Learning Objectives
By the end of this section, you will be able to:
- Discuss the importance of theories of development for care across the life span
- Identify multiple theories of development used in health care
Theories of development help provide a framework for healthcare providers to understand how patients develop over their life span. These theories can help healthcare providers identify ways to help patients move through the growth and development process by noting prevention and intervention techniques. Commonly accepted theories of development include Erik Erikson’s theory of psychosocial development, Jean Piaget’s theory of cognitive development, Lawrence Kohlberg’s theory of moral development, and Sigmund Freud’s theory of psychosexual development.
Link to Learning
Watch this video of developmental theories to test your knowledge of the subject.
Importance of Theories of Development
While growth and development are not linear, theories of development can help nurses care for and interact with patients based on their developmental needs. Additionally, these theories help healthcare providers predict possible future behaviors to guide education and anticipatory guidance for caregivers. Most importantly, when healthcare providers understand and appreciate theories of development, they have a common toolbox for assessing and interacting with patients through the life span.
Theory of Psychosocial Development—Erik Erikson
Erik Erikson’s theory of psychosocial development states that an individual’s personality develops in a predetermined order through a series of stages. Erikson believed there are two outcomes at each stage: successful completion or unsuccessful completion. Successful completion leads to advancing to the next stage in a healthy and holistic manner. Unsuccessful completion of a stage can lead to unsuccessful completion of subsequent stages and an unhealthy self-attitude (Erikson, 1963). These stages can be reviewed in Table 38.2.
| Developmental Stage | Erikson’s Developmental Stage | Age Range per Developmental Stage |
|---|---|---|
| Infant | Trust vs. mistrust | 0–1.5 years |
| Toddler | Autonomy vs. shame and doubt | 1.5–3 years |
| Preschool | Initiative vs. guilt | 3–5 years |
| Middle childhood | Industry vs. inferiority | 5–12 years |
| Adolescent | Identity vs. role confusion | 12–18 years |
| Young adult | Intimacy vs. isolation | 18–40 years |
| Adult | Generativity vs. stagnation | 40–65 years |
| Older adult | Ego integrity vs. despair | 65+ years |
Trust vs. Mistrust
Trust vs. mistrust is the first stage in Erikson’s theory of psychosocial development; it begins at birth and continues until about 18 months of age. During this stage, the child is learning about the world and the uncertainties within it. As they need support for all basic needs, they rely on their primary caregiver for safety and consistent care. If the child receives reliable and predictable care from their caregiver(s), they will feel safe and develop a sense of trust. This sense of trust will then carry on to other relationships, so that the child may feel secure even if they are in an intimidating or challenging situation. If children do not receive consistent care, however, they will develop a sense of mistrust and apprehension. This ultimately leads to a lack of confidence in the people and world around them as well as their possible influence on events in the world. Thus, the child may feel a lack of confidence in their ability to influence events within the world and may approach the world with uneasiness.
Autonomy vs. Shame and Doubt
The second stage of Erikson’s theory is autonomy vs. shame and doubt. This phase occurs between 18 months and 3 years of age. A foundational keystone of this stage is the child developing a sense of control over physical skills as they gain a sense of independence. If independence is fostered, the child will become more confident and secure in their ability to make decisions and survive in the world. In contrast, if children are overly controlled or criticized, they will develop feelings of inadequacy. This may lead to a lack of self-esteem and an unhealthy dependence on others. It is important for caregivers to strike a balance between encouraging children to complete age-appropriate tasks by themselves—such as getting dressed and taking dishes to the sink—while providing constructive guidance that sets up children to succeed.
Initiative vs. Guilt
Initiative vs. guilt is the third stage, encompassing children between 3 and 5 years of age. During this stage, children assert themselves through social interactions and play activities. The foundation of this stage is the significant interactions that children have with one another. If they are given the opportunity to plan activities and make up games, children will feel secure in their ability to lead and harness a feeling of initiative. If this initiative is suppressed or criticized by caregivers, children will form a sense of guilt. This sense of guilt can inhibit creativity and cause the child to resist interacting with others. One way caregivers can support this stage is to validate the many questions that children tend to ask. If caregivers treat these inquiries as trivial or an annoyance, the child may develop a sense of guilt or embarrassment.
