CHILD DEVELOPMENT AND BEHAVIOR PROBLEMS
From the 2007 Scientific Assembly of the American Academy of Family Physicians, October 3-6, 2007, Chicago, IL
Barbara Howard, MD, Assistant Professor of Pediatrics, Johns Hopkins University School of Medicine, Baltimore,
MD
| Introduction: 25% to 50% of presenting problems in pediatric primary care associated with behavior and development;
90% of mothers of children 2 to 4 yr of age have some concern about child’s behavior; 20% of parents of
children 4 yr of age feel “there’s something wrong” with child; prevalence of mental health disorders in school-
aged children and adolescents, 20%; mental health disorders can be diagnosed by age 3 to 4 yr; behavior management
strategies effective in 2 to 3 wk; dependence vs independence—child’s dependence on parent and child’s desire
for independence must be balanced; parent must accept child’s desire for independene
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| Need for regulation of state: state of consciousness (eg, awake or asleep) and degree of arousal (eg, out-of-control
crying or inability to be engaged); younger children have less ability to regulate themselves and need more input
from adults (eg, routines for being fed, regular bedtimes); routines and consistent responsiveness by caregiving
adult stabilize child’s mood and reduce resistance; children can be overstimulated easily by, eg, noise, being allowed
to stay awake too long, exposure to sexual materials; children with central nervous system (CNS) damage,
developmentally immature children, children with subtle brain injury (from, eg, lead poisoning or prenatal substance
exposure), and children living in social chaos or overextended families more likely to have difficulty with
state regulation
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| Normal pattern of crying: starting at 2 wk of age, number of minutes of crying per day increases, then peaks (2.75 hr
of crying per day) at 6 to 8 wk post-term; after 6 to 8 wk, crying declines; at 3 mo of age, crying reaches steady state (1
hr of crying per day) for rest of first year of life; crying peaks between 6:00 PM and 11:00 PM; parents feel helpless, angry,
and guilty (vulnerability to child abuse increased during child’s first 3 mo of life); crying more common in temperamentally
difficult children; resolves as other signs of CNS organization recognized (eg, child can bring hand to mouth
or vocalize in other way besides crying [eg, cooing])
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| Colic: crying ≥3 hr/day for ≥3 times/wk, starting in first 3 mo of life; deviation from normal pattern of crying, with
significant peak; characteristics include burping, distended abdomen, red face, pulled-up legs, gas, and inconsolability;
no relationship between colic and amount of air on plain abdominal radiograph of kidneys, ureter, and bladder
(KUB), type of food, constipation, diarrhea, rashes, sex, birth order, ethnicity, or age of parents; usually resolves by
4 mo of age, but higher end of normal associated with pathology; 10% to 15% of babies cry excessively and meet
criteria for colic; some studies show large proportion of babies with colic have lower threshold for sensitivity and
stimulation (smaller proportion have medical problem); environmental changes can reduce symptoms; when to
worry—onset of crying at wrong age or sudden; ceaseless crying; failure to grow or develop as expected; other
symptoms (eg, diarrhea, vomiting); pain; can cause significant caregiver distress and may be associated with potential
for child abuse; management—physical examination; be empathic; ask about social support; discuss temperament;
reassure parents that excessive crying does not indicate child will be difficult later in life; if babies breast-
feeding sufficiently, consider advising mothers to eliminate cow’s milk, cabbage, and brussel sprouts from their
(mother’s) diet; studies show that when babies carried by parents, overall crying reduced in babies without colic; 5
Ss—swaddling (wrapping baby tightly in blanket); laying baby on side, prone on knee, or on warm water bottle;
sucking (allow baby to suck thumb, pacifier, or parent’s finger); shushing or white noise (eg, radio set between stations);
swinging (vestibular stimulation; be gentle to avoid brain injury); change formula only if formula appears
problematic (eg, diarrhea, vomiting, rash, failure to thrive); medications—placebo nearly 80% effective; chamomile
tea helped 57% of time vs 26% with placebo; dicyclomine (eg, Bentyl) not recommended; simethicone (eg, Mylicon)
ineffective; no scientific data to support improvement of colic when nursing mother drinks beer (alcohol increases
sleep and can cause failure to thrive)
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| Sleeping through night: 50% of full-term babies can go 8 hr without middle-of-night feeding by 1.3 mo of age,
