Which Pediatrician Should We Choose?

They’re skilled listeners, and can pick up the cues of what’s said between the lines to know what’s really worrying a parent. Children feel at ease around a good pediatrician, so exams are more thorough and enjoyable. If you’ve found your dream pediatrician, your children will look forward to their visits. You’ll be relying on the pediatrician’s office, too: How well is it run? How good is the staff? If their office is poorly run, even great pediatricians won’t be able to keep parents happy.

Pediatricians come in all shapes and personalities. Which one to choose often comes down to personal preference and comfort.

Old versus Young
The stereotype is that older doctors have more years of valuable experience, and younger doctors are more up-to-date on the latest research and techniques. There’s some truth in this. Whether you end up favoring youth versus experience, you’ll want to work with doctors who keep up on their reading and maintain a healthy curiosity about children’s health. Any doctor, young or old, who feels they already know all they need to know is someone you should avoid. If your gut feeling is that you’d prefer a doctor with some grey hairs, go with that; if you think your children would prefer a younger physician, go that route. Either way can be fine, as long as you are confident and comfortable with your pediatrician’s skills and experience. 

I’m sometimes asked if I have children, or if a pediatrician needs to have children to be competent. Although I’ve certainly learned a tremendous amount from my own three kids, I think pediatricians who keep their minds open and really watch children will be able to learn what they need to know, even if they don’t have children of their own.

Man versus Woman
Most general pediatricians coming out of training are now women, so it’s going to get more difficult to find a male pediatrician in the future. If you’ve got your own comfort zone about who seems more competent, go with your gut. Most younger children don’t care whether their doctor is a man or woman, but many teenagers do. Though you may have to change doctors in ten years, don’t get too concerned about matching the genders of your baby and your pediatrician.

Personality Types
Some doctors are quiet and thoughtful; some are kind of kooky. Some are quite direct, and don’t beat around the bush; some are much more “gentle” in the way they communicate. Some doctors become more emotionally attached to their families and might act more “friendly”; others prefer to maintain a profession detachment. These and many other aspects of a pediatrician’s personality may fit better or worse with what you’re looking for. Meet a variety of doctors until you find one that “clicks” for you.

Availability
An otherwise excellent pediatrician with commitments to teaching, research, or other matters may not be regularly available. This may matter more to you if your children are younger or have special health needs that require more frequent visits to a doctor who knows them well.

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Developmental Milestones

A method of evaluation has been developed using an interview technique in which parents are asked questions regarding milestones in achievements that most will remember. The child's developmental quotient (DQ) can be determined according to the parents' answers. A DQ less than 70% signifies a delay requiring further evaluation.
AGE	GROSS MOTOR	VISUAL-MOTOR/PROBLEM-SOLVING	LANGUAGE	SOCIAL/ADAPTIVE
1 month	Raises head slightly from prone, makes crawling movements	Birth: visually fixes 1 mo: has tight grasp, follows to midline	Alerts to sound	Regards face
2 month	Holds head in midline, lifts chest off table	No longer clenches fist tightly, follows object past midline	Smiles socially (after being stroked or talked to)	Recognizes parent
3 month	Supports on forearms in prone, holds head up steadily	Holds hands open at rest, follows in circular fashion, responds to visual threat	Coos (produces long vowel sounds in musical fashion)	Reaches for familiar people or objects, anticipates feeding
4 month	Rolls front to back, supports on wrists and shifts weight	Laughs, orients to voice	Enjoys looking around environment
5 month	Rolls back to front, sits supported	Transfers objects	Says “ah-goo,” blows raspberries, orients to bell (localizes laterally)	—
6 month	Sits unsupported, puts feet in mouth in supine position	Unilateral reach, uses raking grasp	Babbles	Recognizes strangers
7 month	Creeps	—	Orients to bell (localized indirectly)	—
8 month	Comes to sit, crawls	Inspects objects	“Dada” indiscriminately	Fingerfeeds
9 month	Pivots when sitting, pulls to stand, cruises	Uses pincer grasp, probes with forefinger, holds bottle, throws objects	“Mama” indiscriminately, gestures, waves bye-bye, inhibits to “no”	Starts to explore environment; plays gesture games (eg, pat-a-cake)
10 month	Walks when led with both hands held	—	“Dada/mama” discriminately; orients to bell (directly)	—
11 month	Walks when led with one hand held	—	One word other than “dada/mama,” follows 1-step command with gesture	—
12 month	Walks alone	Uses mature pincer grasp, releases voluntarily, marks paper with pencil	Uses two words other than “dada/mama,” immature jargoning (runs several unintelligible syllables together)	Imitates actions, comes when called, cooperates with dressing
13 month	—	—	Uses three words	—
14 month	—	—	Follows 1-step command without gesture	—
15 month	Creeps up stairs, walks backwards	Scribbles in imitation, builds tower of 2 blocks in imitation	Uses 4 to 6 words	15 to 18 mo: uses spoon, uses cup independently
17 month	—	—	Uses 7 to 20 words, points to 5 body parts, uses mature jargoning (includes intelligible words in jargoning)	—
18 month	Runs, throws objects from standing without falling	Scribbles spontaneously, builds tower of 3 blocks, turns 2 to 3 pages at a time	Uses 2-word combinations	Copies parent in tasks (sweeping, dusting), plays in company of other children
19 month	—	—	Knows 8 body parts	—
21 month	Squats in play, goes up steps	Builds tower of 5 blocks	Uses 50 words, 2-word sentences	Asks to have food and to go to toilet
24 month	Walks up and down steps without help	Imitates stroke with pencil, builds tower of 7 blocks, turns pages one at a time, removes shoes, pants, etc.	Uses pronouns (I, you, me) inappropriately, follows 2-step commands	Parallel play
30 month	Jumps with both feet off floor, throws ball overhand	Holds pencil in adult fashion, performs horizontal and vertical strokes, unbuttons	Uses pronouns appropriately, understands concept of “1,” repeats 2 digits forward	Tells first and last names when asked; gets self drink without help
3 year	Can alternate feet when going up steps, pedals tricycle	Copies a circle, undresses completely, dresses partially, dries hands if reminded	Uses minimum 250 words, 3-word sentences; uses plurals, past tense; knows all pronouns; understands concept of “2”	Group play, shares toys, takes turns, plays well with others, knows full name, age, sex
4 year	Hops, skips, alternates feet going down steps	Copies a square, buttons clothing, dresses self completely, catches ball	Knows colors, says song or poem from memory, asks questions	Tells “tall tales,” plays cooperatively with a group of children
5 year	Skips alternating feet, jumps over low obstacles	Copies triangle, ties shoes, spreads with knife	Prints first name, asks what a word means	Plays competitive games, abides by rules, likes to help in household tasks
Custer, J.W., Rau, R.E., and Lee, C.K. (Eds.) (2008). The Harriet Lane Handbook (18th ed.). Philadelphia: Elsevier

