How do you know if your child’s behavior is “normal”? What should
parents do about temper tantrums? Can toddlers develop mood disorders?
Pediatrician Dr. Steven Parker answers reader questions.
The opinions expressed herein
are the guest’s alone and have not been reviewed by a WebMD physician. If
you have questions about your health, you should consult your personal
physician. This event is meant for informational purposes only.
Moderator: Dr. Steven Parker, WebMD’s own in-house pediatric
expert joins us now to answer your questions about evaluating and
understanding your child’s emotional and developmental health. Dr. Parker,
we titled today’s chat “Spirited or Struggling,” because we parents often
wonder if our kids’ behavior is “normal.” From a medical standpoint, can you
give us some signs that spirited has crossed over into something that needs
a doctor’s help?
Parker: That’s a really good question and difficult to answer.
However, you as the parent are in the best position to make this
distinction. Here is the most important question to ask: How much are these
behaviors getting in the way of your child’s success in his or her various
worlds? By that I mean:
Are these “spirited” behaviors making his or her relationship with you
difficult and unpleasant most of the time?
Are these behaviors interfering with his or her ability with making and
keeping friends?
Is school complaining that something needs to be done and that they just
cannot handle him or her?
I think the key point is that when any behavior makes your child’s
life extremely difficult in any of his or her important relationships and in
school, it’s a problem. However, most children with a difficult temperament
are able to rein it in enough that their relationships, while sometimes
shaky, are generally strong and nurturing. Having said that, sometimes it’s
just not clear whether or not there might be a significant problem or just
normal temperamental variations. That’s the time when a trusted professional
(perhaps your pediatric provider) can counsel you on the next step.
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Moderator: Here’s a specific example from a member who is
dealing with this situation: My son is 3 1/2 years old and has temper
tantrums that are uncontrollable (calls me names, throws things, hits,
bites, spits). What should I do?
Parker: As always, the first step is to try to figure out what
might be going on. Certainly by 3 1/2, I would expect the tantrums to be
much better than when he was a toddler. So let’s think about why he’s still
having such a hard time controlling intense emotions and expressing his
frustration.
Could he have a problem with communication? Some children who are a
little behind in their expressive skills cannot verbally negotiate what they
want or talk about how they feel. They get very frustrated because of their
insufficient language abilities, and this can be the reason for significant
tantrums.
Or perhaps, for some reason, he is having some significant stresses
in his life. You should look to see if any experiences at home or outside
the home might be causing him significant stress. Certainly, children in
such circumstances often have a hard time when they are frustrated and this
can show up in tantrums.
Or is this part of a very intense temperament? Some children who have
a hard time transitioning from one situation to another and who are very
persistent in not wanting to change and have an intense response pattern can
show significant temper tantrums.
There are many other possible reasons for your little guy’s behaviors
and again, you are in the best position to figure out what that might be.
What to do about it, of course, depends on what you think is fueling the
tantrums. You do want to be sure that you do not cave in to his wishes to
avoid a tantrum, because then he may use them just to manipulate you. You
always want to be sure that there is no “secondary gain” (meaning a reward)
for having tantrums. Assuming that’s not going on, then try to help him to
“use his words” when he’s frustrated. You can talk with him ahead of time
about better ways to express frustration. You can even play out a little act
with him and pretend he’s upset, and ask him to respond using words, rather
than tantrums.
He’s a little young, but there is a book I really like that may also
help you to figure this out. It’s called “The Explosive Child,” by Ross
Greene. Good luck with your little guy! Hopefully, with maturity, time, and
love, these distressing behaviors will diminish. Keep me posted on how he
does.
Member: Dr. Parker, I’ve written to you in the past regarding
my 3-year-old daughter Sydney. She is diagnosed with Sensory Integration
Dysfunction. OCD had been thrown around; however no official diagnosis has
been made. Once she sets her mind to something, not doing that will cause a
meltdown. She has no self-regulating skills. Once she gets started being
upset, there is no turning back. She can’t calm herself. Also, she is
extremely dependant on me. She needs me to do everything with her, carry
her, and get her dressed. She is fully capable, but wants me to help. Her
pediatrician said it’s because she was nonverbal for so long that she needed
me for everything. Now she doesn’t, but hasn’t learned to let go. In what
ways can I help her learn to be more independent without making her feel
that mommy isn’t there for her?
Parker: I think many of my answers to the last question are
applicable here. In this case, you seem to have a pretty good handle on why
Sydney is having a tough time. I would be cautious about making a diagnosis
of OCD in any child this young. It sounds like language was also an issue
for her and certainly, the best way to help a child learn to control their
feelings is to help them use language both to identify their feelings (on
feeling frustrated: “I’m very upset”). And then to express those feelings in
words rather than actions. Again, I’m a believer in rehearsing with children
before they are frustrated how they can use words to control their emotions.
Aside from that, in my experience, adapting the environment to make it less
frustrating to a child with Sydney’s challenges also tends to make things
much better in a reasonably short period of time. Keep me posted on the
message board and we will work on this together as time goes on.
