During this time, the baby will learn to hold the head for a longer time. When the 3 month old is lying on its stomach, it will be able to lift his head for a longer period and will also try to lift the chest which looks like push ups. When the child is sitting, it will hold his head erect and straight. The child can be encouraged by making sure the parents sit in front of the baby and move a toy encouraging the child to do the same.

The development of knees and hip joints can be seen when the baby is 3 month old. The joints become more flexible and the child starts waving and kicking. The muscles become stronger and if the baby is held up and she feels the ground under her feet, she will start pushing her legs down.

The 3 month old will now learn to grasp objects. The coordination of hands and legs get better. However, the child still uses fists to hit any objects. The grasping stage can be developed by encouraging the child to hold objects.

The new mothers can be at some relief during this period. When the child is 3 month old, the sleeping patterns change. The baby now sleeps through out the night. They may wake up sometimes but most of the times, they are fast asleep. Some of the babies may not sleep during the night and they might do this for the first six months.

The 3 month old now has a clear understanding of the parents. They start to recognize their parents. The sense of smell, language and hearing develops in the child and they will be able to use these senses to recognize the objects and their parents. The 3 month old baby may start smiling at strangers who smile at them or may be talk to them; however, they will still prefer having known people around them.

The sense of language can be developed by reading things to the 3 month old. The baby will develop the hearing and language. He will learn the accents, voice and this will develop the aural connection with the child. If the baby looses interest, do not force the baby and let the baby rest for a while.

The 3 month old does not have any demands with the diet. The baby demands only for milk during this period and it is advisable to keep the baby only on breast feeding. Only in situations where the mother’s milk is not available, the other supplements of food can be used. However, research has to be done before helping the baby with other food.

The feeding completely depends on the development and growth. There is no formula that can calculate the amount of food consumed by the baby. As the baby grows, the quantity of food consumed increases. The easiest way to feed the baby is breast feeding.

As the child completes one month, the developments starts where the child becomes stronger now. The 1 month old will develop on the neck muscles. The neck muscles will become strong and help the new born to hold their head for a little while.

The 1 month old can hold the head for a little longer when they are lying on their stomach, or when they are turning sideways. They may also be able to hold their heads when they are in the carriers where they get some support for their neck.

The baby will start exploring new things. The baby is not even aware about the hands and legs attached to her. The child now starts learning about their body parts. They will notice the hands and legs first and the development can be improved by holding the child’s hand over the head and counting the toes, so that the child explores her body parts.

The 1 month old now learns to talk. He may start gurgling, grunting and making different sounds to express what she wants to convey. The mother should make sure that the baby is always encouraged to speak and it has to be done face to face. As the child is learning to talk, the one month old will start laughing and squealing. If you talk to her from a distance, she will be gazing at you for longer time and will enjoy what you talk.

The 1 month old will now recognize the parents by looking at them. They start behaving differently when they are with their parents and when they see any strangers. They will either keep an eye contact or smile when they look at their parents.

The sleeping pattern of the 1 month old can be changed as per your convenience. The babies sleep for 15 hours during the day. The sleeping pattern can be changed with the feeding time. The babies sleeps in regular periods and if you wish to make sure the child sleeps during the night, make sure u try to keep the child awake during the day.

If the 1 month old is fed around 7 pm, the baby might wake up by 2 am again for another feed. In that case, wake up the baby and feed him again around 11pm so that the baby sleeps till 5 or 6 am. In this way, the child will have a continuous and sound sleep.

This can become consistent if the routine is followed regularly. Also to make sure the baby sleeps back, make sure the baby is not played with and the feeding is done in dark. This will give a message to the 1 month old baby that you are tired and not interested and the baby will go back to sleep again.

A tic may last on and off for a number of weeks or months then go away for good or be replaced by a new one. Blinking, sniffing, throat-clearing, and dry coughing often start with a cold but continue after the cold is gone. Shoulder-shrugging may begin when a child has a new loose-fitting garment that feels as if it were falling off. Children may copy a mannerism from another child with a tic, especially from a child they look up to, but these mannerisms don’t last long.

tics in children

The main cause of tics in children seems to lie in the development of the brain. But psychology also plays a role. Tics are more common in tense children with fairly strict parents. There may be too much pressure at home. Sometimes the mother or father is going at the child too hard, directing him, correcting him whenever he is in sight.

Or the parents may be showing constant disapproval in a quieter way, setting standards that are too high, or providing too many activities, such as dancing, music, and athletic lessons. If the child were bold enough to fight back, he would probably be less tight inside. But being, in most cases, too well brought up for that, he bottles up his irritation, and it keeps backfiring in the form of a tic.

No child should be scolded or corrected on account of his tics. Tics in children are out of their control. The parent’s whole effort should go into making his home life relaxed and agreeable, with the least possible nagging, and making his school and social life satisfying.

About one child in ten has mild tics like this; they almost always go away with benign neglect. May be one in hundred children will continue to have multiple tics that persist for over a year. This one child may have Tourette’s Syndrome and should be checked by the doctor or nurse practitioner.

Tics in children isn’t something you need to bothered a lot with. They also do not need any medication or treatment. Many parents panic and end up asking for medications and these medications have their own side effects. So if your child shows the signs of getting tics, then try to resolve it without medications.

Check out the below advise from a professional regarding tics in children:

Other examples are touching every third picket in a fence, making numbers come out even in some way, saying certain words before going through a door. If you think you have made a mistake, you must go back to where you were absolutely sure that you were right, then start over.

We now know that a very strong tendency of obsessive compulsive disorder in children is often the result of brain characteristics that are inherited. Rarely, a child suddenly develops severe compulsions as a complication of an infection with strep. From a psychological perspective, compulsions may be a way for children to deal with anxious feelings.

One source of anxiety may be hostile feelings toward parents that the child cannot acknowledge. Think about the childhood saying, “Step on a crack, break your mother’s back.” Everyone has hostile feelings at times toward the people who are close to him, but his conscience would be shocked at the idea of really harming them and warns him to keep such thoughts out of his mind.

And if a person’s conscience becomes excessively stern, it keeps nagging about such bad thoughts even after he has succeeded in hiding them away in his subconscious mind. He still feels guilty, though he doesn’t know what for. It eases his conscience to be extra careful and proper about such a senseless thing as how to navigate a crack in the sidewalk.

The reason a child is apt to show compulsions around the age of nine is not that his thoughts are more wicked but that his conscience just naturally becomes stricter at this stage of development.

Mild obsessive compulsive disorder in children are so common around the ages of 8, 9, and 10 years that for the most part they can be considered normal. Mild compulsions, like stepping over cracks, shouldn’t be a concern, in a child who is happy, outgoing, and doing well in school.

On the other hand, I’d call on a mental health professional for help if a child has obsessive compulsive disorder that occupy a lot of his time: for instance, excessive hand-washing or if he is tense, worried, or unsociable. This is because such a habit can change into a disorder which is quite commonly found in young children. This disorder is termed as obsessive compulsive disorder in children

Boys and girls around three have reached a Preschooler stage in their emotional development when they feel that their fathers and mothers are wonderful people and they want to be like them. The automatic resistance and hostility that were just below the surface in the two-year-old seem to lessen after three in most children.

The feelings towards the parents aren’t just friendly now; they are warm and tender. However, preschooler children are not so devoted to their parents that they always obey them and behave well. They are still real people with ideas of their own. They want to assert themselves, even if it means going against their parents’ wishes at times.

While I emphasize how agreeable children usually are between three and five, I ought to make a partial exception for 4-year-olds. A lot of assertiveness, cockiness, loud talk, and provoking comes out around four years in many children, when they come to the realization that they know everything—a misconception that mercifully soon fades.

Striving to be like the parents

At 2 years of age, children eagerly imitate their parents’ activities. If they are playing at mopping the floor or hammering a pretend nail, their focus is on the use of the mop or the hammer. By 3 years of age, the quality of their imitation changes. Now they want to be like their parents as people. They play at going to work, tending house (cooking, cleaning, laundering), and caring for children (a doll or a younger child). They pretend to go for a drive in the family car or to step out for the evening. They dress up in their parents’ clothes, mimic their conversation, manners, and mannerisms. Psychologists call this process identification.

