Infancy is a time of intense growth and development.
Both physical growth and acquisition of new motor skills slow somewhat during the toddler years. Refinement of motor skills, continued cognitive growth, and acquisition of appropriate language skills are of prime importance during toddlerhood. The nurse uses the knowledge of normal toddler development as a roadmap for behav- ioral assessment of the 1- to 3-year-old child.
Physical Growth
The toddler’s height and weight continue to increase steadily, though the increase occurs at a slower velocity compared to infancy. Toddler gains in height and weight tend to occur in spurts, rather than in a linear fashion (Fig. 26.1). The average toddler weight gain is 3 to 5 pounds per year. Length/height increases by an average of 3 inches per year. Toddlers generally reach about half of their adult height by 2 years of age. Head circumference increases about 1 inch from when the child is between 1 and 2 years of age, then increases an average of a half- inch per year until age 5. The anterior fontanel should be closed by the time the child is 18 months old. Head size becomes more proportional to the rest of the body near the age of 3 years (Hagan, Shaw, & Duncan, 2008).
Organ System Maturation
Though not as pronounced as the changes occurring dur- ing infancy, the toddler’s organ systems continue to grow and mature in their functioning. Significant functional
changes occur within the neurologic, gastrointestinal, and genitourinary systems. The respiratory and cardiovascular systems undergo changes as well.
Neurologic System
Brain growth continues through toddlerhood, and the brain reaches about 80% of its adult size by 3 years of age (Zero to Three, 2011). Myelinization of the brain and spinal cord continues to progress and is complete around 24 months of age. Myelinization results in improved coordination and equilibrium as well as the ability to exercise sphincter control, which is important for bowel and bladder mastery. Integration of the primitive reflexes occurs in infancy, allowing for the emergence of the pro- tective reflexes near the end of infancy or early in tod- dlerhood. The forward or downward parachute reflex is particularly helpful when the child starts to toddle. Rapid increase in language skills is evidence of continued pro- gression of cognitive development.
Respiratory System
The respiratory structures continue to grow and mature throughout toddlerhood. The alveoli continue to increase in number, not reaching the adult number until about 7 years of age. The trachea and lower airways continue to grow but remain small compared with the adult. The tongue is relatively large in comparison to the size of the mouth. Tonsils and adenoids are large and the Eusta- chian tubes are relatively short and straight.
FIGURE 26.1 The typical toddler appearance is that of a rounded abdomen, a slight swayback, and a wide-based stance.
922 U N I T 9 Health Promotion of the Growing Child and Family
also results in the toddler’s favorite response, “no.” The toddler will often answer “no” even when he or she really means “yes.”
This negativism—always saying “no”—is a normal part of healthy development and is occurring as a result of the toddler’s attempt to assert his or her indepen- dence. Table 26.1 gives further information related to developing a sense of autonomy.
Cognitive Development
According to Jean Piaget (1969), toddlers move through the last two substages of the first stage of cognitive development, the sensorimotor stage, between 12 and 24 months of age. Young toddlers engage in tertiary cir- cular reactions and progress to mental combinations.
Rather than just repeating a behavior, the toddler is able to experiment with a behavior to see what happens. By 2 years of age, toddlers are capable of using symbols to allow for imitation. With increasing cognitive abili- ties, toddlers may now engage in delayed imitation. For example, they may imitate a household task that they observed a parent doing several days ago.
Piaget identified the second stage of cognitive development as the preoperational stage. It occurs in children between ages 2 and 7 years. During this stage toddlers begin to become more sophisticated with sym- bolic thought. The thinking of the older toddler is far more advanced than that of the infant or young toddler, who views the world as a series of objects. During the preoperational stage, objects begin to have characteris- tics that make them unique from one another. Objects are considered large or small, a particular color or shape, or a unique texture. This moves beyond the connec- tion of sensory information and physical action. Words and images allow the toddler to begin this process of developing symbolic thought by providing a label for the objects’ characteristics (Piaget, 1969).
Toddlers also use symbols in dramatic play. First they imitate life with appropriate toy objects, and then they are able to substitute objects in their play. A bowl may be used to pretend to eat from, but then later it can be used upside down on the head as a hat (Fig. 26.2).
Human feelings and characteristics may also be attrib- uted to objects (animism) (Papalia & Feldman, 2011).
See Table 26.1 for further explanation of cognitive devel- opment in toddlerhood.
Take Note!
Mothers who are depressed may not be as sensitive to their children as other mothers. For this reason, maternal depression is a risk factor for poor cognitive develop- ment. Be alert to the mental status of a toddler’s mother so that appropriate referrals can be made if needed (Cummings &
Kouros, 2009).
