Behavioural problems in toddlerhood

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  • Normal need not be average and not average is not nessecarily abnormal
  • Green
  • Testing their limits and power near the mother Changing their minds all the time Magical thinking: Piaget’s preoperational stage of development Focusing only on their own needs and happiness/ being self-centred
  • Some behaviours are common early Lying, breath holding, defiance are common in 2-4 yr olds
  • It is a relieving theory for those parents who cannot find anything from therselves on their children/ Help them accept some characteristics without feeling responsible for having caused them Activity Regularity Approach and withdrawal Adaptability Stimuli thershold Intensity Mood Attention span Distractibility Self-control
  • 1966: 133 children followed up from birth to adulthood Negative, easily frustrated Negative, loud, overactive, crying, frustrated, irregular sleeping and eating/ even with the most perfect parents
  • David Hall, Health for All Children, 4 th edition Disability Survey by the UK Office of Populations, Censuses and Surveys 1985-1988/ Bone M and Meltzer H Point prevalence among 3 yr olds for polymorphous behavioural problems(combination of tntrums,overactivity,aggression, clinging etc) is about 10% 7% have moderate or severe behaviour problems, as defined by their parents (Polnay L, Community Paediatrics, Churchill Livingston) Polymorphous: Over activity, disobedience, temper tantrums, aggressive out bursts under 3yrs
  • Causing distress to child, parents or neighbours Tantrums, agression, overactivity, eating/ sleeping/ continence problems, unusual habits
  • Children who fail to gain reasonable control of their anger and tempers by 5 years are likely to continue to have problems with aggression (Polnay)
  • Although most behaviours are non-specific and may or may not indicate an underlying disorder, a few almost invaraibly indicate significant abnormality It signifies at least poor supervision Polnay L, Community Paediatrics
  • Exposed to unknown environment Ie when a child cries in the middle of the night and receives a cuddle, he engages the mother to a false cycle to get more comfort Erkison psychosocial theory
  • Ie divorce, only parenrt
  • First, poor children are more likely to be exposed to risk factors which are postitively related to adverse outcome (ie maternal depression). Second, the effects of these risk factors tend to be greater than they are for non-poor children The families who might benefit the most from help with behavioural problems are less likely and often unable to make use of the strategies suggested
  • SOFT: touch, smile, praise, attention HARD: sticker, sweets etc
  • Ignoring the inappropriate ( after stating it is) Not delayed
  • Polnay Divert the child’s attention Say to the child that the response is unacceptable Time out: a safety valve to avoid escalation: separate in another room/ Don’t lock the door Selective deafness and blindness
  • Patience, persistence and consistency
  • Duration 1 hr in infants, 1,5 in adults
  • They get comforted and enjoy attention. When they get better they continue to play the game
  • BH, PMH, FH, examination, development unremarkable
  • Constant bedtime, avoid overstimulation before, calm them down-story, bath, cuddle-, minimal light, close the door decisively aftersaying goodnight Let the child cry for a short period, then give some incomplete comfort and walk away, let them cry a little longer each time, giving more incomplete and delayed comfort, until the child understands that he doesn’t gain reward when wakening
  • Behavioural problems in toddlerhood

    1. 1. BEHAVIOURAL PROBLEMS IN TODDLERS S. Papaventsis MRCPCH DCH IBCLC 2008
    2. 2. Defining abnormal behaviour <ul><li>Normal behaviour: immense variation </li></ul><ul><li>Average behaviour: statistical concept </li></ul><ul><li>Tolerable behaviour: depending on the eye of the beholder </li></ul>
    3. 3. 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
    4. 4. TYPICAL TODDLER BEHAVIOUR <ul><li>Crave attention and hate being ignored </li></ul><ul><li>Are active, busy little people </li></ul><ul><li>Are stubborn and wilful </li></ul><ul><li>Do not respect property </li></ul><ul><li>Are impulsive with little sense of danger </li></ul><ul><li>Have more power than sense </li></ul><ul><li>Live only for the here and now </li></ul><ul><li>Have tunnel vision </li></ul><ul><li>Have fluctuating behaviour </li></ul>
