TODDLERS & PRESCHOOLERS

1. TODDLERS & PRESCHOOLERS Health Promotion

2. Overview • Toddlers: 12 to 36 mos.; intense exploration of the environment; negativism; limit-setting; terrible twos; parents need support & guidance • Preschooler: 3-5 yr. old; preparation for entering school; refine tasks mastered during toddler yrs; increase control over bodily functions; increase attention span & frustration limits; caution! muscle development & bone growth still not mature; overexertion can injure delicate tissue

3. Bodily Changes • Weight: Birth wt. quadrupled by 2.5 yrs • 2 yr. 12 kg (27#) • 3 yr. 14.6 kg (32#) • 4 yr. 16.7 kg (36.75#) • 5 yr. 18.7 kg (41.25#) • Growth slows to approx. 4-6 lbs (1.8-2.7 kg) per year

4. Height • Height: adult ht = ~ 2x child’s at 2 yrs • 2 yrs 86.6 cm (34”) • 3 yrs 95 cm (37.25”) • 4 yrs 103 cm (40.5”) • 5 yrs 110 cm (43.25”) • Growth slows to ~ 3” /yr (7.5 cm); mainly in legs, not trunk

5. Toddler Changes • H.C. = C.C. @ 1-2 yrs, then C.C.>H.C. • Ant. Font. Closes 12-18 mos. • Visual acuity 20/40 • Persistent Strabismus – REFER • Hearing, smell, taste & touch become more developed • Develop taste preferences—finicky eater • Physiologic anorexia

6. Maturation of Systems • Brain growth • Myelination of spinal cord at 2 years allows for control of bowel and bladder • RR and HR slows & BP increases • Resp. sys. growth leads to less infections • Ear and throat structures still immature so URI, otitis media, tonsillitis common • Pot belly and bow legged til after 2nd yr

7. Maturation of Systems • GI/GU: gastric acidity now protective • Bladder capacity increase • Skin: tightly bound now • Body temp regulation no longer problem • Defense mechanisms more effective • Dentition complete – all 20 deciduous teeth by 30 mos

8. Gross Motor • 12-15 m walk alone w/wide stance • 18 m try to run but falls easily • 2 yr walk up and down stairs • 2.5 yr jump w/ both feet • 3 yr tricycle, walk on tiptoe, balances on 1 foot for few seconds, broad jumps • 4 yr skips & hops w/1 foot; catches ball • 5 yr skips w/alt. feet, jumps rope, skates, swim

9. Fine Motor • 12 m grasps very sm object • 15 m drops raisin into narrow neck btl; put round object in hole; scribble • 18 m throw ball overhand keeping balance; build tower of 3-4 blocks • 24 m tower of 6-7 blks; imitate circular stroke & verticle line • 30 m tower of 8 or more Activities done to produce a purposeful result

10. Fine Motor (cont) • 3 yr copies circle, imitates cross; holds pen with fingers, not fist • 4 yr trace cross & diamond; copies square; uses scissors; adds 3 parts to stick figure • 5 yr copies diamond & triangle; adds 7-9 parts to stick figure; prints a little • Scribbling & drawing essential for development & readiness skills for school

11. Psychosocial Development • Infancy: Trust vs mistrust • Toddler: Autonomy vs shame & doubt; need limit setting, consistent discipline; negativism & ritualism part of autonomy • Ego overcomes id as learn to delay gratification; rudimentary start of superego (conscience)

12. Psychosocial Development • Preschool: Initiative vs guilt; time of learning & accomplishment; learning right from wrong • Wishes same-sex parent dead –resolves during school age as identifies with parent • Major guilt and long lasting problems if parent actually dies during this time period • Superego cont. to develop; good vs bad; beginning of morality • Should be allowed to question & disagree

13. Oedipal Stage (Freud) • Result of learning separateness as persons • Oedipus complex – male wishes father dead so can marry his mother • Castration complex – thinks girls lost their penis d/t wrongdoing so worries same will happen because of bad thoughts • Electra complex – female wishes mother dead so can marry her father • Penis envy – desire to have a penis • Masturbation common as they discover their sexuality

14. Cognitive DevelopmentPiaget • 12-24 m: main goal is acquisition of language • Differentiation of oneself from objects • Aware of causal relationships but can’t transfer knowledge to new situations • Spacial awareness – nesting boxes • Object permanence advanced – know it exists even when it is gone

15. Cognitive (cont) • 19-24 m:object permanence: will search in several hiding places, not just original one • Domestic mimicry: household tasks • Time: still immature; developing some sense in terms of anticipation • Egocentrism: every event in reference to self, unable to see from another’s perspective

16. Cognitive (cont) • Preoperational Phase (Piaget): 2-7 yrs. bridges egocentric behavior & rudimentary social awareness of latency • Egocentric speech – repeats to hear oneself, only communicates about themselves “I do” • Animism: lifelike qualities to inanimate objects especially begins in toddlers • Magical thinking – believe thoughts are all powerful and can cause events. Play most effective for understanding children’s thinking. May misconstrue fantasy and reality.

