Toddler Behavior

Rick Brandt-Kreutz, LICSWProvidence Medical Group – St. Peter Family

Medicine

Objectives

• Improve your understanding of your toddler’s development, temperament and the “Goodness of Fit” between you and your child

• Learn positive skills and strategies that can help you work with your toddler’s tantrums

• Know how to develop effective routines for your toddler with sleep, eating and potty training

• Learn what to look for and benefits of your toddler’s day care, at-home care or preschool

When is a toddler a toddler?

• When your baby starts toddling– Walking independently– Range: 9-17 months

• When your baby starts talking– First words besides “mama/dada” at 12

months– 50-100 words on average by 18 months• Learning to talk varies greatly

• Walking, talking…just not your little baby anymore

Toddler Psychosocial Development

Four key parenting concepts

1. Understand temperament

2. Behavior is purposeful-search for the meaning

3. Discipline with kindness and firmness

4. Enforce consistent standards

1. Understanding Temperament

• Your child’s behavior style• At 6 months old mothers can identify

accurately• Characteristics that will help shape your

child’s personality• Characteristics that may be “easy,”

“spirited,” or somewhere in-between• Tends not to change…though we as

parents may need to change– Example: 2-year old with “easy” parents

Temperamentactivity (handout)

• Fill out as we go• Assess the temperament of yourself AND

your child

Nine Traits of temperament

1. Sensitivity: strong reactions to light, sound, etc.2. Regularity: eat, sleep same or different each day3. Activity level: “idle speed,” or “wigglyness”4. Intensity: energy level of typical responses5. Approach/withdrawal: first reaction to something

new6. Adaptability: adjusting to transitions and changes7. Persistence: continues in the face of obstacles8. Distractibility: aware of noises, people, touch or toys9. Mood: tendency to react positively or negatively

• How similar are you to your child?• How different are you from your

child?• How does this help or hinder how you

parent your child?

Ask yourself:

Three Types of Temperament

• The nine temperament characteristics can be grouped into three groups:– Easy child (40% of the population)• Regular routines, cheerful, adaptable

– Spirited child (10% of the population)• Irregular, strong reactions, slow to accept

change and tending to respond negatively– Slow-to-warm up child (15% of the population)• Inactive, mild, low-key responsiveness

– Mixed (35% of the population)

Temperament traits

Easy (40%) Spirited (10%) Slow-to-Warm-up (15%)

1. Sensitivity Low High

2. Activity level Low High Low

3. Regularity Regular Irregular

4. Intensity Low High Low

5. Approach/ Withdrawal

Outgoing Withdrawl Withdrawal

6. Adaptability Quickly Slowly Slowly

7. Persistence Low High

8. Distractibility Low or High High or Low

9. Mood Positive “Serious”

“Goodness of Fit”• The match between your child’s traits and your

caretaking style• Poor fit can lead to:– Difficulty bonding with my child– Difficulty dealing with my child’s behavior– Difficulty for the child

• More challenging for families with children with spirited temperamental traits

• Parenting goal: Improve the “fit”

Temperament helps meto understand my child

• My child is unique, different from me, different from brother or sister

• My child is not “a problem,” though he may be challenging for me

• Remember: “Spirited” children often become leaders

• Adjust to temperament– Active child needs more space– Slow-to-warm-up child needs more time to

adjust– Spirited child needs more 5 and 1 minute

warnings before ending a fun activity

2. Behavior is purposeful

• http://www.youtube.com/watch?v=Gk-OfmmRaqs

• Goal of every behavior is to increase our sense of belonging and significance

i.e., To get attention

Cycle of behavior

interpretation

belief

perception

decision(private logic)

Remember: There is REASON for the behavior you see

Look for MEANING

• What is your child’s INTENT?– Tired, hungry, scared,

frustrated…curious?• E.g., tired toddler in

clinic• Did your child learn the

behavior?– Intentionally or

unintentionally reinforced?

– Did they copy someone? (central process = imitation)

Developmental context of behavior (Milestone and Meaning Card)

• Tantrums• Potty training• Sleeping• Eating

• Developmental Tasks– Elaboration of

locomotion– Fantasy play– Language

development– Self Regulation and

control

Why Tantrums?

18 month old: Walking + talking +understanding = CHOICES

HOWEVER: No delayed

gratification!= TANTRUMS=“developmentally

predictable” -Martin Stein, MD

50%-80% = weekly 20% = daily

Tantrums

• Tantrums affected by 3 things:1. Attachment: What is the emotional bond like

with your toddler and are you transitioning to allow more independence?

