4-Year-Old Well Child Check

Four-year-olds have a lot of energy and move fast. They love to play and are boisterous, noisy and silly and talk constantly.

Please click here to download the 4-year developmental assessment form that you will need to complete and bring with you to your child's appointment. Due to copyright laws the documents are password protected, the password is child.

The four-year-old begins to develop a clearer sense of self as an individual with definition beyond the immediate family. Exploration of the place, the roles, and the identity that one has is the proper work of this age. This is done through observing the modeling of significant others, trying out various persona in looks and actions and experimenting with social roles in the family, the preschool, the neighborhood, and with peers. These are the child's laboratories in developing a real sense of self in many dimensions. The preschool child is faced with the task of gaining enhanced mastery over emotional, sexual, and aggressive impulses. He is learning not only who he is, but how he is expected to behave. More self-control, self-care, and self-regulation should be asked of him to support healthy development; the family must be ready to give more over to him at this age. If not, struggles, diminished self-esteem, and anger or sadness ensue.

Behavior

Being Four

The four-year-old is more of everything. Expansive and extreme, wild and wonderful, energetic, ridiculous, and silly. She likes new things, is a nonconformist and a free thinker, and a very fast study. This year you may ask yourself in wonder "What in the world did I do to have a child like this?" The answer is, there's nothing much you could or can do. Your child is just being four.

Thinking

By now images and symbols are old hat to your four-year-old, and she's used to using one object to represent another. Very often she will mix up fantasy and reality in her mind - she's not really a liar and a teller of tall tales - it's just the way she thinks. At four she's just beginning to understand the idea of classification - that a tulip is just one kind of flower, for example, or a football is one type of ball. She can understand the idea of parts and wholes, and can tell you if a leg is missing from a table in a drawing. She knows what things are made of, too - that the table is made of wood. And she may even know her colors. Four-year-olds are learning about cause and effect, and like to play games like "what would happen if…" She is full of information and looking for more. And because she's so good at expressing herself, her relationships with others are more rewarding.

Feelings

Four-year-olds can strut around and brag about how great they are during the day, and then wake up at night from a bad dream and suck their thumbs. Be careful that they don't fool you - they seem to be older than they really are. For all their exhibitionist behavior and aggressiveness, the four-year-old can understand and respond very well to limits. And even though they act more independent, they are aware of criticism and thrive on praise and support.

Because four-year-olds seem precocious, many parents try to tell the child he's "too old" for finger-sucking or that favorite stuffed toy. But these are stress reducers, and to take them away can make a child more anxious. Four is a time of fast changes and big risks, and often night wetting, bad dreams, stomachaches and headaches are normal responses to subconscious tension or fear.

Talking

A four-year-old is apt to open a conversation with his name, his age, and his address. And after that he can talk up a storm, using as many as 2000 words by the end of the year, and using them well. By now he knows most of the sounds of the English language, and loves to use them at different volumes - chattering, whispering, singing and shouting. He loves nonsense words and silly rhymes, and can make up rather violent little stories. Ask him the difference between a penny, a nickel, and a dime, and he may know that plus the alphabet and his numbers.

He's fun to talk to, because his sentences may be as long as six words, and he's beginning to use plurals correctly but his word endings aren't quite right yet. He's absolutely fascinated with the world around him, and his "how", "why", "when" questions are the way he's trying to make sense of it all.

Playing

Most four-year-olds are gregarious and can play in groups although they still do best with just one other child. They are boisterous, noisy and silly, and talk constantly as they play. In fact they can get carried away, especially with physical violence. Your four-year-old probably loves to play house and store, play indoors and go on little trips. This is the perfect age for a trip to the zoo, a ride on a train, or a walk in the country. A trip to the library is just right for your four-year-old. She can learn all about books and get truly engrossed in story-telling hours.

At four, children can construct whole cities, farms, and elaborate forts and they're wonderful at creating play situations from ordinary materials. Pretend play, role play, and playing with dolls are very elaborate this year, and fantasy is a way to act out their feelings. Four is also a truly creative age, and art supplies and music makers are favorite playthings and should be encouraged. Also anything "scientific" like magnets, puppets, and puzzles are well received. This is also a good year for a pet if Mom can take responsibility for it.

