Common Childrearing Concerns
TEMPER TANTRUMS
Geraldine R. Stephens
Joyce A. Pulcini
Temper tantrums are part of the development process of learning to cope with frustration and gain self-control. Temper tantrums occur at one time or another in 70%-75% of children ages 18 months to 5 years.
Five sequential stages in the development of self-control are identified:
Passive acceptance: bewilderment and noncompliance
Physical aggression: biting, hitting, throwing objects, running, stamping feet
Verbal aggression: screaming, using “no,” name calling, making demands, using expletives
Socially acceptable behavior: bargaining, accepting alternative means or goals
Cooperation: compromising own wishes and maintaining self-control
These stages may overlap, but they resolve quickly in normally developing children.
Manifestations of frustration
Infant
Uncontrolled crying can be caused by baby’s inability to stop once he or she has started.
Requires quiet soothing and rocking to let baby know there is comfort
If such crying spells occur frequently, physical and environmental factors need investigation.
Toddler
Still completely ego-centered: Own needs and wishes come first
Does not tolerate fatigue, hunger, pain, overstimulation well
Schedule, physical condition, nutrition, and family patterns of behavior should be investigated.
Best to head off temper tantrums by carefully noting precipitating events and trying to avoid them
Having to make choices can be frustrating to a toddler. A definite schedule and decisive tone of voice (“Now it is time to eat.” “Now it is time for bed.”) can help toddler accept the rules and standards of the world.
Preschool child
Verbal aggression best ignored
Adults are excellent role models. Parents should express frustration in positive ways.
A 4-year-old realizes he or she can get attention by using forbidden words.
If the child is getting enough attention and having success in daily routine, this language will soon pass.
Playing word games with child and listening to his or her stories seem to be the best ways to handle this problem.
Preschoolers are learning socially acceptable ways of handling frustration.
Language skills should now be sufficient for child to state wishes and needs.
Child is learning to bargain.
A 4-year-old is usually still working on these skills and may still occasionally lose control and have a temper tantrum. An adult should help him or her develop positive ways of handling frustration.
By age 5, the child has become an expert in bargaining. Girls learn this skill earlier than boys; boys need more supervision and male role models to help them control their behavior through words rather than aggression.
Learning self-control enhances self-esteem; punishment control only lessens child’s feeling of being able to control self.
School-age child
If uncontrolled outbursts of frustration persist at this age, referral to appropriate professionals is imperative.
School, family, and environmental pressures must be evaluated before new skills in behavior control can be established.
Frequent outbursts at this age may be suggestive of behavioral problems, depression, or secondary to undiagnosed learning disabilities.
Child’s ability to control own behavior is seen in his or her success with peers and teachers, in school and at home.
School-age child has come a long way since toddlerhood; with caregivers providing good examples and guidance, child has learned to stand up for what he or she thinks is right and yet is willing to cooperate and bargain when appropriate.
Caregivers’ responsibilities
Appreciate that they are role models with respect to behavior patterns for coping with anger and frustration.
Demonstrate processes of bargaining, accommodation, compromise, and cooperation.
Review the successes or problems the child is encountering with each developmental task.
Understand the child’s individual temperament and let a fiery-tempered child know that he or she must work harder than others to build behavior control.
Respect the child’s need to protect own self-esteem and growing need for independence.
Identify precipitating events that lead to loss of self-control, and head them off.
Create a family environment in which all members are expected to respect and help one another.
Help the child develop positive ways of expressing anger and frustration to experience the satisfaction of learning to control behavior.
Set up time-out periods or a thinking bench to be used when child’s behavior is unreasonable.
Watch for and praise successful attempts at self-control.
Help child develop a vocabulary to express feelings, and talk about one’s own feelings so that the child will learn how adults handle their frustrations.
Help child learn songs and poems to use to relieve anger and frustration.
Provide child with plenty of opportunity for physical exercise.
Make available a caring adult with whom the child can share concerns.
Understand that parents’ own emotional states may be reflected in child’s behavior.
