Growth and development of the toddler

Which report by a parent would indicate normal social development of the 2-year-old patient?

"He will play next to another child and watch the child, but won't interact with the child."

Match the activity with the age at which it is first exhibited.

15 months: Walking independently 18 months: Turning the pages as they are read to 24 months: Dressing themselves 36 months: Stacking multiple blocks to build towers

Which head circumference measurement would be expected for a two-year-old whose head circumference was 18 inches at the 12-month checkup?

19.5

A toddler who weighs 22 lbs at 1 year of age would be expected to weigh approximately lbs by the third birthday.

32 The average weight gain is 5 lbs (2.26 kg) per year. Therefore, a toddler weighing 22 pounds at 1 year of age would be expected to weigh approximately 32 pounds (22 + 5 + 5) by the third birthday.

A toddler who was 33 inches in height on his or her second birthday would be expected to measure approximately inches in height on his or her third birthday.

36 The average toddler grows approximately 3 in. (7.62 cm) each year. The toddler would therefore be expected to be 36 inches (33 + 3) on his or her third birthday.

Which would be the expected adult height for a toddler who is 34 inches tall at the 30-month checkup? Use numbers only.

68

Which toy is appropriate to encourage cognitive development in the toddler?

Stacking cups Stacking cups would encourage cognitive development. Cups are also safe and durable. This would be an appropriate toy.

What anticipatory guidance can the nurse give parents of a toddler to support the toddler's need for increasing autonomy?

Allow the toddler to practice feeding with a spoon. Allowing the toddler to practice feeding with a spoon will help increase autonomy at mealtimes.

Identify the gross motor capability of the toddler.

Ascending the stairs Throwing a ball overhand

Climbs

At approximately 15 months of age, many toddlers become avid climbers. Chairs, tables, and bookcases present irresistible challenges and risks for injury. Parents may have difficulty keeping the toddler in a crib and may decide to move the child to a regular bed or toddler bed.

Turns the pages of a book

By 18 months vision is 20/50 and toddlers will learn to turn book pages. The toddler begins to imitate vertical and circular drawings, such as a straight line or a circle (it may not be completely round).

The critical milestones the toddler should demonstrate include:

Critical gross motor skills Walking well forward and backward Stooping and recovering Walking up and down stairs Critical fine motor skills Building a tower with increasing number of blocks Scribbling Being able to put a block in a cup

Which cognitive advancements are expected between 19 and 24 months?

Domestic mimicry Domestic mimicry (imitating a parent of the same sex) and deferred imitation (imitating an action hours after the toddler watched the original action) are expected cognitive advancements of the toddler.

Identify fine motor capabilities for the toddler.

Drawing a circle Stacking blocks or toys Drinking from a sippy cup

Summary

During the toddler years, children change rapidly. Changes occur in physical growth, motor-skill development, and cognitive/social development. The rapid changes in motor skills and the toddler's inability to make judgements about the safety of actions place the toddler at risk for unintentional injury. The importance of safety regarding the most common injuries of the toddler period, including aspiration, burns, drowning, and falls, should be communicated to parents of toddlers. The toddler years are characterized by a struggle for autonomy as the child develops a sense of self separate from the parent. Nurses should help parents understand that toddler behaviors, which include negativism, ritualism, temper tantrums, and separation anxiety, are normal processes of toddler development. Parents should be given information to help cope with these behaviors appropriately. During the well-child checkup, the nurse's role is to be a child advocate by providing parents of toddlers with anticipatory guidance related to growth, safety, and common age-related concerns. Nurses should also listen to any concerns that parents have about the development of their toddler because parental concerns provide a reliable indicator of possible developmental delay.

Which one of the following developmental characteristics explains why a toddler frequently uses the words me, I, and mine?

