be preserved to protect the den- Common Health Problems of the Preschooler tal arch. If teeth have to be pulled as a result of disease, the permanent teeth can drift out of position or the jaw may not The mortality of children during the preschool years is low grow enough to accommodate them. and becoming lower every year as more infectious diseases 15610_Ch31.qxd 7/6/09 6:43 AM Page 872 872 UNIT 5 The Nursing Role in Health Promotion for a Childrearing Family strate frequent whining or clinging behavior because they do BOX 31.5 ✽ Focus on Communication not feel completely well. Such constant illness can cause par- ents to perceive a child as sickly or not able to cope with Cathy’s father brings her for a well-child visit. You over- everyday life. Whereas parents encouraged independence be- hear him talking to his daughter in the waiting room. fore, they may now begin to overprotect (to shelter to too great a degree). Give reassurance that frequent minor ill- Less Effective Communication nesses are common in preschoolers. As parents become more Cathy: Why do we have to wait so long? experienced in handling these conditions, their perception of Mr. Edwards: It’s how things work here. whether an illness is a problem will change. Cathy: Why? Table 31.2 shows the usual health maintenance schedule Mr. Edwards: I have no idea. for preschoolers. Table 31.3 lists common problems parents Cathy: Why is that girl here? Is she sick? may have in evaluating a preschooler’s illness. Mr. Edwards: I have no idea. Cathy: When are we going home? Common Fears of the Preschooler Mr. Edwards: I have no idea. Cathy: What’s that girl’s name? Because preschoolers’ imagination is so active, this can lead Mr. Edwards: I have no idea. to a number of fears. Fears of the dark, mutilation, and sep- aration or abandonment are all very real to a preschooler. More Effective Communication These can rise in incidence when combined with the stress of Cathy: Why do we have to wait so long? an illness or hospitalization (Anderzen-Carlsson et al., 2007). Mr. Edwards: It’s how things work here. Although most of these fears can be handled by comforting Cathy: Why? from parents, in some children, fears are so intensified that Mr. Edwards: People have to take turns. We’re waiting they need therapy such as desensitization to the fear (Gordon for our turn. et al., 2007). Cathy: Why is that girl here? Is she sick? Mr. Edwards: She might be. Some children are here Fear of the Dark. The tendency to fear the dark is an exam- because they’re sick and some are just in for a ple of a fear heightened by a child’s vivid imagination: a check-up like you. stuffed toy by daylight becomes a threatening monster at Cathy: When are we going home? night. Children awaken screaming because of nightmares. Mr. Edwards: As soon as the nurse practitioner checks They may be reluctant to go to bed or to go back to sleep by you over. themselves. Cathy: What’s that girl’s name? If parents are prepared for this fear and understand it is a Mr. Edwards: I don’t know. Do you want to ask her? phase of growth, they are better able to cope with it. It is Preschoolers ask 300 to 400 questions a day as they generally helpful if they monitor the stimuli their children explore their world. In the first scenario, the father tries are exposed to, especially around bedtime. This includes to discourage questions by offering almost no answers. television, adult discussions, and frightening stories. Parents In the second scenario, when he tries to answer a are sometimes reluctant to leave a child’s light on at night child’s questions, he is not only supplying information because they do not want to cater to the fear. Burning a dim but is also helping a child build vocabulary. Because night light, however, can solve the problem and costs only preschoolers ask so many questions, you may have to pennies. Children who awake terrified and screaming need encourage parents to continue to answer questions this reassurance they are safe, that whatever was chasing them way. Otherwise, discouraging questions can become was a dream and is not in their room. They may require an the method of interaction. understanding adult to sit on their bed until they can fall back to sleep again (Fig. 31.4). Most preschoolers do not re- member in the morning that they had such a dream; they re- member for a lifetime they received comfort when they needed it. are preventable. This results in the major cause of death If parents take sensible precautions against fear of the being automobile accidents, followed by poisoning and falls dark or nightmares and a child continues to have this kind (Centers for Disease Control and Prevention [CDC], 2008). of disturbance every night, it may be a reaction to undue The number of minor illnesses, such as colds, ear infec- stress. In these instances, the source of the stress needs to be tions, and flu symptoms, is also high. Children who live in investigated. Giving sleep medication to counteract the homes in which parents smoke have a higher incidence of sleep disturbance does not help solve the basic problem, so ear (otitis media) and respiratory infections than others this is rarely recommended. Fear of the dark can become in- (Kaul & Stevens-Simon, 2008). Children who attend child tensified in a hospital setting and requires careful planning care or preschool programs also have an increased incidence to relieve. of gastrointestinal disturbances (such as vomiting and diar- rhea) from the exposure to other children (Butterton & Fear of Mutilation. Fear of mutilation is also significant dur- Calderwood, 2008). ing the preschool age, as revealed by the intense reaction of a Many parents find it extremely difficult to cope with the preschooler to even a simple injury such as falling and scrap- parade of constant minor infections that occur, causing stress ing a knee or having a needle inserted for an immunization. between parent and child, an almost monthly battle of “Stay A child cries afterward not only from the pain but also from indoors until you feel better,” conflict. Children may demon- the intrusiveness of the injury or procedure. Part of this fear 15610_Ch31.qxd 7/6/09 6:43 AM Page 873 CHAPTER 31 Nursing Care of a Family With a Preschool Child 873 TABLE 31.2 ✽ Health Maintenance Schedule, Preschool Period Area of Focus Methods Frequency Assessment Developmental milestones History, observation Every visit Formal Denver Developmental Screening Before start of school Test (DDST II) Growth milestones Height, weight plotted on standard growth Every visit chart; physical examination Hypertension Blood pressure Every visit Nutrition History, observation; height/weight Every visit information Parent–child relationship History, observation Every visit Behavior problems History, observation Every visit Vision and hearing defects History, observation Every visit Formal Preschool E and audiometer testing Before start of school Dental health History, physical examination Every visit Tuberculosis PPD test (if there are high-risk factors) Before start of school Immunizations Diphtheria, pertussis, and Check history and past records; inform Before start of school tetanus vaccine (DTaP) caregiver