Preschool Behaviour Problems

and Temper Tantrums

A presentation By Samuel Kimbowa

for CAMHS Training 2nd Module
Dec 2017.
Introduction
• This presentation will cover disruptive behavior problems, including oppositional and
attentional difficulties; emotional problems such as fears, phobias and depression,
feeding problems and temper Tantrums in the age period 0–5 years.

• The term “disorder” should be used cautiously in this age group. Evidence for stability
and predictive significance of preschool problems is not particularly strong, especially
in the under threes. Comorbidity is very high, and there are also concerns about
distinguishing normal from abnormal behavior in this period of rapid developmental
change, and about labeling very young children with disorders.

• Disadvantages may also be of failure to define disorders in young children, including

failure to recognize distress and provide appropriate help.
Introduction continued
• This presentation will use the term “disruptive problems” to refer to a collection of
oppositional or attentional symptoms, and the term “emotional problems” to refer
to depressive and anxious-type symptoms.
• Preschool behavior problems are influenced by biological and environmental
factors, including individual differences in child characteristics and the quality of
the caregiving environment. Genetic and prenatal environmental factors are
influential in this age period.

• In assessment of 0–2 age group, greater emphasis is placed on parenting and

parental functioning (e.g., depression, social support, teen parenthood; Shaw,
Dishion Supplee et al.,2006), as well as factors that may affect the developing
brain (e.g., prematurity; prenatal drug use).
Signs of emotional or behavioural difficulties
• Significant changes in feelings or behaviour
• Behaviour that is out of step with peers at a similar age and stage
• Persistent separation difficulties or attachment problems with family
• Being withdrawn, fearful, anxious or upset much of the time
• Poor-quality play that seems limited and repetitive
• Difficulty managing anger and frustration, frequent tantrums or
aggression
• Difficulty in paying attention, following instructions and completing tasks
• Frequent defiance and refusal to follow instructions
Disruptive behaviour problems
• Disruptive behavior, sometimes referred to as externalizing or “acting-
out” problems where the affected children literally disrupts the
people and activities around them (including at home, at school and
with peers).
• They include;
• oppositional defiant disorder
• Conduct disorder
• Other corresponding disorders include ADHD
Definition
• Disruptive problems represent the most frequent type of problem behavior in
early childhood, particularly after the 2nd year when parental expectations
for children to comply with rules and contain aggressive behavior increase.

• Tremblay (1998) reported that by 17 months, 70% of children take toys away
from other children, 46% push others to obtain what they want and 21–27%
engage in one or more of the following with peers: biting, kicking, fighting or
physically attacking.

• Aggression occurs more frequently for infants with siblings, especially for girls,
providing daily opportunities for conflicts over possessions.
Opposition Defiance Disorder
• A pattern of angry/irritable mood, argumentative/defiant behavior, or
vindictiveness lasting at least 6months
• Angry/Irritable Mood
• Argumentative/Defiant Behavior
• Vindictiveness
• The symptoms maybe confined to one setting particularly home.
• Associated features include ADHD and conduct disorders.
• Prevalence ranges from 1%-11% and slightly more prevalent in boys
than girls.
Development and course
• Oppositional defiant disorder often precedes the development of
conduct disorder, especially for those with the childhood-onset type.
• Oppositional defiant disorder conveys risk for the development of
anxiety disorders and major depressive disorder even in the absence
of conduct disorder.
• Defiant, argumentative, and vindictive symp­toms carry most of the
risk for conduct disorder and angry-irritable mood symp­toms carry
most of the risk for emotional disorders.
 Attention Deficit/Hyperactivity
Disorder(ADHD)
• Core features include inattention, impulsivity and
hyperactivity(Barkley, 1998). In terms of etiology, models tend to
focus is on different biological factors, including activity, impulse and
attention control (see chapter 34; Barkley, 1997; Rothbart, Ellis,
Rueda, & Posner, 2003).
• As with older children, most preschoolers with ADHD show other
difficulties, most typically conduct problems (Barkley, 1997; Shaw,
LaCourse, & Nagin, 2005). This co-occurrence carries risk for more
severe and chronic adjustment problems in adolescence and
adulthood (Moffitt, 1990; Weiss & Hechtman, 1993).
Attention Deficit/Hyperactivity
Disorder(ADHD)
• Preschool children may exhibit inattention through short play
sequences of < 3 minutes, leave activities incomplete and not listening;
over activity by whirlwind and impulsivity by not listening, no sense of
danger.
• Risk and prognostic factors include temperament, environmental (low
birth weight, infections, and alcohol exposure in utero, child
abuse/neglect and neurotoxin exposure e.g., Lead.
• Genetic (stronger component) and physiological
• Family interactions
• However etiology is considered to be multifactorial
Emotional Problems
• Emotional problems such as anxiety, depression and posttraumatic
stress in preschoolers have been much less studied than disruptive
problems.
• Reasons include: the inability of young children easily to communicate
about their emotions, or for adults to notice them as problematic.
• There are difficulties in distinguishing developmentally normal
emotions (e.g., fears, crying) from more severe and prolonged anxiety
or misery that might constitute a disorder is difficult in early years,
due to rapid changes in development of emotions, and in their ability
to communicate these to others.
Emotional problems
• Prevalence
• Estimated prevalence tended to be low for each category: separation
anxiety (0.3–5%), social phobia (2–4%), specific phobia (0–2%) and
depression (0–2%; Egger & Angold, 2006; Lavigne, Gibbons,
Christoffel et al., 1996).
• The causes are multi-faceted. These reflect the interplay between
child and parent genetic factors, parenting and the wider social
environment around the child.
• Studies have suggested quite high heritability for some preschool
emotional problems.
Emotional problems
• Maternal transmission of anxiety also seems to be an important
factor, but also through processes such as modeling and an anxious
style of parenting’
• Individual differences in children’s temperament
Eating and Feeding Problems
• In the preschool years, food refusal or excess fussiness may be linked
to other toddler oppositional behaviors, and intervention may need to
consider parental management of child behavior more broadly.

