Toddlerhood Chapter 7 PDF

7589_Ch07_097-114 29/08/17 12:02 PM Page 97 7 CHAPTER Toddlerhood Key Words Chapter Outline acuity ambivalence amblyopia autonomy child abuse egocentric eustachian tube lordosis negativistic behavior object permanence ossification parallel play regression ritualistic behavior separation anxiety...

7589_Ch07_097-114 29/08/17 12:02 PM Page 97 7 CHAPTER Toddlerhood Key Words Chapter Outline acuity ambivalence amblyopia autonomy child abuse egocentric eustachian tube lordosis negativistic behavior object permanence ossification parallel play regression ritualistic behavior separation anxiety sibling rivalry socialization Physical Characteristics Height and Weight Body Proportions Face and Teeth Bone Development Sensory Development Vital Signs Developmental Milestones Motor Development Gross Motor Skills Fine Motor Skills Toilet Training Psychosocial Development Autonomy Discipline Special Psychosocial Concerns Cognitive Development Moral Development Communication Nutrition Sleep and Rest Play Electronic Devices, Television, and Toddlers Safety Health Promotion Child Abuse Physical Abuse Neglect Psychological Abuse Sexual Abuse Summary Critical Thinking Multiple-Choice Questions Learning Objectives A t th e e n d of th i s ch ap te r , y ou s h ou l d b e ab l e to: • • • • • • • • • Describe the main physical characteristics common to toddlers. Name three developmental skills that the toddler can master independently. Describe the psychosocial task of the toddler as outlined by Erikson. List one method of discipline useful in resolving conflicts during this stage. Describe the stage of cognitive development for the toddler as presented by Piaget. List two factors that help toddlers develop language skills. List three feeding recommendations for parents of toddlers. Describe the type of play typical of toddlers. Name five common safety hazards for this period of development. 97 7589_Ch07_097-114 29/08/17 12:02 PM Page 98 98 Journey Across the Life Span The toddler period usually refers to the period from 1 to 3 years of age. After the fast growth spurts of infancy, the growth rate of the toddler is slow and steady. Many new skills are being developed, including both fine and gross motor skills related to dressing, feeding, toileting, and walking. Another accomplishment during this period is related to language development. These newly acquired skills serve to strengthen the toddler’s newfound autonomy. PHYSICAL CHARACTERISTICS Height and Weight The toddler usually grows an average of 3 inches (7.5 cm) per year. The average height of the child at 2 years is 34 inches (86.6 cm); at 3 years it is 37.25 inches (95 cm). The toddler gains an average of 4 to 6 pounds (1.8 to 2.7 kg) per year during this period. By age 2, the toddler’s weight averages 27 pounds (12 kg). At 3 years, the child usually weighs 32 pounds (14.6 kg). Body Proportions The child’s extremities grow much faster than the trunk, resulting in a more proportionate appearance for the body as a whole. The typical 2-year-old child has a potbellied appearance—a large belly and an exaggerated lumbar curve, known as lordosis. By the end of the third year, the child is taller and more slender, with stronger abdominal muscles and a more erect posture. Head growth slows down in comparison to the rate of growth in the body and extremities. Face and Teeth The face and jaw increase in size to permit room for more teeth. At 21⁄2 years the child can be expected to have 20 teeth, which is a complete set of deciduous or primary teeth. Children at this age should visit the dentist for a preliminary dental examination and dental supervision (Fig. 7.1). Parents should discuss with their dentist the child’s possible need for fluoride treatments, depending on their local water supplies. Parents should also help the child learn proper oral hygiene. Toddlers should brush their teeth at least twice a day under parental supervision. Some toddlers may continue a habit of thumb-sucking that may have started early in infancy. Experts vary in their opinions of the harmful effects of this habit. FIGURE 7.1 Toddlers should visit the dentist regularly. Thumb-sucking may lead to malposition of the teeth. There is no easy, sure way of interrupting this habit; it is usually self-limiting. If it persists into the preschool years, parents should seek advice from a specialist. Bone Development Like the child’s general growth, bone growth and development are greatest in the first year and then gradually slow down. As the child grows, the bones increase in density and hardness. Cartilage is gradually replaced with bone tissue. This process, known as ossification, will not be completed until puberty. The hardening of the soft, spongy tissues is gradual and occurs at different rates for different parts of the body. For example, by 18 months the toddler’s anterior fontanel is closed, although other bones remain soft and pliable. This explains why infants and young children appear more flexible and can bend and put their toes into their mouths. In fact, this also explains why some young children develop a type of bone fracture known as a “greenstick fracture.” In this fracture the bone is angulated beyond the limits of normal bending, similar to the bend in a green, unripe stick. Sensory Development The toddler’s visual acuity changes gradually. The eye muscles strengthen, a process that further develops binocular vision. The toddler’s vision may be 20/40—and better—when large objects are placed 7589_Ch07_097-114 29/08/17 12:02 PM Page 99 Toddlerhood at a distance of 6 feet (2 m). Visual acuity will improve to 20/20 by the end of this stage. Depth perception improves as the child enters toddlerhood but is not fully developed until later during the preschool period. Some children have a condition called “lazy eye,” or amblyopia. Children with amblyopia have double vision but have no way of knowing it because they have nothing to compare it to. It is imperative that toddlers undergo vision screening to help detect this condition (Fig. 7.2). The current treatment for amblyopia involves patching the stronger eye to force the child to use the weak eye. Corrective lenses and exercises also help correct this condition. Untreated amblyopia can lead to blindness in the affected eye. Strabismus, or crossing of the eyes, may be seen from time to time; if it persists, professional attention is indicated. Hearing in the toddler is fully developed. Routine physical examinations should include periodic hearing tests to detect any changes from the norm. Frequent monitoring should be done in a child with delayed speech or who has repeated ear, nose, and throat infections. One structure of the ear, called the eustachian tube, connects the middle ear to the oral pharynx. This structure is shorter and wider in toddlers than in older children, allowing easy passage of microorganisms from the upper respiratory tract to the middle ear. This accounts for a higher incidence of ear infections in the young child compared to the older child. Children with a history of ear infections can be at risk for hearing loss. A common sign of an 99 ear infection in young children is unrelenting crying and rubbing or pulling of the affected earlobe. VITAL SIGNS The toddler’s temperature-regulating mechanism is more stable and more fully developed than that of the infant. For this reason, the toddler is not so sensitive to environmental changes. The toddler’s body temperature is maintained at the normal range of 98°F to 99°F (36.6°C to 37.2°C). The heart rate slows down because the heart is larger and more efficient. The average toddler’s pulse rate is between 90 and 120 beats per minute. Respirations slow down to 20 to 30 breaths per minute as a result of increased lung efficiency and capacity. At this stage the average blood pressure measurement is 99/64 mm Hg. DEVELOPMENTAL MILESTONES Motor Development The acquisition of skills in the toddler is based on the further development and refining of the crude gross and fine motor abilities achieved during infancy. The motivational force behind the development of these skills is rooted in the child’s search for independence. By the end of toddlerhood, the child will have developed skills related to independent FIGURE 7.2 Eye examinations may detect vision problems. 