behavioural problems in toddlerhood
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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
Behaviour Age 2 Age 3 Age 4
Eats too little 50% 26% 37%
Resists going to bed 70% 46% 56%
Awakens during the night
52% 52% 56%
Has nightmares 17% 18% 36%
Stubborn 95% 92% 85%
Temper outbursts 83% 72% 70%
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
HABIT TIME
Regular feeding 4-12 weeks
Sleep routine 4-12 months
Dressing and undressing
1-3 years
Toiletting 2-4 years
Eating 3-5 years
Self-care 4-6 years
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
Significantlyabnormal 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
0
2
4
6
8
10
12
14
16
1 2 3 4 5Social class
Hall D, Health for All Children, 4th 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 behaviour, 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
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
The approach The methods
Prevention • Avoid high-risk situations (tired, hungry)• Divert if possible
Training the child to express anger in an acceptable way
• Teaching by example• Rewarding self-control
Ignoring the behaviour
• Remove any audience• Time out
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
0 2 4 6 8 10 12 14 16
4 years
2 years
1 year
6 months
1 month
Nightsleep
Daytimesleep
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