Evaluation of children pSychomotor development
As biologic maturation progresses there is a concurrent development of behaviors, which increasingly allows the infant to respond to and cope with the environment. These adaptive behaviors can be classified into various categories: (1) gross motor, (2) fine motor, (3) language, and (4) personal-social. The acquisition of skill in each area occurs in an orderly sequence, following the usual cephalocaudal-proximodistal laws.
Knowledge of the developmental sequence allows the doctor to assess normal growth as well as minor or abnormal deviations. Knowledge of developmental milestones helps parents TO gain realistic expectations of their child’s ability and provides guidelines for suitable play and stimulation. Emphasizing the child’s developmental age rather than chronologic age strengthens the parent-child relationship by fostering trust and lessening frustration. Therefore, one cannot overemphasize the importance of a thorough understanding and appreciation of the growth and developmental process of children.
Reflexes of the newborn
There are three groups of reflexes in the newborn. The first group includes the unconditioned reflexes that persist throughout life. They are divided into swallowing reflex, papillary reflex, sneeze reflex, blinking or corneal reflex, glabellar reflex, yawn reflex, cough reflex, gag reflex, and tendon reflexes (Table 1).
The second group includes the transitional reflexes or reflexes of neonate and infancy. These reflexes disappear during infancy. The transitional reflexes are divided into:
1. The reflexes of oral automatism.
2. Spinal automatism.
3. Myelocephalic reflex.
The third group includes the righting reflexes that reflexes are absent in the newborn and appear during infancy. The examples of the righting reflexes are upper Landau’s reflex, low Landau’s reflex and a parachute reflex.
Upper Landau’s reflex appears at 4 month. When an infant is placed on the abdomen, he can lift the head and the front portion of the chest about 90 degrees above the table, bearing his weight on the forearms.
Low Landau’s reflex appears at 5-6 month. When an infant prones he extends and holds (lifts) his legs.
Parachute reflex elicits a protective response to falling, and appears at 7 months.
Table 1.
Reflexes of the newborn
|
Reflexes |
Expected behavioral responses |
|
Unconditioned reflex (persists throughout life) |
|
|
Blinking or corneal reflex |
Infant blinks at sudden appearance of a bright light or at approach of an object toward the cornea |
|
Pupillary |
Pupil constricts when a bright light shines toward it |
|
Sneeze |
Spontaneous response of the nasal passages to irritation or obstruction |
|
Glabellar |
Tapping briskly on the glabella (the bridge of the nose) causes the eyes to close tightly |
|
Yawn |
Spontaneous response to decreased oxygen by an increasing amount of inspired air |
|
Cough |
Irritation of the mucous membranes of the larynx or tracheobronchial tree causes coughing, it usually present after the first day of birth |
|
Gag |
Stimulation of posterior pharynx by food, suction, or passage of a tube causes infant to gag |
|
Transitional reflexes or reflexes of neonate and infancy I. Oral automatism |
|
|
Sucking |
Infant begins strong sucking movements of the circumoral area in response to stimulation, it persists throughout infancy, even without stimulation, e.g. during sleep |
|
Doll’s eye |
As the head is moved slowly to the right or left, eyes lag behind and do not immediately adjust to the new position of the head, it disappears as fixation develops; if it persists, it indicates a neurologic damage |
|
Rooting |
Touching or stroking the cheek along the side of the mouth causes the infant to turn the head toward that side and begin to suck, it should disappear at about the age of 3-4 months, but may persist for up to 12 months (fig.1) |
|
Extrusion |
When the tongue is touched or depressed, the infant responds by forcing it outward, disappears by the age of 4 months |
|
Lip or trunk reflex |
In stroking the lips by finger, the infant will make the trunk by lips, it disappears by the age of 4 months |
|
Babkin’s reflex |
Pressing the tenor of palms causes infant to open the mouth and to turn the head toward the chest, it disappears by the age of 2-3 months |
|
II. Spinal automatism |
|
|
Defence |
When the infant is placed on abdomen, he turns the head to the left or right side, it disappears after the age of 2 months |
|
Grasp |
Touching palms of the hands or soles of the feet near the base of digits causes flexion of hands and toes; palmar grasp lessens after the age of 3 months to be replaced by voluntary movement; plantar grasp lessens by 8 months (fig. 2) |
|
Moro reflex |
Sudden jarring or change in equilibrium causes sudden extension and abduction of the extremities and the fanning of fingers, with the index finger and the thumb forming a "C" shape, followed by flexion and adduction of the extremities; the legs may weakly flex; the infant may cry; it disappears after the age of 3-4 months, usually strongest during first 2 months (fig. 3) |
|
Startle |
A sudden loud noise causes abduction of the arms with flexion of the elbows; the hands remain clenched, it disappears by the age of 4 months |
|
Supporting |
If the infant is held so that the sole of the foot touches a hard surface, there is a reciprocal flexion and extension of the leg, it disappears after at the age of 3-4 weeks |
|
Dance (stepping) |
When the supporting reflex is examined, turn the body of the child toward, the child will make stepping, it disappears after the age of 3-4 weeks to be replaced by deliberate movement |
|
Karniga’s reflex |
When the infant’s leg is flexed in the knee and hip joints, the doctor cannot extend the leg in the knee joint completely |
|
Babinski’s reflex |
Stroking the outer sole of foot upward from the heel and across the ball of the foot causes toes to hyperextend and hallux to dorsiflex, it disappears after the age of 1 year |
|
Trunk incurvation (Galant) reflex |
Stroking the infant’s back alongside the spine causes the hips to move toward the stimulated side, it disappears by the age of 4 weeks |
|
Perez reflex |
While the infant is prone on a firm surface, the thumb is pressed along the spine from the sacrum to the neck; the infant responds by crying, flexing the extremities, and elevating the pelvis and the head; lordosis of the spine, as well as defecation and urination, may occur; it disappears by the age of 4-6 months |
|
Crawling reflex |
When the infant is placed on the abdomen, he makes crawling movements with the arms and legs, it disappears at about the age of 6 weeks |
|
Bauer’s reflex |
With infant proned, pressing gently on the soles of the feet causes crawling movements |
|
III. Myelocephalic reflex |
|
|
Asymmetric tonic neck |
When the infant’s head is quickly turned to one side, the arm and leg extend on that side, and the opposite arm and leg flex, it disappears by the age of 3-4 months, to be replaced by the symmetric positioning of both sides of the body |
|
Symmetric tonic neck |
When the infant’s head is turned toward the chest, the arms flex and the legs extend, it disappears by the age of 2 months |
Figure 1. Rooting reflex
Figure 2. Palmer grasp
Figure 3. Moro reflex in newborn
Reflexes in newborn babies (video).