7589_Ch07_097-114 29/08/17 12:02 PM Page 100 100 Journey Across the Life Span functioning, including walking, eating, toileting, dressing, and using language. Gross Motor Skills Gross motor skills depend on growth and maturation of the muscles, bones, and nerves. Until a state of readiness is reached, teaching the child developmental skills such as walking, skipping, or hopping is of little value. Once readiness occurs, the child needs to be given ample time to practice and master each new skill attempted. Walking, first with an unsteady gait, may begin for some children by their first birthday and for others several months later. Typical skills of the average 15-month-old toddler include walking alone without assistance, limited balancing, and creeping up stairs. The 18-month-old child typically can walk up stairs with both feet and sit down on a chair. The 18-monthold toddler runs clumsily, which results in frequent falling. The 2-year-old child can climb the stairs alone using two feet on each step, run with a wide stance, and kick a large ball without losing balance and falling. At this age, the typical child can walk down stairs with assistance, jump in place with both feet, and sit on a chair independently. The 3-year-old can hop, stand on one foot, and walk a few steps on tiptoe. Fine Motor Skills Fine motor skills include self-feeding, dressing, and playing. By 15 months, a toddler can more deftly grasp a spoon and insert it into a dish, but he or she will likely continue to invert and spill its contents until the end of the second year. Most toddlers are fascinated with dining utensils, but the majority use their fingers and prefer finger foods. The 1-year-old child can usually remove his or her socks, shoes, hat, and mittens. By the end of the second year, the typical child can remove all of his or her clothing and will attempt to put some items back on, but only if he or she chooses to. Toddlers usually have enough fine motor dexterity to allow them to wash themselves. This is often seen as a pleasurable activity, but they frequently wash only the face and stomach while ignoring the rest of the body. The 3-year-old child’s fine motor coordination improves to permit him or her to now hold a crayon with the fingers instead of the fist. Threeyear-old children can control drawing to include both vertical and circular strokes. There is slight evidence of hand preference during the first year of life. Usually infants reach for objects with both hands or with the hand closest to the object. Rightor left-hand dominance is evident by 15 months. Table 7.1 lists developmental milestones for a typical 3-year-old child. Toilet Training Using Freud’s theory of psychosexual development, the toddler is at the anal stage, with the pleasurable area being the anus (see Chapter 5). Toilet training is often more important to the parents than to the young child. Successful toilet training depends on a certain degree of maturity in the toddler’s muscles, including sphincter control, and maturation of the sensory centers of the brain. Furthermore, toddlers must develop a system of communication that allows them to alert parents of their needs (Fig. 7.3). The child uses either gestures or words to convey his or her need for toileting. Toddlers will learn bowel control before mastering bladder control. Usually children do not have this control until the second year—after walking for several months. T A B L E 7.1 Dev elo pmental M ilesto nes fo r the 3-Year-O ld Child Gross motor Balances on one foot Jumps on both feet Walks up steps using both feet Runs Rides a tricycle Fine motor Puts simple puzzles together Builds a tower of blocks Copies a circle or vertical line Turns knobs and opens lids Psychosocial Tolerates short separations from mother Dresses and undresses self Is possessive of own property Is nearly fully toilet trained Cognitive Searches and finds toys Locates body parts Knows relationship between things and persons Gives full name Language Uses words and gestures to indicate needs Uses two-word sentences Imitates sounds and words Sings simple songs Has increased vocabulary 7589_Ch07_097-114 29/08/17 12:02 PM Page 101 Toddlerhood 101 Most children achieve daytime dryness long before nighttime dryness. Children of this age need help undressing and with the whole toileting process. By the time the child is 31⁄2 years old, he or she is usually bladder trained. Changes in schedules, emotional stress, fatigue, or illness can often cause setbacks in toilet training. It is best to expect accidents at times when children are engrossed in play or simply miss the signals. These accidents should be handled in a matter-of-fact manner, without punishment, to help build the child’s self-esteem. Psychosocial Development Autonomy According to Erik Erikson, autonomy, or independence, is a major psychosocial task of the toddler (see Chapter 5). In particular, toddlers are trying to master independence in their daily activities, such as toileting, dressing, feeding, and taking care of their belongings (Fig. 7.4). Encouraging children to make simple decisions fosters a sense of independence. Freedom of choice, however, often sets the stage for conflicts between parent and child—that is, fostering autonomy does not preclude parental guidance. Many activities, particularly those concerning the child’s safety, such as playing in the street, are nonnegotiable. How these conflicts, and mishaps FIGURE 7.4 Self-feeding is an early skill to master. and successes, are handled is critical to the toddler’s developing self-esteem. If the toddler is punished for accidents and made to feel worthless, he or she develops a sense of shame and doubt. For example, if toddlers have accidents and soil their clothing, parents should not get angry and scold them. They should try to have a change of clothing handy and treat the accident as a minor event, saying, “You’ll do better next time.” Even with nurturing guidance, toddlers often develop conflicting emotions or feelings of ambivalence as they learn independent behaviors. For instance, toddlers may experience feelings of both love and hate for their caregivers when being reprimanded or disciplined. Toddlers may get angry with parents and say, “I hate you,” but still want to be held and comforted. Parents should be careful not to take over dressing the child who is attempting to carry out this skill. Although it is quicker for the parents to dress the toddler, it is better to support development of the child’s independence by allowing him or her to practice these skills. Box 7.1 lists principles for understanding behavior. B O 7.1 X P rinciples fo r U nd erstand ing B ehav io r • Behavior must be understood in the context in which it occurs by looking at all related factors. • All behaviors have objectives and serve a purpose. • The child’s self-concept influences his or her behavior. • Behavior helps the child maintain psychological equilibrium. • The child’s perception and interpretation of behavior influence his or her actions. FIGURE 7.3 Toilet training should be a positive experience. 