Health Promotion of the Toddler and Family

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Case Study—Toilet Training/Toddler Development

Promoting Optimal Growth and Development

The term terrible twos has often been used to describe the toddler years, the period from 12 to 36 months of age. It is a time of intense exploration of the environment as children attempt to find out how things work; what the word “no” means; and the power of temper tantrums, negativism, and obstinancy. “Getting into things” is their way of learning about their world, especially relationships. Successful mastery of the tasks of this age requires a strong foundation of trust during infancy and frequently necessitates guidance from others when parents and toddlers face the struggles of toilet training, limit setting, and sibling rivalry. Nurses who understand the dynamics of growth and development of toddlers can help families deal effectively with the tasks of this age.

Biologic Development

Developing a Sense of Autonomy (Erikson)

According to Erikson (1963), the developmental task of toddlerhood is acquiring a sense of autonomy while overcoming a sense of doubt and shame. As infants gain trust in the predictability and reliability of their parents, environment, and interactions with others, they begin to discover that their behavior is their own and that it has a predictable, reliable effect on others. Although they realize their will and control over others, they are confronted with the conflict of exerting autonomy and relinquishing the much-enjoyed dependence on others. Whereas exerting their will has definite negative consequences, retaining dependent, submissive behavior is generally rewarded with affection and approval. However, continued dependence creates a sense of doubt regarding their potential capacity to control their actions. This doubt is compounded by a sense of shame for feeling this urge to revolt against others’ will and a fear that they will exceed their own capacity for manipulating the environment. Skillful monitoring and balance of controls by parents allows a growing rate of realistic successes and the emergence of autonomy.

Just as infants have the social modalities of grasping and biting, toddlers have the newly gained modality of holding on and letting go. To hold on and let go is evident with the use of the hands; mouth; eyes; and, eventually, the sphincters, when toilet training is begun. These social modalities are expressed constantly in the child’s play activities, such as throwing objects; taking objects out of boxes, drawers, or cabinets; holding on tighter when someone says, “No; don’t touch”; and refusing or spitting out food as taste preferences become very strong.

Several characteristics, especially negativism and ritualism, are typical of toddlers in their quest for autonomy. As toddlers attempt to express their will, they often act with negativism, the persistent negative response to requests. The words “no” or “me do” can be their sole vocabulary. Emotions become strongly expressed, usually in rapid mood swings. One minute, toddlers can be engrossed in an activity, and the next minute they might be angry because they are unable to manipulate a toy or open a door. If scolded for doing something wrong, they can have a temper tantrum and almost instantaneously pull at the parent’s legs to be picked up and comforted. Understanding and coping with these swift changes is often difficult for parents. Many parents find the negativism exasperating and, instead of dealing constructively with it, give in to it, which further threatens children in their search for learning acceptable methods of interacting with others (see Temper Tantrums, p. 389, and Negativism, p. 390).

In contrast to negativism, which frequently disrupts the environment, ritualism, the need to maintain sameness and reliability, provides a sense of comfort. Toddlers can venture out with security when they know that familiar people, places, and routines still exist. One can easily understand why any change in the daily routine represents such a threat to these children. Without comfortable rituals, they have little opportunity to exert autonomy. Consequently, dependency and regression occur (see Regression, p. 390).

Erikson focuses on the development of the ego, which may be thought of as reason or common sense, during this phase of psychosocial development. Children struggle to deal with the impulses of the id and attempt to tolerate frustration and learn socially acceptable ways of interacting with the environment. The ego is evident as children are able to tolerate delayed gratification. Toddlers also have a rudimentary beginning of the superego, or conscience, which is the incorporation of the morals of society and the process of acculturation.

With the development of the ego, children further differentiate themselves from others and expand their sense of trust within themselves. But as they begin to develop awareness of their own will and capacity to achieve, they also become aware of their ability to fail. This ever-present awareness of potential failure creates doubt and shame. Successful mastery of the task of autonomy necessitates opportunities for self-mastery while withstanding the frustration of necessary limit setting and delayed gratification. Opportunities for self-mastery are present in appropriate play activities, toilet training, the crisis of sibling rivalry, and successful interactions with significant others (Fig. 12-1).

FIG 12-1 Toddlers begin socializing with significant others such as siblings as a part of development. (© 2011 Photos.com, a division of Getty Images. All rights reserved.)

