food is "something to eat" However, such mental symboliza- bel tion is closely associated with prelogical

reasoning. For instance, per a needle is"something that hurts." Such painful experiences take 200 on
new significance because memory is associated with the (Fo specific event, and fears are likely to
develop, such as resistance tual to people who wear uniform scrubs or rooms that look like the ino
practitioner's office. Sometimes parents and health care person- chil nel underestimate the child's ability
to recall events and give feri little thought to preparation for visits to a practitioner's office the or other
health facility, resulting in fears that can last a lifetime. on s Because of the vulnerability of these early
years, it is essential of t to prepare children for new experiences, whether it is a new bei babysitter, a
primary practitioner, or a visit to the dentist.

Toddiers' development of moral judgment is at the most basic level. They have little, if any, concern for
why something is wrong. Kohlberg's theory of moral development is influenced by Piaget's theory of
moral thought; the first phase of Kohl- berg's theory is called the preconventional phase, and it involves
punishment and obedience. Young children behave in accor- dance with the freedom or restriction that
is placed on actions. In the punishment and obedience orientation, whether an action is good or bad
depends on whether it results reward or punishment. If children are punished for it, the action is bad. If
they are not punished, the action is good, regardless of the meaning of the act. For example, if parents
allow hitting, the child will perceive that hitting is good because it is not associ- ated with punishment.
By the age of 36 imonths, developmental aspects of conscience may be present.

The type of discipline also affects children's moral develop- relig ment. When parents use power to
control behavior, such as stan physical punishment or withholding privileges, children receive the a
negative view of morals, especially toward authority figures, thou such as law enforcement officials.
When parents withdraw love God or attention, children behave primarily because of guilt, rather (hea
than from an internalization of morals. However, when parents influ give explanations for the
misbehavior and try to help children change through positive approaches, such as consequences or n
rewards, children feel less hostility and are more likely to base their actions on an analysis of why an act
may be wrong. Of As i course, the effect of discipline is not limited to the toddler years, cog and the sole
use of explanation is inappropriate during this reco period. Because parents usually establish disciplinary
tech- respe niques at this time, the use of constructive approaches should vari begin early. (See Limit
Setting and Discipline, Chapter 2.) talia vear

Perkembangan spiritual pada anak sering dibahas dalam hal tingkat perkembangan anak karena evolusi
kerohanian seringkali paralel dengan perkembangan kognitif (Elkins dan Cav endish, 2004). Keluarga dan
lingkungan anak sangat mempengaruhi persepsinya tentang dunia di sekitarnya, dan ini sering kali
mencakup kerohanian. Lebih jauh lagi, nilai-nilai keluarga, PENGEMBANGAN SPIRITUAL

beliefs, customs, and expressions of these influence theå perception of his or her spiritual self (Eikins
and Ca 2004). Neuman (2011) proposes that Fowler's stages of (Fowler, 1981) be used to better
understand children and tuality; she provides an excellent overview of the stages of in childhood. The
relationship among spirituality, il childhood, and nursing has been studied in the context of fering,
terminal illness such as cancer, and end-of lie ca the past decade there has been an increased interest in
and on spiritual care in aduits and children as further underst of the influence of one's spirituality on
health, illness, and being has progressed.

Toddlers learn about God through the words and atioat those closest to them. They have only a vague
idea of God religious teachings because of their immature cognitie cesses; however, if God is spoken
about with reverence, children associate God with something special. During period the assignment of
powerful religious symbols andi is strongly influenced by the manner in which it is presne therein lies the
potential for the development of guilt and or conversely, love and comparionship with religious syn
(Roehlkepartain, King, Wagener, et al, 2006). Toddlers are to be in the intuitive-projective phase of
Fowler faith constr (Fowler, 1981) wherein thinking is largely based on fantayz rather fluid in relation to
reality and fantasy. God may described as being around like air by the toddler because ofs luidity in
dividing fantasy and reality (Neuman, 2011)

Toddlers begin to assimilate behaviors associated divine (eg, folding hands in prayer). Routines such as sa
prayers before meals or at bedtime can be important and u forting. Because toddlers tend to find solace
in ritualisticbe ior and routines, they incorporate routines associated v religious practices into their
behavioral patterns without un standing all of the implications of the rit uals until latet N the end of
toddlerhood, when children use preopera thought, there is some advancement of their understanding
God. Religious teachings such as reward or fear of punish (heaven or hell) and moral development (see
Chapter 3 influence their beharior (Fosarelli, 2003)

DEVELOPMENT OF BODY IMAGE As in infancy, the development of body insga closely p cognitive
development. With increasing motor ability, tod recognize the usefulness of body parts and gradually
learnta respective names. They also learn that certain body parts various meanings; for example, during
toilet training, the talia become significant and cleanliness is emphasiz years of age toddlers recognize
gender differences and ree self by name and then by pronoun. Gender identity is devel by age 3 years.
By this time the child begins to remembere with reference to their personal significance, forming an
biographic memory that helps establish a continuous i throughout life's events.