95% by 4 mo of age; trained night feeding—parents respond by feeding baby (>4 mo of age) who awakens during
night (baby begins to expect feeding every night); teach parents other ways of consoling children; during first few
months of life, babies should be breast-fed as often as they want; after 4 mo of age, lengthen daytime feeding interval
and wean night feeding (by, eg, 1 oz per night if bottle-fed or 1 min at breast per night if breast-fed); place infant in
bed while infant awake; if baby cries, wait 1 min before consoling baby (feed baby if still hungry); trained night
waking—may start after stress (eg, ear infection); parents pick up child from bed, providing secondary gain (ie, reinforcement);
more common in temperamentally difficult babies; twice as common when mothers depressed; establish
bedtime routine; limit naps to 2 hr; place child in bed awake; if baby cries during night, parents should wait 5
min before checking on baby, and should not pick up or feed baby; some literature recommends brief sedation (“I
don’t recommend it and you don’t need it”); starting at 2 mo of age, place baby in bed while somewhat awake and in
location out of body contact (at night and for naps; baby learns how to establish sleep associations); developmental
night waking—starts with development of object permanence; sometimes combined with ability to crawl and to recognize
and be afraid of strangers; begin bedtime ritual (include transitional object and leave night light on); when
baby cries, parent should wait ≥2 min before checking on baby; baby should be consoled briefly by saying “it’s
okay, I’m right here”; parent should lie on floor or sit in chair for rest of night (move closer to door each night); after
4 nights, child no longer awakens household at night (soothes self back to sleep); strategy effective in children 8 mo
to 6 yr of age
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| Temper tantrums: occur when children have idea of what they want and are able to do more things for themselves
but cannot perform them perfectly, leading to frustration; worse in children with delay in language skills; determine
whether parent reinforces tantrums by giving in to child’s wants; assess child’s developmental skills; some
children have deficits in expressive language or motor abilities; reduce stresses and frustration (ask about child’s
lifestyle and sleep); maximize choices so parents can avoid giving in; managing tantrums—recommend that
parents “just stand there” and wait for child to recover from tantrum; child can be held, as long as parent does not
give in; parent can talk to child after child calm; when to worry—episodes last >10 min (typical tantrum lasts 90
sec to 4 min); multiple tantrums per day; child or family dysfunctional; basic strategies ineffective after 2 to 3
wk; consider history and/or potential for child abuse and mental health disorder of child or parent
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 | Breath-holding spells: occur in 5% of children <8 yr of age; associated with increased behavior problems; positive
family history in ≈23%; cyanotic—child becomes blue, stops breathing, loses consciousness, becomes limp, and
stiffens; usually precipitated by frustration; pale—spells often start with blow to head (eg, falling and hitting
head on coffee table) and crying; child becomes pale, stops breathing, becomes asystolic, and may have seizure;
80% of spells stop by 5 yr of age, 90% by 6 yr of age; management—help parents understand that spells do not
cause brain damage; prevent spells by teaching parents how to manage tantrums; study found oral iron therapy
reduced spells by 80%
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| Need for positive emotional tone: positive tone and stable attachment relationships help children avoid being
suspicious and help to enhance resiliency under stress that might otherwise evoke behavior problems and aggression;
help parents establish calm tone in household (family hostility raises tension and can stimulate aggression);
features of good child care centers—adequate ratio of caregivers to children; attention paid to child’s good behavior;
anticipation of problems and redirecting of anger; adequately stimulating curriculum and fun activities; space
and toys for small-group play; no corporal punishment; management of lack of positive tone in household—
address concerns about parents (eg, depression, domestic violence); teach methods of discipline that do not involve
corporal punishment; ask about parental history of being disciplined; consider need for family or marital counseling,
substance abuse treatment, or removal of child; giving attention—children of different ages require different
amounts of attention; babies need someone continuously present to observe and respond to cues and to fill needs
promptly and gently; preschool-aged children need brief attention immediately and attention when not asking for it;