Cognitive Development: Sensorimotor and Preoperational Phase (Piaget)

The period from 12 to 24 months of age is a continuation of the final two stages of the sensorimotor phase. During this time, the cognitive processes develop rapidly and at times seem similar to those of mature thinking. However, reasoning skills are still primitive and need to be understood to effectively deal with the typical behaviors of a child of this age.

Tertiary Circular Reactions

In the fifth stage of the sensorimotor phase, tertiary circular reactions (13–18 months of age), the child uses active experimentation to achieve previously unattainable goals (see Cognitive Development, Chapter 10). Newly acquired physical skills are increasingly important for the function they serve rather than for the acts themselves. Children incorporate the old learning of secondary circular reactions with new skills and apply the combined knowledge to new situations, with emphasis on the results of the experimentation. In this way, there is the beginning of rational judgment and intellectual reasoning. During this stage, there is further differentiation of oneself from objects. This is evident in children’s increasing ability to venture away from their parents and to tolerate longer periods of separation.

Awareness of a causal relationship between two events is apparent. After flipping a light switch, toddlers are aware that a reciprocal response occurs. However, they are not able to transfer that knowledge to new situations. Therefore, every time they see what appears to be a light switch, they must reinvestigate its function. Such behavior demonstrates the beginning of categorizing data into distinct classes and subclasses. There are innumerable examples of this type of behavior as toddlers continuously explore the same object each time it appears in a new place.

Because classification of objects is still rudimentary, the appearance of an object denotes its function. For example, if the child’s toys are stored in a paper bag or large container, that toy receptacle is no different from the garbage pail or laundry basket. If allowed to turn over the toy receptacle, the child will just as quickly do the same to other similar containers because, in the child’s mind, there is no difference. Expecting the child to judge which receptacles are permissible to explore and which are not is inappropriate for this age group. Instead, the forbidden object, such as the garbage pail, should be placed out of reach. This has significant implications for prevention of accidents and accidental ingestion of injurious agents.

The discovery of objects as objects leads to the awareness of their spatial relationships. Children are able to recognize different shapes and their relationships to each other. For example, they can fit slightly smaller boxes into each other (nesting) and can place a round object into a hole even if the board is turned around, upside down, or reversed. Children are also aware of space and the relationship of their bodies to dimensions such as height. They will stretch, stand on a low stair or stool, and pull a string to reach an object.

Object permanence has also advanced. Although they still cannot find an object that has been invisibly displaced or moved from under one pillow to another without their seeing the change, toddlers are increasingly aware of the existence of objects behind closed doors, in drawers, and under tables. Parents are usually acutely aware of this developmental achievement and find high places and locked cabinets the only places that are inaccessible to toddlers.

Invention of New Means Through Mental Combinations

From ages 19 to 24 months, children are in the final sensorimotor stage, invention of new means through mental combinations. During this stage, children complete the more primitive, autistic-like thought processes of infancy and are prepared for the more complex mental operations that occur during the phase of preoperational thought. One of the most dramatic achievements of this stage is in the area of object permanence. Toddlers will now actively search for an object in several potential hiding places. In addition, they can infer a cause when only experiencing the effect. They can infer that an object was hidden in any number of places even if they only saw the original hiding place.

Imitation displays deeper meaning and understanding. There is greater symbolization to imitation. Children are acutely aware of others’ actions and attempt to copy them in gestures and in words. Domestic mimicry (imitating household activities) and sex-role behavior become increasingly common during this period and during the second year. Identification with the parent of the same gender becomes apparent by the second year and represents the child’s intellectual ability to differentiate different models of behavior and to imitate them appropriately (Fig. 12-2).

FIG 12-2 Domestic mimicry is common during toddlerhood.

The concept of time is still embryonic, but children have some sense of timing in terms of anticipation, memory, and a limited ability to wait. They may listen to the command, “Just a minute,” and behave appropriately. However, their sense of timing is exaggerated—1 minute can seem like an hour. Toddlers’ limited attention spans also indicate their sense of immediacy and concern for the present.