Identification is a lot more important than just playing. It’s how character is built. It depends more on what children perceive in their parents and model themselves after than on what the parents try to teach them in words. This is how  preschooler children’s basic ideals and attitudes are laid down—toward work, toward people, toward themselves—though these will be modified later as they become more mature and knowing. This is how they learn to be the kind of parents they’re going to turn out to be 20 years later, as you can tell them from listening to the affectionate or scolding way they care for their dolls.

Gender awareness

It’s at this age that a preschooler girl becomes more aware that she’s female and will grow up to be a woman. So she watches her mother with special attentiveness and tends to mold herself in her mother’s image: how her mother feels about her husband (lord and master—or beloved partner) and the male sex in general, about women (confidantes or competitors), about girl and boy children (if the child of one sex is favored over the other or each individual is appreciated for herself or himself), toward work and housework (chore or challenge). The little girl will not become an exact copy of her mother, but she will surely be influenced by her in many respects.

A preschooler boy at this age realizes that he is on the way to becoming a man, and he therefore attempts to pattern himself predominantly after his father: how his father feels toward his wife and the female sex generally, toward other men, toward his boy and girl children, toward outside work and housework.

In addition to the predominant identification with the parent of the same sex, there’s a degree of identification with the parent of the opposite sex. This is how the two sexes come to understand each other well enough to be able to live together.

Fascination with babies

Preschooler boys and girls now become fascinated with all aspects of babies. They want to know where babies come from. When they find out that babies grow inside their mothers, they are eager to carry out this amazing act of creation themselves—boys as well as girls. They want to take care of babies and love them, the way they realize they were cared for and loved. They will press a younger child into the role of a baby, spending hours acting as father and mother to him, or they’ll use a doll.

It’s not generally recognized that little preschooler boys are as eager as girls to grow babies inside themselves. When their parents tell them that this is impossible, they are apt to refuse to believe it for a long time. “I will too grow a baby”, they say, really believing that if they wish something hard enough, they can make it come true. In a similar way, a preschool girl may announce that she is going to grow a penis. Ideas of this kind are not signs of dissatisfaction with being one sex or the other. Instead, they come from the young child’s belief that he or she can do everything, be everything, and have everything.

ROMANTIC AND COMPETITIVE FEELINGS

Wishes and worries

Preschooler boys become more romantic toward their mothers, girls toward their fathers. Up to this age, a boy’s love for his mother has been predominantly of a dependent kind, like that of a baby. Now it also becomes increasingly romantic, like his father’s. By the time he’s four, he’s apt to insist that he’s going to marry his mother when he grows up. He isn’t clear on just what marriage consists of, but he’s absolutely sure who is the most important and appealing woman in the world. The little preschooler girl who is growing in her mother’s pattern develops the same kind of love for her father.

These strong romantic attachments help children to grow spiritually and to acquire wholesome feelings toward the opposite sex that will later guide them into good marriages. But there is another side of the picture that creates unconscious tension in most children at this age. When people, old or young, love someone very much, they can’t help wanting that person all to themselves. So as a little preschooler boy of 3 or 4 or 5 becomes more aware of his possessiveness devotion to his mother, he also becomes aware of how much she already belongs to his father. This irritates him, no matter how much he loves and admires his father. At times he secretly wishes his father would get lost, then feels guilty about having such disloyal feelings. Reasoning as a preschooler child does, he imagines that his father has the same jealous and resentful feelings toward him.

The little preschooler girl develops the same possessive love for her father. She wishes at times that something would happen to her mother (whom she loves so much in other respects) so that she can have her father for herself. She may even say to her mother, “You can go away for a long trip, and I’ll take good care for Daddy”. But she imagines that her mother is jealous of her, too—a frightening thought. If you think about classic fairy tales like “Snow White”, you can see these fantasies and worries brought to life in the figure of the wicked stepmother.

Preschooler children try to push these scary thoughts out of their minds, since the parent, after all, is so much bigger and stronger, but they are apt to come to the surface in their play and dreams. These mixed feelings—of love, jealousy, and fear—toward the parent of the same sex can come out in the bad dreams that little children of this age are so apt to have: dreams of being chased by giants, robbers, witches, and other frightening figures.

Moving past possessiveness

This romantic attachment to the parent of the opposite sex in the preschool years is what you might call nature’s way of molding children’s feelings in preparation for their eventual life as spouse or parent. But it wouldn’t do for the attachment to go so far or become so strong that it lasts throughout life or even throughout childhood.

Nature expects that children by 6 or 7 will become discouraged about the possibility of having the parent all to themselves. The unconscious fears of the parent’s supposed anger will turn their pleasure in dreaming about romance into an aversion. From now on children will shy away from kisses by the parent of the opposite sex. Their interests turn with relief to impersonal matters, such as schoolwork and sports. They try now to be just like other children of their own sex, rather than like their parents.

A father who realizes that his young preschooler son sometimes has unconscious feelings of resentment and fear toward him does not help the boy by trying to be too gentle and permissive with him. It’s of no help, either, for the father to try to avoid making his son jealous by pretending that he (the father) doesn’t really love his wife very much. In fact, if a boy becomes convinced that his father is afraid to be a firm father and a normally possessive husband, the boy will sense that he has his mother too much to himself and will feel guilty and frightened. He will miss the inspiration of a confident father, which he must have in order to develop his own self-assurance.

In the same way, a mother best helps her daughter to grow up by being a self-confident mother who doesn’t let herself be pushed around, who knows how and when to be firm, and who isn’t afraid to show her affection for and devotion to her husband.

It complicates life for a preschooler boy if his mother is a great deal more permissive and affectionate toward him than his father is. The same is true if she seems to be closer and more sympathetic to her son then she is to her husband. Such attitudes have a tendency to alienate a boy from his father and make him fearful of him.

In a corresponding manner, the father who is putty in his daughter’s hands and is always undoing the mother’s discipline or the father who acts as if he enjoys his daughter’s companionship more than his wife’s is being unhelpful not only to his wife but to his daughter as well. This interferes with the good relationship that a daughter should have with her mother to grow up to be a happy woman.

Incidentally, it is entirely normal for a father to be a bit more lenient toward his daughter and a mother toward her preschooler son and for a son to feel a little more comfortable with his mother and a daughter with her father, since there is naturally less rivalry between male and female than between two males or two females.

In the average family there is a healthy balance among the feelings of father, mother, sons, and daughters that guides them through these stages of development without any special effort.

How parents can help

Parents can help preschooler children through this romantic, jealous stage by gently making it clear that they belong to each other, that a boy can’t ever have his mother to himself and a girl can’t have her father to herself, and that the parents aren’t shocked to realize that their children are sometimes mad at them on this account.

When a preschooler girl declares that she is going to marry her father, he can act pleased with the compliment, but he should also explain that he’s already married and that when she grow up she’ll find a man her own age to marry.

When parents are being companionable together, they needn’t and shouldn’t let a preschooler child break up their conversation. They can cheerfully but firmly remind her that they have things to talk over and suggest that she get busy, too. Their tactfulness will keep them from prolonged displays of affection in front of her, just as it would if other people were present, but they don’t need to spring apart guiltily if she comes into the room unexpectedly when they’re hugging or kissing.

When a preschooler boy is rude to his father because he’s jealous or to his mother because she’s the cause of his jealousy, the parent should insist on politeness. And the converse is equally true if a girl is rude. But at the same time, the parents can ease the child’s feelings of anger and guilt by saying that they know the child is sometimes cross at them.

CURIOSTIY AND IMAGINATION

Intense curiosity

At this age, children want to know the meaning of everything they encounter. Their imagination is rich. They put two and two together and draw their own conclusions. They connect everything with themselves. When they hear about trains, they want to know right away. ”Will I go on a train someday?” When they hear about an illness, it makes them think, “Will I have that?”

A gift for imagination

Preschooler children are virtuosos of imagination. When children of 3 or 4 tell a made-up story, they aren’t lying in our grown-up sense. Their imagination is vivid to them. They’re not sure where the real ends and the unreal begins. That is why they love having stories told or read to them. That is why they are scared of violent television programs and movies and shouldn’t see them.