school-aged children need parents to make themselves available regularly and to learn about child’s interests; parents
should watch for child’s first bid for attention; they should react by commenting on object of attention for 1 to
2 sec; child may not bid for attention for another 3 to 4 min; parents should then echo what child says and feels (ie,
match body posture, tone, and speed of speaking; do not add own comments); showing empathy gives confidence
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| Positive reinforcement: reinforces approximations of desired behavior; can be verbal or nonverbal (eg, wink); positive
reinforcer should be used consistently for same behavior each time, be of moderate strength, and given with
calm affect; avoid praise with embedded criticism (eg, “Thank you for putting on your coat. Why can’t you do that
every day?”); “marks”—every time child performs particular behavior that parent wants to promote, parent should
thank child and put pen mark on back of child’s hand; goal 6 to 10 marks per hour; afterwards, add up marks and
give treats for having many marks; continue intervention for ≈4 wk
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| Setting limits: often, parents reluctant to set limits for, eg, child with asthma, because of desire to avoid hardships;
some parents become upset when child becomes upset; limit-setting must be reasonable and flexible; “one request
then move”—get child’s attention (eg, turn off television) before giving command; give instruction in short simple
language; maintain eye contact and remain silent; if child does not respond in 10 sec, take hold of child and take to
task without talking to give child experience of cooperation; praise cooperation; if parent not in position to get
child to do as asked, then parent should not ask
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| Need for mastery: after 8 to 12 mo of age, children need more opportunities to do things themselves; respect need
for autonomy without overwhelming child; overprotectiveness, strictness, or inconsistency of limits can produce
aggression or opposition; counsel parents about smaller consequences for behaviors; some children may do better
when placed with younger children while working on skill development
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| Feeding problems: infants—if child grabs spoon, allow child to feed him- or herself; have discussion with parents
about growth, and address such issues as parents not wanting to end infancy, avoiding distractions (eg, television),
and providing finger foods; toddlers—autonomy more important than hunger; toddlers may refuse food, beg, or
gorge on food; discuss such issues with parents; avoid chase games; recommend putting nutritious food on tray,
and when child says he or she is hungry, parent should point to tray and say, “your food is right there”; usually in 4
to 7 days, child prefers coming to table and being sociable; family therapy may be required; when children misbehave
at table, excuse them, place food in refrigerator, and remove chair; do not feed for at least 1 hr; children as
young as 18 mo learn quickly not to misbehave at table; when to worry—child not gaining weight as expected;
gastroesophageal reflux disease (GERD) associated with food aversion in >20% of cases; constipation; oral-motor
incoordination often found in children with problems with choking or drooling (should be addressed by speech pathologist
or occupational therapist); not eating due to marital discord or fighting at table
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| Teaching prosocial behavior and empathy: eg, teaching child to trade, take turns, recognize feelings of others;
reasons children may not be taught by parents—stress; large families; low income; single parents; depression;
substance use; marital difficulty; what such teaching accomplishes—giving child individual attention gives sense
of being cared about; children who do not feel cared about do not do what adults say; suggest use of marks to give
selective attention to child’s good behavior; children need positive role models; show sympathy to victim before
giving attention to perpetrator
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| Promoting good behavior between siblings: praise good behavior, eg, “that was nice how you helped your
brother with his chores”; distract children from irritating interactions; comment on or reward cooperation; setting
joint goals (eg, setting table together) promotes cooperation; noncompetitive games helpful; give each child individual
time (“special time”; child chooses interactive activity and adult chooses time of day; spend 10-15 min every
day with no interruptions); intervening in sibling fights—ignore fighting; studies show more intervention leads