Preoperational Phase

At approximately 2 years of age, children enter the preconceptual phase of cognitive development, which lasts until about age 4 years. The preconceptual phase is a subdivision of the preoperational phase, which spans ages 2 to 7 years. The preconceptual phase is primarily one of transition that bridges the purely self-satisfying behavior of infancy and the rudimentary socialized behavior of latency. Preoperational thought implies that children cannot think in terms of operations—the ability to manipulate objects in relation to each other in a logical fashion. Rather, toddlers think primarily on the basis of their perception of an event. Problem solving is based on what they see or hear directly rather than on what they recall about objects and events. Several characteristics are unique to preoperational thought (Box 12-1).

Box 12-1 Characteristics of Preoperational Thought

Egocentrism—Inability to envision situations from perspectives other than one’s own

Example—If a person is positioned between the toddler and another child, the toddler, who is facing the person, will explain that both children can see the middle person’s face. The young child is unable to realize that the other person views the middle person from a different perspective, the back.

Implication—Avoid moralizing about “why” something is wrong if it requires an understanding of someone else’s feelings or opinion. Telling a child to stop hitting because hitting hurts the other person is often ineffective because, to the aggressor, it feels good to hit someone else. Instead, emphasize that hitting is not allowed.

Transductive reasoning—Reasoning from the particular to the particular

Example—Child refuses to eat a food because something previously eaten did not taste good.

Implication—Accept child’s reasoning; offer refused food at different time.

Global organization—Reasoning that changing any one part of the whole changes the entire whole

Example—Child refuses to sleep in his or her room because location of bed has changed.

Implication—Accept child’s reasoning; use same bed position or introduce change slowly.

Centration—Focusing on one aspect rather than considering all possible alternatives

Example—Child refuses to eat a food because of its color even though its taste and smell are acceptable.

Implication—Accept child’s reasoning.

Animism—Attributing lifelike qualities to inanimate objects

Example—Child scolds stairs for making child fall down.

Implication—Join child in the “scolding.” Keep frightening objects out of view.

Irreversibility—Inability to undo or reverse the actions initiated physically

Example—When told to stop doing something, such as talking, child is unable to think of a positive activity.

Implication—State requests or instructions positively (e.g., “Be quiet.”).

Magical thinking—Believing that thoughts are all-powerful and can cause events

Examples—Child wishes someone died; then if the person dies, child feels at fault because of the “bad” thought that made the death happen. Calling children “bad” because they did something wrong makes them feel as if they are bad.

Implication—Clarify that thoughts do not make things happen and that child is not responsible.

• Use “I” messages rather than “you” messages to communicate thoughts, feelings, expectations, or beliefs without imposing blame or criticism. Emphasize that the act, not the child, is bad.

Inability to conserve—Inability to understand the idea that a mass can be changed in size, shape, volume, or length without losing or adding to the original mass (instead, children judge what they see by the immediate perceptual clues given to them)

Example—If two lines of equal length are presented in such a way that one appears longer than the other, child will state that one line is longer even if child measures both lines with a ruler or yardstick and finds that each has the same length.

Implication—Change the most obvious perceptual clue to reorient child’s view of what is seen.

• Give medicine in a small medicine cup, rather than a large cup, because the child will imagine that the large vessel contains more liquid. If child refuses the medicine in the small cup, pour it into a large cup because the liquid will appear to be less in a tall, wide container.

• Give a large, flat cookie rather than a thick, small one or do the reverse with meat or cheese; child will usually eat larger size of favorite food and smaller size of less favorite food.

Within the second year, children increasingly use language symbolically and are concerned with the “why” and “how” of things. For example, a pencil is “something to write with,” and food is “something to eat.” However, such mental symbolization is closely associated with prelogical reasoning. For instance, a needle is “something that hurts.” Such painful experiences take on new significance because memory is associated with the specific event, and fears are likely to develop, such as resistance to people who wear colored uniforms or rooms that look like the practitioner’s office. Because of the vulnerability of these early years, it is essential to prepare children for any new experience, whether it is a new babysitter or a visit to the dentist.

Spiritual Development

Spiritual development in children is often discussed in terms of the child’s developmental level because the evolution of spirituality often parallels cognitive development (Elkins and Cavendish, 2004). The child’s family and environment strongly influence the child’s perception of the world around him or her, and this often includes spirituality. Furthermore, family values, beliefs, customs, and expressions of these influence the child’s perception of his or her spiritual self (Elkins and Cavendish, 2004). Neuman (2011) proposes that Fowler’s (1981) stages of faith be used to better understand children and spirituality; she provides an excellent overview of the stages of faith in childhood. The relationship between spirituality, illness in childhood, and nursing has been studied in the context of suffering, terminal illness such as cancer, and end-of-life care. In the past decade, there has been an increased interest in and focus on spiritual care in adults and children as further understanding of the influence of one’s spirituality on health, illness, and well-being has progressed.