The stages of the psychomotor development of the child
I stage - 0-1 month
II stage - 1 - 3 months
III stage - 3-6 months
IV stage - 6-9 months
V stage - 9-12 months
VI stage - 1 - 3 years
The encephalopathy (mental retardation) makes when psychomotor retardation is more than 2 stages.
The clinical significance. At no other time are the biologic and developmental changes and achievements more dramatic than during infancy. Each month the infant learns new skills, is increasing aware of the environment, and develops closer interpersonal attachments.
Summary of physical, neurologic and psychomotor development during infancy
Child at the age of 1 month
Physical development
Ø Weight gain is from 150 to 210 g (5 to 7 ounces) weekly for the first 6 months
Ø Height gain of 2.5 cm (1 inch) monthly for the first 6 months
Ø Head circumference increases by 1.5 cm (1/2 inch) monthly for the first 6 months
Ø Primitive reflexes are present and strong
Ø Doll’s eye reflex and dance reflex are fading
Ø Obligatory nose breather
Gross motor development
Ø Assumes flexed position with the pelvis high, but the knees not under the abdomen when prone (at birth, the knees flexed under the abdomen)
Ø Can turn head from side to side when prone, lifts head momentarily from bed
Ø Marked head lag, especially when pulled from a lying to a sitting position
Ø Holds head momentarily parallel and in midline when suspended in a prone position
Ø Assumes asymmetric tonic neck reflex position when supine
Ø Makes crawling movements when prone
Ø When held in a standing position, the body limp at the knees and hips
Ø In a sitting position the back is uniformly rounded, absence of head control
Fine motor development
Ø Hands are predominantly closed
Ø Grasp reflex is strong
Ø Hand clenches in contact with a rattle
Sensory development
Ø Can to fixate on moving object
Ø Follows light to midline
Ø Quiets when hears a voice
Vocalization development
Ø Cries to express displeasure
Ø Makes small throaty sounds
Ø Makes comfort sounds during feeding
Socialization development
Ø Watches the parent’s face intently as she or he talks to the infant
Child at the age of 2 months
Physical development
Ø Posterior fontanel closed
Ø Crawling reflex disappears
Gross motor development
Ø Assumes less flexed position when prone the hips flat, the legs extended, the arms flexed, the head leaned to the side.
Ø Less head lag when pulled to a sitting position
Ø Can maintain head in the same plane as the rest of the body when held in ventral suspension
Ø When prone, can lift the head almost 45 degrees off the table
Ø When held in a sitting position, the head is held up but the bobs forward
Ø Assumes an asymmetric tonic neck reflex position intermittently
Fine motor development
Ø Hands are frequently open
Ø Grasp reflex is fading
Sensory development
Ø Binocular fixation and convergence to near objects are beginning
Ø When supine, follows a dangling toy from the side to the point beyond the midline
Ø Visually searches to locate sounds
Ø Turns the head to the side when a sound is made at the level of the ear
Vocalization development
Ø Crying becomes differentiated
Ø Coos
Ø Vocalizes to a familiar voice
Socialization development
Ø Social smile in response to various stimuli
Child at the age of 3 months
Physical development
Ø Primitive reflexes are fading
Gross motor development
Ø Able to hold the head more erect when sitting, but still the bobs forward
Ø Only a slight head lag when pulled to sitting
Ø Assumes a symmetric body positioning
Ø Able to raise the head and the shoulders from a prone position to a 45- to 90-degree angle from the table; bears the weight on the forearms
Ø When held in a standing position, able to bear a slight fraction of weight on the legs
Ø Regards his (or her) own hand
Fine motor development
Ø Actively holds a rattle but will not reach for it
Ø Grasp reflex is absent
Ø Hands are kept loosely open
Ø Clutches his (or her) own hand, pulls at blankets and clothes
Sensory development
Ø Follows an object to the periphery (180 degrees)
Ø Locates a sound by turning the head to the side and looking in the same direction
Ø Begins to be able to coordinate stimuli from various sense organs
Vocalization development
Ø Squeals aloud to show pleasure
Ø Coos, babbles, chuckles
Ø Vocalizes when smiling
Ø “Talks” a great deal when spoken to
Ø Less crying during periods of wakefulness
Socialization development
Ø Much interest in surroundings
Ø Ceases crying when the parent enters the room
Ø Can recognize familiar faces and objects, such as feeding bottle
Ø Shows awareness of strange situations
Child at the age of 4 months
Physical development
Ø Drooling begins
Ø Moro, tonic neck, rooting, and Perez reflexes have disappeared
Gross motor development
Ø Almost no head lag when pulled to a sitting position
Ø Balances head well in a sitting position
Ø Back less rounded, curved only in the lumbar area
Ø Able to sit erect if propped up
Ø Able to raise the head and the chest off couch to angle of 90 degrees
Ø Assumes a predominant symmetric position
Ø Rolls from the back to the side
Fine motor development
Ø Inspects and plays with the hands, pulls clothing or blanket over face in play
Ø Tries to reach objects with the hand but overshoots
Ø Grasps object with both hands
Ø Plays with a rattle placed in the hand shakes it, but cannot pick it up if dropped
Ø Can carry objects to the mouth
Sensory development
Ø Able to accommodate to near objects
Ø Binocular vision is fairly well established
Ø Can focus on a 1.25-cm (1/2-inch) block
Ø Beginning eye-hand coordination
Vocalization development
Ø Makes consonant sounds n, k, g, p, b
Ø Laughs aloud
Ø Vocalization changes according to mood
Socialization development
Ø Demands attention by fussing, becomes bored if left alone
Ø Enjoys social interaction with people
Ø Anticipates feeding when sees bottle
Ø Shows excitement with the whole body, squeals, breathes heavily
Ø Shows interest in strange stimuli
Child at the age of 5 months
Physical development
Ø Growth rate may begin to decline
Ø Beginning signs of tooth eruption
Ø Able to breathe when nose is obstructed
Gross motor development
Ø No head lag when pulled to a sitting position
Ø When sitting, able to hold the head erect and steady
Ø Able to sit for longer periods when the back is well supported
Ø Back straight
Ø When prone, assumes symmetric positioning with arms extended
Ø When held in a standing position, able to bear most of weight
Ø Can turn over from the abdomen to the back
Ø When supine, puts the feet to the mouth
Fine motor development
Ø Able to grasp objects voluntarily
Ø Uses palmar grasp, bidexterous approach
Ø Plays with toes
Ø Takes objects directly to the mouth
Ø Holds one cube while regarding a second
Sensory development
Ø Smiles at a mirror image
Ø Visually pursues a dropped object
Ø Able to sustain visual inspection of an object
