Jean-François Lemay, MD FRCPCJean-François Lemay, MD FRCPC

Professor of PediatricsProfessor of Pediatrics

Dept of PediatricsDept of Pediatrics

ACH, University of CalgaryACH, University of Calgary

Sept 6 2012Sept 6 2012

Learning about Normality Learning about Normality

ObjectivesObjectives

The participant will learn:The participant will learn:– general principles in infant growth and general principles in infant growth and

developmentdevelopment– essential to understand normal essential to understand normal

development and acceptable variations in development and acceptable variations in normal developmental patternsnormal developmental patterns

Once upon a time …Once upon a time …

… … a miracle was born !a miracle was born !

Important messageImportant message

Infant development occurs in an Infant development occurs in an orderly and predictable manner that is orderly and predictable manner that is determined intrinsicallydetermined intrinsically

Question:Question:

What is the difference between:What is the difference between:

–Developmental screeningDevelopmental screening

–Developmental assessmentDevelopmental assessment

–Developmental surveillanceDevelopmental surveillance

General principlesGeneral principles

Physician’s rolePhysician’s role – Performing routine developmental screening, Performing routine developmental screening,

(assessment) and surveillance(assessment) and surveillance– Discussion of normal developmental Discussion of normal developmental

variations with parents and professionalsvariations with parents and professionals– Explaining test results to parentsExplaining test results to parents– Acknowledging parental concernsAcknowledging parental concerns– Providing referral/facilitating management Providing referral/facilitating management

interventionsinterventions

What areas of development What areas of development are monitored in any child ?are monitored in any child ?

Developmental SpheresDevelopmental Spheres

Motor

Speech-Language

Sensory

Cognitive

Adaptive

Social

Stages of developmentStages of development

Step 1: StandingStep 1: Standing

Step 2: SpeakingStep 2: Speaking

Step 3: ThinkingStep 3: Thinking

Step 4: PracticingStep 4: Practicing

Step 1: Standing (0 -1 year)Step 1: Standing (0 -1 year)

Innate will to reach the worldInnate will to reach the world

This will is the impulse to be alive, to learn, This will is the impulse to be alive, to learn, to becometo become

Sitting position: offers a new view of life-can Sitting position: offers a new view of life-can reach for, and grasp objects, etc.reach for, and grasp objects, etc.

Then, tries to stand with supportThen, tries to stand with support

By the end of the 1st yr, baby can stand By the end of the 1st yr, baby can stand freely and begin his-her first stepsfreely and begin his-her first steps

3 goals of the 13 goals of the 1stst yr of life yr of life

Sitting Sitting

GraspingGrasping

WalkingWalking

Motor skills: summary FM and Motor skills: summary FM and GM-first year of lifeGM-first year of life

Step 2: Speaking (1-2 years)Step 2: Speaking (1-2 years)

Language: Language: – exists and is understood long before it is exists and is understood long before it is

spokenspoken– follows walkingfollows walking– Develops through imitationDevelops through imitation– World begins to make sense when speech World begins to make sense when speech

is developingis developing– 3 periods: pre-speech, naming period, and 3 periods: pre-speech, naming period, and

word combination periodword combination period

Stage 1 : NewbornStage 1 : Newborn

Predisposed to make order Predisposed to make order out of chaosout of chaosAble to find human facesAble to find human facesAble to imitate human Able to imitate human actionsactionsProcess bits of human Process bits of human languagelanguageThey can hear, and they They can hear, and they can produce reflexive can produce reflexive vocalizations-such as vocalizations-such as crying, sneezing, and of crying, sneezing, and of course burping!course burping!

Prefer to hear mother ’s Prefer to hear mother ’s voicevoice quite soon in lifequite soon in lifeDistinguish voices at 4 Distinguish voices at 4 weeks of age—mom and weeks of age—mom and daddadSensitive +++ to language Sensitive +++ to language soundssoundsLinguistic stimulation is Linguistic stimulation is crucial-contact with crucial-contact with human faces +++human faces +++Come prepared to learn Come prepared to learn languagelanguage

Stage 2, 3 and 4Stage 2, 3 and 4

Stage 2: Coos 2-3 monthsStage 2: Coos 2-3 months

Stage 3: Gurgles 4-6 monthsStage 3: Gurgles 4-6 months

Stage 4: Babbles 6-7 months Stage 4: Babbles 6-7 months – first babbling sounds that sound like real words-gaga, mama, dada, etc.first babbling sounds that sound like real words-gaga, mama, dada, etc.