Tips for handling temper tantrums
Infant: Hold closely, rock, play music, sing.
Toddler
Pick up, hold under caregiver’s arm (child may be frightened by loss of control), keep calm, sing.
Do not reason or explain.
Preschooler
Do not allow child to hurt self or others; hold under caregiver’s arm if necessary.
Walk out of room if possible.
Do not try to reason or explain.
Do not take the episode too seriously. Respond with a casual statement, such as, “Oops, see if you can’t hold on to your temper” or “Now that you are 4, you don’t need to do that anymore; tell me why you are angry.”
Praise child for getting behavior under control.
Do not use threats or punishments.
In public
Remove child from scene; walk with child outside until he or she calms down.
Take child home if possible.
Help child practice how to act in public and set limits he or she knows about before going out.
Carefully study child’s world to make sure such episodes are not his or her only way of getting attention.
Refer to limit-setting protocol.
Risk factors
Children who are too quiet, too good, and too shy: Their behavior may be controlled by low self-esteem or fear of punishment.
Sudden burst of destructive acts toward self or others may occur, as child has not learned a positive way to cope with frustrations.
Early identification and family interaction need further investigation or referral for these destructive behaviors.
High-risk tantrum styles in children ages 3-6 years have been identified by Belden, Renick Thomson, & Luby (2008) as:
Tantrums marked by self-injury (most often associated with depression)
Tantrums marked by violence to others or objects
Tantrums in which children cannot calm themselves without help
Tantrums lasting more than 25 minutes
Tantrums occurring more than 5 times per day or between 10 and 20 times per month.
These children should be considered for referral or further evaluation, considering that these styles are more likely to be associated with behavioral or emotional problems.
Reference
Belden, A., Renick Thomson, N., & Luby, J. L. (2008). Temper tantrums in healthy vs. depressed and disruptive preschoolers: Defining tantrum behaviors associated with clinical problems. Journal of Pediatrics, 152(1), A2.
TOILET TRAINING
Geraldine R. Stephens
Toilet training is a developmental task of toddlerhood. Success will help the toddler continue to develop awareness of his or her own ability for self-control and self-esteem. There appears to be a critical period at about 18 to 24 months of age when the child becomes aware of body functions; attempts at training too early or too late may influence long-range behavior.
Indications of readiness
Maturation of muscles and nerves to allow voluntary sphincter control
Myelination occurs in a cephalocaudal direction, so the ability to walk well indicates that myelination has occurred in the trunk of the body and that sphincter control is possible.
Body awareness: Toddler shows discomfort in soiled diapers, can anticipate the need to go, and is developing some coordination.
Toddler can follow simple directions and use language to make wishes known.
Toddler can anticipate and postpone events in daily schedule.
Toddler is not under any new stresses.
Toddler has loving caregivers to look to for approval and attention.
Technique
Pre-training when the above indicators are present
Have child observe others using bathroom.
Talk about it as an expected accomplishment; comment with appropriate word when child is observed having bowel movement (BM) so that he or she becomes aware that this will get attention.
Have potty chair or insert ring for toilet seat available.
Use training pants occasionally.
Toddler shows awareness of plan by bringing to caregiver’s attention that he or she is having a BM. This is the beginning of gaining the child’s cooperation and may take more time and effort than expected.
This is only one of the many tasks the toddler is attempting to master at this age, so frequent lapses may occur.
Bowel control
First make sure toddler is becoming aware of the connection between the potty chair and the BM.
If child’s bowel movements are regular, use the potty chair at those times.
If no regularity is apparent, watch for signal from child and then take him or her to the bathroom. This is where patience and perseverance by the caregivers are rewarded.
Leave child on potty chair for only a short time; long sitting sessions may lead him or her to rebel. Child may be afraid of the toilet seat.
Do not distract child with books or toys; he or she is there for one reason.
Treat success as a normal expectation. Over-enthusiasm may cause child to use toileting as a way to get attention; positive feedback should be reserved for other daily activities.
If training is unsuccessful, reevaluate maturation indicators and repeat pre-training techniques. It seems to take more time and effort to train boys than girls, particularly if they are larger than average.