Once they begin preoperational thought, toddlers cu symbols to represent objects, but their thinking
may inaccuracies. For example, if someone who is pregnant at hey will describe all "fat" ladies
(sometimes even men!) babies. They have a beginning recognition of words o describe physical
appearance, such as "pretty" "hand- bigboySuch epressions eventually influence how sndc n view their
own bodies, and such labeling (negative or baving tive) becomes part of their body image. it is ody
integrity is poorly understood in children and that intrusive experiences are threatening Dablquist,
Busby, Slfer, et al, 2002). For example, toddlers forcefully resist procedures such as examining the ear or
mouth and taking an axillary temperature. The procedure itself (e.g. uking vital signs) does not hurt the
child, but it represents an intrusion into the child's personal space, which elicits a strong rotest. Toddlers
also have unclear body boundaries and may sociate nonviable parts, such as feces, with essential body
parts. This can be seen in a toddler who is upset by flushing the posi oung toidet and watching the stool
disappear.

Researchers have tound that children possess a rudimentary bpographic (i.e., children's awareness of
their body's shape and sputial confguration) representation of their own body's shape, sructure, and size
by 30 months of age (Brownell, Nicholas Sietlora.et al, 2010). Research has also shown that toddlers are
egitning to develop body self-awareness as a dimension of edective self awareness (Brownell, Zerwas,
and Ramani, 2007). There is evidence that one's awareness and perception of self nuy be partially
developed by the end of the toddler period, bet further development takes placc as one grows
(Brownell, Zas, and Ramani, 2007), Nurses can help parents fostera pesitive body image in their child by
encouraging them to avoid negative labels, such as "skinny arms" or "chubby legs"; such sef-perceptions
are internalized and can last a lifetime. Body purts especially those related to elimination and
reproduction, bould be cailed by their correct names. Respect for the body should be practiced.

DEVELOPMENT OF GENDER IDENTITY usi as toddlers explore their environment, they also explore heir
bodies and find that touching certain body parts is plea- surable this process actually begins in infancy as
infants become ware of pleasurable effects of human touch. Genital fondling masturbation) can occur
and involves manual stimulation and posturing movements (especially in young girls) such as tight- 3 the
thighs or applying mechanical pressure to the cor suprapubic area Other demonstrations of pleasurable
ities include rocking, swinging, and hugging people and arental reactions to toddlers' behavior influence
the chil own attitudes and should be accepting rather than criti- such acts are performed in public,
parents should not ondone or bring attention to the behavior but should teach the t t is more acceptable
to perform the behavior in toys. ral If i suanrinbe Prrate. Children in this age-group are learning
vocabulary associ- th anatomy, elimination, and reproduction. Certain sociations between words and
functions become significant rd can influence future attitudes about sexual matters. For campl if parents
refer to the genitalia as dirty, especially in and

the context of elimination, this association between "genitalia" and "dirty" may be transferred to sexual
functions later in life. Sex-role differences become obvious to children and are evident in much of
toddlers' imitative play. Although current research indicates that prenatal exposure to testosterone
strongly influ ences the individual's gender identity, researchers also indicate that there are sensitive
periods (e.g, puberty) that may influ- ence the development of gender identity (Berenbaum and Beltz,
2011; Hines, 2011; Savic, Garcia-Falqueras, and Swaab, 2010). A sense of maleness or femaleness, or
gender identity, is formed by age 3 years, and the child's feelings about being male or female begin to
form (Fonseca and Greydanus, 2007). Early attitudes are formed about affectionate behaviors between
adults from observing parental and other adult intimate activi- ties. (See also Sex Education, Chapter 13.)
The quality of rela- tionships with parents is important to the child's capacity for sexual and emotional
relationships later in life (DeLamater and Friedrich, 2002

SOCIAL DEVELOPMENT Separation and Individuation A major task of the toddler period is differentiation
of self from significant others, usually the mother. The differentiation process consists of two phases:
sepazatioz, the children's emer- ce from a symbiotic fusion with the mother, and indiv aiei, those
achievements that mark children's assumption of their individual characteristics in the environment.
Although the process begins during the latter half of infancy, the major achievements occur during the
toddler years Toddlers have an increased understanding and awareness of object permanence and some
ability to withstand delayed grat- ification and tolerate moderate frustration. They begin to lose some of
their resistance to separation, yet appear even more concerned about the parent's whereabouts. They
have learned from experience that parents exist when physically absent Repetition of events such as
going to bed without the parents but waking to find them again reinforces the reliability of such brief
separations. Consequently, toddlers are able to venture away from their parents for brief periods
because of the secu rity of knowing that the parents will be there when they return. Verbal and visual
reassurance from the parent gradually replaces some of the previous need to be physically close for
comfort.

