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Preschooler Psychosocial and Behavioral Development

Elizabeth K. Stanford, MD


Family Relationships

"Behavior around others" is comprised of the quality of relationships, social skills and emotional development, temperament, family discipline, biologically determined behavioral predispositions, and contextual stresses and supports. Controlling emotional states, including delaying gratification and tolerating frustration, separations, and fears without breaking down emotionally, should be mastered during the preschool period. Displays of uninhibited anger and frustration increase during the second year and then decrease in the third.


Tolerating separation from the parents is necessary to the growing autonomy of the child that is characteristic of this period. After the initial developmental task of forming attachments to their primary caregivers over the first 2 years, children now must hold the security of those relationships in their minds to function when separated to go or stay with other adults. The average 3-year-old child can separate easily from parents and go to known adults. However, there is great variability before this age, related primarily to individual temperament. Some children cope by adopting a transitional object, usually a soft, malleable object that can acquire the odor of the mother, to carry in times of stress or separation, which serves as a symbolic reminder of the parent. The use of such an object is associated with greater, not lesser independent activity.

Children who have insecure patterns of attachment or painful separation experiences, whether due to losses of primary caregivers or dysfunctional parent-child relationships, are more likely to react abnormally to separation. They may be excessively clinging and fearful or they may be socially promiscuous, showing affection indiscriminately.


Beyond the most common factor of temperament, children develop their emotional tone in several ways. The pattern of secure attachment to primary caregivers in infancy has some predictive power for "joy in mastery," "sociability," and IQ in the preschooler. Children younger than age 6 are especially responsive to the environment in terms of their emotional states.


Fantasy life becomes very rich during the preschool years. At first, it is indistinguishable from reality, resulting in a tendency for fears. By the age of 4, children frequently have frightening dreams that they can state are "not real," although this does not necessarily reassure them. Excessive fears or nightmares can be related to excessive life stresses on any developmental process; real dangers such as from abuse, dangerous surroundings, or sibling or peer bullies; or from the media. Temperamentally timid children may blame fears for their behavior. Aggressive children sometimes have excessive fears because they realize that they deserve retribution. Conversely, some children act aggressively to avoid that which they fear by attacking others before they are attacked.


Temper tantrums characteristic of 2-year-olds, but they should be infrequent by age 5, although there is another peak at 6 years, perhaps in response to the greater stresses of formal academic schooling. Temper tantrums can be exacerbated by: reinforcement by the parents; modeling in the family; exposure to violence, including physical punishment; temperamental low threshold, high reactivity, or lack of adaptability; fatigue; hunger; and lack of routines. Breath-holding spells may follow a tantrum. They occur in 5% of children younger than 8 years of age, are associated with a family history in 23%, and are related to other behavior problems in 18%. Eighty percent of these spells cease by age 5 and 90% by age 6. They are worsened by parental overconcern and attempts to intervene or to avoid tantrums through giving in. Children who have had a temperamental pattern of easy arousability, as well as those who have developmental weaknesses in expressive language or fine motor skills, often have more tantrums than expected for their age because of their repeated frustrations.


Almost all preschool children are noncompliant, at least some of the time--on average, they comply with adult requests about 50% of the time. This struggle for autonomy can be viewed as a positive milestone of development, with passivity representing a potential symptom of depression or intimidation. It is the parents' job to provide the structure that will influence the child to comply with our culture's standards for behavior. Research indicates that parents who are authoritative and firm but also warm, encouraging, and rational are more likely to have children who are self-reliant and self-controlled. Parents need to establish a system of discipline at least by the preschool years that includes three essential components: positive reinforcement for desired behaviors; consequences for undesired behaviors; and, most importantly, interactions that promote the parent-child relationship. Noncompliance as part of conduct disturbances is more common in families whose parenting practices include lax, harsh, or inconsistent rules; unclear, complex, or emotionally charged instructions; lack of warmth; or poor monitoring of the child.