about any risks and side effects; (4–6 years) administer immunization in accordance with health care agency policies Hepatitis A vaccine If not previously immunized Influenza vaccine Yearly Measles, mumps, and rubella Before start of school (MMR) vaccine (4–6 years) Pneumococcal polysaccharide If underlying medical vaccine (PVV) conditions Poliomyelitis (inactivated) Before start of school vaccine (4–6 years) Varicella vaccine 4–6 years (2nd) Anticipatory Guidance Preschool care Active listening and health teaching Every visit Expected growth and Active listening and health teaching Every visit developmental milestones before next visit Accident prevention Counseling about street and personal safety Every visit Any problems expressed by Active listening and health teaching regarding Every visit caregiver during course preschool illnesses and need for of the visit imaginative play Source: American Academy of Pediatrics. (2009). Recommendations for preventive pediatric health care. Washington, DC: Author. arises because preschoolers do not know which body parts are Fear of Separation or Abandonment. Fear of separation con- essential and which ones—like an inch of scraped skin—can tinues to be a major concern for preschoolers. For some chil- be easily replaced. Boys develop a fear of castration because dren, it intensifies because their keen imagination allows developmentally they are more in tune with their body parts them to believe they have been deserted when they are safe. and are starting to identify with the same-sex parent as they Their sense of time is still so distorted they cannot be com- go through the Oedipal phase. Preschoolers can worry that if forted by assurances such as, “Mommy will pick you up from some blood is taken out of their bodies, all of their blood will preschool at noon.” Their sense of distance is also limited, so leak out. They often lift a bandage to peek at an incision or making a statement such as “I work only a block away” is not cut to see if their body is still intact underneath. They dislike reassuring. Relating time and space to something a child procedures such as needlesticks, rectal temperature assess- knows, such as meals, television shows, or a friend’s house, is ment, otoscopic examination, or having a nasogastric tube most effective. For example, stating, “Mommy will pick you passed into their stomach. They need good explanations of up from preschool after you have had your snack” or show- the limits of health care procedures such as a tympanic ther- ing a child the work site might be more comforting. mometer does not hurt or a finger prick heals quickly or dis- Caution parents to be sensitive to such fears when they traction techniques in order to feel safe (Windich-Biermeier talk about missing children or if they have their preschooler’s et al., 2007). fingerprints taken for identification. Children whose chief 15610_Ch31.qxd 7/6/09 6:43 AM Page 874 874 UNIT 5 The Nursing Role in Health Promotion for a Childrearing Family TABLE 31.3 ✽ Parental Difficulties Evaluating Illness in a Preschool Child Difficulty Helpful Suggestions for Parents Evaluating seriousness of illness or Preschoolers are eager to please and tend to answer all questions such as, condition “Does your stomach hurt?” with a yes. Observing the child for signs of illness—refusing to eat, holding an arm stiffly, having to go to the bathroom frequently—is often more productive as an evaluation technique. Evaluating bowel and bladder Preschoolers are independent in toilet habits for the first time, so parents do problems not have diaper contents to evaluate. Frequent trips to the bathroom, rubbing the abdomen, and holding genitals are the usual signs of bowel or bladder dysfunction. Evaluating nutritional intake Preschoolers begin to eat away from home at friends’ houses or at child care, or to stay overnight with grandparents, so parents do not observe daily food intake as accurately as before. Observing whether a child is growing and active is better than monitoring any one day’s food intake. Evaluating bedwetting Many preschoolers continue to have occasional enuresis at night until school age. If other signs are present—pain, low-grade fever, listlessness—a child should have a urine culture, as persistent bedwetting can indicate a low-grade urinary tract infection. Evaluating activity vs. hyperactivity Many lay magazines have articles on hyperactivity in children. Parents often wonder whether their active child is truly hyperactive. As a rule of thumb, if a child can sit through a meal (when he is hungry), watch a half-hour television show (that is his favorite), or sit still while his favorite story is read to him, he is not hyperactive. Age-specific diseases to be aware of Preschool age is a time for vision and hearing assessment. For the first time, a child is able to be tested by a standard chart or by audiometry. Urinary tract infections tend to occur with a high frequency in preschool-age girls. Language assessment should be done if a child is not able to make wants known by complete, articulated sentences by age 3 (exceptions are transposing w for r and broken fluency: “I want-want-want to go”). fear is that they will be abandoned or kidnapped might not Behavior Variations hear that fingerprints are being taken to keep them safe, only that someone might take them away from their parents. A combination of a keen imagination and immature reason- A hospital admission or going to a new school often ing results in common behavior variations in preschoolers. brings a child’s fear of separation to the forefront. Help Telling Tall Tales. Stretching stories to make them seem parents thoroughly prepare preschoolers for these experi- more interesting is a phenomenon frequently encountered in ences so they can survive them in sound mental health this age group. After a trip to the zoo, for example, if you ask (Chapter 36). a child of this age, “What happened today?” a child perceives you want something exciting to have happened, so might an- swer, “A bear jumped out of his cage and ate up the boy next to me.” This is not lying, but merely supplying an expected answer. Caution parents not to encourage this kind of story- telling, but instead help the child separate fact from fiction by saying, “That’s a good story, but now tell me what really happened.” This conveys the idea a child has not told the truth, yet does not squash imagination or initiative. Imaginary Friends. Many preschoolers have an imaginary friend who plays with them (Goldson & Reynolds, 2008). They tell a parent to “wait for Eric” or “set a place at the table for Lucy.” Although imaginary friends are a normal, creative part of the preschool years and can be invented by children who are surrounded by real playmates as well as by those who have few friends, parents may find them disconcerting. If so, ask parents to make certain their child has exposure to real playmates. As long as imaginary playmates do not take cen- FIGURE 31.4 Having mom close by after a bad dream is a ter stage in children’s lives or prevent them from socializing comfort to the preschooler. with other children, they should not pose a problem and 15610_Ch31.qxd 7/6/09 6:43 