You don’t need to scold your child or make him feel guilty for occasionally making up stories. You can simply point out that what he said isn’t actually so, although he may wish it were so. In this way, you’re helping your preschooler child learn the difference between reality and make-believe.

An imaginary friend who shows up now and then, perhaps to help with a particular adventure—daring to go into basement alone, for example—is a sign of a normal, healthy imagination. But sometimes a preschooler child who feels lonely will spend hours each day telling about imaginary friends or adventures, not as a game but as if he believes in them. When you help such a child to make friends with real children, the need for fantasy playmates often lessens.

Children need hugging and piggyback rides

They need to share in parent’s jokes and friendly conversations. If the adults around them are undemonstrative, children dream of comfy, understanding playmates as the hungry man dreams of chocolate bars. If the parents are always disapproving, the preschooler children invent a wicked companion whom they blame for the naughty things they have done or would like to do.

SLEEP ISSUES

Most preschooler children give up taking naps sometime before age 4 but may still need a period of quiet rest in the afternoon. If they sleep much less than ten hours a night, they’re bound to be overtired (although there is a wide range of normal sleep needs at this age, from about 8 hours to as many as 12 or 13). Sleep problems that began earlier in life, such as excessive bedtime stalling or frequent waking, often continue through the preschool years. But new sleep problems also often arise during the preschool years, even for preschooler children who have been good sleepers. Nightmares and night-terrors are common at this age.

Sleep problems can also develop out of the normal feelings of possessiveness and jealousy described above. The preschooler child wanders into the parents’ room in the middle of the night and wants to get into their bed because (without putting these thoughts into words) he doesn’t want them to be alone together. If he is allowed to stay, he might end up literally kicking his father out of the bed. It’s much better for him, as well as for his parents, if they promptly and firmly, but not angrily, take him back to his own bed.

FEARS AROUND THREE, FOUR, AND FIVE

Imaginary worries

New types of fear crop up fairly often around the age of 3 and 4—fear of the dark, of dogs, fire engines, death, crippled people. Preschooler children’s imaginations have by then developed to the stage where they can put themselves in other people’s shoes and picture dangers that they haven’t actually experienced. Their curiosity is pushing out in all directions. They want to know not only the cause of everything but what these things have to do with them. They overhear something about dying. They want to know what dying is. As soon as they get a dim idea, they ask, “Do I have to die?”

These fears are more common in preschooler children who were made tense by battles over such matters as feeding and toilet training, children whose imaginations have been over stimulated by scary stories or too many warnings, children who haven’t had enough chance to develop their independence and outgoingness, children whose parents are too protective. The uneasiness accumulated before now seems to be crystallized by the preschooler child’s new imagination into definite dread.

That is not to say that any child who develops a fear has been handled mistakenly in the past. The world is full of things young preschooler children do not understand, and no matter how lovingly they have been raised, they recognize their own weakness and vulnerability. Some children—about one in seven—have brains that are biologically programmed to respond to changes with anxiety. And all children, no matter how carefully they are brought up, are frightened by something.

Fear of the dark

If your preschooler child develops a fear of the dark, try to reassure her. This is more a matter of your manner than your words. Don’t make fun of her, be impatient with her, or try to argue her out of her fear. If she wants to talk about it, as a few children do, let her. Give her the feeling that you want to understand but are absolutely certain that nothing bad will happen to her. Naturally, you should never threaten her with monsters, policemen or the devil.

Avoid scary movies and television programs and cruel fairy tales. The preschooler child is enough afraid of her own mental creations. Call off any battle you’re engaged in about eating or staying dry at night. Keep her behaving well by firm guidance, rather than by letting her misbehave then making her feel guilty about it afterward. Arrange to give her a full, outgoing life with other preschooler children every day. The more she is absorbed in games and plans, the less she will worry about her inner fears. Leave her door open at night if that is what she wants, or leave a dim light on in her room. It’s a small price to pay to keep the goblins out of sight. Neither the light nor the conversation from the living room will keep her awake as much as her fears will. When her fear subsides, she will be able to tolerate the dark again.

Fear of animals

Preschooler children often develop a fear of one or more animals, even if they have never had a bad experience with them. It doesn’t help to drag a scared child to a dog to prove that nothing bad will happen. The more you pull, the more the child will feel he has to pull in the opposite direction. As the months go by, the preschooler child will try to get over his fear and approach a dog. He’ll do it faster by himself than you can ever persuade him to.

Fear of the water

It’s almost always a mistake to pull a child, screaming, into the ocean or a pool. It is true that occasionally a child is forced in finds that it is fun and abruptly loses the fear, but in more cases, it works the opposite way. Remember that despite the dread she feels, the preschooler child is longing to go in.

Questions about death

Questions about death are apt to come up at this age. Try to make the first explanation casual, not scary. You might say, “Everybody has to die someday. Most people die when they get very old and sick, and their body just stops working.”

You have to tailor your answer to your preschooler child’s developmental level. For example, “We lost Uncle Archibald,” can strike terror into the heart of any child who has himself gotten lost. Since this is the age when children take everything literally, it’s especially important not to refer to death as going to sleep. Many children will then become terrified of going to sleep and dying themselves, or else they’ll say: “Well, wake him up.”

It’s much better to explain as simply as possible—without sugarcoating the facts—that death is a state where the body stops working completely. You can then use the opportunity to discuss your family’s beliefs about death. Most adults have some degree of fear and resentment of death; there is no way to present the matter to preschooler children that will get around this basic human attitude. But if you think of death as something eventually to be met with dignity and fortitude, you’ll be somewhat able to give that same feeling to your preschooler child. Also remember to invite questions and to answer them simply and truthfully. Remember to hug her and remind her that you’re going to be together for a very long time.

Helping your child cope with fears

It is not your job as a parent to banish all fears from your preschooler child’s imagination. Your job is to help your child learn constructive ways to cope with and conquer those fears. In the eloquent words of Selma Fraiberg in The Magic Years: “The future mental health of the preschooler child does not depend on the presence or absence of ogres in his fantasy life. It depends on the child’s solution to the ogre problem.”

When a child has fears of dogs and fire engines and policemen and other concrete things, she may try to get used to the worry and overcome it by making up games about it. This playing-out of a fear is a great help if the preschooler child is able to do it. A fear is meant to make us act. Our bodies are flooded with adrenaline, which makes the heart beat faster and supplies sugar for quick energy. We are ready to run like the wind or to fight like wild animals (flight or fight). The running and fighting burn up the anxiety. Sitting still does nothing to relieve it. If children with a fear of dogs play games in which they become the masters of a toy dog, it partly relieves them. If your preschooler child develops an intense fear or a number of fears that cross over into other parts of his daily life, you ought to get the help of a children’s mental health professional.

WORRIES ABOUT INJURY AND BODY DIFFERENCES

Why these worries arise

Preschooler children at this age want to know the reason for everything, worry easily, and apply dangers to themselves. If they see a crippled or deformed person, they first want to know what happened to that person, then they put themselves in the person’s place and wonder if that injury might happen to them.

This is also the age in which there is naturally a great interest in physical mastery of all kinds (hopping, running, climbing), which makes body intactness very important and its being broken very upsetting. This explains why a child at the age of two and a half or 3 can get so upset about a broken cookie, refusing one that’s in two pieces and demanding a whole one.

Body and sexual differences

Children develop these fears not only about real injuries. They even get mixed up and worried about the natural differences between preschooler boys and girls. If a boy around the age of 3 sees a girl undressed, it may strike him as odd that she hasn’t got a penis as he does. He’s apt to say, “Where is her wee-wee?” If he doesn’t receive a satisfactory answer right away, he may jump to the conclusion that some accident has happened to her. Next comes the anxious thought, “That might happen to me too”. The same misunderstanding may worry the little girl when she realizes that boys are made differently. First she asks, “What’s that?” Then she anxiously wants to know, “Why don’t I have one? What happened to it?” That’s the way a 3-year-old’s mind works. Preschooler children may be so upset that they’re afraid to question their parents.