    5. 5. 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
    6. 6. The Frequency of the behaviour <ul><li>Temper tantrums are common </li></ul><ul><ul><li>At age 2: 1 in 5 will be having at least daily tantrums </li></ul></ul><ul><ul><li>At age 4: 1 in 10 will be having at least daily tantrums </li></ul></ul><ul><li>Some children will have frequent multiple tantrums more than 6 per day </li></ul>
    7. 7. The Duration of the behaviour <ul><li>Many tempers of toddlers are very short with only a few lasting longer than a couple of minutes </li></ul><ul><li>They are easily distracted </li></ul><ul><li>For some children each temper can last in excess of an hour </li></ul>
    8. 8. The Intensity of the behaviour <ul><li>Temper tantrums are not all the same </li></ul><ul><li>Some may yell, cry, throw self to the floor </li></ul><ul><li>Others will bite, kick, hit themselves or others </li></ul>
    9. 9. The Context of behaviour <ul><li>PLACE: School, nursery, home, super market </li></ul><ul><li>TIME: evening, when tired, hungry </li></ul><ul><li>CIRCUMSTANCE: School, housing conditions, acute change in family dynamics, new sibling </li></ul>
    10. 10. The concept of Temperament <ul><li>Simply defined as an individual’s nature/ the innate part of the child’s personality </li></ul><ul><li>Present early in life (infancy), fully recognized at 3-5 years </li></ul><ul><li>Later on, environmental influences become more pronounced and temperament qualities are diluted </li></ul><ul><li>10 distinct qualities </li></ul>
    11. 11. The New York longitudinal study <ul><li>‘ Easy child’: 40% </li></ul><ul><li>‘ Slow to warm child’: 15% </li></ul><ul><li>‘ Difficult child’: 10% </li></ul><ul><li>Intermediate group: 35% </li></ul><ul><li>Results have been confirmed by subsequent studies </li></ul>
    12. 12. Examples of common behaviour problems <ul><li>Unwanted habits: Nail-biting, thumb sucking, head knocking </li></ul><ul><li>Eating problems </li></ul><ul><li>Sleeping problems </li></ul><ul><li>Enuresis and encopresis </li></ul><ul><li>Hyperactivity and attention deficit </li></ul><ul><li>Aggression/ Disobedience/ Temper tantrums </li></ul>
    13. 13. Epidemiology of behaviour problems <ul><li>Point prevalence of problematic psychological conditions in childhood and adolescence: 20% </li></ul><ul><li>74000 UK children (25%) have behaviour disabilities </li></ul><ul><li>In pre-school children: </li></ul><ul><ul><li>Waking and crying at night: 15% </li></ul></ul><ul><ul><li>Overactivity: 13% </li></ul></ul><ul><ul><li>Difficulty settling at night: 12% </li></ul></ul><ul><ul><li>Refusing food: 12% </li></ul></ul><ul><ul><li>Polymorphous behaviour: 10% </li></ul></ul>
    14. 14. Characteristics of common behaviour problems <ul><li>They are a source of considerable misery and family distress </li></ul><ul><li>They are relatively persistent over the years </li></ul><ul><li>They tend to be polymorphous </li></ul>
    15. 15. The Continuity of behaviour <ul><li>Waltham Forrest study assessed 705 children at 3, 4 and 8 years of age </li></ul><ul><li>Of those with behaviour problems at 3 </li></ul><ul><ul><li>63% continued to have significant problems at 4 and 62% at 8 </li></ul></ul><ul><li>Of those with no problems at 3 </li></ul><ul><ul><li>11% developed problems by age 4 and 22% by age 8 </li></ul></ul>
    16. 16. Significantly abnormal behaviours <ul><li>Deliberate destructive behaviour, repeated and without obvious purpose </li></ul><ul><li>Running off from home </li></ul><ul><li>Marked deterioration in function </li></ul><ul><li>Deliberate self-harm </li></ul><ul><li>Repeated fire-setting </li></ul><ul><li>Wandering off </li></ul>
    17. 17. Underlying drives of misbehaving toddlers <ul><li>Stress </li></ul><ul><li>Excitement/ Fear </li></ul><ul><li>Boredom </li></ul><ul><li>Tiredness </li></ul><ul><li>Struggle for autonomy, attempt to control their environment </li></ul><ul><li>Jealousy and competition </li></ul><ul><li>Seeking attention and comfort </li></ul><ul><li>A need to regress developmentally for a while </li></ul>
    18. 18. Predisposing factors <ul><li>Poor parenting </li></ul><ul><li>Boys/ Urban life </li></ul><ul><li>Socioeconomic deprivation </li></ul><ul><li>Children with learning difficulties, developmental delay, health problems </li></ul><ul><li>Looked after children </li></ul><ul><li>Family dynamics </li></ul>