AM Page 875 CHAPTER 31 Nursing Care of a Family With a Preschool Child 875 often leave as quickly as they come. In the meantime, they Sibling Rivalry. Jealousy of a brother or sister may first be- can encourage language development and may provide an come evident during the preschool period (Taylor, 2007). outlet for a child to express innermost feelings or serve as a This occurs partly because this is the first time that children handy scapegoat for behavior about which a child has some have enough vocabulary to express how they feel (know a conflict. name to call) and partly because preschoolers are more aware Parents can help their preschooler separate fact from fan- of family roles and how responsibilities at home are divided. tasy about their imaginary friend by saying, “I know Eric isn’t For many children, this is also the time when a new brother real, but if you want to pretend, I’ll set a place for him.” This or sister is born. response helps a child understand what is real and what is fan- A firstborn child is rarely allowed the privileges of a sec- tasy without restricting a child’s imagination or creativity. ond child. The parents were untried, unsure of how far they should let a child venture or what level of responsibility a Difficulty Sharing. Sharing is a concept that first comes to be child could accept when the child was younger, or the first- understood around the age of 3 years. Before this, children born serves as the “trial run” for all children who come after. engage in parallel play (two children need two toys and two This phenomenon can lead to sibling rivalry, because chil- spaces to play, because they cannot pass one toy back and dren as young as preschool can sense that a younger sibling forth or play together). Around 3 years of age, children begin is being allowed behavior that was not tolerated in them. to understand that some things are theirs, some belong to oth- They are little appeased by the explanation, “Your brother is ers, and some can belong to both. For the first time, they can just a baby.” stand in line to wait for a drink, take turns using a shovel at a To help preschoolers feel secure and promote self-esteem, sandbox, and share a box of crayons. Sharing does not come supplying them with a private drawer or box for their things easily, however; children who are ill or under stress have even that parents or other children do not touch can be helpful. greater difficulty with it than usual. Assure parents that shar- This can help defend their possessions against younger chil- ing is a difficult concept to grasp and that, as with most skills, dren who do not appreciate their property rights. preschoolers need practice to understand and learn it. Parents need to accompany experiences with sharing with Preparing for a New Sibling experiences in learning property rights: “This is my private drawer and no one touches what is in it but me.” “That is Introduction of a new sibling is such a major happening your dresser top, and no one touches the things on it but that parents need to take special steps to be certain their you.” “A shovel is ours and can be used by everyone playing preschooler will be prepared. There is no rule as to when in the sand pile.” Defining limits and exposing children to this preparation should begin, but it should be before the these three categories (mine, yours, ours) helps them deter- time the child begins to feel the difference the new baby mine which objects belong to which category. will make. This is perhaps when the mother first begins to look pregnant. It is certainly before parents begin to make Regression. Some preschoolers, generally in relation to stress, physical preparations for the new child. It is always less revert to behavior they previously outgrew, such as thumb- frightening for a child of any age to understand why things sucking, negativism, loss of bladder control, and inability to are happening, no matter how distasteful they may be, separate from their parents. Although the stress that causes rather than hear people whispering or having parents obvi- this may take many forms, it is usually the result of such ously evading the issue. The unknown is always more fear- things as a new baby in the family, a new school experience, ful than a definite event that can be faced and conquered. seeing frightening and graphic television news, stress in the Help parents not to underestimate the significance of a home from financial or other problems, marital difficulties, bed to a preschool child. It is security, consistency, and or separation caused by hospitalization. “home.” If their preschooler is sleeping in the crib that is to Help parents understand that regression in these cir- be used for the new baby, it is usually best if the preschooler cumstances is normal, and a child’s thumb-sucking is little is moved to a bed about 3 months in advance of the birth. different from the parents’ reaction to stress (smoking many The parents might explain, “It’s time to sleep in a new bed cigarettes, nail biting, overeating), to make it easier for them now because you’re a big boy.” The fact that he is growing to accept and understand. Obviously, removing the stress is up is a better reason for such a move than because a new the best way to help a child discontinue this behavior. The brother or sister wants the old bed. The latter is a direct route stresses mentioned, however, are not easily removed. New to sibling rivalry and jealousy. babies cannot be returned, irreparable marriages cannot be If children are to start preschool or child care, they should patched together, frightening news happens every day, and do so either before the new baby is born or 2 or 3 months af- hospitalizations do occur. terward, if possible. That way, children can perceive starting Techniques for minimizing the stress of hospitalization school as a result of maturity and not of being pushed out of for preschoolers are discussed in Chapter 36. Children’s the house by the new child. reactions to severe and prolonged stress are discussed in If the mother will be hospitalized for the birth, she should Chapter 54. Children undergoing less severe stress can be as- be certain her child is prepared for this separation in advance. sured that although situations are changing, the important As the mother is likely to go to the hospital during the night, aspect of their life—someone still loves them and will con- it is unrealistic to expect a child in the morning to be happy tinue to take care of them—is not. Thumb-sucking or other about the arrival of a new sibling when he realizes the new manifestations of stress are best ignored; calling them to a baby has taken away his mother. Some communities offer child’s attention merely causes more stress, because it makes preparation for birth classes for preschoolers, the same as for children aware they are not pleasing parents, in addition to parents, or include children in adult preparation courses to experiencing the primary stress. help them master this new experience. 