History

The period between 18 and 24 months is characterized by rapid acquisition of developmental milestones. By 18 months, children should be able to remove some of their clothing, speak six words, follow simple commands, scribble with a crayon, self-feed using a spoon, and run. As language develops, the 24-month-old child can speak in 2- to 3-word phrases and speak between 50 and 200 words. At 2 years, 50% of the child’s speech should be understandable to strangers. Motor milestones at 24 months include throwing a large ball, jumping, climbing stairs, and running.¹ Up to 18% of children are affected by a developmental delay. Developmental surveillance at 18 and 24 months should use historical information and clinical observation. At the 18-month visit, a formal developmental screening tool, such as the Ages and Stages Questionnaire or the Parents’ Evaluation of Developmental Status (PEDS) is recommended.² In addition, an autism-specific screening tool, such as the Modified Checklist for Autism in Toddlers (M-CHAT) is recommended at both 18 and 24 months. (See Chapter 14, Developmental Screening and Surveillance.)

Current estimates of autism prevalence are 6 to 7 per 1000 children. Recent increases in autism diagnosis are related in part to improved awareness of parents and physicians of the early presenting signs (see Chapter 26, Autism). Autistic spectrum disorders are characterized by delays in communication and social interaction and/or restricted behaviors and interests. Impairment in joint attention, the enjoyment in sharing an event with another person by looking back and forth between the two, is one of the earliest indicators of autism. Other red flags include regression, failure to spontaneously use two-word phrases by 24 months, lack of pointing, and absence of emotional responses to engaging stimuli.² The “watch and see” approach to developmental delays has proved to be ineffective; although many parents recognize signs of autism before 18 months of age, the mean age at diagnosis is 61 months.² Concerns about development should be referred to an early intervention specialist, audiologist, and, if indicated, an autism specialist. Early intervention has the potential to maximize long-term social and academic functioning² (see Chapter 25, The Special Needs Child).

Discipline strategy. By 18 months of age, an effective discipline strategy is required. Assess where the parents are with development of this skill. A successful discipline strategy is one that nurtures the child’s desire for autonomy while minimizing dangerous behaviors and promoting desirable behaviors. Components of such a strategy include the development of a strong parent-child relationship, positive reinforcement for desirable behaviors, adult role modeling of these behaviors, and the consistent (but not excessive) use of punishment. Despite its widespread acceptance even among some pediatricians, corporal punishment is not a recommended method of discipline. It is associated with various adverse outcomes, including aggressive behavior and violence perpetration. Time-out, the removal of an enjoyable stimulus such as parental attention, in response to negative behavior may be equally efficacious without the adverse consequences of corporal punishment. To be effective, time-out must be used selectively, consistently, and for an appropriate amount of time (approximately 1 minute per each year of age). Practice and patience are required, because the undesired behavior may initially worsen with this technique.³

Temper tantrums are a common response to restrictions on the toddler’s autonomy. These are normal responses that peak between 18 and 24 months of age. Successful strategies to manage these angry outbursts include distraction, removal from the environment, and verbal dialogues that encourage the child to use words, instead of tantrums, to express himself/herself.¹ Recognize that children with expressive language delay may experience prolonged or more frequent tantrums because of the inability to effectively communicate with words. Temper tantrums may aggravate parents, especially if they lack social support. Frustrated parents may physically abuse their children as a way to curb these unwanted behaviors. Any suspicion of abuse, such as inadequately explained physical injuries, neglect, or sexualized behaviors should be reported to local child welfare authorities⁴ (see Chapter 96, Physical Abuse). Routine screening of female caregivers for domestic violence may serve as an effective screening tool for child abuse.⁵