66 Part II ◆ Growth, Development, and Behavior

Table 10-1 Developmental Milestones in the 1st 2 Yr of Life

AVERAGE AGE OF
MILESTONE ATTAINMENT (MO) DEVELOPMENTAL IMPLICATIONS
GROSS MOTOR
Holds head steady while sitting 2 Allows more visual interaction
Pulls to sit, with no head lag 3 Muscle tone
Brings hands together in midline 3 Self-discovery of hands
Asymmetric tonic neck reflex gone 4 Can inspect hands in midline
Sits without support 6 Increasing exploration
Rolls back to stomach 6.5 Truncal flexion, risk of falls
Walks alone 12 Exploration, control of proximity to parents
Runs 16 Supervision more difficult
FINE MOTOR
Grasps rattle 3.5 Object use
Reaches for objects 4 Visuomotor coordination
Palmar grasp gone 4 Voluntary release
Transfers object hand to hand 5.5 Comparison of objects
Thumb-finger grasp 8 Able to explore small objects
Turns pages of book 12 Increasing autonomy during book time
Scribbles 13 Visual–motor coordination
Builds tower of 2 cubes 15 Uses objects in combination
Builds tower of 6 cubes 22 Requires visual, gross, and fine motor coordination
COMMUNICATION AND LANGUAGE
Smiles in response to face, voice 1.5 More active social participant
Monosyllabic babble 6 Experimentation with sound, tactile sense
Inhibits to “no” 7 Response to tone (nonverbal)
Follows one-step command with gesture 7 Nonverbal communication
Follows one-step command without gesture 10 Verbal receptive language (e.g., “Give it to me”)
Says “mama” or “dada” 10 Expressive language
Points to objects 10 Interactive communication
Speaks first real word 12 Beginning of labeling
Speaks 4-6 words 15 Acquisition of object and personal names
Speaks 10-15 words 18 Acquisition of object and personal names
Speaks 2-word sentences (e.g., “Mommy shoe”) 19 Beginning grammatization, corresponds with 50 word
vocabulary
COGNITIVE
Stares momentarily at spot where object disappeared 2 Lack of object permanence (out of sight, out of mind
[e.g., yarn ball dropped])
Stares at own hand 4 Self-discovery, cause and effect
Bangs 2 cubes 8 Active comparison of objects
Uncovers toy (after seeing it hidden) 8 Object permanence
Egocentric symbolic play (e.g., pretends to drink from cup) 12 Beginning symbolic thought
Uses stick to reach toy 17 Able to link actions to solve problems
Pretend play with doll (e.g., gives doll bottle) 17 Symbolic thought

seek information about “normal development” during this period and should grow at approximately 30 g (1 oz)/per day during the 1st mo
should be directed to reliable sources, including the American Academy (see Table 15-1). This is the period of fastest postnatal growth. Arms
of Pediatrics website (www.AAP.org). are held to the sides. Limb movements consist largely of uncontrolled
writhing, with apparently purposeless opening and closing of the
AGE 0-2 MONTHS hands. Smiling occurs involuntarily. Eye gaze, head turning, and
In the full-term infant, myelination is present by the time of birth in sucking are under better control and thus can be used to demonstrate
the dorsal brainstem, cerebellar peduncles, and posterior limb of the infant perception and cognition. An infant’s preferential turning
internal capsule. The cerebellar white matter acquires myelin by 1 mo toward the mother’s voice is evidence of recognition memory.
of age and is well myelinated by 3 mo of age. The subcortical white Six behavioral states have been described (see Chapter 9). Initially,
matter of the parietal, posterior frontal, temporal, and calcarine cortex sleep and wakefulness are evenly distributed throughout the 24 hr day
is partially myelinated by 3 mo of age. In this period, the infant experi- (Fig. 10-2). Neurologic maturation accounts for the consolidation of
ences tremendous growth. Physiologic changes allow the establishment sleep into blocks of 5 or 6 hr at night, with brief awake, feeding periods.
of effective feeding routines and a predictable sleep–wake cycle. The Learning also occurs; infants whose parents are consistently more
social interactions that occur as parents and infants accomplish these interactive and stimulating during the day learn to concentrate their
tasks lay the foundation for cognitive and emotional development. sleeping during the night.

