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Jean-François Lemay, MD FRCPC Professor of Pediatrics Dept of Pediatrics ACH, University of Calgary Sept 6 2012. Learning about Normality. Objectives. The participant will learn: general principles in infant growth and development - PowerPoint PPT Presentation
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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