Toddlers learn about God through the words and the actions of those closest to them. They have only a vague idea of God and religious teachings because of their immature cognitive processes; however, if God is spoken about with reverence, young children associate God with something special. During this period, the assignment of powerful religious symbols and images is strongly influenced by the manner in which it is presented; therein lies the potential for the development of guilt and fear or, conversely, love and companionship with religious symbols (Roehlkepartain, King, Wagener, and others, 2006). Toddlers are said to be in the intuitive-projective phase of Fowler’s (1981) faith construct wherein thinking is largely based on fantasy and rather fluid in relation to reality and fantasy. God may be described as being around like air by the toddler because of the fluidity in dividing fantasy and reality (Neuman, 2011).

Toddlers begin to assimilate behaviors associated with the divine (folding hands in prayer). Routines such as saying prayers before meals or at bedtime can be important and comforting. Because toddlers tend to find solace in ritualistic behavior and routines, they incorporate routines associated with religious practices into their behavioral patterns without understanding all of the implications of the rituals until later. Near the end of toddlerhood, when children use preoperational thought, there is some advancement of their understanding of God. Religious teachings, such as reward or fear of punishment (heaven or hell) and moral development (see Chapter 5), may influence their behavior (Fosarelli, 2003).

Development of Body Image

As in infancy, the development of body image closely parallels cognitive development. Developing psychologic understanding provides greater self-awareness, and young children learn to answer the question: “Who am I?” During the second year, children recognize themselves in a mirror and make verbal references to themselves (“Me big”). With increasing motor ability, toddlers recognize the usefulness of body parts and gradually learn their names. They also learn that certain parts of the body have various meanings; for example, during toilet training, the genitalia become significant, and cleanliness is emphasized. By 2 years of age they recognize gender differences and refer to themselves by name and then by pronoun. Gender identity is developed by age 3 years. Also by this time, children begin to remember events with reference to their personal significance, forming an autobiographic memory that helps to establish a continuous identity throughout life’s events.

After they begin preoperational thought, toddlers can use symbols to represent objects, but their thinking may lead to inaccuracies. For example, if someone who is pregnant is called “fat,” they will describe all “fat” women as having babies. They begin to recognize words used to describe physical appearance, such as pretty, handsome, or big boy. Such expressions eventually influence how children view their own bodies.

Although little research has been done on body image development in young children, it is evident that body integrity is poorly understood and that intrusive experiences are threatening. For example, toddlers forcefully resist procedures such as examining their ears or mouths and having their axillary temperature taken. The procedure itself (e.g., taking vital signs) does not hurt the child, but it represents an intrusion into the child’s personal space, which elicits a strong protest. Toddlers also have unclear body boundaries and may associate nonviable parts, such as feces, with essential body parts. This can be seen in a toddler who is upset by flushing the toilet and watching the stool disappear.

Nurses can assist parents in fostering a positive body image in their child by encouraging them to avoid negative labels, such as “skinny arms” or “chubby legs”—self-perceptions that can last a lifetime. Body parts, especially those related to elimination and reproduction, should be called by their correct names. Respect for the body should be practiced.

Development of Gender Identity

Just as toddlers explore their environment, they also explore their bodies and find that touching certain body parts is pleasurable. Genital fondling (masturbation) can occur and involves manual stimulation, as well as posturing movements (especially in young girls) such as tightening of the thighs or mechanical pressure applied to the pubic or suprapubic area. Other demonstrations of pleasurable activities include rocking, swinging, and hugging people and toys. Parental reactions to toddlers’ behavior influence the children’s own attitudes and should be accepting rather than critical. If such acts are performed in public, parents should not condone or bring attention to the behavior but should teach the child that it is more acceptable to perform the behavior in private.