-What is the crucial factor that-What is the crucial factor that

stimulates this vocalization process? stimulates this vocalization process? answer… eye gaze!!!!answer… eye gaze!!!!

If babies are so capable, If babies are so capable, why don’t they talk sooner?why don’t they talk sooner?

Reason: infant vocal tract resembles the Reason: infant vocal tract resembles the vocal tract of non human primatesvocal tract of non human primatesprevents babies from using the mouth as an prevents babies from using the mouth as an instrument in the ways necessary for speechinstrument in the ways necessary for speechOral cavity has lengthened and expanded at Oral cavity has lengthened and expanded at 1 yr. of age-first word1 yr. of age-first word

Stage 5: First word !Stage 5: First word !

Spent a year preparing for this Spent a year preparing for this achievement-enormous mental leapachievement-enormous mental leap

Around 12 months (10 mo-24 mo.)Around 12 months (10 mo-24 mo.)

Now can communicate and represent Now can communicate and represent objects, actions, and events in objects, actions, and events in his/her mindhis/her mind

TABLE A : EXPRESSIVE LANGUAGE DEVELOPMENT: AVERAGE AGE OF ACQUISITION AND TABLE A : EXPRESSIVE LANGUAGE DEVELOPMENT: AVERAGE AGE OF ACQUISITION AND AGE INDICATING SIGNIFICANT DELAY OR RED FLAGAGE INDICATING SIGNIFICANT DELAY OR RED FLAG

Expressive Language MilestonesExpressive Language Milestones Average Age RangeAverage Age RangeSignificant DelaysSignificant Delaysand Red Flagsand Red Flags

CooingCooing 2-3 mo2-3 mo 6 mo6 mo

BabblingBabbling 6-8 mo6-8 mo 10 mo10 mo

Nonverbal purposeful messages Nonverbal purposeful messages (requests with a reach; shows objects)(requests with a reach; shows objects)

9-10 mo9-10 mo 12 mo12 mo

PointingPointing 10-11 mo10-11 mo 14 mo14 mo

Says 3 different spontaneous wordsSays 3 different spontaneous words 12-15 mo12-15 mo 16 mo16 mo

Vocabulary at least 35-50 wordsVocabulary at least 35-50 words 18-22 mo18-22 mo 24 mo24 mo

Production of 2-word phrases Production of 2-word phrases (“Mommy sock”; “No water”)(“Mommy sock”; “No water”)

18-22 mo18-22 mo 24 mo24 mo

Simple sentences (“I want juice”; Simple sentences (“I want juice”; “Where’s my ball?”)“Where’s my ball?”)

24-30 mo24-30 mo 36 mo36 mo

Intelligibility to unfamiliar adult at > Intelligibility to unfamiliar adult at > 50%50%

30-36 mo30-36 mo 42 mo42 mo

Able to tell about a past event with Able to tell about a past event with parent asking questions (personal parent asking questions (personal narrative)narrative)

24-30 mo24-30 mo 36 mo36 mo

Able to tell or retell a familiar storyAble to tell or retell a familiar story 36-48 mo36-48 mo 54 mo54 mo

Fully intelligible to an unfamiliar adult Fully intelligible to an unfamiliar adult (despite some immature sounds, such (despite some immature sounds, such as consonant clusters or /r/ and /l/as consonant clusters or /r/ and /l/

48-54 mo48-54 mo 60 mo60 mo

Fully mature speech soundsFully mature speech sounds Up to 72 moUp to 72 mo > 72 mo> 72 mo

TABLE B: RECEPTIVE LANGUAGE DEVELOPMENT: AVERAGE AGE OF ACQUISITION AND TABLE B: RECEPTIVE LANGUAGE DEVELOPMENT: AVERAGE AGE OF ACQUISITION AND AGE INDICATING SIGNIFICANT DELAY OR RED FLAGAGE INDICATING SIGNIFICANT DELAY OR RED FLAG

Receptive Language MilestonesReceptive Language Milestones Average Age of AcquisitionAverage Age of AcquisitionSignificant DelaysSignificant Delaysand Red Flagsand Red Flags

Alerts or quiets to soundAlerts or quiets to sound Birth to 1 moBirth to 1 mo 2 mo2 mo

Turns to the source of soundTurns to the source of sound Birth to 1 mo, then again 3-5 moBirth to 1 mo, then again 3-5 mo 6 mo6 mo

Responds to own nameResponds to own name 6-8 mo6-8 mo 10 mo10 mo

Follows verbal routines/games (‘Wave Follows verbal routines/games (‘Wave bye-bye”)bye-bye”)

8-10 mo8-10 mo 12 mo12 mo

Understands simple questions Understands simple questions (“Where’s mommy?”)(“Where’s mommy?”)