2. Temperament: Easy, Spirited or Slow-to-Warm-up? Goodness of fit?

3. Your style of responding:• React with anger? Stay calm? Assist your

child to calm?• Tantrums are the child’s way of learning how to

handle their anger

Tantrums:What to do?• Accept tantrums as normal• Praise when not tantruming• Always stay calm, (“three deep breaths”)

– If you cannot stay calm then get some help

• EVERYONE Calm before talking– Your child gets energy from you trying to stop it

• See if your child can calm themselves on their own first– Distraction and Redirection

• Ignore when possible: –Move away, but still monitor and keep

safe– Stay quiet– Expect it to get worse before getting

better• When calm or calming, use helpful words– “Tell me when you are mad”– “Use your words”

Tantrums:What to do?

When should I ask mydoctor for help?

• Anytime you feel you need help, ask for help– Especially if tantrums are more than 3 times a

day and more than 20 minutes long– Explosive tempers = 5% throughout childhood

in all kids• Severe Tantrums = accompanied by sleep, eating

or other problems– Illness, disability, language delay, history of

abuse or neglect may be factors• Safety concerns• If what we discussed today does not work, ask for

help

3. Discipline withkindness and firmness(handout)

High kindness (respect for child)

Low kindness(mean)

Authoritative

(democratic)

Authoritarian/Abuse

Low firmness

High firmness(respect for self)

Neglect

Permissive Rigid

4. Enforce standards consistently

• Children need all caregivers to be “on the same page”

• Children need parents to set limits– Chose your battles– Selective = effective – Don’t sweat the small stuff

• Consistency is essential– Inconsistency leads to more testing of limits– Every child is “gambler” (intermittent

reinforcement)• Don’t “do battle” often, but if you do, you need to

win

Rules for Rules

• Set only rules that you will enforce

• Give as many choices as possible– But, not unlimited choices

• Teach and explain rules ahead of time: – Ask the child: “Tell me what the rule is?”– Child’s ability to understand what you say is

likely 10 times greater than their ability to speak

Avoid PowerStruggles

• Rules help avoid power struggles by establishing expectations

• Respect child’s temperament and preferences when possible

• What are the 3 things you can never force a child to do?– SET:

• Sleep• Eat• Toilet

HowHow the parent does it makes all the difference the parent does it makes all the difference

No Need to Yell

• Nagging, threatening, pleading, screaming demean the parent.

• Humiliation, name-calling, and inducing guilt demean the child.

• Neither are necessary.

Time out • When should you use Time out?

– Some say after 18 months, some say after 36 months

– Try it, see if it works• Preparation: Place, timer, rehearsals, rules• Use single warning• Send to time out immediately after behavior

and calmly explain why• Start timer-reset if not cooperating

– One minute per year of age• Ignore child while in time out• End with buzzer and move on

• Question: What do you do if it does not work?• Shorten the time (object is to get

success)• Try sitting with the child• Talk with your health care professional

Time out

Spanking?

Use Time-In!

• Special Time (handout)

• Regular child directed play• Daily• Not used as punishment• Scheduled 15-30 min

Reduce undesiredbehaviors

• Talking• Reasoning • Ignoring• Distracting• Removing • Time out• Time in!

QUESTION: HOW might the parent reduce this undesirable behavior? http://www.youtube.com/watch?v=Gk-OfmmRaqs

SUMMARY:

• 4 key parenting concepts– 1. Understanding temperament helps

understand behavior• Goodness of fit?

– 2. All behavior serves a purpose• Including tantrums

– 3. Authoritative parenting style is the most effective

• With kindness and firmness– 4. Consistent rules and limits are essential• Everybody on the same page

Toilet Training

• Average age 30 months• 98% of children are dry

during the day by 36 mo of age

• Avoid toilet teaching during stressful times

• Do not rush or pressure the child– “pull” not “push”

• Introducing the concept earlier than you expect to train is helpful

When is my childready?

• Dry at least 2 hours or dry after naps• Bowel movements become regular and

predictable• Facial expressions, posture, or words reveal that

your child is about to urinate or have a bowel movement

• Can follow simple instructions• Can help undress• Seems uncomfortable with soiled diapers and

wants to be changed• Asks to use toilet or potty chair• Asks to wear grown-up underwear

Steps to toilet training

• Decide on what you will call it (potty? Throne time?)