Personality

Many experts feel that a child's personality is already set at birth and that your parenting and the environment can do little to change it. What you can do is help your child develop the type of personality he has. You may have, for instance, a high-energy child who is always on the go and needs little outside stimulation. Or you may have a low-energy level child who does need to be encouraged to take risks. You may have a "right brained learner" who sees a whole toy box first, then selects a toy or a "left brained learner" who looks at each individual toy first, then sees the toy box. Your child may "stick to it" or tire easily. He may be able to organize time, or needs you to help him do it. He may be intellectual, or an emotional reactor. He may be easily difficult, fast or slow. All children seem to have one time of day that's better for them and one area of the body that seems to be a target of stress.

Your child's personality is expressed in how he eats, sleeps, plays and even in his toilet habits. If you are alert of his weaknesses and encourage his strengths, and understand and accept him for what he is, you will both be happier.

Body Control

Four-year-olds have a lot of energy, and they move fast. They can climb like monkeys, and hang upside down. They can swing all by themselves, do somersaults, hop, skip, and jump. Because their balance is better, they are good at riding tricycles. They can play ball and do gymnastics, and get carried away with their newly developed body control that they often take too many chances. Your four-year-old will develop better hand control too, and may be able to button, lace her shoes , and string smaller beads. She can use tools, paint with a brush, and use scissors. She may be trying to print her name, but fine motor tasks are at the beginning stages, so praise her efforts, but don't expect perfect control. When she eats, it's with a fork and spoon, and afterwards she can (and should) brush her teeth.

Development

Movement
  • Hops and stands on one foot up to five seconds
  • Goes upstairs and downstairs without support
  • Kicks ball forward
  • Throws ball overhand
  • Catches bounced ball most of the time
  • Moves forward and backward with agility
Hand And Finger Skills
  • Copies square shapes
  • Draws a person with two to four body parts
  • Uses scissors
  • Draws circles and squares
  • Begins to copy some capital letters
Language
  • Has mastered some basic rules of grammar
  • Speaks in sentences of five to six words
  • Speaks clearly enough for strangers to understand
  • Tells stories
Cognitive
  • Correctly names some colors
  • Asks a lot of questions
  • Recognizes familiar words in simple books or signs (STOP sign)
  • Understands the concept of counting and may know a few numbers
  • Approaches problems from a single point of view
  • Begins to have a clearer sense of time
  • Follows three-part commands
  • Recalls parts of a story
  • Understands the concept of "same" and "different"
  • Engages in fantasy play
Social
  • Interested in new experiences
  • Cooperates with other children
  • Plays "Mom" or "Dad"
  • Increasingly inventive in fantasy play
  • Dresses and undresses
  • Negotiates solutions to conflicts
  • More independent
  • Thrive on praise and support
Emotional
  • Imagines that many unfamiliar images may be "monsters"
  • Views self as a whole person involving body, mind and feelings
  • Often cannot distinguish between fantasy and reality
  • Takes turns and shares; may still be rather bossy
  • Can express anger verbally rather than physically (most of the time)
  • Still throws occasional tantrums over minor frustrations
  • Capable of carrying on elaborate conversations
  • Capable of feeling jealous
  • Understands the concept of lying - imagination often gets in the way
Indicators For Concern
  • Is excessively aggressive or withdrawn with other children
  • Plays in repetitious, stereotyped ways
  • Is less physically capable than other children of the same age
  • Still speaks unclearly or is not talking in sentences
  • Is unable to follow verbal instructions
  • Is not talking during play

Growth And Nutrition

Childhood obesity has become one of the main concerns of our nation in the Twenty First Century.

Daily nutritional guide for the 4 to 6 year old

Grains - One Serving

  • 6/11 servings/day Bread, ½ slice
  • Cereal, rice, pasta cooked, 1/3 cup
  • Cereal, dry ½ cup
  • Crackers, 3 to 4

Vegetables

  • 2-3 servings/day Vegetables, cooked or canned ¼ cup
  • Salad, ½ cup

Fruits

  • 2-3 servings/day Fruit, cooked or canned, ¼ cup
  • Fruit, fresh, ½ piece
  • Juice, 1/3 cup

Dairy

  • 2-3 servings/day Milk (does not have to be whole) ½ cup
  • Cheese, 1 ounce
  • Yogurt, ½ cup

Meats and Proteins

  • 2 servings/day Meat, fish, poultry, tofu, 1 ounce (2 1 inch cubes)
  • Beans, dried, cooked, 1/3 cup
  • Egg, 1

Calcium 800 mg/day

Keep snacks healthy, encourage drinking water and keep juice to a minimum.