Egocentrism

2-Year-Old Child

Has an approximately 300-word vocabulary; uses two-word sentences Points to six body parts and pictures of several familiar objects (e.g., bird, man, dog, plane) Understands cause and effect, object permanence, sense of time Follows two-step directions; uses egocentric language Shows immature thinking, limited in its logic, and bound to the present Demonstrates egocentrism, negativism, ritualism, irreversibility, magical thinking, and centration

Appearance of the Toddler

Immature abdominal musculature gives the toddler a potbellied appearance, with an exaggerated lumbar curve. The child's short legs may appear slightly bowed, and the feet seem flat because of a plantar fat pad that disappears around age 2 years. During the toddler years, muscle tissue gradually replaces much of the adipose tissue (baby fat) present during infancy. As the musculoskeletal system matures and the child walks and runs more, the cherubic infant disappears, and the child grows into a taller, leaner preschooler.

15-18-Month-Old Child

Increasing receptive language Begins to understand and say "no" May begin to put two words together Can point to familiar objects Begins to use memory Understands spatial and temporal relations and exhibits increased object permanence Has a basic moral understanding (reward and punishment) Understands simple directions By 18 months has a vocabulary of approximately 30 words

Which characteristics are typical of the toddler's physical appearance?

Leaner Flattened plantar arch Inward curve of the spine

Gross Motor Skills—Toddler

Learning to walk well is the crowning achievement of the toddler period. The child is in perpetual motion, seemingly compelled to pull up, take a few steps, fall, and repeat the process over and over, oblivious to bumps and bruises. The toddler will repeat this performance hundreds of times until the skill of walking has been perfected. Toddlers will also learn to walk backward. Other gross motor milestones include throwing a ball overhand, jumping, and climbing.

Drinks from a cup

Most 18-month-olds can hold a cup with both hands and drink from it without much spilling, although eating with a spoon is difficult. Most of the food conveyed in a spoon is spilled, which is normal.

What important parental guidance advisory needs should caregivers be reminded of when discussing motor development in the toddler?

Motor development in this age group is far ahead of development of judgment and perception.

Toddler crying. Negativism

Negativism, one of the most dramatic expressions of independence, is shown in a variety of ways. The toddler's favorite word seems to be "no." Unable to distinguish between requests and directives, the toddler seems to believe that saying "yes" would mean giving up free will. The child often seems to delight in this test of wills with the parent. Negativism may result in screaming, kicking, hitting, biting, or breath-holding. Nurses can help parents understand their toddler's behavior as an important sign of the child's progress from dependence to autonomy and independence.

Parallel Play

Play begins to become imitative and imaginative. Toddlers spend most of their time at play. Play during this period reflects the egocentric toddler's developmental level. Toddlers should play with safe and durable toys. The toddler engages in parallel play, in which children play alongside but not with other children. Little regard is given to the feelings of others. Children engaged in this type of play frequently grab toys away from other children or may hit or fight to obtain a desired toy. Because toddlers are egocentric, they do not realize that they are hurting the other child and feel no shame for aggressive actions.

Which physical changes are normally seen as an infant transitions into a toddler?

Protruding abdomen Excessive curve of the back Wide gap between knees when standing erect

Ritualism

Ritualism helps the child venture out and away from the safety of the parents by ensuring uniformity and security and allowing the toddler to have a sense of control. The toddler insists on sameness. Milk may have to be poured into the same cup, parents may have to sit in the same chairs at dinnertime, and a specified routine may have to be followed countless times throughout the day. The child may experience distress if this routine is not followed exactly. The nurse can decrease the stress of hospitalization by incorporating the child's usual rituals and routines from home into nursing care activities.

When caring for a toddler in the hospital, which nursing intervention is most developmentally appropriate?

Scheduling evening medications to follow the toddler's bedtime routine.

Separation Anxiety

Separation anxiety peaks again in the toddler period. Although the concept of object permanence is fully developed in the toddler, children at this stage have difficulty differentiating their own feelings from those of their parents. Although the children experience a strong desire to be independent and leave their mothers, they fear that their mothers also want to leave them. Leave-taking and brief separations are acceptable to a toddler if they are the toddler's idea, but the parent's departure may cause desperate clinging and crying.