It’s wise to realize ahead of time that normal children between two and a half and three and a half are likely to wonder about things like bodily differences, and if they aren’t given a comforting explanation when they become curious, they’re apt to come to worrisome conclusions. It’s no use waiting for them to say, “I want to know why a preschooler boy isn’t made like a girl,” because they won’t be that specific. They may ask some kind of question, or they may hint around, or they may just wait and become worried. Don’t think of this as an unwholesome interest in sex. To them it’s just like any other important question, at first. You can see why it would work the wrong way to shush them, scold them, or blush and refuse to answer. That would give them the idea they are on dangerous ground, which you want to avoid.

On the other hand, you don’t need to be solemn, as if you were giving a lecture. It’s easier than that. It helps, first of all, to bring the child’s fear out into the open by saying that he probably thinks a girl had a penis but something happened to it. They you try to make it clear, in a matter-of-fact, cheerful tone, that girls and women are made differently from preschooler boys and men; they are meant to be that way. A small child understands an idea more easily from examples. You can explain that Johnny is made just Daddy, Uncle Harry, David, and so on and that Mary is make like Mommy, Mrs. Jenkins, and Helen (listing individuals the child knows best).

A little girl needs extra reassurance because it’s natural for her to want to have something she can see. (One little girl complained to her mother, “But he’s so fancy and I’m so plain.”) It will help her to know that her mother likes being made the way she is, that her parents love her just the way she is. This may also be a good time to explain that preschooler girls when they are older can grow babies of their own inside them and have breasts with which to nurse them. That’s a thrilling idea at three or four.

2 year old toddler live in contradictions

They are independent and dependent, loving and hateful, generous and selfish, mature and infantile. They stand with one foot in the warm, cozy, dependent past and the other in an exciting future full of autonomy and discovery. With so much excitement going on, it’s no wonder that two is a challenging age for parents and children alike. But terrible, it isn’t. It’s really pretty amazing.

2 year old toddler learn by imitation

In a doctor’s office, a 2 year old toddler girl solemnly places the stethoscope bell on different spots on her chest. Then she pokes the otoscope in her ear and looks puzzled because she can’t see anything. At home she follows her parents around, sweeping with a broom when they sweep, dusting with a cloth when they dust, brushing her teeth when they do. It’s all done with great seriousness. She is making giant strides forward in skill and understanding by constant imitation.

Young children also imitate their parents’ behavior patterns. For example, when you treat others politely, your 2 year old learns to be polite. It’s okay to tell a 2-year-old to say please and thank you, but it’s much more effective to let him hear you use those words in appropriate circumstances. (Don’t expect to see politeness right away, but 4 or 5, your early investment in politeness is bound to begin to pay off). In the same way, young children who see parents using hurtful language or threats often develop similar troublesome behaviors. That doesn’t mean that parents can’t ever argue or disagree. But a steady diet of angry conflict is harmful to children, even if they are just bystanders.

Communication and imagination: At two, one child speaks in 3 and 4-word sentences while another is just beginning to link two words together. A 2 year old who only says a few isolated words probably should have a hearing test and developmental evaluation, even though the chances are good that the child will simply be a late talker.

Imagination and language grow together

It’s wonderful to watch a young child’s imagination unfold over the year from 24 to 36 months. What starts out as a simple imitation and experimentation becomes rich make-believe play. As a spur to imagination, let your child experience blocks, dolls, musical instruments, old shoes, cookie dough, water for splashing and pouring, and as many other interesting objects you can think of. Expose your child to nature, even if just he neighborhood park. Look at picture books together, and let your child use paper and crayons. Scribbling is the first step on the path to writing.

One thing I strongly recommend against is television. Even high-quality children’s television can limit a child’s imagination, simply because it does all the work, demanding so little effort from the child. Even at two, television teaches children to become passive consumers of entertainment, rather than learning how to amuse themselves.

Parallel play and sharing

2 year old don’t play cooperatively with each other very much. Although they may love to watch each other’s occupations, they mostly enjoy playing alongside each other in what is called parallel play. There is no point in trying to teach a 2 year old to share; he simply isn’t ready. To share, a child has to understand that something belongs to him—that he can give it away and expect to get it back. That a 2 year old won’t share has nothing to do with how generous a person he well become when he is older.

But this doesn’t mean you have to accept bad manners, even if he hasn’t a clue why you consider his grabbing a toy away from a companion to be bad form. You can firmly but cheerfully take the toy away from him, return it to its rightful owner, and quickly try to distract him with another object of interest. Long harangues about why he should share things are wasted breath. He will start to share when he understands the concept of sharing (usually around 3 to 4) and not before.

WORRIES AROUND TWO

Separation fears

By age two, some children have gotten over their toddler clinginess, others haven’t. A 2 year old seems to realize clearly who it is that gives her a sense of security, and she shows it in different ways. A mother complains, “My 2 year old seems to be turning into a mama’s girl. She hangs on to my skirts when we’re out of the house. When someone speaks to us, she hides behind me.” Two is great age for whining, which can be a kind of clinging. She may be timid about being left anywhere by her parents. She’s apt to be upset if a parent or other member of the household goes away for a number of days or if the family moves to a new house. It’s wise to take her sensitivity into account when changes in the household are being considered.

Here’s what can happen when a sensitive, dependent child of 2 year old, particularly an only child, is abruptly separated from the parent who has spent the most time with him. Perhaps it is the mother, and she has to go out of town unexpectedly for a couple of weeks. Or she decides that she has to go to work and arranges for a stranger to come in and take care of the child. Usually the child makes no fuss while the mother is away, but when she returns, he hangs on to her like Velcro and refuses to let the other person come near. He panics whenever he thinks his mother may be leaving again.

Bedtime separations of 2 year old

Separation anxiety is worst at bedtime. The terrified child fights against being put to bed. If his mother tears herself away, he may cry in fear for hours. If she sits by his crib, he remains lying for only as long as she sits still. Her slightest move toward the door brings him instantly to his feet. If your 2 year old has become terrified about going to bed, the surest advice, though the hardest to carry out, is to sit by her crib in a relaxed way until she goes to sleep.

Don’t sneak away before she is asleep. That will alarm her again and makes her more wakeful. This campaign may take weeks but should work in end. Making the child more tired by keeping her up later or omitting her nap may help a little but usually won’t do the whole job. Even if she’s exhausted, a panicky child can keep herself awake for hours. You have to take away her worry, too.

If your child was frightened because one of you left town, try to avoid going away again for many weeks. If you have taken a job for the first time since you child was born, say good-bye each day affectionately, cheerfully, and confidently. If you have an anguished, unsure-whether-you’re-doing-the-right-thing expression, it will add to your child’s uneasiness.

Concern about wetting the bed

Sometimes when a 2 year old has bedtime anxieties, there is also worry about urinating. The child keeps saying “Wee-wee” or whatever word he uses. His mother takes him to bathroom, and he does a few drops, then cries “Wee-wee” again as soon as he is back in bed. You might say that he is just using this as an excuse to keep her there. This is true, but there is more to it. Children like 2 year old are really worried that they may wet the bed.

They sometimes wake every two hours during the night thinking about it. This is the age when the parents are apt to show disapproval when there is an accident. May be the 2 year old figures that if he wets, his parents won’t love him so much and will therefore be more likely to go away. If so, he has two reasons to fear going to sleep. If your child is worried about wetting, keep reassuring her that it doesn’t matter if she does wee-wee in bed—that you’ll love her just the same.

A 2 year old who is frightened by separation—or anything else—is very sensitive to whether her parents feel the same way about it. If they act hesitant or guilty every time they leave her side, if they hurry into her room at night, their anxiety reinforces her fear that there really is great danger in being apart from them.

This may sound contradictory after having said that a parent must reassure a frightened 2 year old by sitting by her bed as she goes to sleep and by not going away on any more trips for a number of weeks. It means that parents must give her this special care the way they give special consideration to a sick child. However, they should strive to be confident, unafraid and cheerful. They should keep an eye on the indications of the child’s readiness to give up his dependence, encourage him, step by step and compliment him. This behavior is the most important factor in getting rid of their fear. That and the maturational forces which, with time and maturity, will allow the 2 year old to better understand and master her fears.

Children may use separation anxiety to control

A child clings to his mother because he has developed a genuine fear of being separated from her. Then if he finds that she is so concerned about his fear that she will always do anything he wants for reassurance, he may begin to use this as coercion. There are 3-year-olds, for instance, who are anxious about being left at preschool whose parents to reassure them not only stay at school for days but stay close to the children and do what they ask.