Children in this age group are learning vocabulary associated with anatomy, elimination, and reproduction. Certain associations between words and functions become significant and can influence future sexual attitudes. For example, if parents refer to the genitalia as dirty, especially in the context of elimination, this association between “genitalia” and “dirty” may be transferred to sexual functions later in life. Sex-role differences become obvious to children and are evident in much of toddlers’ imitative play. Although current research indicates that prenatal exposure to testosterone strongly influences the individual’s gender identity, researchers also indicate that there are sensitive periods (e.g., puberty) that may also have an influence on the development of gender identity (Berenbaum and Beltz, 2011; Hines, 2011; Savic, Garcia-Falqueras, and Swaab, 2010). A sense of maleness or femaleness, or gender identity, is formed by age 3 years, and the child’s feelings about being male or female begin to form (Fonseca and Greydanus, 2007). Early attitudes are formed about affectionate behaviors between adults from observing parental and other adult intimate or sensual activities. (See also Sex Education, Chapter 13.) The quality of relationships with parents is important to the child’s capacity for sexual and emotional relationships later in life.

Social Development

A major task of the toddler period is differentiation of the self from significant others, usually the mother. The differentiation process consists of two phases: separation, the children’s emergence from a symbiotic fusion with the mother; and individuation, those achievements that mark children’s expression of their individual characteristics in the environment. Although the process begins during the latter half of infancy, the major achievements occur during the toddler years.

Toddlers have an increased understanding and awareness of object permanence and some ability to withstand delayed gratification and tolerate moderate frustration. As a result, toddlers react differently to strangers than do infants. The appearance of unfamiliar persons does not represent such a significant threat to their attachment to their mothers. They have learned from experience that parents exist when physically absent. Repetition of events such as going to bed without the parents but waking to find them there again reinforces the reliability of such brief separations. Consequently, toddlers are able to venture away from their parents for brief periods because of the security of knowing that the parents will be there when they return. Verbal and visual reassurance from the parents gradually replaces some of the previous need to be physically close for comfort.

According to Harpaz-Rotem and Bergman (2006), the separation-individuation phase encompasses the phenomenon of rapprochement; as a toddler separates from the mother and begins to make sense of experiences in the environment, he or she is drawn back to the mother for assistance in verbally articulating the meaning of the experiences. Developmentally, the term rapprochement means the child moves away and returns for reassurance. If the mother’s response to the toddler is inappropriate, the toddler may experience insecurity and confusion.

Transitional objects, such as a favorite blanket or toy, provide security for children, especially when they are separated from their parents, dealing with a new stress, or just fatigued (Fig. 12-3). Security objects often become so important to toddlers that they refuse to let them be taken away. Such behavior is normal; there is no need to discourage this tendency. During separations, such as daycare, hospitalization, or even staying overnight with a relative, transitional objects should be provided to minimize any fear or loneliness.

FIG 12-3 Transitional objects, such as a warm and fuzzy stuffed animal, are sources of security to a toddler. (© 2011 Photos.com, a division of Getty Images. All rights reserved.)

Learning to tolerate and master brief periods of separation is an important developmental task for children in this age group. In addition, it is a necessary component of parenting because brief periods of separation allow parents to restore their energy and patience and to minimize directing their irritations and frustrations at the children.

Language

The most striking characteristic of language development during early childhood is the increasing level of comprehension. Although the number of words acquired—from about four at 1 year of age to approximately 300 at age 2 years—is notable, the ability to comprehend and understand speech is much greater than the number of words the child can say. Bilingual children can also achieve their early linguistic milestones in each of the languages at the same time and produce a substantial number of semantically corresponding words in each of their two languages from the very first words or signs.

At age 1 year, children use one-word sentences or holophrases. The word “up” can mean “pick me up” or “look up there.” For children, the one word conveys the meaning of a sentence, but to others, it may mean many things or nothing. At this age, about 25% of the vocalizations are intelligible. By the age of 2 years, children use multiword sentences by stringing together two or three words, such as the phrases “mama go bye-bye” or “all gone,” and approximately 65% of their speech is understandable. By 3 years, children put words together into simple sentences, begin to master grammatical rules, acquire five or six new words daily, know their age and gender, and can count three objects correctly. Looking at books during this period provides an ideal setting for further language development (Feigelman, 2011). Authorities have evaluated the impact of television viewing on toddler language development and found that those who started watching television at younger than 12 months of age and who watched longer than 2 hours per day had significant language delays (Chonchaiva and Pruksananonda, 2008). Adult–child conversations with infants and toddlers have been shown to positively affect language development; the researchers recommend reading, storytelling, and interactive adult–child communication (Zimmerman, Gilkerson, Richards, and others, 2009). The American Academy of Pediatrics (AAP), Council on Communications and Media (2011) reaffirms that televised or recorded media usage in children less than 2 years of age decreases language skills, as well as the time parents interact with the child. Furthermore, educational programs have not been shown to increase cognitive skills in young children (AAP, Council on Communications and Media, 2011).

