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Difficulty: MediumNormal Growth and Development

A 24-month-old girl is brought to the family medicine clinic for a routine well-child examination. Her parents express concern about her social skills and physical abilities compared to her older cousins. They report that at her daycare, she typically sits next to other toddlers playing with her own toys but does not actively engage or share with them. The child's medical history is unremarkable, and she takes no medications. On examination, the child runs smoothly around the exam room. When navigating the clinic step stool, she places both feet on each step before taking the next one. During play, she successfully stacks six wooden blocks but is unable to copy a drawing of a circle. Her vocabulary consists of roughly 60 distinct words, and she frequently combines two words to express needs, such as "more juice." Based on these findings, which of the following is the most appropriate next step in management?

  1. Reassurance and routine anticipatory guidanceAnswer
  2. B
    Referral for comprehensive autism spectrum disorder evaluation
  3. C
    Referral to early intervention for fine motor delay
  4. D
    Referral to a pediatric physical therapist
  5. E
    Formal audiometry and speech-language pathology referral

Answer

Reassurance and routine anticipatory guidance should be provided, as all of the child's developmental findings are normal for a 2-year-old.
This 24-month-old (2-year-old) girl is exhibiting completely normal developmental milestones across all domains: gross motor, fine motor, language, and social. Normal 2-year-old gross motor skills include running well and walking up/down stairs by placing both feet on each step. Alternating feet on stairs is typically achieved at 3 years of age. In the fine motor domain, building a tower of 6 cubes is appropriate for a 2-year-old, whereas copying a circle is a 3-year-old milestone. For language, a 24-month-old should have a vocabulary of at least 50 words and use 2-word phrases; this patient has a 60-word vocabulary and uses 2-word phrases. Finally, in the social domain, parallel play (playing alongside but not actively engaging with other children) is the classic play style of a 2-year-old, with cooperative/associative play emerging closer to 3 or 4 years of age. Because her development is entirely age-appropriate, no specialist referrals are indicated, and the physician should simply provide reassurance and routine anticipatory guidance.

Step-by-Step Solution

1
Evaluate the child's gross motor skills.
Running well and walking up stairs placing both feet on each step.
These findings precisely match normal 24-month (2-year) gross motor milestones.
2
Evaluate the child's fine motor skills.
Stacks 6 wooden blocks, cannot copy a circle.
Building a tower of 6 cubes is normal at 2 years. Copying a circle is not expected until 3 years of age.
3
Evaluate the child's language and social skills.
Vocabulary of 60 words, 2-word phrases, and parallel play.
A 2-year-old typically has a vocabulary of 50-200 words, uses 2-word phrases, and engages in parallel play (playing alongside others rather than with them).
4
Determine the appropriate management.
No specialty referrals are needed; provide reassurance.
Because all evaluated domains reflect entirely normal development for her age, the parents should be reassured.

Key Concept

Normal developmental milestones for a 2-year-old (24 months) include running, navigating stairs (both feet on each step), building a tower of 6 cubes, 50-200 word vocabulary, 2-word phrases, and parallel play.
Estimated Time:1m 0s
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Topics

Normal Growth and Development

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