15610_Ch31.qxd 7/6/09 6:43 AM Page 876 876 UNIT 5 The Nursing Role in Health Promotion for a Childrearing Family BOX 31.6 ✽ Focus on Family Teaching Suggestions to Help Minimize Sibling Rivalry Q. Cathy’s father says to you, “Cathy’s acting jealous of her new sister and she’s not even born yet. How can I reduce sibling jealousy?” A. This isn’t a simple problem, but the following sug- gestions might help: After returning home from the hospital, devote atten- tion to your preschooler and spend some special time together after the baby has gone to bed. When friends and family visit, encourage them to spend time with the preschooler as well as the baby. FIGURE 31.5 A preschooler greets a new baby sister. She feels If they bring gifts for the baby, it is often wise for them special as dad explains how important it is to be a big sister. to bring a small present for the preschooler as well. So that your preschooler does not come to expect gifts (promoting sibling rivalry), teach her to help Encourage women to maintain contact with their open the baby’s gifts. Explain to her that it is the preschooler during the short time they are hospitalized for baby’s birthday and on her birthday she will receive the new birth. Some preschoolers may react very coldly to gifts, too. their mothers, turning their head away and refusing to come Do not ask your preschooler a question such as, “Do to them after even a few days’ separation when they return you like your new sister?” It is better to express feel- home. This is a reaction not to the new baby but to the ings of empathy such as, “New babies cry a lot. It’s separation, the same phenomenon that may occur when a hard to get used to that, isn’t it?” child returns home after being hospitalized (see Chapter 36). Provide special time for your preschooler during Allowing the child to visit in the hospital can help relieve this each day, so that when you say, “Mother and Daddy type of separation anxiety. love you just the same,” it seems real. This might be Ask pregnant women or couples what kind of preparation a quiet time for talking or reading. such as this they are making for older children; ask the While feeding the baby, read or tell a story to your mother of a new baby how everything is working out. Most preschooler. Some children enjoy feeding a doll while parents find the problem of jealousy is bigger than they an- a parent feeds the baby or giving a doll a bath while ticipated and welcome a few suggestions about how to pro- the baby has one. vide more time for their preschooler during the day and which activities a preschooler would especially enjoy (Fig. 31.5; Box 31.6). part is called a penis.” It is important for parents not to con- ✔Checkpoint Question 31.2 vey that these body parts are never to be talked about to leave Cathy will need to change to a new bed because her baby an open line of communication for sexual questions. sister will need Cathy’s old crib. What measure would you Occasionally, girls attempt to void standing up as they have suggest that her parents take to help decrease sibling rivalry seen boys doing; boys may try sitting down to void as they between Cathy and her new sister? try to use this new body knowledge. a. Ask her to get her crib ready for the new baby. It is common for preschoolers to engage in masturbation b. Tell her she will have to share with the baby. while watching television or being read to or before they fall c. Move her to the new bed before the baby arrives. asleep at night. The frequency of this may increase under d. Explain that sisters grow up to become best friends. stress, as does thumb-sucking. If observing a child doing this bothers parents, suggest they explain that certain things are done in some places but not in others. Children can relate to Sex Education this kind of direction without feeling inhibited, just as they can accept the fact that they use a bathroom in private or eat Children during the preschool age become acutely aware of only at the table. Calling unnecessary attention to the act can the difference between boys and girls, possibly because it is a increase anxiety and cause increased, not decreased, activity. normal progression in development and possibly because this An important part of sex education for preschoolers is may be the first time in their lives they are exposed to the teaching them to avoid sexual abuse, such as not allowing genitalia of the opposite sex as they watch while a new anyone to touch their body unless they agree it is all right (see brother or sister has diapers changed, they see other children Chapter 32, Box 32.5). Because children have been taught using the bathroom at a preschool, or they see a parent nude. this, remember to ask permission before giving nursing care Preschoolers’ questions about genital organs are simple that involves touching. and fact-finding; for example, “Why does James look like Because this may be the time a new brother or sister that?” or “How does Jasmine pee?” Explanations should be comes into the family, it is also the most likely time for ques- just as simple: “Boys look different from girls. The different tions such as, “Where do babies come from?” Because a child 15610_Ch31.qxd 7/6/09 6:43 AM Page 877 CHAPTER 31 Nursing Care of a Family With a Preschool Child 877 Choosing a Preschool or Child Care Center A school or child care experience is helpful for preschoolers, as peer exposure appears to have a positive effect on social de- velopment (Zoritch, Roberts, & Oakley, 2009). Children who have learned to be comfortable in a preschool group ap- proach school comfortably and ready to learn; children who have played only infrequently in groups during the preschool age are forced into this new situation in kindergarten or first grade. They can be so busy adjusting to this new concept they are left behind in learning new skills. The terms “child care center,” and “preschool,” are often used interchange- ably, so parents cannot depend on the name of a school to define its structure. Traditionally, the main purpose of a child care center is to provide child care while parents work or are otherwise occupied. A preschool is dedicated to stim- ulating children’s sense of creativity and initiative and intro- ducing them to new experiences and social contacts they would not ordinarily receive at home. Head Start programs and many modern child care centers fulfill both functions FIGURE 31.6 Preschool children are interested in learning (Olsen & DeBoise, 2007). where babies grow and have beginning sexual awareness. If there are other 3- or 4-year-old children in a neighbor- (From Taeke Henstra/Science Source/Photo Researchers, Inc.) hood with whom a child has almost daily contact, and if a parent can supervise organized play dates and projects (pro- viding peer interaction, in which working together is the is asking a simple fact-finding question, parents usually find key), a preschool program may not be necessary. On the a simple, factual answer to this type of question is best: other hand, if all the neighborhood children are either older “Babies grow in a special place in a mother’s body called a or younger or there is only one other child available to play uterus.” Saying “uterus” rather than “tummy” prevents chil- with during the day, a preschool experience will probably be dren from envisioning babies and food all