7589_Ch07_097-114 29/08/17 12:02 PM Page 102 102 Journey Across the Life Span Discipline Toddlers need discipline because they do not have enough information to understand what is acceptable or unacceptable behavior. A simple, direct “No” followed by some diversion will help lay the foundation for learning impulse control. It is crucial that caregivers be consistent and repeatedly reinforce limitations. Discipline should not deny the child freedom but rather give the child a greater opportunity to explore and learn within safe limits. Discipline should guide, correct, strengthen, and improve the child’s choices. Nonnegotiable issues include items such as not hurting themselves or others, not destroying property, and not placing themselves in unsafe conditions such as a street. With these nonnegotiable issues the parents should give clear, simple instructions, such as, “Bobby is a friend to play with, not to hit!” Sometimes discipline triggers temper tantrums or rebellious behavior. This negativistic behavior occurs as a result of frustration that the child encounters when his or her needs or wants are not met immediately (Fig. 7.5). The toddler is eager to take control and be independent beyond what skill or judgment allows. Toddlers have a limited vocabulary; this makes it difficult for them to express their feelings and may result in outbursts of kicking, screaming, and breath holding when they cannot FIGURE 7.5 Negative behavior is related to the child’s frustration. have their way. Temper tantrums are commonly seen between ages 2 and 3 and diminish in intensity and frequency by ages 4 and 5 years. To avoid conflicts, parents can place less emphasis on minor issues and allow the child to make some choices. For example, the parents may find it better not to rush or hurry the dawdling child, or they may allow the child to postpone dressing until after breakfast. Giving choices when possible may help to reduce the number of conflicts and temper tantrums. If a tantrum occurs, the parents should ensure the child’s safety and, if possible, leave the child in his or her room or limit the number of onlookers. Another intervention that may be used to resolve a conflict of wills is the concept of “time-out.” The child is usually removed from the center of activity to a quiet place where he or she can regain some control. Time-out should be immediate and used only for a few minutes. Following the time-out, the parent and child should talk about the events leading up to the conflict and possible solutions. This teaches the child to talk about what he or she is feeling and helps the child learn alternative solutions to problems. The natural curiosity of toddlers makes it necessary for parents to identify and eliminate temptations. It is very common for 2-year-old children to demand that things go their way. It is usually best not to share plans in advance of an expected event. If the parent or caregiver promises to take the child to the park on the following day, the child may demand fulfillment of these plans regardless of bad weather or other happenings. Sometimes parents need to ignore attention-seeking behavior when it does not put the child at risk or in danger. Caregivers should remember to offer praise and positive reinforcement for desired behaviors. See Box 7.2 for tips on discipline. Special Psychosocial Concerns Toddlers are affected by what is called separation anxiety. As they become more independent, they can tolerate only brief periods of separation from their parents. Children in this age group are naturally warm and affectionate (Fig. 7.6), but they are still somewhat fearful of strangers unless they are accompanied by a family member. Parents should be honest about leaving or going out without the child and telling them when they will return. This helps reinforce to the child that his or her parents will come back as they said they would. Toddlers do not have a clear concept of time; rather, they relate time in reference to a particular event. For 7589_Ch07_097-114 29/08/17 12:02 PM Page 103 Toddlerhood H E L P F U L 103 H I N T S Positive Parenting Avoid saying: • “Stop acting like a baby.” This uses a negative label that hurts the child’s feelings. It is better to focus on the behavior by saying, “You’re crying because you’re upset and mad at . . .” • “There’s no reason to be afraid.” This makes the child feel that his or her worry is not important. It is better to acknowledge the fear and reassure with a simple explanation such as, “The noise you heard isn’t a monster. It’s the wind blowing against the window.” • “Why did you do that?” Very often young children don’t understand why they acted in a certain way. Asking them why may be something that they are unable to explain. It is better to offer them an explanation for their behavior: “You grabbed the child’s toy because you were angry with him.” Or, “Can you tell me a better way to act?” FIGURE 7.6 Toddlers are warm and affectionate. H E L P F U L B O 7.2 • • • • • • • • • • • • • • • • • X T i p s on Di s c i p l i n e Try to understand the reason for the misbehavior. Respect the child as a person. Be firm but kind. Be patient. Reward and praise often. Encourage open expression of feelings. Ignore negative behavior when safety allows. Provide a healthy environment. Listen and be attentive. Encourage independence. Avoid pity. Maintain control of emotions. Allow for trial and error. Reinforce consequences. Use familiar routines when possible. Model desired behaviors. Offer choices. example, toddlers do not understand when noon is, but they can relate to lunch time. For this reason, when parents must leave they can best reassure their toddler that they will return after lunch or after their nap. Toddlers sometimes use certain “comfort items” to decrease their anxieties. These items are often blankets, soft toys, or other common household H I N T S Giving Up Comfort Items • Recognize the transitional object as a part of the child’s journey toward independence. • Try to offer a substitute item rather than insisting on removing the object. • Allow enough time for the child to reach a state of readiness. items. These transitional objects, as they are sometimes called, are important to the child but often a concern to the parents. Children should not be expected to give up their transitional objects all at once. Significant changes in the child’s life, such as arrival of a new sibling, a move, or the onset of preschool or day care, may cause stress and result in the need for the comfort item. The birth of another child often creates sibling rivalry, or feelings of jealousy and insecurity in the toddler. It is difficult for a 2- or 3-year-old child to share time, attention, and parental affection with a brother or sister. Angry outbursts or regressive behavior may be seen in the toddler