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Infant to Adolescent Growth and Development

AGE AND PHYSICAL CHARACTERISTICS	BEHAVIOR PATTERNS	NURSING CONSIDERATIONS
Birth-4 Weeks (1 Month) ▪ Significant neurologic disorganization. ▪ Strong Moro reflex. ▪ Sleep cycle disorganized. ▪ GI system too immature for solid foods.	Motor development ▪ Momentary visual fixation on objects and adult face. ▪ Eyes follow bright moving objects. ▪ Lies awake on back. ▪ Immediately drops objects placed in hands. ▪ Responds to sounds of bell and other similar noises. ▪ Keeps hands fisted. Socialization and vocalization ▪ Mews and makes throaty noises. ▪ Shows interest in human face. Cognitive and emotional development ▪ Reflexive. ▪ External stimuli are meaningless. ▪ Responses are generally limited to tension states or discomfort. ▪ Gains satisfaction from feeding and being held, rocked, fondled, and cuddled. ▪ Has an intense need for sucking pleasure. ▪ Quiets when picked up.	Play stimulation ▪ Use human face—smile and talk. ▪ Dangle bright and moving object (eg, mobile) in field of vision. ▪ Hold, touch, caress, fondle, kiss. ▪ Rock, pat, change position. ▪ Play soft music or have infant listen to ticking clock, sing. ▪ Talk to infant, call by name. Parental guidance ▪ Begin to expose infant to different household sounds. ▪ Change crib location in room. ▪ Use bright-colored clothing and linen. ▪ Put infant to sleep on back until old enough to roll. ▪ Keep infant nearby. ▪ Play with infant when awake. ▪ Hold during feeding.
4-8 Weeks (2 Months) ▪ Crossed extensor reflex disappears. ▪ Tonic neck reflex begins to fade.	Motor development ▪ Reflexive behavior is slowly being replaced by voluntary movements. ▪ Turns from side to back. ▪ Begins to lift head momentarily from prone position. ▪ Shows eye coordination to light and objects. ▪ If bell is sounded nearby, infant will stop activity and listen. ▪ Eyes follow better, both vertically and horizontally. Focuses well. Socialization and vocalization ▪ Begins vocalization—coos, especially to a voice. ▪ Crying becomes differentiated. ▪ Visually looks for sounds. ▪ May squeal with delight when stimulated by touching, talking, or singing. ▪ Begins social smile. ▪ Eyes follow person or object more intently. Cognitive and emotional development ▪ Recognizes familiar face. ▪ Becomes more aware and interested in environment. ▪ Anticipates being fed when in feeding position. ▪ Enjoys sucking—puts hand in mouth.	Play stimulation ▪ Arrange mobile over crib so infant's movement will set it in motion. ▪ Hang wind chimes near infant. ▪ Hang bright-colored pictures on wall (yellow and red-colored stripes, for example). ▪ Use cradle gym and infant seat. ▪ Use rattles. ▪ Hold infant and walk around room. ▪ Allow freedom of kicking with clothes off. Parental guidance ▪ Talk to infant and smile; get excited when infant coos. ▪ Place infant seat on a secure surface (eg, floor, center of a table—never near edge of table) near mother's activities. ▪ Put infant in prone position in bed or on floor. ▪ Expose infant to different textures. ▪ Exercise infant's arms and legs. ▪ Sing to infant. ▪ Provide tactile experience during bathing, diapering, and feeding.
8-12 Weeks (2-3 Months) ▪ Landau reflex appears at 3-4 months. ▪ Positive support reflex disappears. ▪ Posterior fontanelle closes. ▪ Increase in body fluids—real tears appear, drooling, and GI juices increase.	Motor development ▪ When prone, will rest on forearms and keep head in midline—makes crawling movements with legs, arches back, and holds head high; may get chest off surface. ▪ Indicates preference for prone or supine. ▪ Discovers hands—bats objects with hands. ▪ Holds objects in hands and brings to mouth. ▪ Has fairly good head control. Socialization and vocalization ▪ Smiles more readily, babbles, and coos. ▪ Stops crying when mother enters room or when caressed. ▪ Enjoys playing during feeding. ▪ Stays awake longer without crying. ▪ Turns head to follow familiar person. Cognitive and emotional development ▪ Shows active interest in environment. ▪ Recognizes familiar faces and objects. ▪ Focuses and follows objects. ▪ Shows repetitiveness in play activity. ▪ Is aware of strange situations. ▪ Derives pleasure from sucking—purposefully gets hand to mouth. ▪ Begins to establish routine preceding sleep.	Play stimulation ▪ Encourage socialization, smiling, and laughing. ▪ Place on mat on floor. ▪ Continue to introduce new sounds. Parental guidance ▪ Take outdoors with proper clothing (similar warmth as that of adults), hat, and PABA-free sunscreen. ▪ Bounce on bed. ▪ Play with infant during feeding. ▪ Rattles can be used effectively for visual following and for hand play. ▪ Encourage older siblings to “make faces,” sing, and talk to infant.
12-16 Weeks (3-4 Months) ▪ Moro reflex fades. ▪ Stepping reflex disappears. ▪ Rooting reflex disappears. ▪ By 4-5 months infant's weight approximately doubles birth weight. ▪ Average weekly weight gain, 4-7 ounces (113.5-198.5 g). ▪ Average monthly height gain, 1 inch (2.5 cm). ▪ Pulse rate slows to 100-140 beats/minute. ▪ Respirations, 20-40 breaths/minute. ▪ Grasp becomes voluntary. ▪ Sucking becomes voluntary.	Motor development ▪ Eyes focus on small objects, may pick a dangling ring. ▪ Holds head up (when being pulled to sitting position). ▪ Becomes more interested in environment. ▪ Hand comes to meet rattle. ▪ Listens—turns head to familiar sound. ▪ Sits with minimal support. ▪ Intentional rolling over, back to side. ▪ Reaches for offered objects. ▪ Grasps objects with both hands, and everything goes into mouth. Socialization and vocalization ▪ Laughs and chuckles socially. ▪ Demands social attention by fussing. ▪ Recognizes mother. ▪ Begins to respond to “No, no.” ▪ Enjoys being propped in sitting position. Cognitive and emotional development ▪ Actively interested in environment. ▪ Enjoys attention; becomes bored when alone for long periods. ▪ Recognizes bottle. ▪ More interested in mother. ▪ Indicates increasing trust and security. ▪ Sleeps through night; has defined nap time.	Play stimulation ▪ Encourage mirror play. ▪ Provide soft squeeze toys in vivid colors of varying texture. ▪ Allow infant to splash in bath. ▪ Infant still enjoys holding and playing with rattles. ▪ Enjoys old-fashioned clothespins and playing pat-a-cake and peek-a-boo. Parental guidance ▪ Be certain button eyes on toys and other small objects cannot be pulled off. ▪ Hold rattle and let infant reach and grasp it. ▪ When infant is in high chair, strap in. ▪ Move mobile out of reach—infant may grab it and cause injury. ▪ Repeat child's sounds. ▪ Talk in varying degrees of loudness. ▪ Begin looking at and naming pictures in book. ▪ Begin roughhousing play by both parents. ▪ Give space in playpen or on sheet on floor to practice rolling over. ▪ Place on abdomen for part of playtime.