mixed together in beneficial. Parents with large families point out that their their mother’s stomach (Fig. 31.6). child gets ample exposure to groups, that every meal is a It is so natural for preschoolers to ask about where ba- “group session.” This is not a peer group, however. Older bies come from that those who do not ask are exceptions. siblings give in to the 3- or 4-year-old child, and younger sib- Preschoolers who do not ask may be reticent because they lings are not capable of peer competition. This situation does sense from a preliminary exploratory question that the subject not offer the same experience as does preschool. is closed. A parent could introduce the subject by visiting a Be sure parents investigate preschools or child care centers new baby in the neighborhood with the child or pointing out carefully before they enroll their child to be certain their a neighbor who is pregnant. The birth of kittens or puppies child will be safe there and have an enjoyable experience. can also offer the chance to introduce the subject. If a new Guidelines to aid parents in this assessment are shown in brother or sister will be born at a birthing center or at home, Table 31.4. many parents allow preschoolers to watch the birth. Encourage To continue to evaluate their child’s school experience, parents to prepare children well for this experience, or else the urge parents to make a habit of asking children what hap- sight of their mother in pain and the wonder of birth can be- pened at school, what they learned, and the names of any come an overwhelming and negative experience rather than a new friends. For the remainder of the growing years, school positive one for them. will have important effects on their child’s development. By Preschool children generally do not ask how babies get in- taking an active role in education, parents influence what and side mothers to start growing or how babies get out at the how their child learns. end of the process. Should they ask, a suitable explanation Child care centers are often blamed for the spread of in- might be, “When a woman and a man love each other and fectious disease among the 5-and-under population because decide they want a baby, the man plants a seed inside the bringing together children from so many different homes to woman. The man’s seed and the woman’s seed grow together one setting each day does increase the risk of spreading con- in the special place inside the mother into a new baby.” Some tagious disease. Preschoolers in day care settings may develop parents prefer to say, “God plants a seed.” This answer may frequent upper respiratory infections or gastrointestinal ill- leave preschool boys feeling cheated that men have such a lit- nesses. Outbreaks of cytomegalovirus and human parvovirus tle role in this wondrous process. Perhaps a compromise (fifth disease) make working in such centers a particular haz- statement is, “God helps the man plant a seed.” If preschool- ard to pregnant women as these are potentially teratogenic. ers ask how the baby gets out, an answer might be, “The To prevent the spread of infection, children need to wash woman goes to the hospital and the doctor or nurse helps the their hands frequently and cover their mouths when cough- baby get out from the vagina.” ing. Child care centers where infants as well as older children Many new books for children explain where babies come are enrolled need to take special precautions against hepatitis from, including descriptions of sexual relations and orgasm. A or parasitic infections, as these can be spread by caregivers’ These are helpful for parents to read to a child to increase not washing their hands or the changing table after changing understanding. diapers. Hepatitis may be subclinical in the preschooler, 15610_Ch31.qxd 7/6/09 6:43 AM Page 878 878 UNIT 5 The Nursing Role in Health Promotion for a Childrearing Family TABLE 31.4 ✽ Questions to Use in Evaluating Child Care Centers Question Finding Management How long has the center been in operation? Length of operation does not necessarily indicate quality, but it allows you to locate other parents who have used the center to ask about their experience there. Is the center licensed, registered, approved, or Ask in your local community what agency has the responsibility inspected by the appropriate agency? for licensing child care centers. If not licensed, its quality is suspect. What are the qualifications of staff members? If staff members are teachers, more learning activities will be provided; staff should be qualified to perform cardiopulmonary resuscitation. Is there a fast turnover rate of staff? A fast turnover rate means little continuity of care will be provided (and probably suggests dissatisfaction with center administration). What is the child–staff ratio? A ratio of 3 or 4 children to 1 staff member provides time for quality interaction. What is the center’s policy on parental visits? Parents should be able to drop in at any time. Be wary of facilities that restrict parental visiting in any way. Physical Environment Is there adequate space in the center? There should be opportunities for rough-and-tumble and imaginative play and naptime as well as table activities. Does the space appear safe? Stairways should be fenced. No paint should be peeling. Can children get in and out of the building easily? A first-floor plan is safest. Fire exits should be well marked. An evacuation plan should be practiced. Is there a safe play area for children outside? Find out how often children are taken outside: once or twice a day, or only occasionally for “outings”? Is there a quiet place for naps? Ask if a child can nap if tired or has to wait until a set naptime. Can the bathroom be reached easily? Both potty chairs and small toilet seats should be available. If food is provided, does it meet preschool Food should be “preschool friendly.” recommendations? Is there adequate refrigeration? Food poisoning is a concern without refrigeration. Staff Philosophy Are the workers warm and affectionate toward the Watch how they greet children. They should ask questions and children? listen to answers. Do caretakers spend more of their time performing It is best if cleaning staff is separate from care staff. janitorial tasks (cleaning) and reprimanding children, or can they devote their time to the children? Is each child assigned to a particular caregiver on Ask staff to describe their care pattern; if this is not planned, little a continuing basis? continuity of care results. Are the children provided stimulating Imaginative items, such as a puppet theater, finger paint, and toys and equipment? water play, should be included. How do the staff discipline children? Do they yell The method should reflect the parents’ philosophy. Staff should or treat the children roughly? be able to talk to children calmly without raising their voices in anger. Is there a planned curriculum? There should be specific individualized goals the staff hopes to accomplish. Can the child pursue an individual interest? Play or learning activities should be individualized. Health Care Protocols How does the center care for an ill child? There should be access to a nurse. Staff should be able to evaluate for illness. They should know actions to take in an emergency. What precautions does the staff take to prevent Counter where diapers are changed should be wiped with a spread of infection? disinfectant; tissues and handwashing facilities should be present. Does the center follow good sanitary practices? Be sure the center requires waterproof disposable diapers to minimize contamination of the environment and other children, and separates diaper-changing areas from other activities, especially anything related to food handling. Observe adult caregivers changing diapers. Do they wash hands after each change? 