9-11 mo9-11 mo 15 mo15 mo

Stops when told “No”Stops when told “No” 9-10 mo9-10 mo 15 mo15 mo

Understands at least 3 different wordsUnderstands at least 3 different words 10-13 mo10-13 mo 15 mo15 mo

Points to 3 different body partsPoints to 3 different body parts 12-16 mo12-16 mo 18 mo18 mo

Follow simple commands (“Show me Follow simple commands (“Show me the ball” or “Get your shoes”)the ball” or “Get your shoes”)

12 mo12 mo 18 mo18 mo

Follows 2-part commands (“Get your Follows 2-part commands (“Get your shoes and give them to Dad”)shoes and give them to Dad”)

24 mo24 mo 30 mo30 mo

Answers simple questions (“Who is Answers simple questions (“Who is that?” or What are you doing?”)that?” or What are you doing?”)

24-30 mo24-30 mo 36 mo36 mo

Important tips: Important tips: Expressive languageExpressive language

Age in months/minimal amount of words Age in months/minimal amount of words

•12 months: 1 x 2 or 1+212 months: 1 x 2 or 1+2•15 months: 1 x 5 or 1+515 months: 1 x 5 or 1+5•18 months: 1 x 8 or 1+818 months: 1 x 8 or 1+8

•Vocabulary Spurt Vocabulary Spurt •24 months: 24 mo x 2y24 months: 24 mo x 2y•36 months: 36 mo x 3y36 months: 36 mo x 3y

Step 3 : Learning-ThinkingStep 3 : Learning-Thinking

Infants learn to do virtually everything Infants learn to do virtually everything that is typically human during the first 2 that is typically human during the first 2 years of lifeyears of life

Defined as a change of behaviour Defined as a change of behaviour resulting from experience and practiceresulting from experience and practice

Exploration-practical reasoningExploration-practical reasoning

Step 4: PracticingStep 4: Practicing

Now you are ready to use your skillsNow you are ready to use your skills

Kindergarten is starting at age 5: why?Kindergarten is starting at age 5: why?

Similarities with medical school studentsSimilarities with medical school studentsPreparation to medical schoolPreparation to medical school- Step I: Year 1 and 2 of Med SchoolStep I: Year 1 and 2 of Med School- Step 2: Clerkship Step 2: Clerkship - Step 3: MCC examStep 3: MCC exam- Step 4: Residency Step 4: Residency

In order to determine if a child is In order to determine if a child is normal or abnormal, you need to do…normal or abnormal, you need to do…

History and Physical ExaminationHistory and Physical Examination

Detailed historyDetailed history– Family Family – Prenatal Prenatal – Perinatal Perinatal – PostnatalPostnatal

Detailed Physical ExaminationDetailed Physical Examination

Family HistoryFamily History

Three generations, maternal and paternalThree generations, maternal and paternalConsanguinity, PedigreeConsanguinity, PedigreePrevious pregnancy outcomes:Previous pregnancy outcomes:– miscarriages, stillbirths, neonatal or childhood miscarriages, stillbirths, neonatal or childhood

deaths, infertilitydeaths, infertility

Family history of birth defects, childhood Family history of birth defects, childhood deaths, MR, SD, LD, ASD, and known genetic deaths, MR, SD, LD, ASD, and known genetic conditionsconditionsEthnic backgroundEthnic background

Prenatal HistoryPrenatal History

Potential teratogensPotential teratogens– Alcohol, medications,vitamins, maternal Alcohol, medications,vitamins, maternal

infection (rubella, toxoplasmosis,varicella)infection (rubella, toxoplasmosis,varicella)– Maternal diabetes, hyperthermia, maternal Maternal diabetes, hyperthermia, maternal

PKUPKU

Fetal movementsFetal movements

Prenatal testsPrenatal tests– Eg. amniocentesis, ultrasoundEg. amniocentesis, ultrasound

Perinatal HistoryPerinatal History

Gestation, mode of delivery, APGAR, Gestation, mode of delivery, APGAR, resuscitationresuscitation

