Manual of Ambulatory Pediatrics – Well Child Visits & Anticipatory Guidance: 12-month to 24-month visits

This is a period of consolidation. Newfound physical skills are being refined, and the progression from dependence toward independence is becoming a smoother path, although frequent backsliding is still seen. The excitement of mastering physical skills and the courage to do it by themselves make for happier and more relaxed toddlers.

1. Overview
   1. Parent
      1. A quieter period with a more relaxed, cooperative toddler. A more consistent schedule can be established with new activities and out- side excursions, giving the toddler a wider view of the
      2. Identify any abuse of family
   2. Child
      1. Physical
         1. Eating and sleeping habits
         2. Improving coordination and large muscle strength

2. Emotional: Shows more confidence in using new skills, reflecting caregiver’s attitude toward child of acceptance and affection ver- sus disapproval and mistrust
3. Intellectual
   1. Concentrates on one thing at a time
   2. Language interest, which may be subordinated to improving physical capabilities
4. Risk factors
   1. Unresponsive or overactive
   2. Frequent illness or accidents
   3. No consistent caregiver
5. Injury prevention
   1. Review safety
   2. Age-appropriate precautions
      1. Constant activity, insatiable curiosity, poor coordination, and lack of body awareness necessitate constant
      2. Child-proofing house related to child’s new physical ability
      3. Safe area needed for play and investigation
      4. Curiosity leads to putting everything in mouth
         1. Poison control number available in prominent
      5. Behavior control not yet reliable; beginning to notice “no” or “stop”
         1. Certain tone of voice used for emergencies
         2. Praise given when attention paid

• Child abuse
  1. Physical identification
     1. Tumbles and falls rarely cause broken bones, so any broken bone needs a detailed history and investigation, as do burns, bruises, and
     2. Delayed visit for care and unreliable history
  2. At-risk child
     1. Fearful, unresponsive, or overreacting to being touched
     2. Continued illnesses: Parents making seemingly unnecessary visits
     3. Physical disabilities, retardation, and difficult to care for
  3. Identify:
     1. At-risk caregivers
     2. Unsafe environment
     3. Abuse of other family members
  4. Developmental process
     1. Parents
        1. Show pride and pleasure in each new step of child’s growth and development
        2. Establish consistent family schedule
        3. Set realistic limits for acceptable behavior
        4. Identify abuse of any family member

 

 

1. Child
   1. Behavior characterized by playfulness and good humor
   2. Testing own power by frequent use of “no”
   3. More selectivity and control in activity
2. Family status
   1. Parental concerns and problems: Ability to identify problems and to cope
   2. Toddler now meshed happily into family circle
   3. Adequate child care arrangements
3. Health habits
   1. Nutrition
      1. Diet history
         1. Being offered and accepting a balanced diet. Servings should be small: A good rule is to offer a measuring tablespoon of each food for each year of age, or one-quarter of an adult serving.
         2. Accepting new foods; high-protein and foods high in iron, vita- min C and calcium essential
      2. Eating habits
         1. Self-feeding of finger foods
         2. Drinking from cup, attempting to use spoon
         3. Mealtimes are short and matter-of-fact
         4. No forcing of unwanted foods
         5. Food never used as reward or punishment
         6. Decreased milk intake to 12 to 16 oz/d; increased intake of other foods, especially iron-rich foods
      3. Sleep
         1. Falls asleep more quickly
         2. Improvement in sleeping all night
         3. Sleeps total of up to 10 to 15 h/d
         4. Long afternoon nap; morning nap short or discontinued
         5. Crib: Attempts to climb out; safety factors assessed
      4. Elimination and toilet training
         1. By end of this period, baby developing awareness of soiling
         2. Avoid praise or threat; a matter-of-fact attitude to prevent putting too much importance on something child may not yet be able

to control. Toilet training usually accomplished between 2 and 3 years of age.

• Growth and development
  1. Physical
     1. Smooth, coordinated movements
     2. Gross motor: Increase in strength; climbs stairs on hands and knees; throws ball overhand
     3. Fine motor: Good pincer movement; improving eye–hand coordination

 

 

4. Speech
   1. Uses phrases but cannot use individual words out of the phrases
   2. Uses about seven true words
   3. Has developed phrasing and sounds into jargon talk
5. Vision
   1. Smooth ocular movements
   2. Good eye–hand coordination being established
   3. Improved depth perception: Dropping and watching objects fall
6. Hearing
   1. Reacts to soft sounds (likes to be whispered to)
   2. Traces source of sound
   3. In a loud, shouting, noisy environment, baby tunes out sounds; this decreases natural response from stimuli and can result in undeveloped language
7. Emotional development. Erikson: Completing the passage from basic trust to autonomy is to work toward establishing self-esteem and Children’s improving physical skills push them

to new and daring feats. They turn from such adventures to those around them for admiration and from these responses, they learn that they are special. Without this response, they learn nothing positive about themselves.

1. Cheerful and playful versus irritable and destructive
2. Energetic and curious versus apathetic and fearful
3. Eye contact with strangers

1. Intellectual development. Piaget: Period of consolidation or equilib- rium. Toddler is comfortable with new skills and beginning to appreci- ate own competencies. This confidence allows him or her to take the next step of observing the consequences of
   1. General mood of self-satisfaction
   2. Attends specifically to one toy rather than being distracted by other toys
   3. Attempts to solve a problem before turning to parent for help
   4. Language
      1. Development may still be subordinated while toddler is attend- ing to new motor skills and
      2. Attends to objects and people named by caregiver

• Risk factors
  1. Parents
     1. Lack of pride in child, reflected in attitude and actions toward child
     2. Lack of confidence in child care ability
     3. Unrealistic expectations of toddler, such as behavior control and successful toilet training
     4. Overwhelming personal problems

 

 

1. Baby
   1. Frequent health problems
   2. Not settling into family circle
   3. Distractible, tense
   4. Not moving out to investigate surroundings
2. Physical examination
   1. Growth: Continuing on established pattern; if parent states child is not eating, use growth chart to help parent understand child is eating enough to maintain normal
      1. Use CDC growth charts (2000) available at: http://www.cdc.gov/ growthcharts
      2. Calculate BMI at every well child visit during childhood (see Barlow, 2007).
   2. Appearance and behavior
      1. Has lost roundness of babyhood
      2. Energetic but better able to sit still and concentrate on one toy
      3. Less fearful of strangers
   3. Specific factors to note during routine physical examination
      1. Skin: Excessive bruising, burns, scratch lines
      2. Teeth: Central incisors present
      3. Ears: Mobility of tympanic membrane
      4. Hair: Texture, nits
      5. Musculoskeletal: Bearing weight on legs; hips (Ortolani’s click); equal gluteal folds; check for tibial torsion, genu varum, externally rotated hips; stance; gait
      6. Reflexes: Presence of parachute reflex
   4. Parent-child interaction
      1. Parents understand child’s behavior
      2. Toddler shows recognition of parents’
      3. Cheerful, pleasant rapport between parents and child
   5. Assessment
      1. Physical
      2. Developmental
      3. Emotional
      4. Environmental
   6. Plan
      1. Screening: Hematocrit or hemoglobin, lead recommended by AAP at 9–12 months
      2. Problem list (devised with parent); SOAP for each
      3. Appropriate timing for office visits
         1. Continue close contact during this critical
         2. Visits planned according to needs of family and developmental and physical needs of toddler
         3. Home visits to assess environment as needed

Review the previous outlines to identify the parental and toddler tasks that have been accomplished. Development is such an individual process that the stages cannot be specifically related to a specific age period. Office or home visits still need to be set up on an individual basis.