After a while, you begin to see that such children are exaggerating their uneasiness because they have learned to use it to boss their parents around. A parent should say, “I think you are grown up now and aren’t afraid to be in school. You just like to make me do what you want. Tomorrow I won’t need to say here anymore.”

How to help a fearful 2 year old

When it comes to management of children’s fear, a lot depends on how important it is from a practical point of view for them to get over it in a hurry. There’s no great necessity for anxious children to be hurried into making friends with dogs or going into deep water in the lake. They’ll want to do these things as soon as they dare.

One the other hand, children should not be allowed to come into the parents’ bed every single night (unless you’ve decided that cosleeping is for you). They should be comforted and soothed in their own beds so that sleeping with the parents doesn’t become a pleasant habit for which there is no motivation for the child to stop.

Once children have started preschool, it’s better for them to go regularly unless they’re deeply terrified. A skillful teacher can help a 2 year old become engaged in play so that the separation becomes easier. A child with school-refusal problem must go back to school sooner or later; the longer it is put off, the harder it is. Parents are wise to consider whether overprotectiveness is playing a part in these various separation fears. This is a tough task, and parents are certainly entitled to help from a doctor or other professional.

Some causes of overprotectiveness: Overprotective feelings occur mostly in devoted parents who are inclined to feel guilty when there is no need to.

Hidden cause is often anger

The parent and child who are afraid to recognize that there are naturally moments when they resent each other, when each wishes that something bad would happen to the other, have to imagine instead that all the dangers in the world come from somewhere else and grossly exaggerate them. The 2 year old who denies the resentment in her parents and herself places it in monsters or robbers or dogs or lightning, depending on her age and experience.

She clings tightly to her parents for protection and to reassure herself that nothing is really happening to them. A mother, for instance, may suppress her occasional resentful thoughts and exaggerate the dangers of kidnappers or home accidents or inadequate diet. She has to stay close to the 2 year old to make sure the dangers don’t strike, and her anxious expression convinces the child that her own fears are well founded.

Of course, the answer is not for parents to take out all their angriest feelings on the child or to let her be abusive toward them. But it is certainly helpful for parents to recognize the inevitability of their occasional feelings of resentment toward their child and to admit them to each other. It helps to clear the air if parents occasionally admit to a 2 year old how angry they felt—especially if the anger was not quite fair. And it’s good to say to a child once in a while, “I know how angry you feel toward me when I have to make rules like this for you.”

CHALLENGING BEHAVIORS

Negativism

In the period between age two and age three, children are apt to show signs of negativism and other inner tensions. Your baby probably began to be balky and negativistic way back when she was fifteen months old, so this is nothing new. But it reaches new heights and takes new forms after two. One-year-old Petunia contradicts her parents. 2 year old Petunia even contradicts herself! She has a hard time making up her mind, then wants to change it. She acts like a person who feels she is being bossed too much, even when no one is bothering her or when she tries to boss others. She insists on doing things just so, doing them her own way, doing them exactly as she has always done them. It makes her furious to have anyone interfere in one of her jobs or rearrange her possessions.

The child’s nature between two and three seems to be urging her to decide thing for herself and to resist pressure from other people. Trying to fight these two battles without much worldly experience seems to make her tight inside. For that reason, it’s often hard to get along with a child between two and three.

The parents’ job is to keep from interfering too much, and, when possible, let their children work at their own pace. Let your 2 year old child help to dress and undress himself when he has the urge. Start his bath early enough so that he has time to dawdle and scrub the tub. At meals, let him feed himself without urging. When he is stalled in his eating, let him leave the table. When it’s time for bed, going outdoors, or coming in, steer him while conversing about pleasant things. Get things done without raising issues. Your goal is keep him from being a little tyrant but not to sweat the small stuff.

2 year old behave best when parents set firm, consistent, and reasonable limits. The key is to choose those limits carefully. If you find yourself saying no a lot more than yes, you’re probably setting too many arbitrary limits. A battle of wills with a 2-year-old is exhausting, so save it for issues that are truly important. Safety issues, such as sitting in the car seat, are clearly important. Wearing mittens on a cold day may not be so very important. (After all, you can always surf the mittens in your coat pocket and whip them out when your 2-year-old’s hands become cold.)

Temper tantrums

Nearly every 2 year old has a tantrum from time to time; some healthy children have lots of them. Tantrums usually start around age one and peak around age 2 or 3. These are due to many reasons like fear, frustration, fatigue and hunger. Those kids who are more inclined towards change tend to have these factors. The best way for the parent to deal with such tantrums is by distracting the mind by providing unscheduled snack or changing the play. Sometimes there is sudden burst of tantrum. In such cases, just quietly wait till the kid calms down.

Do not react angrily to your child’s tantrums as most of the time the child stops throwing them if he finds that you are supportive.

Whining. Young mammals of many species whine for attention and nurturance (think of puppies.) so whining is natural and universal, but it’s still annoying. Early on you have no choice but to try to figure out what your child needs. Once your 2 year old can use words, however, it’s reasonable to insist that she do that. A firm, unemotional, “Use your words, I don’t listen to whining,” is all it usually takes, although you may have to repeat this message over many months before it fully sinks in. Be aware that if you sometimes give in to whining—the temptation to do so is strong—it may become much harder to put a stop to it.

Favoritism toward one parent

Sometimes a child around 30 to 36 months can get along with either parent alone, but when the other one comes on the scene she flies into a rage. It may be partly jealousy, but at an age when she’s sensitive about being bossed around and trying to do a little bossing herself, she may just feel outnumbered when she has to take on two important people at once.

It’s more often the father who is particularly unpopular at this period; he sometimes has the feeling he’s pure poison. He shouldn’t take the child’s reaction too seriously or feel hurt and turn away from her. It will help if he regularly cares for her by himself, doing things that are fun, as well as everyday chores, such as feeding and bathing. That way she gets to know him as an enjoyable, loving, and important person, not just an intruder. If a 2 year old child objects at first when her father takes over, he should cheerfully but firmly carry on, and the mother should have the same firm and cheerful attitude as she leaves.

Taking turns this way will give each parent one-on-one time with their child and also time alone. But there is also value in time spent all together, even if the 2 year old acts cranky. It’s good for a child (particularly a first ch 2 year oldild) to learn that her parents love each other, want to be with each other, and will not be bullied by her.

DIET AND NUTRITION

Changes in the diet

A 2 year old can eat pretty much what the family does. You still need to be aware of choking hazards – small or hard foods such as peanuts, grapes, carrots, and hard candies—and keep these out of your child’s diet. If you’ve been giving your toddler whole milk, you can switch to 1 percent or skim. Brain growth slows down after age two, so a high-fat diet isn’t needed. Also, getting used to a lower-fat diet early in childhood probably lowers the risk of heart disease years later.

Young children usually can’t wait five to six hours between meals. Three meals and three snacks is a reasonable schedule. Snacks should be healthy and substantial, not junk food.

Food choices

Most 2 year old handle cups and spoons with ease but may still need help with forks and knives. Since many 2-year-olds resent getting help, even if they need it, you may want to focus on foods that can be eaten with a spoon or fingers.

Young children need practice making food choices. Peas or squash? Burger on the bun or off? One or two small choices is enough; more and bigger choices are likely to be overwhelming and may lead to tantrums. Wise parents offer a small selection of attractive foods at each meal, so that whatever the child chooses is healthy.

Food choices start with what you bring home from the store. Choose fresh vegetables instead of chips ad other high-fat snacks, fruits instead of cookies and cakes, and juice or water instead of soda. If you want your child to eat healthy, the best strategy is to keep the house stocked with healthy foods and keep the junk food out.

Food fads and fights

One 2 year old wants only grilles cheese every meal; another demands noodle soup. Usually such fads last only a few days, then fade away only to be replaced by other food obsessions. In the interest of peace and harmony, you may want to five in to some extent. Five days in a row of peanut butter and jelly for lunch isn’t harmful, and if there’s milk, fruit, or some green vegetable at other meals, chances are your 2 year old child is getting a reasonably balanced diet. If you think about what your child eats not in just one day but over the course of a week or so, you may see that the diet is pretty well balanced after all.

