4 Years

Four years.

They have a vocabulary that surprises you, friends they ask about by name, opinions on dinner (or every meal), theories about how the world works (some of them very wrong, but all of them very confident). They tell jokes and stories. Some of those stories are about things that never happened, and they’ll defend the fictional version with their whole heart.

This visit checks on how you and your child are doing, it’s the first booster vaccine visit since toddlerhood, and the first one where we start talking about kindergarten. On top of the normal screening, there are the kindergarten booster shots today, and depending on how they remember past visits, your child may have feelings about it. We’ll handle it all together.

Your visit at a glance

What we’ll do

• Measure weight, height, and BMI
• Blood pressure
• Physical exam
• Kindergarten readiness conversation
• Vaccines for kindergarten

Vaccines today

Final doses of DTaP and IPV (polio), given together as one combination shot (Quadracel), plus final doses of MMR and Varicella, given as two separate shots. This is the “kindergarten booster” round, which works out to three shots in all (four if it’s flu season).

Screenings we’ll review

• Vision and hearing
• Development

Bring with you: Your top 3 questions and anything you’ve been wondering about kindergarten readiness, behavior, friendships, or development.

A note on today’s vaccines: Your keiki is now old enough to remember past shot visits and feel nervous about today.

Some practical things that help: Tell them the truth in age-appropriate language (“we’re going to the doctor and you’ll get shots, which will pinch for a second and then be done”). Save any reward for after and keep it small. A big build-up beforehand tells them today is something to dread.

Bring a small comfort item. Keep them upright and close, on your lap or sitting beside you with your arm around them. Give them something to do: pick the arm, squeeze your hand, count to three together. Breathe with them. Praise them after, briefly and matter-of-factly. Plan a quiet rest of the day.

The story they tell themselves about today matters. We’re aiming for one where they walk out brave and proud of themselves.

Vision and hearing rescreening today. We rescreen at 4 because vision especially can change between 3 and 4. About 5 to 10 percent of 4-year-olds have a refractive error, most often farsightedness, that benefits from glasses. Some had a borderline result at 3 that’s now clearer one way or the other. Early correction, especially for vision, makes a real difference.

What’s happening at this age

Body

• Running, jumping, climbing fluidly
• Hopping on one foot
• Catching a ball
• Riding a tricycle confidently. Some kids on a balance bike or bike with training wheels.
• Drawing a person with body parts
• Dressing themselves (mostly)
• Brushing teeth with supervision
• Sleep usually 10 to 13 hours total, most have dropped the nap

Brain

• Sentences of 4 to 5 words or longer. Telling stories with beginning, middle, and end.
• Beginning to count to 10 or beyond
• Letter recognition emerging, especially for letters in their name
• Beginning understanding of time (today, tomorrow, yesterday)
• Elaborate imagination

Behavior

• Less tantrum-y than 3 for most. More able to express frustration verbally. More negotiating.
• More sophisticated lying is possible. Stronger sense of fairness, often loudly defended.
• Beginning to follow rules in simple games
• Forming real friendships. Beginning to feel excluded sometimes, or excluding others.
• Worry and anxiety can emerge.

🌿 Mind / Body / Spirit, for your keiki

 🌟 Kindergarten readiness: what actually matters and what doesn’t

Kindergarten is about a year away. Here’s what the evidence actually shows about readiness, and what does NOT matter as much as parents have been told.

What actually matters:

• Social-emotional skills. Ability to separate from a parent for the school day. Ability to follow simple group instructions. Ability to wait briefly. Ability to handle a small disappointment without melting down. Basic attempts at conflict resolution with peers.
• Self-care. Using the bathroom independently (including hand washing). Eating lunch independently. Asking for help when needed. Putting on a jacket. Putting on shoes.
• Speaking in full sentences. Understanding stories read aloud. Answering questions about what they heard. Communicating their needs clearly to adults.
• Curiosity and engagement. Showing interest in books. Asking questions. Paying attention to a story for 10 to 15 minutes.

What does NOT matter as much as you’ve been told:

• Knowing all letters and sounds before kindergarten. That’s what kindergarten teaches.
• Counting to 100. Counting to 10 is plenty.
• Writing their full name. Helpful but absolutely not required.
• Reading any words. The K teacher starts from zero and that’s the plan.
• Being “academically ahead.” Being curious and emotionally regulated matter more.

If your child can manage themselves, communicate clearly, follow basic group instructions, and is curious about the world, they’re ready. The academic skills are built in school, not before.

Pre-academic skills emerging at 4. Fine motor skills they’ll work on this year: tripod crayon grip, using scissors safely, building with small blocks. You don’t need to teach these explicitly. Daily reading, drawing, playing with letters in their environment (cereal boxes, signs, license plates), and counting things during the day are more effective than worksheets. More from NAEYC on what kids learn in preschool and AAP on developmental milestones 4-5.

