Common emotional and behavioural problems

These problems are seen so often that many would regard them as normal, although in a small minority the behaviour is so disruptive that it causes major family upset. GPs and paediatricians should be comfortable giving basic guidance on behaviour management to help parents through what can be a stressful, exasperating and exhausting phase of their child’s development.

Crying babies and colic

Crying is usually periodic and related to discomfort, stress or temperament. However, it may indicate a serious problem, particularly if the onset is sudden. In most instances it is just a case of ensuring that the baby is well fed, warm but not too hot, has a clean nappy, comfortable clothes and a calm and peaceful environment. A persistently crying baby can be very stressful for inexperienced parents. It is important that they recognize when they are no longer coping and are offered support.

Infantile colic is a term used to describe periodic crying affecting infants in the first 3 months of life. The crying is paroxysmal, and may be associated with hunger, swallowed air or discomfort from overfeeding. It often occurs in the evenings. Crying can last for several hours, with a flushed face, distended and tense abdomen and drawn-up legs. In between attacks the child is happy and well.

It is important to consider more serious pathology such as intussusception or infection. Colic is managed by giving advice on feeding, winding after feeds and carrying the baby. It is not a reason to stop breastfeeding, but discontinuing cow’s milk in the mother’s diet can be helpful. Various remedies are available but there is little evidence for their effectiveness. Infantile colic usually resolves spontaneously by 3 months.

Feeding problems

Once weaned, infants need to gradually move from being fed with a spoon to finger feeding and feeding themselves. This is a messy time, but the infant needs to be allowed to explore his/her food and not be made to eat or reprimanded for making a mess.

Toddler eating habits can be unpredictable – eating large amounts at one meal and sometimes hardly anything at the next. At this age, mealtimes can easily become a battle and it is important that they are kept relaxed and the child is not pressurized into eating. Small helpings that the child can finish work best, and second helpings can be given if wanted. Eating together as a family encourages the child to eat in a social context. Feeding at mealtimes should not become a long protracted battle!

Sleeping problems

Babies and children differ in the amount of sleep they need and parents vary in how they tolerate their child waking at night. In most cases sleeping ‘difficulties’ are really just habits that have developed through lack of clear bedtime routine. Difficulty sleeping may also reflect conflict in the family or anxieties, for example about starting school or fear of dying. Successfully tackling sleeping problems requires determination, support and reassurance.

• Refusal to settle at night. Difficulty settling may develop if babies are only put to bed once they are asleep. A clear bedtime routine is important for older children; for example, a bath, a story and a drink.
  
• Waking during the night. This often causes a lot of stress as the parents become exhausted. It is important to reassure the child, then put them back to bed quietly. Sometimes a technique of ‘controlled crying’ can be helpful – the child is left to cry for a few minutes, then reassured and left again, this time for longer. Taking the child into the parents’ bed is understandable, but usually stores up problems for later when it is difficult to break the habit.
  
• Nightmares. The child wakes as the result of a bad dream, quickly becomes lucid and can usually remember the content. The child should be reassured and returned to sleep. If particularly severe or persistent, nightmares may reflect stresses and may need psychological help.
  
• Night terrors. Night terrors occur in the preschool years. The child wakes up confused, disorientated and frightened and may not recognize their parent. He/she takes several minutes to become orientated and the dream content cannot be recalled. These episodes should not be confused with epilepsy. They are short-lived and just require reassurance, especially for the parents.

Temper tantrums

Tantrums are very common in the third year of life (the ‘terrible twos’) and are part of the child learning the boundaries of acceptable behaviour and parental control. They can be extremely challenging, especially when they occur in public.

The key to dealing with toddler tantrums is to try to avoid getting into the situation in the first place. This does not mean giving in to the child’s every demand, but ensuring the child does not get overtired or hungry, and setting clear boundaries in a calm consistent way. It is generally best to ignore the tantrum until the child calms down. If this fails then ‘time out’ can be a useful technique.

The child is taken to a safe quiet environment, such as a bedroom, and left for a few minutes (1 minute for each year of age is a good guide) until calm. This is usually very effective as it removes the attention the child desires, and allows the parents time to control their own anger.

Unwanted or aggressive behaviour

Young children often have aggressive outbursts which may involve biting, hitting or scratching other children. These require consistent firm management, with use of time out and star charts for good behaviour. It is important not to respond with more aggression, as this sends conflicting messages. If aggressive behaviour is persistent, it is important to explore other tensions or disturbances within the family. In older children, the school may need to be involved.

Unwanted behaviours such as thumb-sucking, hair-pulling, nail-biting and masturbation are also common in young children. Most can be ignored and resolve with time. Masturbation can usually be prevented by distracting the child or dressing them in clothes that make it more difficult. Older children should not be reprimanded but informed that it is not acceptable in public.

Chapter reproduced from Miall l, Rudolf M & Smith D (2012) Paediatrics at a Glance, 3rd edition. Copyright John Wiley & Sons, Ltd.