15610_Ch31.qxd 7/6/09 6:43 AM Page 879 CHAPTER 31 Nursing Care of a Family With a Preschool Child 879 Under what conditions are children not allowed to A center should have a very specific policy on what illness attend the center? symptoms require a child to be kept home—and they should enforce this policy strictly. For instance, a runny nose may be acceptable, but a fever is not; children with chickenpox should be kept at home until the scabs are healed over. Talk to parents whose children have been at the center long enough to have experienced some illnesses, and find out what the family did and how the center responded. Children’s Behavior Do the children appear happy and relaxed? Observe for at least one morning. Do they rush to greet any new visitors? This could be a sign of boredom with their center’s activities and a strong need for adult attention. but other members of the preschooler’s family can develop Some kindergartens suggest children know how to tie overt symptoms as the illness spreads through the family their shoes, name basic colors, and print their name before (Friedman, 2009). they begin. Parents should familiarize themselves with any such suggestions from the school, but the wisdom of requir- Preparing a Child for School ing these skills can be questioned. Identifying colors should be established by this age, but some children are not coordi- At the end of the preschool period, children begin a formal nated enough at 41⁄2 years to tie their shoes or print. A better school experience as they enter kindergarten. Parents may contribution for parents to make toward their children’s wonder whether their child is old enough for this, especially achievement in school is to instill in their children the con- if a child’s birthday is in the late summer or early fall. If this cept that learning is fun and a certain child may not always is so, urge parents to discuss their concern with school offi- be able to do all the things other children can do, but trying cials to determine whether their child should be registered for to do individual best is what is important. Trying to make kindergarten or delayed for a year. As school involves a great children complete fine motor tasks for which they are not de- deal of children’s time and influences their future greatly, it velopmentally prepared does not instill that concept. is important for parents to take time to prepare preschoolers For children to do well in a formal school setting, they not only physically by being certain their immunizations are must be able to follow instructions and sit at a table and chair up to date but emotionally as well. for a short work period. When some parents examine their Essential to this preparation is the parents’ attitude. If child’s day, they are surprised to realize how few instructions school is always discussed as something to look forward to, as they give their child in a day. They put on the child’s coat, an adventure that will be satisfying and rewarding, a child pick up the child’s toys, and lead the child to the table for comes to view it as a positive experience. If school is pre- dinner. Similarly, they never encourage their child to spend sented as a punishment (“Wait until you get into first any time in a chair, which is something the child will have to grade—your teacher will make you sit up and behave”), there do for at least short periods in school. Coloring at a table can be little delight in anticipating it. rather than on the floor will introduce this situation without If a child was not attending preschool, some parents may any problem. have to change their child’s daily routine a few months in Finally, going to school is a form of separation and a new advance of beginning school to accustom a child to waking experience if a child has not attended child care or preschool, earlier or going to bed earlier. School has so many new com- so parents must make preparations for this. It might be good ponents that it is wise to try to eliminate as many distractions to arrange to have a child stay with another caregiver for like this as possible. part of a day. Staying at school can then be compared with If a child is to ride a bus to school, a parent might take a that event. child on a municipal bus as an introduction to this form of These are minimum preparations parents can complete to transportation. If a child is to walk, a trial walk is in order. In ready their child for school. Caution both parents and chil- either instance, safety should be stressed: “Don’t walk behind dren that no matter how hard they try, not everything can be the bus because the driver can’t see you” and “Wait for the anticipated; school will bring some new happenings that can crossing guard to help you cross the street.” not be predicted. If a child has been led to believe that learn- If a child will be required to take a lunch to school, a par- ing is fun and new experiences are enjoyable (creating a ent can introduce this new experience by preparing a bagged strong sense of initiative), these unpredictable instances can lunch at home some noon. If a child is to purchase lunch at be accepted as fun. The concept that new experiences are en- school, the parent can play “cafeteria” at home by serving a joyable will prepare a child not only for a first day at school meal buffet-style and letting a child practice walking from but for thousands of profitable days and experiences ahead one dish to another to select food. (see Focus on Nursing Care Planning Box 31.7). 