The child has now become a toddler, and with this new title come, fortu- nately for the family, the skills to settle down. Physically, the child has better coordination and muscle control, and his or her energy is no longer spent on random activities but can be used to accomplish specific tasks. The child is bet- ter able to pay attention to caregivers and more willing to respond with the type of behavior that gets the most attention. In order to satisfy the need for atten- tion and approval through behavior control, the toddler is becoming a more cooperative member of the family.

 

1. Overview
   1. Parents
      1. Understand toddler’s progress and appreciate new skills and needs. Both parents’ roles are important to give toddler broader experiences and
   2. Child
      1. Physical
         1. Decreased appetite as growth rate slows
         2. Falls asleep more easily
         3. Increased strength; needs opportunity to use large muscles
         4. Toilet training; see guidelines
      2. Emotional
         1. Attempts to set balance between doing things his or her way and accepting necessary constraints on behavior; uses “no” as an experimental tool
         2. See guidelines for specific factors of development of self- esteem, temper tantrums, and childrearing practices
      3. Intellectual
         1. Returns to fascination with language
         2. Needs a listener but not one who overcorrects
      4. Risk factors
         1. See safety
         2. Frequent illnesses with slow recovery
      5. Watch for:
         1. Increase in physical strength and activity
         2. Curiosity and persistence in new adventures
         3. Single-word commands; uses “no” and observes its effect on caregiver

 

 

4. Quiet periods of watching and listening
5. Responses to caregivers’ authority when needed

1. Expectations of this period
   1. Parental tasks
      1. Encourage with attention and reward (baby love pats, not food) the type of behavior
      2. Continue to provide a safe environment and regular
      3. Stimulate new activities and then allow toddler to carry on (but without pressure to complete activity).
      4. Provide a loving, caring
   2. Child tasks
      1. Settling into household routine
      2. Developing positive behavior pattern that receives the most attention from primary caregiver
      3. Turning to caregiver for encouragement and affection

• Family status
  1. Basic needs being met
     1. Adequate finances, secure environment, stable lifestyle
     2. Knowledge of where to obtain aid
  2. Parents
     1. Good interactive pattern; problem-solving skills
     2. Cooperation in establishing childrearing practices
  3. Working mother
     1. Adequate child care arrangements
     2. Acceptance of sharing child care with others
     3. Communicating philosophy of childrearing practices to caregiver
     4. Health maintenance
  4. Single parent
     1. Adequate support system
     2. Good health habits
     3. Career goals being implemented
  5. Father and mother important to child’s well-being
     1. Broaden emotional response of toddler
     2. Adults serve as appropriate role models
     3. Help children develop ability to form close relationship with opposite sex
  6. Siblings
     1. Independent activities and separate schedules
     2. Positive behavior patterns established toward toddler
  7. Identify sexual abuse to or by any family member

1. Health patterns
   1. Nutrition
      1. Emotional and physical factors may increase difficulty of main- taining adequate
         1. Physical factors: Slower growth rate; appetite and need for food decrease

 

 

1. Emotional factors: Distractibility and negativism; using refusal to eat as means of showing power

2. Eating habits: Will sit still longer; enjoys feeding self finger foods; still a poor family dinner companion

1. Sleep
   1. By 18 months of age, falls asleep more easily
   2. Can amuse and talk to self; will turn off outside stimuli
   3. Sleeps through the night; awakens early and can amuse self for longer period
   4. Naps: Changing from two naps to one longer one during the middle of the day
   5. Regular daily schedule important
2. Elimination
   1. Regular pattern established; new foods less irritating
   2. Distention and flatulence: Return to simpler
   3. Dry for longer periods, as bladder is larger
   4. Toilet training (see protocol for more information, p. 178)
      1. Catch bowel movement if pattern
      2. Have toddler practice sitting on potty chair (regular toilet too frightening) with diaper on, then finally with it
      3. Do not expect success too early; pressure to comply only adds to confusion for
      4. Girls train earlier than boys and smaller-sized children more easily than big
      5. Play it cool; toddlers who realize they can get a lot of atten- tion from this will prolong the Toilet training usually accomplished between 2 and 3 years of age.
   5. Growth and development
      1. Physical
         1. Able to get to most places; practices getting back down
         2. Increased strength: Needs to use large muscles; pushes or car- ries around large objects
         3. Fine motor: Established pincer movement; delights in handling small objects, poking, pushing, turning
         4. Grasping and releasing at will: If well-established, may indicate the time to begin toilet training
         5. Spatial relations: Spends much time working this out, doing things such as putting toys in and out of boxes, dropping and throwing objects, climbing up and down, steering self around obstacles
      2. Emotional development. Erikson: Development of autonomy. Toddler is setting a balance between the drive for independence and the need to become a member of society. This means being able to accept constraints on self-will and impulses, which he or she will learn to do through the expectations and approval of caregivers.

 

 

1. Development of self-esteem established through:
   1. Negativism: Testing power to affect others
   2. Challenging physical activities: Climbing higher, carrying heavier objects
   3. Taking initiative for actions: Self-amusement
   4. Demanding attention by showing off, being mischievous and joyful
   5. Attempting more than he or she has the ability to do
   6. Absorbing attitudes and feelings shown by others  toward him or her; beginning to select behavior that fits into these expectations
2. Development of self-control
   1. Identified by:
      • Accepting and anticipating daily routine; being less impulsive; fitting into family plans more easily
      • Learning that behavior has consequences; parental reaction teaches what is right and what is
   2. Development of aggression
      1. Frustrations from too many commands and unrealistic expectations lead to stored-up energy; toddler has few ways of releasing this energy
      2. Frustrations also caused by siblings, fatigue, hunger, illness, and changes in routine, in caregiver, and so forth
      3. Stored-up energy can be released in a way destructive to child and others, such as temper tantrums, breath-holding, biting,
   3. Intellectual development. Piaget: Toddler is learning intuitively about the environment with the increase in physical agility and memory development. He or she is also taking the first steps in symbolic thinking but needs concrete symbols first (drink for teddy bear requires a cup).
      1. Independent actions; beginning to observe actions of others and to imitate caregivers, siblings, peers
      2. Studying
         1. Experimenting (things in motion, difference in weights)
         2. Varying a pattern and observing the results
         3. Varying response to an activity and observing the results
      3. Language
         1. Returns to fascination with words; is word-hungry
         2. Articulation lags behind vocabulary; carries on jargon con- versations with self and toys
         3. Experiments with using words to affect those around him or her
      4. Risk factors
         1. Parents
            1. Demanding behavior that is beyond toddler’s developmental ability to comply

 

 

