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Introduction

Between the ages of 1 and 13, children's physical, intellectual, and emotional capabilities expand
tremendously. Children progress from barely tottering to running, jumping, and playing organized sports. At
age 1, most children can utter only a few recognizable words. By age 10, most children can write book
reports and use computers. Physical, intellectual, and social development, however, proceed at an individual
pace.

Milestones From Ages 18 Months to 6 Years


Age Gross Motor Skills Fine Motor Skills
18 months • Walks well • Draws vertical stroke

• Walks upstairs holding on • Makes a tower of 4 cubes


2 years • Runs with coordination • Handles a spoon well
• Turns single book pages
• Climbs on furniture
• Makes a tower of 7 cubes
2½ years • Jumps • Scribbles in a circular pattern

• Walks upstairs and downstairs unaided • Opens doors


3 years • Mature gait in walking • Favors using one hand over the other

• Rides tricycle • Copies a circle


4 years • Walks downstairs, alternating feet • Copies a cross
• Hops on 1 foot
• Dresses self
• Throws ball overhand
5 years • Skips • Copies a square

• Catches a bounced ball • Draws a person in 6 parts


6 years Walks along a straight line from heel to toe Writes name

Intellectual Development

At the age of 2, most children understand the concept of time in broad terms. Many 2- and 3-year-olds
believe that anything that happened in the past happened "yesterday," and anything that will happen in the
future will happen "tomorrow." A child at this age has a vivid imagination but has difficulty distinguishing
fantasy from reality. By age 4, most children have a more complicated understanding of time. They realize
that the day is divided into morning, afternoon, and night. They can even appreciate the change in seasons.

From 18 months to 5 years of age, a child's vocabulary quickly expands from about 50 words to several
thousand words. Children can begin to name and to actively ask about objects and events. By age 2, they
begin to put two words together in short phrases, progressing to simple sentences by age 3. Pronunciation
improves, with speech being half-understandable to a stranger by age 2 and fully understandable by age 4. A
4-year-old child can tell simple stories and can engage in conversation with adults or other children.

Even before 18 months of age, children can listen to and understand a story being read to them. By age 5,
children are able to recite the alphabet and to recognize simple words in print. These skills are all
fundamental to learning how to read simple words, phrases, and sentences. Depending on exposure to books
and natural abilities, most children begin to read by age 6 or 7.
By age 7, children's intellectual capabilities have become more complex. By this time, children become
increasingly able to focus on more than one aspect of an event or situation at the same time. For example,
school-aged children can appreciate that a tall, slender container can hold the same amount of water as a
short, broad one. They can appreciate that medicine can taste bad but can make them feel better, or that their
mother can be mad at them but can still love them. Children are increasingly able to understand another
person's perspective and so learns the essentials of taking turns in games or conversations. In addition,
school-aged children are able to follow agreed-upon rules of games. Children of this age are also
increasingly able to reason using the powers of observation and multiple points of view.

Physical Development

Physical growth begins to slow at around age 1. As growth slows, children need fewer calories and parents
may notice a decrease in appetite. Two-year-old children can have very erratic eating habits that sometimes
make parents anxious. It seems as though some children eat virtually nothing yet continue to grow and
thrive. Actually, they eat little one day and then make up for it by eating everything in sight the next day.

Children who are beginning to walk have an endearing physique, with the belly sticking forward and the
back curved. They may also appear to be quite bow-legged. By 3 years of age, muscle tone increases and the
proportion of body fat decreases, so the body begins to look leaner and more muscular. Most children are
physically able to control their bowels and bladder at this time.

During the preschool and school years, growth in height and weight is steady. The next major growth spurt
occurs in early adolescence. During the years of steady growth, most children follow a predictable pattern.
Doctors report how the children are growing in relation to other children their age and monitor the children's
weight gain compared to their height. Some children can become obese at an early age. Doubling the child's
height at age 24 months fairly accurately predicts adult height.
Height and Weight Charts for Boys and Girls

Source: The National Center for Health Statistics in collaboration with the National Center for
Chronic Disease Prevention and Health Promotion (2000). Available at
www.cdc.gov/growthcharts.
Toilet Teaching
Most children can be taught to use the toilet when they are between 2 and 3 years old. Using the toilet to
defecate is usually accomplished first. By age 5, the average child can go to the toilet alone, managing
all aspects of dressing, undressing, wiping, and handwashing. However, about 30% of healthy 4-year-
olds and 10% of 6-year-olds have not yet achieved regular nighttime bladder control.

Recognizing signs of the child's readiness is the key to toilet teaching. Readiness is signaled when the
child:

• Has dry periods lasting several hours


• Wants to be changed when wet
• Shows an interest in sitting on a potty chair or toilet
• Is able to follow simple commands

Children are usually ready to start training between the ages of 18 months and 24 months. Despite
physical readiness to use the toilet, some children may not be emotionally ready. To avoid a lengthy
struggle over toileting, it is best to wait until children indicate emotional readiness. When children are
ready, they will ask for help in the bathroom or make their way to the potty chair on their own.

