Developmental Management of Toddlers and Preschoolers

6 Developmental Management of Toddlers and Preschoolers



Mary A. Murphy, Anita D. Berry


Developmental changes in the second through fifth years of life are subtler than those seen in the first year, yet they are highly significant. Children enter toddlerhood as babies, dependent on parents and caregivers for their survival and leave as accomplished children with elaborate and sophisticated skills. Ready to enter the social world of school and community, 5-year-olds have a sense of self that shapes the quality of their character as older children, adolescents, and adults. Children begin this change process by refining abilities acquired in the first year, learning, for example, to walk smoothly with control and speed, to run and climb, and to combine words into phrases and sentences. They add to their repertoire of skills, growing stronger, bigger, and more socially, emotionally, and intellectually capable. This chapter reviews some of the many changes that occur for toddlers (usually defined as a child 12 to 24 months old) and preschoolers (a child 2 to 5 years old), and describes the primary health care provider’s role when working with these children and their families.



image Development of Toddlers and Preschoolers



Physical Development


Physical and physiologic changes in toddlers and preschoolers continue at a much slower pace than in the first year of life. Statistically, children gain weight faster and earlier than children in earlier decades (Trifiletti et al, 2006); however, growth charts continue to show the average 2-year-old weighs 26 to 28 pounds (12.5 to 13.5 kg), with boys being slightly heavier than girls, and is 34 to 35 inches (85 to 90 cm) tall. Head circumference in the average 2-year-old is 19 to 19.5 inches (48 to 50 cm). Although most toddlers have no palpable fontanelles by 12 months, the anterior fontanelle should completely close by 18 to 19 months. During the fourth and fifth years, skeletal growth continues as additional ossification centers appear in the wrist and ankle and additional epiphyses develop in some of the long bones. For the 4- to 5-year-old, the legs grow faster than the head, trunk, or upper extremities. Changes related to body systems are highlighted in Table 6-1. More detailed discussion of development, systems, and disease processes can be found in Units 3 and 4 of this text.


TABLE 6-1 Physical Development of Toddlers and Preschool-Age Children















































































Body System Developmental Changes
Dental By 12 mo, the child usually has 6 to 8 primary teeth.
By 2 yr, the child has a complete set of 20 primary teeth.
By 3 yr, the second molars usually erupt.
During the second year, calcification begins for the first and second permanent bicuspids and second molars.
Most growth and calcification of the permanent teeth occur within the gums; it is not visible.
Neurologic Continued myelinization and cortical development occurs.
Fine motor movements are more detailed and sustained:


• 2-year-olds can easily manipulate fingers to stack 4 blocks.



• 3-year-olds can create a tower of 8 or more blocks.



• 4-year-olds can easily build a 12-block step design.



• 5-year-olds can grasp a pencil appropriately to copy simple geometric designs accurately and write their name in block letters.

Gross motor skills are smoother and more coordinated.
Sensory function is more mature.
Visual acuity is 20/70 for 2-year-olds; 20/30 for 5- to 6-year-olds.
Cardiovascular Little change occurs in the second and third year.
By the fifth year, the heart has quadrupled in size since birth.
By 5 years, the heart rate is typically 70 to 110 bpm.
Normal sinus arrhythmia may continue, and innocent murmurs are common.
The hematologic system should produce only adult hemoglobin by the fifth year.
The hemoglobin level stabilizes at 12 to 15 g/dL.
Pulmonary Abdominal respiratory movements continue until the end of the fifth or sixth year.
Respiratory rate slows to about 30 breaths per minute.
Gastrointestinal By 2 years, the salivary glands reach adult size.
The stomach becomes more bowed and increases its capacity to about 500 mL. Many children still require a nutritious snack between meals because of small stomach size.
During the second year, the liver matures and becomes more efficient in vitamin storage, glycogenesis, amino acid changes, and ketone body formation. The lower edge of the liver may still be palpable.
By 4 to 5 years, the gastrointestinal system is mature enough for the child to eat a full range of foods.
Stools are more like those of adults.
Renal Kidneys begin descending deeper into the pelvic area and grow in size.
Ureters remain short and relatively straight.
A 2-year-old may excrete as much as 500 to 600 mL of urine a day.
A 4- to 5-year-old excretes between 600 and 750 mL daily.
Endocrine Quiescent time for sexual growth, with few physical or hormonal changes.
Growth hormone stimulates body growth.

bpm, Beats per minute.