16-26 Weeks (4-7 Months) ▪ By 5-6 months, tonic neck reflex disappears. ▪ By 6-7 months, palmar grasp disappears. ▪ By 7-9 months, develops eye-toeye contact while talking; engages in social games. ▪ Two central lower incisors erupt. ▪ Spine “C-shaped”—lacks lordotic and lumbar curves. ▪ Eustachian tube short and horizontal, which may be a factor in ear infections. ▪ GI system mature enough for solid foods.	Motor development ▪ Shows momentary sitting with hand support. ▪ Bounces and bears some weight when held in standing position. ▪ Transfers and mouths objects in one hand. ▪ Discovers feet. ▪ Bangs objects together. ▪ Rolls over well. ▪ May begin some form of mobility. Socialization and vocalization ▪ Discriminates between strangers and familiar people. ▪ Crows and squeals. ▪ Starts to say “Ma,” “Da.” ▪ Play is self-contained. ▪ Laughs out loud. ▪ Makes “talking” sounds in response to others' talking. ▪ Begins fear of strangers, 8½-10 months. Cognitive and emotional development ▪ Secures objects by pulling on string. ▪ Searches for lost objects that are out of sight. ▪ Inspects objects; localizes sounds. ▪ Likes to sit in high chair. ▪ Drops and picks up objects. ▪ Displays exploratory behavior with food. ▪ Exhibits beginning fear of strangers. ▪ Becomes fretful when mother leaves. ▪ Shows much mouthing and biting.	Play stimulation ▪ Enjoys social games, hide-and-seek with adult, toys, and large blocks. ▪ Likes to bang objects. ▪ Plays in bounce chair and walker. ▪ Enjoys large nesting toys (round rather than square). ▪ Likes to drop and retrieve things. ▪ Likes metal cups, wooden spoons, and things to bang with. ▪ Loves crumpled paper. ▪ Enjoys squeeze toys in bath. ▪ Likes peek-a-boo, bye-bye, and pat-a-cake. Parental guidance ▪ Will play as long as you can. ▪ Tie toys to chair with short string. ▪ Let play with extra spoon at feeding. ▪ Give soft finger foods. ▪ Because infant puts everything in mouth, use safety precautions. ▪ Keep small items away from infant; could choke on them. ▪ Show excitement at achievements. ▪ Supply safe kitchen items for toys.
26-40 Weeks (7-10 Months) ▪ Four upper incisors erupt around 7-9 months. ▪ By 9-12 months, plantar reflex disappears. ▪ By 9-12 months, neck-righting reflex disappears. 6-12 months ▪ Average weekly weight gain, 3-5 ounces (85-141.7 g). ▪ Average monthly height gain, ½ inch (1.25 cm).	Motor development ▪ Sits without support. ▪ Recovers balance. ▪ Manipulates objects with hands. ▪ Unwraps objects. Creeps. ▪ Pulls self upright at crib rails. ▪ Uses index finger and thumb to hold objects. ▪ Rings a bell. ▪ Can feed self a cracker and can hold a bottle. Chewing reflex develops. ▪ Can control lips around cup. ▪ Does not like supine position. ▪ Can hold index finger and thumb in opposition. Socialization and vocalization ▪ Claps hands on request. ▪ Responds to own name. ▪ Is very aware of social environment. ▪ Imitates gestures, facial expressions, and sounds. ▪ Smiles at image in mirror. ▪ Offers toy to adult, but does not release it. ▪ Begins to test parental reaction during feeding and at bedtime. ▪ Will entertain self for long periods. Cognitive and emotional development ▪ Begins to imitate. ▪ Shows more interest in picture books. ▪ Enjoys achievements. ▪ Has strong urge toward independence—locomotion, feeding, dressing.	Play stimulation ▪ Encourage use of motion toys—rocking horse and stroller. ▪ Water play. ▪ Imitate animal sounds. ▪ Allow exploration outdoors. ▪ Provide for learning by imitation. ▪ Offer new objects (blocks). ▪ Child likes freedom of creeping and walking, but closeness of family is important. ▪ Good toys: plastic milk carton; bean bag for tossing; fabric books; things to move around, fill up, empty out; pile-up and knock-down toys. Parental guidance ▪ Protect from dangerous objects—cover electrical outlets, block stairs, remove breakable objects from tables. ▪ Have child with family at mealtime. ▪ Offer cup. ▪ Talk and sing to infant.
10-12 Months (1 Year) ▪ Develops lordotic and lumbar curves to make walking possible. ▪ By 12-24 months, Landau reflex disappears. ▪ Weight should approximately triple birth weight. ▪ Two lower lateral incisors appear. ▪ Four first molars appear by 14 months. Child development theories ▪ Freudian: Behavior - Birth-1 year—Oral Stage ▪ Eriksonian: Emotion/Personality - Birth-1 year—Sense of Trust vs. Mistrust ▪ Piagetian: Intellectual Activity (Thought Process) -Birth-2 years—Sensorimotor Period	Motor development ▪ Cruises around furniture. ▪ Beginning to stand alone and toddle. ▪ Turns pages in book. ▪ Tries tossing object. ▪ Shows hand dominance. ▪ Navigates stairs; climbs on chairs. ▪ Builds a tower of 2 blocks. ▪ Puts balls in box. ▪ May use spoon. ▪ Can release objects at will. ▪ Has regular bowel movements. Socialization and vocalization ▪ Uses jargon. ▪ Points to indicate wants. ▪ Loves give-and-take game. ▪ Responds to music. ▪ Enjoys being center of attention and will repeat laughed-at activities. Cognitive and emotional development ▪ Shows fear, anger, affection, jealousy, anxiety, and sympathy. ▪ Experiments to reach new goals. ▪ Displays intense determination to remove barriers to action. ▪ Begins to develop concepts of space, time, and causality. ▪ Has increased attention span.	Play stimulation ▪ Ball play. ▪ Cloth doll. ▪ Motion objects and toys. ▪ Transporting objects. ▪ Name and point to body parts. ▪ “Put-in” and “take-out” toys. ▪ Sand box with spoons and other simple objects. ▪ Blocks. ▪ Music. Parental guidance ▪ Allow self-directed play rather than adultdirected play. ▪ Continue to expose to foods of different textures, taste, smell, and substance. ▪ Offer cup. ▪ Show affection and encourage child to return affection. ▪ Safety teaching: Child gets into everything within reach. Place medications in safe, locked place. Create a safe environment for child. Use stair guards, faucet protectors, and drawer locks. Have Poison Control Center phone number on hand.