Physical Development Cognitive Development

A newborn’s weight may initially decrease 10% below birthweight in Infants can differentiate among patterns, colors, and consonants. They
the 1st wk as a result of excretion of excess extravascular fluid and can recognize facial expressions (smiles) as similar, even when they
limited nutritional intake. Nutrition improves as colostrum is replaced appear on different faces. They also can match abstract properties of
by higher-fat breast milk, as infants learn to latch on and suck more stimuli, such as contour, intensity, or temporal pattern, across sensory
efficiently, and as mothers become more comfortable with feeding modalities. Infants at 2 mo of age can discriminate rhythmic patterns
techniques. Infants regain or exceed birthweight by 2 wk of age and in native vs non-native language. Infants appear to seek stimuli actively,
 Chapter 10 ◆ The First Year 67

Table 10-2 Emerging Patterns of Behavior During the 1st Yr of Life*

NEONATAL PERIOD (1ST 4 WK)
Prone: Lies in flexed attitude; turns head from side to side; head sags on ventral suspension
Supine: Generally flexed and a little stiff
Visual: May fixate face on light in line of vision; “doll’s-eye” movement of eyes on turning of the body
Reflex: Moro response active; stepping and placing reflexes; grasp reflex active
Social: Visual preference for human face
AT 1 MO
Prone: Legs more extended; holds chin up; turns head; head lifted momentarily to plane of body on ventral suspension
Supine: Tonic neck posture predominates; supple and relaxed; head lags when pulled to sitting position
Visual: Watches person; follows moving object
Social: Body movements in cadence with voice of other in social contact; beginning to smile
AT 2 MO
Prone: Raises head slightly farther; head sustained in plane of body on ventral suspension
Supine: Tonic neck posture predominates; head lags when pulled to sitting position
Visual: Follows moving object 180 degrees
Social: Smiles on social contact; listens to voice and coos
AT 3 MO
Prone: Lifts head and chest with arms extended; head above plane of body on ventral suspension
Supine: Tonic neck posture predominates; reaches toward and misses objects; waves at toy
Sitting: Head lag partially compensated when pulled to sitting position; early head control with bobbing motion; back rounded
Reflex: Typical Moro response has not persisted; makes defensive movements or selective withdrawal reactions
Social: Sustained social contact; listens to music; says “aah, ngah”
AT 4 MO
Prone: Lifts head and chest, with head in approximately vertical axis; legs extended
Supine: Symmetric posture predominates, hands in midline; reaches and grasps objects and brings them to mouth
Sitting: No head lag when pulled to sitting position; head steady, tipped forward; enjoys sitting with full truncal support
Standing: When held erect, pushes with feet
Adaptive: Sees raisin, but makes no move to reach for it
Social: Laughs out loud; may show displeasure if social contact is broken; excited at sight of food
AT 7 MO
Prone: Rolls over; pivots; crawls or creep-crawls (Knobloch)
Supine: Lifts head; rolls over; squirms
Sitting: Sits briefly, with support of pelvis; leans forward on hands; back rounded
Standing: May support most of weight; bounces actively
Adaptive: Reaches out for and grasps large object; transfers objects from hand to hand; grasp uses radial palm; rakes at raisin
Language: Forms polysyllabic vowel sounds
Social: Prefers mother; babbles; enjoys mirror; responds to changes in emotional content of social contact
AT 10 MO
Sitting: Sits up alone and indefinitely without support, with back straight
Standing: Pulls to standing position; “cruises” or walks holding on to furniture
Motor: Creeps or crawls
Adaptive: Grasps objects with thumb and forefinger; pokes at things with forefinger; picks up pellet with assisted pincer movement;
uncovers hidden toy; attempts to retrieve dropped object; releases object grasped by other person
Language: Repetitive consonant sounds (“mama,” “dada”)
Social: Responds to sound of name; plays peek-a-boo or pat-a-cake; waves bye-bye
AT 1 YR
Motor: Walks with one hand held; rises independently, takes several steps (Knobloch)
Adaptive: Picks up raisin with unassisted pincer movement of forefinger and thumb; releases object to other person on request or gesture
Language: Says a few words besides “mama,” “dada”
Social: Plays simple ball game; makes postural adjustment to dressing
*Data are derived from those of Gesell (as revised by Knobloch), Shirley, Provence, Wolf, Bailey, and others.
Data from Knobloch H, Stevens F, Malone AF: Manual of developmental diagnosis, Hagerstown, MD, 1980, Harper & Row.