Motor Development


Motor development is divided into two components—gross and fine. Gross motor refers to the development and use of the large muscles. Fine motor includes hand and finger development and oral-motor development (see Table 5-1 for a review of gross and fine motor milestones by age).


Use of the dominant hand may appear as early as 8 to 12 months but generally emerges between 2 and 4 years. There are some children, however, who do not show a hand preference until 5 to 6 years old. The 4-year-old can thread small beads on a chain; grasp a pencil appropriately to copy some letters (v, h, t, o); draw a person with head and features, legs, trunk, and arms; use scissors to cut on a line; fasten buttons; and eat with a fork. By 5 years these movements expand to copying a square and additional letters (x, l, a, c, u, y), writing some letters spontaneously, producing identifiable pictures, counting fingers on one hand, and using all eating utensils appropriately.


Two-year-olds may still be “toddling,” using their arms for balance and frequently falling as they try to run or move quickly. They begin to master climbing and by 3 to 4 years are walking smoothly. The following are gross motor behaviors that average toddlers and preschoolers demonstrate:



2-year-old


image Tosses or rolls large ball

image Walks up stairs with help (may or may not alternate feet)

image Walks with control

3-year-old


image Jumps with both feet

image Climbs stairs with alternate feet both up and down to any height, up ladders

image Rides a tricycle using the pedals to move from place to place

image Kicks ball forward

4-year-old


image Tries to skip using alternate feet

image Catches a bouncing ball

image Runs around corners lightly on toes and stops voluntarily


Communication and Language Development


Language uses symbols for thoughts; thus it emerges with Piaget’s preoperational stage of development. Beginning around 2 years old, toddlers use words to convey their thoughts and feelings. Once the process begins, it develops rapidly. Cognitive development is a basic requirement for language development because the child must decipher the rules of language independently, problem solve to understand the communication of others, and create symbols that reflect his or her ideas and emotions and can be understood by others. Language development requires mastery of the following:



• Oral-motor ability to articulate sounds


• Auditory perception to distinguish words and sentences


• Cognitive ability to understand syntax, semantics, and pragmatics


• Psychosocial-cultural environment to motivate the child to engage in language use


Language milestones are evident in two general categories—receptive and expressive language. These are presented for infants and children younger than 5 years old in Table 5-2.



Articulation


Young children practice articulation skills daily, and by 24 months speech sounds are 25% intelligible to a stranger. The intelligibility rate jumps to about 66% between 24 and 36 months, with 90% intelligibility by 3 years old. By 4 years, speech should be completely intelligible with the exception of particularly difficult consonants. By 5 years the tongue-contact sounds of “n,” “t,” “d,” “k,” “g,” “y,” and “ng” are more intelligible. Some sounds, such as the “zh” sound, are not added until the child is 6 to 8 years old. Figure 6-1 identifies sounds articulated by children at specific ages.


image

FIGURE 6-1 Norms for development of speech sounds. θ, th as in thin; image as in this.


(From Van Riper C, Erickson RL: Speech correction: an introduction to speech pathology and audiology, ed 9, Needham Heights, MA, 1996, Allyn & Bacon, p 98. Reprinted by permission.)