12-18 Months ▪ Note: Between ages 1 and 3 years the child is called a “toddler.” ▪ Anterior fontanelle closes. ▪ Abdomen protrudes, arms and legs lengthen. ▪ Big muscles become well developed. ▪ Four cuspids appear by 18 months. ▪ Fine muscle coordination begins to develop. ▪ Average yearly weight gain, 4½-6½ lb (2-3 kg). ▪ Average height gain during second year, 4¾ inch (12 cm).	Motor development ▪ Walks up stairs with help, creeps downstairs. ▪ Walks without support and with balance. ▪ Falls less frequently. ▪ Throws ball. ▪ Stoops to pick up toys, look at bug. ▪ Turns pages of book. ▪ Holds and lifts cup. ▪ Builds 3-block tower. ▪ Picks up and places small beads in container. ▪ Begins to use spoon. Cognitive and emotional development ▪ Has vocabulary of 10 words that have meanings. ▪ Uses phrases, imitates words. ▪ Points to objects named by adult. ▪ Follows directions and requests. ▪ Imitates adult behavior. ▪ Retrieves toy from several hiding places. Psychosocial development ▪ Develops new awareness of strangers. ▪ Wants to explore everything in reach. ▪ Plays alone, but near others. ▪ Is dependent on parents, but begins to reach out for autonomy. ▪ Finds security in a blanket, toy, or thumbsucking.	Play stimulation ▪ Allow unrestricted motor activity (within safety limits). ▪ Offer push-pull toys. ▪ Child selects favorite toy. ▪ Child likes blocks, pyramid toys, teddy bears, dolls, pots and pans, cloth picture books with colorful large pictures, telephone, musical top, and nested blocks. Parental guidance ▪ Begin to teach tooth brushing to establish good dental habits; however, continue to brush child's teeth. ▪ Establish limits to give toddler sense of security, but encourage exploration. ▪ Reinforce safety teaching.
1½-2 Years ▪ Protruding abdomen less noticeable. ▪ Landau reflex disappears. ▪ During first 2 years, 14 inches (35 cm) are added to height. ▪ Slight bowing of legs with a wide-based walk. ▪ Handedness may become apparent.	Motor development ▪ Walks up and down stairs. ▪ Opens doors; turns knobs. ▪ Has steady gait. ▪ Holds drinking cup well with one hand. ▪ Uses spoon without spilling food (may prefer fingers). ▪ Kicks a ball in front of him without support. ▪ Builds a tower of 4-6 blocks. ▪ Scribbles. ▪ Rides tricycle or kiddie car (without pedals). Cognitive development ▪ Has 200-300 words in vocabulary. ▪ Begins to use short sentences. ▪ Refers to self by pronoun. ▪ Obeys simple commands. ▪ Does not know right from wrong. ▪ Begins to learn about time sequences. Psychosocial development ▪ Uses word “mine” constantly. ▪ Is possessive with toys. ▪ Displays negativism—uses “no” as assertion of self. ▪ Routine and rituals are important. ▪ May begin cooperation in toilet training. ▪ Resists restrictions on freedom. ▪ Has fear of parents' leaving. ▪ Shows parallel play. ▪ Dawdles. ▪ Resists bedtime—uses transitional objects (blanket, toy). ▪ Vacillates between dependence and independence.	Play stimulation ▪ Shows parallel play, although enjoys having other children around. ▪ Has very short attention span. ▪ Enjoys same toys as child of 18 months. ▪ Likes doll play and balls. ▪ Imitates parents in domestic activities. ▪ Likes swing, hammering, paper, and large crayons. Parental guidance ▪ Has need for peer companionship, although displays immaturity by inability to share and take turns. ▪ A decrease in appetite normally occurs at this stage. ▪ Toilet training should be started (each child follows own pattern). ▪ Begin to have child eat meals with family if not already doing so. ▪ Begin to read to child; child likes storybooks with large pictures.
2-3 Years ▪ Height approximates one-half adult height. ▪ Legs are about 34% of body length. ▪ Begins 5 lb (2.3 kg) or more weight gain per year until age 5 years. ▪ At 2½ years has full set (20) of baby teeth. ▪ Four second molars appear by 2½ years. ▪ Height gain, 23/8-3¼ inches (6-8 cm). ▪ Lordosis and protuberant abdomen of toddler disappear. Child development theories ▪ Freudian: - 1-3 years—Anal Stage ▪ Eriksonian: - 1-3 years—Sense of Autonomy vs. Shame and Doubt ▪ Piagetian: - 2-7 years—Preoperational Period; shows egocentrism and centering	Motor development ▪ Throws objects overhead. ▪ Pedals tricycle. ▪ Walks backward. ▪ Washes and dries hands. ▪ Begins to use scissors. ▪ Can string large beads. ▪ Can undress himself. ▪ Feeds himself well. ▪ Tries to dance. ▪ Jumps in place. ▪ Builds tower of 8 blocks. ▪ Balances on one foot. ▪ Swings and climbs. ▪ Can eat an ice cream cone. ▪ Drinks from a straw. ▪ Chews gum without swallowing it. Cognitive development ▪ Shows increased attention span. ▪ Gives first and last name. ▪ Begins to ask “why.” ▪ Is egocentric in thought and behavior. ▪ Beginning ability to reflect on own behavior. ▪ Talks in short sentences. ▪ Uses plurals. ▪ May attempt to sing simple songs. ▪ Has vocabulary of 900 words. ▪ Begins fantasy. ▪ Begins to understand what it means to take turns. ▪ Can repeat three numbers. ▪ Shows interest in colors. Psychosocial development ▪ Negativism grows out of child's sense of developing independence—says “no” to every command. ▪ Ritualism is important to toddler for security (follows certain pattern, especially at bedtime). ▪ Temper tantrums may result from toddler's frustration in wanting to do everything for self. ▪ Shows parallel play as well as beginning interaction with others. ▪ Engages in associative play. ▪ Fears become pronounced. ▪ Continues to react to separation from parents but shows increasing ability to handle short periods of separation. ▪ Has daytime bladder control and is beginning to develop nighttime bladder control. ▪ Becomes more independent. ▪ Begins to identify sex (gender) roles. ▪ Explores environment outside the home. ▪ Can create different ways of getting desired outcome.	Play stimulation ▪ Plays simple games with other children. ▪ Enjoys story-telling and dress-up play. ▪ Plays “house.” ▪ Colors. ▪ Uses scissors and paper. ▪ Rides tricycle. ▪ Read simple books to child. ▪ Will assist in developing memory skills, visual discrimination skills, and language. Parental guidance ▪ From 2-3 years, the child develops a seeming maturity; do not expect more than child is able to do. ▪ Arrange first visit to the dentist to have teeth checked. ▪ Be aware that negativistic and ritualistic behavior is normal. ▪ Be consistent in discipline. ▪ Control temper tantrums. ▪ Begin to teach traffic safety. ▪ Supervise outdoor play.
