Toddlerhood and the Preschool Years

For additional material related to the content of this chapter, please see Chapters 41 , and 44 .

Vignette

Nicky is a handsome, healthy 3-year, 6-month-old boy who was referred for “behavior and developmental concerns” by his primary care clinician. His parents are worried because he is having trouble communicating and becomes easily upset. Nicky began using single words at 12 months of age, phrases shortly before his second birthday, and short sentences by about 36 months of age. He currently has considerable difficulty expressing his thoughts. In addition, he is only about 75% intelligible to his parents and 50% intelligible to strangers. He throws tantrums that last about 30 minutes several times per week, typically triggered when he is unable to communicate effectively, is not getting his way, or experiences unexpected changes in his routine. Nicky sleeps through the night in his own bed, feeds himself with utensils, and helps with dressing. He is toilet trained for urine and stool during the day. He runs smoothly, rides a tricycle, and likes to draw with a crayon. He began preschool about 2 months ago. His teachers note that he is affectionate with the adults and his peers in the classroom, is motivated by praise, and is progressing with early preacademic skills such as counting and letter recognition. However, he does not remain seated during classroom activities, refuses to participate in selected classroom activities, especially answering questions at circle time, and has been aggressive with teachers on occasion, again mostly at circle time.

Introduction

This chapter describes developmental and behavioral considerations during toddlerhood and the preschool period. For our purposes here, toddlerhood refers to the period between 18 and 36 months of age, and the preschool period refers to the period between 3 and 5 years of age. Hallmarks of both periods include significant increases in receptive and expressive language skills, growth of social-emotional development and play, and increases in adaptive skills. The chapter will:

1.
Review developmental domains (e.g., communication, motor, social-emotional, cognitive, adaptive) as they relate to the toddler and preschool periods
2.
Review overarching concepts important for development such as self-regulation and school readiness
3.
Discuss clinical implications for providers, including screening/assessment and appropriate recommendations for parents

Developmental Domains

The toddler and preschool years are characterized by remarkable changes in development, with acquisition of a repertoire of skills critical to a child’s overall development and functioning. Table 7.1 reviews developmental expectations by domain. Looking broadly, children enter toddlerhood completely dependent on caregivers for almost all aspects of their lives and leave the preschool years with elaborate, well-developed skills. This remarkable acquisition of skills is well characterized in the Erikson stages of development (see Chapter 3 ). In the toddler years children seek autonomy. If that desire is not well negotiated, then they are left with a sense of shame. In the preschool years children demonstrate increasing initiative. If they cannot succeed with self-directed activities, then the result is a sense of guilt.

Table 7.1

Developmental Milestones by Domains

Adapted from ; ; ; ; ; ; ; .