Many 2 year old get locked into power struggles with their parents about food. On the child’s side, worrisome behaviors include food refusal, extreme pickiness, demands for special foods, gagging, or tantrums; on the parent’s side, nagging, cajoling, threatening, or outright force-feeding.

TOILET TRAINING

One step toward independence

By 24 to 36 months, when most children have learned how to use the toilet, most parents can’t wait to see their last dirty diaper. But in their hurry to have the process over with, many parents push, prod, or pester, with the result that training takes longer and is more stressful than it needs to be.

Toilet training is part of a learning process that begins in the first year and ends several years later with a child who handles toileting, including wiping and hand-washing, who feels comfortable about bodily processes, and has adopted her parents’ views on privacy and modesty. If you take this long view, you may feel more comfortable allowing toilet training, including specific suggestions on how and when to start and what to do.

Dawdling: A mother of eighteen-year-old boy talks with him every day to the grocery store. She complains that instead of walking right along, he wanders across the sidewalk and climbs the front steps of every house they pass on the way. The more she calls to him, the more he lingers. When she scolds him, he runs in the opposite direction. She is afraid that he is developing a behavior problem.

This baby doesn’t have a behavior problem, though he may be made to have one. He’s not at an age when he can keep the grocery store in mind. His natural instincts say to him, “Look at that sidewalk to explore! Look at those stairs!” Every time his mother calls to him, it reminds him of his newly felt urge to assert himself.

What can the mother do? If she has to get to the store promptly, she can take him in his stroller. But if she’s going to use this time for his outing, she should allow four times longer that if she were going alone and let him make his side trips. If she keeps moving-slowly- he’ll want to catch up to her every once in a while.

Challenge in stopping fun activities: It’s time to go in for lunch, but your small daughter is digging happily in the dirt. If you say, “Now it’s time to go in,” in a tone of voice that means, “Now you can’t have any more fun,” you will get resistance. But if you say cheerfully, “Let’s go climb the stairs,” you may give her a desire to go.

But suppose she’s tired and cranky that day and that nothing that’s indoor has any appeal. She just becomes disagreeably resistant right away. I’d pick her up casually and carry her indoors, even if she squeals and kicks. Do this in a self-confident way, as if you were saying to her, “I know you’re tired and cross, but when we have to go in, we have to.” Don’t scold her; that won’t make her see the error of her ways. Don’t argue with her, because that won’t change her mind; you will only become frustrated. A small child who is feeling miserable and making a scene is comforted underneath by sensing that the parent knows what to do with out getting angry.

Young children are very distractible, and that’s a big help. Year-old babies are so eager to find out about the whole world that they aren’t particular where they begin or stop. Even if they’re absorbed by a ring of keys, you can make them drop it by giving them an empty plastic cup. If toward the end of the first year your baby fights against having food  washed off his faces and hands with a cloth after meals, set a pan of water on the tray and let him dabble  his hands in it while you wash his face with your wet hand. Distractibility is one of the handles by which wise parents guide their children.

Throwing and Dropping around things: Around the age of one year, babies learn to drop things on purpose. They solemnly lean over the side of the high chair and drop food on the floor or toss toys, one after the other, out of the crib. Then they cry because they haven’t got them. Are these babies deliberately trying to annoy their parents? No. They aren’t even thinking about their parents. They fascinated by a new skill and ride a new two-wheeler. If you pick up the dropped object, they realize it’s a game that two can play and are delighted.

Unless you want to play this game a lot, it’s better not to get in the habit of picking up dropped toys right away. Instead, simply put your baby on the floor when he gets in this dropping mood. If you don’t want him throwing food from a high chair, promptly take the food away when he starts dropping and put him down to play. You can firmly say, “Food is for eating, toys are for playing, “but there’s no need to raise your voice. Trying to scold a baby out of dropping things leads to nothing but frustration for the patient.

Tantrums of anger: Almost all children have temper tantrums between one and three years, some temperamentally intense infants start as early as nine months. They’ve gained a sense of their desires and individuality. When they’re thwarted, they know it and feel angry. A temper tantrum once in a while doesn’t mean anything; a child is bound to be frustrated sometimes.

A surprising number of tantrums are a result of fatigue or hunger or of putting a child into a situation that is too stimulating. (Most shopping mall tantrums fall in this category.) If the tantrum is of this sort, a parent can ignore the apparent cause and deal with the underlying problem: “You’re tired and hungry, aren’t you? Let’s get you home and fed and to bed, you’ll feed a lot better.”

Some tantrums arise out of fear. This happens all the time at the doctor’s office. The best thing to do in these situations is to be calm and reassuring. No good comes from scolding a scared child.

Tantrums happen more frequently in children who tend to be easily upset by changes or who are especially sensitive to sensory input (noises, motion, or the feel of clothing against the skin, for instance). Tantrums often last longer in persistent children. Once they get started, it’s hard for them to stop, whether they’re playing, practicing walking, or screaming at the top of their lungs. Excessive tantrums- for example, more than three a day, lasting more than ten to fifteen minutes each- are sometimes a sign of illness or stress, it’s reasonable to consult your child’s doctor.

SLEEP ISSUES

Changing nap hours: Nap times are shifting in most babies around the age of a year. Some who were taking a nap at about 9 A.M. may refuse it altogether or show that they want it later in the morning. If they take it late, they are unready for their next nap until the middle of the afternoon. This probably throws off their bedtime after supper. Or they may refuse the afternoon nap altogether. A baby may vary a lot from day to day at this period, even going back 9 A.M. nap after two weeks of refusing it. So don’t come to a final conclusion too soon. Put up with these inconveniences as best you can, realizing that they are temporary. With some babies who are not ready to sleep in the first part of the morning, you can remove the need for the before-lunch nap by putting them in their beds anyway, around nine in the morning, if they are willing to sit or lie quietly for a while. Of course, another kind of baby only gets in a rage of put to bed when she’s not sleepy, so nothing is accomplished.

If a baby becomes sleepy just before noon, it’s the parent’s cue to move lunch up to 11.30 or even eleven for a few days. The long nap will then come after lunch, but for a while, cutting down to one nap a day, whether morning or afternoon, may make the baby frantically tired before suppertime.

Don’t get the idea from this section that all babies give up their morning nap in the same way or at the same age. One is through with it at nine months; another craves it and benefits from it as later as two years. There is often a stage in a baby’s life when two naps are too many and one is not enough! You can help babies through this period by giving them supper and putting them to bed for the night a little earlier for the time being.

Bedtime routines: Though you need to be a little flexible about sleep issues, it’s also very helpful to have a bedtime routine. When things happen in the same way every day, it gives a young child a comforting sense of control. Bedtime routines can include stories, songs, prayers, hugs, and kisses, what’s important is that the same things happen in roughly the same order. Television or videos and roughhouse play tend to keep children excited and awake, so these activities are best left out of the bedtime routine.

EATING AND NUTRITION

Changes around one year: Around twelve to fifteen months, growth normally slows down and a toddler’s appetite is likewise apt to level off. Some actually eat less then they did a few months before, causing their parents to worry. But if a child’s growth plots out okay on the standard growth curve at the doctor’s office, you can be assured that he is getting enough. If you make the mistake of showing your toddler that you want him to eat more, chances are he’ll reward you by eating less, just to show you who’s in charge. A better strategy is to give your baby small helpings, so he can enjoy demanding more, and not to pay much attention to how much goes in. Instead, watch your baby to see whether he is happy and full of energy and pay attention to the growth chart.

Early in the second year, many parents wean their babies from their breast or the bottle. Unless you are giving your toddler a nondiary diet, the drink of choice should be whole cow’s milk (or full-fat soymilk) to build their brains. After age two, it’s sensible to switch to 1 percent or skim milk to lower the risk of heart disease as an adult.

Eating is a learning experience: For children to approach eating in a reasonable and healthy manner, they need to leaner to pay attention to the body signals that tell them when they are hungry and when they’ve had enough. They need confidence that food will be there when they’re hungry and that they won’t be forced to eat when they’re not hungry. You help your toddler learn these important lessons by making good food available and leaving it up to your child to decide how much to eat.

