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

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