17. Moral Development • Preconventional or Premoral(Kohlberg) • Punishment & obedience orientation 2-4 yr • Good/bad depends on reward/punishment • Type of discipline affects moral development • Use power (physical) – neg. view of morals, esp. authority figures • Withdraw love – behave out of guilt • Explain & use positive approaches & limit setting • More likely to internalize & be less hostile

18. Spiritual Development • Toddler: idea of God is vague; routines and rituals are important and comforting • Preschoolers: concrete thinking; God w/physical characteristics like imaginary friend; books are helpful • Important to view God as unconditional love vs judge of good or bad behavior esp. if ill or in hospital

19. Body Image • By 2 yr recognizes sexual differences • Words used to describe appearances become part of body language and image, • Unclear body boundaries – fear blood & insides will leak out – need bandaid • Preschoolers recognize diff. in skin color • Vulnerable to learning prejudices & biases

20. Sexuality • Toddlers: explore bodies and find pleasure • May fondle or masturbate; don’t label “dirty” • Preschoolers: very imp.time for sexual identity; strong attach. to opp. sex parent while identify with same sex parent • Childrearing practices & imitation are powerful ways to learn their identity

21. Social Development • Individuation-Separation: major accomplishments as toddler – completed by preschool age. • Tolerating & mastering brief periods of separation is imp.devel.task of this age • Very upset when parents leave; must prepare children ahead of time • Transitional objects provide security • Preschoolers cope better esp w/preparation & can work thru anxieties/fears through play

22. LANGUAGE • 1 yr: 4 words • 2 yr: 300 words, 2-3 word sentences • 3 -4 yrs: use 3-4 word sent. & incl. only words needed to get message across – telegraphic. Can give and follow simple commands • 4-5 yrs: longer sent. w/more words to convey message; Follow simple directional commands, but only 1 at a time • By 5: 2100 words; comprehension even greater; even if bilingual. By 6 uses all parts of speech.

23. Personal-Social Behavior • 15 m: feed selves; covered cup; spoon; helps dress, takes shoes & sox off • 18 m: removes gloves, may unzip • 24 m: use spoon well; removes clothes & puts on sox, shoes, pants • 36 m: using fork • 2-3 yrs: eats w/family, helps, but no table manners, hard to sit thru meal • 4-5 yr: need little or no help w/dressing, eating, or toileting

24. Play Toddlers: parallel play; need wide variety of play interactions, environments, activities Inspects toy, talks to toy, tests strength & durability, invents several uses for it Imitation: dress up, houses, farms, trucks, etc. Locomotive skills (balls, riding toys); fine motor (paints, chalk, puzzles), interlocking blocks Talking is play; imitating animal sounds, reading books, appropriate child’s TV shows Tactile play: water, sand, finger paints, clay

25. Play • Preschoolers: associative play; group play w/o rigid rules or organization • Begin to enjoy crafts; one simple project per year of age • Dramatic play: 4-5 yr esp. • Imaginary playmates: between 2.5 & 3 yr • Purposes: friends when lonely, accomplish what child is still trying to do, experience what child wants to forget or remember.

26. NUTRITION • Growth slows and caloric, protein, & fluid requirements decrease • Vits/mineral needs increase • Milk: 2-3 cups/day; >qt. limits other food intake; Fe def as well as others • After 2 yrs can be skim or low fat • ~18 m physiologic anorexia: picky, fussy, eaters w/strong taste preferences; social aspect of meals and control of refusing food; happens again about 4 yr.

27. Nutrition • 1 Tbsp. solid food per yr of age Eating habits first 2-3 yr have lasting effect • Older toddler and preschooler: quality more imp. than quantity • Toddlers – ritualism – same dish, cup, etc • Juice – 4-6 oz/day; not replace fruits • Allow to give up btl. when ready • By 5, tot. fat < 30% and > 20% tot. calories • Daily Ca 800 mg. 4-8 yrs. old

28. Sleep and Activity • Average 12 hr. sleep • Naps may stop by end of 2nd or 3rd yr • Bedtime rituals, transitional objects help with fears and trouble getting to sleep • Don’t put child in bed w/parent • Sleep terror : 1-4 hr after falls asleep; thrashing, yelling; goes right back to sleep • Nightmares: 2nd half of nite; scary dream; wakes up and hard to go back to sleep