One major concern of parents of preschoolers that affects both the relationship and the child's compliance is his activity level. Sturner found that 25.3% of parents of 4-year-olds included "overactive" in a checklist of adjectives about their child. However, poor control of attention is a greater detriment to academic success than high activity level. Multiple factors affect the attentional system, including health (eg, lead levels, anemia, past neurologic insult), current presence of medications, emotional problems such as anxiety or depression, environmental stresses, ability to see and hear adequately, hunger and fatigue, and temperament. Attention deficit disorder with (DSM 314.01) or without hyperactivity (DSM 314.00) is one of the most common mental health diagnoses of preschool children. Two to seven percent of preschoolers are affected, and it may coexist with oppositional defiant disorder (DSM 313.81 ).

A preschooler's aggression is said to reach the "problem" level when the negative impact of the behaviors causes people to change their routines, property begins to be damaged seriously, and the aggression is frequent. Symptoms rarely reach the level of a conduct disorder (DSM-PC 312.81) before 5 or 6 years of age, but the launching of such a trajectory can be seen.


Problems with siblings are a common concern of both children and their parents. Sixty-five percent of children report fights with their siblings that only decrease "some" after third grade and reduce "more significantly" after one of the children passes 15 years of age. Many factors are associated with greater sibling rivalry, including opposite gender, difficult temperament, insecure pattern of attachment, family discord, corporal punishment, and, most importantly, perception of differential treatment. The entrance of a new baby into the family is likely during the preschool years. How a child interacts with the new arrival in the first 3 weeks predicts interactions into the second year. More than 90% of children "regress" when a new baby is born, exhibiting behavioral changes of increased naughtiness, thumb sucking, and altered patterns of feeding, sleeping, or toileting that are considered by some to be signs of "imitation" of the newborn. These same types of responses occur under stress of any kind to the young child. The stress in this case entails separation and loss or threatened loss of the parents' love and attention as well as actual worries in older children over danger to the mother. Parents have been noted to become stricter in their discipline during and after pregnancy as well.

On the other hand, children, like adults, experience excitement, love of the infant, and enhanced self-esteem through their relationships with a new sibling. Preparation for the sibling through sibling classes, avoidance of forced interactions and descriptions of the mother's pain during labor and delivery, a strong pre-existing relationship between the older child and the father, good support for the mother postpartum, individual time continued with each parent, and intense empathetic talk about the new baby's feelings and point of view have been shown to be helpful. Logical practices to assist adjustment to a new sibling include having visitors greet the older child first, providing presents for the older child, giving the child some role in caring for the infant, and allowing an attempt (albeit with an attitude of mild surprise) when the older child requests a breastfeeding.

Interaction between siblings can be improved through prompt limiting of aggression toward the sibling, acknowledgment of the child's positive and negative feelings, reinforcement through praise, and teaching such strategies as distraction, trading, taking turns, and teaching. Siblings can be encouraged to cooperate by having the parents show that they value cooperation by talking about it and commenting on its presence or absence, having the parents distract the children from irritated interactions, setting tasks with joint goals, promoting noncompetitive games, and working continually for individualized treatment.

When siblings fight in spite of all efforts to guide positive relationships, it is important to know that parents' interventions tend to increase fighting several fold. Instead, a "graded" approach is better. Minor skirmishes are ignored if possible. More intense disputes can be handled by having the parent enter the scene, describe what is seen (especially the feelings and dynamics present), hear both sides briefly, then leave, stating confidence in the children's good intentions and ability to resolve it. More serious disputes should be handled similarly except that the children or the object of dispute should be removed. Physical battles require further actions, such as time-out for both children for the length of time appropriate for the younger child. Attempts to determine fault are generally unproductive, but chronic bullying or sibling abuse must be avoided. Positive sibling relationships often result in lifelong loyalty, friendship, and support.

Peer Relationships


One of the most obvious tasks of developmental progress for the preschool child is learning to interact happily with peers. At the age of 2 years, most play still is parallel, although children frequently look at peers and copy some of their actions. By the age of 3, children should have mastered aggression and should be able to initiate associative play with a peer, have joint goals in their play together, and take turns, although children generally can play effectively only with groups of children in the same numbers as their years of age. Thus, by age 4, children usually can play with three others fairly well. Fantasy or pretend play gains prominence at about age 3. Children can play out longer stories as they mature, with each child taking a specific role. By age 5, the child has many social skills expected of adults, such as responding to the good fortune of others spontaneously with positive verbal messages, apologizing for unintentional mistakes, and relating to a group of friends.