Ø Can localize sounds made below the ear
Vocalization development
Ø Squeals
Ø Vowellike cooing sounds interspersed with consonant sounds (for example, ah-goo)
Socialization development
Ø Smiles at a mirror image
Ø Pats a bottle with both hands
Ø More enthusiastically playful but may have rapid mood swings
Ø Able to discriminate strangers from the family
Ø Vocalizes displeasure when the object taken away
Child at the age of 6 months
Physical development
Ø Birth weight is doubled
Ø Weight gain of 90 to 150 g (3 to 5 ounces) weekly for the next 6 months
Ø Height gain of 1.25 cm (1/2 inch) monthly for the next 6 months
Ø Teething may begin with eruption of two lower central incisors
Ø Chewing and biting occur
Gross motor development
Ø When prone, can lift the chest and the upper abdomen off the table, bearing weight on the hands
Ø When about to be pulled to a sitting position, lifts the head
Ø Sits in a high chair with the back straight
Ø Rolls from the back to the abdomen
Ø When held in a standing position, bears almost all of weight
Ø Hand regard is absent
Fine motor development
Ø Resecures a dropped object
Ø Drops one cube when another is given
Ø Grasps and manipulates small objects
Ø Holds a bottle
Ø Grasps the feet and pulls to the mouth
Sensory development
Ø Adjusts posture to see an object
Ø Prefers more complex visual stimuli
Ø Can localize sounds made above the ear
Ø Will turn the head to the side, then look up or down
Vocalization development
Ø Begins to imitate sounds
Ø Babbling resembles one-syllable utterances - ma, mu, da, di, hi
Ø Vocalizes to toys, a mirror image
Ø Laughs aloud
Ø Takes pleasure in hearing own sounds (self-reinforcement)
Socialization development
Ø Recognizes the parents, begins to fear strangers
Ø Holds arms out to be picked up
Ø Has definite likes and dislikes
Ø Beginning the imitation (cough, protrusion of the tongue)
Ø Excites on hearing footsteps
Ø Laughs when the head is hidden in a towel
Ø Briefly searches for a dropped object (object permanence beginning)
Ø Frequent mood swings - from crying to laughing with little or no provocation
Child at the age of 7 months
Physical development
Ø Eruption of the upper central incisors
Gross motor development
Ø When supine, spontaneously lifts the head off the table
Ø Sits, leaning forward on both hands
Ø When prone, bears weight on one hand
Ø Sits erect momentarily
Ø Bears full weight on the feet
Ø When held in a standing position, bounces actively
Fine motor development
Ø Transfers objects from one hand to the other
Ø Unidexterous approach and grasp
Ø Holds two cubes more than momentarily
Ø Bangs a cube on the table
Ø Rakes at a small object
Sensory development
Ø Can fixate on very small objects
Ø Responds to own name
Ø Localizes sound by turning the head in a curving arch
Ø Beginning awareness of depth and space
Ø Has taste preferences
Vocalization development
Ø Produces vowel sounds and chained syllables - baba, dada, kaka
Ø Vocalizes four distinct vowel sounds
Ø “Talks” when others are talking
Socialization development
Ø Increasing fear of strangers; shows the signs of fretfulness when mother disappears
Ø Imitates simple acts and noises
Ø Tries to attract attention by coughing or snorting
Ø Plays peekaboo
Ø Demonstrates dislike of food by keeping the lips closed
Ø Exhibits oral aggressiveness in biting and mouthing
Ø Demonstrates expectation in response to repetition of stimuli
Child at the age of 8 months
Physical development
Ø Begins to show regular patterns in the bladder and bowel elimination
Ø Parachute reflex appears
Gross motor development
Ø Sits steadily unsupported
Ø Readily bears weight on the legs when supported, may stand holding on
Ø Adjusts posture to reach an object
Fine motor development
Ø Beginning pincer grasp using the index, fourth, and fifth fingers against the lower part of the thumb
Ø Releases objects at will
Ø Rings bell purposely
Ø Retains two cubes while regarding the third cube
Ø Secures an object by pulling on a string
Ø Reaches persistently for toys out of reach
Sensory development
Ø Can fixate on very small objects
Ø Responds to own name
Ø Localizes a sound by turning head in a curving arch
Ø Beginning awareness of depth and space
Ø Has taste preferences
Vocalization development
Ø Makes consonant sounds t, d, and w
Ø Listens selectively to familiar words
Ø Utterances signal emphasis and emotion
Ø Combines syllables, such as dada, but does not ascribe the meaning to them
Socialization development
Ø Increasing anxiety over loss of the parent, particularly mother, and fear of strangers
Ø Responds to word "no"
Ø Dislikes dressing, diaper change
Child at the age of 9 months
Physical development
Ø Eruption of the upper lateral incisor may begin
Gross motor development
Ø Crawls, may progress backward at first
Ø Sits steadily on the floor for prolonged time (10 minutes)
Ø Recovers balance when leans forward but cannot do so when leaning sideways
Ø Pulls self to a standing position and stands holding onto furniture
Fine motor development
Ø Ability to use the thumb and the index finger in crude pincer grasp
Ø Preference for use of the dominant hand now evident
Ø Grasps the third cube
Ø Compares two cubes by bringing them together
Sensory development
Ø Localizes sounds by turning the head diagonally and directly toward sound
Ø Depth perception is increasing
Vocalization development
Ø Responds to simple verbal commands
Ø Comprehends “no-no”
Socialization development
Ø Parent (mother) is increasingly important for own sake
Ø Increasing interest in pleasing mother
Ø Begins to show fears of going to bed and being left alone
Ø Puts arms in front of the face to avoid having it washed
Child at the age of 10 months
Physical development
Ø Labyrinth-righting reflex is strongest
Gross motor development
Ø Crawls by pulling self forward with the hands
Ø Can change from prone to a sitting position
Ø Pulls self to a sitting position
Ø Stands while holding onto furniture, sits by falling down
Ø Recovers balance easily while sitting
Ø While standing, lifts one foot to take a step
Fine motor development
Ø Crude release of an object is beginning
Ø Grasps a bell by a handle
Sensory development
Ø Localizes sounds by turning the head diagonally and directly toward the sound
Ø Depth perception is increasing
Vocalization development
Ø Says dada, mama with meaning
Ø Comprehends "bye-bye"
Ø May say one word (for example, hi, bye, what, no)
Socialization development
Ø Inhibits behavior to verbal command of "no-no" or own name
Ø Imitates facial expressions, waves bye-bye
Ø Extends a toy to another person but will not release it
Ø Looks around a corner or under a pillow for an object
Ø Repeats actions that attract attention and are laughed at
Ø Pulls clothes of another to attract attention
Ø Plays interactive games such as pat-a-cake
Ø Reacts to an adult is anger, cries when scolded
Ø Demonstrates independence in dressing, feeding, locomotive skills, and testing of parents