Industry vs. Inferiority
The fourth stage, industry vs. inferiority, encompasses children from 5 to 12 years of age. During this stage, peers play increasingly significant roles in a child’s self-esteem. As tasks such as reading, writing, and mathematics become more prominent, children feel they need to gain approval by demonstrating these competencies. As they experience success, they develop a sense of pride and feel accepted and valued in society. If children are encouraged for their initiative during this stage, they will feel industrious and gain confidence to complete more difficult tasks. However, if children cannot develop the specific skills they feel that society values, they may develop a sense of inferiority.
Identity vs. Role Confusion
The fifth stage of Erikson’s theory, identity vs. role confusion, takes place between about 12 and 18 years of age. The foundation of this stage is an individual’s search for a sense of personal identity, particularly in two realms: sexual and occupational. Individuals who successfully move through this stage are able to identify the transformations that occur during this time and work through these changes to ultimately feel comfortable and stand firm in their identity. This allows patients to accept themselves and others, even if there are major differences between them. Unsuccessful completion of this stage can lead to role confusion, meaning that the individual is not certain about their place in society. In an effort to avoid role confusion, patients may experiment with different lifestyles. It is important to note that if people in this process are pressured into a certain lifestyle, they may develop a sense of anger and rebellion, ultimately leading to unhappiness.
Intimacy vs. Isolation
The sixth stage, intimacy vs. isolation, occurs between 18 and 40 years of age. Erikson believed people in this stage focus on forming intimate and loving relationships with other people; they explore relationships with the goal of making a long-term commitment to someone other than their family unit members. Successful completion of this stage leads to happy relationships centered around commitment and safety. Unsuccessful completion of this stage, driven by a fear of intimacy and commitment, can lead to loneliness and isolation.
Generativity vs. Stagnation
The second-to-last stage in Erikson’s theory is generativity vs. stagnation, which takes place between approximately 40 and 65 years of age. In this context, generativity is when an individual makes a mark on the world with something that will outlast their own life. Common examples include having mentees, raising children, making an impact at work, and being involved in community organizations. Individuals who experience generative success typically feel useful and accomplished. In contrast, failure to make a lasting mark can lead to stagnation, leaving the individual feeling unproductive and disconnected.
Ego Integrity vs. Despair
The eighth and final stage in Erikson’s theory is ego integrity vs. despair, which occurs from about 65 years of age until death. Patients in this stage spend time reflecting on their lives. Patients who find value in their experiences and accomplishments will successfully move through this stage and attain wisdom. They achieve a sense of completeness and integrity. Conversely, those who reflect back on their life and deem it unproductive or regret missed opportunities may end up with a sense of despair.
Theory of Cognitive Development—Jean Piaget
Jean Piaget’s theory of cognitive development claims that individuals pass through four stages from birth to adolescence, noting changes in the person’s ability to use logic and scientific theory along the way. As shown in Figure 38.4, these stages are sensorimotor thinking, preoperational thinking, concrete operational thinking, and formal operational thinking, sequentially. Piaget’s theory assumes that every person experiences all four stages in the same order, that a cognitive transformation happens within each stage, and that each latter stage incorporates the previous stage (Malik & Marwaha, 2023).
Sensorimotor Thinking (0–2 Years)
During this stage, children use their senses and physical actions—such as crawling, visual tracking, balancing, and coordinating their body in relation to their surroundings—to learn about the world and their place within it. The landmark achievement during this stage is object permanence, which is the understanding that an object still exists even after it is hidden or moved from sight. This corresponds to the knowledge that the world exists separately from the child themselves. Once this landmark has been accomplished, the child moves on to the next stage.
Preoperational Thinking (2–6 years)
Thinking in this stage is influenced by how things appear versus how they really are. Children in this stage are able to mentally represent objects in multiple ways, though their thought processes remain incomplete and, at times, disorganized. A landmark of thinking during this stage is dramatic play, in which participants use their imagination to take on roles and characters as they interact with their surroundings. A common example is when children take on the role of a doctor and provide medical care to dolls or other people; they may use plastic sets of look-alike medical equipment, or they may imaginatively repurpose everyday objects. Though thinking during this stage tends to be illogical and lacking in reason, it is an important step on the way to higher levels of cognition.