15610_Ch31.qxd 7/6/09 6:43 AM Page 880 880 UNIT 5 The Nursing Role in Health Promotion for a Childrearing Family BOX 31.7 ✽ Focus on Nursing Care Planning A Multidisciplinary Care Map for a Preschooler With Fears Cathy Edwards is a 3-year-old girl. Her father cares up stories about events that cannot possibly be for her because her mother is hospitalized with true. When corrected, Cathy stutters so badly no one preterm labor for a second pregnancy. Her father tells can understand her. At a well-child visit, her father you he is concerned because Cathy talks constantly says he is concerned about his daughter’s crying at with an imaginary friend named Emma. She makes day care. Family Assessment ✽ Family lives in rented apartment She states, “He forgot me.” Child refuses to return to in inner city. Mother is hospitalized with complications of preschool. Cries, sticks finger in mouth to make herself second pregnancy. Father works as city police detec- vomit, and complains that her stomach hurts when he tive. Mother is stay-at-home mom. tries to drop her off now. Client Assessment ✽ 3-year-old girl within normal limits Nursing Diagnosis ✽ Fear related to separation and for height, weight, and development. Child currently abandonment during preschool period enrolled in all-day preschool program while mother is Outcome Criteria ✽ Child verbalizes fear. Father demon- hospitalized. Father picks child up after his work. Father strates measures to minimize child’s fears; reports by 2 arrived late to pick child up from preschool last week. weeks that crying episodes at school have decreased. Team Member Responsible Assessment Intervention Rationale Expected Outcome Activities of Daily Living Nurse Ask father to detail a Father describes differ- People are unable to Father details a typical 24-hour day in ences in family life solve a problem day and may express family to gain clear since wife has been until the extent of his wish to continue picture of child’s hospitalized, strain it the problem is clear. the preschool role and capabilities. causes on Cathy. experience Consultations Nurse Assess if father feels Encourage the father to Discussion with care Father states he will referral to child talk with the providers can help consult with guidance service is preschool staff about reinforce the preschool staff to necessary to help the problem and measures used by help solve problem. reduce fear. common methods to the father, providing decrease a child’s consistency and fear. thereby helping to minimize a child’s fears. Procedures/Medications Nurse Assess what father Instruct the father in Reassurance helps to Father describes steps knows about measures to help reduce a child’s fear he will take to be measures to reduce reduce child’s fear, of abandonment. certain he will not be fear in preschoolers. such as reinforcing late again at the time he will preschool for return. Will call if pick up. he’s running late. Post memo to self to pick her up. Nutrition Nurse Assess if child uses Stress effect of eating Frequent vomiting in Father states whether threat of vomiting at disorders is young children can he has ever seen any other time. potentially lead to fluid and pseudovomiting dangerous. electrolyte before. imbalances. 15610_Ch31.qxd 7/6/09 6:43 AM Page 863 CHAPTER 31 Nursing Care of a Family With a Preschool Child 863 The preschool period traditionally includes ages 3 to 6 Nursing Process Overview years. Although physical growth slows considerably during this period, personality and cognitive growth continue at a For Healthy Development of the Preschooler rapid rate. This is also an important period of growth for par- ents. They may be unsure about how much independence Assessment and responsibility for self-care they should allow their Regular assessment of a preschooler includes obtaining a preschooler. Most children of this age want to do things for health history and performing both a physical and devel- themselves—choose their own clothing and dress by them- opmental evaluation. Preschoolers speak very little during selves, feed themselves completely, wash their own hair, and a health assessment; they may even revert to baby talk or so forth. As a result, parents of a preschooler may find their babyish actions such as thumb-sucking if they find a child dressed in one red sock and one green sock, going to health visit stressful. A history that details their usual per- preschool with unwashed ears, or trying to eat soup with a formance level is therefore very important for accurate fork. They need reassurance that this behavior is typical as it evaluation. is the way that children adjust to new experiences. Parents Assess a child’s weight and height according to standard may also need some guidance in separating those tasks a growth charts (see Appendix E). Keep in mind these charts preschooler can accomplish independently from those that are based on average weights and heights of white American still require some adult supervision so they can set sensible children, so those for children from other ethnic or cultural limits. Setting limits this way protects children from harming backgrounds may not completely agree with these norms. themselves or others while participating in all the interesting Also assess a child for general appearance. Does the child experiences available to them (Thompson & Rivera, 2009). appear alert? Happy? Active? Healthy? Ask whether a child Box 31.1 lists National Health Goals related to the period. can play actively without becoming exhausted. Assess the teeth for presence of cavities. Evaluate for a symmetrical gait. As preschoolers develop frequent upper respiratory in- fections (the average preschooler may have 6 to 12 a year), assess for these as well. BOX 31.1 ✽ Focus on National Health Goals Nursing Diagnosis A number of National Health Goals are designed to tar- Nursing diagnoses for preschoolers typically concern get the preschool population: health promotion. Examples are: Increase the number of states with laws requiring Health-seeking behaviors related to developmental helmets for bicycle riders under 15 years of age from expectations a baseline of 10 states to 50 states. Readiness for enhanced parenting related to parent’s Reduce infectious diarrhea by at least 25% among pride in child children in licensed child care centers. Other nursing diagnoses include: Reduce acute middle ear infections among children age 4 and younger from a baseline of 344.7 health care Risk for injury related to increased independence visits per 1000 children to 294 visits per 1000 children. outside the home Increase the rate of use of child auto restraints Delayed growth and development related to frequent among children age 4 and younger from a baseline illness of 92% to 100%. Risk for poisoning related to maturational age of child Reduce the proportion of children 2 to 4 years of age Parental anxiety related to lack of understanding of who have dental caries in their primary or permanent childhood development teeth from a baseline of 18% to 11%. Imbalanced nutrition related to child’s many food Reduce the rate of deaths caused by poisoning from dislikes a baseline of 6.8 per 100,000 to 1.5 per 100,000 (http://www.nih.gov). Outcome Identification and Planning For many parents, preschool is a difficult time because a Nurses can help the nation achieve these goals by serv- child is at an in-between stage: no longer an infant, al- ing as consultants at day care and preschool settings to though not yet ready for formal school. Planning and es- be certain that protection from the spread of infectious tablishing expected outcomes for care of the preschooler diseases in these settings is provided and by urging often begin with establishing a schedule for discussing parents to protect against poisoning and to fit their chil- normal preschool development with the parents (this dren with helmets before beginning bicycle riding. should be done at all health maintenance visits). Planning A number of questions could benefit from additional for accident prevention such as how to cross streets safely nursing research, such as: What practices seem most becomes increasingly important as children begin to enjoy effective in reducing the spread of