Member: A follow-up: Her pediatrician asked if she is/will be
seeing a psychologist. At what point do we need to see a psychologist or how
is that decision made?
Parker: That’s a really good question and one that doesn’t
have a simple answer. Off the top, I tend to err on the side of having a
professional evaluation when in doubt. A skilled professional can often
clarify what is going on and suggest effective interventions even if the
problem is not all that significant. The key, of course, is to find the
right professional. Some criteria:
You want one with sufficient experience looking at children with the kinds
of problems that yours has.
For whom you feel an instant sense of trust.
Who communicates to you honestly and openly and without a lot of jargon
that’s difficult to understand.
Who understands and is empathic toward the challenges parents face who have
a child with problems.
Hopefully your pediatric provider knows of such professionals in your
community. That’s where I would start asking about where an appropriate
referral should be made.
Moderator: I’ve seen a few stories about teaching babies and
toddlers a kind of basic sign language to help them communicate before they
are verbal. There are whole books on the subject. Parents who have tried it
say their kids can communicate with less crying and frustration. What do you
think of this, and could it help with children who are throwing tantrums or
who are developmentally delayed?
Parker: There are really two questions here. First, is sign
language a good thing to teach normal babies? I think it’s cute and it’s fun
and unlikely to make one bit of difference in anything that’s important for
your baby. It’s true that “baby sign” can teach a baby in the first year of
life to sign for something before they can say it. That’s a neat trick, but
so what? If you want to do it because it’s fun, be my guest. If you think it
will enhance your baby’s development in some significant way, don’t bet on
it.
Your second question concerns the usefulness in teaching sign
language to children who, for some reason, have trouble communicating
through speech. In my clinic for children with developmental disabilities,
learning sign language has been a wonderful skill for some of them. Any
means that allows a child to communicate better (whether through speech,
sign, or even a computerized machine) is absolutely critical to their sense
of being involved in the world and being able to form relationships.
Member: My son started speech therapy one month ago. He’s 2,
with maybe 10 words. All the therapist does is what I do everyday - repeat
words, points at pictures, etc. It doesn’t seem like a big help. Am I
expecting too much or to soon?
Parker: That’s a really good observation. The fact is, the
most important “speech therapy” for a 2-year-old is what happens not in the
one hour of “speech therapy” a week, but what happens in the other 167
hours. By providing your little guy with a language-rich environment, you
are absolutely doing the most important work. By a “language-rich
environment” I mean talking to him a lot, asking him a lot of questions,
responding to anything that comes out of his lips, reading to him, pointing
at things and naming them, and generally having a good time while always
narrating what is going on (“See how I’m washing the dishes?!”).
At this age, the speech therapist should be helpful to you to:
Monitor his progress and help decide if this issue is going to need
long-term help or if it’s getting better.
Help figure out why his expressive language may be slow.
Give you other suggestions on what you can do at home to promote his
language development.
Member: Thank you. I just worry that he isn’t catching on, and
yet I’ve heard new sounds from him lately.
Moderator: Good Luck!
Member: My child’s second grade teacher advised me that she
sees some symptoms of ADHD in him. She said that the school could look into
this. Should I go to my pediatrician first? I am not sure where to start.
Parker: Hmm. ADHD can be a difficult diagnosis to make. In
general, schools are able to contribute important information to a possible
diagnosis, but do not have the ability to actually make the diagnosis. So if
you think it could be a possibility, I would ask his pediatrician how he or
she likes to go about evaluating this. The school can also begin their own
evaluation, so that they can supplement whatever other workups your
pediatrician decides to do.
I would say that to make a diagnosis of ADHD, both the school and the
parents need to see symptoms of inattention, impulsivity, and (sometimes)
hyperactivity. If you have never thought that your child was pretty high in
any of these symptoms, the diagnosis is less likely. Some children don’t pay
attention well in school, not because they have ADHD, but because they have
a learning disability. This could also be something that the school could
begin to look into with your little guy and a possibility for you to discuss
with his pediatric provider. Whenever teachers raise questions, I always
think it’s a good idea to consider what they are saying and have the matter
looked into more closely, as you are doing. Good luck.
Member: His teacher said that if he was medicated, and not
ADHD, it would not change his behavior at all. I don’t believe that. What do
you think?
Parker: Stimulant medications will improve anybody’s attention
span. So whether or not a child responds does not really tell you whether or
not they have ADD. However, in children who have significant attentional
difficulties, the improvement is much more dramatic than in a “normal”
child. By the way, I think it’s completely inappropriate for a teacher to
ever recommend medications for a child. That’s not their job and that’s not
their area of expertise.
Moderator: The diagnosis and treatment of ADD and/or ADHD is
an increasingly controversial subject. On one hand, research shows that it’s
not confined to just young boys. Girls have it too, and it doesn’t always
“go away” as one ages; it can continue into adulthood. On the other hand,
there are many critics of medicating so many kids, and some say ADD is a
sham diagnosis. What’s a parent to believe?