to more fights; parent should describe conflict (eg, “I see you can’t agree who gets to play with the truck”), listen to
both sides briefly, say “I’m sure you can work it out,” and walk away (if ineffective, separate children or put truck
in time out); if children aggressive, place each child in time out for equal lengths of time
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| Assistance regulating negative affect: negative affect normal; give child chance to hear words for anger (instead
of using fist); provide alternative outlets (eg, teething ring for biters); set clear limits; aggressive behavior common
in children, but high levels of aggression predict later conduct disorder and criminal behavior in adulthood; important
to remember aggression can be stimulated by thwarting of developmental needs; biting—worsens when child
stressed or learning to cope; often in frustrated children who cannot talk; assess developmental skills; time out—
time away from reinforcement and attention; usually accompanied by disapproval, loss of freedom, and loss of interesting
things to do; use for 2 or 3 specific negative behaviors; practice before using for first time; give one warning
before placing child in time out (no warnings for aggression); make brief statement of offense and place child
in uninteresting place for 15 sec to 1 min per year of age; giving praise for positive or neutral behavior observed after
time out important; physical punishment—as effective as time out, but with many negative side effects; in
United States, corporal punishment used on 25% of children 1 to 6 mo of age and 25% of children 17 yr of age
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| Behavior screening: recommendations by American Academy of Pediatrics for development and autism include
screening behavior; information about behavior screening with online questionnaire available at www.childhealthcare.org
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Suggested Reading
Adair RH et al: Sleep problems in childhood. Curr Probl Pediat 23:147, 1993; Beers NS: Managing temper tantrums.
Pediatr Rev 24:70, 2003; DeLeon CW et al: Intrinsic and extrinsic factors associated with night waking in
9-month-old infants. Infant Behav Dev 30:596, 2007; Fitzpatrick E et al: Positive effects of family dinner are undone
by television viewing. J Am Diet Assoc 107:666, 2007; Groopman J: Crybabies: solving the colic conundrum.
New Yorker:46, 2007; Hall WA et al: Effects of an intervention aimed at reducing night waking and
signaling in 6- to 12-month-old infants. Behav Sleep Med 4:242, 2006; Howard BJ: Discipline in early childhood.
Pediatr Clin North Am 38:1351, 1991; Howard CR et al: Parental responses to infant crying and colic: the effect
on breastfeeding duration. Breastfeed Med 1:146, 2006; Karp H: Swaddling and excessive crying. J Pediatr 151:e2,
2007; Kolkiran A et al: Autonomic nervous system functions in children with breath-holding spells and effects of
iron deficiency. Acta Paediatr 94:1227, 2005; Leung AK et al: Temper tantrums. Am Fam Physician 44:559,
1991; Pike A et al: Sibling relationships in early/middle childhood: links with individual adjustment. J Fam Psychol
19:523, 2005; Pinilla T et al: Help me make it through the night: behavioral entrainment of breast-fed infants'
sleep patterns. Pediatrics 91:436, 1993.
Educational Objectives
| The goal of this program is to review normal child development and to improve the management of behavior problems
in children. After hearing and assimilating this program, the clinician will be better able to:
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| 1. Differentiate colic from normal patterns of crying.
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| 2. Counsel parents about trained night feeding and waking.
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| 3. Advise parents about temper tantrums and breath-holding spells.
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| 4. Discuss feeding behavior and positive reinforcement.
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| 5. Outline strategies for controlling aggression and fighting among siblings.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and planning committee members
to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified
conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business
or commercial interest. For this program, the following has been disclosed: Dr. Howard is a consultant for Total Child Health, Inc.
The planning committee reported nothing to disclose.
Acknowledgements
Dr. Howard was recorded in Chicago, IL, at the 50th annual Scientific Assembly, presented October 3-5, 2007, by the American
Academy of Family Physicians. The Audio-Digest Foundation thanks Dr. Howard and the American Academy of Family Physicians
for their cooperation in the production of this program.
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