Screen Time

Television and other entertainment media should be avoided for infants and children under age 2. A child's brain develops rapidly during these first years, and young children learn best by interacting with people, not screens. Television or tablet use near bedtime can cause irregular sleep schedules. Toddlers who have heavy media usage are at risk for delays in language development once they start school (AAP).

How does the ability for a 24-month-old to build a two-block tower demonstrate a toddler's fine motor development?

The ability to stack one block on top of another demonstrates an improvement in a toddler's hand-eye coordination.

Psychosocial Development of the Toddler

The acquisition of language is one of the most dramatic developments of early childhood. Although the age at which children begin to talk varies widely, most can communicate verbally by their second birthday. The rate of language development depends on physical maturity and the amount of reinforcement that the child has received. Between 15 and 24 months of age, language ability develops rapidly. Toddlers understand many more words than they can say because receptive language (what the child understands) develops earlier and more quickly than speech. Sometime after 18 months, many children experience a sudden spurt in speech production and comprehension, resulting in a vocabulary of three hundred or more words at 24 months. By 2 years of age, roughly 60% to 70% of toddlers' speech should be understandable. Children age 24 to 30 months become less egocentric and better able to consider another's point of view. They will engage in more conversation with others and less monologue.

Walks

The age at which children learn to walk varies widely. Most children can walk alone by 15 months. By 18 months of age, toddlers walk well and try to run but fall often.

weight

The average weight gain is 5 lbs (2.26 kg) per year. A child's birth weight will quadruple by age 2 to 3 years.

head circumference

The brain grows at a slower rate during this period than during infancy. Head circumference reflects this growth, increasing approximately 1.5 in. (3.7 cm) during the toddler years compared with a growth of 4.8 in. (12.2 cm) in the first 12 months. By age 2 years, the head circumference has reached 90% of its adult size. Head circumference needs to be measured by the nurse up to 36 months of age.

Introduction

The developmental changes that mark the transition from infancy to early childhood are dramatic. During the toddler years, ages 12 through 36 months, the child will venture out independently because they have a secure base of trust that was established in infancy. The toddler years are characterized by a struggle for autonomy, or independence, as the child develops a sense of self separate from the parent.

height

The rate of increase in height slows, with the average toddler growing approximately 3 in. (7.62 cm) per year. Children attain half their adult height between ages 2 and 3 years.

Builds a tower of blocks

The toddler will learn to build a tower with an increasing number of blocks. Between 12 and 18 months, the toddler may build a tower of two blocks. By the time the child is 3 years old, he or she may be able to build a tower of nine blocks.

Which behaviors are expected in the toddler?

Throwing tantrums Crying when the toddler's parent leaves for work Developing a sense that bad behavior is punished Insisting on same book being read every morning

Fine Motor Skills—Toddler

Toddlers are also engaged in perfecting fine motor skills. Hand-eye coordination improves with maturity and practice. Mealtimes are still messy. Toddlers need a great deal of practice with a spoon before they can feed themselves without spilling. Most toddlers can feed themselves with a spoon by their second birthday if they have been allowed to practice. At 18 months of age, the toddler enjoys removing clothing. By 24 months, the toddler can put on simple items of clothing but cannot differentiate front from back. Children at this age also can zip large zippers, put on shoes, and wash and dry their hands. Two-year-olds brush their teeth but need help in adequately removing plaque.

Throws ball and jumps

Toddlers begin to throw a ball overhand without falling over, and should be able to do so by 24 months of age. Toddlers also learn to jump in place with both feet by 30 months of age. Stooping and recovering are critical gross motor development milestones and should be accomplished by 15 months of age.

The toddler is developing a sense of

autonomy, giving up the dependence of infancy. As toddlers develop a sense of self away from parents, they also develop a will of their own. Toddlers have a developmental need to exert their autonomy and this often conflicts with social norms, the need for safety, or parental expectations. It often leads to temper tantrums because the toddler is not permitted to exert his or her independence and does not have the ability to verbally express this frustration.