Parker: You are certainly right that this is a confusing
field, partly because of the conflicting opinions everyone reads in the
media. It’s also true that professionals may differ somewhat in their idea
of what ADD is or is not. So what should a parent believe when faced with
such conflicting information? I think that you need to read up on it and
decide what makes sense to you.
Let me give you my take. I think ADD is a very real diagnosis in
children and not a “sham.” I think it’s also true in some cases it’s
overdiagnosed. Unskilled professionals may call any challenging behavior
ADD. That’s in part because the medication works so well that it’s always
tempting to try it and see if things get better. If all you have is a
hammer, everything looks like a nail. It’s also true in my experience that
ADD is often very much under-diagnosed. Some people do not believe that the
child’s behaviors truly constitute a problem and mostly blame it on the
school and/or the parents. Consequently, they never make a diagnosis, and in
my opinion, tragically miss the opportunity to provide significant help to
children with ADD. The key is for the evaluation to be done by a thoughtful
and experienced professional; one who doesn’t rush to judgment one way or
another. That means the evaluation must include a description of the child’s
behavior from all the important people in his or her life. That means
especially parents and teachers.
If a child is showing similar problems with attention and impulsivity
and perhaps hyperactivity, in all the environments in which he spends a lot
of time, and, most important, if those behaviors are making his or her life
extremely difficult and unpleasant in all of those areas, then that’s the
child I would say probably has ADD, and might benefit very much from
appropriate treatment.
While I’m at it, a word about stimulant medication for ADD. These
medications have been studied now for over 30 years, and there’s no question
in my mind that they are almost always extremely safe and have provided
tremendous benefit to many children and families. While certainly they can
be overused, I think the benefit they provide to many children make it a
tragic mistake to avoid their use based on speculation and misinformation,
disseminated by a very vocal anti-medication group. Hope that helps.
Member: Have you seen any growth problems with kids on
stimulant medicines for ADHD?
Parker: This has been well studied. It is true that stimulant
medications can take away the appetite and some kids can get skinny. In the
long run, most studies do not show a difference in the child’s adult height,
although a few studies have suggested that stimulant medication could knock
an inch or so off the child’s ultimate height. In my mind, even if that were
true, if the benefits for the child are so great in the here and now, it
seems a reasonable trade-off.
Member: I have a child with sensory integration disorder who
was not diagnosed for a number of years because his pediatrician thought he
would “outgrow” it. I have heard of many similar stories from parents. While
it is understandable that doctors want to be cautious, how can a parent know
what to do?
Parker: First, don’t be too hard on your pediatrician.
“Sensory Integration Disorder” is a new idea and is not totally accepted by
the mainstream as yet. Furthermore, while I do believe SI disorder is a
helpful and useful diagnosis, there are literally no studies showing that
the therapy given (usually by occupational therapists) works.
I’m not saying that therapy does not work, but until there is more
scientific proof, many pediatricians are going to be slow in making the
diagnosis and recommending treatment. But perhaps the real message is that
as a parent, if you continue to feel that something “just isn’t right” about
your child, trust yourself and insist on a second opinion or other
professional evaluation to help decide what might or might not be going on.
Good luck. Let me know how things go with your little guy.
Member: I suffer from bipolar [disorder] and have a 4-year-old
son who is overly emotional and cries excessively — basically every day.
Lately he has been showing signs of aggression, has trouble sleeping through
the night, and grinds his teeth in his sleep. He goes from being an
incredible sensitive, sweet, loving child to uncooperative in a second. I am
concerned this is not normal. What do you think?
Parker: This is pretty complicated (as of course it always
is), so I can’t really say what might be going on. Certainly, everyone is
reading more and more about children being diagnosed with possible mood
problems at a younger and younger age. Could your 4-year-old be showing some
signs of a biological tendency to moodiness or even bipolar disorder? It’s
possible. But it’s also possible that these are just normal temperamental
variations or that some stressful experiences in his life are contributing
to the moodiness. It can be very difficult to sort out what might be going
on when you have a child who has such mood swings and behavioral
variability. But I wouldn’t want to jump the gun and say that because you
have bipolar disorder, he does, too.
If these problems are a significant worry to you and to others, a
thoughtful evaluation by a child professional may help to clarify what is or
what is not going on. Good luck. Let me know how things go on my WebMD
message board.
Moderator: We are out of time. Thanks to Dr. Steven Parker for
being our guest, and thank you members for joining us today. We tried to
cover a lot of ground today (this is a big subject!) and may not have
touched on your interests in enough detail. If so, please visit Dr. Parker’s
Parenting message board on WebMD to ask him more questions and for support
from other WebMD parents.
Dr. Steven Parker is director of the division of behavioral and
developmental pediatrics at Boston Medical Center and an associate professor
of pediatrics at the Boston University School of Medicine. He is the author
of “Behavioral and Developmental Pediatrics: A Handbook for Primary Care”
and is co-author of the 1998 edition of “Dr. Spock’s Baby and Child Care.”
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