Table manners are also important: Every toddler experiments with mixing and smearing, testing the limits of what is acceptable.  When your toddle crosses the line- throwing mashed potatoes, for instance- all you need to do is tell her firmly but calmly that food is for eating. Then remove her from the table and find her a ball or a cloth toy to throw. When eating turns to playing and it’s clear that your child isn’t hungry any more, it’s time for the meal to end. Twenty minutes or so is usually long enough.

TOILET TRAINING AND LEARNING

Readiness to train: At twelve or eighteen months, most toddlers aren’t ready for toilet training. They don’t have the body awareness yet to recognize when they have to go, nor the control to hold everything in then let it out at the right time. Mostly, they don’t really understand why they should sit on the potty instead of just filling up their diapers. Toddlers typically find their bodily productions interesting, not disgusting. They don’t see what all the fuss is about if the contents of their diapers get smeared around a bit.

Of course, there are some toddlers who train early, making all the other parents think that their children are behind. But for most children, training much before age eighteen months is bound to be difficult and unsatisfying, and many aren’t ready until two and a half. The psychologist Nathan Azrin and Richard Foxx describe an approach using powerful behavior modification techniques in their book, Toilet Training in Less Than a Day. But the instructions are fairly complicated; if you don’t follow them to the letter or your child doesn’t cooperate, you’re both likely to end up frustrated.

So my advice to most parents is to wait with training until a child is two to two and a half. At that age, most can master the potty without a fuss. If you do start earlier and things don’t go well, I don’t think you have to worry that you’ve caused long term psychological damage (as long as you dint use harsh punishment or abuse), but the training process may involve more upset and take longer in the end.

Toilet learning: While most one-year-olds aren’t ready for training, they can certainly learn about the potty. If you let your child into the bathroom with you and there is a child sized potty, your toddler may sit on it or even pretend to use it, just as she mimics vacuuming and other adult activities. This early interest is a sign that your child is learning about toileting, but it doesn’t mean she’s ready to take the next step. If you pressure her or even overdo the praise, there’s a good chance she’ll balk.

Part of using the toilet is washing the hands afterwards, and many toddlers are happy to have an excuse to get their hands wet and soapy. It’s helpful to talk about what you’re doing in the bathroom as you do it so that your child learns the words. I favor simple terms like pee and poop rather than cutesy baby talk or euphemisms (wee-wee or number two, for example). By talking in a straightforward way, you let your child know that toileting is simple a fact of life, not something secret, shameful, exciting, or mysterious.

While some children have all three components of Attention deficit hyperactivity disorder, others manifest with abnormality in only one or two fields. Accordingly, three major types are recognized as combined type (—25%), predominantly inattentive type (—50%), predominantly hyperactive/impulsive type (-25%).

Prevalence

Reported prevalence of Attention deficit hyperactivity disorder varies according to diagnostic criteria, awareness among health professionals and cultural norms of the community. Frequently under diagnosed, It is estimated to be present in 5-10% of Indian children, with striking preponderance in boys (4-6:1). Boys are more likely to be hyperactive/impulsive, while girls are usually inattentive.

Pathology: Hypoplasia and hypo functioning system is considered as the key pathological defect in Attention deficit hyperactivity disorder, with altered balance between two important neurotransmitters that modulate attention, mood and movements — neuroinhibitory Dopamine and neuroexcitatory Norepinephrine.

Modern investigative techniques have shown significant structural and abnormalities in children like smaller volumes of frontal lobes and cerebellum, diminished cerebral blood flow, impaired cerebral oxygen/glucose metabolism, and reduced levels or end-receptor sensitivity of dopamine.

Etiology

Exact etiology for these pathological changes is uncertain, currently thought to be a complex interplay of both hereditary and environmental factors. Some important causative factors include —

a) Hereditary seems to play a crucial role in Attention deficit hyperactivity disorder as 1/3rd of these cases have similar family history and concordance rate in monozygotic twins is — 75-90%. Genetic studies have implicated defect in several genes, modulating dopamine/norepinephrine action like D2 receptor gene (DRD2), D4 receptor gene (DRD4), and over expression of dopamine transporter-i gene (DAT- 1), all located on short arm of chromosome 16.

b) Environmental factors seem to be more important in Attention deficit hyperactivity disorder children without family history. Low birth weight and prenatal exposure to smoking, alcohol/drug abuse and environmental toxins like lead, dioxins and PCBs (plastic constituents) have been frequently implicated. Other adverse factors in family environment like psychosocial stress, maternal mental disorder, paternal criminality, low socioeconomic status etc. have also been linked to increased risk of Attention deficit hyperactivity disorder.

Clinical presentations: Although the diagnosis of Attention deficit hyperactivity disorder is usually made in pre-school years, most Attention deficit hyperactivity disorder children have abnormal behaviour traits in earlier life like excessive crying and disturbed sleep in infancy or even unusual intrauterine activity. Many of them achieve gross motor milestones at an earlier age.

Characteristic core-group manifestations are as follows, though all children do not have all component

- Inattentiveness, though commonest manifestation is often overlooked in preschool years and and rarely noticed before school-age. These children have difficulty in controlling their activity in situations that call for sitting still like classrooms or dinner tables. They can only engage themselves in brief activities, and change activities frequently. Children with predominantly inattentive type of Attention deficit hyperactivity disorder often seem to drift away into their own thoughts or lose track of what was going on around them.

- Hyperactivity, the commonest cause of parental concern is usually noticed in pre-school years as — excessive movements, restlessness, fidgety, and shortened attention span. As preschoolers by nature have shorter attention span that improves with time, persistence of such behavior beyond 3 years of age is a more reliable indicator of Attention deficit hyperactivity disorder. Even in older children and adolescents, attention span often depends on the level of interest in a particular activity. Most teenagers can listen to music or talk to their friends for hours but may be less focused during homework. Hyperactivity tends to increase when child is tired, hungry, anxious or facing a new environment.

- Impulsivity is closely associated with hyperactivity and often manifests as a dislike for waiting for his/her turn. They interrupt others in their conversations and some of their actions may be extremely erratic or dangerous. Some children are extremely sensitive to sensory stimuli like sight, sound and touch. When stimulated, they can quickly get out of control and turn aggressive or abusive.

Co-morbidity: Apart from core-group manifestations, —30-50% of these children have co-existing cognitive, learning and language disorders. Further, most of them develop secondary behavioral problems with advancing age like conduct disorders, antisocial behavior, drug abuse, sexually transmitted diseases, teenage pregnancy etc. Early identification of Attention deficit hyperactivity disorder may prevent these complications in late childhood/adolescence.

Diagnosis

There is no specified diagnostic test and diagnosis is exclusively clinical, based on well-defined criteria (Table 4.4). It should be noted that —

a) As many indicators are normally present in pre-school children, diagnosis should be reviewed after repeated evaluation and preferably kept as provisional till 5 years of age.

b) Some signs/symptoms like verbal impulsivity and restlessness may not be evident in highly-structured situations like clinics and their absence does not preclude the diagnosis.

Considering the complex nature of disease, a multidisciplinary assessment is necessary for in all cases of Attention deficit hyperactivity disorder, including Detailed perinatal & developmental history, psychometric testing as well as other standardised rating scales to be completed by the parents and child’s school, thorough physical examination and developmental assessment, evaluation for above-mentioned diagnostic criteria, evaluation for co-morbidities or secondary behavioral problems and psychosocial evaluation of the family and school environment. Laboratory investigations are indicated only to exclude other causes of hyperactivity/inattention.

D/D: Although features of Attention deficit hyperactivity disorder are quite characteristic, transient/persistent hyperactivity or inattention may also be due to mental retardation, seizure disorders like absence seizures, sensory impairment like hearing/visual defects, chronic physical disability, dmg toxicity like anticonvulsants, and sleep deprivation.

Management

Optimum treatment for Attention deficit hyperactivity disorder is a matter of intense debate, although effective interventions may be broadly divided into two categories — a) Pharmacotherapy, b) Clinical behavioural management.