trying to deal with changes in the family brought about by the birth of a new baby. Regression, a return to an earlier form of behavior with which the child felt comfortable and secure, 7589_Ch07_097-114 29/08/17 12:02 PM Page 104 104 Journey Across the Life Span can occur at any stressful time. It is not uncommon for the toilet-trained child to regress and have accidents, particularly following an illness or separation from parents. When this form of regression occurs, parents should minimize the significance and be confident that once the stressful period is over the child will return to normal behavior patterns. Sometimes after the birth of a new baby, the toddler may regress and want to use a bottle or be carried around like the newborn child. Parents should expect some regression and plan for special time alone with the older child to make him or her feel as important as the new baby. Cognitive Development Cognition continues to develop by trial and error. At 2 years of age the child begins what Piaget described as preoperational thought (see Chapter 5). The toddler’s problem-solving abilities are limited. For example, the child may correctly identify a garbage receptacle but indiscriminately throw everything into the receptacle. The child also responds to the total situation rather than to a part. In other words, when objects and things have common elements, the child responds to them as if they were all the same. As memory begins to develop, many behaviors are imitated. The toddler’s interpretation of new experiences is based on memory of previous happenings. For example, the toddler recognizes familiar objects and people and responds to them with pleasure but may demonstrate a fear of unfamiliar things and strangers. Toddlers begin to experiment by trying out new ideas or actions. As the child’s understanding of object permanence develops, his or her thinking follows a simple and direct pattern. Object permanence refers to the understanding that things will not disappear even if they cannot be seen. The child uses the further development of memory to create mental images. These mental images have a magical quality and are usually incorporated into the toddler’s play. Events are seen as having a simplistic causal relationship. For example, toddlers believe that their own feelings can directly affect events. Some children are concerned that their angry thoughts may cause bad things to happen. Toddlers have an egocentric view of the world—that is, they cannot sense the world from any point of view other than their own. For example, a child grabs a toy from another child but cannot understand that this may hurt the other child’s feelings. It is best for caregivers to simply explain that this behavior is not acceptable. Time is still incompletely understood or can be interpreted by events within the child’s own frame of reference. It is best to avoid using words like tomorrow, yesterday, or next week. It is clearer to the child if the speaker uses a familiar event to relate to a particular happening—for example, “We will go out to the park after your lunch.” This is more meaningful than saying, “We will be going to the park in the afternoon.” Moral Development As they grow, children learn their moral values based on their parents’ moral codes and by imitating parental behavior and teachings. Parents begin to teach toddlers what is right and wrong. For example, toddlers are taught that it is wrong to stand in the car and that instead they must always be buckled and seated in their safety seats. Parents must use their own seat belts when driving or riding in a car. This sets a good example for children and helps to teach them right from wrong. Repeated instructions and consistency reinforce moral decisions. All caregivers should work together as a team to help instill the same principles. Respect between the parent and child teaches the toddler that justice is reciprocal. Reasonable discipline that draws on the respect for others is an integral part of the child’s own moral development. Learning socially acceptable behaviors is a long, slow process that begins in this stage and extends through adolescence. Refer to Box 7.3 for tips on promoting self-esteem. Communication Language acquisition is automatic and spontaneous. Language skills are enhanced with practice. Encouraging children’s speech and reading to them help build language skills. The language of toddlers is based on symbolic function and memory. This means that their words not only name things, but B O 7.3 • • • • • • • • • X P ro mo ting Self-E steem Attend to the child’s needs immediately. Spend special time with the child. Ignore minor mishaps. Listen attentively. Convey positive regard. Label behavior, not the child. Give positive feedback. Be congruent with communication. If indicated, offer an apology. 7589_Ch07_097-114 29/08/17 12:02 PM Page 105 Toddlerhood also show understanding of the meaning. In other words, when the child uses the word “potty,” he or she means the process of toileting. Cognitive development and imitation play important roles in early language acquisition. Children understand what is said to them before they are able to put their thoughts into words. Early on, sentence structure may not be correct and pronunciation may be unclear, but toddlers are still able to complete their intended messages. Sometimes only the immediate caregivers can understand the child’s language. The first sentences consist of a noun or a verb. Toddlers quickly develop the ability to use nouns or verbs in a two-word sentence. “Me go” is an example of an early sentence. To make the two-word sentence clearer, most toddlers use hand gestures to support the meaning of their words. Most 2-year-old children are able to use words to represent their actions and make their needs known. For example, if a toddler is thirsty, he or she may repeatedly say, “juice” until the need is met. When the toddler learns the use of the word “why,” he or she often uses it to challenge adults and keep them talking. This dialogue ultimately helps the child to learn more about the world. By 21⁄2 to 3 years of age, the toddler begins to use short, three-word sentences. Toddlers often confuse the pronouns “I” and “me.” “Mine” becomes a part of the child’s vocabulary rapidly thereafter because at this time the child begins to show awareness of ownership. Everything becomes “mine.” From a vocabulary of 50 words at age 2, the child moves rapidly to a vocabulary of 1,000 words by age 3. The 3-year-old child can put a noun and verb together to create a short sentence such as, “I go” or “Give it to me.” Young children living in a bilingual family can learn more than one language at the same time. Bilingualism is possible for the toddler if both languages are used in the home. When one language is used at home and another at playgroup or nursery school, it is much more difficult for the child to learn the second language. 