Common Issues And Concerns

Discipline

This year or next year, your child's conscience will emerge. The conscience acts as a stand-in for the parent - an internal voice that will tell him what is "right" and "wrong" in terms of behavior. A strong conscience can help a child to fit into society. It sets morals, ideals, and behavior standards, and lets the child judge and criticize himself. It helps transform basic drives into acceptable outlets, and provides guilt feelings appropriate to the situation. A weak conscience on the other hand, is too strict, overly critical, and easily corrupted.

Although the conscience will do part of your job, you will still need to discipline your child. The disciplinary actions you take with him are a way to help him set his limits. Without them, he will be anxious, provocative, demanding, and "spoiled."

To effectively discipline your child, you need to be firm, and explain to the child what he did wrong. Make your punishment "fit the crime," be concise, and be "immediate." To be effective, discipline should not be delayed. Finally, continue to be firm, but also be understanding. Selma Fraiberg, author of The Magic Years says: "the child cooperates in his training because he wants parental love and approval and he feels parental disapproval as a temporary withdrawal of affection and esteem."

Two key elements to good discipline are consistency and balance. Be sure you disapprove of the same thing tomorrow that you punished for today. And when you catch your child doing something well or right, praise him so he doesn't get only negative messages.

Reading

It is important to read to you child. Children not only love to be read to, but the story and fairy tales assist kids in working through their own fantasies, conflicts, and experimentation with roles. Book reading starts in the first year with familiarity, turning pages, and looking at and pointing to pictures and progresses from there. At the age of 3 to 4, children learn how the pictures are connected in a story and then can tell the story with no book present. By ages 3 to 5 most children are just beginning to learn the alphabet - singing the ABC's and knowing the letters of their names. Read alphabet books with your child and point out letters read. Help your child recognize whole words as well as letters. If children are read to at home, they will do better in school, have more complex vocabularies, and ask more complex questions. A good screening tool to assess your child's pre-reading skills can be found at Get Ready to Read!

Television

Even though your child is older now, it's important to realize that until age seven, television and movies are risky business. Because your child still can't differentiate between reality and fantasy, certain scenes-even in classic family entertainment movies-can terrify her and cause nightmares. Although television seems to have a calming effect on children because they watch it quietly, it is a very stimulating medium. The fast, animated pace and short segments are a suspected cause for making children impulsive and creating short attention spans, which become a problem in school. Studies have shown that although children can learn from imitating television, they do not learn to think or solve problems. It's been proven that children who watch hours of television every day lag behind their peers in development. Remember, children can't set their own limits.

The average American watches 6 or more hours of television per day, and most children over age 2 watch at least 2 hours per day. The influence of TV on young children has been a matter of concern for the past five decades. These concerns include the content of the material, and what other parts of a child's life TV displaces. Not all TV is bad. Many shows are developed with the young child's needs and interests in mind, such as pre-academic, social, and fantasy programs. Children are exposed to things, good and bad, that couldn't otherwise be available in the home.

Basic Guidelines for parent management of Television and Videos:

  • Spouses should discuss the TV plan for their child
  • Never use TV as a reward
  • Limit to 1 hour per day maximum
  • Plan what is watched
  • Turn off the television when the program ends
  • NO TV during meals
  • Consider channel lockouts or V-chips
  • Specifically suggest and set up another activity
  • Discuss programs with kids, including advertising
  • Watch TV with kids
Sex Play

By the fourth year, children become interested in sex differences and body functions. In fact, the first place your four-year-old may want to visit in a friend's house is the bathroom - out of curiosity.

Four-year-olds pepper their language with "toilet talk" and are very interested in "playing doctor." They're fascinated with their own and other children's genitals, and may handle their own. Children do have sexual feelings, and in moderation this is perfectly normal. Instead of seeing such behavior as "bad" and punishing or ridiculing your child, try to be casual about it. You can try to keep your child out of situations that involve public sex play and supervise play more closely, but you probably can't put a stop to it. Sex play is almost universal at this age, and no child is to "blame" more than others... especially because the initiator may be your own child! Given the four-year-old's insatiable curiosity and newly discovered sex identity, all this is normal. You can use this stage to see how ready your child is to learn about where babies come from, and then explain the privacy of sexual behavior. Your pediatrician can be a big help here.