During the second year the child practices playful changes in pitch and loudness. Three- and 4-year-olds show normal hesitance in speech or stuttering. They “stutter” by repeating words, especially those at the start of a sentence, or when excited such as when they want to convey an important message (e.g., “Mommy, I…Mommy, I…Mommy, I want to tell you I hear the ice cream truck”). This normal speech variant does not include syllable repetition or cause undue stress for the child. These dysfluencies should pass if ignored; they can be considered abnormal if they occur in 5-year-olds or if they involve syllable repetition instead of word repetition.


Children usually progress through a regular sequence of mispronunciations as they learn new articulation skills. At first they simply omit the new sound, and then they try to substitute a more familiar sound for the new one (e.g., the “w” for “r” substitution, as in “wabbit” for “rabbit”). Distortion is followed by “addition” as the child adds an extra sound (e.g., “gulad” for “glad”). Knowing each of these steps allows the examiner to assure the parent that the child is developing normally or needs monitoring.



Lexicon


Lexicon refers to vocabulary. Vocabulary size is influenced by many factors, including environment, stimulation, intelligence, multilingualism, culture, and personality. Children usually understand more words than they are able to express, and addition of words to their expressive vocabulary comes with continued practice. Girls typically say their first word between 8 and 11 months, boys about 14 months. Most 2-year-olds have more than 200 words in their vocabulary, and most 4- to 5-year-olds add approximately 50 words a month to their vocabulary. Five-year-olds should be able to define some words with other words (e.g., “cup” is “you drink with it,” or “chair” is “to sit on”).



Syntax


Syntax, or grammar, refers to the structure of words in sentences or phrases. The ability to construct sentences that convey meaning is a complex skill, proceeding through several stages in children: receptive, holophrastic, and telegraphic speech. Much of this skill is developed between 8 months and 3.5 years. By 8 months children develop receptive language (i.e., they understand others who use a new word or structure before they are able to use it themselves). When asked “Where is the ball?” an 8-month-old searches for the ball. Between 12 and 18 months, children begin to use holophrases or single words to express whole ideas. The child says “milk,” perhaps to mean the whole sentence, “Give me a glass of milk.” A complex idea is expressed in one succinct word. Holophrastic sentences are denominative (labeling) or imperative (commanding).


Around 18 months children begin using telegraphic speech, phrases that have many words omitted and sound like a telegram, to convey their message (e.g., “get milk,” “go bye-bye”). At around 2 years of age, children begin to expand their vocabulary and to form short sentences like “my big ball” and “the yummy cookie.” This is the age when toddlers begin to mimic phrases and gestures used by caregivers like “Oh, my goodness.” Sentence structure becomes more complex as children move from active sentences, to questions, to passive and negative construction, and then add plurals (at 3 years old) and past tenses (at 4 years old) to their grammar. Three- or four-word sentences should be evident by 3 years, and by 5 years old, the child’s syntax is close to adult style, including use of future tense and complete sentences of five or six words in length.



Semantics


Semantic development, the understanding that words have specific meaning and the child’s use of words to convey specific meaning, is an ongoing process extending into adulthood. This development occurs in stages from global to more specific and requires interaction through conversation, listening, and reading. Words used in any language have both denotative (the specific, concrete referent of the word) and connotative (a broader range of feelings aroused by the word) meanings. Even though children may be quite adept at using words correctly, they may have only a vague, diffuse connotative understanding of these words. For example, the 3-year-old who drops a toy and uses an expletive she heard when her father dropped a dish does not understand the connotative meaning of what she has said. As language progresses from simple to more complex, meaning and cognitive understanding evolve.



Bilingualism


Raising children to be bilingual can help preserve the family culture and heritage, and studies suggest that fluent bilingual children have greater mental flexibility and enhanced employment and lifestyle opportunities. Initially, normal toddlers from bilingual homes show mild delays in initial spoken words and mixing of the words and phrases from the two languages. Children who associate a clear environmental context for each language (e.g., home is Spanish, and school is English) may progress faster in acquiring both languages (Feldman, 2005). Maintaining bilingualism should be encouraged, but it requires time and effort as the child learns to read and write to maintain fluency in both. For families anxious to integrate culturally in a society with a different language, emphasizing skill in the language of the new community may be viewed as a first priority.