Worry and anxiety

If your child who never worried suddenly does, that’s developmental and it usually passes. The 4-year-old brain is big enough now to imagine things going wrong. Common worries: separation, sleep (monsters, the dark, intruders), social fears (being left out, being laughed at), and death (the realization that people and animals die, often set off by losing a pet or hearing about death in a story).

Signs the worry has become a problem: avoidance behaviors that interfere with daily life (won’t go to preschool, won’t sleep alone), physical symptoms (stomachaches, headaches when anxious), persistent worry about specific things for weeks, sleep disrupted by worry. If you’re concerned, mention it today. Childhood anxiety responds very well to early support.

More from Child Mind Institute on signs of anxiety and AAP on anxiety disorders in children.

Sleep

Most 4-year-olds need 10 to 13 hours of sleep total. Most have dropped the nap. Bedtime typically settles between 7:00 and 8:00pm depending on your family rhythm.

Sleep trouble worth flagging at this age:

• persistent night wakings
• sleepwalking or sleep terrors (peak age is 3 to 7, can look alarming but rarely concerning unless frequent or injury-prone)
• bedtime fears
• snoring (worth mentioning, sometimes signals sleep-disordered breathing)

A consistent simple routine still works, but it may need to evolve. Books before bed, no screens in the hour before sleep, lights low.

Milestones Check-In

CDC Milestone Tracker: 4-year milestones. Check on their progress in the app!

💗 Family / Community, for you and your ʻohana

🌟 Friendships, cooperative play, and inclusion

Real friendships solidify at 4. Your child has favorite people now. They ask about them by name. They get excited to see them and sad when they leave. They talk about people as “my friend Kainoa.”

Cooperative play is the norm now (building together, role-playing together, making up games with rules they invent and renegotiate constantly). Real social skills at work!

What also starts at 4: exclusion. Kids begin to say “you can’t play” and your child may be on either side of that. It hurts. It’s developmentally normal. Your response matters more than the moment.

How to coach without solving: don’t try to fix every social moment for them. Listen and validate the feeling without dismissing the situation. Don’t lawyer it, coach it. “It really hurt when she said you couldn’t play. What do you think you could do next time?” If your child is the one excluding others, the conversation runs the same in reverse. “It really hurt his feelings when you said he couldn’t play. Can you think about how he felt?” The hard social moments at 4 build skills that matter at 8, 12, and 20. Your job is witness and coach.

Body education starts here

Body parts, safe touch, and starting body education can start now. At 4, your child is ready for basic body education that prevents harm and builds healthy attitudes.

The basics:

• Teach proper anatomical names for body parts, including genitals. Vulva. Vagina. Testicles. Kids who know proper names are better protected against abuse because they can describe if anything happens to a trusted adult.
• Teach that some parts are private. The parts covered by a swimsuit. Private means only your child sees and touches them, with limited exceptions (medical care with a parent present, hygiene help, bath time when you’re helping).
• Teach that no one should touch private parts without permission, and that secrets about touching are not okay. The phrasing many child-safety experts use is “surprises are okay, secrets are not.” A surprise has a happy ending and a known end date. A secret is something you’re never supposed to tell.
• Teach that they can tell you anything, and they will not be in trouble for telling. This is the message that matters most. Even if someone said they would get in trouble. Even if the person told them not to tell you.

It’s not a single conversation but an ongoing one across childhood. The next big update is when they start kindergarten and have more autonomy in public spaces.

Reading at 4

Your child at this age can follow a story, ask questions about characters and motivations, predict what happens next, and retell stories in their own words. Pick longer books with real plots: Frog and Toad, Henry and Mudge, Mercy Watson, the longer classic picture books. Reading just before bed (not screens) is a wiring habit that lasts a lifetime. For multilingual families: keep reading in every language. By 4, your child can hold and switch between multiple languages without confusion. More from Reach Out & Read family resources and Hanen on early literacy.

What’s different about parenting my 4-year-old?

The 4-year-old is more verbal, more deliberate, and more sophisticated than the 3-year-old.

Strategies that work better now: real conversations (not just brief limit-setting), genuine apologies and repair when you mess up, involving them in solving problems (“the room is messy, what’s a plan for cleaning it up?”), letting natural consequences do some of the teaching (within reason and safety).

What still doesn’t work: long lectures, predicting feelings for them (“you’re going to love this!”), shame, threats you won’t follow through on.

A great book to consider: How to Talk So Little Kids Will Listen by Joanna Faber and Julie King.