The timing method is the most commonly used method of toilet teaching. Children who seem ready are
introduced to the potty chair and gradually asked to sit on it briefly while fully clothed. The children are
then encouraged to practice taking their pants down, sitting on the potty chair for no more than 5 or 10
minutes, and redressing. Simple explanations are given repeatedly and are reinforced by placing wet or
dirty diapers in the potty bowl. Praise or a reward is given for successful behavior. Anger or punishment
for accidents or for lack of success should be avoided. The timing method works well for children who
have predictable bowel and urine schedules and who can be placed on the potty chair at their normal
time of elimination. Teaching children with unpredictable schedules is better delayed until they can
anticipate the need to visit the bathroom on their own.

A child who resists sitting on the toilet may be allowed to get up and try again after a meal. If resistance
continues for days, postponing the teaching for several weeks is the best strategy. Giving praise or a
reward for sitting on the toilet and producing results is effective. Once the pattern is established, rewards
can be given for every other success and then gradually withdrawn. Power struggles are unproductive
and may strain the parent-child relationship.

Preventive Health Care Visits

Scheduled visits to the doctor provide parents with information about their child's growth and development.
Such visits also give parents an opportunity to ask questions and seek advice. The American Academy of
Pediatrics recommends that after the first year of life children see their doctor for preventive health care
visits at 12, 15, 18, and 24 months of age and then yearly until age 6. It is then recommended that the child
visit the doctor at age 8 and again at age 10. Visits can be made more often based on the advice of the doctor
or the needs of the family.

A variety of measurements, screening procedures, and vaccinations are performed (see Vaccinating Infants
and Children ) at each visit. Height and weight are checked, and head circumference is measured until the
child is about 18 months old. Good growth is one indicator that the child is generally healthy. The child's
actual size is not nearly as important as whether the child stays at or near the same percentile on the height
and weight charts at each visit. A child who is always in the 10th percentile is fine (although smaller than
most children of the same age), whereas a child who drops from the 35th percentile to the 10th may have a
medical problem. Beginning at age 3, blood pressure is measured at each visit.

Preventive visits should include a check of vision and hearing. Some children may need to have their blood
checked for anemia or an increased level of lead (see Poisoning: Lead Poisoning). The age of the child and
various other factors determine which tests are performed. Some doctors also recommend that the child's
urine be checked, although the value of such testing has not been established.

The doctor also monitors how the child has progressed developmentally since the last visit. For example, the
doctor may want to know whether an 18-month-old has begun speaking or whether a 6-year-old has begun
reading a few words. In the same way, doctors often ask age-appropriate questions about the child's behavior.
Does the 18-month-old have tantrums? Does the 2-year-old sleep through the night? Does the 6-year-old wet
the bed at night? Parents and doctors can discuss these types of behavioral and developmental issues during
the preventive health care visits and together design approaches to any behavioral or developmental
problems.

Child safety is discussed during preventive visits. Specific safety concerns are based on the age of the child.
For a 6-month-old, the doctor may wish to talk about childproofing the house to prevent unintentional
poisonings or injury. For a 6-year-old, the discussion might be focused on bicycle safety. The doctor may
also emphasize other safety topics, such as the importance of installing and maintaining smoke alarms and
the hazards of keeping guns in the home. Parents should take the opportunity to bring up topics that are most
relevant to their unique family situation. As the children get older, they can be active participants in these
discussions.

Finally, the doctor performs a complete physical examination. In addition to examining the child from head
to toe, including the heart, lungs, abdomen, genitals, and head and neck, the doctor may ask the child to
perform some age-appropriate tasks. To check gross motor skills (such as walking and running), the doctor
may ask a 4-year-old to hop on one foot. To check fine motor skills (manipulating small objects with the
hands), the child may be asked to draw a picture or copy some shapes.

Promoting Optimal Health and Development

Parents can help their children achieve the best possible health. For example, they can help prevent obesity
by establishing healthy eating patterns and promoting regular exercise. Children should consume a variety of
healthy foods, including fruits and vegetables along with protein. Regular meals and small nutritious snacks
encourage healthy eating in even a picky preschooler. Although children may avoid some healthy foods, such
as broccoli or beans, for a period of time, it is important to continue to offer healthy foods. In addition,
parents should limit intake of fruit juices, which, despite their apparent healthy origin, are mainly sugar
water. Some children lose their appetite for food at mealtime if they drink too much fruit juice. Children who
drink from a bottle should be weaned by about 1 year of age to prevent excess juice and milk intake and to
avoid tooth decay.