as though satisfying an innate need to make sense of the world. These response to stimuli that may be obvious (a soiled diaper), but are often
phenomena point to the integration of sensory inputs in the central obscure. Infants who are consistently picked up and held in response
nervous system. Caretaking activities provide visual, tactile, olfactory, to distress cry less at 1 yr and show less-aggressive behavior at 2 yr.
and auditory stimuli; all of these support the development of cognition. Cross-cultural studies show that in societies in which infants are
Infants habituate to the familiar, attending less to repeated stimuli and carried close to the mother, babies cry less than in societies in which
increasing their attention to novel stimuli. babies are only periodically carried. Crying normally peaks at about
6 wk of age, when healthy infants may cry up to 3 hr/day, then
Emotional Development decreases to 1 hr or less by 3 mo. Infants cry in response to the cry of
The infant is dependent on the environment to meet his or her needs. another infant, which has been interpreted as an early sign of empathy
The consistent availability of a trusted adult to meet the infant’s urgent development.
needs creates the conditions for secure attachment. Basic trust vs mis- Crying/fussiness is present in 20% of infants younger than 2 mo of
trust, the first of Erikson’s psychosocial stages (see Chapter 6), depends age and although in most it is a transient and normal behavioral activ-
on attachment and reciprocal maternal bonding. Crying occurs in ity, it is often associated with parental concern and distress. Excessive
 Chapter 11 ◆ The Second Year 75

use the parent as a secure base from which to explore independently.

