Developmental milestones (toddler): Clinical sciences

Developmental milestones are behaviors and functional skills that children are expected to acquire by a specific age. These milestones are typically achieved in a predictable sequence and are divided into five major categories: gross motor development, which relates to the movement of large muscles; fine motor development, which relates to the movement of small muscles; cognitive development, which includes reasoning, memory, and problem-solving; social-emotional development, which describes attachment to and interactions with others; and finally, language development, which consists of receptive and expressive communication.

Understanding normal developmental milestones will help you recognize when a child is at risk for a developmental delay that would benefit from a more detailed evaluation and early intervention services, such as physical, occupational, or speech-language therapy.

Now, when a toddler presents for assessment of their developmental milestones, first, you should obtain a focused history and physical exam.

During the history, be sure to review birth history, including gestational age and weight at birth, since prematurity and low birth weight are associated with developmental delays.

Also, ask whether there is a family history of developmental delays, as some developmental disorders have a genetic component.

You should also take an interval history to determine what new skills the toddler has learned since the last clinic visit.

Now, here’s a clinical pearl to keep in mind! Caregivers spend the most time with their toddler and are often the first to notice when something isn’t quite right.

Whenever a caregiver is concerned about their child’s development, that is a red flag, so be sure to investigate further!When it comes to the physical exam, you should check reflexes, assess muscle tone, and test their balance.

You should also observe how the child interacts with their caregiver, the world, and with you, as this can help you gauge the child’s development.

Remember, at each well child visit, your goal is to assess the child’s developmental milestones according to their age, using a combination of direct observation and caregiver report.Once you are done with history and physical exam findings, it’s time to assess the toddler’s developmental milestones, based on age.

Let’s start by discussing expected milestones for a 15-month-old. By this age, toddlers achieve several gross motor milestones, including the ability to walk well, run with a stiff-legged gait, and crawl up stairs using their hands and feet.

Fine motor coordination has improved, and now they can build a three-block tower. As far as cognitive development goes, a 15-month-old can turn the pages of a thick board book and will explore their toys with purpose.

They will also try to use objects appropriately, like reading from a book or talking on the phone. Newly acquired social-emotional skills include copying other children while playing; demonstrating affection, like giving hugs and kisses; and showing empathy when someone else is hurt or crying.

Their understanding of language has grown, and now they can follow simple one-step directions, like “bring the ball,” and they use 3 to 5 of their own words.In addition to assessing the developmental milestones, remember to check for red flags that may signal a developmental delay.

These include the absence of a pincer grasp; the inability to say “mama” or “dada”; and not pointing or using other gestures to ask for things.Next, let’s discuss the developmental milestones you should see in an 18-month-old.

Newly acquired gross motor skills include the ability to run well and creep down stairs. At this age, toddlers can seat themselves in a chair and have enough coordination to throw a ball while standing.

Fine motor coordination has become more refined, and now they can build a four-block tower. As far as cognitive development goes, 18-month-olds can use spoons and drink from cups, and they can match pairs of objects, like toys, socks or shoes.

Further social-emotional development has given them the skills to engage in simple pretend play. And because they are now self-conscious, they will demonstrate shame when caught doing something wrong.

At this age, toddlers have achieved the language skills needed to understand the word “mine” and to point to themselves and to familiar people when named.

Finally, in this age group, toddlers have a vocabulary of 10 to 25 words.Red flags to look for in an 18-month-old include an inability to walk, a vocabulary of fewer than 6 words, and not pointing or using other gestures to show interest in their environment.

Now, let’s turn our attention to the 24-month milestones! For gross motor skills, these toddlers will walk up and down stairs by placing both feet on each step; they can also kick a ball, and throw overhand.

Newly acquired fine motor skills include drawing vertical and horizontal lines, as well as circles. A 24-month-old will have gained new cognitive skills, such as knowing to put only food items in their mouth, taking off their clothes, using knobs to open doors, and solving simple puzzles, like sorting small objects like buttons or beads.

One significant social-emotional milestone at this age is parallel play. This means that in the presence of other children, a child can play independently without interacting.

They also begin to understand social rules enough to mask their emotions, and they begin to use social referencing, meaning they look to their caregiver for cues about how to respond in new situations.

At this age, toddlers begin to assert themselves by communicating their likes and dislikes. So, when they are told “no”, they might express their frustration through tantrums.

As far as language skills go, a 24-month-old can understand the concepts of “me” and “you”, refer to themself by name, and follow simple two-step directions, like “Put your toys away and wash your hands.” This is also the time toddlers begin to build two-word sentences by combining a noun and a verb, like “mommy look.” Finally, a 2-year-old toddler has a vocabulary of more than 50 words.Red flags to look for in a 24-month-old include the inability to walk well, a lack of words or lack of vocabulary growth, the inability to follow one-step directions, and poor eye contact.Finally, let’s go over milestones for a 30-month-old.

At this age, newly acquired gross motor skills include walking up stairs with alternating feet, walking on tiptoes, and jumping.

Additionally, the toddler will have developed new fine motor skills, such as turning paper pages of a book and unscrewing lids.

Further cognitive development has given the 30-month-old simple problem-solving skills, like climbing a chair to reach cookies on a countertop, and matching shapes and colors.

From a social-emotional standpoint, 30-month-olds like to imitate adult activities, like cooking and cleaning, and they might try to help with chores.

They are also familiar with simple routines and try to follow them, like putting on socks before shoes and brushing their teeth before bed.

Language skills have advanced further, and the toddler is now able to use pronouns, like “I”, “me”, “you”, and “we”. At this point, a child has the attention and memory needed to recite well-known stories.

For example, they may hold a favorite book and pretend to read familiar words or phrases aloud.Red flags that you should look for in a 30-month-old include the inability to run; a lack of words or vocabulary growth; and an inability to form two-word sentences.

Another red flag is lack of social referencing, which means the child does not seek the caregiver’s cues to guide their decision-making in new situations.Once you’ve reviewed the developmental milestones, you should assess the toddler for red flags.

If red flags are present, then the toddler is at risk for a developmental delay. In this case, you should administer an age-appropriate developmental screening tool to assess and document the child’s development, as well as obtain hearing and vision screens, if able to, based on the toddler’s age.

You should also consider a referral to a specialist for diagnostic evaluation. On the other hand, if there are no red flags, then development is likely progressing appropriately, and you can provide reassurance and anticipatory guidance to the family and continue with developmental assessments.Alright, as a quick recap… Developmental milestones represent behaviors and skills that children acquire by a certain age.

The developmental assessment of a toddler starts with obtaining a focused history and physical exam. Milestones are assessed by age and divided into five main categories, which include gross motor, fine motor, cognitive, social-emotional, and language milestones.

Once you’ve reviewed the developmental milestones, you should assess the toddler for red flags. When a developmental red flag is identified during your assessment, proceed with an age-appropriate developmental screening tool, as well as hearing and vision screens, if able.

Also, consider referral for developmental and behavioral evaluation. On the flip side, if you identify no red flags,