BW, length, HCBW, length, HC

Feeding, muscle tone, other problemsFeeding, muscle tone, other problems

Postnatal HistoryPostnatal History

Developmental Milestones, school performanceDevelopmental Milestones, school performanceEvidence of regressionEvidence of regressionUnusual behavior, personality, temperamentUnusual behavior, personality, temperamentCoordination, seizures, unusual movements, Coordination, seizures, unusual movements, increased or decreased toneincreased or decreased toneGrowth, nutrition, sleepingGrowth, nutrition, sleepingVision, HearingVision, HearingPrevious illnessesPrevious illnessesComplete review of systemsComplete review of systems

Physical ExaminationPhysical Examination

Syndromic versus Non-syndromic Syndromic versus Non-syndromic developmental delaydevelopmental delay

Growth parametersGrowth parameters

Complete physical examinationComplete physical examination

Careful neurological examinationCareful neurological examination

Careful skin examinationCareful skin examination

QuestionQuestion

At birth… At birth… – Head Circumference :Head Circumference :– Weight:Weight:– Height:Height:

At 12 months…At 12 months…

SocialSocial

SummarySummary

Infant development occurs in an Infant development occurs in an orderly and predictable manner that is orderly and predictable manner that is determined intrinsicallydetermined intrinsically

It proceeds from cephalic to caudal and It proceeds from cephalic to caudal and proximal to distal as well as from proximal to distal as well as from generalized reactions to stimuli to generalized reactions to stimuli to specific goal-directed directions that specific goal-directed directions that become increasingly precisebecome increasingly precise

Review of developmental skills and Review of developmental skills and quiz/questionsquiz/questions

6 Months6 Months

Babbles “baba”, “gaga”Babbles “baba”, “gaga”

Interacts with othersInteracts with others

Looks to floor when Looks to floor when drops toydrops toy

Discriminates strangersDiscriminates strangers

Transfers objects hand-Transfers objects hand-to-handto-hand

Immature rake of pelletImmature rake of pellet

Sits propped on handsSits propped on hands

Red flags-may Red flags-may indicateindicateNot rolling or poor head Not rolling or poor head control-neuromotor control-neuromotor dysfunctiondysfunction

Absence of babbling-Absence of babbling-hearing losshearing loss

12 Months12 Months

Follows commands Follows commands with gesturewith gestureOne word with meaningOne word with meaningPoint for objectPoint for objectRemoves lid to find toyRemoves lid to find toyFine pincer graspFine pincer graspMarks on paper with Marks on paper with crayoncrayonStands alone, may even Stands alone, may even take a few stepstake a few steps

Red Flags-may indicateRed Flags-may indicateNo protective reactions- No protective reactions- neuromotor disorderneuromotor disorder

Persistent mouthing or Persistent mouthing or not looking for hidden not looking for hidden object-cognitive delayobject-cognitive delay

No “mama”, “dada”-No “mama”, “dada”-speech language delayspeech language delay

18 Months18 MonthsPoints to self and 3 Points to self and 3 body partsbody partsAverage 20-50 word Average 20-50 word vocabulary (minimal 8-vocabulary (minimal 8-10)10)Matches pairs of Matches pairs of objectsobjectsFunctional use of itemsFunctional use of itemsScribbles Scribbles spontaneouslyspontaneouslyTower of 4 blocksTower of 4 blocksWalks confidentlyWalks confidentlyAble to seat self at Able to seat self at small tablesmall tableThrows ball while Throws ball while standingstanding

Red flags-may indicateRed flags-may indicateLack of imitation or of Lack of imitation or of protodeclarative pointing- deficits protodeclarative pointing- deficits in cognition or social in cognition or social developmentdevelopment

Lack of walking-neuromuscular Lack of walking-neuromuscular or neuromotor conditionor neuromotor condition

Hand dominance< 18 months- Hand dominance< 18 months- contralateral weaknesscontralateral weakness

<10 words- language delay <10 words- language delay

Does not show affection-delayed Does not show affection-delayed social developmentsocial development

Doesn’t play functionally with Doesn’t play functionally with toys-delayed cognition/social toys-delayed cognition/social developmentdevelopment

2 Years2 YearsFollows 2-step commandsFollows 2-step commands

Understands me, youUnderstands me, you

Average 100-250 words Average 100-250 words (Minimal 50)(Minimal 50)

Combines noun + verb (2 words Combines noun + verb (2 words together)together)