1. Child
   1. Excessive negativism
   2. Frequent temper tantrums
   3. Dominant mood of irritability or apathy
   4. Frequent illnesses

• Childrearing practices
  1. Emotional development
     1. Development of child’s self-esteem
        1. Treat toddler with respect; attempt to see the world from his or her
        2. Avoid battles over “no” when possible, and do not try to win them all. Try to find situations when able to praise child or say “yes” they are doing the correct
        3. Provide enough freedom for toddler to try new
        4. Constructively reinforce
     2. Child’s development of self-control
        1. Control of impulses will continue to take time and much reinforcement.
        2. Provide a safe environment, as a toddler of this age cannot be completely trusted not to act on
     3. Temper tantrums
        1. Provide firm but soothing restraints (hold under arm); do not leave alone, as child is frightened by loss of
        2. Keep record of events preceding the incident, intervention, and
        3. Seek professional help if such destructive behavior
        4. Provide a quiet, gentle, consistent
     4. Negativism
        1. “No” used as a means of learning which behaviors are acceptable. Caregiver must demonstrate that acceptable behavior has more power to get attention and approval than unacceptable
        2. Avoid opportunities for toddler to use negative response. Do not ask him or her to make a choice; state what is to be done, such as, “this is what we will have to eat” or “now it is time for bed.”
        3. Set limits; do not give in to unreasonable
        4. Maintain a cheerful, fun-loving, well-organized daily
        5. Provide a large, stimulating, safe
     5. Intellectual development: Language
        1. Talk and sing to child; name objects, feelings, odors, textures, sounds.
        2. Listen; pay particular attention as child attempts to talk to
        3. Accept child’s strivings to express self; do not overcorrect and do not overload; let child take the lead in how much he or she

 

 

4. Look at pictures and name things, but do not expect the tod- dler to sit still for story

• Stimulation
  1. Communication and sounds: Parents
     1. Read short, simple stories
     2. Give simple directions
     3. Say words for objects child desires
     4. Provide books with cardboard pages, simple colorful pictures, rhymes, songs
  2. Touch: Water tubs, sandboxes
  3. Sight: Bulletin board in child’s room, using large single picture; point at things at a
  4. Gross motor
     1. Walks up and down stairs
     2. Balances on one foot
     3. Jumps
     4. Rides kiddie car
  5. Fine motor
     1. Uses paper and crayons to scribble; provide large paper, such as old newspapers
     2. Enjoys finger
     3. Puts on shoes
     4. Washes and dries hands
  6. Safety
     1. Accidents happen most frequently:
        1. When usual routine changes (holidays, vacations, illness in family)
        2. After stressful events for caregivers
        3. When caregivers are tired or ill
        4. Late in the afternoon
     2. Accident prevention
        1. Most dangerous age, because child is mobile but has little abil- ity to control behavior and poor depth perception (for instance, may step off a high step)
        2. Child-proof house, yard, porches
        3. Constant surveillance is necessary
        4. Insist that child remain in car seat
     3. Investigate possibility of child abuse and neglect
     4. Instructions to babysitters
     5. Emergency telephone numbers posted

For the last few months, the toddler has been concentrating on mastering and per- fecting physical skills. Now that physical skills take less concentration and energy, the child turns to the next developmental task: language acquisition.

 

 

1. Overview
   1. Parents
      1. Understand toddler’s self-centered world and growing willingness to conform by controlling behavior. Child does this for the return of support and affection; if misbehavior is the only behavior that gets attention, child will continue that
      2. Identify any abuse of family members
   2. Child
      1. Physical
         1. Walks alone
         2. Manipulates small objects
         3. Slower growth rate
         4. Falls asleep more easily
      2. Emotional: Struggle toward independence can lead to excessive use of “no.” Child is a keen observer of how this word affects care- givers.
      3. Intellectual: Increased interest and use of language can begin the development of pretending or
   3. Risk factors
      1. Parents who let the use of “no” develop into battle of wills
      2. Whiny child needs
      3. Illness becoming a way to gain attention
   4. Injury prevention
      1. Review safety
      2. Age-appropriate precautions: Toddler’s increase in physical ability and boundless energy, intense curiosity, persistence in endeavors, and mini- mal behavior control combine to make this a dangerous
      3. Safety standards that need to be carefully maintained
         1. House: Safe environment
            1. Gates or doors on stairwells, kitchen, bathroom, bedroom
            2. Crib: If child is climbing out, use bed or mattress with gate on door so toddler does not roam the house while parents are asleep.
            3. Bureau drawers with safety locks so toddler cannot climb into a drawer and have bureau topple over on him or her
            4. Windows and screens securely fastened; cords and drapes removed; window guards installed in upper level apartments or houses
            5. Bathroom: Gate and toilet seat locked
         2. Car: Child in car seat at all times in back seat facing rear
      4. Caregiver
         1. Alert to toddler’s ability to dash off into danger
         2. Carefully and quietly demonstrates what behavior is expected and pays particular attention to toddler’s steps toward behavior control

• Child abuse
  1. Age-specific concern: Toddler’s activities often lead to injuries, so it is important to differentiate between injury and

 

 

1. Physical identification
   1. Investigate unusual burns, injuries, and broken
   2. Consider corporal punishment and shaken child
2. At-risk child
   1. Overactive, impulsive
   2. Cranky, whiny, angry
   3. Continuing health problems
3. Identify:
   1. Careless caregiver
   2. Unsafe environment
   3. Abuse of other family members
4. Developmental process
   1. Parents
      1. Listen to toddler’s
      2. Talk to child about child’s
   2. Toddler
      1. Attends to speech of others
      2. Assertive; gives two-word commands
      3. Physical agility and coordination
   3. Family status
      1. Basic needs being met
      2. Stable family structure
      3. Siblings receiving appropriate care and age-specific activities; relation- ships evaluated and referrals given as needed
      4. Parental concerns and problems: Ability to identify problems and to cope
   4. Health habits
      1. Nutrition
         1. Diet history
            1. Variety of foods
            2. Amount of milk: Should be drinking from cup
            3. Adequate caloric intake; relate to pattern on growth chart
         2. Eating habits: Avoid high-calorie or fried foods; begin good food habits to prevent obesity
            1. Self-feeding, manages spoon
            2. Reasonable time spent on meals
            3. Atmosphere pleasant; no attention given to rejected foods
         3. Sleep
            1. Sleeps 10 to 15 h/d
            2. Contented in crib for longer periods; practicing jargon and new words
            3. In a bed if able to climb out of crib; gate on door of room; win- dows, screens fastened securely
            4. Room not too stimulating to promote restfulness
            5. Accepting bedtime routine
            6. Daytime naps: Parents aware of type of behavior child will display when he or she runs out of steam
            7. Able to turn off stimulation and relax

 

 

1. Elimination
   1. Toilet training not usually accomplished by 18 months of age (see Protocol, p. 178)
   2. Parents understand principles of toilet
   3. Regularity of bowel movements established
   4. Longer periods between urinating
2. Dental
   1. Teeth cleaned with soft brush
   2. See tooth eruption schedule, p.