3-4 Years ▪ Note: Between ages 3 and 5 years, the child is called a “preschooler.” ▪ May appear “knock kneed.”	Motor development ▪ Drawings have form and meaning, not detail. ▪ Copies a circle and a cross. ▪ Buttons front and side of clothes. ▪ Laces shoes. ▪ Bathes self, but needs direction. ▪ Brushes teeth. ▪ Shows continuous movement going up and down stairs. ▪ Climbs and jumps well. ▪ Attempts to print letters. Cognitive development ▪ Awareness of body is more stable; child becomes more aware of own vulnerability. ▪ Is less negativistic. ▪ Learns some number concepts. ▪ Begins naming colors. ▪ Can identify longer of two lines. ▪ Has vocabulary of 1,500 words. ▪ Uses mild profanities and name-calling. ▪ Uses language aggressively. ▪ Asks many questions. ▪ May not be abstract enough to understand body parts that cannot be seen or felt. ▪ Can be given simple explanation as to cause and effect. ▪ Thinks very concretely; demonstrates irreversibility of thought. ▪ Immature concept of death—believes it is reversible. ▪ Has beginning understanding of past and future. ▪ Is egocentric in thought. Psychosocial development ▪ Is more active with peers and engages in cooperative play. ▪ Performs simple tasks. ▪ Frequently has imaginary companion. ▪ Dramatizes experiences. ▪ Is proud of accomplishments. ▪ Exaggerates, boasts, and tattles on others. ▪ Can tolerate separation from mother longer without feeling anxiety. ▪ Is keen observer. ▪ Has good sense of “mine” and “yours.” ▪ Behavior still frequently ritualistic. ▪ Becomes curious about life and sex. Often indulges in masturbation.	Play stimulation ▪ Plays and interacts with other children. ▪ Shows creativity. ▪ Likes ring-around-the rosy. ▪ “Helps” adults. ▪ Likes costumes and enjoys dramatic play. ▪ Toys and games: record player, nursery rhymes, housekeeping toys, transportation toys (tricycle, trucks, cars, wagon), blocks, hammer and peg bench, floor trains, blackboard and chalk, easel and brushes, clay, crayon and finger paints, outside toys (sandbox, swing, small slide), books (short stories, action stories), drum, scrapbook. Parental guidance ▪ Base your expectations within child's limitations. ▪ Provide limited frustrations from environment to assist in coping. ▪ Give small tasks to do around the house (putting silverware on table, drying a dish). ▪ Expand child's world with trips to the zoo, to the supermarket, to restaurant, etc. ▪ Prevent accidents. ▪ Provide for brief nonthreatening separation from parents and home. ▪ Reinforce correct use of language. ▪ Use opportunities for simple sexual education as child's needs arise. ▪ Accept masturbation as a normal phenomenon to be discouraged in public. ▪ Provide consistent discipline, motivated by love rather than anger. ▪ Consider nursery school.
4-5 Years ▪ By 2-5 years adds 9½ inches (25 cm) to height. ▪ At age 4, legs comprise about 44% of body length. Child development theories ▪ Freudian: - 3-6 years—Phallic Stage ▪ Eriksonian: - 3-6 years—Sense of Initiative vs. Guilt ▪ Piagetian: - 2-7 years—Preoperational Period; shows egocentrism and centering	Motor development ▪ Hops two or more times. ▪ Dresses without supervision. ▪ Has good motor control—climbs and jumps well. ▪ Walks up stairs without grasping handrail. ▪ Walks backward. ▪ Washes self without wetting clothes. ▪ Prints first name and other words. ▪ Adds three or more details in drawings. ▪ Draws a square. Cognitive development ▪ Has 2,100-word vocabulary. ▪ Talks constantly. ▪ Uses adult speech forms. ▪ Participates in conversations. ▪ Asks for definitions. ▪ Knows age and residence. ▪ Identifies heavier of two objects. ▪ Knows weeks as time units. ▪ Names days of week. ▪ Begins to understand kinship. ▪ Knows primary colors. ▪ Can count to 10. ▪ Can copy a triangle. ▪ Has high degree of imagination. ▪ Questioning is at a peak. ▪ Begins to develop power of reasoning. Psychosocial development ▪ May have an imaginary companion. ▪ Has a sense of order (likes to finish what was started). ▪ Is obedient and reliable. ▪ Is protective toward younger children. ▪ Begins to develop an elementary conscience with some influence in governing behavior. ▪ Has increased self-confidence. ▪ Accepts responsibility for acts. ▪ Is less rebellious. ▪ Has dreams and nightmares. ▪ Is cooperative and sympathetic. ▪ Shows generosity with toys. ▪ Begins to question parents' thinking. ▪ Identifies strongly with parent of same sex.	Play stimulation ▪ Demonstrates gross motor activity—likes to jump rope, skip, climb on jungle gyms, etc. ▪ Prefers group play and cooperates in projects. ▪ Plays simple letter, number, form, and picture games. ▪ Plays with cars and trucks. ▪ Still likes being read to. ▪ Continues to enjoy fantasy play. Parental guidance ▪ Child no longer takes an afternoon nap. ▪ Prepare child for kindergarten. ▪ Tell him stories. ▪ Provide opportunities and reassurance for group play; have his friends visit for lunch and an afternoon of playing. ▪ Prevent accidents. ▪ Encourage child's participation in household activities.
Middle Childhood (5-9 Years) ▪ Growth rate is slow and steady. ▪ Gains an average of 7 lb (3.2 kg) per year. Height increases approximately 212 inch (6.3 cm) per year. ▪ Among children there is considerable variation in height and weight. ▪ Appears taller and slimmer. ▪ Early lordosis disappears. ▪ Begins to lose baby teeth; permanent teeth appear at a rate of about 4 teeth per year from 7-14 years. ▪ Neuromuscular and skeletal development allows improved coordination. ▪ Eyes become fully developed; vision approaches 20/20. ▪ Handedness should be well developed. Child development theories ▪ Freudian: - 5-9 years—Beginning of Latency Period ▪ Eriksonian: - 5-9 years—Industry vs. Inferiority ▪ Piagetian: - 5-9 years—Enters Stage of Concrete Operations	Motor development 6 years ▪ Is active and impulsive. ▪ Balance improves. ▪ Uses hands as manipulative tools in cutting, pasting, hammering. ▪ Can draw large letters or figures. 7 years ▪ Has lower activity level. ▪ Capable of fine hand movements; can print sentences. ▪ Nervous habits, such as nail biting, are common. ▪ Muscular skills, such as ball throwing, have improved. 8 years ▪ Moves with less restlessness. ▪ Has developed grace and balance, even in active sports. ▪ Has developed coordination of fine muscles, allowing child to write in script. 9 years ▪ Uses both hands independently. ▪ Has become skillful in manual activities because of improved eye-hand coordination. Cognitive development 6 years ▪ Begins to learn to read. Defines objects in terms of use. Time sense is as much in past as present. ▪ Is interested in relationship between home and neighborhood; knows some streets. ▪ Uses sentences well; uses language to share others' experiences; may swear or use slang. ▪ Distinguishes morning from afternoon. 