Daytime bladder control
Follows BM control, because voiding signal is less intense
Watch for increasingly long periods of dryness; this signifies an increase in bladder size.
Put child on potty chair before and after meals, naps, and playtime; treat as usual part of daily schedule.
Dress child in clothing that is easy to remove.
Boys may prefer to sit backward on toilet seat.
Treat success casually.
Nighttime bladder control
Follows daytime control; may not be accomplished until after age 3 years
Bladder must have capacity of 8 oz before child is able to be dry all night.
Getting child up at night may be helpful in the short-term but is not a good long-term solution to nighttime voiding.
Put child on toilet or potty chair as soon as awake, whether dry or not, to develop routine.
Outside pressure makes child feel inadequate and discouraged with ability to please those important to him or her.
In a happy, healthy child, bladder control is a natural process that takes time.
Limit use of pull-ups which might actually lengthen the time to toilet training.
Success
Depends on toddler’s physical maturation
Depends on parents’ positive attitudes and patience in following through and helping child
Problems: See enuresis in Part II, p. 284.
Reference
Toilet training links (podcast). (2007, July). Contemporary Pediatrics, 24(7), 67.
LIMIT SETTING
Elizabeth S. Dunn
Discipline can best be defined as training that helps a child develop self-concept and character. Parents are often hesitant to set firm and consistent limits on their children because they are afraid of damaging their psyche or fear that their children won’t love them or feel loved by them if they are stern. On the contrary: Being allowed to act in a way the child knows should not be tolerated because it causes him or her to feel anxiety and insecurity. Children feel their parents do not love them if parents fail to make an effort to help them develop inner controls.
The ultimate goal for any child is parental approval; children will do their best to live up to parental expectations. For example, if a mother conveys the impression that she does not expect her toddler to go to bed without a struggle, a struggle will surely ensue. If parents expect their son only to get by in school, he probably will; if the same parents were to expect A’s, the child would probably strive to achieve them. Parental disapproval helps children develop a conscience; they know that, after committing a naughty deed, they have not measured up.
Health care providers involved in routine physical concerns must not neglect the issue of discipline, especially as the child develops initiative and autonomy. The following points can be discussed with parents, and it is generally helpful to raise the issue before the need arises and to reinforce significant areas when the parents have a specific concern.
Principles of limit setting
United front
Parents must be in accord.
Parents must agree on what limits will be imposed.
Parents must agree on penalties for infractions.
Consistency
Rules must be consistently enforced.
Expectations must be consistent.
Child should not be allowed to perform unacceptable behaviors at some times and be punished for similar behaviors at other times.
Limits clearly delineated
Parental expectations must be defined.
Rules and regulations must be clear.
Behavioral expectations in relation to child’s developmental and intellectual level
A 12-month-old cannot be relied on not to touch something because mother or father said no.
A 2-year-old does not understand what can happen if he or she goes in the street or gets into a car with a stranger.
A school-age child can be expected to understand that he or she must go home after school before playing with friends.
If expectations are made clear to the child, he or she will strive to achieve them.
Bumping point: Every parent has a point up to which he or she can be pushed. Children quickly learn this point and use it to their own advantage.
Unemotional approach
Children repeat behaviors that they know get a parental response, whether positive or negative.
A toddler learning to walk takes another step when parents laugh and applaud.
The perfect entertainment for a school-age child on a boring rainy day is to tease a sibling and watch Mom hop.
Overreacting under stress and in anger leads to irrational threats and perhaps violence.
Stress that the deed is bad, not the child.
Attack the deed, not the child; this preserves the child’s respect for self and parent.
Breaking windows (throwing stones, and so forth) is not an acceptable thing to do.
Children need to know, however, that they are responsible for their actions.
Immediacy of action
For most effective learning, especially with a toddler or preschool child, the consequences of inappropriate behavior should not be delayed.
With older children and adolescents, a conference with parents may be more appropriate; in this case, the consequence is delayed.