Cardiovascular System
The heart rate decreases and blood pressure increases in toddlerhood. Blood vessels are close to the skin surface and so are compressed easily when palpated.
Gastrointestinal System
The stomach continues to increase in size, allowing the toddler to consume three regular meals per day. Pepsin production matures by 2 years of age. The small intestine continues to grow in length, though it does not reach the maximum length of 2 to 3 meters until adulthood.
Stool passage decreases in frequency to one or more per day. The color of the stool may change (yellow, orange, brown, or green) depending on the toddler’s diet. Since the toddler’s intestines remain somewhat immature, the toddler often passes whole pieces of difficult-to-digest food such as corn kernels. Bowel control is generally achieved by the end of the toddler period.
Genitourinary System
Bladder and kidney function reach adult levels by 16 to 24 months of age. The bladder capacity increases, allowing the toddler to retain urine for increased periods of times. Urine output should be about 1 mL/kg/hour.
The urethra remains short in both the male and female toddler, making them more susceptible to urinary tract infections compared to adults.
Musculoskeletal System
During toddlerhood, the bones increase in length and the muscles mature and become stronger. The abdomi- nal musculature is weak in early toddlerhood, resulting in a pot-bellied appearance. The toddler appears to have a swayback along with the potbelly. Around 3 years of age, the musculature strengthens and the abdomen is flatter in appearance.
Psychosocial Development
Erikson defines the toddler period as a time of auton- omy versus shame and doubt. It is a time of exerting independence. Since the toddler developed a sense of trust in infancy, he or she is ready to give up depen- dence and to assert his or her sense of control and autonomy (Erikson, 1963). The toddler is struggling for self-mastery, to learn to do for himself or herself what others have been doing for him or her. Toddlers often experience ambivalence about the move from depen- dence to autonomy, and this results in emotional lability.
The toddler may quickly change from happy and pleas- ant to crying and screaming. Exertion of independence
C h a p t e r 2 6 Growth and Development of the Toddler 923
As the toddler masters a new task, he or she has con- fidence to conquer the next challenge. Thus, mastery in motor skill development contributes to the toddler’s growing sense of self-esteem. The toddler who is eager to face challenges will likely develop more quickly than one who is reluctant. The senses of sight, hearing, and touch are useful in helping to coordinate gross and fine motor movement.
Gross Motor Skills
As gross motor skills are mastered and then used repeatedly, the large muscle groups in the toddler are strengthened. The “toddler gait” is characteristic of new
Motor Skill Development
Toddlers continue to gain new motor skills as well as refine others. Walking progresses to running, climb- ing, and jumping. Pushing or pulling a toy, throwing a ball, and pedaling a tricycle are accomplished in tod- dlerhood. Fine motor skills progress from holding and pinching to the ability to manage utensils, hold a crayon, string a bead, and use a computer. Development of eye–hand coordination is necessary for the refinement of fine motor skills. These increased abilities of mobil- ity and manipulation help the curious toddler explore and learn more about his or her environment (Fig. 26.3).
TABLE 26.1 DEVELOPMENTAL THEORIES
Theorist Stage Activities
Erikson Autonomy vs. Shame & Doubt Age 1–3 years
Achieves autonomy and self-control Separates from parent/caregiver Withstands delayed gratification Negativism abounds
Imitates adults and playmates Spontaneously shows affection
Is increasingly enthusiastic about playmates Cannot take turns in games until age 3 years Piaget Sensorimotor
Substage 5: Tertiary Circular Reactions Age: 12–18 months Substage 6:
Mental Combinations Age: 18–24 months
Preoperational Age: 2–7 years
Differentiates self from objects
Increased object permanence (knows that objects that are out of sight still exist [e.g., cookies in the cabinet]) Uses ALL senses to explore environment
Places items in and out of containers Imitates domestic chores (domestic mimicry) Imitation is more symbolic
Starting to think before acting
Understands requests and is capable of following simple directions
Has a sense of ownership (my, mine)
Time, space, and causality understanding is increasing Uses mental trial and error rather than physical Makes mechanical toys work
Plays make-believe with dolls, animals, and people Increased use of language for mental representation Understands concept of “two”
Starting to make connections between an experience in the past and a new one that is currently occurring
Sorts objects by shape and color Completes puzzles with four pieces Play becomes more complex Freud Anal Stage
Age: 1–3 years Focus is on achieving anal sphincter control. Satisfaction and/or frustration may occur as the toddler learns to withhold and expel stool.