105 model good eating practices. It is especially important that caregivers provide toddlers with the appropriate amounts of foods from the various categories in the food pyramid or MyPlate chart. See Chapter 1 for the MyPlate chart and further discussion. Toddlers particularly need foods that allow muscle development and mineralization of the bones— foods containing adequate protein, calcium, iron, phosphorus, and vitamins. Three servings of vegetables and three to four servings of fruits per day will provide the needed vitamin C. Offer foods with adequate fiber, and provide iron-rich foods such as cereals, meats, and fruits. Because most children continue to like milk, its intake must be monitored and limited to 1 quart per day. The need for milk will decrease as the amount of solid foods increases. By age 2 to 3 years, the child should be eating the same foods as the rest of the family. Most toddlers need about 1,300 calories a day, although the amount of food needed varies greatly, depending on the child and his or her activity level. The child who is very active needs more calories than the child who is sedentary. Allowing a toddler to select junk food, including food high in sugar, is detrimental to the child’s nutritional state (Fig. 7.7). Snacks, like meals, need to be nutritious. Avoid or only sparingly give candy and other sugar-concentrated foods. The calories, protein, and other vital nutrients of snacks must be considered part of the child’s daily nutritional intake. Caregivers can comply with many of the toddler’s food preferences and still offer nutritious foods. Most toddlers prefer plain foods to mixtures. They will learn about textures from a variety of foods offered. Foods that are easy to manipulate and chew are among toddlers’ favorites. For example, NUTRITION The toddler needs to establish good eating patterns because the eating habits taught at this stage will be lifelong. Because toddlers’ eating habits are easily influenced by the eating preferences of older siblings and parents, other family members need to FIGURE 7.7 Sweets should be limited in the toddler’s diet. 7589_Ch07_097-114 29/08/17 12:02 PM Page 106 106 Journey Across the Life Span hand-held sandwiches, bite-size pieces of meats, pizza, pasta, and fruits are some of their favorite foods. Initially young toddlers bite and chew with their front teeth; however, as the back teeth (molars) appear, they will begin to chew in the back of the mouth. Because toddlers have their full set of deciduous teeth by 21⁄2 years of age, they are able to chew and swallow all sorts of table foods. It is not uncommon for children of this age to develop ritualistic behavior in relation to eating. For example, toddlers sometimes prefer using the same plate or cup at each meal. Their ritualistic preferences may be upsetting to caregivers, but it is best to remember that such behavior is typical for many toddlers. In addition, toddlers may develop food fads or habits. For instance, they may go for a time not eating or eating only small amounts every day. Common reasons for toddlers not eating include excitement or distraction, exhaustion, illness, lack of hunger, and attention seeking. Sometimes, a toddler will want to eat only peanut butter sandwiches day after day. Eating the same foods—although seemingly boring from an adult perspective—will not be detrimental to a child’s nutrition if the foods selected contain the appropriate nutrients. Also, a food fad is likely to disappear just as suddenly as it began. Toddlers also like consistency and familiar routines at mealtimes. These qualities foster good eating habits; thus meals should be at the same time each day. Because toddlers’ stomach capacity is small, caregivers should plan for three small meals along with three nutritious snacks. See Box 7.4 for tips for nutritious snacks. Mealtimes should be used to promote family time together and socialization of the toddler, including promotion of the child’s autonomy in self-feeding. It is best at this stage to offer simple choices such as, “Would you like cereal or toast for breakfast?” This is better than offering vague choices such as, “What do you want for lunch?” Children sometimes test their autonomy by refusing to eat. Toddlers may also refuse to eat because their appetites fluctuate and they may not be hungry at mealtime. Caregivers should be careful not to offer snacks too close to mealtimes. Toddlers may also be too tired, excited, or distracted to eat. Sometimes refusal to eat is an attentionseeking behavior. It is best to ignore most refusals because they are usually short-lived: The child will eat when he or she is hungry. At times, toddlers will play with their food or dawdle. They need to be given adequate time to finish eating but not so much time that one meal runs into the next. Caregivers should give as little attention to a toddler’s negative behaviors at mealtimes as possible. To promote good eating habits and socialization of the child, mealtime should not be stressful. Parents should expect that accidents and spills will happen and react matter-of-factly to unintentional happenings. The toddler can be taught simple table manners—for example, how to use the correct eating utensils. Using the proper utensil also enhances fine motor coordination. Eating utensils can be of normal size or sized for a child, if desired. Caregivers should provide positive reinforcement for desired mealtime behaviors. Sometimes setting the table with a special cloth or with the “fancy” dinnerware helps to show toddlers that they are growing up and able to use the “grown-up stuff.” See Box 7.5 for tips for fostering good eating habits. B B O 7.4 X Ti ps for N u t r i t i ou s Sn ac ks • Snacks can be an excellent means of providing additional calories, proteins, and other vital nutrients. • Avoid offering snacks immediately before mealtimes. • Avoid the use of foods high in sugar with little nutritional value (for example, candy or processed baked goods). • Choose healthy snacks such as cheese cubes, fresh fruits, raw vegetables, milk, crackers, dried cereals, dried fruits, peanut butter on bread or crackers, or plain low-fat yogurt. SLEEP AND REST Toddlers sleep less than infants and often resist sleep because they want to play and be involved in adult activities. Short nap periods during the day help prevent toddlers from becoming overtired. Bedtime should include a ritual such as reading to the child O 7.5 X Fo stering P ro per E ating Habits • Encourage the toddler to taste new foods. • Introduce new foods in small amounts along with regular foods. • Use child-sized portions. • Present colorful foods of different textures. • Eat with the child. • Never force a child to eat. • Provide a comfortable atmosphere. • Minimize confusion at mealtimes (for example, turn off the television). • Recognize that accidents or spills will occur. 