Simultaneous bilingualism occurs when children hear and learn two languages from infancy. These bilingual children should be equally competent in both languages by 3 years old. Sequential bilingualism occurs when the child, usually 3 years or older, learns one language and then is immersed in another. Children learning sequentially may have more apparent differences in their skills from language to language until they have developed proficiency in both.


Bilingual preschoolers experience no delays in vocabulary development and are proficient in sorting one language from the other, although they may “code switch” to the other language for clarity as they talk. They switch languages depending on the person with whom they are speaking and the circumstances. Some even translate for others, seeming to understand that not everyone speaks or understands both languages. Ultimately, whether a second, third, or even more languages are learned simultaneously or sequentially, most children have one dominant language. Bilingual children with significant vocabulary delays require the same evaluation as delayed monolingual children.



Social and Emotional Development


Psychosocial changes in toddlers and preschoolers are remarkable. Emotions and cognition are interconnected so that assessment of any one area of development is somewhat arbitrary. Toddlers spend most of their time up, running about, verbalizing, and demanding to join in family activities. These are years of intense learning about and managing feelings such as love, happiness, anger, frustration, aggression, and jealousy, and social skills such as sharing, giving, and receiving affection. They learn the words that go with their feelings and, with guidance, the appropriate behaviors. A major developmental milestone for this age is the achievement of a sense of independence and autonomy. The road from depending on parents for everything to doing some things for themselves, however, can be rocky and uneven.


The toddler and preschooler’s ability to achieve independence is influenced, in part, by the strengths in their social environment. In particular, maternal depression (chronic and postpartum) has a significantly negative effect on the development of normal infant engagement behaviors that can persist into the toddler and preschool years. Based on the child’s emerging sense of identity, maternal depression can lead to social, emotional, and language concerns (Pascoe et al, 2006). Specifically, research indicates that young children whose mothers have depression are significantly more likely to have emotional dysregulation at age 4 years and altered perceived competence at age 5 (Maughan et al, 2007).


Toddlers need a great deal of love, warmth, and comfort, primarily from their parents and caregivers. Toddlers learn to give love and find satisfaction in pleasing their parents. They learn to respond to kisses, hugs, and cuddles they have received by giving kisses, hugs, and cuddles in return. Toddlers who make these early attempts at giving love and are rejected or ignored soon stop trying and begin to find pleasure elsewhere. Toddlers with sensory issues learn to avoid some gestures unless they are in control and decide they can handle the tactile or sensory feelings. Some toddlers find that thumb sucking, rhythmic body movements, and body manipulation are more pleasurable and reliable than person-to-person contacts.


Preschoolers develop more sophisticated ideas about feeling, giving, and sharing. The 4- to 5-year-old moves away from the extremely self-centered attitude of earlier toddlerhood. Parents are viewed as the epitome of wisdom, power, integrity, and goodness. If early stages of the love relationship are not satisfied, preschoolers show more fears, inhibitions, explosive behavior, and demands for attention.


Toddlers and preschool-age children gradually increase their ability to follow commands consistently as they work to gain and maintain approval of adults and to behave as “good” children are expected to do. By preschool years, children begin to show interest in table manners, being polite, saying “thank you” without a reminder, sharing, saying (and meaning) “I’m sorry,” and taking turns. These social skills are learned through daily interactions at home, school, and church, from parents, peers, relatives, and neighbors. Children learn to read social cues of others’ behavior (e.g., the voice tone, slight facial expression, posture) and correct their own behavior. Some children, frequently boys, find these cues vague and difficult to learn, and parents can help by modeling, explaining, and discussing them.