Adapted from Erikson, E. H. (1963). Childhood and society (2nd ed.). New York: W.W. Norton and Company; Feigelman, S.
(2011a). Preschool years. In R. M. Kliegman, Stanton, B. F., St. Geme, J. W., Schor, N. F. & R. E. Behrman, H. B. Jenson, & B. Stanton (Eds.), Nelson textbook of pediatrics (19th ed.). Philadelphia, PA: Saunders; Feigelman, S. (2011b). The second year. In R. M. Kliegman,
Stanton, B. F., St. Geme, J. W., Schor, N. F. & R. E. Behrman, H. B. Jenson, & B. Stanton (Eds.), Nelson textbook of pediatrics (19th ed.).
Philadelphia, PA: Saunders. Philadelphia: Saunders; and Piaget, J. (1969). The theory of stages in cognitive development. New York: McGraw-Hill.
924 U N I T 9 Health Promotion of the Growing Child and Family
feelings verbally. Table 26.2 lists motor skill expectations in relation to age.
Fine Motor Skills
Fine motor skills in the toddler period are improved and perfected. Holding utensils requires some control walkers. The toddler does not walk smoothly and
maturely. Instead, the legs are planted widely apart, toes are pointed forward, and the toddler seems to sway from side to side while moving forward (Fig. 26.4). Often the toddler seems to speed along, pitching forward, appear- ing ready to topple over at any moment. The toddler may fall often, but will use outstretched arms to catch him- self or herself (parachute reflex). After about 6 months of practice walking, the toddler’s gait is smoother and the feet are closer together. By 3 years of age, the toddler walks in a heel-to-toe fashion similar to that of adults.
Toddlers often use physical actions such as running, jumping, and hitting to express their emotions because they are only just learning to express their thoughts and
FIGURE 26.2 The toddler will (A) pretend with items in the way they are intended to be used as well as (B) find other creative uses for them.
A B
FIGURE 26.3 The toddler’s curiosity about the world
increases, as does her ability to explore it. FIGURE 26.4 The young toddler (early walker) walks with a wide-based stance, feet pointing forward and arms akimbo.
C h a p t e r 2 6 Growth and Development of the Toddler 925
Communication and Language Development
Language development occurs rapidly during the tod- dler years. The acquisition of language is a dynamic and complex process. The child’s age and social interactions and the types of language to which he or she has been exposed influence language development. Receptive language development (the ability to understand what is being said or asked) is typically far more advanced than expressive language development (the ability to communicate one’s desires and feelings) (Feigelman, 2011b; Goldson & Reynolds, 2011). In other words, the toddler understands language and is able to follow com- mands far sooner than he or she can actually use the words himself or herself. Language is a very important part of the toddler’s ability to organize his or her world and actually make sense of it. Thoughtfully planned use of language can provide behavior guidance and con- tribute to the avoidance of power struggles. In regard to expressive language development, the young toddler begins to use short sentences and will progress to a vocabulary of 50 words by 2 years of age (Feigelman, 2011b; Goldson & Reynolds, 2011). Echolalia (rep- etition of words and phrases without understanding) and agility, but even more is needed for buttoning and
zipping. Adequate vision is necessary for the refine- ment of fine motor skills because eye–hand coordination is crucial for directing the fingers, hand, and wrist to accomplish small muscle tasks such as fitting a puzzle piece or stringing a bead. See Table 26.2 for age expecta- tions for various motor skills.
Sensory Development
Toddlers use all of their senses to explore the world around them. Toddlers examine new items by feeling them, look- ing at them, shaking them to hear what sound they make, smelling them, and placing them in their mouths. Toddler vision continues to progress and should be 20/50 to 20/40 in both eyes. Depth perception also continues to mature.
Hearing should be at the adult level, as infants are ordi- narily born with hearing intact. The sense of smell contin- ues to mature, and toddlers may comment if they do not care for the scent of something. Though taste discrimina- tion is not completely developed, toddlers may exhibit preferences for certain flavors of foods. The toddler is more likely to try a new food if its appearance or smell is familiar. Lack of complete taste discrimination places the toddler at risk of accidental ingestion.