7589_Ch07_097-114 29/08/17 12:02 PM Page 107 Toddlerhood and allowing him or her to have a comfort toy such as a teddy bear or blanket. Ritualistic behavior or habitual acts surrounding bedtime practices can establish a familiar routine for the child to follow. Such rituals help reduce anxiety and give the child a sense of security. Sleep disturbances caused by nightmares that awaken and frighten the child are not unusual. The child usually resists sleep after a bad dream because of fear. The events surrounding the nightmares usually appear real and lifelike, and the child needs to be comforted. The period of comfort should be brief, and it is usually recommended that parents comfort the child in the child’s room rather than taking the child to their own bed. Toddlers should understand that each person in the family has his or her own space for sleeping. Taking the toddler into the parents’ bed may set up a habit that later can be hard to undo. Other factors that can produce sleep disturbance in the toddler include fear of separation from the parent, illness, and physical exhaustion. PLAY Play is a very important activity in the toddler years and is the major means by which children continue to explore and understand the world around them. At first, play mimics the activities performed by others around the toddler, such as talking on the telephone. This type of mimicking is not only pleasurable, but also helps the toddler try out adult roles. By 2 years of age, the play appears to be symbolic rather than nonsymbolic, as is the play of infants. Nonsymbolic play is demonstrated when the young child squeezes a soft ball. Piaget described symbolic play as the emergence of make-believe and pretense. Objects become the symbol, or represent something else slightly similar. Children between the ages of 2 and 4 years most often engage in symbolic play. It is thought that symbolic play H E L P F U L 107 helps children to explore different possibilities, control aggression through fantasy, and pretend. An example of symbolic play is building a castle or city with blocks. Other examples of symbolic play are when a child first pretends to drink from a cup and later pretends to feed a doll. Parents have the fundamental responsibility for guiding their children’s play by modeling desired activities. Play is good in that it helps ego and development, cognition, and socialization. Many 2- and 3-yearold children are enrolled in some type of structured playgroup. Even though they cannot always interact with other children at play, they benefit from being in the presence of children of the same age group who are learning socializing skills. Playgroups may also be beneficial for the mother or caregiver, allowing them time to be with other siblings or by themselves. Children with working parents may develop similar social skills in a day-care setting. Although children are encouraged to play with other children, many confrontations occur over playthings. Toddlers usually prefer parallel play, in which they play alongside other children without interactions. As toddlers develop language proficiency and the capacity to think, they are capable of incorporating their elaborate imaginations into their play activities (Fig. 7.8). Many 3-year-old children, for instance, develop imaginary playmates. Girls tend to have imaginary playmates more often than boys do. These imaginary friends are often blamed by the child when accidents or other mistakes occur. This type of play is a very normal part of development and should be treated with sensitivity by caregivers. The selection of playthings is one of the many critical decisions parents have to make (Box 7.6). Toys foster fine and gross motor development and entertain the toddler. Push toys, riding toys, swings, and pots and pans assist with gross motor development. Finger H I N T S Resolving Sleep Problems • Set a consistent routine, and remember that you cannot force a child to sleep. • Encourage quiet rituals before bedtime. • Use a nightlight if the darkened room frightens the child. • Remember that not all children require the same amount of sleep. FIGURE 7.8 Toddlers use their imagination in play. 7589_Ch07_097-114 29/08/17 12:02 PM Page 108 108 Journey Across the Life Span painting, drawing, puzzles, and building blocks strengthen fine motor development. Some 2-year-old children like to unscrew tops from bottles, open boxes and containers, turn pages in a book, and cut with scissors. Toddlers should use safety scissors with supervision from a grown-up. Musical instruments help provide rhythm and exploration (Fig. 7.9). Many of the objects used in these favorite activities are readily found in the home. Electronic Devices, Television, and Toddlers Many parents allow their infants and toddlers to use tablets and smartphones to keep the child occupied and decrease crying. The concern with infants and toddlers using these devices is that they provide no or very little sensory stimulation. They do not have a texture, smell, or taste and do not stimulate fine motor skills. At this age children are great imitators and look to use these devices as they see others doing. Parents should limit the amount of time they spend using tablets or smartphones around their children. B O 7.6 X P l a y a n d Pl ay t h i n g s f or Y ou n g To ddler s Parallel play: Plays alongside other children but does not interact or share Playthings: Uses tricycles, swings, climbers, rocking horse, color cubes, paint and brushes, and simple musical instruments such as drums or bells FIGURE 7.9 Toddlers enjoy musical instruments. If toddlers are allowed to play with these devices, parents should choose applications that allow the child to draw, color, or arrange puzzles. Parents should play along with the child and teach colors and vocabulary, remembering that the more parents talk to the child, the more he or she will learn. About 90% of parents report that their child under the age of 2 years watches some form of electronic media or television. Some programs may be beneficial to children under 2 years, but there is no scientific proof. What research has shown is that overuse of media can cause language delay. As a result of these findings the American Academy of Pediatrics has suggested limiting the use of media to less than 2 hours per day, parental review of program content, and never placing a television in the child’s bedroom. SAFETY Because of their natural curiosity and explorative behavior, toddlers are prone to accidents (Fig. 7.10 and Fig. 7.11). Accidents are the leading cause of death in children of this age and the most frequent reason why medical services are sought. Most accidents are preventable, and prevention requires parental education. The toddler requires constant supervision because there are many hazards both inside and outside the home. Toddlers are incapable of recognizing danger or threats to their safety; this, along with their curiosity, places them at great risk for injury. Recent statistics indicate that, in this age group, more than half of all accidents that result in death or FIGURE 7.10 Toddlers show an interest in animals at the zoo. 7589_Ch07_097-114 29/08/17 12:02 PM Page 109 Toddlerhood FIGURE 7.11 Toddlers are fascinated by water and a hose. serious injury are motor vehicle accidents. Car safety seats and restraints are regulated and strictly mandated by state laws to reduce the numbers of injuries and deaths. Children must be taught what is expected of them with regard to car safety. For example, the child must know that he or she is expected to be seated in the proper seat and restrained when in any vehicle. Car windows and door handles should be offlimits to all young children. However, many car seats are installed next to the window in the back seat, putting the door handle and window controls within the child’s reach. Child safety locks for car doors and windows are standard on most cars sold in the United States. When used correctly, the window buttons and door handles are disabled and prevent curious toddlers from opening their doors or windows. These locks must be activated by the driver. A consistent approach to rules pertaining to car safety, or safety in general, will better ensure a child’s compliance. In this age group, injuries resulting from burns rank second to those from motor vehicle accidents. Safety in the kitchen includes removing stove knobs and turning pot handles toward the back of the stove to prevent spills. Cover electrical sockets with safety caps when not in use to prevent shocks. Children are at risk for burns from hot liquid spills, hot bath water, or playing with matches. Play areas should be carefully selected to provide child safety. Children should not play near roads or in active driveways. Continuous watchful supervision is necessary to prevent accidents. No child of this age can be trusted to remember all the safety rules or be able to recognize potential dangers. 