7 years ▪ More reflective and has deeper understanding of meanings. ▪ Interested in conclusions and logical endings. Begins to have scientific interests in cause and effect. ▪ More responsible in relation to time, is more punctual. Sense of space is more realistic; child wants some space of own. ▪ Knows value of coins. ▪ Concept of death maturing—includes idea of irreversibility. 8 years ▪ Thinking is less animistic. Is aware of impersonal forces of nature. Begins to understand logical reasoning, conclusions, and implications. ▪ Less self-centered in thinking. Personal space is expanding; goes places on own. Aware of time; plans events of day. Understands right from left. 9 years ▪ Intellectually energetic and curious. Realistic; reasonable in thinking. Able to plan in advance. Breaks complex activities into steps. ▪ Focuses on detail. ▪ Sense of space includes the entire earth. ▪ Participates in family discussions. ▪ Likes to have secrets. Psychosocial development 5-9 years ▪ Still requires parental support, but pulls away from overt signs of affection. ▪ Peer groups provide companionship in widening circle of persons outside the home. Child learns more about self as he learns about others. ▪ “Chum” stage occurs at about age 9 or 10. Child chooses a special friend of same sex and age in whom to confide. This is usually child's first love relationship outside of home, when someone becomes as important to him as himself. ▪ Play teaches the child new ideas and independence. Child progressively uses tools of competition, compromise, cooperation, and beginning collaboration. ▪ Body image and self-concept are fluid because of rapid physical, emotional, and social changes. ▪ Latency-stage sexual drive is controlled and repressed. Emphasis is on the development of skills and talent. Patterns of play 6-7 years ▪ Child acts out ideas of family and occupational groups with which he has contact. ▪ Painting, pasting, reading, simple games, watching television, digging, running games, skating, riding bicycle, and swimming are all enjoyed activities. 8 years ▪ Child enjoys collections; loosely formed, short-lived clubs; table games; card games; books; television; and records.	Parental guidance ▪ Family atmosphere continues to have an impact on the child's emotional development and future response within the family. ▪ The child needs ongoing guidance in an open, inviting atmosphere. Limits should be set with conviction. Deal with only one incident at a time. When punishment is necessary, the child should not be humiliated. Child should know that it was the act that the adult found undesirable, not the child. ▪ Needs assistance in adjusting to new experiences and demands of school. Should be able to share experiences with family. Parents need to have communication with the teacher to work together for the health of the child. ▪ Convey love and caring in communication. The child understands language directed at feelings better than at intellect. Get down to eye level with the child. ▪ Focus attention on child's abilities and accomplishments rather than shortcomings and limitations. ▪ The child is sex-conscious and should be able to discuss questions at home rather than with friends. Requires simple, honest answers to questions. ▪ Common problems include teasing, quarreling, nail biting, enuresis, whining, poor manners, swearing, lying, cheating, and stealing. These are usually fleeting phases and should not be handled negatively. The causes for such behavior should be investigated and dealt with constructively. ▪ The child needs order and consistency to help in coping with doubts, fears, unacceptable impulses, and unfamiliar experiences. ▪ Encourage peer activities as well as home responsibilities and give recognition to child's accomplishments and unique talents. ▪ Television may stimulate learning in several spheres, but should be monitored. ▪ Accidents are a major cause of disability and death. Safety practices should be continued. (Refer to section on safety, page 1408.) ▪ Exercise is essential to promote motor and psychosocial development. The child should have a safe place to play and simple pieces of equipment. ▪ A school health program should be available and concerned with the child's physical, emotional, mental, and social health. This should be augmented by information and example at home. ▪ Medical supervision should continue with yearly examination to detect developmental delay and disease. Appropriate immunizations should be administered. ▪ The child frequently has “quiet days”—periods of shyness, which should be tolerated as part of growing up and deciding who he or she is. ▪ The child may be subject to nightmares, a situation that requires reassurance and understanding. ▪ Parents, teachers, and health professionals should be available and able to provide information and answer questions about the physical changes that occur.
Late Childhood (9-12 Years) ▪ Vital signs approach adult values. ▪ Loses childish appearance of face and takes on features that will characterize individual as an adult. ▪ Growth spurt occurs, and some secondary sex characteristics appear: in girls, between ages 10 and 12 years; in boys, between ages 12 and 14 years. Physical changes of puberty: ▪ Increased height and weight, increased perspiration and activity of sebaceous glands; vasomotor instability; increased fat deposition. Physical changes in girls: ▪ Pelvis increases in transverse diameter; hips broaden; tenderness in developing breast tissue; enlargement of areola diameter; appearance of pubic hair. Physical changes in boys: ▪ Size of testes increases; scrotum color changes; breasts enlarge, temporarily; height and shoulder breadth increase. ▪ Appearance of lightly pigmented hair at base of penis. ▪ Increase in length and width of penis. Child development theories ▪ Freudian: - 9-12 years—Latency Period continues ▪ Eriksonian: - 9-12 years—Industry vs. Inferiority continues ▪ Piagetian: - 9-12 years—Stage of Concrete Operations continues	Motor development ▪ Energetic, restless, active movements such as finger-drumming or foot-tapping appear. ▪ Has skillful manipulative movements nearly equal to those of adults. ▪ Works hard to perfect physical skills. Cognitive development 10 years ▪ Likes to reason, enjoys learning. ▪ Thinking is concrete, matter of fact. ▪ Wants to measure up to challenge. ▪ Likes to memorize, identify facts. ▪ Attention span may be short. Space is rather specific (ie, where things are). ▪ Can write for relatively long time with speed. 