Gestures precede or accompany each of the language milestones up to 30 months of age (putting phone to ear, pointing). After sufficient language development, gestures phase out, and the pace of word learning increases (Bates and Dick, 2002).

Personal-Social Behavior

One of the most dramatic aspects of development in the toddler is personal-social interaction. Personal-social behaviors are evident in such areas as dressing, feeding, playing, and establishing self-control. Parents frequently wonder why their manageable, docile, lovable infant has turned into a determined, strong-willed, volatile little tyrant. In addition, the tyrant of the terrible twos can swiftly and unpredictably revert back to the adorable infant. All of this is part of growing up as toddlers acquire a more sophisticated awareness that others’ feelings and desires can be different from their own. Through interactions with caregivers, children are able to explore these differences and their consequences.

Toddlers are developing skills of independence, which are evident in all areas of behavior. By 15 months of age, children feed themselves, drink well from a covered cup, and manage a spoon with considerable spilling. By 2 years, they use a spoon well, and by 3 years, they may be using a fork. Between ages 2 and 3 years, they eat with the family and like to help with chores such as setting the table or removing dishes from the dishwasher, but they lack table manners and may find it difficult to sit through the family’s entire meal.

In dressing, toddlers also demonstrate strides in independence. Fifteen-month-old children help by putting their arms or feet out for dressing and pull off their shoes and socks. Eighteen-month-old children remove gloves, help with pullover shirts, and may be able to unzip. By age 2 years toddlers remove most articles of clothing and put on socks, shoes, and pants without regard for right or left and back or front. Help is still needed to fasten clothes.

Toddlers also begin to develop concern for the feelings of others and develop an understanding of how adult expectations for behavior apply to specific situations (e.g., causing a sibling to cry while playing rough). As their understanding is fostered, they are able to develop control. Age-appropriate discipline contributes to healthy social and emotional development. Positive reinforcement, redirection, and time-outs are appropriate for most toddlers. Social and emotional problems can develop in the youngest children. Early screening and intervention promote more positive outcomes as young children grow and develop.

Play

Play magnifies toddlers’ physical and psychosocial development. Interaction with people becomes increasingly important. The solitary play of infancy progresses to parallel play—toddlers play alongside, not with, other children. Although sensorimotor play is still prominent, there is much less emphasis on the exclusive use of one sensory modality. Toddlers inspect toys, talk to toys, test toys’ strength and durability, and invent several uses for toys. Imitation is one of the most distinguishing characteristics of play and enriches children’s opportunity to engage in fantasy. With less emphasis on gender-stereotyped toys, play objects such as dolls, carriages, dollhouses, balls, dishes, cooking utensils, child-size furniture, trucks, and dress-up clothes are suitable for both genders (Fig. 12-4); however, whereas boys may be more interested than girls in activities related to trucks, trailers, action figures, and building blocks, girls may prefer doll-related activities.

FIG 12-4 Young children enjoy dressing up. (© 2011 Photos.com, a division of Getty Images. All rights reserved.)

Increased locomotive skills make push–pull toys, straddle trucks or cycles, a small gym and slide, balls of various sizes, and riding toys appropriate for energetic toddlers. Finger paints; thick crayons; chalk; blackboard; paper; and puzzles with large, simple pieces use toddlers’ developing fine motor skills. Interlocking blocks in various sizes and shapes provide hours of fun and, during later years, are useful objects for creative and imaginative play. The most educational toy is the one that fosters the interaction of an adult with a child in supportive, unconditional play. Toys should not be substitutes for the attention of devoted caregivers, but toys can enhance these interactions (Glassy, Romano, and Committee on Early Childhood, 2003). Parents and other providers are encouraged to allow children to play with a variety of simple toys that foster creative thinking (e.g., blocks, dolls, and clay) rather than passive toys that the child observes (battery-operated or mechanical). Active play time should also be encouraged over the use of computer or video games, which are more passive (Ginsburg and AAP, Committee on Communications, 2007).