109 The ingestion of poisons is another safety hazard as the toddler begins to climb and open drawers and closets. Special care must be taken in storing household cleaning agents, garden products, car products, and prescription and nonprescription drugs. These agents should be stored on a high shelf out of the reach of children and securely locked. Parents should never refer to medicine as candy or say that it tastes good; otherwise, toddlers may be tempted by it. Parents should make it a point not to take their own medications in front of their children so that their behavior is not copied. All caregivers should have the national poison control number (800-2221222) readily available in the event of accidental poisoning. Choking or aspirating a small object is a continued concern for this age group, just as it is for infants, particularly because toddlers often eat food on the run. Certain food items have been identified as frequent offenders. They include hard candies, popcorn, fruit pits or seeds, and large pieces of meat. Other potential safety hazards are toys with small removable parts that can be placed in the child’s mouth and either swallowed or aspirated. This kind of toy should not be given to young children. Suffocation can be avoided by advising parents not to use plastic coverings on beds or furniture. Balloons have been implicated in many toddler deaths: While attempting to blow up a balloon, toddlers may accidentally inhale the deflated balloon into the windpipe, obstructing the airway. Drowning accounts for high numbers of deaths in this age group. Drowning can occur in the bathtub, swimming pool, or another body of water— even in only a few inches of water. Supervise toddlers at all times during bathing. Adult supervision and teaching children to swim can make water a safe, fun activity (Fig. 7.12). HEALTH PROMOTION Regular physical examinations should be scheduled for toddlers. These examinations include monitoring the child’s growth patterns, health screening, identification and correction of any deviation, education, and disease prevention. Visits to the health provider should be scheduled when the child is 18, 24, and 36 months old. A history and physical examination is done at each yearly visit; it should include an assessment of the child’s growth and development. At the 24-month checkup, the child will need to be screened for tuberculosis. To strengthen parenting 7589_Ch07_097-114 29/08/17 12:02 PM Page 110 110 Journey Across the Life Span T A B L E 7.2 Sig ns o f Child Abuse Physical abuse Bruises, welts (may be at different stages of healing) Signs of multiple fractures at different stages of healing Lacerations or tears Cigarette or immersion burns on extremities or buttocks Head injuries Swollen, blackened eyes Sexual abuse Difficulty walking or sitting Bruises or bleeding from genitalia Recurrent urinary tract infections Symptoms of sexually transmitted diseases Inappropriate sexual behavior in young teenagers Psychological /affective abuse Excessive anger, aggression Poor peer relationships Negativism, loss of pleasure Low self-esteem, lack of trust Developmental delays Withdrawn behavior, regression FIGURE 7.12 Water safety is important skills, child-rearing classes may be indicated. Toddlers should receive the measles, mumps, and rubella vaccine at 12 to 15 months of age. The varicella vaccine is currently recommended for 12- to 15-monthold toddlers. The complete schedule of recommended immunizations is found in Appendix B. Child Abuse Health care workers, caregivers, and teachers should be alert for signs of mistreatment or abuse. Abuse of any kind can occur in any family type and at any level of social standing. Child abuse can include physical, emotional, and sexual mistreatment. See Table 7.2 for the common signs of child abuse. Child abuse is defined as any recent act or failure to act by a parent or caregiver that results in death, serious physical or emotional harm, sexual abuse, or exploitation. In some cases, the failure of the parent or caregiver to act places the child at imminent risk for serious harm. This law targets persons under 18 years old who, in the care of a parent or caregiver, suffered a sustained injury or harm. However, the law also holds all health care workers who interact with children responsible for assessing and reporting suspected abuse or maltreatment. Primary care providers are in a unique position to identify children experiencing abuse or neglect during well-child and other visits. The law does not require the health care worker to be sure the abuse has taken place; “suspicion is all that is necessary” for the abuse to be reported and child services to investigate. There are four common forms of abuse or maltreatment: physical abuse, neglect, psychological abuse, and sexual abuse. Physical Abuse Physical abuse is any nonaccidental physical injury that a child sustains while being cared for by a parent or caregiver. This includes bruising; hitting with any object (for example, a belt or hands); shaking, commonly seen in infancy and toddler years; burning with cigarettes, flames, or hot liquids; kicking; choking; biting; or stabbing. This category also includes any verbal threats of harm. Neglect Neglect is the failure of a parent or caregiver to provide for the basic physiological needs of the child, such as food, clothing, shelter, medical care, or supervision. As a result, the parent or caregiver causes harm and injury to the child’s health, safety, and well-being. The first type of neglect is educational. Educational neglect describes parents or caregivers who fail to comply with a school authority complaint of chronic absence from school, a failure to enroll a child in school, or a failure to provide special education needs for a child who has been diagnosed with a learning disorder. 