The Canandaigua Medical Group
Well Child Care - Your 6 Year Old Child

Your doctor knows you and your family best. Nothing takes the place of talking directly with your doctor about your health and questions that you have. The information presented here is not medical care or treatment and is not specific to your situation. You need to contact your own doctor for your medical care.

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YOUR SOUND SIX YEAR OLD

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By now your child is beginning to have the concept of a sound body and mind. The habits you’ve instilled by good consistent discipline and excellent example are paying off as you see successful social, cultural, spiritual, and academic adjustment into a larger world. Self-confidence and a sense of purpose in the grand scheme of things emerge, and industriousness with expected tasks is expressed. Do not give up your goal of incorporating values and moral decision making abilities in your child just because he/she is not under your direct supervision. Now is crucial time to reestablish your role as the primary adult influence and to make sure your limited time with your child is supportive, directive, intimate and continues to be pleasing. Now is also the time to address emerging problems in peer or teacher relationships, in emotional or behavioral difficulties, or in physical problems that may be rooted in adjustment disorders. Positive ways to discipline include establishing and keeping bedtime and TV rules, continuing chores consistently, and working on verbalizing disagreements and coming to compromises, if the situation is negotiable. Provide a small allowance with part set aside for saving, spending and charity. Promote social and community activities outside of the home (but don’t get consumed), and continue to be a good role model. Encourage age-appropriate independence and responsibility taking. Praise liberally, but not falsely. Show your child how important he/she is to you by spending focused time together; if possible, separate time from the rest of the family activities on a regular basis. Same sex parent time and opposite sex time are both important!

Most of the motor gains now come in the form of smoothing and coordinating movements, often in athletic areas. Differences among children can be magnified to embarrass and humiliate some, so activities that encourage stamina, teamwork, and have some mental challenge can be used to equalize if one is not a gifted, strong, and balanced superstar. Unnecessary movements during activities begin to cease (disappear by 8), bicycle, skating and ball skills emerge and improve (especially catching and throwing), and sophisticated walking maneuvers are experimented with. Fine motor gains enable shoe tying, letter formation, neat eating, copying a square next to a circle (touching), and folding a paper in half three times. Some letter reversals are common. A ten block pyramid can be imitated. A person now takes on up to 12 details or features. A diamond is copied. Balance skills enable smooth skipping, standing on each foot alternately with eyes closed and jumping off a stair with ability to land on toes.

Cognitive skills progress from uni-dimensional thinking to consideration of multiple factors in an effort to deduce a conclusion. Concepts of “greater and lesser”, “larger and smaller”, “sooner and later”, and comparisons enable math learning. Your six year old should count to well above 10, print first name, print numbers to 10 and begin to add and subtract numbers under 5. He/sh knows right from left, knows number of fingers and toes, and can define words more specifically. Dysfluencies should resolve, but enunciation can still be poor in complex consonant combinations (street, breath). Sequencing skills also emerge. Other issues that may be raised particular to this time include some bad habit development such as unkemptness, poor grooming and messiness. Sometimes these are due to delays in fine motor acquisition. Sufficient time without nagging, simpler clothes and toys may help. If negativism is the cause (it may be tricky to sort this out), a non-emotional discussion with a reward and punishment system can be set up (e.g. “points” or sticker chart for each successful grooming skill or chore completion). A larger reward should be provided at the end of a week for a certain number of successes with removal of points for non-compliance. There should be room for debate and reorganization of the plan periodically.

School avoidance or refusal can emerge and must be handled promptly. Above all, keep the child going to school every day while the issues are sorted out. Try to identify specifically the fears or things trying to be avoided (it could be as simple as no privacy in the bathroom). Re-evaluation for subtle learning disability should precede if a concrete reason (e.g. a bully), cannot be identified as the primary cause. Academic pressures, real or perceived, should be modified to the child’s abilities (the teacher and counselors will be needed here). Remember, 50% of all children are below the mean! Social exclusion due to peer differences begins and is a serious concern. Do not diminish the concern, rather try to put it in a greater context, (e.g. “it’s really not important to have a friend who tries to get you to do the wrong thing.”) Offer comfort without babying, offer alternative social outlets (scouts, church groups), and try to avoid direct intervention in particular relationships. Do not compromise family values!

Peers begin to try to affect your child in negative ways. Tolerate small non-conformities (e.g. limited home make-up play), but you may need to restrict contact with severely negative influences (or, if you are sturdy, invite the offender to learn from and experience some of your family). Attention difficulties may surface (15 minutes of undivided attention is expected at age 6). Television is not a good measure of attention duration. A small percentage of school age children will be diagnosed with “attention deficit disorder”. Sometimes this is associated with hyperactiveness or another learning disability. It is a complex diagnosis to make, involving your pediatrician, school psychologist, and family, and does not mean that you child is doomed for failure. Be alert for excessive daydreaming, non-completion of tasks and more than normal squirminess on a regular basis in the absence of external stress.