Ø Looks at and follows pictures in a book
Child at the age of 11 months
Physical development
Ø Eruption of the lower lateral incisors may begin
Gross motor development
Ø Creeps with the abdomen off floor
Ø When sitting, pivots to reach toward the back to pick up an object
Ø Cruises or walks holding onto furniture or with both hands held
Fine motor development
Ø Can hold a crayon to make a mark on paper
Ø Explores objects more thoroughly (for example, clapper inside the bell)
Ø Neat pincer grasp
Ø Drops an object deliberately for it to be picked up
Ø Puts one object after another into a container (sequential play)
Ø Able to manipulate an object to remove it from tight-fitting enclosure
Sensory development
Ø Localizes sounds by turning the head diagonally and directly toward sound
Ø Depth perception is increasing
Vocalization development
Ø Imitates definite speech sounds
Ø Uses jargon
Socialization development
Ø Experiences joy and satisfaction when a task is mastered
Ø Reacts to restrictions with frustration
Ø Rolls a ball to another on request
Ø Anticipates body gestures when a familiar nursery rhyme or story is being told (for example, holds the toes and the feet in response to “This little piggy went to market”)
Ø Plays game up-down, “so-big”, or peekaboo by covering the face
Ø Shakes the head for “no”
Child at the age of 12 months
Physical development
Ø Birth weight has been tripled
Ø Birth length has been increased by 50%
Ø Head and chest circumference is equal (head circumference 46.5 cm )
Ø Has total of six to eight deciduous teeth
Ø Anterior fontanel is almost closed
Ø Landau reflex is fading
Ø Babinski’s reflex disappears, the lumbar curve develops, the lordosis is evident during walking
Gross motor development
Ø Walks with one hand held
Ø Cruises well
Ø May attempt to stand alone momentarily
Ø Can sit down from a standing position without help
Fine motor development
Ø Releases a cube in a cup
Ø Attempts to build a two-block tower but fails
Ø Tries to insert a pellet into a narrow-neck bottle but fails
Ø Can turn pages in a book, many at a time
Sensory development
Ø Visual acuity is 20/50 +
Ø Discriminates simple geometric forms (for example, circle)
Ø Amblyopia may develop with lack of binocularity
Ø Can follow rapidly a moving object
Ø Controls and adjusts response to a sound, listens to a sound to recur
Vocalization development
Ø Says two or more words besides dada, mama
Ø Comprehends the meaning of several words (comprehension always precedes verbalization)
Ø Recognizes objects by name
Ø Imitates animal sounds
Ø Understands simple verbal commands (for example, “Give it to me”, “Show me your eyes”)
Socialization development
Ø Shows emotions such as jealousy, affection (may give hug or kiss on request), anger, fear
Ø Enjoys familiar surroundings and explores away from mother
Ø Fearful in strange situation, clings to mother
Ø May develop habit of “security blanket” or a favorite toy
Ø Unceasing determination to practice locomotor skills
Child at the age of 15 months
Physical development
Ø Has total of eight to 10 deciduous teeth
Ø Anterior fontanel is almost closed
Ø Sucking reflex disappears, the lumbar curve develops, the lordosis is evident during walking
Gross motor development
Ø Walks without help (usually since the age of 13 months)
Ø Creeps up stairs
Ø Kneels without support
Ø Cannot walk around corners or stop suddenly without losing balance
Ø Assumes a standing position without support
Ø Cannot throw a ball without falling
Fine motor development
Ø Constantly casting objects to the floor
Ø Builds a tower of two cubes
Ø Holds two cubes in one hand
Ø Releases a pellet into a narrow-necked bottle
Ø Scribbles spontaneously
Ø Uses cup well but rotates a spoon
Sensory development
Ø Able to identify geometric forms; places round object into appropriate hole
Ø Binocular vision well-developed
Ø Displays an intense and prolonged interest in pictures
Vocalization development
Ø Uses expressive jargon
Ø Says four to six words, including names
Ø “Asks” for objects by pointing
Ø Understands simple commands
Ø May use head-shaking gesture to denote “no”
Ø Uses “no” even while agreeing to the request
Socialization development
Ø Tolerates some separation from mother
Ø Less likely to fear strangers
Ø Beginning to imitate parents, such as cleaning house (sweeping, dusting, folding clothes)
Ø Feeds self using a cup with little spilling
Ø May discard a bottle
Ø Manages a spoon but rotates it near mouth
Ø Kisses and hugs parents, may kiss pictures in a book
Ø Expressive of emotions, has temper tantrums
Child at the age of 18 months
Physical development
Ø Physiologic anorexia from decreased growth needs
Ø Anterior fontanel is closed
Ø Able to control sphincters
Gross motor development
Ø Runs clumsily, falls often
Ø Walks up stairs with one hand held
Ø Pulls and pushes toys
Ø Jumps in place with both feet
Ø Seats self on a chair
Ø Throws a ball overhand without falling
Fine motor development
Ø Builds a tower of three to four cubes
Ø Release, prehension, and reach well-developed
Ø Turns pages in a book two or three at a time
Ø In drawing, makes stroke imitatively
Ø Manages spoon without rotation
Sensory development
Ø Able to identify geometric forms; places a round object into appropriate hole
Ø Binocular vision is well-developed
Ø Displays an intense and prolonged interest in pictures
Vocalization development
Ø Says 10 or more words
Ø Points to a common object, such as a shoe or a bail, and to two or three body parts
Socialization development
Ø Great imitator (“domestic mimicry”)
Ø Manages a spoon well
Ø Takes off gloves, socks, and shoes and unzips
Ø Temper tantrums may be more evident
Ø Beginning awareness of ownership (“my toy”)
Ø May develop dependency on transitional objects, such as "security blanket"
Child at the age of 24 months
Physical development
Ø Head circumference is 49 to 50 cm (191/2 to 20 inches)
Ø Chest circumference exceeds the head circumference
Ø Lateral diameter of the chest exceeds anteroposterior diameter
Ø Usual weight gain is from 1.8 to 2.7 kg (4 to 6 pounds)
Ø Usual gain in height is from 10 to 12.5 cm (4 to 5 inches)
Ø May achieve readiness for beginning daytime control of the bowel and the bladder
Ø Primary dentition of 16 teeth
Gross motor development
Ø Goes up and down stairs alone with two feet on each step
Ø Runs fairly well, with wide stance
Ø Picks up an object without falling
Ø Kicks a ball forward without overbalancing
Fine motor development
Ø Builds a tower of six to seven cubes
Ø Aligns two or more cubes like a train
Ø Turns pages of a book one at a time
Ø In drawing, imitates vertical and circular strokes
Ø Turns the doorknob, unscrews a lid
Sensory development
Ø Accommodation is well-developed
Ø Visual acuity, 20/40
Ø In geometric discrimination, able to insert square block into oblong space
Vocalization development