Concrete Operational Thinking (7–11 Years)
During this stage, children can solve problems more systematically than in previous stages, though their thinking remains focused on concrete objects and events rather than abstractions or hypotheticals. One major concept gained during this stage is reversibility, or the ability to understand a process and the steps of a process in any order. (Children in previous stages may be able to recite the steps of an experiment, for example, but only in the original order.) Another skill acquired during this stage is decentering, or the ability to investigate more than one problem at a time. This helps children to understand that others may have a different point of view. Children also acquire the concept of conservation: they understand that something may change its size or appearance without also changing its quantity. For example, children in the previous stage may understand that two cubes of clay that weigh the same contain the same amount of clay; however, children capable of concrete operational thinking understand that the two lumps remain equal even after one is reshaped into a pyramid.
Formal Operational Thinking (12 Years and Older)
People who successfully pass through the fourth and final stage of Piaget’s theory achieve the skill of hypothetical thinking, logical thought, deductive reasoning, and systemic planning. They are able to think logically and reasonably at more advanced levels about abstract objects and events in addition to tangible ones. Additionally, inferential reasoning is a key distinction of this stage. It is also understood with this theory that some people may never achieve or use formal operational thinking in their everyday lives. As an example, according to Piaget’s theory, hypothetical thinking is necessary to scientific problem-solving. Many people do not deal with scientific problems or the scientific problem-solving process during the course of their lives; thus, it is understood that those people may never achieve or use formal operational thinking demonstrated through scientific problem-solving. Similarly, there is a subset of people who use it only in certain areas in which they are most comfortable and familiar such as tasks at home, but not at work, or vice versa. Piaget believed that though adolescents who are able to achieve formal operational thinking may have more success in some facets of academia, it is not mandatory for students to achieve educational success.
Link to Learning
Jean Piaget’s theory of cognitive development is further explained in this video.
Theory of Moral Development—Lawrence Kohlberg
Lawrence Kohlberg’s theory of moral development builds upon Piaget’s theory of cognitive development. The foundational understanding of Kohlberg’s theory is that moral reasoning develops in stages (Kohlberg, 1981). Specifically, it identifies six stages distributed across three levels (Figure 38.5).
Level 1: Pre-Conventional Morality (0–9 Years)
This level is considered the premoral level. Thinking is primarily egocentric, and behavior is driven by the desire to gain pleasure and avoid punishment or other types of pain. A hallmark of premoral thinking is that actions that lead to rewards must be good, while actions that lead to punishment must be bad.
Stage 1: Obedience and Punishment
In the first stage of Level 1 a child’s response to a moral dilemma is that of obedience to rules and authority. In this stage, a child must follow the rules or they will be punished. The physical or tangible consequence of punishment is the driver of decision-making. Children believe if they are not being punished, they are good, and if they are punished, they must be bad or wrong.
Stage 2: Individual Interest
Progressing from the first stage, in this stage children comprehend that authority figures may have different views of what is “right and wrong,” and that definitions may change depending on individual viewpoints. Thus, they realize the moral decisions they have learned may be influenced by personal needs while still considering the needs of others. This may guide children in this stage to believe it is okay to do something wrong if it will benefit them overall. Children move away from thinking that punishment is the sign of what is “right and wrong,” while still knowing it is something to be avoided.
Level 2: Conventional Morality (10–15 Years)
Moral reasoning at this level is based on one’s own interpretation and internalization of societal expectations. Individuals make decisions based on how they may impact interpersonal relationships in addition to their own self-interest. At this level, moral standards begin to be internalized.
Stage 3: Interpersonal
During this stage, the individual wants to gain and maintain the approval of those in their immediate group. Children want to be considered “good” or “nice,” and they equate these titles with having positive motives, showing mutual concern for others, and fostering friendly relationships based on loyalty, trust, and respect.
Stage 4: Authority
Within this fourth stage, individuals expand their decision-making process beyond their relationships with close acquaintances. Now, they also take societal norms and perspectives into consideration. The foundation of decision-making is no longer avoiding punishment or gaining rewards. Instead, individuals focus on doing their duty and maintaining social order.