Your wellbeing is still part of every visit

Parent wellbeing at 4: from survival to intentional parenting. Parenting becomes less physical and more about teaching, conversation, and modeling. Time for self returns in small but real amounts. Many parents are in a sustainable rhythm for the first time in years. Some feel grief about the loss of the physical baby phase even while enjoying the bigger kid.

Signs worth attention: ambivalence about losing the physical baby phase, surprise at how much you’re enjoying the bigger kid and feeling weird about that, restlessness as time and energy return and you don’t quite know what to do with it, partnership patterns from the survival phase that need updating, anxiety about who you are now that survival mode is fading.

What helps at this stage: therapy as growth work, not just maintenance. Real career and life conversations as your capacity returns. Partnership check-ins now that the survival-phase glue is dissolving. Friendships that flex with this new stage. Permission to enjoy the parts of bigger-kid parenting that feel different from baby parenting. Movement and adult health investments that were hard to prioritize before.

Crisis resources: 988 (Suicide & Crisis Lifeline), Hawaiʻi CARES 808-832-3100. You don’t have to wait for a crisis to seek support.

Local Oʻahu resources 🌺

🌺 Outdoor places and active play for 4-year-olds

Your 4-year-old can do real sustained outdoor activity now. Beach time, swimming, short hikes, playgrounds, balance bike or starter bike, kicking a ball, playing tag. Continuing spots: Kapiʻolani Park, Ala Moana playground, Magic Island, Honolulu Zoo (newly educational at this age), Hawaiʻi Children’s Discovery Center, Waimea Valley, Foster Botanical Garden. Tire them out. Get yourself outside too.

🌺 Structured programs for 4-year-olds on Oʻahu

At 4, structured activities start to be meaningful. Options that work well: YMCA Hawaii children’s programs (swim lessons especially), Hawaii Youth Soccer Association (HYSA) for beginner programs, keiki hula classes through various hālau, gymnastics classes, beginner art studios that accept 4+. The point at this age is not specialization. It’s exposure, fun, structure, and getting them comfortable in group settings before kindergarten. Pick one. Maybe two if you have the bandwidth.

True at every age

Some things never stop mattering, no matter the age on this page:

• Dental care: cleanings every 6 months.
• Water safety. In Hawaiʻi it’s a year-round priority at every age.
• Sun protection, every day, even when it’s overcast.

🚨 When to call us

For a child 4+ years old, call us right away (or go to the ED) for any of these:

• Fever with your child looking unwell, lethargic, dehydrated, or not interactive. The number matters less than how they look.
• After today’s vaccines: fever 104°F or higher, persistent inconsolable crying or distress, breathing problems, swelling beyond the injection site, severe pain at the injection site days later.
• After a new food: hives, vomiting, swelling, breathing changes.
• A choking event of any duration.
• A fall from height that ends with a head bump, loss of consciousness, prolonged sleepiness, repeated vomiting, or unusual behavior change.
• A drowning event of any duration.
• Significant dehydration: refusing all fluids, no urine output in 8+ hours, sunken eyes, lethargy.
• Significant anxiety that’s interfering with daily life: avoiding preschool, refusing to sleep alone, physical symptoms (stomachaches, headaches) tied to worry.
• If your child has stopped doing things they were doing. Loss of skills always warrants a call.
• A fall on the playground or sports area that you suspect may have caused a fracture (refusal to use a limb, visible deformity, persistent pain).
• Your gut says something is wrong. Call.

📞 Call us when you need us: 808-600-2180

During office hours, you’ll reach our team. After hours, call the same number and select option 1 for our after-hours line (Hello Pediatrics), who follow our medical protocols.

For anything life-threatening, call 911.

What’s ahead before your 5-year visit

The 5-year visit is your official “kindergarten check-up.” Big changes ahead:

Reading and writing skills emerge. By 5, most kids recognize all the letters of the alphabet, write their first name, recognize some sight words, and may be reading simple words. Don’t push if it’s not happening, and don’t worry if your child isn’t there yet. Kids on the later end of the range catch up by first grade.

Physical skills refine. Hopping, skipping, running with control, kicking and catching with more accuracy. Balance bikes graduate to pedal bikes for many. Swimming skills can develop significantly if there’s exposure (Hawaiʻi kids get a real advantage here).

Sleep usually settles. The 4-year fears mostly pass by 5 and sleep gets more reliable. The 5-year visit often catches the last of the nighttime fears.

Independence and school readiness. They can contribute now, be helpers at home, and practice doing self care activities on their own, all of which builds confidence toward their next big milestone!

Message us anytime before your next visit. Until then, watch your school-age kid emerge. They’re not little anymore, not big yet, just right in-between.