I. Description of the problem. A “difficult child” is a normal young child whose innate temperament makes them hard to raise. Inherent in this definition is a view of normality that is broad: children are different and do not have to be average in order to be normal. For a child to be considered temperamentally difficult, a basic criterion has to be met: the child’s constitutionally determined personality traits—their very nature—must cause significant problems in child rearing.
A. Epidemiology.
About 15% of young children are temperamentally difficult according to this definition.
Difficult children are not all alike. Some are impulsive, distractible, and highly active; others are shy and clingy. Some throw loud tantrums; others whine and complain. Some can hit, kick, or even bite; others are verbally defiant. Some are unpredictable in their eating or sleeping habits; others are sensitive to noise, textures, or tastes. Most difficult children have trouble dealing with transition and change, and almost all are strong-willed and extremely stubborn.
Highly active, impulsive, difficult children are more likely to be boys. All other temperamentally difficult traits are as likely to be seen in girls as in boys.
There is no correlation with birth order, intelligence, or socioeconomic status.
B. Etiology.
Temperament refers to dimensions of personality that are largely constitutional in origin. Genetic factors definitely contribute. Pregnancy and delivery complications may be somewhat more common in the histories of difficult children. Some of these children are allergic, with a propensity to develop ear infections. Uneven language and development of learning skills are not uncommon. Many difficult children are intelligent but socially immature. All of these factors suggest a biologic basis for a difficult temperament.
C. The concept of temperament. Temperament is the how of behavior, rather than the why (motivation) or the what (ability). For example, three equally motivated and able children may approach a homework assignment quite differently, depending on their behavioral style. One will begin on time and work steadily to completion, the second will delay and procrastinate but then work very persistently, and the third will jump in immediately and quickly lose patience. Inherent in the temperamental perspective is a broad view of normality and a bias toward seeing atypical behavior as different rather than abnormal.
Temperament may also be defined as the behavioral expression, evident early in life, of those dimensions of personality that are constitutional in origin. Family, twin and adoption studies point to a 50% multigenetic heritability. The stability of temperament is detectable at 18 months, substantial at 3 years, and most evident in middle childhood. As development proceeds, temperamental qualities are neither rigidly fixed nor completely malleable—like cartilage rather than bone or muscle. A range exists for each category. Table 81-1 lists the categories of temperament.
1. The child and the environment: A transactional model. The concept of a difficult temperament should always be combined with that of goodness of fit—the match or compatibility between a child and their environment. Behavior that presents a problem to one family may be readily accepted by another. For example, a child’s idiosyncratic and strongly held tastes in clothing and food would only trouble a fashionand nutrition-conscious parent. The context of the behavior is always important. A highly active boy who has some problems with self-control and concentration, if placed in a class of 25 children (of whom another 5 are “challenging”) with one somewhat inexperienced teacher, would undoubtedly meet all the criteria for attention deficit hyperactivity disorder (ADHD). However, if the following year he is in a class of 15 children with a high ratio of girls to boys and the teacher has an assistant, the child would still be a handful but a clinical diagnosis of disorder would be inappropriate.
2. Difficult children are, above all, hard to understand. Their behavior confuses and upsets the most experienced parent or teacher. The tried-and-true methods of child rearing simply do not work, so that effective discipline is replaced by inconsistency, power struggles, excessive punishment, or overindulgence. Parents will say that “nothing works” or that the child controls the family. A vicious cycle develops wherein the child’s trying behavior and the erratic overreactions of the parent augment each other.
Table 81-1. Categories of temperament
Trait
Description
Easy
Difficult
Activity level
General statement about level of motor activity; actual amount of physical motion during play, eating, sleep etc.
Low to moderate
Very active, restless, fidgety; always into things; makes you tired; “ran before they walked”; easily overstimulated; gets wild or “revved up”; impulsive, loses control, can be aggressive, hates to be confined
Self-control
Ability to delay action or demands
Good, patient
Poor, impulsive
Concentration
Ability to maintain focus in the face of distractions
Good, stays with task
Poor, distractible, has trouble concentrating and paying attention especially if not really interested; doesn’t listen, tunes you out; daydreams, forgets instructions
Intensity
Energy level of responses; how forcefully or loudly reactions are expressed, whether positive or negative
Low, mild, low-keyed
High, loud, forceful whether miserable, angry, or happy
Regularity
Predictability of physical functions such as appetite, sleep-wake cycle, and elimination
Regular, predictable
Irregular, erratic, can’t tell when they’ll be hungry or tired; has conflicts over meals and bedtime; wakes up at night; moods are changeable; has good or bad days for no obvious reason
Persistence
Single-mindedness, “stick-to-itiveness”; may be positive (focused when involved) or negative (stubborn and doesn’t give up
Low, easily diverted
High, stubborn, won’t give up, goes on and on nagging, whining, or negotiating if wants something; gets “locked in”; has long tantrums
Sensory threshold
Sensitivity to physical stimuli—sound, light, smell, taste, touch, pain, temperature
High, unbothered
Low, physically sensitive, “sensitive”—physically not emotionally; highly aware of color, light, appearance, texture, sound, smell, taste or temperature; “creative” but with strong and unusual preferences that can be embarrassing; clothes have to feel and look right; picky eater; refuses to dress warmly when weather is cold
Initial response
Characteristic initial reaction to new persons or new situations
Approach, goes forward
Withdrawal, holds back, doesn’t like new situations; may tantrum if forced to go forward
Adaptability
Tolerance of change; ease with which gets used to new or altered situations
Good, flexible
Poor, rigid, has trouble with change of activity or routine; inflexible, very particular, notices minor changes; can want the same food or clothes over and over
Predominant mood
General quality of mood; basic disposition
Positive, cheerful
Negative, serious, or cranky; doesn’t show pleasure openly; not a “sunny” disposition
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Temperamentally Difficult Children
Temperamentally Difficult Children
Stanley Turecki