A multi-disciplinary approach involving pediatrician, psychiatrists, psychologist, teachers as well as parents is essential for best results.

a) Pharmacotherapy: Psychostimulants like Methyiphenidate, are the cornerstone of pharmacotherapy in Attention deficit hyperactivity disorder, which boost and balance the level of neurochemicals like dopamine and norepinephrine, by facilitating their synaptic release and inhibiting their reuptake. About 70-80% cases show positive response to stimulants as reduced hyperactivity, increased attention span, and improved visual/motor skills. However, these agents do not address other problems like academic failure or social maladjustment.

Methyiphenidate (MPH) – a dexamphetamine derivative with rapid action, short half-life and wide safety margin is the preferred choice in most cases. Other psychostimulants like dexamphetamine or pemoline are rarely used in pediatric practice.

Dosage and frequency requirements of MPH vary in different children, unrelated to body weight. MPH therapy should begin with low dose of P0 2.5 mg/dose 30 minutes before meals and should be increased gradually to maximum of 60 mg/day, according to the clinical effect. The action begins with 20-30 minutes with peak effect at 1-2 hours and lasts for 3-5 hours.

Side effects like anorexia, headache, abdominal discomfort, mood instability and insomnia (MPH should not be given after 4 PM) are common at the onset of therapy but rarely require dosage modifications and disappear after few days.

Other side-effects like tics or persistent hypertension are rare and may require dose reduction. Clonidine (P0 1-4 mg/kg/d) may be used as adjuvant to reduce side-effects like tics, aggression and sleep difficulties. Long-term use of MPH is known to cause growth suppression and hence, intermittent drug- vacations are recommended to minimize growth effects and re-evaluate the need of further medications. Dependence is rare in children.

A tomoxetine hydrochloride, a non-stimulant norepinephrine transport inhibitor, has been recently established as safe and effective alternative to MPH in clinical trials. Unlike psychostimulants, which are predominantly useful in hyperactive children, atomoxetine has shown effectiveness in both the inattentive and hyperactive symptoms domains.

Tricyclic antidepressants like Imipramine/ Desipramine (P0 1-4 mg/kg/d) are used in children who do not respond to stimulants, develop major side effects or severe co-morbidity like anxiety or depression.

b) Psychosocial interventions are as important as pharmacotherapy in management of these cases and include child’s behavior modifications, as well as parentallteacher training to cope with the problem and enhance child’s potential, using a multidisciplinary approach involving psychiatrist, psychologist, social workers, support groups etc.

Child’s behavior modification is a complex issue and involves need-based strategies like cognitive behavioral procedures to facilitate self-regulated behavior and psychotherapy for secondary Attention deficit hyperactivity disorder. However, efficacy of these interventions is unproven. A stress-reducing biofeedback technique to control body responses via audiovisual stimulation has been shown to be effective in sustenance of drug-induced behaviour control in selected cases.

Parental/teacher behavior mod (fication and training is important as care of these high-energy, inattentive, and impulsive children is usually frustrating and unrewarding.

c) Dietary interventions like elimination of foods considered as allergens like wheat, milk, eggs etc. or incriminated to increase hyperactivity like sugar, chocolate and caffeine etc. are of no proven value, as also the Fein-Gold diet (free of additives).

Prognosis

Attention deficit hyperactivity disorder is incurable but can be managed successfully in most cases. Hyperactivity/impulsivity usually lessens with age, but often replaced by other problems like antisocial and learning difficulties. Inattention tends to persist throughout the life.

In general, 30% children show near-complete resolution of symptoms by adulthood, 40% persist with some symptoms but overall adequate functioning and the rest continue to have severe dysfunction with secondary complications like antisocial behavior. Most adults with childhood Attention deficit hyperactivity disorder have emotional and social problems, unemployment, and criminality.

Functional prognosis is better in cases with absence of co-psychiatric conduct disorders at the time of diagnosis, early pharmacotherapy and co-operative or understanding parents/teachers.

Guidelines for parents and teachers in Attention deficit hyperactivity disorder

• Ensure a regular routine & environment

• Divide his/her work into small chunks

• Provide simple & clear instructions

• Make frequent eye contacts with child

• Allow liberal breaks between the tasks

• Positive reinforcement: praise on task completion

• Non-accusatonj feedback on task completion

• Avoid overstimulation/fatigue to the child

• Avoid exciting TV programs/games at bed time

• Keep dangerous articles beyond the child’s reach

• Be loving but consistent and firm with child

• Encourage peer-relations and teach social skills

• Promote his strengths to build self-confidence

Check out the below video from National Institute of Health on Attention deficit hyperactivity disorder (ADHD)

Conversion disorder denotes loss or alteration of physical functioning without a demonstrable illness. This disorder is usually seen in adolescents and older children and more common in females.

Etiologically, it is considered as a physical medium of expression (somatization) of suppressed anger or frustration, especially in over-disciplined children.

Clinically, these cases may present with —

a) Conversion reactions with motor component (hysteria) e.g. mimicked seizures, paralysis, blindness etc. or rarely,

b) Dissociative reactions e.g. recurrent abdominal pain, vague body aches/pains, anorexia etc.

Psychosomatic Disorders – Diagnosis is usually based on exclusion of organic cause, absence/inconsistency of clinical signs and prolonged observation of behavior.

Conversion reactions tend to increase during family/doctor’s attention, though frequently, these responses are not within the patient’s voluntary control (did fictitious illnesses).

Treatment for Psychosomatic Disorders is non-specific during acute phase except exclusion of organic/concomitant illnesses, while psychotherapy is necessary on recovery to prevent recurrence.

Munchausen syndrome by proxy: is a form of child abuse, characterized by fabricated illnesses in children by their parents, usually mother, in order to get medical attention.

Clinically, these children present with large spectrum of unexplained symptoms e.g. fever, vomiting, diarrhea, seizures, hematuria etc. Important ecological factors of Psychosomatic Disorders include disturbed family, mentally unstable mother or unwanted child.

Diagnostic indicators of Psychosomatic Disorders include — a) unexplained recurrent illnesses in child or other siblings, b) inconsistent history, c) unusually calm or concerned mother in the hospital, d) poor response to rational therapy, and e) absence of symptoms on separation from parents.

a) Phobia e.g. school phobia or social phobia,

b) Obsessive-compulsive anxiety disorders with repetitive thoughts, acts or rituals e.g. compulsive hand washing, checking of locks etc.,

c) Generalized anxiety disorder with non-specific and unrealistic worry towards future events e.g. examination failure, and

d) Specific anxiety disorders e.g. separation anxiety and post-traumatic stress disorder.

Post-traumatic stress disorder (PTSD) is an anxiety disorders seen in all age groups, including children, in response to any external event experienced or witnessed by an individual and perceived as dangerous.

Etiology

Life-threatening situations with serious injuries or death e.g. riots, natural disasters etc. are frequently associated with PTSD. Younger children, females and individuals with high-anxiety personality trait, are at an increased risk of PTSD. Child/sexual abuse is an important cause of PTSD in children.

Incidence of PTSD depends on the severity of precipitating event. Although only 1% of exposed adults satisfy the DSM criteria for PTSD, >15% are estimated to suffer with more non-specific stress behavior for a variable period of time. Though not documented statistically, children seem to be more vulnerable for PTSD than adults.

Clinical features

PTSD may be acute or chronic. Acute PTSD (type I) is characterized by — a) recurrent recollections and dreams of the traumatic event, b) intense anxiety, c) sleep disturbances with. startle reactions and d) concentration difficulties.

Chronic PTSD (type II) is generally seen in children with prolonged physical/sexual abuse, leading to a) changed-attitude towards life, people, future etc., b) psychologic numbing i.e. forced amnesia and c) isolated life-style.

Management of anxiety disorders

Early identification and management of PTSD is essential to prevent long-term psychotic morbidity and includes —

• Initial evaluation to explore the child’s understanding, vulnerability and reactions to the traumatic event,

• Psychotherapy to provide the child an opportunity to discuss the event and express his/her feelings of helplessness, sadness or anger. He or She should be helped to understand everyday events and distinguish them from past-trauma.

• Family therapy & counseling to make them understand the basis of child’s behavior and encourage their participation in day-to-day management.

• Phannacotherapy with drugs e.g. benzodiazepenes to modify the sleep & arousal anxiety disorders, in selected cases.