Many theorists have attempted to organize and classify the complex phenomena of growth and development. No single theory can adequately explain the wondrous journey from infancy to adulthood. However, each theorist contributes a piece of the puzzle. Theories are not facts but merely attempts to explain human behavior. Table 5-2 compares and contrasts theories discussed in the text. The chapters on each age-group provide further discussion of these theories.
TABLE 5-2 THEORIES OF GROWTH AND DEVELOPMENTPIAGET’S PERIODS OF COGNITIVE DEVELOPMENT FREUD’S STAGES OF PSYCHOSEXUAL DEVELOPMENT ERIKSON’S STAGES OF PSYCHOSOCIAL DEVELOPMENT KOHLBERG’S STAGES OF MORAL DEVELOPMENT Infancy Period 1 (Birth-2 yr): Sensorimotor Period Oral Stage Trust vs. Mistrust Premorality or Preconventional Morality, Stage 0 (0-2 yr): Naivete and Egocentrism Reflexive behavior is used to adapt to the environment; egocentric view of the world; development of object permanence. Mouth is a sensory organ; infant takes in and explores during oral passive substage (first half of infancy); infant strikes out with teeth during oral aggressive substage (latter half of infancy). Development of a sense that the self is good and the world is good when consistent, predictable, reliable care is received; characterized by hope. No moral sensitivity; decisions are made on the basis of what pleases the child; infants like or love what helps them and dislike what hurts them; no awareness of the effect of their actions on others. “Good is what I like and want.” Toddlerhood Period 2 (2-7 yr): Preoperational Thought Anal Stage Autonomy vs. Shame and Doubt Premorality or Preconventional Morality, Stage 1 (2-3 yr): Punishment-Obedience Orientation Thinking remains egocentric, becomes magical, and is dominated by perception. Major focus of sexual interest is anus; control of body functions is major feature. Development of sense of control over the self and body functions; exerts self; characterized by will. Right or wrong is determined by physical consequences: “If I get caught and punished for doing it, it is wrong. If I am not caught or punished, then it must be right.” Preschool Age 
Phallic or Oedipal/Electra Stage Initiative vs. Guilt Premorality or Preconventional Morality, Stage 2 (4-7 yr): Instrumental Hedonism and Concrete Reciprocity Genitals become focus of sexual curiosity; superego (conscience) develops; feelings of guilt emerge. Development of a can-do attitude about the self; behavior becomes goal-directed, competitive, and imaginative; initiation into gender role; characterized by purpose. Child conforms to rules out of self-interest: “I’ll do this for you if you do this for me”; behavior is guided by an “eye for an eye” orientation. “If you do something bad to me, then it’s OK if I do something bad to you.” School Age Period 3 (7-11 yr): Concrete Operations Latency Stage Industry vs. Inferiority Morality of Conventional Role Conformity, Stage 3 (7-10 yr): Good-Boy or Good-Girl Orientation Thinking becomes more systematic and logical, but concrete objects and activities are needed. Sexual feelings are firmly repressed by the superego; period of relative calm. Mastering of useful skills and tools of the culture; learning how to play and work with peers; characterized by competence. Morality is based on avoiding disapproval or disturbing the conscience; child is becoming socially sensitive. Morality of Conventional Role Conformity, Stage 4 (begins at about 10-12 yr): Law and Order Orientation Right takes on a religious or metaphysical quality. Child wants to show respect for authority, and maintain social order; obeys rules for their own sake. Adolescence Period 4 (11 yr-Adulthood): Formal Operations Puberty or Genital Stage Identity vs. Role Confusion Morality of Self-Accepted Moral Principles, Stage 5: Social Contract Orientation New ideas can be created; situations can be analyzed; use of abstract and futuristic thinking; understands logical consequences of behavior. Stimulated by increasing hormone levels; sexual energy wells up in full force, resulting in personal and family turmoil. Begins to develop a sense of “I”; this process is lifelong; peers become of paramount importance; child gains independence from parents; characterized by faith in self. Right is determined by what is best for the majority; exceptions to rules can be made if a person’s welfare is violated; the end no longer justifies the means; laws are for mutual good and mutual cooperation. Adulthood 
Intimacy vs. Isolation Development of the ability to lose the self in genuine mutuality with another; characterized by love. Generativity vs. Stagnation Morality of Self-Accepted Moral Principles, Stage 6: Personal Principle Orientation Production of ideas and materials through work; creation of children; characterized by care. Achieved only by the morally mature individual; few people reach this level; these people do what they think is right, regardless of others’ opinions, legal sanctions, or personal sacrifice; actions are guided by internal standards; integrity is of utmost importance; may be willing to die for their beliefs. Ego Integrity vs. Despair Morality of Self-Accepted Moral Principles, Stage 7: Universal Principle Orientation Realization that there is order and purpose to life; characterized by wisdom. This stage is achieved by only a rare few; Mother Teresa, Gandhi, and Socrates are examples; these individuals transcend the teachings of organized religion and perceive themselves as part of the cosmic order, understand the reason for their existence, and live for their beliefs. 
