1. Separation
2. Strangers

1. Provide consistent caretakers.
2. Decrease parents' anxiety, Since it is transmitted to infant.
3. Minimize separation from parents.

1. Separation
2. Loss of control

1. Egocentric, primitive, magical (inability to recognize views of others)
2. Little concept of body integrity

1. Prepare child a few hours ro even minutes before some procedures, since preparation too far in advance produces even more intense anxiety.
2. Keep explanation very simple, and choose wording carefully, avoiding words with double meanings and other connotations.
3. Let the toddler play with equipment, put mask on teddy bear, and so on.
4. Minimize separation from parents; keep security objects close by.
5. Recognize that any intrusive procedure (e.g., rectal temperature or ear examination) is likely to provoke an intense reaction (the problern is not pain but fear of injury).
6. Use restraints judiciously, since being held down may provoke more fear or protest than the actual procedure.

1. Bodily injury and mutllatlon
2. Loss of control
3. Unknown, dark, being left alone

1. Preoperational: egocentric, rnagical, animistic, transductive
2. Tendency to repeat and use words they do not really understand, providing their own explanations and definitions
3. Highly literal interpretation of words
4. Inability to abstract
5. Primitive ideas about their bodies (e.g., fearing that all their blood will leak out if a bandage is removed)
6. Difficulty in differentiating a "good" hurt (beneficial treatmentl from a "bad" hurt (illness or injury)

1. Prepare the preschooler days in advance for major events (hours for rninor ones), since advance preparation is important.
2. Keep explanations simple and concrete, and choose wording carefully; do not use words like "cut," "take out," and "dye."
3. Emphasize that the child will wake up after surgery, since anesthesia described as "bcing put to sleep" may be frightening.
4. Use pictures, models, actual equipment, or hospital play, since verbal explanations are not enough.
5. Emphasize that the procedure or surgery is to help the child be healthier.
6. Repeat many times that the child has not done anything wrong and is not being punished.
7. Use explanations that include what the child will see, hear, feel, smell, and taste.
8. To check understanding, ask the child to reexplain the information to another person or doll.
9. Reexplain things every time they happen; do not assume the child remembers.
10. Listen to what the child says when playing; look at what the child draws.
11. Be honest! Explain. deviations from routines, unfulfilled promises, changes in plans.
12. Do not tell the child he wili feel better after surgery, since he will undoubtedly feel worse in the immediate postoperative period.
13. Since the child has a very limited concept of time, tie explanations to known events (e.g., "after your nap" or "after lunch")
14. Give child choices whenever possible. .
15. Reassure the child that the room will not be dark and that there will always be someone close by.
16. Do not tie evaluations of the child to behavior during the procedures (e.g., he is not "a good boy" for holding still but rather "That was good holding still")

1. Loss of control
2. Bodily injury and mutilation
3. Not being able to live up to expectations of important others
4. Death

1. Concrete operational period ,. -.
2. Beginning of logical thought but continuing tendency to be literal
3. Vague, false, or nonexistent ideas about illness and body construction and functioning
4. A tendency, particularly in older children, to nod with understanding when in reality they do not understand
5. Ability to listen attentively to all that is said without always comprehending : -..
6. Reluctance to ask questions or admit not knowing something the child thinks he is expected to know
7. Better ability to understand relationship between illness and treatrnent.
8. Increased awareness of the significance of various illnesses, potential hazards of treatments, life-long consequences of injury, and the meaning of death.
   

1. Prepare days to week in advance for major events because it is extremely important to the child's ability to . cope effectively, to cooperate, and to comply with treatment; in addition preparation gives the child a greater sense of control.
2. Have thc child explain what he understands.
3. Use body diagrams, pictures, and models, since these children enjoy lcamulg scientific terminology and handl ing actual equipment because their thinking is concrete (although somc older school-age children object to being seen looking at a doll)
4. Since these children are beginning to assert rnore independence, give them a choice of whether they want their . parents present during the procedure.
5. Since the peer group is now important, stress that this contact can be rnaintained.
6. Since the child does not want to be seen as different, emphasize the "normal" things the child will be able to do.
7. Give as many choices as possible to increase the child's sense of control.
8. Reassure the child that he has done nothing wrong and that necessary procedures and surgery are not punishments.

1. Loss of control
2. Altered body image
3. Separation from peer group .

1. Beginning of formal operational thought and ability to think abstractly
2. Existence of some magic thinking (e.g., feeling guilty for illness) and egocentrism
3. Tendency toward hyperresponsiveness to pain; thus reactions are not always in proportion to the event, and even minor injuries and illnesses are usually magnified.
4. Little understanding of the structure and workings of their body.

1. Allow adolescents to be an integral part of decision-making about their care, since they can project to the future, see long-term consequences, and thus are able to understand much more.
2. Since advance preparayion is vital to adolescents' ability to cope, cooperate, and comply, prepare them advanceÑpreferabiy weeks before major events.
3. Give information sensitively, since adolescents react not only to what they are told but to the manner in which they are told.
4. Explore tactfully what adolescents know and what they do not understand, since they are extremely concemed that others will think they are "dumb" or will discover their feelings of inadequacy, dependency, and confusion.
5. Stress how much adolescents can do for themselves and how important their compliance and cooperation are to their treatment and recover; be honest about the consequences.
6. Allow the adolescent as many choices and as much control as possible.
7. Respect the adolescent's need to exert independence from parents, and remember that he may alternate between dependency and a wish to be independent.

It is important to remember that the child's psychosocial developmental stage may not always match his chronologic age. Particularly in chronically ill cbildren, development may be delayed. For example, an adolescent who is delayed in development may need to be approached more like a school-aged child. When preparing children and their parents, it should be remembered that siblings also need preparation and reassurance. They may havc fantasies about what is happening to their sibling, and they may fear that they caused what happened (the illness or injury) or that the same thing will happen to them. It is ntal to discuss these issues with parents who may not rcalize what the siblings are experiencing, they may not know how to approach the preparation.