Level 3: Post-Conventional Morality (16+ Years)
In this third level, individuals define their own moral principles and value as they begin to create an image of how an ideal society could look. Balance is found between basic rights, societal expectations, and obligations. It is important to note that Kohlberg believed only 10 to 15 percent of people reach this stage of moral development.
Stage 5: Social Contract
Those within this stage still find value in and follow society’s law and norms, but they can also imagine possible changes to make society better. Individuals in this stage believe that subgroups can have different values, but everyone should be able to agree on foundational principles. Morality of this stage is the basis for the United States Constitution. The belief in this stage is that laws are flexible in order to accommodate new and changing circumstances.
Stage 6: Universal Ethics
The sixth and final stage of Kohlberg’s theory bases moral reasoning upon universal ethical considerations coupled with abstract thinking. A sense of justice is a guide within this stage, even if this conflicts with societal rules and laws; thus, there is an understanding that there are higher laws that go above and beyond laws that are imposed socially. Individuals in this phase believe all humans have value and thus are willing to accept the consequences of going against social norms if it is the “right” thing to do.
Theory of Psychosexual Development—Sigmund Freud
Many people consider Sigmund Freud to have been one the most influential minds of the twentieth century; however, he may also be one of the most controversial, and many people today discount his ideas. Freud had a background in neurology, which was the foundation for his theories of personality and human development. Freud believed that the human mind has three sections: the unconscious, the preconscious, and the conscious (Lantz & Ray, 2022). As shown in Figure 38.6, these sections are often compared to the parts of an iceberg. According to Freud, the unconscious is like the part of an iceberg, well below the water’s surface, that cannot be seen; the preconscious is the part just at and directly below the water’s surface; and the conscious is the part of the iceberg, above the water, that can be seen.
Freud also believed the mind has three fundamental structures: the id, the ego, and the superego. He claimed the id is the primitive or unconscious part of the mind, which seeks gratifications through physical needs; the superego is responsible for upholding social norms and making moral decisions; and the ego is the regulator between the id and the superego. From these beliefs, Freud established his psychosexual theory of development for children. His theory has five stages, each of which focuses on a different physical center of pleasure: oral, anal, phallic, latency, and genital.
Freud is often criticized by those in the medical community, who fault him for basing his theory of development solely on biological or physical determinants while ignoring social, cultural, and experiential factors. Furthermore, many believe this theory is not applicable to different cultures and communities.
Oral (Birth–1 Year)
During this stage, babies gain pleasure through their mouth: for example, by sucking, biting, and tasting. If needs are unmet during this phase, Freud believed a child’s development could be hindered. For example, the child might compensate by developing oral fixation behaviors such as gum chewing, candy eating, smoking, and nail biting.
Anal (1–3 Years)
This phase happens as children typically begin the process of potty training and learn to control defecation. Therefore, the anal region is the focus of pleasure during this stage. Freud believed children who experience conflicts during this stage will develop either anal-retentive or anal-explosive tendencies as they move into adulthood. An anal-retentive personality is one that compulsively sees order and tidiness. An anal-expulsive personality is generally messy and lacks self-control.
Phallic (3–6 Years)
Genital organs become the focus of pleasure during this stage. Children become aware of the presence or absence of a penis in individual bodies, and they may have internal conflict with either side of awareness as they demonstrate an increased interest in their genitals and the genitals of the opposite sex. Pending their desire to adopt the characteristics of the same-sex parent, this may lead to internal struggle if they are not able to achieve these full characteristics. Freud believed by the end of this stage, children resolve this conflict by identifying with a caregiver of the same sex in order to gain acceptance.
Latency (6–12 Years)
During this stage, Freud believed that children repress their sexual focus and energy due to a dormant libido and channel it into other activities of development, such as hobbies, schoolwork, friendships, and social maturing, demonstrating an overall state of calmness. Children may focus their time on social or intellectual skills, such as hobbies, education, and friendship, versus a focus on romantic interests.
Genital (Puberty and Beyond)
During this last and final stage, Freud believed the sexual urges of adolescents re-emerge and are directed toward another person. This leads to solicitation and pursuit of intimate relationships. After sexual experimentation, this stage is considered resolved when someone is capable of having a mature and emotionally safe adult sexual relationship. Unresolved conflicts during this stage can lead to emotional issues, sexual dysfunction, and inability to form and sustain healthy relationships.