COMMON BEHAVIORAL PROBLEMS IN TODDLERSAND YOUNG CHILDRENBY DR / NAGWAN SAID MOHAMEDREGISTRAR PAEDIATRICIAN.PAEDIATRIC DEPARTMENTCEDARS JEBEL ALI INTERNATIONAL HOSPITAL

Case presentation:
A 5 year old girl named Sue is brought to the paediatricians office with a chief complaint of temper tantrums. Her mother is frustrated and explains that Sue kicks and screams any time she doesn't get her way. She sometimes swears and destroys things in her fits of rage. Two days ago she flailed her arms around while out of control and sustained a scratch on her forearm that bled. Her mother has tried yelling at Sue, spanking her on the buttocks, and embarrassing her in public. None of these techniques seem to work. In fact, her mother says that the harder she tries to control Sue, the worse she gets. This problem is causing difficulty especially between Sue's parents, as they don't agree on how to handle these tantrums. Sue's mother feels that they should take action immediately by confronting Sue and telling her that what she is doing is not acceptable.Sue's father would prefer to spank her several times on the buttocks and give her a lecture after sending her to her room for an hour or so. They openly disagree on how to discipline Sue, and Sue seems well aware ofthe difference in their parenting styles.

Exam:VS are normal. Height, weight and head circumference are at the 50th percentile.Sue is a well developed, well nourished attractive little girl in no acute distress.She comes in quietly with her mother and father and sits on the chair near hermother, looking up shyly at the examiner.No abnormalities can be identified on examination of HEENT, neck, heart, lungs,abdomen, and back.There is a healing 5 cm healing linear abrasion to her right forearm.There are multiple bruises to both anterior tibial surfaces at different stages ofhealing, with normal range of motion, no deformities , Her neurological exam isintact.

some children seem to get through childhood without many problems at all and others seem to have an unusual amount of difficulty.Parents are often puzzled as to why their children do not behave or listen while their friend's children seem to be perfect angels.Some of the most common behavioural problems in children include:1- Temper tantrums .2- Not following directions .3-Whining .4-Fighting with siblings or other children .5-Breaking rules .6-And talking back.Fortunately there is hope in dealing with everyday discipline problems using methods that are effective and easy to learn.

Parents have the ability to shape their children's behaviour towards both good and bad results.All behaviours are shaped by rewards that are given to them. A common mistake that parents make is to accidentally reward their children's bad behaviour.Example :Four year old Jack gets to eat ice cream before dinner. He has been whining and begging for the ice cream long enough that his mother gives it to him so she can finish preparing dinner.Unfortunately, by rewarding bad behaviour it is often strengthened. On the other hand behaviour that is not rewarded, but instead punished, will often weaken and therefore decrease .

Developmentally, it is expected that young children will have a difficult timecontrolling their emotions, particularly if tired, hungry or stressed.Toddlers and preschoolers often lack the self-control necessary to expressanger and other unpleasant emotions peacefully.When this happens it is important for the child's caregiver to be able to providehim or her with the support to deal with these difficult and uncomfortablefeelings.Children learn a lot through their parents' modeling of behaviours and this isthe main reason for parents needing to be most in control when their childrenare feeling out of control.If a father or mother joins the child in an uncontrollable emotional state, thesituation will likely worsen because the child will feel less safe and more out ofcontrol.

**the basic principle is that children want to please their parents :Parents can therefore use this to their advantage when deciding how todiscipline children. When a parent shows joy for a behaviour that is good, thechild will be positively reinforced for doing this behaviour. On the other hand ifA parent shows disapproval for a behaviour, the child is less likely to repeat thisbehaviour..**Do's and Don'ts: Three Good Child-Rearing Rules to Keep in Mind :1) Reward good behaviour and do it quickly and often. A child's good behaviourwill be positively reinforced and therefore strengthened when they receive areward from a caregiver. Social rewards are the most effective rewards andinclude smiles, hugs, kisses, words or praise, eye contact and attention. Otherrewards include activity rewards such as going to the park or helping to bakecookies and material rewards like ice cream or money .Social rewards are the most powerful easiest to give and least expensive.

2) Avoid accidentally rewarding bad behaviour. This will strengthen the badbehaviour and is a very easy trap for parents to fall into.**Example :when a child whines to get their parents attention. If a parent gives theChild attention while they are whining, even if this attention is to yell at theirchild, it will act to reward the bad behaviour of whining.Parents are very prone to making this mistake, especially if preoccupied withanother activity like making dinner, talking on the phone or having a long day.

3) Punish some bad behaviour by using mild punishment. Examples of mildpunishment include:1) Time-out .2) Scolding .3) Natural consequences .4) Logical consequences .

**Time-out :can be used initially with one or two target behaviours and once the parent andchild get used to the technique it can be expanded to more problem behaviours.Getting started with time-out should occur after caregivers agree on this as aform of mild punishment. It should then be explained to the child before it isinitially used so the child can understand what to expect the first time it isUsed.The child should immediately be placed in a very boring and safepredetermined location using up to ten words in less than ten seconds from thetime the target behaviour occurred. The child should be placed in time-out forone minute for every year of life (for example a five year old would sit in timeout for five minutes) up to a maximum of about 10 minutes.After time out the child will be asked why they went to time-out. Once they produce the answer the parent drops the issue and goes about theirdaily activities as usual. Time-out is not designed to make a child feel bad orhumiliated.

Time Out Examples

**Scolding :` is a common form of mild punishment used by parents. When scolding a child for bad behaviour it is important to move close to the child, maintaining good eye contact, being stern, and expressing your feelings while naming the undesirable behaviour. It is important to be brief and calm, showing disapproval for the behaviour not the child.Another type of mild punishment is:** Natural Consequences:. This is an event that would naturally occur after a child does a bad behaviour. Some examples include not wearing an appropriate outfit to school and getting sent to the principal's office or being careless in not packing a lunch and being hungry at lunchtime.

** Logical consequences : occur for behaviours that do not have natural consequences. Some examplesinclude not eating all of your dinner and then not having any dessert; orriding the bicycle in the street and having the bike taken away for three days.

**There are several ways in which parents can accidentally increase badbehaviours or decrease good behaviours.Once parents become aware of these common mistakes, avoiding them will beeasier and promote a healthier parenting style. These errors include failing to reward good behaviour, accidentally punishing good behaviour, accidentally rewarding bad behaviour and failing to punish bad behaviour.A parent can fail to reward good behaviour by not praising or recognizing that their child cleaned their room or brought home a great report card.Parents accidentally punish good behaviours by not being satisfied with a job well done and commenting that they could have done more or better.Some parents accidentally reward bad behaviour by giving in to child who is whining and making unreasonable demands.Finally, parents can fail to punish bad behaviour by ignoring it and sayingsomething like "Oh well, boys will be boys"

Common behavioural problems are challenges that all parents and caregivers face. Some caregivers have more difficulty than others in managing their children. Parents will often come to the paediatrician with questions about behavioural problems. It is important to listen to these parents, take them seriously and offer suggestions as to how some of these problems can be remedied. It is essential to praise the parents for the things that they are doing correctly and gently try to shape some of the less helpful things that they are doing in a positive way. Most children will show great improvements if the strategies mentioned in this presentation followed. For those children with more serious behavioural problems, these strategies may not be enough and this is when the paediatrician may consider referral to a psychiatrist, psychologist or other behaviourally astute professional.

The training of children is a profession, where we must know how to waste time in order to save it.!Jean-Jacques Rousseau

Dr.Nagwan Said

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