infection in day care experiences away from home. It is important to plan op- or preschool settings? What are the barriers to parents portunities for adventurous activities or messy play. When buying helmets for this age child? What proportion of asking parents to incorporate adventurous activities or parents know the signs and symptoms of common ill- messy material into a preschooler’s play, you may be ask- nesses their child might contract in a child care or ing them to do something they do not personally enjoy. preschool setting? Most parents do initiate these activities with their child if 15610_Ch31.qxd 7/6/09 6:43 AM Page 881 CHAPTER 31 Nursing Care of a Family With a Preschool Child 881 Patient/Family Education Nurse/nurse Assess father’s knowl- Review with the father Knowledge of normal Father acknowledges practitioner edge of typical the typical fears growth and develop- he deals with adults preschool fears experienced by the ment helps to in his business; such as preschooler, reduce the father’s expresses desire to abandonment, fear including those of anxiety about the learn more about of the dark. separation and behavior and preschool period. abandonment. possible causes. Psychosocial/Spiritual/Emotional Needs Nurse Explore with child why Encourage the father to Special time for a fa- Father states he will she is so fearful her set up a special ther and daughter plan for a special father will not return time for himself and enhances the time each week, for her. his daughter in the parent–child even if it is difficult evening or on relationship. to arrange because weekends, so they Consistently of wife’s hospitaliza- have a consistent adhering to this time tion and his irregular close time. helps to foster a work schedule. sense of trust and security and show he is dependable. Discharge Planning Nurse Assess if father would Arrange for a follow-up Follow-up provides Father states he is find a follow-up telephone call additional support receptive to telephone call (if desired) in and means for follow-up care. helpful. one week. evaluating the effectiveness of the methods used. Broken Fluency necessarily understand what the words mean; they have simply heard them, just as they have heard hundreds of Developing language is such a complicated process that other words and have decided to use them. Correction children from 2 to 6 years of age typically have some speech should be unemotional; for example, “That’s not a word I difficulty. A child may begin to repeat words or syllables, like to hear you say. When you’re angry, why don’t you say saying, “I-I-I want a n-n-new spoon-spoon-spoon.” This is ‘fudge’ (or whatever)?” The correcting is no different called broken fluency (repetition and prolongation of from that involved when a child uses poor grammar. If par- sounds, syllables, and words). It is often referred to as ents become emotional, a child realizes the value of such secondary stuttering because the child began to speak words and may continue using them for the attention they without this problem and then, during the preschool years, create. developed it. Unlike the adult who stutters, children are unaware that they are not being fluent unless it is called to their attention. It is a part of normal development and, if ac- Concerns of the Family With a Physically cepted as such, will pass. It is associated with rapid speech Challenged or Chronically Ill Preschooler patterns that may also be present in the parents (Savelkoul et al., 2007). A parent who knows a persistent stutterer or who Learning how to do things when you have physical limi- was a persistent stutterer as a child may react to this normal tations can be frustrating. Being unable to understand how broken fluency of the preschooler in a more emotional way to do things because of physical or mental limitations can than the problem deserves. If a child becomes conscious of a be even more so. To learn problem solving, however, is part disrupted speech pattern, it is less likely the problem will cor- of developing a sense of initiative. A preschooler with a rect itself. It is resolved most quickly if parents follow a few disability such as cerebral palsy has a greater need for simple rules, listed in Box 31.8. problem-solving skills than the average child, because even simple procedures such as eating or getting dressed can be “Bathroom Language” difficult if a physical challenge limits the options. Physically challenged or chronically ill preschoolers Many preschoolers imitate the vocabularies of their parents should attend a preschool program if at all possible because or older children in the family so well during this time that of the socialization benefits. Many of the learning activities they incorporate swear words into their vocabularies. that preschoolers enjoy, such as playing with paint, clay, or Parents may have to be reminded that children do not soap bubbles, are messy. If a child must remain in bed, 15610_Ch31.qxd 7/6/09 6:43 AM Page 882 882 UNIT 5 The Nursing Role in Health Promotion for a Childrearing Family BOX 31.8 ✽ Focus on Family ✔Checkpoint Question 31.3 Teaching Cathy’s parents want to know how to react to her when she begins to masturbate while watching television. What would Suggestions to Reduce Stuttering in the you suggest? Preschool Child a. They give her “timeout” when this begins. Q. Mr. Edwards says to you, “My 3-year-old daughter b. They refuse to allow her to watch television. stutters. What can I do to stop this?” c. They remind her some activities are private. A. What sounds like stuttering in a preschooler is often d. They schedule a health check-up for vaginal disease. broken fluency. Helpful tips to improve fluency are: Do not discuss in a child’s presence the difficulty she is having with speech. Do not label her a “stutterer.” This makes her conscious of her speech patterns Key Points for Review and compounds the problem. If you have to think about every word you say, it is difficult not to have Although preschoolers grow only slightly and gain just a trouble speaking. Listen with patience to what a child is saying. Do not little weight, they seem much taller than when they were interrupt or fill in a word for her. Do not tell her to toddlers because their contour changes to more childlike speak more slowly or to start over. These actions proportions. make a child conscious of her speech, and her bro- Erikson’s developmental task for the preschool period is ken fluency increases. to gain a sense of initiative or learn how to do things. Play Talk to her in a calm, simple way. It is difficult for a materials ideal for this age group are those that stimulate child to keep up with adult speech. If adults talk creativity, such as modeling clay or colored markers. slowly to her, she sees no need to rush and so Promoting childhood safety is a major role because speaks more clearly. preschoolers’ active imaginations can lead them into dan- Protect space for her to talk if there are other children gerous situations. in the family. Rushing to say something before a Appetite is not large in this age group because this is not second child interrupts is the same as rushing to conform to adult speech. a rapid gr