• Growth and development
  1. Physical
     1. Gross motor: Testing strength; pushes and carries heavy and large objects
     2. Fine motor: Handedness; scribbling
     3. Speech
        1. Uses two- or three-word phrases, but cannot use the words separately
        2. Gives two-word commands
        3. Follows one-step directions
        4. Perfects inflections and rhythms of speech in jargon
        5. By 18 months of age, understands most basic language
     4. Emotional development. Erikson: Feelings of autonomy and self- esteem continue to grow through toddler’s mastery of physical control of body and activities. Language acquisition continues to add to self- esteem by giving child a new tool with which to understand and control the
        1. Physical agility, good coordination, high energy level
        2. Plays with putting together a string of sounds
        3. Experiments with words and observes their effect on caregiver
        4. Content to play by self for longer periods
        5. Instigates own activities
     5. Intellectual development. Piaget: Sensori-motor learning is progressing to the beginning of preoperative or intuitive learning, which is the abil- ity to store mental images (as in memory) and to symbolize (as in words being substituted for the actual object, feeling, or event).
        1. Attends carefully to activities of peers, but does not play interactively
        2. Shows interest in names of things and people
        3. Remembers where possessions belong
        4. Simple pretending

• Risk factors
  1. Parents
     1. Too helpful; fearful of providing physical challenges
     2. Too busy or uninterested to spend time listening to or talking with child
     3. Unhappy, frustrated

 

 

1. Child
   1. Physically cautious
   2. Does not initiate activities for self; sits doing nothing for long periods
   3. Clings to caregiver; whiny or irritable
   4. Does not attempt to use words to get what he or she wants
2. Physical examination
   1. Growth: Continues on established pattern; periods of illness will affect the pattern, but growth should be made up within a period of
      1. Use CDC growth charts (2000) available at: http://www.cdc.gov/ growthcharts
      2. Calculate BMI at every well child visit during childhood (see Barlow, 2007).
   2. Appearance and behavior
      1. Good physical coordination
      2. Energetic, playful
      3. Cautious when relating to strangers, but more trustful than at pre- vious visit
      4. Eye contact possible
   3. Specific factors to note during routine physical examination
      1. Skin: Excessive bruising, burns
      2. Head: Anterior fontanelle usually closed
      3. Eyes: Smooth tracking; no strabismus
      4. Teeth: Lateral and central incisors present; first and second molars may be
      5. Cardiovascular system: Heart rate 90 to 100 beats/min
      6. Musculoskeletal: Coordination, gait
   4. Parent-child interaction
      1. Parent understands child’s behavior
      2. Toddler shows recognition of parents’
      3. Rapport between parent and child appears cheerful,
   5. Assessment
      1. Physical
      2. Developmental
      3. Emotional
      4. Environmental
   6. Plan
      1. Immunizations per office protocol
      2. Problem list (devised with parent); SOAP for each
      3. Appropriate timing for office visits

 

 

These months continue the long road toward establishing a balance between the individual’s needs and society’s expectations. A very tentative beginning has been made by the toddler’s experiencing and anticipating the results of control- ling behavior. However, the toddler’s impulses and drive for independence rule most of his or her activities. It is the caregiver’s task to persuade the toddler, through attention and affection, that it is worth the effort to conform. The acqui- sition of language is an added tool that can make this development easier.

 

1. Overview
   1. Parents
      1. Able to discuss understanding of discipline versus punishment and the establishment of realistic goals for toddler
      2. Parents who cannot provide such support need referrals, more

frequent visits, or home visits.

1. Child
   1. Physical
      1. Better able to concentrate on meals. Milk intake should be no more than 16 oz/d, because too much milk will curb appetite for other Foods high in iron vitamin C and calcium.
      2. Enjoys strenuous activities; needs appropriate and safe

environment

178. Toilet training; see protocol, p.

2. Emotional
   1. Increased feeling of competence so “no” is used less often; continues to be egocentric (selfish, stubborn, assertive)
   2. See guidelines for childrearing practices and risk
3. Intellectual
   1. Learns words important to him or her first. Careful listening by caregiver encourages use of
   2. Able to symbolize a thing by using words, so can begin to

pretend

4. Social development
   1. Egocentric: Unable to share
   2. Moral: Will show signs of guilt if found doing something wrong
5. Risk factors
   1. See safety
   2. Frequent illness
   3. No interest in using language
   4. No primary caregiver to help establish behavior control through positive reinforcement
6. Watch for:
   1. Happy, healthy, energetic child
   2. Acceptance of daily routine
   3. Language used to make wishes known
   4. Guilt if found doing an established behavior wrong
   5. Behavior control for attention and approval

 

 

1. Expectations of this period
   1. Parental tasks
      1. Continue to provide a safe
      2. Provide opportunities to develop physical strength and
      3. Provide a variety of
      4. Provide a caring adult to encourage and praise child’s efforts, to talk with him or her, and to listen to his or her efforts to use
   2. Child tasks
      1. Bargains for behavior control
      2. Attempts to use language to control activities
      3. Increasing socialization; delights in being with and watching others

• Family status
  1. Basic needs being met; referrals providing needed help, with follow- up of these referrals
  2. Parents
     1. Health and resources sufficient to maintain satisfactory lifestyle
     2. Appreciate importance of this age period
     3. Wholesome childrearing practices established
     4. Derive satisfaction and pride from role
     5. Content with lifestyle
  3. Working mother
     1. Health and energy level sufficient for daily schedule
     2. Satisfactory child care arrangements
     3. Arranges some time each day to be alone with toddler
  4. Single parent
     1. Adequate parenting skills developed
     2. Adequate support system
     3. Career goals being implemented
  5. Siblings
     1. Older siblings demonstrate caring and gentleness with
     2. New baby in family
        1. Toddler will show crude reactive patterns to hold parents’ attention; regressive behavior understood and not punished
        2. New emotion of jealousy; toddler must learn another step in

coping with world.

1. Child
   1. Basic physical and emotional needs being met
   2. Learning that needs, but not all wants, are met
2. Risk factors
   1. Reaction of parents to children during divorce or separation: Lack of attention, overprotection, use as emotional crutch, bro- ken routine, abandonment
   2. Siblings: Teasing or aggressive acts; frustrating toddler into

destructive action toward self or others

1. Identify sexual abuse to or by any family member or other person

 

 