Uses basic pronounsUses basic pronouns Plays parallel to othersPlays parallel to others Matches objects to pictures Matches objects to pictures Train of cubes, no stackTrain of cubes, no stack Imitates vertical strokeImitates vertical stroke Jumps in placeJumps in place Kicks a ball and throws Kicks a ball and throws

overhandoverhand Walks down stairs holding railWalks down stairs holding rail

Red Flags may indicateRed Flags may indicate Absent symbolic play-Absent symbolic play-

cognitive and/or social cognitive and/or social development problems development problems

Not climbing stairs-may Not climbing stairs-may reflect lack of opportunity, reflect lack of opportunity, or neurodevelopment or neurodevelopment disorderdisorder

Not scribbling- Not scribbling- neurodevelopment disorderneurodevelopment disorder

Lack of categorizing-Lack of categorizing-cognitive delaycognitive delay

No novel 2-word No novel 2-word combinations-speech, combinations-speech, language delaylanguage delay

The period between age 2 and 3:The period between age 2 and 3:

– The miraculously rapid development of The miraculously rapid development of functional languagefunctional language

– Refinement of basic fine motor skills for Refinement of basic fine motor skills for eating and manipulating objectseating and manipulating objects

– Increased knowledge about concepts of Increased knowledge about concepts of shapes, colors and daily routines as well shapes, colors and daily routines as well as social skills (please, thank you)as social skills (please, thank you)

– Time of social reactivity as children strive Time of social reactivity as children strive to gain increasing self-controlto gain increasing self-control

Motor milestones: 3 and 4 yearsMotor milestones: 3 and 4 years

3 years old3 years old– Feeds self with spillingFeeds self with spilling– Opens doorsOpens doors– Holds glass with one Holds glass with one

handhand– Holds crayons wellHolds crayons well– Throws a ball overheadThrows a ball overhead– Dresses self with helpDresses self with help– Uses toilet with helpUses toilet with help– Kicks balls forwardKicks balls forward– Jumps with both feetJumps with both feet– Pedals tricyclePedals tricycle

4 years old4 years old– Feeds self, uses forkFeeds self, uses fork– Holds pencils-tries to Holds pencils-tries to

writewrite– Draws circle, faceDraws circle, face– Cuts with small scissorsCuts with small scissors– Brushes teeth with helpBrushes teeth with help– UnbuttonsUnbuttons– Uses toilet aloneUses toilet alone– Tries to skipTries to skip– Catches a bouncing ballCatches a bouncing ball– swingsswings

Developmental age?Developmental age?

An infant who will walk with one hand An infant who will walk with one hand held, has a 3-word vocabulary, will give held, has a 3-word vocabulary, will give an object to another person on request an object to another person on request and waves bye-bye is closest and waves bye-bye is closest

Your answer: Your answer:

Developmental age?Developmental age?

This child has a fine pincer grasp, will This child has a fine pincer grasp, will put to stand, and uses dada and mama put to stand, and uses dada and mama non specifically non specifically

Developmental age ?Developmental age ?

A child who is able to run and jump, A child who is able to run and jump, scribbles in a circular pattern, uses a scribbles in a circular pattern, uses a spoon and puts three words togetherspoon and puts three words together

Question Question

You would expect a 15-month-old child to You would expect a 15-month-old child to be able to do all the following except:be able to do all the following except:

A-Walks about the room independentlyA-Walks about the room independentlyB-Can say 8 words in addition to mamaB-Can say 8 words in addition to mamaC-Begins to use cup C-Begins to use cup D-Responds to one-step verbal commandD-Responds to one-step verbal commandE-Spontaneously doing a circle E-Spontaneously doing a circle

Question Question

You would expect a 24-month-old child You would expect a 24-month-old child to be able to do all the following to be able to do all the following except:except:

A-walks unassisted up and down stairsA-walks unassisted up and down stairs

B-copies a crossB-copies a cross

C-50% of speech intelligible to strangerC-50% of speech intelligible to stranger

D-removes simple clothingD-removes simple clothing

E-kicks ballE-kicks ball

Question Question

You would expect a 3-year-old child to You would expect a 3-year-old child to be able to do all the following except:be able to do all the following except:

A-copies a circleA-copies a circle

B-engages in group playB-engages in group play

C-can tell his/her nameC-can tell his/her name

D-speaks in sentences of 3-6 words in D-speaks in sentences of 3-6 words in lengthlength

E-Draws a person with six body partsE-Draws a person with six body parts

Developmental age ?Developmental age ?