Increased body awareness may be expressed in more physical complaints at this time. This is especially true in children who are out of the norm for weight, height, or other appearance. Complaints should be addressed first by the parents, then the pediatrician if deemed necessary, but a full, normal schedule should be maintained if no fevers, injury, or serious illness is suspected. Sexual experimentation may begin with peers and almost always is explorative, not erotic. Any unusual or excessive behaviors should be discussed. Remember to shelter your child from arousing images in videos, TV or magazines, as he/she is not developmentally ready yet for these concepts. Again, appropriate TV, video, electronics, and computer use should be kept to a minimum and supervised. Bed wetting can still occur, hopefully with less frequency. Alarms can and should be introduced for this to train awareness of bladder sensation and night voiding. Kegel exercises will help (discuss with your doctor). Soiling is a more serious concern and merits a complete physical and addressing possible constipation causing diets or stool withholding.

Childhood fears, particularly at night (monsters, snakes) should be addressed with discussion and reassurance of safety. “Macho” play or seductive attitudes may be flags for real underlying fears that should not be ignored. Special fears about abandonment need addressing when family changes like divorce or death occur. This is a crucial time to be consistent and affirming of your constant relationship. Bedtime refusals should be treated as other areas of non-compliance -- gently, but firmly enforce the rules and discipline for persistent defiance.

Behavior battles continue with all the new ideas and concepts introduced by being out in the world. Remember, you are still the experienced member of the team, the captain, the play-caller Don’t expect perfection, but don’t compromise on the things you’ve decided as a family are important. Consistency is the key word – an offense should be met with punishment or limit setting every time, not just if it is particularly annoying at present. Set up structured homework, play, chore times as well as free time. You will minimize the negative interactions by working on listening and communicating, being available, participating in play and hobbies, and showing your child how important he/she is to you. This may take some restructuring of your own schedules, but the investment is worth it. Parents need to treat each other with love and respect as this is the primary relationship they observe and it sets the standards for how they relate to others. Any severely maladaptive behaviors such as excessive lying, cheating, stealing, aggression, cruelty to animals or disrespect will need careful evaluation with your doctor, teacher, guidance counselor, psychologist and clergy person to address and evaluate possible causes and set up a plan for reversal and rehabilitation/repentance. Lifelong people skills are ingrained at these ages so if your child is not developing into the individual you had imagined in infancy, do not give up, back down or despair. Do seek help! Know what your moral code is and teach it!

Nutritional concerns center around cementing down good eating habits that will promote lifelong health. These include regular, unhurried, family times with attention to family conversation, sharing and addressing non-food oriented issues. Limits for how much, how long, and what types of expected consumption should be clear and modified according to age. Continue to allow help with meal preparation. Occasionally, (perhaps once a week), let your child plan and help prepare the entire meal (you may get something like broccoli, pizza and jellybeans, but that’s OK). Address any obesity problems with your doctor. Keep the TV off for meal times and limit it to 1-2 hours per day. Supervise viewing and allow only if other priorities like chores and homework are accomplished. Continue dental hygiene and regular dental visits. Fluoride may still be necessary if not in the municipal water supply.

Immunization status will be checked at this visit and any “catch-up” or new recommendations accomplished if possible. A general physical will be performed; please bring any concern up as they arise. Growth, hearing, and vision will be assessed, as well as blood pressure and perhaps a urinalysis if not done prior to this.

Safety issues should not be abandoned, particularly with respect to street supervision, safe play areas, bicycle and helmet safety, seat belt use and pool/water play. Accidents remain a leading cause of death and disability. Keep matches and lighters away, medicines and chemicals locked away, and dangerous tools and equipment should be used only with close adult supervision. Continue to reinforce how to respond to strangers. Keep firearms unloaded and locked away!

There is more and more to think about as your child progresses through middle childhood. Take pride in where you’ve been able to be a good role model and continue to adapt and grow with your child. Enjoy these times of exploration, intellectual growth, and moral development.

“The chances are that you will never be elected president of the country, write the great American novel, make a million dollars, stop pollution, end racial conflict or save the world. However valid it may be to work at any of these goals, there is another one of higher priority – to be an effective parent”. – Landrum R. Bolling

Prepared by David L. Ragonesi, M.D., F.A.A.P.

Revised 3/07

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