1. Health patterns
   1. Nutrition
      1. Sufficient calories for high energy level; include high-value food (potatoes, dark bread, peanut butter, yogurt, molasses).
      2. Avoid junk food (if such foods are not bought, they will not be available).
      3. Food variety: Keep menus and seasoning simple; add new foods in small
      4. The following foods must not be given  to  toddlers:  Potato chips, coconut, nuts, popcorn,  whole  kernel  corn,  hot  dogs, raw carrots, and peanut butter on a cracker. They are difficult to chew and swallow and can cause choking or
      5. Eating habits
         1. Less distractible, so improved attention to food
         2. Expects to feed self, so finger foods best
         3. Simple, bland foods offered; no substitutes, no snacks between meals if food refused at mealtimes
         4. Watch milk intake, and offer only after or between
         5. Keep mealtime a short, matter-of-fact event; give no atten- tion to rejected
         6. Do not offer food as a reward or withhold it as a
      6. Sleep
         1. Sleeps up to 12 to 15 h/d
         2. Definite schedule and routine at bedtime continued
         3. Now better able to tune out stimulation around him or her, so falls asleep more easily
         4. Enjoys talking to self, and wants a bedtime companion, such as a teddy bear
         5. Returns to sleeping through the night
         6. Naps: One long nap in middle of day
         7. Fatigue: Watch for behavior when tired; help child establish a quiet
      7. Elimination: Toilet training
         1. Girls train earlier than boys and smaller-sized children earlier than bigger
         2. Treat as a matter-of-fact event; special attention encourages delaying the training for continued
         3. Attempt training if:
            1. Regular pattern of bowel movement established
            2. Toddler connects physical awareness of bowel movement and parental request to use toilet (heads for potty at time of bowel movement)
            3. Toddler willing to sit still on potty chair
         4. Full bladder control may not be accomplished until 3 years of age
      8. Dental
         1. Clean teeth with soft
         2. No extreme discomfort with teeth eruption

 

 

1. Growth and development
   1. Physical
      1. Improved coordination and agility
         1. Needs large area to expend energy
         2. Improved agility; running and jumping
      2. Spatial relations: Exploring possibilities by climbing up and down, crawling in and out, dropping toys over and over again; fascination with balls rolling and bouncing
   2. Emotional development. Erikson: Continued development of self-

esteem. Language is a new tool that can be used to increase self- worth by helping toddler control activities and influence environment.

1. Less negativism; developing feeling of competence, which

diffuses need for testing power

2. Shallower mood swings; words help others understand needs and wishes
3. Continues to demonstrate affection
4. Fewer frustrations since learning to put problems into words
5. Continues to be egocentric (selfish, stubborn, assertive)
6. Destructive feelings of defiance, willfulness, and combativeness need careful investigation of what is wrong in the child’s

1. Intellectual development. Piaget: Language allows for use of words to symbolize actions, objects, and feelings. This skill develops by repeti- tion of activities, object permanence, and vocabulary
   1. Language opens a new world; labeling and categorizing the

world is a difficult job. “What’s that?” is toddler’s favorite ques- tion; he or she needs a simple answer, not a long explanation.

2. Improved problem-solving techniques; works out alternative

solutions

3. Increase in memory; knows own possessions and where they belong
4. Spends time observing the world around him or her; increased interest while looking out the window, riding in the car, going shopping
5. Mimics actions of others (tone of voice, facial expressions,

mannerisms)

6. Periods of apparently doing nothing; taking time to catch up (a risk factor if this becomes a dominant mood)
7. Language
   1. Toddlers learn best what they need to know when they need to know it and remember first the words that are important to them, such as:
      • Words that gain attention (me do, watch)
      • Words that express feelings (tired, hungry)
   2. Uses own name and I, which indicates increased awareness of self
   3. Reaction of caregivers to efforts of toddler to express self gives or takes away motivation to acquire

 

 

1. Social development
   1. Autonomy: Uses own name; is possessive about own things; if pressured by older siblings or peers, shows hostility and fights back; is bossy with younger siblings
   2. Self-control: Less impulsive; beginning to comprehend effect of

actions

3. Egocentric: Unable to share; sees the world only from his or her perspective
4. Amoral: Beginning to appreciate what is acceptable behavior

through caregivers’ teaching; will eventually accept cultural and moralistic code of parents in return for security, respect, and love. Will show signs of guilt if  found  doing  something  he  or she knows is wrong.

1. Risk factors: Child
   1. General
      1. Frequent illnesses
      2. Divergence from expected growth pattern
      3. Irritable, whiny, distractible
      4. Problems with eating, sleeping, elimination
      5. Failure to respond to speech with speech
      6. Lack of consistent caregiver to listen to and talk with toddler
   2. Emotional
      1. Temper tantrums, breath-holding, irritability, crying (see Proto- col, p. 175)
      2. Developmental lag; continues characteristics of 14-month-old

(distractible, no interest in naming objects, extreme negativism)

3. Overdependent; lack of initiative
4. Excessive crying; whining; appears uninterested in activities (be sure no physical problem exists)

• Childrearing practices
  1. Emotional development
     1. Exaggerated praise can be detected as
     2. Expect compromises to be
     3. Provide different environments for toddler to
     4. Play games (e.g., hide and seek) to use memory
     5. Avoid putting toddler in situations where more is expected of him or her than he or she can
     6. Overstimulation can reduce desire to
     7. Provide a regular, quiet schedule most of the
     8. Provide a caring adult to
     9. Begin to identify learning style (an observer, a toucher, a talker).
  2. Intellectual development
     1. Minimal instruction and correction; toddler turned off if expec- tations are beyond his or her capacity
     2. Interesting to watch errors, as they demonstrate method of

learning

 

 

3. Caregivers should describe in simple terms what they are doing, their reactions, and their emotions; this helps the toddler develop appropriate
4. Caregivers should maintain eye contact when toddler is attempting to tell them
5. Books: Simple action books; toddler has short attention span

and cannot be expected to sit still and listen to a story.

6. Fascinated with rhymes and music; enjoys nursery rhymes, recordings; have toddler sing with caregiver.
7. Listening: Identify various sounds and point out new ones;

observe if child can pick up faint sounds.

8. Handle toddler’s commands with gentleness, humor, and

1. Social development
   1. Provide opportunity for toddler to observe other
   2. Do not expect toddler to share or play cooperatively with
   3. Emphasize acceptable behavior through attention and
   4. Ignore unacceptable behavior as far as safety will

• Stimulation
  1. Communication and sounds
     1. Toddler fills in words of stories and
     2. House and small dolls
     3. Naming games
     4. Listening: Naming sounds, music, poetry
     5. Books, nursery rhymes
  2. Sight
     1. Identifies some colors
     2. Identifies some shapes
     3. Points out and identifies things at a distance
  3. Gross motor
     1. Dresses with help
     2. Walking games: Well-defined track to follow
     3. Large riding toys
     4. Wooden blocks
  4. Fine motor
     1. Busy board
     2. Clay
     3. Simple puzzles
     4. Play to enjoy, not to accomplish a task
     5. Parents interact in
  5. Safety
     1. Accidents happen most frequently:
        1. When usual routine changes (holidays, vacations, illness in the family)
        2. After stressful events (either for caregivers or for toddler)

 

 

3. When caregivers are tired or ill
4. Late in the afternoon

1. Accident prevention
   1. Negativistic period makes toddler seem
      1. Save severe tone of voice for
      2. Develop a method for emergency compliance (use of whis- tle, hand clap); practice and use
   2. Do not trust toddler’s training; lack of behavior control and little

memory will not stop child from dangerous activity.

1. Investigate frequent injuries to consider possible child abuse and neglect.
2. Instructions to babysitters
3. Emergency telephone numbers posted

The acquisition of a few important words has given the toddler a new sense of power. It is of great help to be able to name a desired activity or object and to verbalize feel- ings. With amazing rapidity, the toddler is labeling and categorizing the world. This makes for an easier and more pleasant rapport between toddler and family.