Certain aspects of play are related to emerging linguistic abilities. Talking is a form of play for toddlers, who enjoy musical toys such as age-appropriate compact disc (CD) players, “talking” dolls and animals, and toy telephones. Children’s television programs are appropriate for some children over age 2 years, who learn to associate words with visual images. However, total media time should be limited to 1 hour or less of quality programming per day. Parents are encouraged to allow the child to engage in unstructured playtime, which is considered much more beneficial than any electronic media exposure (AAP, Council on Communications and Media, 2011). Toddlers also enjoy “reading” stories from a picture book and imitating the sounds of animals.

Tactile play is also important for exploring toddlers. Water toys, a sandbox with a pail and shovel, finger paints, soap bubbles, and clay provide excellent opportunities for creative and manipulative recreation. Adults sometimes forget the fascination of feeling textures such as slippery cream, mud, or pudding; catching air bubbles; squeezing and reshaping clay; or smearing paints. These types of unstructured activities are as important as educational play to allow children the freedom of expression.

Selection of appropriate toys must involve safety factors, especially in relation to size and sturdiness. The oral activity of toddlers puts them at risk for aspirating small objects and ingesting toxic substances. Parents need to be especially vigilant of toys played with in other children’s homes and toys of older siblings. Toys are a potential source of serious bodily damage to toddlers, who may have the physical strength to manipulate them but not the knowledge to appreciate their danger (Stephenson, 2005). Government agencies do not inspect and police all toys on the market. Therefore, adults who purchase play equipment, supervise purchases, or allow children to use play equipment need to evaluate its safety, including toys that are gifts or those that are purchased by the children themselves. Adults should also be alert to notices of toys determined to be defective and recalled by the manufacturers. Parents and health care workers can obtain information on a variety of recalled products and can report potentially dangerous toys and child products to the U.S. Consumer Product Safety Commission* or, in Canada, the Canadian Toy Testing Council.^† Printable tips on toy safety are also available from Safe Kids Worldwide (http://www.safekids.org).

Table 12-1 summarizes the major features of growth and development for the age groups of 15, 18, 24, and 30 months.

