Behavioural problems in toddlerhood

BEHAVIOURAL PROBLEMS IN TODDLERS S. Papaventsis MRCPCH DCH IBCLC 2008

Defining abnormal behaviour
Normal behaviour: immense variation
Average behaviour: statistical concept
Tolerable behaviour: depending on the eye of the beholder

Mother’s description of their toddlers 70% 72% 83% Temper outbursts 85% 92% 95% Stubborn 36% 18% 17% Has nightmares 56% 52% 52% Awakens during the night 56% 46% 70% Resists going to bed 37% 26% 50% Eats too little Age 4 Age 3 Age 2 Behaviour

TYPICAL TODDLER BEHAVIOUR
Crave attention and hate being ignored
Are active, busy little people
Are stubborn and wilful
Do not respect property
Are impulsive with little sense of danger
Have more power than sense
Live only for the here and now
Have tunnel vision
Have fluctuating behaviour

The age of developing everyday habits 3-5 years Eating 4-6 years Self-care 2-4 years Toiletting 1-3 years Dressing and undressing 4-12 months Sleep routine 4-12 weeks Regular feeding TIME HABIT

The Frequency of the behaviour
Temper tantrums are common
At age 2: 1 in 5 will be having at least daily tantrums
At age 4: 1 in 10 will be having at least daily tantrums
Some children will have frequent multiple tantrums more than 6 per day

The Duration of the behaviour
Many tempers of toddlers are very short with only a few lasting longer than a couple of minutes
They are easily distracted
For some children each temper can last in excess of an hour

The Intensity of the behaviour
Temper tantrums are not all the same
Some may yell, cry, throw self to the floor
Others will bite, kick, hit themselves or others

The Context of behaviour
PLACE: School, nursery, home, super market
TIME: evening, when tired, hungry
CIRCUMSTANCE: School, housing conditions, acute change in family dynamics, new sibling

The concept of Temperament
Simply defined as an individual’s nature/ the innate part of the child’s personality
Present early in life (infancy), fully recognized at 3-5 years
Later on, environmental influences become more pronounced and temperament qualities are diluted
10 distinct qualities

The New York longitudinal study
‘ Easy child’: 40%
‘ Slow to warm child’: 15%
‘ Difficult child’: 10%
Intermediate group: 35%
Results have been confirmed by subsequent studies

Examples of common behaviour problems
Unwanted habits: Nail-biting, thumb sucking, head knocking
Eating problems
Sleeping problems
Enuresis and encopresis
Hyperactivity and attention deficit
Aggression/ Disobedience/ Temper tantrums

Epidemiology of behaviour problems
Point prevalence of problematic psychological conditions in childhood and adolescence: 20%
74000 UK children (25%) have behaviour disabilities
In pre-school children:
Waking and crying at night: 15%
Overactivity: 13%
Difficulty settling at night: 12%
Refusing food: 12%
Polymorphous behaviour: 10%

Characteristics of common behaviour problems
They are a source of considerable misery and family distress
They are relatively persistent over the years
They tend to be polymorphous

The Continuity of behaviour
Waltham Forrest study assessed 705 children at 3, 4 and 8 years of age
Of those with behaviour problems at 3
63% continued to have significant problems at 4 and 62% at 8
Of those with no problems at 3
11% developed problems by age 4 and 22% by age 8

Significantly abnormal behaviours
Deliberate destructive behaviour, repeated and without obvious purpose
Running off from home
Marked deterioration in function
Deliberate self-harm
Repeated fire-setting
Wandering off

Underlying drives of misbehaving toddlers
Stress
Excitement/ Fear
Boredom
Tiredness
Struggle for autonomy, attempt to control their environment
Jealousy and competition
Seeking attention and comfort
A need to regress developmentally for a while

Predisposing factors
Poor parenting
Boys/ Urban life
Socioeconomic deprivation
Children with learning difficulties, developmental delay, health problems
Looked after children
Family dynamics

Hyperactivity at age 10 years and social class Social class Hall D, Health for All Children , 4 th edition, 2003

Behavioural problems and socioeconomic status
Group V children have higher prevalences at the age of ten in hyperactivity, conduct disorder and anxiety
The problem of ‘double jeopardy’
The problem of the ‘inverse care law’

Maternal Depression
Baby blues in 50% of mothers
Postnatal depression in 10% of mothers
Affects mothers quality of life.
Impacts on the child's
b ehaviour, cognition,
emotional development
Boys>girls
Few prevalence data on father's mental health on child birth ,partners, children

Understand the family dynamics
Structure Housing
School Special needs
culture

Parental qualities that reduce the risk of behavioural problems
Routine/ Regularity in everyday life
Setting clear limits/ simple goals
Unconditional love and affection
A high level of supervision
Consistency
Praise and rewards
Keeping a sense of humour

Managing behavioural problems
Managing one problem at a time, in particular the one that comes earliest in the developmental sequence
Identifying possible causes
Rewarding promptly appropriate behaviour
Avoiding punishment
Setting a good example
Keeping a diary

How to manage childhood tempers
Remove any audience
Time out
Ignoring the behaviour
Teaching by example
Rewarding self-control
Training the child to express anger in an acceptable way
Avoid high-risk situations (tired, hungry)
Divert if possible
Prevention The methods The approach

Tackling behavioural problems
Changes come gradually
Things can get worse before better
From Public Health perspective:
Community-based prevention and treatment is needed with specialized child and adolescence psychiatry teams providing leadership
Important role for Health Visitors and School Nurses

Sleep problems
The sleep cycle: driffting off, deep sleep, dream, brief conscioussness, cycle repeated
Considered a problem when causing toddlers, parents or neighbours to be tired, irritable or unhappy
Hours of sleep

Type of sleep problem
Middle-of-the-night wakening
Not getting to bed on time
Coming to parent’s bed during the night
A few present since birth
Many triggered at a time of teething, illness or home disruption

A case
Parents bring 3-year old Tom to clinic, asking you to prescribe a hypnotic for him. In the last year, Tom has refused to go to bed at the appropriate time. He would insist on going to his parent’s bed. If put to bed, he would scream until his parents took him downstairs again 5 min later. He would often wake up in the middle of the night demanding attention.
He has a young sister aged 13 months. His father is a taxi driver working irregular hours. His mother is a part time cleaner in the evening

Case
What factors may have contributed to Tom’s sleeping problems?
Which further details from the history do we need?
How would you advise the parents?

Simple steps to tackle sleep problems
Reduce the daytime nap
Bedtime routine
Give the child attention during the day
The controlled crying technique
Avoid feeds during the night (>1year olds)
Be firm, patient and anticipate that things might get worse in short-term
Last resort to sedatives only for short-term

References
Green C, Toddler Taming , Vermilion, 2001
Spencer N, Poverty and Child Health , Radcliff Medical Press, 2000
Hall D, Health for All Children , Oxford University Press, 2003
Polnay L, Community Paediatrics , Churchill Livingston, 2002

Behavioural problems in toddlerhood

by papave1 on May 05, 2011

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