1. Overview
   1. Parents
      1. Understand and appreciate toddler’s personality and capabilities
      2. Provide a safe, stimulating, varied environment
      3. Identify physical or emotional abuse of any family member
   2. Child
      1. Physical
         1. Continues on usual growth curve; short illnesses will not affect this
         2. Needs a quiet place of his or her own to use during the day
         3. Walks with confidence
         4. Uses hands to carry toys while walking
      2. Emotional
         1. Dominant mood of cheerfulness and cooperation
         2. Attempts new activities
         3. Responds to parents’ tone of voice and will act sorry if found doing something wrong
      3. Intellectual
         1. Enjoys experimenting with language and using it to get what he or she wants
         2. Can symbolize words for things so can now enjoy pretending

 

 

1. Risk factors
   1. Not attempting to use speech
   2. Using aggressive behavior to get what he or she wants
2. See guidelines for specific factors to be noted in physical

1. Injury prevention
2. Review safety protocol (see TIPP guidelines, available at: http://www. aap.org/family/tippmain.htm)
   1. Toddler still needs constant surveillance but is becoming less impulsive in activities and is better able to attend to vocal commands.
   2. Safe environment
      1. Needs constant review as toddler’s physical ability increases
      2. Voice commands and tone of voice
      3. Continue to establish simple command for use in emergency; may take time and a great deal of positive reinforcement
   3. Acting out and continued negativism may indicate that such behavior is the best way for toddler to get

• Child abuse
  1. Physical identification
     1. Frequent injuries or injuries more severe than history indicates
     2. Corporal punishment accepted by parents as means of behavior control
  2. At-risk child
     1. Overly submissive, shy, fearful
     2. Extreme negativism, aggressiveness
     3. Overactive, impulsive
     4. Continued illness and disabilities
  3. Identify:
     1. At-risk caregivers
     2. Assessment of all adults with access to child
     3. Abuse of other family members
  4. Developmental process
     1. Parents
        1. Give simple, concise, gentle commands; do not attempt to reason with child
        2. Demonstrate understanding of toddler’s capabilities
     2. Child
        1. By 18 months of age, vocabulary is about 20 to 25 words; half of speech is intelligible to others outside family circle; understands most simple
        2. By 24 months of age, vocabulary is 150 to 300 words; two-thirds of speech is intelligible to other than family
        3. Responds to parents’ requests
     3. Family status
        1. Basic needs being met
        2. Parental concerns and problems: Ability to identify problems and to cope

 

 

1. Illness in family since last visit; course; resolution
2. Parental assessment of child’s development
3. Fear of violence and abuse identified

1. Health habits
   1. Nutrition
      1. Diet history: Food intake, including snacks; balanced diet being offered
      2. Eating habits, appetite: Regular schedule of meals and snacks; self-feeding; pleasant atmosphere at mealtime; limited time for eating; no attention paid to unwanted foods; food not used as reward or punishment
      3. Dietary recommendations for all children over age 2 years by the American Heart Association are found at http://circ.ahaorg/cgi/content/Full/112/13/2061.
   2. Sleep
      1. Well-established bedtime routine
      2. Sleeping all night
      3. Danger of climbing out of crib: Put child in a bed or leave sides of crib down; make room safe, and put a gate on bedroom door; win- dows and screens securely fastened; bureau drawers locked
      4. One nap period
      5. Quiet place for rest periods
   3. Elimination
      1. Regular bowel movements; effects of new foods; periods of con- stipation or diarrhea
      2. Urinating less frequently as bladder capacity increases
      3. Color of urine indicator of state of hydration
      4. Toilet training only if bowel movements regular (see Toilet Train- ing protocol, p. 178)
         1. Practicing with potty chair with or without diapers
         2. Too much pressure on toilet training can result in regressive behavior patterns, such as eating problems, waking during the night, and increased

• Growth and development
  1. Physical
     1. Gross motor
        1. Improved coordination and agility
        2. Increased muscle strength
        3. Rides kiddie car
     2. Fine motor
        1. Improved hand–eye coordination
        2. Observes and handles small objects, such as pebbles and crumbs
     3. Emotional Erikson: Toddler is reaching a plateau of phys- ical and emotional development for first period of growth. Language acquisition will lead to next developmental task of using words to help control environment and own actions. Toddler is now willing

 

 

to accept compromises in behavior for affection and attention from important adults. Without this positive reinforcement, child will reflect the negative feelings of discouragement and shame. Positive and nega- tive reinforcements are the origin of the basic values of optimism and pessimism.

1. Physical well-being
2. Dominant mood of cooperation and cheerfulness
3. Uses words appropriately

1. Intellectual development. Piaget: Being able to symbolize thoughts and actions through words opens up a new world of imagination and fantasy.
   1. Vocabulary development
   2. Pretending without actual object present (can pretend to give teddy bear a drink without needing an actual cup)

• Risk factors
  1. Parents
     1. Unrealistic demands on child for self-control
     2. Harsh vocal commands
     3. Too busy or distracted for a quiet, gentle approach to child
  2. Child
     1. Frequent illnesses
     2. Failure to respond to speech with speech
     3. Exhibits behavior of earlier period (distractible, unobservant, pronounced negativism)
  3. Physical examination
     1. Growth: Continuing on established pattern; use this as a guide for parents for toddler’s continued growth and caloric
        1. Use CDC growth charts (2000), available at: http://www.cdc.gov/ growthcharts
        2. Calculate BMI at every well child visit during childhood (see Barlow, 2007).
     2. Appearance and behavior
        1. High energy level, but a degree of ability to control actions (sit still, follow directions)
        2. Losing cherubic look; taller and thinner
     3. Specific factors to note during physical examination
        1. Skin: Excessive bruising, burns; birthmarks fading
        2. Eyes: Equal tracking; no strabismus
        3. Teeth: Complete set of 20 teeth by 5 years of age
        4. Musculoskeletal: Smooth coordination and gait; check hips
     4. Parent-child interaction
        1. Child turns to parent for
        2. Parent is able to quiet child after painful experience, such as immunization or blood
        3. Child can separate from

 

 

1. Assessment
   1. Physical
   2. Developmental
   3. Emotional
   4. Environmental
2. Plan
   1. Immunizations per office protocol
   2. Problem list (devised with parent); SOAP for each
   3. Appropriate timing for office

Review previous guidelines for a reference point as to the toddler’s developmen- tal level, and schedule future visits as needed. In this most important year, the toddler completes the tasks of the first period of growth. By 3 years of age, suc- cessful completion of these developmental tasks can be expected.

 

1. Overview
   1. Parent: Some characteristics of the “terrible twos” can be eliminated if parents can appreciate the toddler’s attempts to give up comfort- able baby ways to accept a new world of playing with peers, going off without parent to play school, completing toilet training, and often coping with a new baby in the family. This is a time of great fluctuation between independence and
   2. Child
      1. See guidelines for expectations of this period for toddler and
      2. Physical
         1. Increased agility and eye–hand coordination
         2. Diet: Provide various foods, but no pressure to eat; do not use food as a
         3. Sleep: Change of pattern needs
         4. Speech: Two- or three-word sentences intelligible to family
      3. Emotional
         1. Greater range of emotional responses
         2. See guidelines for development of personality
      4. Intellectual
         1. By age 3 years, can symbolize, using words for objects; world of pretend becomes part of
         2. Listening carefully to toddler is a way to understand how he

or she is beginning to see the world and the things that are important to him or her.