• Potty chair in convenient and accessible place

• Encourage child to tell parent when he/she needs to void

• Parent learns behavioral cues and reminds child to go

• Praise efforts and success: sticker chart• Ignore mistakes• Avoid coercion and shaming

Toilet training refusal

• Battle you can’t win-child ultimately has control• If your child begins holding it in, this can result in

constipation and encopresis• More common with spirited temperament and if

you are having difficulty setting limits• What do you do?– Cease all efforts for 1-3 months– Assure soft stools– Resume with incentives but not punishment– See your medical provider if your child is over

4 years old

Toddler Sleep

• Toddlers sleep about 12 hours a day• 1 nap per day after 18 months, 1.5-3.5

hours long• Up to 18 months, toddler may wake more

due to normal separation anxiety• Important to set “time to sleep” routine

Bedtime struggles• Bedtime = favorite time for tantrums• Resistance and clinginess are common• Transitional objects are very important (doll,

blanket)• Predictable bedtime routines

(books, songs, prayers, not TV or activating games)

• “Curtain calls” – “I want a story…water…doggie…kiss…”– Set your limit: calm, firm, matter of factly

• Try sitting in the room with your child and progressively move your chair closer to the door on successive nights

• Or, try a sticker chart

Toddler picky eating

• Parents report 1/3 of Toddlers do not want to eat or try new foods– 54% often not hungry– 33% don’t like mealtimes– 34% have strong food preferences– 26% refuse to eat– 21% request certain foods and then refuse to

eat them– 42% try to end a meal after a few bites

• On average, a food is offered 10 times before a child will accept it

• So, why the problem with so many toddlers?

Picky eaters

• From an evolutionary perspective, for simple survival children should be skeptical about eating any new food

• Children have a more acute sense of taste than adults

• Spirited Temperament children are more likely to have battles over eating

Toddler EatingBasics #1

• Don’t expect your toddler to eat all the foods you do

• Have your child sit at the table at least 10 minutes

• Child feeds her or himself• Involve your child in food selection• If your child has difficult behavior, remove for the

remainder of the meal, but offer healthy food 30 – 60 minutes later

Toddler EatingBasics #2

• Families that eat together and establish clear eating routines early on, do better

• Never “force feed”– Remember SET: No control over, Sleep, Eat,

Toilet– You control what and when food is available– Your child controls whether and how much

• With a “spirited eater,” can you put up with a bit more mess?

• Learn to breathe and relax: Most kids get the right nutrition

• Anytime you feel you need help, ask for help

• Poor weight gain• Misses more than a meal or 2• Gorging, begging for food, refusal to eat,

hoarding food

When should I ask mydoctor for help?

Quality Child Care

Higher quality child care associated with:• Better language abilities at 15, 24, and 36 months.• Higher cognitive development at age 24 months.• Greater school readiness skills at 36 months.

Caveat:• The combination of family income, mom’s vocabulary,

home environment, and how mom helped their child learn are bigger factors promoting child development than child care alone

Take Home Point: Children need BOTH a nurturing home and stimulating environment to thrive

(NICHD)

Tips for Child Care In-home or out

• Pretend Play– Develops their ideas, imagination, language– Reading, Art…having fun

• Read lots of books with them• Limit and set boundaries on screen time• Remember– Your child’s talents are multiple:• Music, athletic, creative, interpersonal

What Do I Look for Safe, Quality Child Care?

• What is the child : caregiver ratio?• Do the caregivers/teachers seem to enjoy talking,

playing and nurturing the children? • Are there plenty of toys and learning materials

within a child’s reach? • How does the center deal with discipline and

misbehaviors?• Resources:

Child Care and Parenting Resources

CHILD CARE Child Care Action Council 360-754-0810 or 1-800-845-0956 or (360) 786-8907Crisis short-term child care and assistance, referrals to child care. Head Start: 360-464-6800. Español 464-6827 Free quality preschool for children 3-5 years old from low-income families. Sites located in Olympia, Lacey, Tumwater, Rainier, Rochester and Yelm. DSHS Olympia Community Services Office (CSO) 360-725-6650 or 1-877-501-2233Working Connections program6860 Capitol Blvd, Tumwater, WA 98501Show up at 7:30AM and apply for subsidized child care for low income persons

Child Care and Parenting Resources

Child Care and Parenting Resources

Questions?

References

• Straus MA. Spanking and the making of a violent society. Pediatrics. 1996;98:837–842

• Graziano AM, Hamblen JL, Plante WA. Subabusive violence in child rearing in middle-class American families. Pediatrics. 996;98:845–848

• Eron LD. Research and public policy. Pediatrics. 1996;98:821–823

• AMERICAN ACADEMY OF PEDIATRICS, Committee on Psychosocial Aspects of Child and Family Health Guidance for Effective Discipline. PEDIATRICS Vol. 101 No. 4 April 1998

• Needlman, R. Temper Tantrums, IN, Parker, S., Zuckerman, B., Augustyn, M. Developmental and behavioral pediatrics: a handbook for primary care, 2nd ed. Lippincott Willimas and Wilkins, Philadelphia, 2005. P. 338.