• Feeding problems are common, but are more prevalent in children

with developmental disabilities, pointing to the combination of
physical health, family factors and developmental delay that are often
involved in feeding problems.
Food Refusal

• A term for a range of feeding problems, broader than DSM “Feeding

disorder of infancy and early childhood,” as it focuses on child
behavior rather than requiring growth failure.
• It includes children of normal weight who consistently or selectively
refuse to eat. Selective refusal may be unpredictable, or may be
specific to certain foods or situations (Chatoor & Ganniban, 2004;
Douglas, 2002).
• In toddlers, it may be linked to other behavioral problems, or may be
limited to feeding contexts. It may be related to long-standing early
feeding problems or arise anew in the “terrible twos.”
Feeding problems
• The causes are likely to be multifactorial, including combinations of
temperament, family stress and poor parenting skills, as for other
oppositional problems.
Anxiety disorders
• Children with anxiety disorders may present with fear or worry but
may not recognize their fears as unreasonable

• Younger children often cannot articulate their feelings, and so we

often see physical symptoms presenting first, which include:
• Headaches, upset stomach or nausea, increased heart rate, diarrhea or
constipation, sleep disturbance, increased vulnerability to common viruses,
tightness in chest, tight neck or back, appetite change, fatigue & exhaustion
Physical Symptoms (Provoked and
Non-Provoked)
• Anxious children listen to their bodies (too much!)
• Headache & stomachache
• Sick in the morning
• Frequent urge to urinate or defecate
• Shortness of breath
• Chest pain, tachycardia
• Sensitive gag reflex/fear of choking or vomiting
• Difficulty swallowing solid foods
• Dizziness
• Tension/exhaustion
• Avoidance to present physical symptoms
 DSM: Separation Anxiety Disorder
• Developmentally inappropriate and excessive anxiety
concerning separation from home or from those to whom
the individual is attached, as evidenced by 3 or more:
• Excessive distress upon separation from home or attachment figures
occurs or is anticipated
• Excessive worry about losing or harm befalling attachment figures
• Excessive worry that an event will lead to separation from an attachment
figure (e.g., kidnapping)
• Reluctance to attend school b/c of fear of separation
• Reluctance to be alone or without attachment figures at home or other
locations
• Reluctance to sleep alone or away from home
• Repeated nightmares involving separation
• Repeated complaints of physical symptoms when separation occurs or is
anticipated
• Duration at least 4 weeks
DSM: Post-Traumatic Stress Disorder
1) Exposed to a traumatic event in which:
• The person experienced, witnessed, or was confronted with an event or
events that involved actual or threatened death or serious injury, or a
threat to the physical integrity of self or others
• The person’s response involved intense fear, helplessness, or horror. In
children, this may be expressed instead by disorganized or agitated
behavior.
2) The traumatic event is persistently reexperienced in one (or more) of the
following ways:
• Recurrent and intrusive distressing recollections of the event, including
images, thoughts, or perceptions. In young children, repetitive play may
occur in which themes or aspects of the trauma are expressed.
• Recurrent distressing dreams. In children, there may be frightening
dreams without recognizable content
• Acting or feeling as if the traumatic event were recurring (includes a sense
of reliving the experience, illusions, hallucinations, and dissociative
flashback episodes). In young children, trauma-specific reenactment may
occur
• Intense psychological distress at exposure to internal or external cues that
symbolize or resemble an aspect of the traumatic event
DSM: Post-Traumatic Stress D/O (2)
3) Physiological reactivity on exposure to internal or external cues
4) Persistent avoidance of stimuli associated with the trauma and numbing of
general responsiveness (not present before the trauma), as indicated by three (or
more) of the following:
• efforts to avoid thoughts, feelings, or conversations associated with the trauma
• efforts to avoid activities, places, or people that arouse recollections of the
trauma
• inability to recall an important aspect of the trauma
• markedly diminished interest or participation in significant activities
• feeling of detachment or estrangement from others
• restricted range of affect (e.g., unable to have loving feelings)
• sense of a foreshortened future (e.g., does not expect to have a career, marriage,
children, a normal life span)
Persistent symptoms or increased arousal (not present before the trauma), as
indicated by two (or more) of the following:
• difficulty falling or staying asleep
• irritability or outbursts of anger
• difficulty concentrating
• hypervigilance
• exaggerated startle response
Duration of the disturbance is more than 1 month.
DSM: Selective Mutism
• Consistent failure to speak in specific social situations (in which there
is an expectation for speaking, e.g., at school) despite speaking in
other situations

• Duration of at least one month with significant disturbance

 Selective Mutism
• Associated features often include shyness, fear of
social embarrassment, social isolation, and
withdrawal, clinging, negativism, temper tantrums,
and oppositional behavior (esp at home)
• Teasing by peers is common
• Although affected children usually have normal
communication skills, SM is occasionally associated
with a communication disorder.
• Onset is usually before age 5
General management of preschool problems
• Structure the environment- provide a secure and structured
environment so that the child can interact with other children
• Psychotherapy- teach parents problem solving skills, anger
management,
• Organized activities- to encourage social acceptance
• Parenting skills- to promote positive relationships with children,
discipline and manage behavioural problems
• Questions?

• Thank you