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Question

Difficulty: MediumNormal Growth and Development

A 24-month-old girl is evaluated at a community health center prior to enrolling in a new childcare program. She is accompanied by her grandmother, who expresses concern regarding the child's social and language skills. The grandmother reports that at the local playground, the girl will play alongside other toddlers but refuses to share her toys, frequently pulling them away if another child approaches. Furthermore, the child communicates her needs using short phrases such as "want juice" or "go home." Her total vocabulary consists of approximately 80 words. On physical examination, the child is cooperative, can kick a small ball, and jumps with both feet off the floor. When given wooden cubes, she successfully stacks a tower of 6 cubes. She accurately follows two-step verbal instructions without visual cues. Which of the following is the most appropriate next step in management?

  1. Routine care with age-appropriate anticipatory guidanceAnswer
  2. B
    Speech-language pathology assessment
  3. C
    Formal behavioral evaluation for autism spectrum disorder
  4. D
    Brainstem auditory evoked response testing
  5. E
    Occupational therapy consultation for fine motor skills

Answer

Routine care with age-appropriate anticipatory guidance
The correct answer is routine care with age-appropriate anticipatory guidance because the child is meeting all developmental milestones expected for a 24-month-old (2-year-old). At 24 months, gross motor skills include jumping with both feet and kicking a ball. Fine motor skills include building a tower of 6 cubes. Language skills expected at this age are a vocabulary of at least 50 words, the use of 2-word phrases, and the ability to follow 2-step commands. Socially, 2-year-olds engage in parallel play (playing alongside other children rather than cooperatively with them) and generally do not share well. Because this child's development is completely normal, the grandmother can be reassured, and no further diagnostic testing or specialist referral is indicated.

Step-by-Step Solution

1
Identify the patient's chronological age and the specific concerns raised by the caregiver.
The patient is 24 months old. The grandmother is concerned about a lack of sharing and the use of short, two-word phrases.
Establishing chronological age is strictly required to determine which developmental milestones the child should be meeting.
2
Evaluate the patient's social and language skills against established 24-month milestones.
Parallel play (playing next to others without sharing) and knowing 50-200 words with 2-word phrases perfectly match normal 24-month social and language milestones.
This confirms whether the caregiver's concerns represent a true developmental delay or normal physiologic progression.
3
Assess the gross and fine motor exam findings.
Kicking a ball, jumping with both feet, and building a 6-cube tower are all normal milestone achievements for a 24-month-old.
A comprehensive developmental assessment must evaluate all four domains (gross motor, fine motor, language, social).
4
Determine the appropriate clinical intervention based on the milestone analysis.
Since all domains are developing normally, no specialist referrals or diagnostic tests are required. Routine care is the best step.
Unnecessary referrals or testing can cause caregiver anxiety and waste healthcare resources when a child is developing normally.

Key Concept

Normal developmental milestones at 24 months (2 years) include parallel play, a 50-200 word vocabulary, 2-word phrases, building a tower of 6 cubes, jumping, and kicking a ball.
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Topics

Normal Growth and Development

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