Table 11-1 Emerging Patterns of Behavior from 1-5 Yr Proud of her or his accomplishments, the child illustrates Erikson’s
of Age* stage of autonomy and separation (see Chapter 6). The toddler who is
15 MO overly controlled and discouraged from active exploration will feel
Motor: Walks alone; crawls up stairs doubt, shame, anger, and insecurity. All children will experience tan-
Adaptive: Makes tower of 3 cubes; makes a line with crayon; trums, reflecting their inability to delay gratification, suppress or dis-
inserts raisin in bottle place anger, or verbally communicate their emotional states. The
Language: Jargon; follows simple commands; may name a familiar quality of the parent–child relationship may moderate negative effects
object (e.g., ball); responds to his/her name of childcare arrangements when parents work.
Social: Indicates some desires or needs by pointing; hugs
parents Linguistic Development
18 MO Receptive language precedes expressive language. By the time infants
Motor: Runs stiffly; sits on small chair; walks up stairs with 1 speak their first words around 12 mo of age, they already respond
hand held; explores drawers and wastebaskets appropriately to several simple statements, such as “no,” “bye-bye,” and
Adaptive: Makes tower of 4 cubes; imitates scribbling; imitates “give me.” By 15 mo, the average child points to major body parts and
vertical stroke; dumps raisin from bottle uses 4-6 words spontaneously and correctly. Toddlers also enjoy poly-
Language: 10 words (average); names pictures; identifies 1 or syllabic jargoning (see Tables 10-1 and 11-1), but do not seem upset
more parts of body
Social: Feeds self; seeks help when in trouble; may complain
that no one understands. Most communication of wants and ideas
when wet or soiled; kisses parent with pucker continues to be nonverbal.
24 MO Implications for Parents and Pediatricians
Motor: Runs well, walks up and down stairs, 1 step at a time; Parents who cannot recall any other milestone tend to remember when
opens doors; climbs on furniture; jumps
their child began to walk, perhaps because of the symbolic significance
Adaptive: Makes tower of 7 cubes (6 at 21 mo); scribbles in
circular pattern; imitates horizontal stroke; folds of walking as an act of independence and/or because of the new
paper once imitatively demands that the ambulating toddler places on his or her parent. All
Language: Puts 3 words together (subject, verb, object) toddlers should be encouraged to explore their environments; a child’s
Social: Handles spoon well; often tells about immediate ability to wander out of sight also increases the risks of injury and the
experiences; helps to undress; listens to stories when need for supervision.
shown pictures In the office setting, many toddlers are comfortable exploring the
30 MO examination room, but cling to the parents under the stress of the
Motor: Goes up stairs alternating feet examination. Performing most of the physical examination in the par-
Adaptive: Makes tower of 9 cubes; makes vertical and horizontal ent’s lap may help allay fears of separation. Infants who become more,
strokes, but generally will not join them to make not less, distressed in their parents’ arms or who avoid their parents
cross; imitates circular stroke, forming closed figure at times of stress may be insecurely attached. Young children who,
Language: Refers to self by pronoun “I”; knows full name when distressed, turn to strangers rather than parents for comfort are
Social: Helps put things away; pretends in play particularly worrisome. Children raised in “toxic” stressful environ-
36 MO ments have increased vulnerability to disease. The conflicts between
Motor: Rides tricycle; stands momentarily on 1 foot independence and security manifest in issues of discipline, temper
Adaptive: Makes tower of 10 cubes; imitates construction of tantrums, toilet training, and changing feeding behaviors. Parents
“bridge” of 3 cubes; copies circle; imitates cross should be counseled on these matters within the framework of normal
Language: Knows age and sex; counts 3 objects correctly; repeats development.
3 numbers or a sentence of 6 syllables; most of Parents may express concern about poor food intake as growth
speech intelligible to strangers
slows. The growth chart should provide reassurance. Most children still
Social: Plays simple games (in “parallel” with other children);
helps in dressing (unbuttons clothing and puts on take two daytime naps, although the duration steadily decreases (see
shoes); washes hands Fig. 10-1).
48 MO AGE 18-24 MONTHS
Motor: Hops on 1 foot; throws ball overhand; uses scissors to
cut out pictures; climbs well
Physical Development
Adaptive: Copies bridge from model; imitates construction of Motor development during this period is reflected in improvements in
“gate” of 5 cubes; copies cross and square; draws balance and agility and the emergence of running and stair climbing.
man with 2-4 parts besides head; identifies longer of Height and weight increase at a steady rate during this year, with a gain
2 lines of 5 in and 5 lb. By 24 mo, children are about half of their ultimate
Language: Counts 4 pennies accurately; tells story adult height. Head growth slows slightly. Eighty-five percent of adult
Social: Plays with several children, with beginning of social head circumference is achieved by age 2 yr, with just an additional
interaction and role-playing; goes to toilet alone 5 cm gain over the next few years (see Fig. 11-1 and Table 15-1).
60 MO
Motor: Skips Cognitive Development
Adaptive: Draws triangle from copy; names heavier of 2 weights At approximately 18 mo of age, several cognitive changes coalesce,
Language: Names 4 colors; repeats sentence of 10 syllables; marking the conclusion of the sensory-motor period. These can be
counts 10 pennies correctly observed during self-initiated play. Object permanence is firmly estab-
Social: Dresses and undresses; asks questions about meaning lished; toddlers anticipate where an object will end up, even though
of words; engages in domestic role-playing the object was not visible while it was being moved. Cause and effect
*Data derived from those of Gesell (as revised by Knobloch), Shirley, Provence, are better understood, and toddlers demonstrate flexibility in problem
Wolf, Bailey, and others. After 6 yr, the Wechsler Intelligence Scales for Children solving (e.g., using a stick to obtain a toy that is out of reach, figuring
(WISC-IV) and other scales offer the most precise estimates of developmental out how to wind a mechanical toy). Symbolic transformations in play
level. To have their greatest value, they should be administered only by an
experienced and qualified person. are no longer tied to the toddler’s own body, so that a doll can be “fed”
from an empty plate. Like the reorganization that occurs at 9 mo (see
Chapter 10), the cognitive changes at 18 mo correlate with important
changes in the emotional and linguistic domains (see Table 11-1).