TABLE 12-1

GROWTH AND DEVELOPMENT DURING THE TODDLER YEARS

PHYSICAL	GROSS MOTOR	FINE MOTOR	SENSORY	LANGUAGE	SOCIALIZATION
Age 15 Months
Steady growth in height and weight Head circumference, 48 cm (19 inches) Weight, 11 kg (24 pounds) Height, 78.7 cm (31 inches)	Walks without help (usually since age 13 months) Creeps up stairs Kneels without support Cannot walk around corners or stop suddenly without losing balance without support Cannot throw ball without falling Runs clumsily; falls often	Constantly casting objects to floor Builds tower of two cubes Holds two cubes in one hand Releases a pellet into a narrow-necked bottle Scribbles spontaneously Uses cup well but often rotates spoon before it reaches mouth	Able to identify geometric forms; places round object into appropriate hole Binocular vision well developed Displays an intense and prolonged interest in pictures	Uses expressive jargon Says four to six words, including names “Asks” for objects by pointing Understands simple commands May use head-shaking gesture to denote “no” Uses “no” even while agreeing to the request Uses common gestures such as putting cup to mouth when empty	Tolerates some separation from parent Less likely to fear strangers Beginning to imitate parents, such as cleaning house (sweeping, dusting), folding clothes May discard bottle Kisses and hugs parents; may kiss pictures in a book
Age 18 Months
Picky eater as a result of decreased growth needs and need to assert independence Anterior fontanel closed Physiologically able to control sphincters	Assumes standing position Walks up stairs with one hand held Pulls and pushes toys Jumps in place with both feet Seats self on chair Throws ball overhand without falling	Builds tower of three or four cubes Release, prehension, and reach well developed Turns pages in a book two or three at a time In a drawing, makes stroke imitatively Manages spoon without rotation		Says 10 or more words Points to a common object, such as a shoe or ball, and to two or three body parts Forms word combinations Forms gesture–word combinations (points while naming) Forms gesture–gesture combinations	Expresses emotions; has temper tantrums Great imitator (domestic mimicry) Takes off gloves, socks, and shoes and unzips zippers Temper tantrums may be more evident Beginning awareness of ownership (“My toy”) May develop dependence on transitional objects, such as security blanket
Age 24 Months
Head circumference, 49–50 cm (19.5–20 inches) Chest circumference exceeds head circumference Lateral diameter of chest exceeds anteroposterior diameter Usual weight gain of 1.8–2.7 kg (4–6 pounds) per year Usual gain in height of 10–12.5 cm (4–5 inches) per year Adult height approximately double height at 2 years of age Primary dentition of 16 teeth May demonstrate readiness for beginning daytime control of bowel and bladder	Goes up and down stairs alone with two feet on each step Runs fairly well, with wide stance Picks up object without falling Kicks ball forward without overbalancing	Builds tower of six or seven cubes Aligns two or more cubes like a train Turns pages of book one at a time In drawing, imitates vertical and circular strokes Turns doorknobs; unscrews lids	Accommodation well developed in geometric discrimination; able to insert square block into oblong space	Has a vocabulary of approximately 300 words Uses two- or three-word phrases Uses pronouns “I,” “me,” “you” Understands directional commands Gives first name; refers to self by name Verbalizes need for toileting, food, or drink Talks incessantly Able to remember and imitate arbitrary sequences of manual actions and gestures	Stage of parallel play Has sustained attention span Temper tantrums decreasing Pulls people to show them something Increased independence from parent Dresses self in simple clothing Develops visual recognition and verbal self-reference (“Me big”) Develops awareness that feelings and desires of others may be different and begins to explore implications and consequences
Age 30 Months
Birth weight quadrupled Primary dentition (20 teeth) completed May have daytime bowel and bladder control	Jumps with both feet Jumps from chair or step Stands on one foot momentarily Takes a few steps on tiptoe	Builds tower of eight cubes Adds chimney blocks to train of block Good hand–finger coordination; holds crayon with fingers rather than fist In drawing, imitates vertical and horizontal strokes; makes two or more strokes for cross; draws circles		Gives first and last name Refers to self by appropriate pronoun Uses plurals Names one color	Separates more easily from parent In play, helps put things away; can carry breakable objects; pushes with good steering Begins to notice gender differences; knows own gender May attend to toilet needs without help except for wiping Emotions expand to include pride, shame, guilt, embarrassment

Coping with Concerns Related to Normal Growth and Development

Toilet Training

One of the major tasks of toddlerhood is toilet training. Anticipatory guidance and clinical intervention for families surrounding toilet training should begin during routine well-child visits before the child’s developmental readiness to toilet train. Preparation and education reveal and allay misconceptions; lead to the development of appropriate expectations; and provide information, guidance, and support to parents for managing this potentially frustrating process.

Case Study—Toilet Training/Toddler Development

Voluntary control of the anal and urethral sphincters is achieved sometime after the child is walking, probably between ages 18 and 24 months. However, complex psychophysiologic factors are required for readiness. The child must be able to recognize the urge to let go and hold on and be able to communicate this sensation to the parent. In addition, some motivation is probably involved in the desire to please the parent by holding on rather than pleasing oneself by letting go. Cultural beliefs may also affect the age at which children demonstrate readiness (Feigelman, 2011).

Schmitt (2004) notes that comparative studies over the past 5 decades indicate that children in the 1990s in the United States were toilet trained at a later age (18 months in the 1960s vs. 36 months in the 1990s); one possible contributing factor is the availability and convenience of disposable diapers. Another study found that the child’s average age at initiation of toilet training was 20.6 months (Horn, Brenner, Rao, and others, 2006).

Five markers signal a child’s readiness to toilet train: bladder readiness, bowel readiness, cognitive readiness, motor readiness, and psychologic readiness (Schmitt, 2004). According to some experts, physiologic and psychologic readiness is not complete until ages 22 to 30 months (Schum, Kolb, McAuliffe, and others, 2002); however, Schmitt (2004) emphasizes that parents should begin preparing their children for toilet training earlier than 30 months. By this time, children have mastered the majority of essential gross motor skills, can communicate intelligibly, are in less conflict with their parents in terms of self-assertion and negativism, and are aware of the ability to control the body and please their parents. There is no universal right age to begin toilet training or an absolute deadline to complete training. An important role for the nurse is to help parents identify the readiness signs in their children (see Nursing Care Guidelines box).* On average, girls are developmentally ready to begin toilet training 2 to months before boys (Schum, Kolb, McAuliffe, and others, 2002).