7589_Ch07_097-114 29/08/17 12:02 PM Page 111 Toddlerhood The second form of neglect is when a parent or caregiver places the child in an environment where there is chronic exposure to domestic violence or spousal abuse or allows the child to use drugs or alcohol. The third form of neglect is abandonment. In some states abandonment is a form of abuse or neglect, especially when the parent or caregiver leaves the child and does not explain where the child will be, how the child can be contacted, or if (or when) the child will return. The child is left in an environment without reasonable support and as a result can sustain serious physical, sexual, or emotional harm. Psychological Abuse Psychological abuse describes attitudes and behavior by the parent or caregiver that interfere with the child’s mental and social well-being. This includes belittling, shaming, yelling, and failing to provide the needed love and affection that will foster 111 growth and development and the child’s physical health. Sexual Abuse All states include sexual abuse in their definitions of child abuse. Sexual exploitation is also considered child abuse. Sexual exploitation is when a parent or caregiver allows the child to engage in prostitution or in the production of child pornography. Sexual abuse is the act of touching or introducing anything into the vaginal or anal cavity other than when providing needed care. This includes anal or vaginal intercourse, oral sex, verbal seduction, and threats. Many individuals sexually abuse children, and parents and caregivers must be mindful that offenders can be family members, friends, neighbors, babysitters, and clergy. Findings of sexual abuse include symptoms of sexually transmitted diseases; injury to the genital area; difficulty and/or pain when sitting or walking; and sexually suggestive, inappropriate, or promiscuous behavior in teenagers. CRITICAL THINKING SUMMARY 1. Toddlerhood refers to the period of development from 12 months to 3 years of age. 2. Growth rates of toddlers are slower than those of infants. Growth during this period results in the body appearing more proportionate with a taller, more slender look. 3. Bone development continues with a gradual hardening or ossification. 4. By 21⁄2 years of age, toddlers usually have a complete set of deciduous teeth. Children at this age must visit the dentist for dental examination and treatment to help ensure healthy teeth later in life. 5. Gradually, visual acuity will improve and can be enhanced with the use of large objects held at close range. Hearing is fully developed and should be tested during periodic examinations. 6. Heart rate, respiratory rate, and blood pressure readings will decrease during the toddler period. 7. Gross and fine motor skills develop further. 8. By the end of toddlerhood, the child gains skills related to walking, eating, toileting, dressing, and communicating independently. 9. Development of gross motor skills depends on growth and maturation of muscles, bones, and nerves. Teaching new skills is of little value until a state of readiness is reached. 10. Fine motor skills achieved during this stage are related to self-feeding, dressing, and playing. By the end of toddlerhood, children should be actively participating in dressing, washing, and brushing their teeth. 11. Freud’s theory of psychosexual development places the toddler at the anal stage, with the pleasurable area being the anus. Toilet training can be successful once the child has achieved a degree of maturity in sphincter muscles, nerves, and language. 12. Autonomy (independence) is a primary psychosocial task of toddlers. It encourages toddlers to make decisions, especially in their activities of daily living. 13. Two-year-old children need guidance and discipline. Caregivers should be consistent and repeatedly reinforce limitations. Limits should not deny children freedom; limits should give them greater opportunity to explore. 7589_Ch07_097-114 29/08/17 12:02 PM Page 112 112 Journey Across the Life Span 14. Piaget suggested that toddlers interpret new experiences based on memory of previous happenings. This is referred to as preoperational thought. 15. Moral development depends on children imitating their parents’ moral behavior and teachings. 20. Electronic media, tablets, and other devices, while commonly available to young children, offer them no or very little sensory stimulation. The American Academy of Pediatrics recommends limiting the use of electronic media by toddlers to less than 2 hours per day, parental review of program content, and never placing a television in the child’s bedroom. 16. Language acquisition develops along with memory and cognition. Young toddlers use one-word sentences. Three-year-old children have a vocabulary of approximately 1,000 words and use multiple words in a sentence. 21. Natural curiosity and the child’s inability to recognize danger make accident prevention extremely important at this stage. For this reason, toddlers require continuous supervision in all of their activities. 17. Toddlers need a well-balanced diet and good eating habits to support muscle and bone growth. Food amounts vary greatly depending on individual activity levels. Likes and dislikes are influenced by other family members’ dietary habits. Foods that are most frequently accepted are those that the child can eat as he or she moves about. 22. Schedule regular physical examinations for toddlers. These visits should be at 18, 24, and 36 months. Dental examinations are scheduled when children have their complete set of deciduous teeth. 18. Sleep needs decrease during this stage of development. However, short naps are still indicated. Bedtime rituals are common; they help reduce anxiety and give the child a sense of security. Nightmares should be handled in a consistent, comforting manner. 23. Health care workers and others should be alert for signs of mistreatment or abuse in children. Child abuse can include child neglect and physical, psychological, and sexual mistreatment. Under the law, health care works are responsible for assessing patients for abuse and reporting suspected abuse to authorities. 19. Play is the major means by which the child continues to explore and understand the world. Toddlers usually prefer parallel play. Imaginary play and imaginary playmates are common and normal at this stage. CRITICAL THINKING Exercise #1 Ms. Sterdowski brings Eric, 28 months of age, to the clinic because she believes that he is not thriving. She explains that he walks alone without assistance but only attempts to say about four words. His pronunciation is unclear to anyone outside of the immediate family. She states that she has not yet been successful with potty training him. She further explains that her older child had mastered all these skills and more by this age. 1. Describe the best approach to use to reassure Ms. Sterdowski that Eric is developing normally. 2. Based on expected growth timetables, what is the best interpretation of Eric’s performance? 7589_Ch07_097-114 29/08/17 12:02 PM Page 113 Toddlerhood CRITICAL THINKING 113 (continued) 3. List three instructions that should be given to assist Ms. Sterdowski with accomplishing toilet training. Exercise #2 The parents of a 21⁄2-year-old toddler are anxious that they are not able to get their child to agree to their wishes. They report that all he does is say “No.” What advice could you offer these parents? MULTIPLE-CHOICE QUESTIONS 1. Toddlers’ motivation to acquire and master most psychomotor skills is related to their need for: a. Balance b. Independence c. Sameness d. Dominance 2. A child usually has a complete set of deciduous teeth by age: a. 12 months b. 18 months c. 24 months d. 30 months 3. Fine motor skills that should be mastered by 3 years of age include: a. Holding the spoon with the fist b. Using a crayon to draw a circle c. Drawing a complete face d. Recognizing dangerous situations 4. Toilet training depends on the child’s ability to: a. Sit alone on the toilet b. Attain sphincter control c. Want to please the parents d. Properly digest a regular diet 5. According to Erikson, the psychosocial task for the toddler is: a. Trust b. Initiative c. Autonomy d. Industry 6. Moral development in the toddler is based on: a. Innate instincts b. Mature behavior c. Promptly meeting needs d. Copying parental values 7. The type of play seen in a 2-year-old child is: a. Solitary play b. Parallel play c. Cooperative play d. Compet