29. Dental • First see dentist at 1 yr., then q 6-12 m • Complete eruption of deciduous teeth by beginning of preschool period • Toddlers can help but parents do most brushing and all flossing • Preschoolers still need supervision and flossing done by parents • Fluoridation of water most cost-effective

30. Injury Prevention • Child protection & adult ed. are crucial • Preschoolers esp imitate what they see so must be good role models (bike helmets) • MVA: #2 cause of accidental death ages 1-4 yrs; restraints not used or not used properly • At 20# can use convertible restraint in forward facing position until 40 #, then use booster seat til 60 # or 8 yr or midpoint of head is higher than seat back • > 3 yr involved more in ped traffic injuries d/t increased locomotion and unaware of dangers • Must teach safe ways to cross street and role model

31. DROWNING & BURNS • Drowning: #1 cause of accidental death in 1-4 year old. • Near-drowning one of leading causes of “vegetative” state in young children • Encourage parents to learn CPR • Burns: #5 cause of death in 1-4 yr old • Flame burns - one of most fatal; play w/matches & set self and home on fire • Scald burns: Keep hot water heater <49°(10” for burn) usually kept at 54°(30 sec. for burn)

32. Poisoning • Highest incidence is 2 yr. olds • Morbidity such as esophageal stricture • Major problem – improper storage • Locomotion and curiosity – only a locked cabinet is safe • Syrup of Ipecac is NO LONGER RECOMMENDED to cause emesis with ingestion of harmful substance. • Know Poison Control number: 1-800-222-1222 nationwide

33. Dental • No fluoride supplement before 6 months of age • Fluorosis: excess; causes cosmetic problems if occurs before 5-6 yrs. • Use pea size amt. of toothpaste for child • Cariogenic foods: honey, molasses, dried fruits, raisins, complex carbs, fruit juice • Baby bottle tooth decay (BBTD) p. 575 may need crowns; juice always should be in cup

34. Other Injuries • Playground injuries common • Falling from stairs – head injuries • Falls from open windows or leaning against screens • Falls from cribs; once 35” tall, need bed • No top bunk til at least 6 yr • Aspiration/suffocation: Hot dogs still need to be cut up! • Traumatic asphyxiation: electric garage doors, drawstrings on jackets or hoods • Suffocation: old refrig., ovens, toy boxes w/heavy hinged lids

35. Bodily Damage • Walking while holding sharp or pointed object: fork, scissors, etc. • Walking w/food or objects in mouth such as a spoon or toothbrush • All firearms must be locked up • Workshop tools locked up • Keep indoors while mowing • Teach safety w/ animals • Only have toys of appropriate age range

36. Temper Tantrums • Common in toddler; not <1 or >4 • Fatigue contributes • Breath holding usually not a problem • Head banging IS a problem • Ignore but stay close during tantrum • Reward post tantrum behavior

37. Toilet Training • 18-25 mos, girls earlier than boys • Day by 30-36mos; nite 37-48mos • Limit time on toilet to 5-10 min. • Bowel before bladder usually • Motivation – want to please parents • Readiness signs p. 620 (9th ed.), p. 501 (10th ed.) • Physical • Mental • Psychologic • Parental

38. Negativity • Part of development • Provide less chance to say “no” • Give choices • Use humor • Play games to distract

39. Stress • Limited ability to cope; prevention is best • Be aware of signs: regression, aggression • Prepare children for changes • Allow play to work things through • ↑ rest periods; gentle music • Older children: imagery & relaxation

40. Sex Education • By 3, aware of anatomic differences • Remember the 2 rules: • What do they know and think? • Be honest and use exact terminology • Like to talk about bodily functions; watch others go potty • Curious – may play “doctor” • Masturbation – normal occurrence • Distract with alternate acceptable behaviors

41. Aggression • Behavior that attempts to hurt persons, animals, or destroy property • Depends on quantity, severity, distribution, onset & duration (at least 4 wks) • Contributing factors: parenting practices, frustration, modeling, reinforcement

42. Speech Problems • Most critical time 2-4 yrs. • Stuttering at this time is normal & usually passes unless emphasis put on it • Causes of speech problems: hearing loss, developmental delay, lack of verbal stimulation • 3 year-old talks incessantly, time of great exploration of new vocabulary

43. Fears • Fear of dark, being left alone (bed time), animals, people, objects, loss of blood or other body parts or insides, etc. • Parent induced – these fears may become instilled and long lasting • Help find practical ways to deal with: desensitization, modeling, etc. • If do not subside & disrupt family - refer