Age	Communication	Gross Motor	Fine Motor	Adaptive	Social-Emotional	Cognitive
18 mo	Uses about 6–10 words (other than names) Uses giant words (e.g., “thank you”), then two-word phrases (19–24 mo) Identifies at least two body parts Points to at least one picture in book	Walks up stairs with two feet per step with hand held Sits in small chair Carries toy while walking Throws ball a few feet while standing Runs with toddler gait	Scribbles Imitates vertical stroke Builds three/four-cube tower	Helps dress and undress self Begins to scoop with spoon	Engages with others for play Points to object of interest to draw attention to it Turns and looks at adults if something new happens Gives kisses	Matches pairs of objects Copies doing chores
2 yr	Uses 50 words Combines two words into sentence Follows two-step command Points to ~10 pictures in book Speech is 50% intelligible to strangers	Walks down stairs with two feet per step holding rail Kicks ball Runs with coordination	Stacks objects Turns book pages Uses hands to turn objects (such as knobs, toys, lids)	Takes off some clothing Scoops and feeds self with spoon, spilling little	Plays alongside other children (parallel) Plays with more than one toy at the same time	Uses toys for simple play, like pushing a toy car Tries to use switches or buttons on a toy Sorts objects Matches objects to pictures
2.5 yr	Uses pronouns correctly Understands “just one” Follows two-step directions Follows two prepositions ( in, on )	Begins to walk up stairs with alternating feet Jumps in place Walks backward 10 steps Runs well without falling	Grasps crayon with thumb and fingers instead of fist	Urinates in toilet Spears food with fork	Engages in pretend or imitative play Uses objects to pretend, like feeding a block to a doll as if it were food	Shows simple problem-solving skills, like standing on a small stool to reach something Names at least one color Matches colors
3 yr	Uses three word sentences Speech is 75% intelligible to strangers Understands simple prepositions (e.g., on, under ) Answers “what” and “where” questions	Pedals tricycle Ascends stairs alternating feet Jumps forward Balances on one foot for 3 s	Copies a single circle Cuts with child scissors Unbuttons large button Strings small beads	Urinates independently Puts on coat, jacket, or shirt by self Eats independently	Plays cooperatively and shares Early imaginative play	Does puzzles with 3 or 4 pieces Picks the bigger of two items when asked Draws 2–3 part person Understands big/small Knows age and gender
4 yr	Uses four-word sentences Speech is 100% intelligible to strangers Answers “when” questions Tells stories Follows three-step command Points to things that are same vs. different	Gallops Balances on one foot for 4–8 s Hops on one foot two/three times Standing broad jump 1–2 ft Throws ball overhead 10 ft	Draws cross Copies square Unbuttons and buttons medium-size buttons Grasps pencil with thumb and fingers instead of fist	Independent for bowel habits Brushes teeth Dresses and undresses with minimal assistance	Engages in well-developed imaginative play Engages in group play Labels emotions in self (happy, sad, fear, anger)	Knows full name Names at least a few colors of items Understands simple time words (yesterday, tomorrow, morning, night) Knows what comes next in a well-known story Draws a person with 4+ body parts
5 yr	Understands left and right on self Understands adjectives Produces rhyming words Answers “why” questions Defines simple words Tells stories with beginning, middle, end	Balances for 8–10 s on one foot Jumps backward Skips	Writes first name Copies triangle Can button 1-in buttons	Completes simple chores well Bathes independently Dresses independently	Plays games with rules or turn taking with other children Likes to sing, dance, or act for others Tries not to hurt others while playing Apologizes for mistakes	Counts to 10 Identifies some single-digit numbers and letters Uses simple time words (yesterday, tomorrow, morning, night) Keeps attention for at least 5 to 10 min during activities

Note. These milestones generally represent the mean or average age of performance of these skills when available.

Communication

The development of communication involves evolution of both speech and language (see Chapter 44 ) and supports other important developments. The capacity to understand language and effectively communicate intentions, ideas, and emotions is necessary for virtually all aspects of learning. Receptive language advances result in the toddler learning from what people say in addition to what they do. Toddlers quickly learn that speech is a more efficient means of communication than gestures or facial expressions alone. Between 18 and 24 months of age, astounding changes in communication occur as toddlers experience a “word explosion,” rapidly moving from using single words to combining words into phrases and then sentences. They use language to communicate their desires and emotions and to learn what is going on around them. By 3 years of age, children talk about past experiences and use language to pretend. By 4 years of age, children can tell stories and express their thoughts and ideas. Because young children think faster than they can talk, up to about 3.5 years of disfluent speech (known as developmental or typical disfluency) sometimes results in whole word or phrase repetition.

Language acquisition involves complex interactions between biologic, psychosocial, and environmental factors. Wide variation is found in the rate of speech and language development. Yet, children who learn two languages simultaneously generally follow the same pattern of language development as monolingual language learners ( ). Although, on average, girls use more words than boys between 12 and 30 months of age, boys are only modestly behind and typically develop words within the accepted time frame ( ). Delays in speech and language development are rarely due solely to bilingual exposure or to sex.

Toddlers enter the word combination period at around 18 to 24 months of age. Children begin combining two-word phrases once they spontaneously use enough single words to label, request, and comment. Initially, word combinations may be holistic phrases or giant words; these are phrases the child often hears used together such as “thank you” or “let’s go.” Next, the child combines words into novel phrases such as “more juice” or “bye-bye mama.” By 24 months of age, toddlers combine words into two-word sentences with a verb + noun, such as “eat cookie” or “read book” ( ).

Following the initial word combination period is the sentence formation period. A rough rule of thumb is that 90% of children use two-word sentences at 2 years, three-word sentences by 3 years, and four-word sentences by 4 years of age ( ). Sentences become more complex as the child’s comprehension of grammar and language advances. By 3 to 4 years of age, children comprehend and use prepositions, adjectives, and adverbs and begin to ask and answer questions. Semantics (word meanings) and syntax (grammar) improve over time, and by 5 years of age children completely master grammatical tense marking. As children learn the rules of social communication, pragmatic language skills are refined. By 4 to 5 years of age, most children regularly use language to discuss emotions and feelings ( ) (see Social-Emotional Development, later).