Toddlers also show less fear of strangers, but only when their parents are present. When left alone with
a stranger, they are fearful and acutely anxious; manifest depressive behavior, such as crying and
withdrawal; and may become restless, hyperactive or passive, reverting to regressive behaviors. Such
reactions may be evident when a child is left with a babysitter; is beginning kindergarten, preschool, or
day care; or is hospitalized. (See Chapter 22.) These behaviors are not pathologic or harmful if parents
realize how desperately their children need them. Indiscrimi nate friendliness toward strangers and lack
of anxiety during separation from parents may be reasons for concern. Sensitive perceptive parents will
be aware of the child's need for increased

love, affection, and attention when they are together. An atti- tude such as "They will get used to the
babysitter" will not help young children positively tolerate separation. According to Harpaz-Rotem and
Bergman (2006), the separation-individuation phase encompasses the phenomenon of rapprochement;
as the toddler separates from the mother and begins to make sense of experiences in the environment,
the child is drawn back to the mother for assistance in verbally articulating the meaning of the
experiences. Developmentally the term aprsneae: means the child moves away and returns for
reassurance. If the mother's response to the toddler is inappropriate, the toddler may experience
insecurity and confusion Parents often need help in realizing the necessity of prepar- ing children for an
inevitable separation. Particularly with the firstborn, parents tend to overprotect children, shield them
from any anxiety-producing experience, and insulate them from less than immediate gratification.
Although this is not necessarily harmful, especially if opportunities for indepen- dence are allowed later,
it does not prepare children-for unex- pected events. A typical example is the birth of a sibling. The child
is faced with the crisis of sibling rivalry and separation from the parent. Allowing children to experience
brief periods of separation during early infancy prepares them for such expe- riences later. Indeed, they
may still manifest the typical behav- iors of protest, but they will also have learned that their mother or
father always returns. Therefore, it is important to appreciate the tremendous loss that the death of a
parent reprcsents for young children; unlike their other experiences with separation this time the parent
will nct return.

Transitional objects, such as a favorite blanket or toy, provide security for young children, especially
when they are separated from parents, are dealing with a new stress, or are just fatigued (Fig. 12-3).
Security objects often become so important to tod- dlers that they refuse to let them be taken away.
Such behavior is normal; there is no need to discourage this tendency. During separations, such as day
care, hospitalization, or even overnight stays with a relative, transitional objects should be provided to
minimize any feelings of fear or loneliness Learning to tolerate and mastering brief periods of separa-
tion are important developmental tasks of children in this age- group. In addition, it is a necessary
component of parenting because brief periods of separation from their children allow parents to recoup
their energy and patience and to avoid direct ing their irritations and frustrations at the children
Language Development The most striking characteristic of language development during early childhood
is the increasing level of comprehen- sion. Although the number of words acquired-from about 4 at 1
year of age to approximately 300 at age 2 years-is notable, the ability to understand speech is much
greater than the number of words the child can say At age 1 year the child uses one-word sentences, or
holo- phrases. The word "up can mean "pick me up" or "look up there." For the child the one word
conveys the meaning of a sentence, but to others it may mean many things or nothing. At

this age about 25 % of the vocalizations are intelligible . E age of 2 years the child uses multiword
sentences by strin ogether tvo or three words, such as the phrases, "Mamy bye - bye " or " all gone , and
approximately 65 % of the understandable. At 30 months the toddler knows her or hs name. By 3 years
the child puts words together inom sentences, begins to master grammatical rules, acquires b six new
words daily, knows his or her age and gender, and count three objects correctly (Feigelman, 2011).
Reading together during this period provides an ideal setting for fj language development. Authorities
have evaluated the of television viewing on toddler language developmnt found that those who started
watching television at less months and who watched longer than 2 hours per significant language delays
(Chonchaiva and Pruksan 2008). Adult-child conversations with infants and todd been shown to
positively affect language developm researchers recommend reading, storytelling, and n adult-child
communication (Zimmerman, Gilkerson, et al, 2009). The American Academy of Pediatrics, Co
Communications and Media (2011) reaffirms that tele recorded media usage in children younger than 2y
decreases language skills and the time child. Furthermore, educational programs have no to increase
cognitive skills in young childrern parents interact t been Gestures (such as putting phone to ear or
pointing or accompany each of the language milestones u months of age. Once language is sufficiently
mastered