Promoting optimal development in a child works best if approached with flexibility, keeping the individual
child's age, temperament, developmental stage, and learning style in mind. A coordinated approach involving
parents, teachers, and the child usually works best. Throughout these years, children need an environment
that promotes lifelong curiosity and learning. The child should be provided with books and music. A routine
of daily interactive reading, with parents asking as well as answering questions, helps children pay attention,
read with comprehension, and encourages their interest in learning activities. Limiting television and
electronic games to less than 2 hours per day encourages more interactive play.

Playgroups and preschool have benefits for many young children. Children can learn important social skills,
such as sharing. In addition, they may begin to recognize letters, numbers, and colors; learning these skills
makes the transition to school smoother. Importantly, in a structured preschool setting, potential
developmental problems can be identified and addressed early.

Parents who are in need of child care may wonder what the best environment is and whether care by others
may actually harm their child. Available information suggests that young children can do well both in their
own home and in care out of the home, as long as the environment is loving and nurturing. By closely
watching the child's response to a given child care setting, parents are better able to choose the best
environment. Some children thrive in a child care environment where there are many children; others may
fare better in their own home or in a smaller group.

When the child begins to receive homework assignments, parents can help by showing interest in the child's
work, by being available to sort through questions but not finishing the work themselves, by providing a
quiet work environment at home for the child, and by communicating with the teacher about any concerns.
As the school years progress, parents need to consider their child's needs when selecting extracurricular
activities. Many children thrive when offered the opportunity to participate in team sports or learn a musical
instrument. These activities may also provide a venue for improving social skills. On the other hand, some
children become stressed if they are "over-scheduled" and expected to participate in too many activities.
Children need to be encouraged and supported in their extracurricular activities without having unrealistic
expectations placed on them.

Social and Emotional Development

Emotion and behavior are based on the child's developmental stage and temperament. Every child has an
individual temperament, or mood. Some children may be cheerful and adaptable and easily develop regular
routines of sleeping, waking, eating, and other daily activities; these children tend to respond positively to
new situations. Other children are not very adaptable and may have great irregularities in their routine; these
children tend to respond negatively to new situations. Still other children are in between.

At about 9 months of age, infants normally become more anxious about being separated from their parents.
Separations at bedtime and at places like child care centers may be difficult and can be marked by temper
tantrums. This behavior can last for many months. For many older children, a special blanket or stuffed
animal serves at this time as a "transitional object" that acts as a symbol for the absent parent.

At 2 to 3 years of age, children begin to test their limits and do what they have been forbidden to do, simply
to see what will happen. The frequent "nos" that children hear from parents reflect the struggle for
independence at this age. Although distressing to parents and children, tantrums are normal because they
help children express their frustration during a time when they cannot verbalize their feelings well. Parents
can help decrease the number of tantrums by not letting their children become overtired or unduly frustrated
and by knowing their children's behavior patterns and avoiding situations that are likely to induce tantrums.
Rarely, temper tantrums need to be evaluated by a doctor (see Behavioral and Developmental Problems in
Young Children: Temper Tantrums). Some young children have particular difficulty controlling their
impulses and need their parents to set stricter limits around which there can be some safety and regularity in
their world.

At age 18 months to 2 years, children typically begin to establish gender identity (see Sexuality: Gender
Identity). During the preschool years, children also acquire a notion of gender role, of what boys and girls
typically do. Exploration of the genitals is expected at this age and signals that children are beginning to
make a connection between gender and body image.

Between 2 and 3 years of age, children begin to play more interactively with other children. Although they
may still be possessive about toys, they may begin to share and even take turns in play. Asserting ownership
of toys by saying, "That is mine!" helps establish the sense of self. Although children of this age strive for
independence, they still need their parents nearby for security and support. For example, they may walk
away from their parents when they feel curious only to later hide behind their parents when they are fearful.

At 3 to 5 years of age, many children become interested in fantasy play and imaginary friends. Fantasy play
allows children to safely act out different roles and strong feelings in acceptable ways. Fantasy play also
helps children grow socially. They learn to resolve conflicts with parents or other children in ways that will
help them vent frustrations and maintain self-esteem. Also at this time, typical childhood fears like that of
"the monster in the closet" emerge. These fears are normal.

At 7 to 12 years of age, children work through numerous issues: self-concept, the foundation for which is
laid by competency in the classroom; relationships with peers, which are determined by the ability to
socialize and fit in well; and family relationships, which are determined in part by the approval children gain
from parents and siblings. Although many children seem to place a high value on the peer group, they still
look primarily to parents for support and guidance. Siblings can serve as role models and as valuable
supports and critics in what can and cannot be done. This period of time is very active for children, who
engage in many activities and are eager to explore new activities. At this age, children are eager learners and
often respond well to advice about safety, healthy lifestyles, and avoidance of high-risk behaviors.

Last full review/revision May 2006 by Eve R. Colson, MD