Pretend friends are very common in children up to the age of 4. These fantasy figures often fill the role of scapegoat for misbehavior, demonstrating that the child recognizes correct behavior but cannot always do the right thing. Alternatively, the pretend friend can be an "alter ego" or ideal self, such as an outgoing companion for a naturally shy child, who can help children through difficult or anxiety-provoking experiences. In general, children who invent imaginary friends are well-adjusted and believed to be creative, reflective, and cooperative. However, when fantasy friends dominate the child's play, his opportunities for interaction and social abilities should be evaluated.

Mastery of aggressive impulses should improve after 2 1/2 years of age. Prior to that time, most children will try aggression for "instrumental" reasons to obtain a desired toy. Hostile aggression (intended to hurt the other) is more common in boys, especially those who have poor impulse control, who are punished physically, who view violence, or who are suffering from a difficult separation experience. These aggressive drives, although quite variable from one individual to the next, usually are converted progressively into language and symbolic violent play. Children create gun play even without apparent models and use it to express aggression safely as well as to fantasize powerful roles that help them deal with their fears about their very real vulnerability.

Fathers play an important role in teaching young children to modulate their aggression, partly through horseplay on which the father sets limits. Boys raised without a father figure tend to have more difficulty mastering their aggression. Thwarting of any major developmental need can result in hyperaggressivity. Lack of adequate expressive language or fine motor skills; lack of appropriate parental limits (either through excessive strictness or little control); and modeling or exposure to violence through television, the neighborhood, or within the home also promote aggression.

TABLE 1. Peer Relationships





Amount of interaction

Parallel play with peers, copies others, self-talk, solitary play, offers toy, plays games

Takes on a role, prefers some friends over others, plays associatively with others

Interactive games, best friend <2 y difference, may visit neighbor by self, plays cooperatively with others

Group of friends

Duration of interaction

Briefly alone from adult, sudden shifts in intensity of activity

20 min with peers

Prefers peer play to solitary

Level of fantasy

Symbolic doll, action figures; mimics domestic activities hours later

Simple fantasy play; unfamiliar may be monsters

Elaborate fantasy play, distinguishes fantasy from reality, tells fanciful tales

Make-believe and dress up

Imaginary friends

May have one


If present, private

Favorite toys/ activities

Things that move, turn, or fit together; water; books; music; listens to stories

Listens to stories, dresses and undresses dolls

Sings a song, dances, acts, listens to stories

Rule use

Able to take turns, beginning property rights, "mine," "right places"

Shares some

Shares spontaneously, follows rules in simple games, facility with rules, alternately demanding/cooperative

Follows rules of the game, follows community rules


Aggressive to get things

Negotiates conflicts

Wants to please friends


Social development during the preschool years should include acquisition of the human characteristics of shame, guilt, empathy, self-awareness, and classification of events and preferences among peers. Although prosocial behaviors such as concern over the distress of others is present during infancy, children initially can take another's point of view with true empathy at around 3 years of age. However, this does not protect others from impulsive acts or prevent "cheating" when temptations arise, even in school-age children. Two-year-olds have a sense of self, exemplified in the classic experiment of recognizing rouge on the nose as being a difference in their own appearance. Three-years-olds do not yet compare themselves with others in a rank order, eg, as "braver" or "smarter." A profound lack of feelings for others can signal pervasive developmental disorder (Autistic Disorder DSM-PC 299.00) or reactive attachment disorder (DSM 313.89). Autistic disorder is defined by delays or abnormality in social interaction, social use of language, or symbolic or imaginative play.


Sexual feelings are clearly present before the preschool years, but become more obvious now. Handling the genitals for pleasure (masturbation) peaks at 2 1/2 years of age before becoming more private, and exploring the genitals of others also is common. Compulsive masturbation or that which interferes with other activities or infringes on the rights of others is a problem that suggests sexual abuse. The solidification of gender identity and gender role identity occurs during the preschool period. Freud entitled this the Oedipal period in recognition of the working through of identification with the same-sex parent and letting go of sexual desires and possessiveness toward the opposite-sex parent in the face of competition with the spouse. Parents often are dismayed by their child's gender-stereotyped play, even when the family has espoused less traditional roles. Occasional cross-gender role playing and dressing is common, especially in girls, but it is of concern only if it persists for 6 months or includes statements that the child would prefer to be of the opposite sex and total rejection of attributes of his own sex (DSM-PC Cross-Gender Behavior Problem V40.3 or Childhood Gender Identity Disorder 302.6).