Kohlberg’s Theory of Moral Development
Lawrence Kohlberg (1927-1987), a psychologist and philosopher, described a stage theory of moral development that closely parallels Piaget’s stages of cognitive development. He discussed moral development as a complicated process involving the acceptance of the values and rules of society in a way that shapes behavior. This cognitive-developmental theory postulates that, although knowing what behaviors are right and wrong is important, it is much less important than understanding and appreciating why the behaviors should or should not be exhibited (Kohlberg, 1964).
Guilt, an internal expression of self-criticism and a feeling of remorse, is an emotion closely tied to moral reasoning. Most children 12 years old or older react to misbehavior with guilt. Guilt helps them realize when their moral judgment fails.
Building on Piaget’s work, Kohlberg studied boys and girls from middle- and lower-class families in the United States and other countries. He interviewed them by presenting scenarios with moral dilemmas and asking them to make a judgment. His focus was not on the answer but on the reasoning behind the judgment (Kohlberg, 1964). He then classified the responses into a series of levels and stages.
During the Premorality (preconventional morality) level, which has three substages (see Table 5-2), the child demonstrates acceptable behavior because of fear of punishment from a superior force, such as a parent. At this stage of cognitive and moral development, children cannot reason as mature members of society. They view the world in a selfish, egocentric way, with no real understanding of right or wrong. They view morality as external to themselves, and their behavior reflects what others tell them to do, rather than an internal drive to do what is right. In other words, they have an external locus of control. A child who thinks “I will not steal money from my sister because my mother will spank me” illustrates premorality.
During the Morality of Conventional Role Conformity (conventional morality) level, which is primarily during the school-age years, the child conforms to rules to please others. The child still has an external locus of control, but a concern for social order begins to emerge and replace the more egocentric thinking of the earlier stage. The child has an increased awareness of others’ feelings. In the child’s view, good behavior is that which those in authority will approve. If behavior is not acceptable, the child feels guilty.
Two stages, stage 3 and stage 4, characterize this level (see Table 5-2). This level of moral reasoning develops as the child shifts the focus of living from the family to peer groups and society as a whole. As the child’s cognitive capacities increase, an internal sense of right and wrong emerges, and the individual is said to have developed an internal locus of control. Along with this internal locus of control comes the ability to consider circ*mstances when judging behavior.
Level 3, Morality of Self-Accepted Moral Principles (postconventional morality), begins in adolescence, when abstract thinking abilities develop. The person focuses on individual rights and principles of conscience during this stage. There is an internal locus of control. Concern about what is best for all is uppermost, and persons step back from their own viewpoint to consider what rights and values must be upheld for the good of all. Some individuals never reach this point. Within this level is stage 5, in which conformity occurs because individuals have basic rights and society needs to be improved. The adolescent in this stage gives as well as takes and does not expect to get something without paying for it. In stage 6, conformity is based on universal principles of justice and occurs to avoid self-condemnation (; Kohlberg, 1964).
Only a few morally mature individuals achieve stage 6. These people, committed to a moral ideal, live and die for their principles.
Kohlberg believes that children proceed from one stage to the next in a sequence that does not vary, although some people may never reach the highest levels. Even though children are raised in different cultures and with different experiences, he believes that all children progress according to his description.
Nursing Implications of Kohlberg’s Theory
To provide anticipatory guidance to parents about expectations and discipline of their children, nurses must be aware of how moral development progresses. Parents are often distraught because their young children apparently do not understand right and wrong. For example, a 6-year-old girl who takes money from her mother’s purse does not show remorse or seem to recognize that stealing is wrong. In fact, she is more concerned about her punishment than about her misdeed. With an understanding of normal moral development, the nurse can reassure the concerned parents that the child is showing age-appropriate behavior.