Ø Has the vocabulary of approximately 300 words
Ø Uses two- to three-word phrases
Ø Uses pronouns I, me, you
Ø Understands directional commands
Ø Gives the first name, refers to self by name
Ø Verbalizes need for toileting, food, or drink
Ø Talks incessantly
Socialization development
Ø Stage of parallel play
Ø Has sustained attention span
Ø Temper tantrums is decreasing
Ø Pulls people to show them something
Ø Increased independence from mother
Ø Dresses self in simple clothing
Child at the age of 30 months
Physical development
Ø Birth weight has been quadrupled
Ø Primary dentition (20 teeth) has been completed
Ø May have daytime bowel and bladder control
Gross motor development
Ø Jumps with both feet
Ø Jumps from a chair or a step
Ø Stands on one foot momentarily
Ø Takes a few steps on tiptoe
Fine motor development
Ø Builds a tower of eight cubes
Ø Adds chimney to a train of cubes
Ø Good hand-finger coordination, holds a crayon with fingers rather than the fist
Ø Can move fingers independently
Ø In drawing, imitates vertical and horizontal strokes, makes two or more strokes for cross
Sensory development
Ø Accommodation is well-developed
Ø Visual acuity, 20/40
Ø In geometric discrimination, able to insert a square block into an oblong space
Vocalization development
Ø Gives the first and last name
Ø Refers to self by an appropriate pronoun
Ø Uses plurals
Ø Names one color
Socialization development
Ø Separates more easily from mother
Ø In play, helps to put things away, can carry breakable objects, pushes with good steering
Ø Begins to notice sex differences, knows own sex
Ø May attend to toilet needs without help except for wiping
Child at the age of 3 years
Physical development
Ø Heart rate is approximately 105-110 beats/min
Ø Respiratory rate is approximately 26-28 breaths/min
Ø Blood pressure: systolic 96-106 mg Hg, diastolic 40-53 mm Hg
Ø Usual weight gain is from 1.8 to 2.7 kg (4 to 6 pounds)
Ø Usual gain in height is from 5 to 6.25 cm (2 to 21/2 inches)
Ø May achieve nighttime control of bowel and bladder
Gross motor development
Ø Rides a tricycle
Ø Jumps off a bottom step
Ø Stands on one foot for a few seconds
Ø Goes up stairs using alternate feet, may still come down using both feet on the step
Ø Broad-jumps
Ø May try to dance, but balance may not be adequate
Fine motor development
Ø Builds a tower of nine to 10 cubes
Ø Builds a bridge with three cubes
Ø Adeptly places small pellets in a narrow-necked bottle
Ø In drawing, copies a circle, imitates a cross, names what he has drawn, cannot draw a stick figure but may make a circle with facial features
Sensory development
Ø Able to copy geometric figures
Ø Can place geometric forms into respective opening if a form board is reversed
Ø Reading readiness may be present
Vocalization development
Ø Has vocabulary of about 900 words
Ø Uses primarily “telegraphic” speech
Ø Uses complete sentences of three to four words
Ø Talks incessantly regardless of whether anyone is paying attention
Ø Repeats sentence of six syllables
Ø Constantly asks questions
Socialization development
Ø Dresses self almost completely if helped with back buttons and told which shoe is right or left
Ø Buttons and unbuttons accessible buttons
Ø Pulls on shoes
Ø Has increased attention span
Ø Feeds self completely
Ø Pours from a bottle or a pitcher
Ø Can prepare simple meals, such as cold cereal and milk
Ø Can help to set table, dry dishes without breaking any
Ø Likes to “help” entertain by passing around food
Ø May have fears, especially of dark and going to bed
Ø Knows own sex and appropriate sex of others
Ø In play, parallel and associative phase, begins to learn simple games and the meaning of rules, but follows them according to self-interpretation, speaks to a doll, an animal, a truck, and so on, begins to work out social interaction through play, able to share toy, although expresses idea of “mine” frequently
Cognition
Ø Is in preconceptual phase
Ø Is egocentric in thought and behavior
Ø Has a beginning understanding of time, uses many time-oriented expressions, talks about past and future as much as about present, pretends to tell the time
Ø Has an improved concept of space as demonstrated in the understanding of prepositions and ability to follow directional command
Ø Has a beginning ability to view concepts from another perspective
Family relationships
Ø Attempts to please parents and conform to their expectations
Ø Is aware of family relationships and sex role functions
Ø Boys tend to identify more with father or other male figure
Ø Has an increased ability to separate easily and comfortably from the parents for short periods
Child at the age of 4 years
Physical development
Ø Pulse, respiration, and blood pressure decrease very slightly
Ø Height and weight gain remains constant
Ø Length at birth is doubled
Gross motor development
Ø Skips and hops on one foot
Ø Catches a ball reliably
Ø Throws a ball overhand
Ø Walks down the stairs using alternate footing
Fine motor development
Ø Imitates a gate with cubes
Ø Uses scissors successfully to cut out a picture following outline
Ø Can lace shoes but may not be able to tie bow
Ø In drawing, copies a square, traces a cross and diamond, adds three parts to stick figure
Sensory development
Ø Maximum potential for development of amblyopia
Vocalization development
Ø Has the vocabulary of 1500 words or more
Ø Uses sentences of four to five words
Ø Questioning is at peak
Ø Tells exaggerated stories
Ø Knows simple songs
Ø May be mildly profane if he associates with older children
Ø Obeys four prepositional phrases, such as “under”, “on top of”, “beside”, “in back of” or “in front of”
Ø Names one or more colors
Ø Comprehends analogies, such as, “If ice is cold, fire is ___”
Ø Repeats four digits
Ø Uses words liberally but frequently does not comprehend meaning
Socialization development
Ø Very independent
Ø Tends to be selfish and impatient
Ø Aggressive physically as well as verbally
Ø Takes pride in accomplishments
Ø Has mood swings
Ø Boasts and tattles
Ø Shows off dramatically, enjoys entertaining others
Ø Tells family tales to others with no restraint
Ø Still has many fears
Ø In play, cooperative and associative, imaginary playmates common, uses dramatic, imaginative, and imitative devices, works through unresolved conflicts, such as jealousy toward sibling, anger toward the parent, or unconquered fear in himself, sexual exploration and curiosity demonstrated through play, such as being “doctor” or “nurse”
Cognition
Ø Is in phase of intuitive thought
Ø Causality is still related to proximity of events
Ø Understands time better, especially in terms of sequence of daily events
Ø Unable to conserve matter
Ø Immediate perceptual clues dominate judgment
Ø Can choose longer of two lines or heavier of two objects
Ø Is beginning to develop less egocentrism and more social awareness
Ø May count correctly but has poor mathematic concept of numbers