    19. 19. Hyperactivity at age 10 years and social class Social class Hall D, Health for All Children , 4 th edition, 2003
    20. 20. Behavioural problems and socioeconomic status <ul><li>Group V children have higher prevalences at the age of ten in hyperactivity, conduct disorder and anxiety </li></ul><ul><li>The problem of ‘double jeopardy’ </li></ul><ul><li>The problem of the ‘inverse care law’ </li></ul>
    21. 21. Maternal Depression <ul><li>Baby blues in 50% of mothers </li></ul><ul><li>Postnatal depression in 10% of mothers </li></ul><ul><li>Affects mothers quality of life. </li></ul><ul><li>Impacts on the child's </li></ul><ul><li>b ehaviour, cognition, </li></ul><ul><li>emotional development </li></ul><ul><li>Boys>girls </li></ul><ul><li>Few prevalence data on father's mental health on child birth ,partners, children </li></ul>
    22. 22. Understand the family dynamics <ul><li>Structure Housing </li></ul><ul><li>School Special needs </li></ul>culture
    23. 23. Parental qualities that reduce the risk of behavioural problems <ul><li>Routine/ Regularity in everyday life </li></ul><ul><li>Setting clear limits/ simple goals </li></ul><ul><li>Unconditional love and affection </li></ul><ul><li>A high level of supervision </li></ul><ul><li>Consistency </li></ul><ul><li>Praise and rewards </li></ul><ul><li>Keeping a sense of humour </li></ul>
    24. 24. Managing behavioural problems <ul><li>Managing one problem at a time, in particular the one that comes earliest in the developmental sequence </li></ul><ul><li>Identifying possible causes </li></ul><ul><li>Rewarding promptly appropriate behaviour </li></ul><ul><li>Avoiding punishment </li></ul><ul><li>Setting a good example </li></ul><ul><li>Keeping a diary </li></ul>
    25. 25. How to manage childhood tempers <ul><li>Remove any audience </li></ul><ul><li>Time out </li></ul>Ignoring the behaviour <ul><li>Teaching by example </li></ul><ul><li>Rewarding self-control </li></ul>Training the child to express anger in an acceptable way <ul><li>Avoid high-risk situations (tired, hungry) </li></ul><ul><li>Divert if possible </li></ul>Prevention The methods The approach
    26. 26. Tackling behavioural problems <ul><li>Changes come gradually </li></ul><ul><li>Things can get worse before better </li></ul><ul><li>From Public Health perspective: </li></ul><ul><ul><li>Community-based prevention and treatment is needed with specialized child and adolescence psychiatry teams providing leadership </li></ul></ul><ul><ul><li>Important role for Health Visitors and School Nurses </li></ul></ul>
    27. 27. Sleep problems <ul><li>The sleep cycle: driffting off, deep sleep, dream, brief conscioussness, cycle repeated </li></ul><ul><li>Considered a problem when causing toddlers, parents or neighbours to be tired, irritable or unhappy </li></ul>Hours of sleep
    28. 28. Type of sleep problem <ul><li>Middle-of-the-night wakening </li></ul><ul><li>Not getting to bed on time </li></ul><ul><li>Coming to parent’s bed during the night </li></ul><ul><li>A few present since birth </li></ul><ul><li>Many triggered at a time of teething, illness or home disruption </li></ul>
    29. 29. A case <ul><li>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. </li></ul><ul><li>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 </li></ul>
    30. 30. Case <ul><li>What factors may have contributed to Tom’s sleeping problems? </li></ul><ul><li>Which further details from the history do we need? </li></ul><ul><li>How would you advise the parents? </li></ul>
    31. 31. Simple steps to tackle sleep problems <ul><li>Reduce the daytime nap </li></ul><ul><li>Bedtime routine </li></ul><ul><li>Give the child attention during the day </li></ul><ul><li>The controlled crying technique </li></ul><ul><li>Avoid feeds during the night (>1year olds) </li></ul><ul><li>Be firm, patient and anticipate that things might get worse in short-term </li></ul><ul><li>Last resort to sedatives only for short-term </li></ul>
    32. 32. References <ul><li>Green C, Toddler Taming , Vermilion, 2001 </li></ul><ul><li>Spencer N, Poverty and Child Health , Radcliff Medical Press, 2000 </li></ul><ul><li>Hall D, Health for All Children , Oxford University Press, 2003 </li></ul><ul><li>Polnay L, Community Paediatrics , Churchill Livingston, 2002 </li></ul>

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