A child who is able to ride a tricycle, A child who is able to ride a tricycle, copy a circle, count to three, copy a circle, count to three, discriminate colors, and remove his discriminate colors, and remove his clothing clothing

At what age are infants able to At what age are infants able to perform the following motor skills?perform the following motor skills?

Sit up by themselvesSit up by themselvesWalkWalkCrawlCrawlSmileSmileHold their head upHold their head upCombine wordsCombine wordsUnderstand speechUnderstand speechUncover a toy that is hidden by a scarfUncover a toy that is hidden by a scarf

At what age are infants able to At what age are infants able to perform the following motor skills?perform the following motor skills?

Tom Brady (NFL quarterback NE Tom Brady (NFL quarterback NE Patriots) comes to you with his 3-year-Patriots) comes to you with his 3-year-old son distressed that he can’t catch a old son distressed that he can’t catch a ball yet. You reassure Tom that ball yet. You reassure Tom that children are not expected to perform children are not expected to perform that motor skill until they are what age?that motor skill until they are what age?

Other questionsOther questions

By what age are 90% of children By what age are 90% of children walking? 99%?walking? 99%?

For an apparently normal appearing For an apparently normal appearing child who is saying no words at 18 child who is saying no words at 18 months, what is the best thing to do?months, what is the best thing to do?

Case Case

A 15-month-old is saying “baba” and A 15-month-old is saying “baba” and has no other words. He points at has no other words. He points at objects all the time and gestures his objects all the time and gestures his understanding of what things are used understanding of what things are used for (phone to ear). He can understand for (phone to ear). He can understand simple commands. His motor simple commands. His motor development is normal- he is walking. development is normal- he is walking. Mother is worried. What do you tell Mother is worried. What do you tell her?her?

Neurodevelopmental Neurodevelopmental assessmentassessment

Child from 3-5 yrsChild from 3-5 yrs

Social: name, eye contact, complianceSocial: name, eye contact, complianceOrientation: child’s ability to establish various Orientation: child’s ability to establish various

spatial ordinates with regard to his own bodyspatial ordinates with regard to his own body– IDENTIFY BODY PARTS: eyes, nose, ears, knee, IDENTIFY BODY PARTS: eyes, nose, ears, knee,

elbow, shoulder, cheeks, heel, ankleelbow, shoulder, cheeks, heel, ankle– IMITATE FINGER MOVEMENTS: 1-2,1-3,1-4,1-5 on IMITATE FINGER MOVEMENTS: 1-2,1-3,1-4,1-5 on

one hand then repeat on the other hand; look for one hand then repeat on the other hand; look for associated mvts (soft neurological signs)associated mvts (soft neurological signs)

– VISUAL TRACKINGVISUAL TRACKING

Gross MotorGross Motor

– Stressed gait: walks forward and backward; Stressed gait: walks forward and backward; runs, jumps, stairs-up and downruns, jumps, stairs-up and down

– Stands on one footStands on one foot– Motor stance; RombergMotor stance; Romberg– Kicks, hops, catches ballsKicks, hops, catches balls

Fine MotorFine Motor

– Dominance: right, leftDominance: right, left– Grasping pencil: mature or immatureGrasping pencil: mature or immature– DrawingDrawing– Copying figuresCopying figures– ScissorsScissors– PuzzlesPuzzles– Blocks (tower; figure)Blocks (tower; figure)– Turns pagesTurns pages– Dress, undress Dress, undress

What do you need to be ready What do you need to be ready for toilet-training ???for toilet-training ???

Toilet Training: Developmental ReadinessToilet Training: Developmental Readiness

Language SkillsLanguage Skills– 2-step command2-step command– 2-word phrases2-word phrases

Cognitive SkillsCognitive Skills– Initiates actionsInitiates actions– Understands cause and Understands cause and

effecteffect Emotional SkillsEmotional Skills

– Desire to please parentsDesire to please parents– Diminishing oppositional Diminishing oppositional

behaviorbehavior Autonomy/IndependenceAutonomy/Independence

– Drive for autonomy and Drive for autonomy and independence in self-careindependence in self-care

– Pride and positiveness Pride and positiveness towards belongingstowards belongings

Motor SkillsMotor Skills– AmbulationAmbulation– Undress independentlyUndress independently– Can sit for 5 minutesCan sit for 5 minutes– Urinary and anal sphincter Urinary and anal sphincter

controlcontrol Body AwarenessBody Awareness

– Awareness of wet or soiled Awareness of wet or soiled diaperdiaper

– Manifests signs of urge to Manifests signs of urge to void or defecatevoid or defecate

The End The End