Ø Still believes that thoughts cause events
Ø Obeys because the parents have set limits, not because of understanding of reason behind right or wrong
Family relationships
Ø Rebels if the parents expect too much from him, such as impeccable table manners
Ø Takes aggression and frustration out on the parents or siblings
Ø Do’s and don’ts become important
Ø May have rivalry with older or younger siblings, may resent older’s privileges and younger’s invasion of privacy and possessions
Ø May run away from home
Ø Identifies strongly with the parent of opposite sex
Ø Is able to run errands outside the home
Child at the age of 5 years
Physical development
Ø Pulse, respiration, and blood pressure decrease slightly
Ø Growth rate is similar to that of the previous year
Ø Eruption of permanent dentition may begin, especially if deciduous tooth eruption was early (before the age of 6 months)
Ø First permanent teeth to erupt are four molars, which come in behind the last temporary teeth (often mistaken for temporary molars)
Ø Handedness is established (about 90% are right-handed)
Gross motor development
Ø Skips and hops on alternate feet
Ø Throws and catches ball well
Ø Skates with good balance
Ø Walks backward with heel to toe
Ø Jumps from height of 30 cm (12 inches), lands on toes
Ø Balances on alternate feet with eyes closed
Fine motor development
Ø Ties shoelaces
Ø Uses scissors, simple tools, or a pencil very well
Ø In drawing, copies a diamond and triangle; adds seven to nine parts to stick a figure, prints a few letters, numbers, or words, such as his first name
Sensory development
Ø Minimum potential for the development of amblyopia
Ø Visual acuity approaches 20/20 (may not be completely achieved until the age of 8)
Vocalization development
Ø Has the vocabulary of about 2100 words
Ø Uses sentences of six to eight words, with all parts of speech
Ø Names coins (nickel, dime, and so on)
Ø Names four or more colors
Ø Describes drawing or pictures with much comment and enumeration
Ø Asks the meaning of words
Ø Asks inquisitive questions
Ø Can repeat a sentence of 10 syllables or more
Ø Knows the names of days of week, months, and other time-associated words
Ø Defines the words using action as well as description
Ø Knows the composition of articles, such as, “A shoe is made of ____ ”
Ø Can follow three demands in succession
Socialization development
Ø Less rebellious and quarrelsome than at the age of 4 years
Ø More settled and eager to get down to business
Ø Not as open and accessible in thoughts and behavior as in earlier years
Ø Independent but trustworthy, not foolhardy
Ø Has fewer fears, relies on outer authority to control the world
Ø Eager to do things right and to please, tries to “live by the rules”
Ø Acts “manly” or “womanly”
Ø Takes an increased responsibility for his actions
Ø Has fairly consistent and polished manners
Ø Cares for himself totally, occasionally needing supervision in dress or hygiene
Cognition
Ø Begins to question what parents think by comparing them with age-mates and other adults
Ø May notice prejudice and bias in outside world
Ø Is more able to view the other’s perspective but tolerates differences rather than understands them
Ø Tends to be a matter-of-fact about differences in others
Ø May begin to show the understanding of conservation of numbers through counting objects regardless of arrangement
Family relationships
Ø Gets along well with parents
Ø Does not run away from home
Ø May seek out mother more often than at the age of 4 years for reassurance and security, especially when entering school
Ø Is upset not to find the parent, for example, when he comes home from school
Ø Tolerates siblings but finds 3-year-old children a special nuisance
Ø Begins to question the parents’ thinking and principles
Ø Strongly identifies with the parent of same sex, especially boys with their fathers
Assessment of the reflexes in the normal neonate
Evaluating the transitional reflexes includes three points:
1. What reflexes present in a child?
2. Are they symmetric?
3. Conformity of the reflexes to the age of a child.
Gross motor behavior
Gross motor behavior includes developmental maturation in posture, head balance, sitting, creeping, standing, and walking. The full-term neonate is born with some ability to hold the head erect and reflexly assumes the postural tonic neck position when supine. Several of the primitive reflexes have significance in terms of development of later gross motor skills. The righting reflexes are those reflexes that elicit certain postural responses, particularly of flexion or extension. They are responsible for certain motor activities, such as rolling over, assuming a crawl position, and maintaining normal head-trunk-limb alignment during all activities. The neck-righting reflex, which turns the body to the same side as the head, enables the child to roll over from supine to prone. Other reflexes, such as the otolith-righting and labyrinth-righting reflexes, enable the infant to raise the head.
The asymmetric tonic neck reflex, which persists from birth to 3 months, prevents the infant from rolling over. The symmetric tonic neck reflex, which is evoked by flexing or extending the neck, helps the infant to assume the crawl position. When the head and neck are extended, the extensor tone of the upper extremities and the flexor tone of the lower extremities increase. The child extends the arms and bends the knees. Because of the strong flexor tone of the lower extremities, the infant may initially crawl backward before forward. This reflex disappears when neurologic maturity allows actual crawling to occur because independent limb movement is required.
Head control. The full-term newborn can momentarily hold the head in midline and parallel when the body is suspended ventrally and can lift and turn the head from side to side when prone. However, a marked head lag is evident when the infant is pulled from a lying to a sitting position. By 3 months the infant can hold his head well beyond the plane of his body, and by 4 months he can lift the head and front portion of the chest about 90 degrees above the table, bearing his weight on the forearms. Only slight head lag is evident when the infant is pulled from a lying to a sitting position. By 6 months he can raise the chest and upper part of the abdomen off the table, maintaining his weight on the hands. By 7 months he can bear weight on one hand while exploring with the other.
Rolling over. The newborn may accidentally roll over because of his rounded back. The neck-righting reflex enables him to roll from the back to the side at 4 months. The ability to willfully turn from the abdomen to the back occurs at 5 months and from the back to the abdomen at 6 months. It is noteworthy that the parachute reflex, which elicits a protective response to falling, appears at 7 months.