Throughout the preschool period, any child from age 2 to 5 years could regress momentarily to total infantile dependence, such as going limp and saying "I'm a baby," then quickly show absolute independence, declaring "I can do it myself," even when the task is something he or she has never done before.

Development of Independence






Uses utensils

Spills little, pours some

Helps set table

Helps cook


Undresses, pulls on simple garment

Dresses with super-vision, unbuttons some

Dresses all but tying


Clean and dry, but with adult effort and motivation

Clean and dry by self-motivated approach



Appropriate eating behaviors for a 2-year-old child include being able to use utensils well but with continued messiness and insistence on rituals. Attempts by a parent to intervene in preventing the mess should be avoided, and their reasons for such interventions should be elicited. Such reasons may include impatience with "babyishness" that the mess represents or a need to continue spoon-feeding their "baby" instead of allowing the autonomy that self-feeding represents. By age 3, children can be expected to feed themselves without spilling much and, if given the opportunity to pour from small containers, will be able to gauge the capacity of a cup correctly. A 4-year-old can be expected to help set the table, and a 5-year-old will assist in mixing and cooking food, if given the opportunity. Preschool-age children should have adequate patience to sit at the table for 10 minutes, but often not any longer. Parents should be asked about their expected length of mealtime cooperation when there are parental complaints; excessive expectations may be the real problem. Mealtime behavior is a frequent complaint during the preschool years; 85% of children are rated by their parents as being picky eaters. When growth is normal (height and weight greater than the third percentile), this may be considered an Inadequate Nutritional Intake Variation. If the child fails to maintain growth velocity for more than 6 months, it is an Inadequate Nutritional Intake Problem. If the young child loses a significant amount of weight or fails to gain weight for more than 1 month, it is a Feeding Disorder.

It is often difficult for parents to cede control of feeding after infancy. The child's decreased caloric needs after 1 year of age; cognitive awareness of differences in texture, taste, and placement on the plate; and desires for autonomy in all areas can make mealtimes ideal battlegrounds. Problematic mealtime behaviors include throwing food and utensils, hitting and kicking siblings, climbing onto parents' laps, eating off others' plates, requesting a different menu, and dominating the conversation. Clear limits need to be set for these, with time-out for aggression and removal from the table until a snack time at least 1 hour later for other disruptive behavior. It is vital for both parents to agree on (and other relatives to stay out of) the plan for this and other behavior problems.

The 2-year-old will be interested but incomplete in washing hands. A struggle often ensues if the child's expectation for continued water play is violated. They assist in bathing themselves. Three-year-olds can wash and dry their hands and face without needing a rewipe. The 4-year-old can towel dry after a bath and even brush his teeth reliably. The 5-year-old can bathe or shower without assistance.


Parental report of independence in dressing should reveal the 2-year-old's ability to and penchant for taking off clothing, including shoes, socks, and pants, but a lack of success in dressing beyond cooperation by thrusting arms through sleeves. Although the 2 1/2-year-old can undress completely, there may be typical resistance to dressing and attempts to run and turn it into an exciting chase game. Parents ideally can cajole with promises of a bedtime story or turn the dressing into a speedy, game-like activity. The 3-year-old will begin to put on pants, socks, and shoes, but cannot be expected to button. His capacity to demonstrate this new dressing ability depends on the level of fatigue and general mood. A 4-year-old usually will be able to dress completely, including distinguishing front from back, but will not be able to tie. These children also can put clothes away without assistance. Dressing difficulty at age 5 years may be due to dawdling or a parental need to speed through the morning events. Children need a dependable routine that accommodates their speed and abilities.


To be independent in toileting, children must be able to signal the need before voiding, walk, climb, pull their clothes up and down, be dry for several hours during the day, understand what the toilet is for, and be motivated to model after adults and please them. On average, these skills come together around age 2 1/2, although 61% of cultures train at the age of walking or even during early infancy. However, such training generally requires much effort on the part of the parents. It is also important that parents who attempt early toileting not misinterpret the likely episodes of regression as behavior that must be punished. There is a wide range of normal for readiness; failure to be trained is not considered abnormal until after age 4.