11 years ▪ Likes action in learning. ▪ Concentrates well when working competitively. ▪ Can understand relational terms, such as weight and size. ▪ Perceives space as nothingness that goes on forever. ▪ Can discuss problems. ▪ Can conceptualize symbolically enough to understand body parts. ▪ Can describe some abstract terms. 12 years ▪ Enjoys learning. ▪ Considers all aspects of a situation. ▪ Motivated more by inner drive than by competition. ▪ Able to classify, arrange, and generalize. ▪ Likes to discuss and debate. ▪ Begins conceptual thinking. ▪ Verbal, formal reasoning now possible. ▪ Can recognize moral of a story. ▪ Defines time as duration; likes to plan ahead. ▪ Understands that space is abstract. ▪ Can be critical of own work. Psychosocial development ▪ Gang becomes important, and gang code takes precedence over nearly everything. Gang codes are typically characterized by collective action against the mores of the adult world. Here, children begin to work out their own social patterns without adult interference. Early gangs may include both sexes; later gangs are separated by sex. ▪ May strive for unreasonable independence from adult control. ▪ Usually interested in religion and morality. ▪ Has increased interest in sexuality. ▪ May reach puberty; resurgence of sexual drives causes recapitulation of Oedipal struggle. Patterns of play ▪ Continues to enjoy reading, TV, and table games. ▪ More interested in active sports as a means to improve skills. ▪ Creative talents may appear; may enjoy drawing, and modeling clay. By age 10, sex differences in play become profound. ▪ Occasional privacy is important. ▪ Begins to have vocational aspirations.	Parental guidance ▪ Continue appropriate interventions related to early childhood. ▪ Continue sex education and preparation for adolescent body changes. ▪ Understanding is important. ▪ Encourage participation in organized clubs and youth groups. ▪ Democratic guidance is essential as child works through a conflict between dependence (on parents) and independence. The child needs realistic limits set. ▪ Needs help channeling energy in proper direction—work and sports. ▪ Requires adequate explanation of body changes. Special understanding is required for the child who lags in physical development. ▪ Continue consistent disciplinary style.
Early Adolescence (12-14 Years) ▪ Phase of development begins when reproductive organs become functionally operative; phase ends when physical growth is completed. ▪ Skeletal system grows faster than supporting muscles. ▪ Hands and feet grow proportionately faster than rest of body. ▪ Large muscles develop more quickly than small muscles. Girls: ▪ Physical changes include beginning of menarche; growth of axillary and perineal hair; deepened voice; ovulation; further development of breasts. ▪ Nutritional need for iron and calcium increase dramatically. Boys: ▪ Physical changes include growth of axillary, perineal, facial, chest hair; deepening of voice; production of spermatozoa; nocturnal emissions. Child development theories ▪ Freudian: - 12-14 years—Begins Stage of Sexuality ▪ Eriksonian: - 12-14 years—Identity vs. Role Diffusion ▪ Piagetian: - 12-14 years—Begins Stage of Formal Operations	Motor development ▪ Usually uncoordinated; has poor posture. ▪ Tires easily. Cognitive development ▪ Mind has great ability to acquire and use knowledge. ▪ Abstract thinking is sufficient to learn multivariable ideas such as the influence of hormones on emotions. ▪ Categorizes thoughts into usable forms. ▪ May project thinking into the future. ▪ Is capable of highly imaginative thinking. Psychosocial development ▪ Interest in opposite sex increases. ▪ Often revolts from adult authority to conform to peer-group standards. ▪ Continues to rework feelings for parent of opposite sex and unravel the ambivalence toward parent of same sex. ▪ Affection may turn temporarily to an adult outside of the family (for example, crush on family friend, neighbor, or teacher). ▪ Uses peer-group dialect—highly informal language or specially coined terminology. ▪ Peer groups are especially important and help adolescent to define own identity, to adapt to changing body image, to establish more mature relationships with others, and to deal with heightened sexual feelings. Cliques may develop. ▪ Dating generally progresses from groups of couples to double dates and finally single couples. ▪ Teenage “hangouts” become important centers of activity. ▪ Begins questioning existing moral values.	Parental guidance ▪ Stresses frequently result from conflicting value systems between generations. The parents may need help to see that the adolescent is a product of the times and that actions reflect what is happening around the youngster. ▪ The parents' limits and rules should be realistic and consistent. They should convey the parent's love and concern and should be a source of comfort and reassurance, protecting the child from activities for which he is not ready. ▪ The home should be an accepting, emotionally stable environment. ▪ Continue sex education, including discussion of ovulation, fertilization, menstruation, pregnancy, contraception, masturbation, nocturnal emissions, and hygiene. ▪ Adolescents have an increased need for rest and sleep because they are expending large amounts of energy and are functioning with an inadequate oxygen supply. ▪ Recreational interests should be fostered. Favorite activities include sports, dating, dancing, reading, hobbies, and television. Socializing via telephone or computer and listening to music are favorite pastimes. ▪ Adolescent health problems that require preventive education are accidents, obesity, acne, pregnancy, sexually transmitted disease, and drug abuse. ▪ Allow the adolescent to handle his own affairs as much as possible, but be aware of physical and psychosocial problems that may require help. Encourage independence but allow the child to lean on the parents for support when frightened or unable to attain goals. ▪ Adolescents with special problems should have access to specialists, such as adolescent clinics and psychologists. ▪ Requires reassurance and help in accepting a changing body image. Parents should make the most of the child's positive qualities. ▪ Give gentle encouragement and guidance regarding dating. Avoid strong pressures in either direction. ▪ Understand conflicts as the child attempts to deal with social, moral, and intellectual issues.