Sitting. The ability to sit follows the progressive head control and the straightening of the back. Although there is a marked head lag in the sitting position at birth, the infant contracts the neck, shoulder, and arm muscles, enabling him to raise the head when pulled halfway to a sitting position. He will make attempts to lift the chin and right the head while sitting. At 3 months the head lag is slight; at 4 months it is absent; by 6 months the infant lifts the head when he is about to be pulled in sitting. By the next month he spontaneously raises the head in an attempt to sit up by himself.
For the first couple of months the back is uniformly rounded. As the spinal column straightens, the infant is able to be propped in a sitting position. By 7 months he can sit alone, leaning forward on his hands for support. By 8 months he can sit well unsupported and begins to explore his surroundings in this position rather than in a lying position. By 10 months he can maneuver from a prone to a sitting position.
Locomotion. If the young infant is placed in a standing position, the body is usually limp at the hips and knees. By 6 to 7 months the infant is able to bear all his weight. By 9 months he stands holding onto furniture and can pull himself to the standing position but is unable to maneuver himself back down, except by falling. At 10 months he can step with one foot and crawls well. At 11 months he can creep and cruise or walk while holding onto furniture or with both hands held. By 52 weeks he is able to walk with one hand held.
Fine motor behavior
Fine motor behavior includes the use of the hands and fingers in the prehension of an object. Grasping occurs during the first 2 to 3 months as a reflex and gradually becomes voluntary. At 1 month the hands are predominantly closed and by 3 months are mostly open. By this time the infant demonstrates a desire to grasp an object, but he “grasps” it more with the eyes than with the hands. If a rattle is placed in his hand, he will actively hold onto it. By 4 months he regards a small pellet and his hands and looks from the object to his hands and back again. Hand regard is common at this age because of the limitation of symmetric positioning, which prevents the infant from exploring the periphery. Hand regard occurs in children who are blind, since it is a developmental process that occurs without visual stimulation. The fingering usually includes pulling at blankets and clothes and sucking on the fists or fingers.
By 5 months the infant is able to voluntarily grasp an object, but prehension is two-handed. The palmar grasp begins with grasping the object in the ulnar side of the palm (toward the fourth and fifth fingers) for the first 6 months. From 6 to 8 months, grasping occurs on the radial side (second and third fingers) and the base of the thumb. From 8 to 10 months the index, fourth, and fifth fingers form a crude pincer grasp with the lower part of the thumb. By 10 months the index finger and thumb are used in apposition for a neat pincer grasp.
By 6 months the infant has increased manipulative skill. He holds his bottle, grasps his feet and pulls them to his mouth, and feeds himself a cracker. He enjoys tearing and crumbling paper and explores it thoroughly in his mouth. If he is given two objects, he will hold one and drop the other.
By 7 months he transfers objects from one hand to the other and employs one hand for grasping. He enjoys banging objects and explores movable parts in a toy.
By 10 months pincer grasp is established and the infant is able to pick up a raisin and other finger foods. He can deliberately let go off an object and will offer it to someone, but true casting, deliberate throwing objects one after the other, is not evident until 12 to 15 months of age. By 11 months he puts objects into a container and likes to remove them. By 1 year of age the infant tries to build a tower of two blocks but fails. Deliberately releasing an object has advanced; he now releases a cube into a cup following a demonstration.
Language behavior
The infant is a very social being. His first means of verbal communication is crying. He learns to signal displeasure before pleasure. Vocalizations heard during crying become the syllables and the words of the child. A classic example is the “mama” heard during vigorous crying. The infant vocalizes as early as 5 to 6 weeks by making small throaty sounds. By 2 months he makes single vowel sounds, such as ah, eh, and uh. By 3 to 4 months the consonants n, k, g, p, and b are added and the infant coos, gurgles, and laughs aloud. By 8 months he adds the consonants t, d, and w and combines syllables, such as dada, but does not ascribe meaning to the word until 11 to 12 months. He makes sounds, such as coughing or snorting, to attract attention. By 9 to 10 months he can comprehend the meaning of the word “no”, obey simple commands, and respond to his name. By 1 year he can say two to three words with meaning.
During the acquisition of new language skills it is not unlikely for the child to temporarily give up other recently learned sounds or words. This is often distressing for parents after waiting in anticipation for the words “dada” or “mama”. However, these sounds are frequently given up for other vocalizations and may not be repeated for several weeks. It is reassuring for parents to know that the child will again say these words, probably with meaning. Not making these sounds bears no negative message from the infant.
Personal-social behavior
Personal-social behavior includes the child’s personal responses to his environment. It is the area most influenced by external stimuli but, as in the other fields of behavior, follows certain developmental laws. Personal-social behavior implies communication with one's self and with others. It is foundational for the successful mastery of skills such as feeding, control of bodily functions, independence, and cooperativeness in play.
Recently research has confirmed what parents knew all along that infants are responsive, social beings. They have the ability to shape their environment and to elicit certain responses. The newborn shows visual preference for the human face and, as early as 1 week of age, begins to watch his mother intently as she speaks to him. As he regards her face his activity diminishes, his head bobs up and down, and his mouth moves almost as if trying to say something.
By 6 to 8 weeks a social smile in response to pleasurable stimuli is present. This has a profound effect on the family members and is a tremendous stimulus for evoking continued responses from others. By 3 months he shows considerable interest in the environment: excitement when a toy is presented, refusal to be left alone, recognition of mother, and demonstration of pleasure by squealing. By 4 months he laughs aloud and enjoys strange, novel stimuli.
By 6 months the infant is a very personable child. He plays games such as peekaboo when his head is hidden in a towel, he signals his desire to be picked up by extending his arms, and he shows displeasure when a toy is removed or his face is washed. There is an increasing demonstration of his ability to control his environment. The acquisition of fine and gross motor skills allows him much more independence in movement.
By the second half of the first year the infant understands simple discipline, such as the meaning of the word "no" or a scolding remark. He comprehends different facial expressions and is sensitive to emotional changes in others. Imitation is developing during this time. By 7 months he imitates acts and noises, by 8 months sounds, and by 10 months games such as pat-a-cake and peekaboo.
From 11 months onward he is increasingly independent. He is learning to feed himself and use a spoon and a cup and can help with dressing by putting his foot out for a shoe or pushing his arm through the sleeve. He not only comprehends the meaning of “no”, but shakes his head to signal his understanding. He can follow simple directions and will gladly perform for others to attract and prolong attention.