Receptive language also develops in an orderly fashion during these years. A child’s receptive vocabulary is much larger than the number of words used expressively. The rule of thumb is that a child should be able to follow two-step directions by 2 years of age, two prepositional commands by age 2.5 years, and three-step commands by 3 years of age.

Children master sounds at different ages depending on the difficulty of producing the sound. More difficult sounds such as consonants /j/, /r/, /l/, /v/ and blends may not be mastered until the end of the preschool period. A formula for expected intelligibility level of toddlers and preschoolers to unfamiliar listeners is: age in years/4 × 100 = % understood by strangers. Therefore by 4 years of age, a child should be 100% intelligible to strangers even if the child has not yet mastered all consonants and blends ( ).

Motor Skills

Gross Motor Skills

Progression of gross motor abilities grants toddlers and preschool-aged children the power to explore their environment, which in turn allows them to enhance other skills such as the development of autonomy. By 18 months of age, toddlers are typically walking. With practice, their gait becomes steadier, and their stance narrows, due to improved core tone. At age 2 years, improved balance provides children with the ability to run, climb, kick a ball, and walk up or down stairs (initially 2 feet per step, then alternating by the end of this year). By the third birthday, children’s enhanced balance skills allow them to stand on one leg, jump, and ride a tricycle. Over the next 2 years, gross motor skills become more complex; they acquire the ability to hop, skip, jump backward, and ride a bicycle. There is a wide variation in milestone achievement in gross motor skills, especially in the advanced skills (e.g., some children will always struggle with balancing on a bicycle). Regression in gross motor skills is an unusual finding and warrants an evaluation by a physician.

Fine Motor Skills

Fine motor skill progression in this developmental period allows children to begin manipulating their environment. Abilities that are developed in the beginning of toddlerhood include spontaneous scribbling and stacking three cubes to make a tower, followed by imitation of vertical or circular strokes at age 24 months. Hand preference is typically established between 2 and 3 years of age. Children put these fine motor skills into their functional activities. At about age 2, they assist with undressing and dressing. Their feeding skills also improve; they progress from feeding themselves with their fingers to using utensils, such as spearing food with a fork. At 30 months of age, a more mature pencil grasp is developed, which involves holding a pencil between the thumb and forefinger. Children can copy a circle and cut with scissors at age 3 years, copy a cross at 3.5 years, copy a square at 4 years, and copy a triangle at 5 years. It is important to note that writing skills not only include fine motor abilities but are also influenced by language, memory, and attention. In regard to dressing, children can undress themselves (usually socks and pants first, then shirts) at 3 years, button and place shoes on the correct foot at 4 years, and tie shoes by 5 years.

Adaptive Functioning

Autonomy and Fear

The transition from dependence on caregivers to the development of autonomy is often first noted after children begin walking and becomes more pronounced as they improve motor skills in toddlerhood. Temperament plays a prominent role in this process (see Chapter 80 ); some children are risk averse and stay close to familiar adults, while others are sensation seeking and may wander far from their home base. Other developmental skills, including cognitive abilities and communication, also facilitate this progression. Children become increasingly able to engage with their environment beyond their caregivers.

Though children generally seek autonomous discovery, exploring “the unknown” may trigger fear. That fear causes them to “check in” with their caregiver(s) who can then provide them with feelings of familiarity and safety. The need for reassurance can be confusing for caregivers as they try to balance granting their children freedom to explore while providing them comfort when they become overwhelmed by fear or curiosity. Anticipatory guidance regarding the development of autonomy and accompanying fear is multifaceted. It should include implementation of safety precautions given that children may test boundaries and place themselves in potentially unsafe situations (e.g., climbing on high furniture). It should mention that children may seek reassurance from caregivers, even becoming physically clingy if their exploration triggers fear. Substantial cultural differences characterize expectations of autonomy in toddlers and preschool children. For example, Eurocentric cultures tend to emphasize autonomy while African, Asian, Latin American, and Indigenous cultures often value interdependence.

Toilet Training

Readiness for toilet training often emerges after 18 months of age, and attainment of this important skill is completed by 3 years of age for many children. Readiness is signaled by an interest in sitting on a toilet and is often accompanied by a desire to not be soiled. Developmental skills that support the toilet training process include the ability to communicate regarding the need to use the toilet and motor skills to remove clothing and sit on the toilet. At this age, children’s ability to imitate others using the toilet also facilitates their learning.