Children at this age vacillate between being a big boy or big girl and a mommy’s baby. They take great pride in doing as many things as possible for themselves, yet they need to feel totally secure in their parents’ care. On some days, toddlers cling to Mother’s skirt, not letting her out of sight; on other days, the child can play for short periods in the next room, trotting back every so often to see, touch, and hear the mother and be reassured by her presence. The child who is securely attached uses the parent as a secure base from which to go out and safely explore the world. Gradually the periods of separation lengthen, and the child needs only to hear the mother’s voice or to check occasionally for security. Separation anxiety is frequent during these years and can be traumatic for both parents and child.


Preschool children are much less dependent on their parents and frequently tolerate physical separation for several hours. As this sense of separateness increases, children are more aware that they are different from their surroundings, their families, and their friends. They begin to realize that other persons also have feelings, fears, and doubts. Peer dependence and learning about how to have and be friends begin to be important.


Toddlers like to have a choice in matters and quickly learn the power of the word “no.” They can become extremely negative, practicing the power of “no” every day for months. As toddlers practice making choices, they are clumsy, awkward, and frequently wrong. This can be very frustrating for them, and their outraged responses can be equally annoying for their parents. Toddlers discover the delights of control over others and themselves. This increases their sense of power but can also lead to misunderstandings and hurt feelings if their parents do not read their moods properly. With time they become more skilled, make better choices, have more successes, and feel more powerful. They no longer have to work so hard to show others their power, and the negative stage passes.


Preschool-age children are more verbal than toddlers and are able to perform many more self-care tasks (e.g., feed themselves using appropriate utensils, blow their own noses, and go to the bathroom unassisted). Interactions become easier and more enjoyable as the child learns to verbally express needs and feelings.



Sibling Interaction


Interaction patterns between siblings vary and are affected by factors such as opposite gender, temperament, insecure attachment, family discord, corporal punishment, and perceptions of unequal treatment. Many toddlers or preschoolers regress when a new baby arrives, whereas older children may experience excitement, love, and enhanced self-esteem with a new sibling. Parents need to promptly limit any aggression expressed by the older child, provide love and attention, and talk about feelings. When older children fight, parents need to describe the situation and provide even-handed control. Blaming a child, except in a clear-cut instance of misbehavior, is usually unproductive. Promoting support, loyalty, and friendship is important for sibling interactions (see Chapter 17).



Morality


Morality, or the ability to know right from wrong, is based on external control during the toddler years and stems from children’s love of their parents and a desire to please them. Parent teaching generally focuses more on helping the child to make safe decisions rather than moral ones. Toddlers cannot be expected to make correct choices if left alone in potentially dangerous situations because their internal sense of conscience is rudimentary and judgment is absent. Any room with electrical sockets, knobs for technical equipment, open windows, or hot food represents a risk. As toddlers gain language skills, they begin to echo the parent’s firm “no,” but they do not understand the full meaning of the term. By 24 months many toddlers show beginning internalization by saying “no” to themselves and stopping the act; they may continue with the act as they talk to themselves, still saying “no.”


Preschoolers form a foundation for their moral development as they develop socioemotionally and cognitively. For the 4- to 5-year-old, morality is more internally controlled. Instead of basing all decisions on the knowledge of the consequences of the act (e.g., “If I take a cookie, I will be sent to my room”), older children show an elementary understanding of what is right and wrong, fair or unfair. They recognize others’ needs and may express a desire to help or comfort others. They begin to think ahead and are able to plan and control their urges, thus avoiding punishment. Four-year-olds can internalize some demands from their parents, and feelings of guilt can be elicited after some transgressions.