Toddlers are consumed with

curiosity. Their boundless energy and insatiable inquisitiveness provide them with resources for the tremendous cognitive growth that occurs during this period. Learning in this stage occurs mainly by trial and error. Toddlers spend most of a busy day experimenting to see what will happen as they dump, fill, empty, and explore every accessible area of their environment.

At approximately 15 months, toddlers begin to

demonstrate their developing autonomy with two almost universal behaviors: negativism and ritualism. Separation anxiety is common in toddlers.

Toddlers enjoy

experimenting with sizes, shapes, and spatial relations. Toddlers are active explorers who are at risk for injury because they have not developed the ability to judge the danger in situations. It is important that toddlers have an opportunity to venture out independently but in controlled and safe environments. The toddler is developing a sense of autonomy, giving up the comfort of dependence enjoyed during infancy. If a basic sense of trust was established during the first year, the toddler can venture forward and separate from parents for short periods to explore and experience the world.

Boundless energy and insatiable curiosity drive the toddler to

explore the environment and master new skills. The combination of increased motor skills and physical and mental immaturity places the toddler at risk for unintentional injury. Toddlers' need for autonomy, combined with an inability to express their feelings and frustrations, often leads to temper tantrums and difficult behaviors. Such negativism has given this age the label "the terrible twos."

Motor development in this age group is

far ahead of development of judgment and perception. This difference in timing of the development of motor skills and judgement increases the risk for injury. While it is likely the toddler will acquire many new gross and fine motor skills, there are several critical milestones that should be assessed at each well-child visit.

Sometimes, allowing a toddler to play with your name badge is enough of a distraction to allow you time to

listen to their heart and lungs for an assessment without the toddler crying. Toddlers are fearful of strangers but can be easily distracted by a name badge, penlight, or even a small toy.

Between 19 and 24 months

object permanence is firmly established. A toddler at this stage is often seen imitating the parent of the same sex performing household tasks (termed domestic mimicry). Late in this stage, the child displays deferred imitation (e.g., imitating the parent putting on makeup or shaving hours after that parent has left for work). Another major developmental milestone of the toddler is tolerating delayed gratification. Toddlers do not have a sense of time, therefore it is best to discuss time in the context of events that they are familiar with. For example, mom will be back when your dinner comes or when your show is over. If the toddler does not understand the concept of "a minute," then it is likely that they don't really understand what an hour feels like either.

The American Academy of Pediatrics (AAP) (2006/2010) recommends that

pediatric providers conduct developmental surveillance (assessing developmental milestones and determining risk for developmental delay) at every routine well visit and that formal developmental screening, using a sensitive and specific screening test, be done at the 9-, 18-, and 30- (or 24-) month visits. In addition, an autism-specific screening should be done at the 18-month and 24-month visit (AAP, 2014). Because parental concerns provide a reliable indicator of possible developmental delay, the nurse should elicit any concerns when taking a developmental history as part of every well visit

During infancy, there is rapid physical growth. As the toddler years begin,

physical growth slows, which leads to a reduced demand for calories and decreased appetite. These growth changes are measured by weight, height, and head circumference. More information on growth measurements is provided here.

Toddlers think in terms of the

predictable routines of their daily schedule. When talking with the toddler, the nurse should use time orientation in relation to familiar activities. For example, a toddler understands "Your mother will be here after your nap" better than "Your mother will be here at 2 o'clock."

Toddlers should be assessed for the following

social/emotional, cognitive, and language milestones at each well-child visit. Critical cognitive, social-emotional, and language developmental milestones include: Saying 3 to 10 single words; pointing to several body parts (15-18 months) Pointing to two pictures; saying three to six words (2 years) Information on the social and cognitive development of toddlers from 15 to 24 months is provided here.

Toddlers experience conflict because they

want to assert their own will but do not want to risk losing the approval of loved ones. If the child continues to practice dependent behavior, doubt related to abilities develops. Toddlers may feel shame for independent impulses, particularly if frequent punishment is associated with their actions. Two-year-olds do not have a conscience but avoid punishment by controlling their behavior. Right and wrong are determined by the consequences of actions.