5. Social
   1. Separates from family easily; enjoys being with peers
   2. Needs external controls for being good

 

 

1. May have an imaginary friend he or she uses as scapegoat
2. Sexual identity: Selects type of behavior that society has accepted for each sex
3. See guidelines for childrearing practices and risk

1. Risk factors
   1. Fails to use speech as a tool
   2. Regresses to earlier behavior patterns
   3. At-risk caregivers
   4. Any family member being abused
2. Watch for:
   1. Attitude of confidence and good will
   2. Cooperative most of the time
   3. Willing to control behavior for positive response
   4. Negative response by caregiver reinforcing negative behavior
   5. Toilet training first big step in behavior control (see Protocol, p. 175)
   6. Beginning of self-fulfilling prophecy: “I am a good child” versus

“I am a bad child.”

7. Whining, fussy child who has not established these positive, cooperative behaviors is at

1. Expectations of this period
   1. Stability of bodily processes and mastery of physical skills
   2. Toddler learns to see self as an individual with ability and value
   3. Appears confident in activities and curious to investigate world
   4. Uses language as a tool to influence own actions and affect environment
   5. Can compromise activities for attention from a meaningful caregiver
   6. Shares affection with a primary caregiver

• Family status
  1. Basic needs being met; self-direction in coping with problems. Able to discuss if abuse present
  2. Parents
     1. Stable lifestyle; family routine established that allows child to predict what is going to happen and gives child a feeling that life has some consistency
     2. Cooperate in and understand their childrearing practices
     3. Understand that child will begin to move away from them and become interested in peers and outside world
     4. Identify and implement a plan for own life goals
     5. Appreciate their role as family coordinators and standard- bearers for the family’s behavioral patterns, mores, and spiritual foundation
     6. Set example of a gentle, caring attitude
     7. Understand importance of child spacing
     8. Abuse of any family member identified

 

 

1. Working mother
   1. Adequate health practices and satisfaction with lifestyle
   2. Schedules sufficient time with toddler to ensure implementation of her philosophy of childrearing
   3. Counseling available for career goals and personal support
2. Single parent
   1. Able to assess childrearing practices of caregivers and to coordi- nate with own
   2. Support system intact; does not use child as the only means of

emotional satisfaction

3. Fear of being abused

1. Siblings
   1. Parents provide opportunity for each child to pass through each developmental stage without undue interference from siblings
   2. Identify whether one child is overly dominant or submissive
   3. Prohibit teasing; teach alternative ways of interacting
   4. Older siblings seen as role models
   5. Initiate use of communication skills as a way of expressing feel- ings and resolving
2. Health patterns
   1. Nutrition
      1. Good appetite; will eat most foods offered
      2. Adequate diet being offered
         1. Adequate nutrients and calories can be supplied by simple, easily eaten finger foods; rely on foods of high caloric con- centration, such as bread, potatoes, peanut butter, and cheese.
         2. Sufficient intake of fluids can be identified by color and odor

of urine. Avoid sweetened drinks, such as chocolate milk, drinks containing colored sweeteners, and sodas; encourage frequent drinks of water and diluted fruit juice.

1. Periods of crankiness and fatigue need to be
   • Offer quickly absorbed foods, such as fruit juice and a cookie.
   • If food is helpful, attempt to avoid such periods by sched-

uling meals and snacks at more frequent intervals.

3. Eating habits: There are so many developmental tasks going on during this period that putting too much attention on food and eating can become an unnecessary burden to the
   1. Asking what the child wants to eat or giving him or her a

choice can be too confusing to a toddler busy experimenting with the things around him or her and learning a language.

1. Using food as a reward can begin establishing the need for

oral satisfaction throughout life, as seen in obese people, chain-smokers, and those who have inverted the process and have difficulty eating and enjoying food.

 

 

1. Children mimic the world around them and will adopt the attitudes and habits about foods and the use of food of those around

1. Sleep
   1. Regular pattern
      1. Sleeps up to 10 to 12 hours at night; one nap period
      2. Falls asleep quickly
      3. Sleeps all night
   2. Disturbances in pattern indicate health or emotional
      1. Review previous anticipatory guidance outlines to identify unaccomplished tasks by age 3 By 3 years, nightmares may occur.
      2. Identify environmental
      3. Check physical examination and laboratory
   3. Safety
      1. Out of the crib and into a bed
      2. Room and windows checked for safety; gate placed on bed- room door to keep toddler from roaming the house while the rest of the family sleeps
   4. Elimination
      1. Regular pattern; little effect with new foods; continued prob- lems need
      2. Toilet training: Expectation of control of bowel movements and

daytime wetting by 3 years of age

1. Schedule regular periods for sitting on
2. Clothing should be easy to remove; use training
3. Carefully watch child’s reaction to
   • If using as a means of getting attention, look for dis- satisfaction in other
   • Successful training provides a feeling of self-control and

adds to feeling of self-worth.

1. Growth and development
   1. Physical
      1. Gross motor: Good coordination, smooth movements, agility, increased muscle strength
      2. Fine motor: Improved eye–hand coordination; can fasten large

buttons; scribbles with some intent

3. Enjoys physical activity; has body confidence: Enjoys being tossed in the air, rolling down a hill, splashing in water, and so forth.
4. Stability of body systems
5. Growth rate leveling off
   1. Grows 3 in./year in length
   2. Gains 5 lb/year in weight
   3. Legs grow faster than rest of body; head slows in growth
   4. Child loses top-heavy

 

 

6. Speech
   1. Vocabulary development encouraged; discards jargon
   2. Articulation
      • 90% of speech intelligible to people outside family
      • Omits most final consonants
      • Uses all vowels
   3. Sentence structure
      • Handles three-word sentences easily; grammatically correct
      • Uses pronouns and at least three prepositions correctly
      • Uses simple adjectives (big, little, short, long)
      • Verb tense denotes sense of time; not always used cor- rectly until 5 years of age
   4. Emotional Erikson: By 36 months, autonomy—or self-

worth—has been established, and child is ready to move on and use physical abilities to learn new skills and interact with others. Without this confidence, the child turns inward, feeling guilty and shameful. However, the period from 2 to 3 years of age is a time of great fluc- tuation between independence and dependence. Personality traits that come into focus during these years are:

1. Temperament
   1. Assertiveness: Accomplishing tasks without using destructive acts toward self or others
   2. Aggressiveness: Child has inadequate controls for the pres-

sures put on him or her.

• Substitutes actions, such as bed-wetting, temper tantrums
• Watch to whom child is aggressive, and identify the reasons.

1. Stubbornness: Ascertain whether caused by giving up a plea-

sure or being overcome by some fear; an expected reaction to child’s drive for autonomy and egocentric outlook.