Four is also the age at which children develop a crush on the parent of the opposite sex. It can be very touching, with marriage proposals, but it is also a conflict with the same-sex parent which can erupt in hostility, guilt feelings, and bad dreams. You may need to put two and two together here and get to the cause of the behavior. Understanding and realizing that this is just a stage will help.

Health Care

Your doctor is experienced in all the stages your child will go through developmentally, and has seen may children go through the same stages. He is an excellent resource for you because he knows your child. He can be a help with behavioral problems such as negativism, temper tantrums, sibling rivalry, poor eating habits, shyness and oversensitivity, toilet training and bed-wetting.

Because this is such an active age for your child, both you and your pediatrician will need to keep your eyes open for changes. The years between two and six are the peak years for childhood illnesses, especially contagious diseases, because the child is exposed to more people outside the home. You should make it a point to schedule regular checkups and an annual exam on or near your child's birthday. Eyes and ears should be examined regularly, and your doctor's office can arrange an immunization schedule so your child can be properly protected.

Remember, it's difficult to diagnose a child, so you need to be extra alert. These are the years that determine health in adulthood, so if you have any doubts at all about a fever or a change in health, call our office.

Common Health Concerns

Stomachaches

Stomachaches are very common in four-year-olds and five-year-olds - especially in girls. If your child complains of recurrent stomachaches, see if you can find a pattern to them. Do they happen in the morning before she goes to preschool, for example, and not on Saturday or Sunday when she's home? If so, they may be her way to express anxiety.

Children seem to develop one "weak spot" or organ that responds to stress. Whether it's the stomach or the lungs or the bowels, it's often an indicator of just what troubles the child. It's important to see which stress sets off the symptoms. And when the symptoms occur, its time for the child to slow down and relax.

If your child has a stomachache, quiet her and feel her abdomen for tenderness. If she has sharp pains in one area, pain which gets worse as time goes on, no bowel movements, vomiting or a hard "rocklike" stomach, call your pediatrician immediately.

Headaches

A child first complains of headaches at about the age of four, early morning and late in the afternoon are common times. Sometimes mild headaches are a form of resistance to pressures on the child or low blood sugar - and will respond to rest or a glass of juice. As a parent, it would be a good idea to note on your calendar when headaches occur so you can see if there is a common cause. Migraine headaches can be inherited, so you should be aware of any family history of migraines. Headaches can also be caused by allergic reactions.

If headaches become worse over time and occur more often, and if other symptoms surface like eye problems, stomach problems, or weakness, call your pediatrician.

Safety

Because your four-year-old is a risk-taker, accidents can happen easily. Accidents are most common when the child is tired and hungry, when he's in a new environment, or when new people are caring for him. If you are pregnant, ill, having trouble with your spouse, rushed, or too busy, an accident could happen. Be sure you know the stage of development your child is in, so you can anticipate new risks.

At four, your child should have a good set of safety guidelines-rules for riding a tricycle, crossing the street, playing on the playground, and swimming. But accidents will happen, and to deal with the unexpected, you should know some first aid. Get a good first aid book for children, and keep a copy on hand for your family.

For further information on safety, you may also visit Healthychildren.org.

Bibliography

A Parent's Guide to Childhood Obesity: A Road Map to Health, 2006.

Baby and Child Care. Spock, Benjamin, New York, Pocket Books, 2004.

Caring for Your Baby and Young Child: Birth to Age 5. 4th Edition.

Caring for Your School-Age Child: Ages 5 to 12.

Encounters with Children: Pediatric Behavior and Development. Suzanne D Dixon, Martin T. Stein. Mosbys, Inc. 2000.

Guide to Your Childs Nutrition: AAP 1999 William Dietz, Loraine Stern.

The Magic Years: Understanding and Handling the Problems of Early Childhood. SH Fraiberg. New York, Charles Scribner & Sons, 1996.

Touchpoints: Both Volumes of the Nation's Most Trusted Guide to the First Six Years of Life. T. Berry Brazelton, October 2002.

www.verywell.com

Next Well Child Visit

The next routine physical examination is at five years of life.