Do not say, “Wait until your father gets home!” This threat can cause an enormous amount of anxiety for a child and makes it appear not only that Dad is the bad guy, but also that Mom does not care enough to set limits. Alternatively, for a child whose parent comes home from work and then usually spends their time in front of the TV, a secondary gain may be involved in the form of attention (albeit negative attention).
Punishment
Punishment must fit the crime.
There should be a logical connection between the two; banning after-school play for 2 weeks for an infraction unrelated to such activity is usually not only inappropriate, but also unhealthy.
Punishment should not exceed the child’s tolerance.
Punishment should not negate educational aims.
Coming in half an hour after curfew does not warrant restricting an adolescent for 1 or 2 months; instead, make the curfew half an hour earlier next time and give the child one of the parent’s tasks the next day because Dad is so tired from waiting and worrying.
As the child gets older, parental disapproval is often the only punishment needed; guilt at letting parents down is often punishment enough.
Punishment should educate.
Punishment is done for and with children, not to them.
Spanking
Produces an external rather than an internal motive for controlling the impulse and therefore does not help develop child’s conscience
Cancels the crime
Relieves sense of guilt too readily
Parental anger often escalates with spanking, resulting in injury
Isolation
Appropriate length of time (one minute per year of age) is preferable to isolating for a specified length of time once child is old enough to understand what behaviors are expected.
Sit on chair: Tell child timer is set for 3 minutes; do not say, “Sit there until I tell you that you can get up.”
Restrictions on privileges
Key points to remember
Treat children with respect.
This teaches them to respect in turn.
Allow them to share in decision-making process.
Children model behaviors they see in parents; be the kind of person you expect your child to be.
Earliest approach to limit setting is based on baby’s ability to learn.
Threats are useless.
Any self-respecting child will try to see whether parents will follow through; threats are an invitation for unwanted behaviors.
Threats are often made in a moment of anger and may be unreasonable.
An ounce of prevention is worth a pound of cure and is certainly easier on parents.
Clearly define limits.
Remove temptation.
Do not pick on insignificant things.
Do not threaten with punishment that you cannot or are unwilling to carry out.
Distract child if it looks as though he or she is getting in trouble.
When child is losing control, pick up and remove him or her.
If you know the child has misbehaved, do not ask whether he or she has done the misdeed. Confront child with it and thereby avoid tempting him or her to lie.
References
Faber, A. (2004). How to talk so kids will listen and listen so kids will talk. New York: Harper-Collins.
Sears, W. (1995). The discipline book. Boston: Little Brown.
Turecki, S. (1995). Normal children have problems too. New York: Bantam Books.
Turecki, S. (2000). The difficult child. New York: Bantam Books.
SIBLING RIVALRY
Rose W. Boynton
Sibling rivalry occurs when children feel displaced, frustrated, angry, and unloved. It is normal for an older child to feel jealous at the arrival of a new baby. Competition and feelings of envy can also occur among older siblings; fighting between brothers and sisters is common. However, if such behavior is allowed to continue, it can persist into adolescence and even adulthood.
Often the arrival of a second child occurs when the first child is at the developmentally stressed age of 2 years. All children show signs of regression after the birth of a sibling, and it is best to allow this regression to occur without interference. If the parents continue to reinforce positive behavior, the older child will gradually begin to feel as important and loved as the younger sibling, and the relationship between the two will become stronger and more supportive.
Parents are responsible for establishing a positive, supportive environment in which competition among siblings is reduced and replaced by a caring, concerned, and affectionate relationship. This takes place over a long period of time. Parents must be fair and consistent in teaching children both by example and by good management of negative behavior.
One successful method used to change negative behavior is time out. This is a proven method in which the fighting children are separated and sent to separate rooms. All the combatants are treated equally, with no favoritism. Parents must praise and encourage positive play, rewarding good behavior and discouraging name calling, baiting, and arguments.
Feelings of jealousy naturally occur at the birth of siblings. If this event does not interfere with the time spent with the older child or affect the love and affection shown, these feelings eventually dissipate.
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