Peer Relationships


Toddlers may be fascinated by children their own age and demonstrate curiosity by physically examining the other child closely, poking and probing. However, they generally do not engage with their peers in an interactive way. Play is an essential component of cognitive, physical, emotional, and social development (Ginsburg and American Academy of Pediatrics [AAP], 2007). Parallel play is the norm. Preschoolers learn to interact with peers as their social world grows. Play is the major mechanism through which toddlers and preschoolers practice gender roles, such as housekeeping, caring for baby dolls, “fixing” household items, and caring for the garden and yard. As symbolic language develops, play becomes more interactive, cooperative, and shared. Imaginary play leads to “let’s pretend,” role-playing, and creation of imaginary friends. Fantasy and make-believe are very important during these years. Children need both structured and free play. Children today spend less time playing outside than previous generations and they are more likely to play in their yard than any other location. Research indicates that children have greater free play time when parents perceive their neighborhoods to be safe, when parents have social relationships within their neighborhoods, and when playgrounds are close (Veitch et al, 2010).


Shared or cooperative play makes simple games of hide-and-seek and tag possible. Games with complicated rules can be frustrating to the preschooler, who prefers simple games with the option of making up the rules as the game proceeds. Cheating is common because the boundaries of acceptable play are not yet clear, and the earliest stages of moral behavior are only beginning to emerge.



Body Image


Toddlers are often highly concerned about body image. They realize that they are separate persons and begin to take notice of their own bodies. They may become fascinated with the different parts of the body and how they work. Bodily injury becomes a concern, and cuts and bruises elicit much discussion. Toward the end of the second year, children may notice the inner feelings of their bodies (e.g., the urge and tension to move the bowels, the release and relaxation resulting from going to the bathroom, the discomfort of hunger, and the pleasure of eating). These are abstract feelings that toddlers cannot put into words but can show with actions.


Preschoolers are equally curious about their bodies but are more capable of understanding and expressing themselves. They reexamine themselves frequently, and worries over a lost tooth or a skinned knee are common. Curiosity about their bodies and those of others generates a wealth of innocent questions that generally require only a simple answer. They learn that genital manipulation brings pleasure, and masturbation peaks around 3 to 4 years.



Cognitive Development


Cognitively, toddler thinking is highly concrete. According to Piaget (see Table 4-1), 18- to 24-month-old children use mental imagery and infer causality when they can see only the effect. By the end of the second year children enter the preoperational stage with preconceptual and intuitive thinking. Primitive conceptualization processes begin with the development of symbolic thinking. A block becomes a car; words become symbols for ideas. The 3-year-old continues to develop symbolic thinking, and this manifests through drawing and acting out elaborate play scenarios. However, children at this age generally are unable to take another’s perspective but continue to view the world egocentrically. Attending to one characteristic at a time is another feature of preschool thinking. For example, the child will try to fit a jigsaw puzzle piece using either color or shape but not both.


Parents may have difficulty understanding the thoughts of preschool children. On the surface preoperational thinking has many characteristics that resemble adult thinking, and parents are often deceived into believing that children are able to think as adults do. Preschool children, for example, are developing the use of language and the ability to symbolize concepts mentally. Some of their verbalizations appear quite precocious, as evidenced by the 3-year-old who stares out the window and then states, “Look, mommy, the trees are saying yes and no.” Preschool children continue to be concrete and egocentric in their thinking, and their logic is the source of many communication problems between parents and children. Table 6-2 identifies major characteristic of preschool thinking and gives examples of each.


TABLE 6-2 Examples of Preschool Children’s Thinking Using Piaget’s Preoperational Stage















Characteristic Example
Egocentricism “It’s snowing so I can go play in it.”
Unable see another’s viewpoint If John is holding a doll with its face toward Ann, Ann thinks John can also see the doll’s face.
Mental symbolization of the environment

“The wind is crying.”


“The (flushing) toilet is an angry animal.”

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Related posts:

  1. Developmental Management in Pediatric Primary Care
  2. Coping and Stress Tolerance: Mental Health and Illness
  3. Respiratory Disorders
  4. Cardiovascular Disorders

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Jul 24, 2016 | Posted by in PEDIATRICS | Comments Off on Developmental Management of Toddlers and Preschoolers

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