2. Fears and anxiety
   1. These develop now because memory and fantasy are work- ing well enough to distort
   2. Demand for impulse control provides fear of failure; child

copes by projecting failure on others or on things and can even conjure up an imaginary friend to take the blame.

1. Help needed if fears interfere with normal functions of age

3. Affection
   1. Forms attachment to others besides parents
   2. Fond, helping relationship with siblings; constant aggression or teasing between siblings needs
4. Ambivalence
   1. Despite urge to “do it myself,” turns frequently to parents for reassurance

 

 

1. Changes in environment and periods of illness cause regres- sion to earlier behavior

5. Cooperation: Continues to develop ability to postpone gratifica-

tion and accept compromise

6. Competence: Wants to try new activities and shows pride in accomplishments
7. Wariness: Keen observer of surroundings
8. Joy: Good health, combined with the feeling of the value of self and others, can make joyfulness the child’s dominant

1. Intellectual development. Piaget: Progression from sensory to intu-

itive learning continues, as shown by the development of memory and symbolic play. Memory is used to recall what has happened in previous incidences and to predict the outcome of the present situa- tion. In symbolic play, by using symbols (words) for actual objects,   the child frees himself or herself from reality and can take off into fantasy or can take reality apart and put it together in a different manner. By 3 years of age, the following characteristics are present:

1. Uses toys to represent different things (blocks become bridges)
2. Anticipates consequences of actions; expects parental reaction when caught doing something wrong and is more cautious when attempting new physical activities
3. Symbolizes and pretends; make-believe becomes part of play
4. Dramatic play, usually imitating those around him or her
5. Concentrates on projects, but keeps an eye on what is going on around him or her
6. Developing sense of time: Before, after, yesterday
7. Language
   1. Increased vocabulary; perfects sentence structure and grammar
   2. Continues labeling and categorizing
   3. Can make most of wants known verbally
   4. Makes statements about feelings (“I like you.” “I hate you.” “I’m mad at ”)
   5. Understands most of what is said to him or her; is learning

what the world is like and what its values are

1. Follows three-step directions
2. Can relate experiences from recent past

1. Social development
   1. Shows initiative to go off on own
      1. Easily separates from parent most of the time
      2. Enjoys being with peers, but can play by self and initiate own activities
   2. Can show affection to others
   3. Practices self-control; learns to accept realistic limits
   4. Continues to need external controls for being good
      1. Approval and affection of parents is the incentive, but child needs consistent limit setting before self-control is

 

 

1. Shows guilt only if found doing something wrong
2. Accepting self-criticism and responsibility for actions takes much gentle insistence on behavior
3. Will blame others and even use an imaginary friend as a

scapegoat

5. Confidence in turning to adults; good eye contact
6. Cooperative, affectionate; eager to please
7. Enjoys small group of peers; keenly observant of their behavior; little sharing; little interchange; each talks about own interest
8. Sexual identity established
   1. Ability to look beyond self; observes physical differences
   2. Selects type of behavior society has accepted for each sex
      • Girls: Given positive reinforcement, indulgence, and protectiveness
      • Boys: Given negative reinforcement and less sympathy;

toys and play of aggressive  nature

1. Role model of female caregiver: Girls rewarded for following role model and boys punished for it; approved behavior is a trial-and-error situation for boys, demanding ingenuity and creativeness
2. Masturbation: Natural result of increased body awareness; a

concern if used as major form of self-satisfaction

1. Risk factors: Child
   1. General
      1. Frequent illnesses; overattention to illnesses by parents
      2. Poor appetite; inadequate nutrition; overweight
      3. Regressive behavior
   2. Intellectual development
      1. Poor motor coordination
      2. Delayed speech development (investigate possible hearing loss); inability to use language as a tool
      3. Inability to initiate activities for self; random play without plan

or make-believe

4. No primary caregiver to turn to for help, comfort, and positive reinforcement

1. Social development
   1. Limit setting does not provide establishment of impulse
      1. Overindulgence: Child never loses parents’ approval, so has no motive to bargain appropriate behavior for approval and attention.
      2. Excessively strict discipline techniques: Child fears rejection by

parents, so does not admit naughtiness done by self; blames others or a mythical friend. Child becomes unsure he or she can control behavior in a new situation, so refuses to try.

2. Child identified as mean and cruel to others; cannot feel or give

affection. In other words, child cannot understand the feelings

 

 

of others, so feels no remorse for actions toward them. Needs referrals and home visits.

3. Parents
   1. Too anxious, strict, or permissive
   2. Exacting standards above child’s ability to conform
   3. Cannot accept child’s sex; foster inappropriate behavior
4. Child
   1. Immature behavior of negativism; distractible and impulsive
   2. Cannot relate to adults or peers with affection; appears furtive, aggressive or shy, unhappy

• Childrearing practices
  1. Intellectual development
     1. Anticipating consequences
        1. Talk about plans for the
        2. Have child take as many plans forward as possible (“after breakfast . . .” “after Daddy or Mommy comes home . . .”).
        3. Discuss “if I do this, then I will have to do ”
        4. Expect and insist on occasional delayed
        5. Get child started on projects, but let him or her carry on as he or she
        6. Show approval when child plans out an activity; help him or

her to anticipate the results and consequences.

2. Dramatic play
   1. Simple make-believe helps stretch the
   2. Help child act out and talk about areas of pressure (sibling rivalry, dominating peers, toilet training, fear of abandon- ment, punishment, abuse).
3. Needs individual attention for personal rewards and exchange

of affection

1. Social development
   1. Safety is greatest concern; caregivers’ expectations of impulse control can be
   2. Stretch expectations, but be aware of signs of too much
   3. Provide friends; watch and listen to interaction; be available as a referee.
   4. Attempt to equalize sex behavior
      1. Treat all children positively and gently with expectations of independence and self-assertiveness.
   5. Accept masturbation as normal; ask for help if
   6. Discipline consists of positive actions toward promoting self- control, in contrast to punishment, which consists of aggressive actions by caregivers, leading to self-degradation of
   7. Limit setting: Provide consistent routine and safe environment;

pay attention to any and all acceptable behavior; correct un- acceptable behavior with as little attention and show of emo- tion as possible.

 

 

8. Parental role: Setting exemplary standards with which child can identify

• Stimulation
  1. Play equipment for large muscle use and agility: Climbing gyms, balance beam, swings
  2. Fine motor: Scribbling, puzzles, variety of textures to handle, toys of

various shapes and sizes

1. Spatial relations: Sandboxes, water tubs
2. Language: Simple stories and picture books; being listened to, talked with, and given minimal instruction and correction;  child  is  turned off if expectations are beyond his or her
3. Not burdened with choices and reasoning

1. Safety
   1. Accidents happen most frequently:
      1. When usual routine changes (holidays, vacations, illness in family)
      2. After stressful events (either for caregivers or for child)
      3. When caregivers are tired or ill
      4. Late in the afternoon
   2. Accident prevention
      1. Increased energy and curiosity with little behavior control con- tinue to make this a dangerous
      2. When in car, child should always remain in car
      3. Accidents: Check
      4. Constant surveillance
   3. Investigate possibility of child abuse and
   4. Instructions to babysitters
   5. Emergency telephone numbers posted