Play. Play is becoming more sophisticated and interdependent. From birth to 3 months the infant’s response to the environment is global and largely undifferentiated. Play is dependent; pleasure is demonstrated by a quieting attitude (1 month), later by a smile (2 months), and then by a squeal (3 months). From 3 to 6 months the infant shows more discriminate interest in the stimuli presented to him and begins to play alone with a rattle or soft stuffed toy or to play with someone else. There is much more interaction during play. By 4 months of age he laughs aloud, shows preference for certain toys, and becomes excited when food or a favorite object is brought to him. He recognizes an image in a mirror, smiles at it, and vocalizes to it.
By 6 months to 1 year play is much more sophisticated and involves sensorimotor skills. Actual games are played, such as peekaboo, pat-a-cake, verbal repetition, and imitation of simple gestures in response to demonstration. Play is much more selective, not only in terms of specific toys, but also in terms of “playmates”. Although play is solitary or one-sided, the infant chooses with whom he will interact. At 6 to 8 months he usually refuses to play with strangers until he begins to know them. Parents are definite favorites, and he knows how to attract their attention. At 6 months he extends his arms to be picked up, at 7 months he coughs to make his presence known, at 10 months he pulls the parents’ clothing, and at 12 months he calls them by name. This represents a tremendous advance from the newborn who signaled biologic needs by crying to express displeasure.
Stimulation is as important for developmental growth as food is for biologic growth. Knowledge of developmental milestones allows the doctor to guide parents regarding proper play for infants. It is not sufficient to place a mobile over a crib and toys in a playpen for a child’s optimum social, emotional, and intellectual development. Play must provide interpersonal contact, as well as recreational and educational stimulation. Infants need to be played with, not merely allowed to play. Although the type of play infants engage in is called solitary, this is only a figurative, not literal, term to denote one-sided play. The kind of toys given to the child is much less important then the quality of personal interaction that occurs.
COGNITIVE DEVELOPMENT.
The 6 mo old infant has discovered his hands and will soon learn to manipulate objects. At first, everything goes into the mouth. In time, novel objects are picked up, inspected, passed from hand to hand, banged, dropped, and then mouthed. Each action represents a nonverbal idea about what things are for (in Piagetian terms, a schema). The complexity of an infant's play, how many different schemata are brought to bear, is a useful index of cognitive development at this age. The pleasure, persistence, and energy with which infants tackle these challenges suggest the existence of an intrinsic drive or mastery motivation. Mastery behavior occurs when infants feel secure; those with less secure attachments show limited experimentation and less competence.
A major milestone is the achievement at about 9 mo of object permanence (constancy), the understanding that objects continue to exist, even when not seen. At 4–7 mo of age, infants look down for a yarn ball that has been dropped, but quickly give up if it is not seen. With object constancy, infants persist in searching, finding objects hidden under a cloth or behind the examiner's back. Peek-a-boo brings unlimited pleasure as the child magically brings back the other player. Events seem to occur as a result of the child's own activities.
EMOTIONAL DEVELOPMENT.
The advent of object permanence corresponds with qualitative changes in social and communicative development. Infants look back and forth between an approaching stranger and a parent, and may cling or cry anxiously, demonstrating “stranger anxiety.” Separations often become more difficult. Infants who have been sleeping through the night for months begin to awaken regularly and cry, as though remembering that the parents are in the next room.
A new demand for autonomy also emerges. Poor weight gain at this age often reflects a struggle between an infant's emerging independence and parent's control of the feeding situation. Use of the 2-spoon method of feeding (1 for the child and 1 for the parent), finger foods, and a high chair with a tray table can avert potential problems. Tantrums make their first appearance as the drives for autonomy and mastery come in conflict with parental controls and the infants' still-limited abilities.
COMMUNICATION.
Infants at 7 mo of age are adept at nonverbal communication, expressing a range of emotions and responding to vocal tone and facial expressions. Around 9 mo of age, infants become aware that emotions can be shared between people; they show parents toys as a way of sharing their happy feelings. Between 8 and 10 mo of age, babbling takes on a new complexity, with many syllables (“ba-da-ma”) and inflections that mimic the native language. Infants now lose the ability to distinguish between vocal sounds that are undifferentiated in their native language. Social interaction (attentive adults taking turns vocalizing with the infant) profoundly influences the acquisition and production of new sounds. The first true word (i.e., a sound used consistently to refer to a specific object or person) appears in concert with an infant's discovery of object permanence. Picture books now provide an ideal context for verbal language acquisition. With a familiar book as a shared focus of attention, a parent and child engage in repeated cycles of pointing and labeling, with elaboration and feedback by the parent.
IMPLICATIONS FOR PARENTS AND PEDIATRICIANS.
With the developmental reorganization that occurs around 9 mo of age, previously resolved issues of feeding and sleeping re-emerge. Pediatricians can prepare parents at the 6 mo visit so that these problems can be understood as the result of developmental progress and not regression. Parents should be encouraged to plan ahead for necessary, and inevitable, separations (e.g., baby sitter, daycare). Routine preparations may make these separations easier. Introduction of a “transitional object” may allow the infant to self-comfort in the parents' absence.
Infants' wariness of strangers often makes the 9 mo examination difficult, particularly if the infant is temperamentally prone to react negatively to unfamiliar situations. Initially, the pediatrician should avoid direct eye contact with the child. Time spent talking with the parent and introducing the child to a small, washable toy will be rewarded with more cooperation. The examination can be continued on the parent's lap when feasible.
References
à) Basic
1. Manual of Propaedeutic Pediatrics / S.O. Nykytyuk, N.I. Balatska, N.B. Galyash, N.O. Lishchenko, O.Y. Nykytyuk – Ternopil: TSMU, 2005. – 468 pp.
2. Kapitan T. Propaedeutics of children’s diseases and nursing of the child : [Textbook for students of higher medical educational institutions] ; Fourth edition, updated and
translated in English / T. Kapitan – Vinnitsa: The State Cartographical Factory, 2010. – 808 pp.
3. Nelson Textbook of Pediatrics /edited by Richard E. Behrman, Robert M. Kliegman; senior editor, Waldo E. Nelson – 19th ed. – W.B.Saunders Company, 2011. – 2680 p.
b) Additional
1. www.bookfinder.com/author/american-academy-of-pediatrics
2. American Academy of Pediatrics Task Force on Mental Health : Enhancing pediatric mental health care: strategies for preparing a primary care practice. Pediatrics 2010; 125(Suppl 3):S87-S108.
3. Glascoe FP, Leew S: Parenting behaviors, perceptions and psychosocial risk: impact on child development. Pediatrics 2010; 125:313-319.
4. www.bookfinder.com/author/american-academy-of-pediatrics
5. www.emedicine.medscape.com
6. http://www.nlm.nih.gov/medlineplus/medlineplus.html
Prepared by Nykytyuk S