hase out and the pace of word learning increases (Bates and Dick, 2002). Personal-Social Behavior One
ofthe most dramatic aspects of developrnent in the toddler nersonal-social interaction. Parents
frequently wonder why s p dmanageable, docile, lovablc infant has turned into a deter- piced, strong-
willed, volatile-tempered litle "tyrant In addi- ion.the tyrant can swiftly and unpredictably revert back to
the dorble infant. All this is part of growing up and is evident n such areas as dressing, feeding, playing,
and establis..n. s-control. Todlers are developing skilis of independence, which are ident in all areas of
behavior. By age 15 months children feed hmsclves, drink well from a covered cup, and manage a spoon,
ith considerable spilling. By age 24 months they use a spoon ell and by age 36 months they may be using
a fork. Between 2 and 3 ycars they eat with the family and like to help with chores such as setting the
table or removing dishes from the dihwasher, but they lack table manners and may find it difficult to sit
tkough the family's entire meal.

In dressing, toddlers also demonstrate strides in indepen- deace. The 15-month-old child helps by
putting the arm or foot ou: for dressing and pul's shoes and socks off. The 18-month- odchild removes
gloves, helps with pullover shirts, and may be able to unzip. By age 2 years the toddler removes most
articles idothing and puts on socks, shoes, and pants without regard for right or left and back or front.
Toddlers still need help to fasten clothes. Toddlers also begin to develop concern for the feelings of
others and develop an understanding of how adult expectations for behavior apply to specific situations
(e.g., causing a sibling to cry while playing rough). As their understanding increases, they develop
control. Age-appropriate discipline contributes to healhy social and emotional development. Positive
reinforce- ment, redirection, and time-out are appropriate for most tod- des it is recognized that social
and emotional problems can drelop in the youngest children. Early screening and interven- con promote
more positive outcomes as the young child grows tod develops.

Play magnifies toddlers' physical and psychosocial develop- raction with people becomes increasingiy
important. tary play of infancy progrcsses to paxaiei play. the der plays alonyside, not with, other
children. Although sen- r play is still prominent, there is much less emphasis exclusive use of one sensory
modality. The toddler e the toy, talks to the toy, tests its strength and durability. onimotor tnd invents
several uses for it. assumes many forms and serves several functions. Tod- benefit from a wide variety of
play interactions (eg,alone, other children, with adults), environments (e.g, own other children's
homes,park,playgrounds), and activities active, quiet, organized, unstructured) tation is one of the most
distinguishing characteristics o and enriches children's opportunity to engage in fantasy
With less emphasis on sex-stereotyped toys, play objects such as dolls, carriages, dollbouses, dishes,
cooking utensils, child- sızed furniture, trucks, and dress-up clothes are used by both sexes; however,
boys may be more interested than girls in activi- ties related to trucks, trailers, cars, miniature plastic
soldiers or superheroes, and building blocks, whereas girls may prefer doll- related activities (Fig. 12-4).
Increased locomotive skills make push-pull toys; stick horses straddle trucks or cycles; a small, low gym
and slide; variously sized balls; and rocking horses appropriate for the energetic toddler. Finger paints,
thick crayons, chalk, chalkboard, paper and puzzles with large, simple pieces use the child's developing
fine motor skills. Interlocking blocks in varied sizes (but large enough to avoid aspiration) and shapes
provide hours of fun and, during later years, are useful objects for creative and imagi- native play. The
most educational toy is the one that fosters the interaction of an adult with a child in supportive,
unconditional play. Parents and other providers are encouraged to allow chil- dren to play with a variety
of simple toys that foster creative thinking (such as blocks, dolls, and clay), rather than passive toys that
the child observes (battery-operated or mechanical). Active play time should also be encouraged over
the use of computer or video games, which are more passive (Ginsburg and American Academy of
Pediatrics, Committee on Commu- nications, 2007). Toys are never substitutes for the attention of
devoted caregivers, but toys can enhance these interactions (Glassy, Romano, and Committee on Early
Childhood, Adop- tion, and Dependent Care, 2003).

Certain aspects of play are related to emerging linguistic abilities. Talking is a form of play for toddlers,
who enjoy musical toys such as age-appropriate compact disc (CD) players "talking" dolls and animals,
and toy telephones. Children's tele- programs are appropriate for some children over 2 years of age who
learn to associate words with visual images. However total media time should be limited to 1 hour or
less of quality programming per day. Parents are encouraged to allow the child to engage in unstructured
playtime, which is considered much more beneficial than any electronic media exposure (Americarn
vision