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Age-appropriate Neuroassessment

Age-appropriate neuroassessment table. A brief guide to developmental milestones in children from infancy to age 12 years as a guide when performing a neurological assessment (Phoenix Children’s Hospital)

Age	Gross Motor	Fine Motor	Personal/social	Language
Newborn	Head down with ventral suspension Flexion Posture Knees under abdomen-pelvis high Head lag complete Head to one side prone	Hands closed Cortical Thumbing (CT)	With sounds, quiets if crying; cries if quiet; startles; blinks	Crying only monotone
4 weeks	Lifts chin briefly (prone) Rounded back sitting head up momentarily Almost complete head lag	Hands closed (CT)	Indefinite stare at surroundings Briefly regards toy only if brought in front of eyes and follows only to midline Bell sound decreases activity	Small, throaty noises
6 weeks	In ventral suspension head up momentarily in same plane as body Prone: pelvis high but knees no longer under abdomen	Hands open 25% of time	Smiles	Social smile (1st cortical input)
2 months	Ventral suspension; head in same plane as body Lifts head 45° (prone) on flexed forearms Sitting, back less rounded, head bobs forward Energetic arm movements	Hands open most of the time (75%) Active grasp of toy	Alert expression Smiles back Vocalizes when talked to Follows dangled toy beyond midline Follows moving person	Cooing Single vowel sounds (ah. eh, uh)
3 months	Ventral suspension; head in same plane as body Lifts head 45° (prone) on flexed forearms Sitting, back less rounded, head bobs forward Energetic arm movements	Hands open most of the time (75%) Active grasp of toy	Smiles spontaneously Hand regard Follows dangled toy 180° Promptly looks at object in midline Glances at toy put in hand	Chuckles “Talk back” if examiner nods head and talks Vocalizes with two different syllables (a-a. oo-oo)
4 months	Head to 90° on extended forearms Only slightly head lag at beginning of movement Bears weight some of time on extended legs if held standing Rolls prone to supine Downward parachute	Active play with rattles Crude extended reach and grasp Hands together Plays with fingers Toys to mouth when supine	Body activity increased at sight of toy Recognizes bottle and opens mouth For nipple (anticipates feeding with excitement)	Laughs out loud increasing inflection No tongue thrust
6 months	Bears full weight on legs if held standing Sits alone with minimal support Pivots in prone Rolls easily both ways Anterior proppers	Reaches for toy Palmar grasp of cube Lifts cup by handle Plays with toes	Displeasure at removal of toy Puts toy in mouth if sitting	Shy with strangers Imitates cough and protrusion of tongue Smiles at mirror image
7 months	Bears weight on one hand prone Held standing, bounces Sit on hard surface leaning on hands		Stretches arms to be taken Keeps mouth closed if offered more food than wants Smiles and pats at mirror	Murmurs “mom” especially if crying Babbles easily (M’s, D’s, B’s, L’s) Lateralizes sound
9 months	Sits steadily for 15 min on hard surface Reciprocally crawls Forward parachute	Picks up small objects with index finger and thumb (Pincer grasp)	Feeds cracker neatly Drinks from cup with help	Listens to conversation Shouts for attention Reacts to “strangers”
10 months	Pulls to stand Sits erect and steadily (indefinitely) Sitting to prone Standing: collapses and creeps on hands knees easily Prone to sitting easily Cruises – laterally Squats and stoops – does not recover to standing position	Pokes with index finger, prefers small to large objects	Nursery games (i.e., pat-a-cake), picks up dropped bottle, waves bye-bye	Will play peek-a-boo and pat-a-cake to verbal command Says Mama, Dada appropriately, finds the hidden toy (onset visual memory)
12 months	Sitting; pivots to pick up object Walks, hands at shoulder height Bears weight alone easily momentarily	Easy pinch grasp with arm off table Independent release (ex: cube into cup) Shows preference for one hand	Finds hidden toy under cup Cooperated with dressing Drinks from cup with two hands Marks with crayon on paper Insists on feeding self	One other word (noun) besides Mama, Dada (e.g., hi, bye, cookie)
13 months	Walks with one hand	Mouthing very little Explores objects with fingers Unwraps small cube Imitates pellet bottle	Helps with dressing Offers toy to mirror image Gives toy to examiner Holds cup to drink, tilting head Affectionate Points with index finger Plays with washcloth, bathing Finger-feeds well, but throws dishes on floor Appetite decreases	Three words besides Mama, Dada Larger receptive language than expressive
14 months	Few steps without support	Deliberately picks up two small blocks in one hand Peg out and in Opens small square box	Should be off bottle Puts toy in container if asked Throws and plays ball	Three to four words expressively minimum
15 months	Creeps up stairs Kneels without support Gets to standing without support Stoop and recover Cannot stop on round corners suddenly Collapses and catches self	Tower of two cubes “Helps” turn pages of book Scribbles in imitation Completes round peg board with urging	Feeds self fully leaving dishes on tray Uses spoon turning upside down, spills much Tilts cup to drink, spilling some Helps pull clothes off Pats at picture in book	Four to six words Jargoning Points consistently to indicate wants
18 months	Runs stiffly Rarely falls when walking Walks upstairs (one hand held-one step at a time) Climbs easily Walks, pulling toy or carrying doll Throws ball without falling Knee flexion seen in gait	Tower of three to four cubes Turns pages two to three at a time Scribbles spontaneously Completes round peg board easily	Uses spoon without rotation but still spills May indicate wet pants Mugs doll Likes to take off shoes and socks Knows one body part Very negative oppositions	One-step commands 10-15 words Knows “hello” and “thank you” More complex ‘jargon’ rag Attention span 1 min Points to one picture
21 months	Runs well, falling some tires Walks downstairs with one hand held, one step at a time Kicks large ball with demonstration Squats in play Walks upstairs alternating feet with rail held	Tower of five to six cubes Opens and closes small square box Completes square peg board	May briefly resist bathing Pulls person to show something Handles cup will Removes some clothing purposefully Asks for food and drink Communicates toilet needs helps wit h simple household tasks 3 body parts	Knows 15–20 words and combines 2–3 words Echoes 2 or more Knows own name Follows associate commands
24 months	Rarely falls when running Walks up and down stairs alone one-step-at-a time Kicks large ball without demonstration Claps hands Overthrow hand	Tower of six to seven cubes Turns book pages singly Turns door knob Unscrews lid Replaces all cubes in small box Holds glass securely with one hand	Uses spoon, spilling little Dry at night Puts on simple garment Parallel play Assists bathing Likes to wash 6 dry hands Plays with food + body parts Tower of 8. Helps put things away	Attention span 2 min Jargon discarded Sentences of two to three words Knows 50 words Can follow two-step commands (ain’t) Refers to self by name Understands and asks for “more” Asks for food by name Inappropriately uses personal pronouns (e.g., me want) Identifies three pictures
3–5 years	Pedals tricycle Walks up stairs alternating feet Tip toe Jump with both feet	Copies circles Uses overhand throw	Group play Can take turns	Uses three-word sentences
5–12 years	Activities of daily living	Printing and cursive writing	Group Sports	Reads and understands content Spells words

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