Problems associated with delays in toilet learning include relapses in training, toileting for only urine (or only stools), accidents, and fears of the toilet. Toileting is such a strong symbol of "growing up" that it often assumes great importance to both parent and child, resulting in battles over control. Parents who are either overcontrolling or underregulating frequently have children who have toileting problems during the preschool years. These problems cannot be resolved until the issues of control have been managed along with any concomitant constipation.

Relapses in toileting occur in 50% of children in the year after training. Many children, especially hyperactive ones, are too busy to sit or return from outdoors. Fears of the toilet can be due to accidents, but also may be developmental fears related to body integrity and magical thinking about the potential for disappearing down the toilet. The degree of modesty in the home or exposure to erotic media may need to be altered to relieve sexual tensions that exacerbate fears. Sexual misuse also should be considered when a new toileting problem occurs.

Nocturnal enuresis is so common that it can be considered normal up to age 6. At age 5, 11% of girls and 14% of boys still are wetting the bed regularly. There is a 15% annual decrease in that event after that age. A return to enuresis after months of dryness is common around age 4. Stressors, presence of urinary tract infection, or signs of sexual abuse should be evaluated. The key task of the clinician during this age period is to assure that the child is not being shamed or punished for enuresis by parents or siblings, often by reflecting on the family history (positive in 75%) of onset of night dryness to elicit patience.

Motor and Cognitive Aspects of Play

The type of play a child prefers reflects cognitive, fine and gross motor, and visual perceptual motor skills. Children will not play for long at activities that frustrate them because of a lack of ability. Fine motor and visual perceptual motor skills are being refined during these years, but there is a broad range of time for normal acquisition (DSM-PC Developmental Coordination Variation V65.49). Observing the child copy shapes can reveal much about attention, temperament, experience with pencil and paper, and progress in skill acquisition. Imitating the examiner drawing the same shapes generally is possible 6 months earlier than the harder task of copying, which, therefore, should be requested by the examiner first. Pencil grip begins awkwardly at age 2 years, moving from the end of the pencil to the mature tripod grip by age 5 years. Lack of control to stop repetitive circular scribbling at 2 1/2 years transforms into controlled closure of circles, followed by the isolated branches of the cross, square corners, and finally the difficult ability to change direction that is needed to complete a triangle.

Motor and Cognitive Play Skills





Pencil grip

Point down

Awkward, high






Person-body parts


Vertical, scribble





Horizontal, cross

Circle before cross

2 parts

Longer line

Cross before square

6 parts


Square before triangle

10, including head, body, arms, legs


One hand

Across paper

Cuts out square

Block tower


Tower of 10

Block figure

Aligns 4 for train

3 block bridge

5 block gate



Turns pages 1 at a time

Ties knot in string, prints letters

To draw a person, additional details are added progressively into the school-age years, starting with a total of two body parts at age 3 and four details per year thereafter. The steady progress in the ability to build higher and higher towers from infancy into the 6-block tower built by the 2-year-old and the 10-block tower by the 3-year-old has been found to be related to general cognitive capacity. Copying designs from blocks requires attention to the details of the model and perception of its form, not simply fine motor skill.

Fine motor skills. Parents generally describe only extreme problems with fine motor skills. They may notice a need for help with utensils, continued finger feeding, or difficulty in dressing oneself after the usual ages of attainment. Delays in these attainments without evidence on examination of skill deficits may be due to inappropriately low expectations by the parents and lack of opportunity, which should be addressed. Vulnerable child syndrome may be signaled by lack of self-care. Some lag in gross or fine motor coordination in areas such as running, climbing, self-care, drawing, or onset of handedness is common and now defined by DSM-PC as a "problem" (Developmental Coordination Problem 781.3) when more than two but not most of these areas are delayed enough to cause some impairment. It is considered a "disorder" (Developmental Coordination Disorder 315.4) if most areas are affected. The prevalence of the Developmental Coordination Disorder is estimated to be as high as 6% among children ages 5 to 11 years.