TABLE 26.2 MOTOR SKILL DEVELOPMENT
Age Expected Gross Motor Skill Expected Fine Motor Skills 12–15 months Walks independently Feeds self finger foods
Uses index finger to point 18 months Climbs stairs with assistance
Pulls toys while walking Masters reaching, grasping, and releasing:
stacks blocks, puts things in slots Turns book pages (singly with board book,
multiple if paper) Removes shoes and socks Stacks four cubes
24 months Runs Kicks ball
Can stand on tiptoe
Carries several toys, or a large toy while walking
Climbs onto and down from furniture without assistance
Builds tower of six or seven cubes Right- or left-handed
Imitates circular and vertical strokes Scribbles and paints
Starting to turn knobs Puts round pegs into holes
36 months Climbs well Pedals tricycle Runs easily
Walks up and down stairs with alternate feet Bends over easily without falling
Undresses self Copies circle
Builds tower of nine or ten cubes Holds a pencil in writing position Screws/unscrews lids, nuts, bolts Turns book pages one at a time
Adapted from Feigelman, S. (2011a). Preschool years. In R. M. Kliegman, Stanton, B. F., St. Geme, J. W., Schor, N. F. & R. E. Behrman, H. B. Jenson, & B. Stanton (Eds.), Nelson textbook of pediatrics (19th ed.). Philadelphia, PA: Saunders; Feigelman, S. (2011b). The second year.
In R. M. Kliegman, Stanton, B. F., St. Geme, J. W., Schor, N. F. & R. E. Behrman, H. B. Jenson, & B. Stanton (Eds.), Nelson textbook of pediatrics (19th ed.). Philadelphia, PA: Saunders.
926 U N I T 9 Health Promotion of the Growing Child and Family
Take Note!
Stuttering usually has its onset between 2 and 4 years of age. It occurs more often in boys than in girls. About 75% of all cases of stuttering resolve within 1 to 2 years after they start (Prasse & Kikano, 2008).
Early identification and referral of children with potential speech delays is critical. If a delay is identified, early intervention may increase the child’s potential to acquire age-appropriate receptive and expressive lan- guage skills.
normally occurs in toddlers younger than 30 months of age. “Why” and “what” questions dominate the older toddler’s language. Telegraphic speech is common in the 3-year-old. Telegraphic speech refers to speech that contains only the essential words to get the point across, much like a telegram. Rather than “I want a cookie and milk,” the toddler might say, “Want cookie milk.” In tele- graphic speech the nouns and verbs are present and are verbalized in the appropriate order (Feigelman, 2011b).
Table 26.3 gives an overview of receptive and expres- sive language development in the toddler.
TABLE 26.3 LANGUAGE DEVELOPMENT IN TODDLERS
Age Receptive Language Expressive Language
12 months Understands common words independent of context Follows a one-step command
accompanied by gesture
Uses a finger to point to things
Imitates or uses gestures such as waving goodbye Communicates desires with word and gesture
combinations Vocal imitation First word 15 months Looks at adult when communicating
Follows a one-step command without gesture
Understands 100–150 words
Repeats words that he or she hears Babbles in what sound like sentences
18 months Understands the word “no”
Comprehends 200 words
Sometimes answers the question,
“What’s this?”
Uses at least 5–20 words Uses names of familiar object
24 months Points to named body parts Points to pictures in books Enjoys listening to simple stories Names a variety of objects in the
environment
Begins to use “my” or “mine”
Vocabulary of 40–50 words
Sentences of two or three words (“me up,” “want cookie”) Asks questions (“what that?”)
Uses simple phrases
Uses descriptive words (hungry, hot) Two thirds of what child says should be
understandable Repeats overheard words 30 months Follows a series of two independent
commands Vocabulary of 150–300 words
36 months Understands most sentences Understands physical relationships
(on, in, under)
Participates in short conversations May follow a three-part command
Speech usually understood by those who know the child, about half understood by those outside family
Asks “why?”
Three- to four-word sentences
Talks about something that happened in the past Vocabulary of 1,000 words
Can say name, age, and gender Uses pronouns and plurals
Adapted from Feigelman, S. (2011a). Preschool years. In R. M. Kliegman, Stanton, B. F., St. Geme, J. W., Schor, N. F. & R. E. Behrman, H. B. Jenson, & B. Stanton (Eds.), Nelson textbook of pediatrics (19th ed.). Philadelphia, PA: Saunders; Feigelman, S. (2011b). The second year.
In R. M. Kliegman, Stanton, B. F., St. Geme, J. W., Schor, N. F. & R. E. Behrman, H. B. Jenson, & B. Stanton (Eds.), Nelson textbook of pediatrics (19th ed.). Philadelphia, PA: Saunders; and Goldson, E., & Reynolds. A. (2011). Child development and behavior. In W. W. Hay, M. J. Levin, J. M.
Sondheimer, & R. R. Deterding (Eds.), Current pediatric diagnosis and treatment (20th ed.). New York: McGraw-Hill.