Toddlers like being ‘in charge’ (as can be seen in Case 15.1). This desire is often thwarted by their abilities and the limits set by their parents. For example, 2-year-olds may want to eat their meal with their parents’ cutlery although they do not have the fine motor skills to do so, or their parents may prevent them from adding tomato sauce to their ice cream, for example.

Case 15.1

A ‘naughty’ girl

Daisy is 3 years old and her parents were anxious about her ‘extreme mood swings’. Daisy would not follow her parents’ instruction: ‘We ask her nicely but she just ignores us and if we try and make her, she goes rigid and falls to the floor’. Daisy had started to vomit during these episodes.

Her father thought that these episodes might be fits, and when they happened he gave Daisy a cuddle and comforted her. Her mother tried to ignore her but felt she had to intervene when she vomited: ‘I can’t ignore her if she’s sick’.

This lack of control causes frustration, and tantrums may follow. This is normal behaviour between the ages of 1 and 4 years.

Tantrums are usually dramatic. Crying, screaming, dropping to the floor and thrashing of limbs are common. Some children are able to induce vomiting. Occasionally these episodes may be mistaken for seizures. The key distinction is a history of provocation and the complex pattern of behaviours seen in tantrums.

Tantrums may be seen in children who receive inconsistent messages from different parents, and may in a sense mimic their parents’ behaviour. Note that children, despite appearances, never really want to ‘win the war’ – to do so would be very frightening as it would affirm their own power and destructiveness.

Management

Specific strategies

Reasonable expectations

Have a reasonable expectation of what the child is able to comply with. Excessive expectations of a child may occur with parents who themselves have unmet needs.

Ignore bad, praise good

Children want responses to their tantrums. If no reaction is gained they get bored and eventually the behaviour stops. If good behaviour is greeted with cuddles and praise, the child will seek this sort of response again. Sanctions should quickly follow bad behaviour as delayed punishment is confusing to the child and ineffective.

Time out

Place the child alone in a safe environment to calm down. This works well if used for short periods. Usually only a few minutes is required.

Consistency

Consistency of approach is crucial. Children like certainty and respond badly to the parent reacting differently on different days. They find it confusing and their poor behaviour is perpetuated. Worse, they may simply learn to read (and manipulate) their parent’s mood state, rather like a traffic light signal, instead of learning to understand the world around them.

Win sometimes

Allowing a toddler to be successful in their unreasonable demand is sometimes OK. There are some battles not worth having. Parents should only insist on compliance if able to carry out behaviour management to a successful conclusion. Anyway, only an angel or a behaviour therapist can be consistent all the time! It may be sensible to start with one specific behaviour. Do not choose the supermarket as the first arena. If the child behaves in one setting, generalization to other settings will usually follow.

Support

With the changing structure of society and families, many parents feel unsupported in managing behaviour problems. Other primary care professionals and voluntary agencies may be able to help. Befriending with emotional and material support may make the difference for vulnerable families between viability or not of the family unit.

Hyperactivity

What is attention deficit hyperactivity disorder?

The girl’s condition in Case 15.2 is an example of attention deficit hyperactivity disorder (ADHD) which is a triad of inattention, impulsivity and hyperactivity, with impairment of social or educational functioning as a consequence. In order to make the diagnosis, these difficulties should be seen before the age of 7 years and usually much younger. The patterns of behaviour need to be chronic (of at least 6 months’ duration), pervasive – i.e. they affect the child in two or more situations, such as at home, at school, or with grandparents and friends – and cause functional impairment.

Case 15.2

A girl who is always on the go

Lauren is 7 years old and had always been ‘hyperactive’. She found it difficult to concentrate on much, other than her computer. Her parents were worried about her schoolwork and her schoolteachers felt she was not fulfilling her potential. She was easily distracted in the classroom and found it difficult to sit at her table. Lauren liked school but got bored easily. She acted without thinking. She had recently been excluded from school for thumping a boy who had teased her.