Training consists of both the child learning internal elimination cues and caregivers educating the child on the expected steps for completing this complicated task. Learning elimination cues tends to occur more quickly for girls than boys. The methods of caregiver education are strongly influenced by cultural factors (e.g., elimination communication).

Caregivers can often feel frustration during this process. Ultimately it is the toddler who must learn to control body movements. Many children respond well to a toileting schedule that is timed with their eating schedule to take advantage of the gastrocolic reflex. A reward system may be used during the toilet training process (see Chapter 4 ). However, it should reward cooperative tasks, such as sitting on the toilet, and not only successful completions. Some children prefer a child-size toilet, whereas others favor a standard toilet. It is highly recommended that children have a footstool provided if they use the standard toilet to help prop their legs, to allow for natural defecation positioning.

Assessment and intervention may be indicated for children who have had minimal progress with toilet training by age 3 years since it may be an indication of a serious condition. The most common medical cause for delayed toilet training is functional constipation, which can be diagnosed via history and physical examination. Interventions may consist of caregiver education about constipation, disimpaction of stool, subsequent maintenance of regular bowel movements (possibly with medication), and behavior strategies to improve toileting habits and behaviors (e.g. having consistent bowel movements inside the bathroom regardless if the child is on the toilet or in a diaper) ( ) (see Chapter 69 ). Teaching children with neurodevelopmental conditions to use the toilet should include consideration of their cognitive level; they may not yet possess the fundamental developmental skills needed for toilet training when they reach the appropriate chronologic age. Diagnostic criteria for encopresis include age of at least 4 years and at least 5 years for enuresis ( ) (see Chapter 69 ).

Feeding and Eating

Early healthy eating patterns can have a long-lasting impact on future health. It is not uncommon for children to become more selective during the toddler period than they were in infancy, as they flex their growing autonomy. They also may eat less during the toddler-preschool years than they did during infancy because of a decreasing rate of growth. Health care providers should share the importance of a varied diet and discuss age-appropriate portions with caregivers. However, socioeconomic status and culture may play roles in many aspects of eating, including food choices, food variety, and expectations for mealtime behavior. Federal grants and programs are available to assist families of young children gain access to healthy food and to avoid food insecurity. Children with neurodevelopmental conditions such as autism spectrum disorder (ASD) may have highly restrictive feeding patterns that require a multidisciplinary approach for treatment. The evaluation of extreme or persistent feeding or eating difficulties, such as highly restricted food choices, may require a team approach: examination by a health care provider for possible contributing medical conditions, assessment of nutritional needs by a dietician, evaluation of oromotor skills by a speech-language pathologist, and assessment of orosensory issues by an occupational therapist.

Sleeping

Though maturation of sleep architecture develops throughout childhood, sleep patterns should become consistent by toddlerhood, including the ability to fall asleep independently and sleep through the night. Night terrors and nightmares may present during toddlerhood and the preschool years. Most of the sleep-related issues that present in this era have a behavioral component (see Chapter 70 ). They may involve bedtime refusal or resistance and prolonged night awakenings that require caregiver involvement. Consistency, to the extent possible, is key. A child’s bedtime and wakeup time should be about the same time every day. Sleep hygiene is also important. A 30-minute bedtime routine that is the same every night should consist of low-stimulation activities such as a warm bath and reading a book in the room where the child sleeps. Screen time should be limited 1 to 2 hours before bed, with all screens (including television, phones, and tablets) out of the child’s bedroom (see Chapter 21 ). Naps should be geared to the child’s age and developmental needs; long naps or too many naps can result in sleeplessness at night. Effective behavior modifications at bedtime for behavioral insomnia include issuing a limited number of “bedtime passes,” use of written or visual schedules for bedtime routines, and caregiver redirection to return to bed without any reinforcement. The diagnostic workup for children presenting with sleepwalking, night terrors, or nightmares requires a focused history (including inquiry of family history of childhood parasomnias), a good sleep diary to assess for sleep deprivation, plus a physical examination. Cultural differences in regard to sleep practices are common (e.g., bedsharing) and should be explored with families to assist with shared decision making about sleep practices ( ). The constellation of frequent nightly snoring, observed apneas, and/or daytime somnolence is concerning for obstructive sleep apnea and may indicate need for a polysomnogram. Restless sleep (including involuntary jerking movements during sleep) may suggest restless leg syndrome or periodic limb movement disorder. Low serum ferritin levels may lead to abnormal sleep movements, and the condition may improve with supplemental iron.

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